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MANUAL
OF
PATHOLOGICAL  ANATOMY.
                BY


    C. HANDFIELD JOXES, M.B., F.R.S.,

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, ASSISTANT PHYSICIAN TO, AND LECTURER
         ON PHYSIOLOGY AT, ST. BIARY'b HOSPITAL}

                AND


      EDWARD H. SIEVEKING, M.D.,

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, ASSISTANT PHYSICIAN TO, AND LECTURER
         ON MATERIA MEDICA AT, ST. MARY'S HOSPITAL.
FIRST AMERICAN" EDITION REVISED.
THREE HUNDRED AND NINETY-SEVEN ILLUSTRATIONS.
     PHILADELPHIA:

BLAN CHARD  AND  LEA.
           1854. 
Qj A,
f'ttTvy  AJO  >   (o/3/;  mcty
       Entered according to the Act of Congress, in the year 1854, by

                   BLAN CHARD  AND  LEA,

in tbe Office of the Clerk of the District Court of the United States, in and for
            the  Eastern District of the State of Pennsylvania.
        PHILADELPHIA:
T. K. AND P. Q. COLLINS, FR1XTERS. 
PUBLISHERS'  ADVERTISEMENT.
  In a work like the present, intended as a text-book for the student
of pathology, accurate engravings of the various results of morbid
action are of the greatest assistance.  The publishers have, therefore,
considered that the value of the work might be enhanced by increasing
the number of illustrations, and, with  this  object, many wood-cuts,
from the best authorities, have been introduced, increasing the number
from 167, in the London edition, to 397 in this.  In the list of illus-
trations,  these  additional cuts will  be found distinguished  by an
asterisk (*) from those for which the authors are alone responsible.
The selection of these wood-cuts has been made by a competent mem-
ber of the profession, who has supervised the  progress of the work
through the press, with the view of securing an accurate reprint, and
of correcting such errors as had escaped the attention of the authors.
He has also added,  at page 197, an account of  the interesting micro-
scopical observations  of Dr. Donaldson, of Baltimore, on  the charac-
teristics of the true cancer-cell.
Philadelphia, November 1854. 
 
PREFATORY  NOTICE.
  The Authors of the present work have  desired to lay before their
professional brethren an outline of what is known in the domain of
Pathological Anatomy.  The absence  of  any original work in  the
English language, which embraces the whole subject, must be their
apology for having made the attempt.  They have sought to place
before the reader a summary of ascertained facts, together with  the
opinions of the most eminent pathologists of this and other countries.
They have regarded it as their duty to select, as far  as  possible,  the
best fruits from the harvest gathered by other  laborers in this wide
and interesting field.   At the same time they have  sought not to
speak solely on the faith of others, even the highest authorities,  but
to investigate, as much as possible, for  themselves, the correctness of
the statements they adopted.  They felt that, in some instances, better
illustrations might have been obtained by borrowing from other works;
but they were of opinion that the present manual would bear a stamp
of greater  truthfulness if the drawings were taken from objects seen
and examined by themselves.  They have therefore preferred (with
few exceptions only) to use such illustrations as their own portfolios
supplied.   Although small drawings, in black and white, necessarily
fail to give the important elements of size and color, almost essential
to illustrations of Pathological Anatomy, the Authors hope that  the
masterly treatment of  Mr. Bagg has achieved as much as  could be
done by wood engraving.   They  have divided the subject in  the
manner indicated  in the Table of Contents, and are each individually
responsible for the chapters which they have treated. 
yi                   PREFATORY  NOTICE.
  They conclude  by expressing a hope that  the  vast  extent  of the
subject, and of the material they had to deal with, will serve, in some
measure, as an apology for the deficiencies which they are fully con-
scious of, and for which they ask the kind and lenient  consideration
of the  Medical Profession.
                                   C. HANDFIELD JOXES,
                                   EDWARD  H. SIEVEKING.

  London, August 5, 1854. 
CONTENTS.
            GENERAL  PATHOLOGICAL  ANATOMY.
                         BY C. HANDFIELD JONES.

                            CHAPTER I.
                                                                  PAGE
General Observations      .      .      .     •      •            •     .33

                           CHAPTER  II.
Morbid States of the Blood       .......   52
161
                          CHAPTER III.
Textural Changes   ....■•••

                           CHAPTER  IV.
New Formations—Tumors   .      •      •      •      •      •      •     .lob

                           CHAPTER V.
Parasites    ...•••••
213
  PATHOLOGICAL ANATOMY OF THE NERVOUS  SYSTEM.
                         BY EDWARD H. SIEVEKING.

                           CHAPTER VI.
                                                                   223
General Observations      ...•••
                          CHAPTER  VII.
                                                                   225
The Dura Mater    ..•••••
                         CHAPTER VIII.
                                                                   230
The Arachnoid and Pia Mater     .
                           CHAPTER IX.
 ,  „  •                                              ...  247
The Brain   ...••••
The Brain (Continued)
CHAPTER  X.
                                     .  262 
viii                           CONTENTS.

                           CHAPTER XI.
                                                                    PAGE
The Spinal Cord and its Membranes      .      ,
                           CHAPTER  XII.
The Arachnoid and Pia Mater of the Spinal Cord  .

                          CHAPTER XIII.
The Spinal Cord    .....
                          CHAPTER  XIV.
The Nerves  ......

                           CHAPTER XV.
The Sympathetic System   ....
      PATHOLOGICAL ANATOMY OF THE  ORGANS OF
                          CIRCULATION.
                         BY  EDWARD H. SIEVEKING.
                          CHAPTER XVI.
General Observations      ........  286

                          CHAPTER  XVII.
The Pericardium    .........  289

                         CHAPTER XVIII.
The Heart   .      .      .      .      .     .      .      .      .      .  296

                          CHAPTER XIX.
The Heart (Continued)     ........  302

                          CHAPTER XX.
The Endocardium   .......               313

                          CHAPTER XXI.
The Valves  .......                   ,319

                          CHAPTER  XXII.
The Bloodvessels    ....._                     031

                         CHAPTER  XXIII.
Aneurism   ....                                        Qaa
.  271


.  274


.  279


.  285 
CONTENTS.
IX
                        CHAPTER XXIV.
                                                                 PAGE
The Veins   ........••  353

                         CHAPTER XXV.
The Lymphatic System     .....•••  367
      PATHOLOGICAL  ANATOMY OF  THE ORGANS OF
                          RESPIRATION.
                        BY EDWARD H. SIEVEKING.

                        CHAPTER XXVI.
General Observations—The Epiglottis—The Larynx—The Trachea       .     .  373

                        CHAPTER  XXVII.
The Bronchial Tubes      .     .      •      •      •      •      •     .384
                       CHAPTER  XXVIII.
The Lungs   ...•••

                         CHAPTER XXIX.
The Lungs (Continued)    ....

                         CHAPTER  XXX.
The Lungs (Continued)    .     .     •      •

                         CHAPTER XXXI.
The Pleura  ..••••
393
405
41'
434
PATHOLOGICAL  ANATOMY  OF  THE ALIMENTARY CANAL.
                         BY C. HANDFIELD JONES.

                        CHAPTER  XXXII.
The Mouth and Fauces-The Teeth-The Pharynx and ffisophagus-The Perito-
  neum—The Stomach—The Intestinal Canal—The Intestinal Contents   .     . 44*

                        CHAPTER XXXIII.
                                                                 507
The Liver—The Biliary Passages—The Bile      .

                        CHAPTER  XXXIV.
The Pancreas, and the other Salivary Glands-The Ductless Glands-The Thyroid ^
  Glands    . 
X
CONTENTS.
PATHOLOGICAL ANATOMY OF THE URINARY APPARATUS.
                         BY C. HANDFIELD JONES.

                        CHAPTER XXXV.
                                                                PAGE
The Kidney—The Urinary Passages—The Bladder—The Urethra—The Urine    .  543

                       CHAPTER  XXXVI.
The Male Generative Organs       .......  585
   PATHOLOGICAL ANATOMY OF THE FEMALE  ORGANS
                        OF GENERATION.
                        BY EDWARD H. SIEVEKING.

                      CHAPTER XXXVII.
The External Organs of Generation—The Vagina .....  607

                      CHAPTER XXXVIII.
The Internal Organs of Generation       ......  614
                       CHAPTER XXXIX.
Morbid Conditions following and preceding Parturition    ....  629

                          CHAPTER  XL.
The Ovaries—The Mammae       .......  644
        PATHOLOGICAL ANATOMY OF THE JOINTS.
                        BY C. HANDFIELD JONES.

                         CHAPTER XLI.
Disease of the Joints      ....
  PATHOLOGICAL  ANATOMY OF THE OSSEOUS  SYSTEM.
                        BY EDWARD H. SIEVEKING.
                        CHAPTER  XLII.
Periosteum—Bone  ......                    f

                        CHAPTER  XLIII.
Adventitious Growths    ... 
LIST   OE  ILLUSTRATIONS.
       THOSE MARKED WITH AN ASTERISK HAVE BEEN ADDED BY THE AMERICAN EDITOR.
FIG.
 I.*  Blood-corpuscles
 2.*  White corpuscles of the blood
 3.*  Blood-corpuscles
 4. Fibrils of healthy fibrin
 5. Corpuscular unhealthy fibrin
 6. Softening fibrin from a vein-clot
 7.*  Cholesterin
 8.*  Fat in blood   .
 9. Contracted artery
10. Haematin crystals
11.*  Changes in blood-globules
12.*  Web in the foot of a frog inflamed
13. Production of  stasis
14. Fibrinous exudation on pleura in process of absorption
15.*  Commencing organization in effused fibrin
16. Corpuscles from a pustule
17.*  Pus-globules  ....
18.*  Natural appearance of pus-corpuscles
19.*  Pus-corpuscles magnified
20.*  Healthy pus-cells
21.*  "J
22.*  > Various forms of pus-cell
23.*  j
24.*  Muco-purulent matter
25. Glomeruli and granulous cells .
26.  Separate corpuscles and two blood-globules
27. Blood in leucocythaemia
28.  Gray tubercle; miliary granulation
29. Yellow tubercle; crude mass  .
30.  Isolated tubercle corpuscles
31.* Tubercle corpuscles from the peritoneum
32.* Tubercle corpuscles, granules, and molecules, from the lung
33.* Tubercle corpuscles from a mesenteric gland
34.* Tubercle corpuscles from the lung
35.* Pus-corpuscles
36.* Plastic or pyoid corpuscles
37.* Granular corpuscles from cerebral softening
38.* Cancer-cells  from the uterus  .
39.* Structure of central portion of a tubercular mass from the brain
40.* Structure of external portion of same mass  .
41.* Fragments of phosphate of lime, crystals of cholesterin, and tubercle corpuscles,
        from a cretaceous mass in the lung
42.* Section of gray granulation in  the lung, after the addition of acetic
43.* Tubercle corpuscles mixed with pigmentary matter
44.* Scrofulous matter from subcutaneous deposit
45.* Scrofulous pus        .
46.* Scrofulous pus from lymphatic gland
47.* Pus from a scrofulous abscess
48. Drawing of a fibrous tumor
49. Fibro-fatty tumor      ....
 50.* Fat cells and granular cells from a steatomatous tumor of the ovary
51.* Structure of a fatty tumor from the back
52. Fibro-cyetic tumor from the back
53. Epithelial growth and tumor  .
 54. Melanic deposit in cells of an engorged lung
 55. Adipose tissue from a fatty tumor
 56. Enchondroma, microscopic structure  .
acid 
Xll
LIST OF ILLUSTRATIONS.
 FIG
  57
  58
  59
  60
  61
  62
  63
  64,
  65
  66.
  67,
  68.
  69.
  70.
  71.
  72.
  73.
  74.
  75.
  76.

  78.
  79.
  8d.
  81.
  82.
  83.
  84.
  85.
  Sli.
  87.
  88.
  89.
  90.
  91.
  92.
  93.
  94.
  9:").
  96.
  97.
  98.
  99.
 100.
 101.
 102.
 103
 104.
 105
 106
 107
 108
 109
 110.
 111.
 112.
 113.
 114.
 115.
 116.
 117.
 US.
 119.
 120.
 121.
 122.
123.
124.
 125.
126.
127.
1
 * Section of the circumference of an enchondroma from the pelvis
 * Corpuscles from softened part of the same tumor
 * The same after the addition of acetic acid .
.* Example of ossification  of enchondromatous tumor

',;, [ Osseous tumor of os innominatum
  Simple serous cyst and epithelial particles from its interior .
  Diagram of compound cysts  .      .       .       .       ■
  Pancreatoid sarcomatous  tumor     ....
  Structural elements of same  .....
  Various forms of encephaloid cells   ....
 * Simple and compound cancer-cells  ....
 * Cells from encephaloid of tongue   ....
 ^ ) Cancer-cells before  and  after the addition of acetic acid; also, the structure
 , f   the reticulatum from  encephaloma of the testicle

 ^ [ Young cancer-cells, before and after the addition of acetic acid

 * Fungus baematodes  ......
 * Cells loaded  with black pigment from a melanotic tumor of the cheek
  Fibroid stroma of a scirrhous tumor of pylorus
  Scirrhous  tumor of cerebrum .....
 * Section of a  carcinomatous tumor of the breast
 * Another  portion of the same treated with  acetic acid
 * Cancer-cells  from the cream-like juice squeezed from the tumor
 * The same with the addition of acetic acid  .
 * Dense fibrous and elastic  tissue, in which cancer-cells are infiltrated, from the rectu
 * Cancer-cells scraped from the surface in the same case
 * The same after the addition of  acetic acid
  Colloid cancer of a lymphatic gland  .
 * Form and structure of  the same
 * Epithelial cancer
 * Cancerous tumor of the cheek      .
 * Epithelial cancer
 * Free cancer nuclei
 * Forms of cancer-cells from the polygonal or type variety
 * Caudated cancer-cells
 * Fusiform cancer-cells
 :' Fusiform corpuscles of fibro-plastic tissue
 *' Concentric cancer-cells
 * Compound cancer-cells
 * Agglomerated nuclei
 * Pus-corpuscles
 * The same after the application of acetic acid
 * Young epithelial scales
* Tessellated epithelium
 * Buccal epithelial scales
   Spherical fibro-plastic cells .
 * Cartilage elements from condyles of femur
* Costal cartilage
*  Corpuscles of tubercle
* Cylindrical and ciliated epithelial elements
 Drawing of mycoderm of favus
  Taenia solium; head and joints
  Taenia lata    ....
 Echinococcus  ....
 Bone-like substance attached to falx cerebri
 Subarachnoid effusion
 Hemorrhagic  effusion in the brain
 Purulent effusion beneath the arachnoid
 Meningeal vessels invested and surrounded by exudation-matter
 | Microscopic appearance of the vessels in meningitis

 Deposit of tubercular matter in the Sylvian fissure of the brain
 A hydrocephalic skull  of a girl aged 11 years
 Tumors at  the  choroid plexus mistaken at first for tubercles'
 Portion of  choroid plexus,  exhibiting a fatty degeneration of the epitheli
 Apoplectic effusion in the brain
 Hemorrhage into the ventricle and substance of the brain
 Vessels from a brain affected with red softening
 Cancerous tumor from  the brain 
LIST OF  ILLUSTRATIONS.
XU1
the aorta
FIG.
128.  Portion of tbe spinal cord of a patient who died paraplegic
129.  Part of the spinal cord from a case of paraplegia with angular curvature of the spin
130. Atrophy of optic nerves      ....

1S2 * f Neuromata of stump after amputation
133.*  Section  of a neuroma       ....
134.*  Fibrous structure of neuroma
135. Tumor implicating the posterior tibial nerve
136. Ordinary form of neuroma    ....
137.*  Tumor implicating a median nerve .
138. A heart covered with plastic exudations
139. Specimens of fatty degeneration of the heart
 140. Aneurism of left ventricle of heart
 141. Fibroid thickening of mitral valve
 142. Fibroid thickening of a pulmonary valve
 143. Aortic valves of a child, opaque, thickened, and adherent
 144. Atheromatous deposit in valves of aorta
 145. Calcareous deposit in aortic valves  .
 146. Ossification of aortic valves  .
 147. Aneurism of mitral valve    .
 148.* Plastic deposits in aorta    ....
 149.* Plastic plugs occluding axillary artery
 150.* Incipient atheroma and fatty degeneration of an iliac
 151.* Fatty deposits in internal coat of an artery
  152.* Early stage of atheroma   .
  153.* Atheroma from old patch   ....
  154.* Steatomatous degeneration  .      .      •      •
  ] 55* Fatty granules, with crystals of cholesterin, from atheromatous deposits in
  156.* Calcareous deposition in coats of an artery  .
  157.* Annular calcification of the coats of an artery
  158.  Aneurism of the arch of aorta
  159.* Aneurism of the brachial artery
  160.  Aneurism of posterior tibial artery    .      .
  161 * Growth of aneurism arrested  by coagulum  .      .
  162.* Spontaneous cure of aneurism by the sac being filled with coagulum
  163/! I Front and back view of aneurism of the arch of aorta which burst into trachea

  165'.* Aneurism of aorta which induced caries of the vertebrae, and fatal compression of
          the  spinal cord   ....
  166* \ Front and back view of aneurism of aorta producing absorption of ribs
  167.* J Xl
  168.* Varicose aneurism  .

  l^Son of Inhibiting the 'appearances presented* inflammation of  vena port*
  171.* Varix of veins of leg        .
  172. Calcareous deposit in the coats of a vein
  173. Acute ulceration of epiglottis .

  175!* I (Edema of tbe epiglottis    .      •  .    •

  176-*3           , v  ,
   177*  Ulceration  of the larynx     .      ■      •      •
   178  Enlargement of follicles of mucous membrane  of the trachea

   S: \f^::^^zv^:z^—.-*». - wu*;
   181. Dilated bronchi      .      •      •       •
   182. Cretaceous enlargement of a bronchial gland
   183. Portion of emphysematous lung
   184. Pulmonary apoplexy  .

   IS" KJ£S3££2ft .1,  -contents nt nn ntr-vcsid. in ^ hnp.ti.nti.n
   187  Pleural surface of a portion of splenified lung
   188. Miliary tubercle of pulmonary tissue .      •                         '



   1M  Hnr/n,r.tpeSn»t.=enrrn,en,„,-. p«,„« of  i. *i* .«- -«i



        S«S°.T.T.ir.veSio'l, fille. *ith yellow t'.b«d. »d snmundrf bj .»d.tl.».
           corpuscles .
193. 
XIV
LIST  OF ILLUSTRATIONS.
 FIG.
 194.
 195.
 1'j6.
 197.
 198.
 199.
 200.
 201.
 202.
 203.
 204.
 205.
 206.
 207.
 20*.
 209,
 210,
 211
 212,

 213

 214.

 215
 216,
 217,
 218,
 219,
 220,
 221,
 222
 223,
 224,
 225

 226
 227
 228
 229
 230
 231
 232
 233
 234
 235
 236
 237
 23S
 239
 240
 241
 242
 243
 244
 215
 246

 247

 248
 249
»250
 251
 252
 253,
 254
 255
 256
 257
 25*
 259
PAGE
  425
  426
  426
  429

  431

  435
Apex of lung affected with tubercular pneumonia   .....
Lung with extensive tubercular disorganization     .             .
Apex of lung containing numerous cavities with tubercular deposit intervening
Cicatrix at the apex of lung, resulting from the previous arrest of tubercular disease

[ Infiltrated cancer of lung, with its microscopic  elements   ....
Straw-colored lymph, coating the lower lobe of an inflamed lung, in recent pleurisy
Portion oflower lobe ofleft lung compressed by turgid serum occupying the pleural cavity  435
                                                                                 436
                                                                                 443

                                                                                 444

                                                                                 452
                                                                                 456
                                                                                 457
                                                                                 459
                                                                                 460
                                                                                 462
 Lymph of pleuritis with new vessels already formed iu it
 Old cartilaginoid capsule of apex of lung

 I Naked-eye and microscopic view of cancer of pleura

* Tongue swollen by glossitis  .....
 Tooth attached by caries, with barrier of secondary dentine
 Imperfect formation of enamol      ....
* Purulent cyst at the faDg of a decayed tooth
* Stricture of the oesophagus  .....
 Portion of inflamed peritoneum with numerous glomeruli between the fibres
 Vertical section of mucous membrane of stomach, the  tubes completely  wasted and
     replaced by fibroid tissue
 Vertical section of mucous membrane of stomach, showing the lower parts of the
     tubes, and  a nuclear mass extending among them  upwards
 Cavity formed  in the mucous membrane of stomach by the disintegration of a nu-
     clear mass         .....
 Perforating ulcer of stomach ....
* Scirrbus pylori      .....
* Strangulation of intestine by mesentery or omentum
 Diagram of intussusception   ....
I Prolapsus ani
 Vertical section of Peyerian patch and solitary gland of large intestine
 Typhous ulcers in small intestines
 Inflamed mesenteric gland in typhus, and so-called typhous matter
 Typhous ulcers in various stages
 ::  Piles after excision, showing the dilated veins of which they are in a great mea
     sure composed    .....
 A slightly lobulated tumor, passed per anum, dividedin its middle and cut edges exposed
 Section of liver, showing nutmeg appearance

 ^  Fatty degeneration of liver  ....

 Fibres originating from fibrous tissue of a cirrhotic liver
 Section of liver in advanced state of fatty degeneration
 Hepatic cells filled with oil, and from which the oil has escaped
 Encephaloid growth in liver  ....
 Gall-stones    ......
 Cholesterin and glomeruli from gall-bladder .
 Gall-bladder and cystic-duct containing calculi
 *  Salivary calculus    .....
 Fibroid thickening of capsule of spleen
 Masses of crude tubercle in  spleen    .      .
 Cyst in the capsule of spleen  ....
 *  Bronchocele  ......
 *  Section of bronchocele, showing calcareous deposits
. Hemorrhage into Malpighian capsules
. Tube from kidney  containing yellow granules, the remains of extra'vasated blood
. Fibrinous deposits in  a granular kidney
. Red deposit from urine  in intense renal hyperaemia  .
  f Renal tube containing an homogeneous cast
  ( Malpighian body, the capsule filled with oily matter
 Diseased cortical tubes of liver
 Diseased cortical and  medullary tubes
 ;  Diseased tubuli uriniferi
 Atrophied kidney     ....
 Cortical portion of granular kidney   .
 Thickened condition of matrix of kidney
 Renal cysts and cyst-like casts      .      .
 Kidney converted into cysts  .
 Pyelitis        .
 7  Extrophy of bladder
 5  Sacculation or partial dilatations of bladder
   Hypertrophy of muscular coat of bladder   .
    468

    469

    469
    472
    477
    482
    484
485-486
    489
    492
    493
    493
    502
    503
    508
508-513
    514
    515
    516
    523
    529
    530
    530
    532
    537
    538
    538
    539
    539
    544
    544
    547
    548
    549
    549
    550
    550
    551
    553
    553
    554
      55
    562
    562
    564
    565
    566 
LIST OF ILLUSTRATIONS.
XV
Uric acid crystals
 FIG.
 260.  "I

 262* <" Strictured urethra
 263.* J
 264. fjrinary deposits
 265.*"
 266.*
 267.*
 268.*
 269.*
 270.*
 271.*
 272*
 273.*
 274.*
 275.*
 276.*
 277.*!
 2^"*  I Earthy phosphates
 28o!*j
 281.* i
 g2. J  I Oxalate of lime

' 284*J
 2|j»-*  I Dumb-bell crystals

 287.* 1
 **$\ Cystine     .
  290.* J
  291.* Lithic calculus
  292.* Section of lithic calculus showing internal structure
  293.* Oxalic or mulberry calculus
  294.* Internal structure of same   .
  295.* Cystic calculus       ....
  296.* Internal structure of same   .
  297.* Phosphatic calculus  ....
  298.* Ammonia magnesian calculus
  299.* Fusible calculus     ....
  300.* Internal structure of same   .
  301. Inflammation of tunica vaginalis
  302. Hydrocele combined with scrotal hernia
  303. Encysted hydrocele of tunica vaginalis
  304. Hasmatocele   .....
  305.* Bruise of scrotum, a form of hematocele
  306.* Acute orchitis              •       •       •  .
  307. Chronic orchitis, with fungous protrusion of testis
  308. Section of cystic sarcoma of testis
  309. Contents of various cysts in the same
  310.* Hypertrophy or elephantiasis of scrotum
  311.* Chimney-sweepers' cancer   .
  312.* Corpuscles from the same
  jj1^* 1 Enlarged prostate
  315]* Lobulated hypertrophy of prostate
  316.* | Hypertrophy of  middle lobe of prostate

  3is!* Irregular hypertrophy of middle lobe
  319.* Abscess of prostate
  320.* Cyst of prostate
  321.* { prostatic calculi

  323.* Chancre of prepuce
  '324.* Phymosis
  325.* Paraphymosis
  326.* Warts on penis
  327. Fibrous tumor projecting in the cavity of uterus
  328. Fibrous tumors of walls of uterus
  329. Atrophied placenta   .
  330. Incipient cyst-formation  in ovary
  331. Multilocular ovarian cyst
571-572

    576
577-576
579
580
580
    581


    581
    581
    582
    582
    582
    582
    583
    583
    583
    583
    587
    588
    58U
    59(1
    59L
    592
    593
    595
    596
    597
    598
    59S

    599

    60d

    600

    601
    602
    603

603-604

    605
    60fi
    606
    606
    619
    620
    636
    647
    64 s 
XVI
LIST OF  ILLUSTRATIONS.
332.* Sero-cystic tumor of mamma      .......
333.* Cysto-sarcoma of mamma   ....••••
334.* Cysto-sarcoma from neighborhood of mamma      .
335. Lobular hypertrophy of mamma     .......
336.* )
337.* > Microscopic sections of simple tumor of mamma  .....
338* J
339.* Carcinoma of mamma bisected     ....•••
340.* Secondary carcinoma       ........
341. Cancerous tumor of mamma  .......      •
342. Secondary deposit in knee-joint     .......
343. Diseased cartilage    .........
344.* Fibriated knee-joint        .      .      .       •       •             •
345.* Trochlea of humerus, showing formation and connection of loose cartilaginous bodies
346. Cartilage of patella in state of usure  .......
347.* 1
PAGE
 652
 (553
 653
 654

 654

 656
 656
 656
 661
 664
 665
 666
349 * f Diseased articular cartilage
350>J
351.* Deposition of calcareous matter, commencing in the walls of the cartilage-corpuscles
352. Ulceration of cartilage      ....
353* Destruction of cartilage in knee-joint
L'l [• Spinal curvature   .....
356.* Enlarged bursa over patella  ....
357.* Microscopic drawing of inflamed and softened bone
358.* Suppuration in bone       ....
359* •)

'•{61 * i Abscess  in bone    .....
362!* J
363* 1
364*
365*
Caries in bone
Necrosis of head of femur, acetabulum, and shaft
367*
368*
369*
370.*
371*
372* \
373.*
374.;
375*
376.*
377. Section of the femur of a rickety child cut with a knife
378* 1
379*
380.* [ Rickets affecting the femur, tibia, and humerus  .
381*
382* J
383 * )
384 * I Permanent curvature of the spine, with rotation, produced by rickets
385* Example of limbs deformed by rickets

oq7'* [ Front and back view of lateral curvature of spine
:;88. Enchondroma ....
389.* Ivory exostoses of os frontis
390. Spongy exostosis on the femur
391.* Exostosis of femur
392. Osteophytes occupying lower end of femur
393.* Osteocephaloma of head of humerus
394.* Section of the same tumor
395.* Osteocystoma of lower end  of femur
396. Section of femur affected with mollities ossium
397. Bone-corpuscles       ....
668-669
670
670
673
674
680
685
687
687
689
690-695
695
696
698
701
705
706
707
707
708
713
713
718
720
722 
MANUAL
OF
PATHOLOGICAL  ANATOMY.
                       CHAPTER  I.

                   GENERAL OBSERVATIONS.

   The object of General Pathology is to examine the various morbid
processes which may occur in the human body, and to obtain, thereby,
such an insight into their nature, that  they may not be looked on as
unknown entities, but that being comprehended as far as is  possible
themselves, the various effects they produce, the particular instances of
their action, may be understood also.
   The course we propose to follow is nearly that  which  Dr. Williams
has adopted so successfully, in his work on The Principles of Medicine.
We shall, therefore,  describe, briefly:  (I.) The morbid alterations of
the several great functions.  (II.) Those of the blood.  (III.) Those
of the various  tissues,  considered generally.  (IV.) The superadded
formations  or growths,  the so-called tumors.   (V.) Parasitic beings,
whether animal or vegetable.
   Some general observations must, however, be premised.   The term
Morbid Anatomy hardly needs  explanation; as ordinary anatomy im-
plies the study  of,  and acquaintance with,  the healthy  structure, so
morbid anatomy implies the same of diseased structure.   The meaning
of Pathology may be clearly conceived, by considering that of  its  twin
sister, Physiology; as the latter imports the  knowledge of the natural
actions of healthy organs,  so does the former  that of the  unnatural
actions  of  diseased  or  disturbed  organs.   Physiology has her  vital
stimuli;  Pathology  her stimuli or excitants to unhealthy  life.   This
expression brings us to notice a point which has been excellently illus-
trated by Prof. Simon.   He remarks  that many unnatural or diseased
conditions are not really unnatural in themselves, but are the proper
and necessary consequences of some cause or influence which has acted
upon a healthy body.  The state of skin which a severe burn produces
is, certainly, very unnatural and diseased, but  the inflammatory and
exudative processes which have produced it  are quite natural, under the
       3 
34
GENERAL OBSERVATIONS.
 circumstances that have  occurred;  they are the  proper reaction  of a
 healthy organism to the unnatural stimulus of extreme heat, and are
 called  forth in the same way as is  the  healthy  flow of blood  into  a
 chilled part by the action of  kindly warmth.  So in a case of variola.,
 the skin, covered all over with unsightly pustules, is in a very unnatural
 state;  but it is not the eruption, nor the constitutional disturbance,
 neither, that is  really unnatural, but the presence  of a certain quantity
 of infectious  matter in  the blood, which, acting on a perfectly natural
 system, thus  calls forth its expulsive efforts.  If we slightly alter  this
 perfectly natural state,  as by premising vaccination, then the introduc-
 tion of the variolous poison no longer produces the same morbid effects,
 and we say the system is protected.  The fact is, the system is changed
 from its  originally perfectly  natural condition,  and will no  longer
 respond to the  unnatural stimulus.   We  find, it may be, a portion of
 the brain so soft as to resemble cream, quite broken up and disorgan-
 ized ; but, we look further and  find that the artery supplying it with
 blood has been plugged up or tied, and we then see  that the locus of
 the disease was not  really in  the brain, but in the  artery; it  would
 have been abnormal had the brain, deprived of its supply of blood, re-
 tained its natural texture.  Or, again, we see a person  suffering from
 violent  epileptic convulsions;  but, he passes a large worm from  the
 bowels, and the  attacks cease:  in the  case  of this individual, the con-
 vulsions were the  natural expression of the unnatural irritation to
 which the brain was  subjected.   Many like instances might be men-
 tioned,  and they certainly show that disease is, very often,  not  to be
 regarded  as a special entity of a peculiar, strange kind, but  as  the
 natural result of the endowments and qualities belonging to our bodily
 organs, when  those organs  are  acted  on by certain unnatural  stimuli.
 Hence,  we can better understand that many diseases have a regular  and
 normal  course  made  up,  so to  speak, of a succession of necessary
 results,  which, however,  is liable  to be  disturbed  by  various extrinsic
 causes,   .bor instance, a person has ague,  the paroxysms occurring in
 regular  succession; he takes quinine, and they diminish and disappear,
 the course of morbid  action is interfered with and  broken.   Or, a child
 has hooping-cough, and the disease is proceeding  in  its usual course,
 but in consequence of  exposure to cold, he is attacked with  inflamma-
 tion of  the lungs, and the paroxysms characteristic of the disease are,
 to  a great degree, interrupted;  the  hooping-cough is merged in  the
 ZnXTl\  J' ^^  auPerS°n haS  tubercul*r deposit in his lungs;
 JaLd S^r   ^  thlS ? t0, 8°ften' break down> and be e^o-
 2ce St?1111 th? T01^ ti8SUe' While' as fr*sh deposits" take
 IZer,  Zl^  T6 °f thG °rgan is destr°jed;  but, before this  can
 3e rhS Z    °YTt UP t0 SUch  an extent> in the surrounding
 traction ^      ? ^ ?0t hj th° effeCtS of the  tubercular  de"
 struction directly, but by the intercurrent inflammation.

 are often ?earmead tW T^^ the SUCCeSsion of morbid actions>
S^he^^                               they maybe ade-
need the assign™ „f    lue"H>ei\ es, to produce their effect, or, may 
GENERAL OBSERVATIONS.
35
  But the question  now occurs, whether all  diseases are of the kind
above mentioned, whether all can be regarded as the natural results of
certain foreign injurious influences  operating  on the system.  To this
the answer, in the present state of  pathology, must be, I think, cer-
tainly not.  There are very many cases where we cannot point out any
exciting cause of the existing malady, where it seems to have originated
spontaneously, so far as we are able to judge.   Of this kind are many
instances  of decay  and degeneration  of tissues, very  many of mal-
assimilation, or mal-secretion, hereditary diseases, and some  congenital
mal-formations.  It may be that, as we advance in knowledge, we shall
be able to include more and more of  the latter class under the former;
that as we obtain more acquaintance with the imponderable influences
which are constantly in operation, we shall  be able to refer to them as
the causes of  changes which now appear spontaneous, but from  this we
are far, at present, and  must thoroughly recognize  the  two classes of
disease which  we have just described.   These classes, however, are not
(and natural groups never are) rigorously defined; there  are numerous
instances of an intermediate kind, such as those where a slight exciting
cause calls into action an inherited predisposition.  We must also no-
tice another great division of diseases into two classes, viz: the Organic
and  Functional.   Of the  existence  of the latter  many of the  best
pathologists greatly doubt, that is to  say, whether it be possible for the
mechanism of an organ to be perfectly uninjured, at the time that its
function  is wrongly performed.  Speaking  in the strictest  sense, and
remembering the advances which have been made in detecting  morbid
alterations formerly unknown,  as well as the amount of progress which
we may yet look  to make, it must certainly  be allowed  that  it is quite
possible that the  division above mentioned is not founded in reality, and
that all diseases are attended with organic change.  But, when this is
conceded, it remains  still  perfectly  clear  that  there  are not  a few
diseases, and some very severe, in which no  organic alteration whatever
can be detected;  and it seems,  further, a point of considerable practical
importance that the student should be fully  aware of this and  alive to
it.  For the functional disease often nearly simulates the  organic, or
may succeed it, or exaggerate it, and the practitioner who is not  care^
fully  on the watch for the possible  occurrence  is very apt to be led
astray.   How often has dyspnoea, depending on disordered innervation,
been treated as pneumonia,  palpitation of similar  origin considered as
the result of  serious cardiac  disease, venesection  been employed to
relieve nervous headache, and so on!    In this time of generally defi-
cient  power, and  sensitive nervous systems,  it behoves us especially to
be on our guard against mistaking a functional for an  organic  disease.
As in the  preceding case, so in this, the two divisions which we recog-
nize of diseases are not rigorously defined, they have each their marked
exemplars, between which the intervening space is filled up with every
possible grade.  Functional disease may produce organic, either of the
organ which itself affects, or of some other.   Thus, epilepsy long con-
tinuing, produces morbid alteration of the cerebral structure;  dyspepsia
may be the cause of some unsightly cutaneous eruption.   Organic  dis-
eases  are much more often  latent than functional.  A man  may have 
36
GENERAL OBSERVATIONS.
serious heart disease, and think nothing about it, but he will be greatly
alarmed if he suffers from an  irritable palpitating  organ.  This fact,
and the oft-repeated observation that post-mortem examination discovers
no  sufficient cause of death, testify, as well as  the  instances in which
functional disease is itself fatal, to the reality and importance of func-
tional disorder, either independent of, or out of all  proportion  to, or-
ganic alteration; and warn us  that, necessary and  philosophic as it is
to investigate to the utmost  the morbid changes of solids or  fluids, and
to  endeavor  to arrive  by this way at  a knowledge of  the essential
causes, and at sound indications of treatment, we must never overlook^
those grand plain intimations which nature gives of functional vigor or
debility.  Such considerations as these may  be  foreign  to  morbid
anatomy;  they are  not inappropriate to  pathology.   What  are  called
idiosyncrasies  are  unusual  peculiarities  of an individual system, in
consequence of which it is affected in a different manner by some  in-
fluences to that which is  commonly experienced.   Thus, some persons
are attacked  by asthma or bronchitis on inhaling  the odor  of hay;
some are almost poisoned by taking the  smallest dose of  a  mercurial.
One at least  has been  mentioned (by Dr. Prout)  who  could not  eat
mutton  in any form without being attacked  by violent vomiting and
diarrhoea.  In such persons the qualities and endowments  of one or
more organs must be essentially different to those of the same parts in
the vast majority of mankind.  Yet there is not the  least reason  for
supposing that, by any scrutiny, we could detect any structural  differ-
ence, and they must, therefore, be deemed instances of aberring  func-
tion.
  One remarkable instance it seems worth while to adduce here, which
affords an excellent illustration of the connection that may obtain  be-
tween disordered function and  alteration  of structure.  The Graafian
vesicle in the  ovary, instinct with a wonderful capacity of  life, which
only needs its appropriate stimulus to rouse it into  that" activity which
issues in the production of another being, not unfrequently, as if affected
by some strange and unnatural stimulus, proceeds to develop itself into
a huge  anomalous  growth, utterly imperfect, and unlike  what,  under
normal  conditions, it should have  produced, and  yet exhibiting some
traces such as are found in no other growth of its original destiny, by
the formation of several of the natural tissues, skin, teeth, hair, nay,
even brain, &c.  Here, it seems impossible to recognize any other cause
of the organic alteration beside the perversion or aberrance of a natural
function or endowment.   The  term Diathesis  is applied  to a  certain
condition of the general system often inherited, which renders it  espe-
cially liable to some particular  form of disease; thus, we speak of the
scrofulous or  tubercular diathesis, of the gouty diathesis, and so  on.
If the diathesis or predisposition be strong, a slight exciting cause will
be sufficient to induce the malady; if it be absent, no  exciting cause
may produce any effect.   A diathesis may, therefore, be considered as
a kind of  special weakness.   Degeneration of a part or tissue  implies
generally  its  slow  and gradual  conversion  into  some  lower kind of
structure less  fitted for the purpose it has to fulfil, as when cartilage is
converted into a kind  of  fibrous  tissue; or it  may imply the  atrophy 
GENERAL OBSERVATIONS.                 37
and destruction of a part, as of the cortical structure of the kidney in
Bright's disease.   It is to be regarded in some measure as a local  in-
firmity.—As in part a corollary and conclusion to  the  above remarks,
I would subjoin the following  great practical truth which  daily experi-
ence presses on our attention, viz : that on the one hand  there is a
sound and  healthy systemic life, of  which all  the organs are or ought
to be possessed, and that, on the other  hand, there  often  comes in  its
stead, either generally or locally,  an unsound and unhealthy life, which
leads to perverted morbid action, or to  actual  decay.   The  one is the
" vis reparatrix," or " conservatrix Naturae," withstanding  and repelling
morbid influences, sending a tide of life and vigor through  the frame,
striving to compensate for a casual  loss or  damage inflicted, and only
sinking at  last in the tranquil decline of a green old age.  The other
is  that deathward taint, infecting and debilitating the even  youthful
system, opening wide the avenues to every casual morbid  influence, in-
creasing the  power of every disease,  and decreasing the capacity of
resistance  to it; and in fine, either embittering the years of a lingering
existence,  or cutting the span  of life  prematurely short.  Well does
the physician know and recognize in his patient the two states, different
as the varieties of the latter may be.   In the  former, he confidently
anticipates a successful result; in the latter, he  prepares himself for a
doubtful, difficult, perhaps only defensive warfare.
   It was formerly a much debated question, whether diseases had their
principal seat in the fluids or solids of  the body; and each of  the two
opposed theories has at times been dominant.  At the present day, we
marvel  how men could have adopted exclusively one view  or the other,
and refused to allow to each  their  share in the production of morbid
phenomena.   There can be no question, from known physical laws, that
the blood  must, in very many cases, be the first recipient of  aeriform
noxious matters, of all such  miasmata  as those of typhus, scarlatina,
&c.   The  instant that these are drawn with the air  into the lungs, they
pass into the blood;  for it  is  impossible that the gases contained in the
blood shall not, according to the law of heterogeneous  attraction,  be
exchanged in part for those which are diffused in the air-cells and cavi-
ties of the lungs.  As little doubt can there be that the blood, as it is
the first to receive, so it  is  also the  first to  be  modified and altered
from its healthy composition by the inhaled miasm.  In the great class
of inflammations, the affection of the tissue and of  the blood must pro-
ceed pari passu: so intimately is the blood concerned in every stage of
the process, that it may almost be said both blood and tissue are alike
the seat of the disease ; but the latter manifestly has the  initiative.
Rheumatic and  gouty inflammations must, however,  be  excepted,  in
which the blood is certainly the primary seat of morbid  alteration.
Scrofulous disease, in all probability, commences in the blood, and pro-
duces  in  it a change, of  the  nature  of which we are  ignorant,  but
which issues in the  deposit of a  peculiar matter in various localities.
In diseases  arising from excess  in eating and drinking, or from  un-
wholesome aliment,  the blood in some  cases, and the alimentary canal
in  others, may be  primarily  affected.  When  we consider what  the
processes  of  nutrition and secretion  imply,  how  the  blood is a  vast 
38
FUNCTIONAL DERANGEMENT.
laboratory, in which  some  secretions  are  actually prepared, and the
materials of others;  how it  conveys to each part the nutriment  that  is
appropriate to it, and receives back in return principles  more  or  less
effete; how continually it  is receiving  supplies of new matter  from
without, and undergoing depuration by various appointed  emunctones;
in short, if we  consider how thoroughly the different solid and fluid
parts of the  frame are correlated, and mutually dependent, we  shall
perceive most clearly  that it is far more important to be fully aware of
the extreme liability,  nay, necessity, of the solids to be affected by the
fluids, and  the fluids  by the solids, and that thus the  disorder of one
part may be the exponent of the error of another, than to  attempt an
almost impossible definition  of the exact origin and site of a disease.
                FUNCTIONAL DERANGEMENT.

  We now proceed to consider the morbid alterations which are observed
in some of the great functions or endowments belonging to some of the
most important tissues of the animal frame.   These have been termed
by Dr. Williams Primary Elements of Disease; and it seems especially
desirable to obtain as  exact an  acquaintance with them as is possible,
because in these instances morbid  action presents itself in its simplest
and least complicated form.   In almost all diseases two or more of these
are variously  combined, and success in  treatment depends very much
on the due appreciation of  the  several existing elements in each <case,
and of the degree in which one or other predominates.  In a common
case of irritative dyspepsia, for instance, the sensibility of  the nerves,
the tonicity of the vessels,  and the secreting action of the follicles, are
all variously affected,  and  all  react upon and aggravate each other.
The  judicious practitioner  will  bear  in mind  the existence of all, and
will endeavor to apportion his remedies according to the predominance
of one or other.
   We shall mention first disordered states of Contractility, including
under this head the modification of it  termed  Tonicity.   This is the
property of muscular fibre,  both of the striped and unstriped varieties,
though it is manifested differently in them.  The contraction  of the
former immediately  takes place on the  application  of a stimulus, and
soon subsides; that of the  latter comes on more gradually, and is of
longer endurance.   It has been supposed  by some  that  the power or
quality was not  resident in the  contractile tissue,  but in the spinal  cord,
from which it was conveyed by the nerves to the muscles ; but this view
seems quite contradicted by observation and by analogy.  It is, however,
perfectly  true that contractility is almost always called into play by
the instrumentality of the nervous system, and that most of its apparent
disorders have really their seat in the nervous system.  Still, we believe
that there are disordered conditions of contractility itself, though  these
may sometimes have been originally produced by disordered innervation.
The principal one of these is a  condition which may be termed unnatural
mobility.   The  tissue  is so irritable that it is thrown  into action on the
least stimulus, or  even seems  almost to contract without  a stimulus. 
FUNCTIONAL DERANGEMENT.                39
At the same time the contraction is often feeble and imperfect, hurried
and irregular.   It reminds  one forcibly of the mental condition of an
anxious, restless, incapable person.  This unnatural mobility is  often
observed in the hearts of anemic patients, sometimes in those of persons
who have undergone severe exertion  without proper previous training.
It is also exemplified in the irritable bladder, which will not contain the
least quantity of urine, in that state of the intestinal canal which gives
rise to what is called lientery, and  in  some  conditions of the stomach,
where every particle  of food or liquid that  is taken is immediately re-
jected.   It seems doubtful whether contractility is ever  so exaggerated
as to amount to a morbid state, that is to say, contractility regarded in
its power of action, not merely in  its readiness of being excited.  We
might have feared that when muscles  became enlarged, and their vigor
increased  by frequent exercise, the  osseous levers which they move,
and which give them  attachment,  might have  proved inadequate to re-
sist the increased strain;  but experience shows us the beautiful adapta-
tion which provides  that,  as the  muscle hypertrophies and  its  force
increases, the bone also enlarges and strengthens  in an equal ratio.   It
may be  that in some cases of  spasm  or cramp  the contractility itself
of the part is excessive, and that it is not only the nervous system that
is at fault.
   Instances on  the other hand are numerous, in which contractility is
defective.  The weakness which we feel on first leaving a sick bed, when
we can scarcely raise our limbs, depends on  defective  contractility of
the muscles, occasioned  by long disuse.  The same may be the result
of paralysis, of rheumatic  inflammation, of the poisonous action of lead,
of tobacco, sulphuretted hydrogen,  &c.  Impaired contractility is a very
frequent cause of habitual  constipation, which may then be best treated,
as in a case recently under our care, by tonics.  The failure of repeated
purgatives in this instance  also exemplifies the truth, that, after violent
excitement, contractility loses still more its energy, and is still more
difficult to be called forth.  The failure of  contractile power in many
cases, but certainly not  in  all,  is  connected with an  actual change in
the structure of the fibre.   Of course, if this has degenerated, it cannot
discharge its  function properly, but  in other cases the failure of the
function probably precedes the  degeneration.
   Tonicity is observed in  the  striped muscular  fibre, as well as in all
the varieties of the organic;  it is what Mr. Bowman has denominated
Passive, in opposition to Active contractility ; the latter being the re-
sponse of a fibre to a stimulus, the former a constant state of tension,
or approximation of  all the points of the fibre  throughout its length.
There is no real difference  between tonicity and passive contractility,
yet it may be stated that  the  former designation is most applicable to
the contractility which is  manifested  by the coats of the bloodvessels,
and the skin.   Heat and cold are  the influences which have most effect
upon tonicity, the former producing  marked relaxation,  the latter con-
traction of the tissues which possess it.   The possession of this property,
by the bloodvessels, is of the very greatest importance ; it is intimately
concerned in many morbid phenomena, and notably in those of inflam-
mation.  When we place our  finger on a small, hard, wiry-feeling pulse, 
40
FUNCTIONAL DERANGEMENT.
such as exists in the outset of peritonitis, and other membranous inflam-
mations, we recognize a condition of the artery in  which its coats are
tensely contracted on the  stream of blood passing through it, and form
such a firm  cvlinder as not to yield to the pressure of the finger.  Here
tonicity is in excess.  The  rigid state of the walls of the arteries prevents
their yielding to the distensive force of the wave of blood thrown in by
each contraction of the heart, and hence there is  not the usual  interval
between the impulse at the chest and the pulse in the limbs.  In persons
of a sanguine temperament, tonicity is  probably in every part somewhat
excessive, the muscles are more rigid, and the pulse more firm, than is
consistent with the most perfect health; while in persons of a lymphatic
temperament the same quality is  deficient in a corresponding degree.
When  tonicity is naturally somewhat excessive, a cold, dry atmosphere,
or an easterly wind, may cause considerable discomfort and disturbance
of the  system.   The superficial vessels and the integuments are so con-
stringed, that the blood is repelled inwards in undue quantity, and the
exhaling function of the skin  materially interfered with.   On  the con-
trary,  where tonicity is naturally defective, the very  same influences
may be of decided benefit.  A case has come within the knowledge of
the writer, in which the tonicity of the cerebral vessels became greatly
impaired in consequence of enfeebled health, and much mental strain.
To such an extent  had this proceeded, that sleep  was very much dis-
turbed, and rest prevented;  as immediately on lying  down  blood was
transmitted in undue  quantity to  the brain, unrestrained by the toneless
vessels, which were felt pulsating violently.   The relief experienced in
this case on the setting in of cold weather  was most marked,  and was
clearly produced  by the diminished temperature  having aroused the
tonicity of tbe weakened  vessels.  That distressing affection which not
remotely simulates aneurism, an atonic condition of  the abdominal aorta,
is another instance of the same kind.   It is clear  that an atonic state
of the vessels must predispose extremely to local congestions, which
may often advance to asthenic inflammations; it must also be a  frequent
cause  of a varicose state  of the veins.   In those alarming, but happily
rare cases, where the slightest wound occasions considerable hemorrhage,
which  can scarcely be restrained, it seems most probable that the tonicity
of the vessels is chiefly in fault, that they do not contract as they should
when  cut across, and thus close the bleeding orifices.  The effect of cold
in restraining  hemorrhage, and  of heat in  promoting it, is matter of
common observation,  and is of course produced  by their action  on the
coats of the vessels.   The state of the pulse is  an excellent indication
of defective, as it is of increased tonicity; the soft, yielding, large vessel
has evidently its coats in a state of relaxation, and  the wave  of blood in
it is not felt till some space after the impulse at  the chest.   Nervous
influence is evidently capable  of  arousing or depressing tonicity; but it
is equally clear that  the  quality itself exists in very  various degrees.
The loss of tonicity in the vessels leading to an  inflamed part, we shall
hereafter see to be an important circumstance in the process of inflam-
mation.
   From the examination  of that great system which is the seat of con-
tractile power, we proceed to that which is  the seat of nervous power; 
FUNCTIONAL DERANGEMENT.
41
and we shall first consider its  disorders with regard to its  faculty of
receiving impressions and converting them into sensations.  This power
is termed Sensibility; it may be morbidly increased, or diminished, or
perverted ; and these alterations may be either general or local.  When
sensibility is generally excessive, the indications of it are so plain, that
it  is almost needless to  enumerate them.   The  sufferer may be com-
pared  to a  sensitive plant—shrinking from  every touch.  Every pain
or ache seems prodigiously magnified in intensity, and is described in
hyperbolic language.  The important  points to bear  in mind  in dealing
with such cases are: (1),  that real disease may coexist with this hyper-
sensitiveness, and that we must not, therefore, too  hastily ascribe all
" to the nerves;"  and (2), that  if such real disease do exist, some of its
symptoms will probably be greatly intensified to the patient's sensations,
so that we might easily be led to think the disease more serious than it
really is.   The condition now mentioned is essentially chronic; and is
to be  distinguished from that state which exists  in  cases of inflamma-
tion of the  brain, or determination of blood  thither, or an irritation of
the organ from any cause.   In  these there is also intolerance of light
and sound,  and any jar or movement is painful.  This condition, how-
ever, is never of long continuance, and is often succeeded by an opposite
state,  and is evidently dependent upon  inflammatory excitement.   De-
lirium tremens is  not properly an  instance of increased  general  sensi-
bility, as it does not appear that the nerves are  concerned  in exciting
the disorder of the sensorium.  It seems, however, so far to  belong to
the morbid  state we are  now considering, in  that it consists, certainly
to a great degree, of an unduly excited state of the sensorial centre, the
excitement, however, being  dependent  rather  on immaterial than on
physical impressions.  The  known exciting  causes of delirium tremens
are also just those which  are likely to produce excessive sensibility; they
are such as irritate and excite the nervous system for a length of time,
succeeded  by such as occasion  general  debility.  This affection,  there-
fore, with  its  occasional tendency towards  inflammatory  excitement
which it sometimes presents, seems to hold an  intermediate place be-
tween the common  chronic  habitual hyperesthesia,  and that excessive
intensity of the  function which is seen in  phrenitis, &c.   Sensibility
may be  increased  locally—a part may be  so  tender as to  be almost
unable to  bear the lightest contact.   This  depends sometimes on an
inflammatory condition of the part, sometimes on a simply altered state
of its innervation.  The illustrations of the first  are of constant occur-
rence  ; those of the second are furnished by the instances of what is
called  irritable breast, testicle, or  uterus.    The intolerance of  light,
which is so marked a feature of scrofulous ophthalmia, shows a condition
of the retina which must be  regarded  as  one  of  hyperesthesia, not
dependent  on  inflammatory  action.  It is  very remarkable that the
internal organs, which, in their healthy life, are devoid of common  sen-
sibility, should, when affected by disease, become so acutely sensitive.
Who knows aught of what is going on in his stomach, while it is digest-
ing healthfully ?  or how his gall-bladder or  intestines or ureters are
acting on,  and  transmitting  their contents ?   But let disease arise in
these°parts, and then their actions become  attended with pain, some- 
42
FUNCTIONAL DERANGEMENT.
times so severe that the like is  seldom experienced.   We are able, in
some measure, to account for the fact, by remembering that the sympa-
thetic nerves, which supply the intestines, &c, contain numerous cerebro-
spinal fibres, and also  that  the nerves, in  their course, pass through
numerous ganglia,  which probably serve, under ordinary circumstances,
as centres of nervous influence, beyond which the impressions are not
conveyed.   Diminished sensibility is not  unfrequently observed as the
result of stupor, or coma, in whatever way induced.   It is necessarily
consequent  on division of  the spinal  cord, in all parts supplied with
nerves below the seat of the  lesion; and it often occurs partially in
apoplectic or paralytic attacks.  In these, however, it is rarely so  com-
plete or so persistent as the  loss of motion.  The retina not  unfre-
quently loses its sensibility, either for  a time  or  permanently, without
exhibiting  any  trace  of disorganization;  and  there  are  analogous
instances in which deafness, more or less complete, results from paralysis
of the auditory  nerve.  The application of cold is a powerful means of
diminishing  sensibility.  Of this, we have a familiar  instance  in the
numbed  condition of the fingers which is  so frequent in cold weather.
In  this  instance, the nerves lose  their sensibility, in  consequence of
their being deprived of their usual supply of blood; the part is anemic,
as well as numb; and this arrest of the circulation again depends  on the
action of cold upon the tonicity of the arteries, which  become so con-
tracted that  they no longer transmit a free current of blood.   Here we
have a  good illustration of the dependence of the several parts and
functions one upon another.   It is, however, most probable,  or almost
certain, that cold directly tends to diminish sensibility, by its  action
upon the  nerves  themselves.   We  have  constant  opportunities  of
observing how confinement  to  warm rooms tends to induce a state of
generally increased sensibility; and how this condition is corrected and
removed by a free exposure  to  the inclemencies of the weather.   Sensi-
bility may be perverted in many various ways.  Persons suffering under
cerebral  affections, either functional  or organic, experience sometimes
peculiar sensations in different parts of their bodies.  These may resemble
the crawling of insects over  the surface  (formication), pricking with pins
and  needles, tingling, &c.   Pruritus, and all the  varieties of itching,
must generally be referred to a peculiar alteration of sensibility in the
nerves, distinct from that which is produced in them by common inflam-
mation.  In the severest forms of this  affection, no inflammation at all
is present.  It is interesting to observe that itching may be dependent
simply on a  disordered crasis  of the blood, or the presence of  some
unnatural element in this fluid.  Thus in jaundice this  symptom is fre-
quently observed, and is doubtless occasioned by some biliary constituent
being absorbed from the liver,  and carried  along with the blood.   Pain
seems to be properly included  also under the head of perverted sensi-
bility, as it is certainly  something more than simply exaltation of this
endowment.  On this ground we may refer to neuralgia, and especially
to the affection called tic douloureux, as affording the extremest instance
of perverted and also  exalted sensibility.   The affected part may be
sometimes the peripheral; more often, probably, the central.   However,
in neither case does there appear to be  any alteration of structure that 
FUNCTIONAL DERANGEMENT.
43
could account for the disease.1   This instance, and that of pruritus, are
especially worthy of notice.  They seem to  afford us strongly-marked
examples of extreme disturbance of a single function, without any com-
plications,  and  unattended by any discoverable  lesion  of structure.
Another circumstance worthy of remark, with respect to altered sensi-
bility, is that the symptom does not always manifest itself in the part
which is the  seat of irritation,  but in some other, at a distance.  Thus,
severe headache is occasioned in some  persons by taking some article of
food which offends the stomach.  Pain in the knee is  a well-known
symptom of  disease of the hip joint;  and pain at the extremity of the
penis, of a stone in the bladder.  No satisfactory explanation of  this
fact has yet  been given;  but it seems most probable that the impres-
sion transmitted to the centre, there affects,  in some unknown  way, the
contiguous extremity of the nerve of the part to which the sensation is
referred.
   Another function of the nervous system, of its  central organ, is that
of Voluntary motion,  and this also is  subject to morbid alteration.   In
mania and delirium, the power is sometimes  extraordinarily intensified,
so that  a naturally weak  person may  resist  the force of several strong
men.  Great mental  energy and powerful emotions also increase the
power to a great  degree.  The  brain in such conditions may be  com-
pared to a highly charged and constantly acting electric battery.  On
the other hand, debilitating and depressing causes, congestion, narco-
tism, or stupor, impair the voluntary power, as also sudden  alarm, or
great anxiety.   To speak of the paralyzing effect of terror is scarcely a
metaphor.   Instances of perversion of this faculty are found in various
strange  affections, more or less allied  to hysteria, such as the tarantula
dance,  certain  religious  ecstasies,  and the cataleptic  state.   Partial
defect of voluntary power is very commonly observed as  the  result of
interruption  of the transmission of nervous influence to the part.  Thus,
if the dynamic  mechanism of  the centre be damaged by apoplexy, or
the  texture of the cord be destroyed, or a nerve  subjected to  atrophic
pressure, paralysis more or less complete of the part must take place.
But there are certain  cases in  which there is no reason to imagine that
any disease of the nervous system exists, yet affected with more or less
complete paralysis of  some part.   To such the term hysterial paralysis
is applied; they are rather diseases  of the mind or emotions than of
any part of  the bodily frame.   It is very important to be aware of the
existence of  such diseased states, both for the sake of avoiding  errors
in treatment, and also that we  may estimate aright the wonderful in-
fluence  which our immaterial is  capable of exerting upon our  material
organism.
   That property of the spinal  cord  and its prolongation upwards within
the  cranium, by virtue of which an impression communicated from an
internal or external surface occasions a motor impulse to be  conveyed
outwards along corresponding nerves which are  distributed to certain
muscles, is liable to be morbidly affected, and thus to become the cause

  1 Dr. Romberg, however, has given  the details of a case in which the most severe facial
neuralgia was caused by disease of the origin of the fifth pair. 
44
FUNCTIONAL DERANGEMENT.
of some of our gravest and most fearful  maladies.   The conception we
have to form of this power is the following:  The gray matter contained
in the spinal cord, medulla oblongata, and associated cranial gangliform
masses, constitutes a great system, which Dr. Marshall Hall terms the
true spinal, as distinguished from  the  cerebral, the latter consisting
especially of the hemispherical ganglia.  Now, whereas voluntary motion
is produced by the will  operating a certain  change in the gray matter
of the hemispheres, which change communicates an impulse to the inter-
woven  nervous filaments, to be conveyed by them to the point of origin
of the  nerve to be affected, and so along this to the  muscles, the mode
in which reflex  action takes place is different.   A  change, generating
an  impulse, is also  produced in the gray matter;  but it is not in the
gray matter of  the hemispheres, but in  that  of some part of the spinal
centre; and the excitor of the change  is not  the immaterial mind, but a
physical change in  some centripetal  nerve,  induced by some stimulus
applied to its extremity, and propagated along it to the point where it
is implanted in the dynamic centre.  The motor impulse thus excited
may affect some adjacent muscular nerve, or  be communicated to others
implanted in some other part of the  spinal centre.  The use of this
power  is clearly for  the  constant maintenance of  certain  muscular
actions, necessary to life, and the protection of important parts, which
could not have been left to the uncertain agency of volition.  In a cer-
tain part of this centre, that  termed the mesocephale, emotional  im-
pulses  appear to be  particularly resident, and to be  called forth by the
nerves herein implanted.  In the natural  condition, scarce a single reflex
act takes place that is not attended with sensation. The same impression
that determines the movement, takes  effect  also as a sensation; but if
the communication with the hemispheres be cut off, or consciousness be
suspended, the reflex actions take place  quite independent of sensation.
So also the will has power over many of the muscles, which are under
the sway of reflex action;  but if volition be cut off, the actions are still
carried on, nay, they cannot be prevented, by any exercise of the  will.
Reflex action may thus  be  regarded as an " imperium in imperio," and
as  absolutely dominant  within its own territory.  To the  power of re-
acting upon motor nerves—i. e. of generating an impulse within itself,
on  the reception of a centrifugal impression, which resides in the spinal
dynamic matter—Dr. Todd has given the name of polarity.   The term
is an  expressive and convenient one,  and we shall adopt it.  Now this
power  is capable of being enormously  increased, both as regards its sus-
ceptibility of being aroused by stimuli, and also as to the extent in
which  it is  exerted, and the potency of its action.   Under ordinary
circumstances, the voluntary muscles  are, speaking  generally, exempt
from its influence; but in  some  diseases they are so  overmastered and
controlled by it, that the will is almost powerless over them.   At the
same time the  polar  susceptibility is  so greatly increased, that every-
thing,  even  a  breath  of air, operates as a  stimulus, and  the dynamic
matter, like a  powerful battery, discharges its impulses  with terrible
force through the motor nerves upon the muscles.   This  condition of
the spinal centre can be  produced artificially  by the administration
of  certain poisons, especially strychnine, which seems, indeed, when 
FUNCTIONAL DERANGEMENT.                45
given in  a sufficiently large dose,  to exalt the  polarity immediately
on its reaching the cord.   In Mr. Blake's experiments, twelve or six-
teen seconds only elapsed from the time when the  poison was injected
into  a vein, until convulsions commenced, the  proof of the cord having
been already affected.  This  fact,  as well as results  of Dr.  Todd's
examination of the spinal, cords of animals who died from the effects of
strychnine, show conclusively  that  inflammation  has  no  share  in  the
production of the phenomena, and  that  the  essence of the malady is
purely  an  unnatural exaltation  of  the  normal  polarity.  Tetanus,
whether idiopathic or traumatic, is precisely identical with the condition
induced by strychnine, and, like it, proves fatal, either  by utter gene-
ral exhaustion, or by unrelaxing contraction of the respiratory muscles,
and  consequent  suffocation.   Chorea is  an analogous  state, in which
volition and the spinal polarity seem to maintain a  doubtful contest for
dominion over the muscles, which  are  usually subject to the will.  Hys-
terical  convulsions are often dependent on some cause of irritation in
the intestines.   The impressions conveyed from hence excite the unduly
susceptible emotional centre; and  while they produce  the peculiar
psychical  phenomena, are  also reflected  upon the muscles in impulses
to convulsive action.  In  eccentric epilepsy,  the mode of causation of
the attacks is essentially similar;  but it is probable that a different part
of the spinal centre is affected.  It is possible  that, in centric epilepsy,
the  attacks  depend on  a  periodical exaltation of  the polarity of  the
centre, in consequence of which, as in tetanus, the slightest impressions
excite the most powerful motor impulses.  In  early infancy, the cere-
bral system has not acquired that predominance over the spinal which
it is subsequently to attain; and,  moreover, the process of dentition, as
well  as the delicacy  and  susceptibility  to disorder  of the intestinal
mucous membrane, seem both  to excite the polarity of the cord, and to
furnish causes of irritation, which, acting on the excited centre, occasion
the  convulsions which are so  common a  manifestation of nervous  dis-
order in children.  One very frequent and important instance of  this
kind of  disorder  deserves particular  notice.  Delicate  and  weakly
children  not uncommonly are affected with  spasmodic contraction of
the  glottis, more or less  complete.   In  its slighter degrees, this pro-
duces a kind of crowing sound, from the rush of air passing  through
a narrowed orifice.  In its extreme degree,  the  glottis is completely
closed; no air can be drawn into  the  chest, and the countenance turns
livid.   In this state death may occur, or  the spasm may suddenly relax,
inspiration be effected, and  the imminent peril escaped.   The system,
however, remains in the  same state of polar tension, and life is in serious
danger from the frequent  recurrence  of such attacks, any one of which
may prove fatal.   How obscure would be the pathology of this disease,
without the clear  light which Dr. Marshall  Hall's discovery has shed
upon the subject!  He points out how it originates in the trifacial nerve
in teething, in the pneumogastric in over or improperly fed infants, in
the  spinal nerves, in cases of constipation, intestinal disorder, or cathar-
sis.   These act through the medium of  the  spinal centre, from which
motor  impulses are reflected upon the inferior laryngeal, and, in some
cases, perhaps, on the intercostals and phrenic nerves  also.  It  is worth 
46
FUNCTIONAL DERANGEMENT.
 remarking, that general debility, which increases sensibility, seems also
 to favor the increase of polarity.  The condition of grave inflammation
 is not that which seems most to promote the occurrence of reflex phe-
 nomena.  The cough,  in a case of pneumonia, or pleurisy, is often not
 nearly so distressing as that which follows upon some  trifling catarrh,
 when some flake of acrid, irritating  mucus, is lodged in the follicles of
 the upper part of the trachea, or larynx, and not being easily detached,
 keeps up a  perpetual excitement  of the  incident nerves, which  is
 reflected upon the motor to the expiratory muscles in ceaseless impulses
 to cough.   Many other instances might be referred to, but enough has
 been  said to show that the  idea of polarity and its disorders should
 never be absent from the mind of the rational physician.   Instances of
 defective polarity  are  not  unfrequent, though less striking  than  those
 of increased.  Such a state is observed in some cases of fever, where the
 blood seems incapable of maintaining the natural power of the medulla,
 in consequence of which the impressions conveyed by the pneumogastric
 are feebly responded to, and require  the occasional assistance of volun-
 tary inspiratory efforts.  The  same is observed in some diseases affect-
 ing the head, and hence this peculiar kind of respiration has been called
 cerebral.  The following quotation, from Dr. Williams's work, contains
 all  that can  be said  upon the subject:  "A failure of this function,
 similar in kind, but less  in degree, is exhibited in all states of ex-
 treme debility, whether from  excessive fatigue or excitement, or  from
 directly depressing and sedative influences, as in  adynamic fevers.  A
 person in this state is  too  weak to sleep, for the medulla, partaking of
 the general exhaustion, cannot  maintain the respiration without assist-
 ance from voluntary efforts.   Hence  the feeling of oppression and the
 frequent sighing, which banish all repose;  or if sleep do occur, it is dis-
 turbed by startings  and  fearful dreams, occasioned by  the  painful
 sensations of imperfect  breathing.
   Derangements of Nutrition  and Secretion  certainly  constitute pri-
 mary elements of disease.   Of the former, we shall speak  particularly
 when  we describe  the  various degenerations that affect the  different
 organs.  The latter will be considered in detail under the head  of the
 several secreting organs and their respective products.   We shall  now
 only offer a few general  remarks on  these  derangements and their
 effects.  Nutrition  and secretion  are evidently in great measure  pro-
 cesses  of identical nature.   The chief difference is, that in the latter
 a considerable part of the nutrient supply  is conveyed out of the organ
 by tubular channels, more or  less altered from the form  in which it
 exuded from  the  bloodvessels.   The  processes of secretion in  the
 different instances presented by the  system are not all exactly alike
 the pulmonary secretion, and  the urinary in  part, seem  to pre-exist
 ready formed in the blood;  the biliary and the gastric,  as  well as the
 seminal, must be formed in their respective glands.  It seems probable
 however, that in all cases an appropriate blastema is requisite for the
 due performance of the function of the  organ, and  that this contains
 either the secretion ready formed, or  principles which are in course of
 change, or ready to change into it.  Part  of the secreting  process is
therefore, accomplished in  the blood,  part in the  several glandular 
FUNCTIONAL  DERANGEMENT.
47
organs; and the proportion which these bear  to  each other varies in
different instances, and perhaps to some  extent in  the same.   In nutri-
tion, there seems scarce any reason to believe that the tissues produce
any very considerable change  on the blastema supplied to them, the
sarcous elements of  muscle are but slight modifications of albumen, the
bones receive phosphate of lime ready formed in the blood, the nervous
matter is chiefly a compound of oil and albumen, the various  pigments
are probably modifications  of that  of the blood-globules;  and  even
those which depart most widely from the composition  of the blood, the
various gelatin-yielding tissues, may fairly be regarded as having no
very  distant connection with  the Protein compounds.  Now  it is a
point of prime importance to  remark, that, in both the nutritive  and
secretive processes, the failure  or imperfect performance of the function
in any one  instance produces  an injurious effect on the circulating
blood.  For the nutrition of  a  part does not imply merely the with-
drawing of a certain amount of Liq. Sanguinis, and  its appropriation
to that part, but the separation of a fluid  differing qualitatively more
or less from the general current, in  consequence of which certain ele-
ments are  retained  in, and become, therefore, more  abundant in the
blood.  Now if the proper selection  of material does not take place in
the maintenance and repair of different  tissues, it is manifest that the
composition of  the blood  must be altered.  Again, nutrition involves
the decay  of tissues, and the reabsorption into the blood of their effete
parts;  from which it is clear that, on the due performance of what Dr.
Prout calls secondary destructive assimilation, the healthy condition of
the blood  is in part dependent.  No  doubt there  are physiological
limits, within which the nutrition of different parts  may vary; but if
these  are  exceeded, disorder,  first of the  blood, and subsequently of
other parts, must ensue.   It is difficult to point out  positive examples
of disease arising from such causes, but  it seems right to refer to them,
as they may probably lie at the bottom  of many obscure and  ill-defined
morbid states.   With respect to the secretive processes, we have familiar
instances of their disorder producing injurious, effects  on the blood, and
through it, upon other parts.  If the liver become sluggish in its action,
and bile is not properly excreted, the countenance betrays by its tinge
the unnatural state of the blood, and the loss of appetite and headache
testify that the stomach and the brain are secondarily affected.  If the
texture of the kidney be spoiled, and the  secretion of urine  in conse-
quence be seriously interfered  with, the  urea is retained in the blood,
and this fluid becomes thus so  altered in its composition, that the red
globules are no longer properly developed, and the patient presents a
sallow, anemic  aspect, while at the same time inflammations  are ex-
ceedingly  apt to arise in various parts, owing to the disordered nutrition
induced by the  unhealthy blood.   If the  secretion of a  gland be
greatly increased, though of  perfectly natural composition in itself,
this  increased  outflow becomes a drain upon the system, and  thus a
cause of debility.   Diabetes may be referred to in illustration  of  this,
as  although an unnatural substance, sugar is added  to the  urine, yet
its' own composition is not materially altered.  Another very striking
instance is afforded by cases of asthenia lactantium, the continued drain 
48
FUNCTIONAL
DERANGEMENT.
 from the mammary glands exhausting the frame and all the vital ener-
 gies in a fearful manner.   Secretions excessive in  quantity, and more
 or less unnatural, also produce great debility; of this, we have frequent
 examples in profuse diarrhoea  or  leucorrhoea.   The material  of these
 fluids is of course so much withdrawn from the circulation.   Unnatural
 secretions often produce irritation  and disturbance  of parts with which
 they come  into contact.   Thus  acrid bile produces  severe  diarrhoea;
 diarrhceal  and leucorrheal discharges often  excoriate the  integument
 around their respective outlets, highly acid urine causes a sensation of
 scalding  in the urethra, or even may give rise to attacks  resembling
 nephritic colic.  Deficient quantity and disordered quality  of a secre-
 tion, often  go  together; thus scanty urine is generally morbid in  some
 other  respect; the  opposite  condition, however, is  quite as  frequent,
 and the  secretion, though plentiful, is very unnatural.   Of the latter
 condition we have examples in debilitated  persons who pass  large quan-
 tities of  pale,  alkaline urine, containing triple phosphate.   The former
 state is constantly observed in  the commencement of various febrile
 affections.   The nervous system has a considerable influence  over the
 various secretions.  Great agitation has been known to cause a mother's«
 milk to assume a poisonous quality, or such,  at least, as  to occasion in
 a few minutes  the death of the infant.   A similar cause  has produced
 jaundice  rapidly in  some  persons,  and in others a bilious  diarrhoea.
 After an  hysterical fit, a  large  flow of pale, almost  aqueous, urine is
 passed.   A flow of tears is the  natural  effect of the  passion  of grief,
 and a flow of saliva of the expectation of  a  meal.   Appetite is imme-
 diately destroyed, i. e. the secretion of gastric juice arrested, by sudden
 distressing  intelligence.   The lessons which these  facts convey  can
 scarcely be too much appreciated.   They show  us that we must never
 forget the wonderful but intimate  connection that  exists between  our
 material and immaterial part, and that it  is  fruitless  to  strive against
 the incessant influence  of  a down-weighed or wounded spirit  by doses
 of drugs.   These cannot "cleanse  the stuffed bosom of that perilous
 stuff which  weighs upon the heart."   Instances are occasionally met
 with, in which  some secretion is manifestly unnatural, and yet there is
 no constitutional disturbance.   It  appears as if some morbid  matter
 were carried off by this channel, the removal of  which left the system
 in health.  Of this kind  are  cases of fetid secretion from the feet,
 some of oxalate of lime in the  urine, and perhaps  the  naturally foul
 breath which is  habitual to some  persons.   It is very probable  that
 several  disorders, among which  may  be particularly mentioned gout
 and  rheumatism, essentially depend, partly  on  a mal-performance of
 that part  of the function of secretion which  takes  place  in  the blood
 and partly upon defective  elimination; so  that various effete  matters'
 not undergoing those  oxidating  changes which  they normally should'
 and being, instead, partly converted into other more noxious and un-
 natural  principles, circulate in  the blood for some time,  producing
 general uneasiness and malaise,  and, sooner or later, break  out in an
eruption of morbid matter,  by the skin, or some other emunctory.   The
gouty paroxysm, with  its foregoing  ill-health, is the rtapaonyua of this
condition.    It is also illustrated  in  rheumatism, and  more  or  less  in 
FUNCTIONAL  DERANGEMENT.
49
other morbid states of the  system, to which the appropriate name of
Excrementitious  Plethora  has been  applied.  Dr. Williams  observes,
that he has often found purpura connected with hepatic congestion  and
imperfect excretion of bile, and most effectually removed  by remedies
which promote the restoration of the  proper  secretion.   It is not  un-
frequently seen that the sudden arrest of a secretion, though it be  a
morbid one, which  has continued long, and produced a  considerable
drain on the  system, is attended with serious, nay, even fatal effects.
These probably depend on the establishment of a condition of plethora,
not, indeed, such, as  under ordinary circumstances  would deserve  the
name, but which  is  felt as  such  by the debilitated, and perhaps  sensi-
tive,  system.   When this state exists, local congestions are very apt to
occur, and may end in fatal extravasation of blood in the brain, if that
be the part affected.   If the natural  secretion of a gland be in  any
way greatly diminished, a  state  of congestion of  the organ is very apt
to follow; the converse occurrence also is often observed, and it is  not
by  any means always to be discerned clearly which of  the  two is to be
regarded as the cause, and which as the effect.   The temperature of a
part  whose natural secretion is arrested, is almost always  higher than
natural.  No more marked instance can be mentioned  of this than  the
skin  in many fevers.   Remedial means,  which diminish the quantity of
blood in a congested part,  often restore  or increase the secretion which
had been  interrupted ; and conformably to  this, we often observe in
cases of profuse  abnormal secretion, that  the  surface  from which  the
flux takes place,  instead of being red with blood, is unnaturally pale;
the contents of the vessels seem to be drained away  as fast as they
arrive;  so that one is almost reminded  of the old theory of exhalant
arteries with open mouths.
4 
CHAPTER  II.
               MORBID  STATES  OF  THE  BLOOD.

  The  saying attributed  to  Cuvier, '" Le  sang  est  chair  coulant,"
expresses  very fairly the  relations that  subsist between  the  nutrient
circulating fluid and the solid tissues.   As we have already remarked,
a change  in  the former involves almost necessarily a change  in  the
latter, and each of  the vital  actions of the latter exerts some influence
on the former.   It is manifest, therefore, that an acquaintance with the
healthy properties and  morbid alterations of  the blood is absolutely
essential to a correct study of the phenomena wrought by disease in the
solid parts.  But the blood itself is a very compound thing, not only as
regards the number  of different matters it  contains, organic and inor-
ganic, not only as regards the manifold additions which it receives from
without in the way  of nutriment, and  those which are poured back into
it as the effete residues of tissues, but also as regards  its own morpho-
logical  condition being made up  of solid and of  fluid  parts, of  organ-
ized particles floating in an  organic liquid.  In diseased  states of the
blood  these  several  parts,  or  some  of their  constituents,  may  be
separately affected,  and it  seems, therefore,  desirable on this  account,
as well as for the sake of greater precision, to examine first  the indi-
vidual component elements of this fluid with reference to  their patho-
logical  changes, and  afterwards  to consider the diseases  of the blood
taken  as  a whole.    Regarding the  blood per se, this inquiry would
rather belong to  special than to general Pathology, but we  include it
under the latter  head on account of  the manifest general relations of
the blood.
                RED AND WHITE  CORPUSCLES.

  The circulating fluid consists, as we know, of two kinds of organized
particles, floating in a transparent slightly yellow fluid.   The organized
particles are the red globules, preponderating immensely in number, and
giving to  the fluid its characteristic  color, and the white or colorless,
which in the healthy state occur somewhat " few and far between," and
impart to  the general mass no distinguishable quality.
                          Becquerel and Rodier.
	In Males.	In Females.
Corpuscles, red and white	. 141.1 .	. 127.2
Water ......	. 779.0 .	. 7'Jl.l
Fibrin......	2.2 .	2.2
Albumen .....	. C<>.4 .	. 70.5
Fat, extractive, salts	W.4 .	y.o
1000.        1000. 
RED AND WHITE CORPUSCLES.
51
  The red globules are vesicles having a distinct homogeneous envelop,
which incloses a central mass of whitish albuminous matter, and a sur-
rounding film of red fluid.   Their form is circular and  biconcave, they
present therefore cupped surfaces and an 8-shaped edge.  They readily
distend  themselves  by endosmosis with  thinner  fluid  and assume a
spherical shape.  On  sudden pressure  being  applied, and sometimes
Fig. 1.
Fig. 2.
Blood-corpuscles, magnified 400 diameters.
White Corpuscles of the Blood, magnified
        400 diameters.
from  other  causes, they assume a kind of crenate form, conveying the
idea that  the central mass, the so-called globulin, is broken up into a
number of  granules, pushing  irregularly outwards, the  homogeneous
envelop.  The white  corpuscles  are much larger,  nearly  double the
size of the colored ones; they are  spherical, and may often be  seen
when a drop of blood is examined under  the  microscope, remaining
motionless and fixed in  the field, while the red  globules are hurried
along on all sides round them  by the currents which are created in the
fluid  by capillary attraction.   No true nucleus can be seen in the white
corpuscles ;' they seem  to consist of a semi-solid mass of  albuminous
matter, inclosed within a delicate envelop.   Their function  is not cer-
tainly known; by some physiologists they are regarded as constituting
together with the similar corpuscles in the lymph and chyle, transitional
forms in  the development of the red particles.  By others  they are
supposed to be  the agent in  the formation of  the fibrin,  which they
elaborate out of  the albumen, imparting to it  its peculiar coagulating
and so-called plastic properties.  The use of  the red globules is  in all
probability connected with the function of respiration ;  this seems well-
nigh  demonstrated by the facts  of comparative  anatomy, and by the
marked changes which  they undergo in the course  of the circulation.
Liebig has expressed  the opinion that they are  the carriers of  oxygen
to the various tissues, or, more  exactly, the  iron which  they contain;
this element in its protoxide form receiving in  the  lungs another atom
of oxvgen, and thereby  passing into the state of peroxide,  while in the
course of the circulation it  again  parts with the  atom  of oxygen in
exchange for one of carbonic acid, and thus passes into the  state of pro-
  ocarbonate.  This view may be  in  part true  but is  doubtless too
exclusive;  there is as much reason  to suppose  the Liquor  Sanguinis to
be the'vehicle of the oxygen  and carbonic  acid, as  the red corpuscles.

   . Acetic acid brings into view, or produces one, two, or three granules similar to those
 contained iu the pus cell. 
52
RED AND WHITE CORPUSCLES.
Mr. Wharton Jones believes that the red  globules elaborate the fibrin,
or rather are transformed into it, bursting and dissolving like secreting
cells.   Various plausible arguments have been advanced in support of
this view,  which was first propounded by  Dr. Simon, of Berlin, and is
adopted also by Wagner and Henle; but  it does not appear  to  the
writer  that  it can be  considered at  all established.  Neither on  the
other hand can Dr. Carpenter's  be considered proved, though the pre-
ponderance of testimony seems on  the whole to be in its favor;  nor is
there, in short, any positive cause to forbid us to believe that the truth
may lie intermediate,  and  that  the production of fibrin  may be  one
result of  the general  cell growth  taking place in  the blood.   With
respect to the red globules, however, this is certainly proved, that their
amount is,  ceteris  paribus, proportionate  to  the vigor,  health, arid
strength of the individual.  In the examinations made by MM. Andral,
Gavarret,  and Delafond, of the  blood of  various  animals, it was  con-
stantly observed that those which  possessed most  strength and vigor,
and were generally the finest  specimens of the race, gave  the  highest
figures in  a series showing the relative amounts of globules ; while those
that were  debilitated  and poor  showed a corresponding  deficiency in
this  particular.  Also, when  the breed  of a species was improved by
crossing  it with  another, there  was  a  corresponding increase  in  the
quantity of red particles.  In the human subject, the comparison of the
general vigor and activity of the  sanguine temperament, both as regards
body and  mind, with  the sluggishness and  dulness  of the lymphatic
temperament, or with the languor and  debility of the anemic patient,
show that  the same rule holds good.  In Prevost's  and Dumas's experi-
ments, animals near death from loss of  blood, were recovered by an
injection into their veins of a  mixture of red particles and serum.  The
serum alone had not this effect.   The proportion of  red globules dried
to 1000 parts of blood, is in  healthy males estimated  at 127  parts by
Andral and Gavarret; lower and higher figures  have been given by
other analysts, but this  probably is the result of somewhat  different
modes of  proceeding.  In females  the proportion  of  globules is lower,
Becquerel and Rodier make the difference to  be about 15  parts per
1000.   The blood of  the foetus appears  to contain an unusually large
amount of globules, stated by Denis in the proportion of 222 to 140 of
maternal; after birth this gradually diminishes.   Plethora is the chief
pathological condition in which  an increase of red  globules has  been
observed.   One of the cases of cerebral congestion mentioned by Andral
presented an amount of  138, 6  parts per  1000, an excess  of 11 above
the normal figure; after venesection, the  globules in this  case were so
far diminished that  the quantity only amounted  to  101, 1 per 1000,
considerably below the mean.  In  various febrile  diseases, an augmen-
tation of the globules has also been observed; thus, in the period imme-
diately  preceding the outbreak  of continued  fever,  their  amount'was
once found as high as 157.7  ; in the early period of a case of severe
inflammatory fever, the  fourth  day of the disease, the globules  had
attained the extraordinary height  of 185 parts per  1000, the greatest
amount ever observed ;  in several cases  of typhoid fever (fever with
intestinal  complication) the globules had risen to  142 or even 140, and 
RED AND WHITE CORPUSCLES.
53
even on the second bleeding were found still  considerably above  the
mean; in scarlatina and in measles  an increase  in  the  amount of
globules was also found,  the  maximum (which existed  in  the  latter)
being as much as 146.  No increase was observed in cases of variola or
of modified  smallpox.  The condition of the general system coexisting
with, and probably occasioned by, the increase in  the  amount of  red
globules  is exaltation of the animal heat, heightened  sensibility,  and
muscular irritability ; the spirits are high, and the mental energy great,
the pulse beats full and firm, the power of resistance to debilitating and
morbid influences  is considerable, the tendency in disease  is to active
inflammation and high febrile excitement, and bleeding, if employed, is
well borne.   Probably, a chief cause of danger when the amount ot red
 globules is considerably increased, is the simultaneous diminution  or at
 least non-proportionate increase of the fibrin; hence arises a liability
 to serious hemorrhages  in  the brain or other parts.   The effect of  iron
 in promoting an increase of the red globules is well known, but it will
 often fail where the  attendant circumstances  are  unfavorable, and we
 have  seen a much more rapid  effect produced  by the change from a
 scanty to an ample diet.  Free exposure to fresh air and light seems
 also powerfully to promote  the formation of red blood, as much as the
 deprivation of them tends to destroy it.  The opposite condition to ple-
 thora, for which the term spanemia («*«»oS, scarce) is more appropriate
 than anemia, is essentially characterized by a deficiency in  red globules.
 Extreme cases of this state are by no means unfrequent, and, which is
 not sufficiently known, are by no means unattended with serious danger
  Sudden death has in several instances taken place apparently from the
  cessation of the heart's action, the debilitated organ  being ^sufficiently
  stimulated by the impoverished blood.  In an extrem.case of ch orosis
  Andral found  the globules at so low ani amoun _as 38.7 pei  1000 the
  water at the  same time being  increased from  790  to 808.7.   bimiiar
  S rat] ns we e found in the blood of other individuals who had become
  anemic from other causes,  from lead poisoning, the cancerous or tuber-
  cX cachexia.   In Bright's disease, there is evidently a marked failure
  in the power  of producing red globules, and the same  is the case in the
  pecdla? rfectiontermed leucocythemia, which either depends on, or is
  ^incidentwith, great hypertrophy of the spleen.   We are inclined to
   link that in spinemic sties the red globules are not only deficient m







   SrSb ^:Si ^sa™ 28= 
54
RED AND  WHITE  CORPUSCLES.
haematin to the surrounding fluid.   The red globules, as has been men-
tioned, are very liable to be affected by the fluid in which they float;  when
this is dilute, they distend themselves by endosmosis, and become spheri-
cal, while the mass at the same time assumes a dark red color.   By the
addition, however, of concentrated saline solutions, the bright red color
is again restored, and the corpuscles again assume their biconcave form.
When carbonic acid  is  added to arterial blood, the corpuscles  change
their biconcave for the biconvex form,1 and  the color at the same time
changes from red to black.  On these facts, Scherer and Nasse maintain
the theory  that the alteration of color in the blood which is effected in
the lungs, depends upon an alteration in the form of the corpuscles, the
biconcave disks acting  as concave mirrors, which collect the reflected
rays instead  of  dispersing them as convex surfaces do.  Whether this
theory be true or not, the facts it records  are certainly worth remem-
bering, as a distended state of  the  corpuscles, by whatever  cause  occa-
sioned, must  greatly increase  the  liability to the  occurrence of  local
congestions.  When the  fluid  in which  the  corpuscles float is  more
aqueous  than natural, the red fluid which  they contain passes out of
them by exosmosis, and mingles with the serum.  When this is the case,
the walls of the vessels,  and the tissues in immediate contact with them,
very commonly become saturated with a red color,  which must be  care-
fully distinguished from  that which  accompanies  inflammation.  The
effect of  diluting the  Liquor Sanguinis upon the  blood-globules is
exceedingly well shown by an experiment performed by Mr.  Lane.   An
animal was bled,  and the serum, after the formation of the clot, was, as
usual, colorless, or of a light yellow;  a certain quantity of  matter was
then injected into the veins, and soon after  blood was again  drawn.
The serum of this, however, was of a decided  red, contrasting strongly
with that of the preceding quantity.  It was, therefore, quite clear, that
the hsematin  had been removed from the globules, and  dissolved in the
serum.  We  have observed  the same thing with the microscope in the
blood of  frogs, and  in that of foetal vertebrata.   When the globules
have not been exposed to the action of water, or only in a slight degree,
the space between the envelop and the nucleus is  filled with red  fluid,
which almost or entirely conceals the latter; but when water has been
freely added, the red fluid entirely disappears, and the nucleus comes
clearly into view.  It seems very probable, as Dr. Williams suggests,
that the instances of sudden death occurring immediately after copious
draughts of cold water in an exhausted state of the system, have been
in some measure owing  to such alterations of  the blood-globules, as  we
have just noticed.   The  same changes may also be  concerned in the
phenomena consequent  on excessive losses of blood, especially in  occa-
sioning the local congestions which are apt  to take place in them, and
in the anemic generally.  The red globules of  human blood exhibit a
tendency to cohere  together in such a manner  as to form tolerably
regular piles, or rouleaux; in the healthy condition the cohesion soon
ceases, and is not nearly so strongly manifested as  in the inflammatory
state.  Of this, indeed, it is quite characteristic that the globules form

 1 The authors of the Physiological Anatomy, however, do not confirm this statement. 
RED AND WHITE CORPUSCLES.
55
Blood-corpuscles, magnified 400
rows of some length, made up of numerous disks cohering together by
their surfaces, and having their edges disposed
so as to form a  tolerably straight line.  The
cause of this tendency  is not certainly  ascer-
tained, but the phenomenon seems  to give some
countenance to the opinion of Mulder, that the
red corpuscles become invested in the lungs with
a film of oxidized protein matter, which is found
more abundantly in inflammation, and may cause
the  adhesion of  the particles  to each  other.
There must, howTever, be some further reason
why the disks should so exactly  adapt  them-       "^meters?
Belves to each other face to face.
   While so much uncertainty prevails respecting the origin of the red
corpuscle,  it  is not possible to point to any foregoing  condition as
specially tending to promote  their growth and increase, or to occasion
their atrophy.  All that can be said is, that a proper constitution of
the  Liquor Sanguinis is certainly  essential, as being the  material out
of which these floating cells are nourished and built up.  If this be im-
poverished, or otherwise deteriorated, the corpuscles will not be properly
developed; and again, by improving the quality of their plasma, their
healthy condition will be restored.   Of this, we have a good example in
those cases of chlorosis, where the administration  of iron is  sufficient
to reproduce the ruddy hue of the  complexion.  In other cases, a de-
fective state of nervous influence,  proceeding from some mental affec-
tion, occasions the  atrophy  of the red particles; but we  cannot tell
whether this cause acts upon  them primarily, or, as is more  probable,
throuo-h the medium of  other organs and functions.   There  can be no
doubt that the blood-globules have an appointed  period  of  existence,
after which they naturally decay.  This decay probably takes place in
the general course of the circulation, at least in part.  Evidence, how-
ever, has recently been  adduced to show, that the  spleen  is  especially
the  seat of a destructive process, affecting the  globules ; and that the
yellow pigment matter, 130 frequently found in this organ, is, in fact,
the  remains  of their altered hsematin.   In the liver, also, the blood-
globules seem to yield up their  coloring matter, to furnish the  yellow
pigment of the bile; and the coloring matter of the urine is no doubt
derived from  the  same source.   The circumstance that so  much  pig-
mentary matter  should, by these  two channels, be ejected out  of the
system, shows, on the supposition  that it is derived from  that of the
red  globules,  how rapidly the latter must undergo  decay ;  and, by con-
sequence, how fast their reproduction must take place.  It is worth re-
marking,  that  one drug, the most  commonly  used, perhaps,  of all,
seems to have almost as much tendency to cause the destruction  of red
corpuscles, as iron has to promote their formation.   This is  mercury,
under a  course  of which, as  Dr. Watson  mentions,  a patient  was
blanched as white  as a lily, who  previously had a  complexion com-
pounded of the rose and the  violet.  The non-depuration of the blood
mass exerts an injurious influence upon  the development of the red
globules, as well as upon its other constituents.   The effect of some 
56
RED AND  WHITE  CORPUSCLES.
diseases of the spleen and of the uterine system, which  have been ob-
served to be especially connected with  an anemic state, may be ex-
plained on this  principle.   A  quantity  of blood  congesting, and dis-
tending the venous  channels  of the  spleen, is detained there longer
than it normally should, and becomes more or less impaired in its  com-
position and spoiled, so that when it again returns to the circulation, or
any portion of it is conveyed  thither, it acts after the manner  of a
poison upon the remaining  blood mass,  corrupting and  contaminating
it, and thus inducing general cachexia.   Suppression  of  the menstrual
discharge seems to act much in the same way, the blood not undergoing
its periodical  depuration, contains  a quantity of effete  matter, which
reacts injuriously upon it, and, after a time, produces a manifest altera-
tion from its healthy composition.
  Of the morbid changes of the white corpuscles, we know indeed very
little positively.   Their number is, we  think, increased in inflammation,
but perhaps not to the degree  that it has often been supposed to be.
Mr.  Wharton Jones remarks, that  the quantity  of white  corpuscles
existing in the blood naturally, has been  estimated at  less than it really
is;  and that, on the other hand, the  accumulation  of colorless  corpus-
cles in the vessels of an inflamed part, and in  the buffy layers of co-
agulated blood, has been referred to as proving the existence of a like
quantity in the general mass of the blood.  In blood  from  a pregnant
female in the eighth month, the quantity of white corpuscles appeared
to me to be increased,  and their contents also  less finely mottled, and
more granular than in those of ordinary blood.   In leucocythemia, the
quantity of colorless corpuscles appears  to be enormously increased,
and their size exaggerated ;  but some doubt may be entertained whether
these colorless corpuscles are of the same nature as those normally ex-
isting.   In pyaemia, Lehmann says, that the  colorless  corpuscles are
increased.  Some of those  observed, however, may have been  of  puri-
form nature.
   There does not appear  to be  any positive instance of diminution of
the colorless corpuscles.
   Having discussed the pathological changes of the corpuscles or cells
of the blood, we next come to consider those of the fluid in which they
float.  This fluid, the  Liquor  Sanguinis, consists of  a watery solution
of certain inorganic salts, in which there are besides  dissolved  a  large
proportion of organic substances.  These are  distinguished into fibrin,
albumen, extractive matter, and oil.   We shall  consider each  of  these
separately.
   When fresh-drawn blood  is left to  itself, it very soon, as we know,
passes from a liquid state  into that of a solid  mass ;  it coagulates.
This  change  can be conclusively shown to be occasioned not by the
corpuscular elements cohering  together, as was once supposed, but by
the solidification of  one of  the constituents of the fluid  portion of the
blood.   Miiller's experiment of filtering frog's blood, so as to  separate
the corpuscles, was decisive as  to this point.   The substance which thus
spontaneously solidifies is  termed fibrin, and  the  name evidently has
reference  to  an inherent  tendency which it possesses  of assuming  a
fibrous arrangement.  Fibrin,  when separated from  healthy blood, is 
RED AND WHITE CORPUSCLES.
57
a tough, tolerably firm, elastic, stringy, whitish-gray-looking substance.
It is insoluble in water, and sinks in this  fluid, or even  in the serum
from which it has been separated.   Under the microscope, it appears as
an homogeneo-granula.r blastema, or basis-substance, with more or less
marked tendency to  fibrillate, or form actual fibres.  The white cor-
puscles of the blood are very commonly seen imbedded in the fibrinous
mass, but  they  do not appear  to contribute  to modify  its character.
This, at least, is true of healthy fibrin; of diseased  we shall presently

                                Fig. 4.
   Fibrils of Healthy Fibrin, entangling red and white blood-corpuscles (three of the latter are figured
                      separately), and a few fibrinous fibrils.

speak.  Lehmann describes as follows  the actual process of coagulation
of the fibrin as  seen  under the microscope.  He  says :  '  lnere ap-
pear here and there individual points  of molecular  granules, from out
of which very soon extremely fine straight threads spring, which go ott
in a radiating manner from that point, but  do not form  star-shaped
masses, as in crystallization;  these threads elongate themselves grad-
ually more and more, and cross with those which have  proceeded from
other solid points, so that at last the whole field  of view appears  as it
were, covered over with a fine,  but  somewhat felted network.   After-
wards this network still proceeds to thicken, and the colorless  corpus-
cles imbedded in it are often scarcely  perceptible."   With regard to its
chemical composition, Lehmann remarks  very properly,  that fabrm,
such as we obtain, cannot by any means be considered  as a  pure  sub-
stance;  it must contain the white corpuscles, and probably some.amount
of albumen and extractive matter.   However,  such as we  findI it all
the chemical  difference between  it and  albumen appears to  be, that
there is a small  quantity more  oxygen in it than  in  albumen   Th s
fact  testifies  strongly that  fibrin  s  characterized  ™^ m°re by it
vital endowments than by its peculiar composition  and would lead us
lo regard it as a modification of the  albumen  of the  serum produced
for o'rnSpecial purpose.  This  may be, in part, to give to the  Au^
portion  of the blood a proper degree  of spissitude, so that the  corpus-
 cTesare better  sustained and mixed with it, and that  the circulaing
     am passes more readily through the capillary^ channels  ban it wodd
 do if it were more dilute.   One very important end  whichthe fabrm
 serves is the  formation  of coagula at the  orifice  of ™unded ^se s,
 prevent ing the occurrence of further  hemorrhage ;  and this is wellillus- 
58               RED AND WHITE  CORPUSCLES.
trated  by those instances occasionally met  with of almost  irrepres-
sible hemorrhage from the slightest wound, in which it seems  pretty
certain that their blood must be very deficient  in  healthy fibrin.  But
a still higher dignity has been  assigned  to the fibrin; it has been re-
garded very generally as the plastic material,  par excellence, from
which all the tissues are formed, and the small amount of it present in
blood was supposed to show that it was constantly being  drawn  off for
the nutrition of the tissues as fast as it was formed.   Of late years,
however, much evidence has been  adduced, which at least  goes some
way to establish an opposite view, and  throws considerable  doubt on
the correctness of the old opinion.  We will  review  the  arguments on
both sides.
  In support of the specially plastic and organizable  character of fibrin,
it is argued that it seems to be by its means that the reparation of wounds
is effected.  A thin layer of coagulating, fibrillating material is the me-
dium which unites and holds  together the divided surfaces, and forms
the first  organic connection.   So also  when a fluid containing much
fibrin is effused on the surface of  serous  membranes, it very commonly
forms bands of adhesion  passing  between the opposed layers.  These
new-formed  structures resemble very much normal, white, fibrous tissue.
There is evidence to show that layers, and even  masses of fibrin, are
capable of being organized; so far, at least, as to become fibroid tissues,
and that vascular networks are developed in them.  Andral mentions a
case of apoplectic effusion in the substance of the brain, in which—death
having occurred many years after—a mass of pale red color, and fibrous
appearance, and traversed by  numerous small bloodvessels, anastomosing
with those of the brain, was discovered.  M. Louis has recorded  the
occurrence of a vascularized  coagulum in a tuberculous cavity in the
lungs;  and many similar instances have been noticed, in which the fibrin
of effused blood has evinced its capacity for organization.   But how lowly
is this  organization ; never in any known instance amounting to more
than the formation of a fibrous tissue, more or less closely resembling the
natural.   This, almost of itself, is a proof that fibrin is not the pecu-
liarly organizable and plastic element that it has been considered to be.
It  may also be said that albumen, which is the only other organizable
constituent  of the  blood,  shows no tendency, even  when collected in
large quantity, as in the fluid  of ascites, to pass into any organized form;
while fibrin, when effused, does  at least assume  the appearance of a
lowly organized tissue.   The condition, moreover, of the fibrin seems
to be in some manner an indication of the vigor and health of the sys-
tem.   If it contracts well, and forms a firm, dense clot,  there  is reason
so far to conclude that the constitution is sthenic and unbroken; but if,
on  the contrary, the clot be  soft and easily  broken up, the system  is
probably in an opposite condition.  The above statements seem to amount
to this, that  fibrin  is certainly capable  of assuming a low type of or-
ganization ; but they entirely fail  to  show that it is the special blood-
constituent which is applied to the nutrition of the different tissues, and
that therefore its abundance is  a sign of vigor and health.
   On the other side, the counter-evidence which  we have to adduce  is
certainly of great force.   Bleeding, which  we saw to have a powerful 
RED AND WHITE CORPUSCLES.
59
effect in diminishing the quantity of red corpuscles, has none such upon
the fibrin;  nay, it  rather seemed to tend to increase it.   In Andral's
ninth case  of articular rheumatism, the fibrin  at  the second bleeding
was 7, and at the third 6, while in the first it was  5.4.  In the tenth
case,  at the fourth bleeding, it presented the extraordinary figure of 10.2
per 1000, while in  the first it did not  amount to more than 6.1.  The
globules, however, were reduced by  the three subsequent bleedings  from
123.1 to 101.0.  Starving also, instead of lessening, was found to in-
crease the  quantity of fibrin.  An increase in this  element  was found
in  meagre, half-starved horses, amounting to  as  much as 7  or 8 be-
yond the healthy mean;  and in one case,  where no  food was given for
four  days, the quantity  of  fibrin  was found  increased from 5 to 9.
On the other hand, the improvement of a  species which we found to be
marked by an  increase in the proportion of globules, seems to be also
characterized,  though less strongly, by a diminution in the quantity of
fibrin.   The average quantity of fibrin in a flock of sheep of pure blood
was determined by Andral to be 3.1; in a cross-breed flock, the average
was only 2.8.   The blood of the  foetus and of the new-born animal,
in  whom certainly development and growth  are proceeding rapidly,
and  in whom  there must, therefore, be  a  constant  demand  for plastic
material, is rich in  globules, but poor in fibrin.   Andral found in lambs,
during the first twenty-four hours after  birth, a proportion of fibrin
 only amounting to 1.9 per 1000;. at the end of the fourth day, it had
 risen to 3.0 parts.  This observation, as well  as  the familiar effect of
 diseases preventing the due  oxygenation  of the blood, in  causing it to
 remain fluid after death, which seems to imply  the non-formation or
 destruction of the fibrin, points very clearly,  as  it seems to us, to the
 conclusion that fibrin is an  oxidation-product, and rather belonging to
 the descending series of  destructive assimilation,  than to the ascensive,
 plastic, and formative.
    That fibrin  takes an important part in the reparative process cannot
 be doubted; we constantly find it forming the uniting medium between
 divided parts,  but have we any evidence that  it becomes further deve-
 loped, and passes into the form of any tissue more highly organized than
 that of the cicatrix ?  Surely, there is not the least; or rather, all that
 we know of the process of reparation tends to contradict such  an idea.
 The case  of a divided nerve serves to  illustrate this point  very well.
 Within a  short time after the operation, the cut ends of the nerve are
 united together by fibrinous effusion, which has  solidified round  them;
 this passes afterwards on into the  form of imperfect fibrous tissue,  and
 so the apparent continuity of the nerve is restored.  But we know that
 it is not  really restored until very  much later; we know that  many
 months must elapse ere the severed nerve-tubules can be again connected
 by their own  proper tissue, and  their function restored.   Now in this
 really reparative act there is no reason to believe that fibrin takes any
 prominent part, that it is at all more concerned than the albumen and
 oily matter of the blood, which are the elements chemically considered
 of which the nerve-matter actually consists.   In the same way, m eveiy
 organizing act in which there is more than the  mere coagulation ot 
60
RED AND  WHITE CORPUSCLES.
fibrin, albuminous serum is also present, and we have no reason to ex-
clude it from participating in the formative process.  Once more, if we
take instances where  deposition of  fibrin has almost exclusively taken
place, do we find development and  growth proceeding actively in these
deposits  or  not?  The well  of an  aneurisinal sac is often  lined  with
dense layers of coagulated fibrin, and yet Professor Simon testifies that,
on the most careful examination of  these layers no trace whatever  is to
be found of new organization.   So  it is with the masses of fibrin that
are deposited in the spleen, the kidney, and in other parts.   They show,
after a time, a tendency to retrograde and dissolve, but none to develop
into any higher grade.  The small, fibrinous, sub-pleural  nodules often
seen in tolerably healthy  lungs, are favorably circumstanced as regards
vascular supply, for growth and further development, but they  do not
appear to enlarge, or  manifest any vital activity.   The deposits of fibrin
upon the valves of the heart, the  wrongly-called  vegetations,  in like
manner show no innate  capacity  of  development  and  growth;  they
tend to contract and  harden, or to become  penetrated with calcareous
matter, and never show any organized  arrangement beyond a low grade
of fibrousness.
   The circumstance which seems to have contributed most,  or at  least
very highly, to  establish  the opinion  of the highly  plastic quality  of
fibrin is, that its quantity is found to be so very largely increased  in
sthenic inflammatory diseases.   Not only its appearance  in the thick,
buffy coat, but the quantity of solid effused matter,  forming layers  of
false membrane, of considerable firmness  and thickness, together with
the character of the attendant  symptoms, inspired an idea that the sub-
stance thus abounding in  these diseases of marked sthenic type, and so-
called increased action,  and comparatively  deficient  in  affections  of
asthenic type, was that which was especially plastic, and employed  in
the construction of all the various tissues  in healthy nutrition.  Dr.
Williams says of fibrin, that it is  a representative of the  active  state
of the processes of reparation, circulation, innervation, and  of those of
nutrition and reparation, and  that " it  therefore exists in larger pro-
portion and higher perfection in arterial  than in venous blood."  Dr.
 Carpenter, mentioning the solvent  power  which a solution of nitre has
upon fibrin, remarks, that this only applies to venous fibrin, and that
 arterial fibrin is not thus soluble.  As the solution of venous fibrin
 is  coagulable by heat, it appears to resemble albumen, but the insoluble
 precipitate which  it  lets  fall on exposure to the  air, seems rather to
 possess  the properties of arterial fibrin.  " Hence," he adds, "it may
 be inferred, that the  fibrin of venous blood most nearly resembles  albu-
 men, whilst that of arterial blood and of the buffy coat contains  more
 oxygen, and is more highly animalized."   We cannot agree with this
 inference, as an increased degree  of oxidation is rather  a  sign of de-
 struction than of development, at least as applied to  the tissues.  More-
 over, the facts do not seem altogether established; Lehmann says that,
 in the human subject, whether it were  taken from venous,  or arterial,
 or inflammatory blood, he has found the fibrin soluble in nitr,e solution,
 excepting two cases of inflammatory blood.  Pig's  blood fibrin, whether
 arterial or venous, dissolved equally well  and very quickly.   This sup- 
RED AND WHITE CORPUSCLES.
61
posed  difference between  arterial  and venous fibrin is not constant.
Thus much for the " higher perfection."   As to the greater quantity
which  is found in arterial blood, it may be observed, (1.) That it is quite
possible that it  is employed to feed the various excretory glands, and is
thus thrown off from the  system, so that it exists in a less proportion
in the  returning venous  current.  (2.) That if arterial blood contains
more fibrin, it contains also less albumen1 than venous,  so that, regard-
ing fibrin  as  a product of oxidation, this is  no more than might be
expected;  the  fibrin being reconverted into albumen in  the venous
blood.
   We  shall conclude this discussion as to the nature of fibrin, with the
following quotation  from  Rokitansky, whose  testimony on  this  point
cannot but be regarded  as of considerable  weight: " Considering  the
frequency  of solid  fibrinous blastemata as the basis  of pathological new
formations, compared to their rarity in the physiological condition,  and
referring also  to the predominance of the development of the tissues
out of  cells in the physiological condition, and to the deficiency of fibrin
in the  embryo, we cannot suppress the declaration, that we are inclined
to see  (with Zimmermann) in fibrin  really an  excretory formation, a
substance  brought  by oxidation  nigh  to the state of disintegration, an
albuminous matter  consumed  by oxidation, which together with albu-
men appears only in the form of pseudo-fibrin to be any longer applied
to nutrition."   While thus rejecting  the doctrine that fibrin is the sole
or chief plastic element, we do not wish, on the  other hand, to deny its
importance when of proper quality in  maintaining the due consistence of
the blood, and in fulfilling such other purposes as those at which we have
glanced.  We now proceed to consider the variations of this substance,
in different morbid conditions as to quantity and quality.
   The  average for the  fibrin of ordinary  venous  blood,  adopted  by
Andral, is 3 parts per 1000, but most observers place  it rather lower.
Scherer found  in  the blood  of healthy men 2.03—2.63  parts.   Its
quantity as mentioned is greater in arterial than in venous blood, and
is said by Schmid, after numerous examinations, to be only one-third in
portal  venous blood of its  ordinary amount in that of the jugular vein.
Sex does not appear to affect the proportion of fibrin, but  the state of
pregnancy does materially;  in the first six months the quantity is  de-
creased, the average being 2.3; during the last three months the quan-
tity is  increased, so  as to average 4.  After parturition, the quantity for
a time  seems  to be still further increased;  a  circumstance which may
have some relation  to the tendency to uterine  inflammation, and mam-
mary abscess,  which marks this period.   In very early infancy,  the
quantity of fibrin in the blood appears to be  small, but^ it experiences
a marked increase at the period of puberty.  Lehmann, in experiments
upon himself, and Nasse, in experiments  upon dogs, found  that animal
diet increased  the   proportion of fibrin  above  that which  was found
under a vegetable diet.

  1 Lehmann found in serum of the venous blood of a horse 11.428 parts of albumen per
100; in  arterial blood 9.217 parts per 100.  The quantity of fibrin in the venous blood
(jugular vein) was 5.3S4, that in the arterial blood was G.814. 
62
RED AND  WHITE CORPUSCLES.
  Passing  now to the morbid conditions in which the fibrin is  found
increased, we find, as a general  law, that in all  inflammatory diseases
especially this is the case.  In acute articular rheumatism, Andral re-
cords in one case as  high a proportion of fibrin  as  10.2 per 1000, in
several  others it amounted to 6, 7, 8,  or 9.   In  bronchitis (acute), the
highest  figure obtained was 9.3, in pneumonia, 10.5.   The maximum in
pleurisy was 5.8, in peritonitis, 7.2.  The increase was nearly the same
in one case of erysipelas, in which it amounted to  7.3, and in another of
tonsillitis, in which it was 7.2.  A  very important  circumstance, well
shown by Andral's  tables, is, that the effect of bleeding was  not to
diminish the fibrin; in this respect, there was a marked contrast  be-
tween the fibrin  and the red  globules ; the latter sunk with each suc-
cessive abstraction of blood, while the former most often rose, sometimes
considerably.  The following examples of this fact are very striking:—
1st bleeding.	2d.	3<f.	4lh.	5th.	U
Acute Rheumatism 6.1	7.2	7.8	10.2	9	7
Pneumonia . . 7.1	8.2	9.0	10.0		
Peritonitis . . 3.8	4.7	' 6.1			
Pleurisy . . 3.9	5.8				
  In tuberculization of the lungs the fibrin  shows a decided increase,
which, however, is most marked when  intercurrent inflammation is  set
up in the part.   In the  crude state of the tubercles the  mean of the
fibrin is about 4; when softening has commenced, it is about 4.5; when
cavities have formed, it is from 5 to  5.5.   The red particles steadily
decrease from the first.  In chlorotic persons the quantity of fibrin is
maintained at its usual average, and is sometimes a little above; this
circumstance, taken together with the great diminution of the globules,
accounts for the formation of a buffy layer on the surface, which is not
uncommon in such blood.
  Deficiency of fibrin is  observed in very various  morbid conditions.
If we take as a certain indication the non-coagulated state  of the blood
(which perhaps, we are warranted in doing), it seems to be very defi-
cient, generally, in all diseases proving fatal by asphyxia, or in which
the  respiration has been  considerably  interfered  with  for some time
before death.   Thus in cases  of obstructive heart disease, the blood is
very  commonly  in  a fluid state,  or very  imperfectly coagulated, the
coagula,  such as they are, being very soft, and extremely friable.  The
same state is observed in cases of  cyanosis, in which, owing to mixture
of the venous and arterial blood, this fluid is never properly oxygenated.
Excessive fatigue is said to prevent the blood from coagulating, but this
has lately been contradicted by Mr. Gulliver, who found the  blood  co-
agulated in a hunted  stag, and in two hares run  down  by harriers.
Various poisons seem to have the effect of preventing coagulation of the
blood; among these are  hydrocyanic acid, carbonic acid,  sulphuretted
and carburetted hydrogen.   Andral states, that if a concentrated solu-
tion  of carbonate of soda be injected into  a vein, the animal presents
the symptoms of typhus, or scurvy (i.  e. of a  blood disease), and the
blood is found fluid in the vessels.   This statement is confirmed by Mr.
Blake, and the same result proved to be produced by many other sub- 
RED AND WHITE CORPUSCLES.
63
stances:  others, again, though of very analogous character, produced a
contrary effect.   For  instance, when  caustic soda, or  carbonate of
soda, was employed, the blood was coagulated imperfectly, or not at all,
but when liquor  potassse or its carbonate were used, the blood coagu-
lated firmly.   We have ourselves  observed the formation of  a buffy
layer on the blood of an animal who had taken liquor potassse for several
days, to the  extent of  disordering  its  health.  Nitrate of potash, and
many other neutral salts, did not at all impede the coagulation of the
blood, while  arsenious  and  oxalic  acid, infusion  of digitalis, and  some
metallic astringent salts, did so decidedly.   We may infer from these
observations,  that it is  not the  alkalies, as such, nor the  neutral salts,
as  such, which produce the effects that are  usually ascribed  to  them
upon the blood,  but certain substances  of particular qualities.   Again,
in  adynamic  fevers, we often find the  blood remarkably fluid, so as to
gravitate after death to all the depending  parts, and  during  life pro-
bably occasioning a tendency  to hemorrhages, petechise, and  vibices,
which occasionally take place.   The deficiency of fibrin in these  cases
is confirmed by analysis.  Andral  noticed some  diminution of this ele-
ment in the outset of continued fevers.  It never  increased, except on
the supervention of an inflammation, and in  the height of the disease
sometimes sunk very low.   In  two cases, on the  fifteenth day, it ^ did
not amount to more than  1. per 1000.  A deficiency of fibrin might
have been anticipated to exist in Purpura Hemorrhagica; and, indeed,
sometimes this seems  to  be the case.   Simon,  in his Animal Chem-
istry, gives two analyses;  in one  of which it is mentioned that^ there
was no  fibrin, in the other it  only amounted to 0.905.   Dr. Watson,
speaking  of  this, or of the allied  disease—scurvy—quotes a  case, re-
 corded by Huxham, in which " neither of the portions of blood that had
been drawn,  separated into serum and crassamentum as usual, though
 it had stood many hours, but continued, as it  were, half-coagulated, and
 of a bluish-livid color on the top.   It  was  most easily divided on the
 slightest touch,  and seemed a  purulent sanies rather than blood,  with
 a kind of  sooty  powder at bottom."   Dr. Copland and others  refer, to
 similar cases.   On the other hand,  Dr. Budd testifies that, in some cases
 of scurvy, the coagulation takes place as  in healthy blood; and in two
 cases lately examined by Dr. Parkes, it appears that the fibrin, at least,
 was  not in  any great  degree  diminished.1    Dr. Graves also mentions
 a case in  which, after each of  three bleedings, there was formed a firm
 coagulum, with a buffy coat.  The plethoric condition, characterized as
 we have seen  by an excess in the quantity of red globules, and evidenc-
 ing a tendency to congestion and hemorrhage, is considered by Andral
 as generally associated with a deficient proportion of fibrin.  He found in
 a strong, athletic  man, who had  symptoms of cerebral  congestion, as
 low a figure of fibrin as 1.6; and  remarks, that the  minimum quantity
 occurred in those cases in which the symptoms of congestion were most

   • In five analyses performed by Becquerel and Rodier, the general results were as fol-
 lows  The clot was always of good consistence, the density of the serum low the water
  leased the quantity of globules diminished as well as their ferrugmous contents; the
 ZLlt never dimiuished-sometimes increased;  there was no increase of alkalinity or
 of salts; the solids of the serum were notably diminished. 
64
RED AND  WHITE CORPUSCLES.
 intense.  In a female, who had been struck down senseless by an attack
 of apoplexy, the first bleeding showed the small proportion of 1.9 of
 fibrin, the globules being at 175.5.  After three days, when conscious-
 ness  had begun to return, she was bled  again ; and now the fibrin
 amounted to 3.5, while the globules had diminished to 137.7.
   Alterations  in  the quality of the fibrin manifest themselves very
 clearly in the varying size and  firmness of the  coagulum, which forms
 in blood drawn from  a vein, as  well as  in the peculiarities of structure
 which microscopic examination  reveals.  We will consider the general
 and the textural differences separately.  To estimate aright the  condi-
 tion of the coagulum of the blood, a full stream should be allowed  to
 flow from a sufficient orifice into a deep vessel, which  should  be  after-
 wards covered  over, and  should  have been  previously warmed.   If
 drawn in a small,  trickling  stream, and received into a  cold, shallow
 vessel, or if subsequently agitated, the coagulation  is disturbed,  and
 takes place either too rapidly, or forms, in  the  case  of being  agitated,
 irregular shreds.
   The coagulum, when formed, may  be very  large and firm,  so as to
 offer  considerable resistance  when an  attempt  is made  to  divide it.
 This implies a fair proportion, or, perhaps,  rather increased, of healthy
 fibrin, with a  considerable  amount  of red corpuscles.   I have  been
 informed of the case  of a  plethoric female, whom it was necessary to
 bleed frequently, during her pregnancy.  The coagulum was described
 to me as so firm " that it might have been  kicked from  one end  of a
 room to the other."  On the  other hand, the coagulum may be large,
 but so lax as to be very easily divided, and, if  handled, readily break-
 ing up.   This  implies either a deficient quantity of fibrin, or  a de-
 fective contractile quality, or  most commonly both.   It may generally
 be taken as a positive sign that  bleeding is  not necessary, and that  it
 will  not be borne well.   The coagulum, again, may be very firm,  but
 considerably shrunken and contracted,  manifesting this not only by its
 recession from  thesides of the vessel, but by the concavity of its upper
 surface, which  at the  same time is  covered  with  a layer, more or  less
 thick, of a light-yellow color.   This layer is fibrin separated from  the
 red corpuscles,  and  is  commonly  termed the  "buffy coat."   In this
 case the quantity of fibrin is much  increased,  and  probably  also its
 contractile quality, which occasions the reduced  size of the clot, and
the drawing in  of  the surface, or, as  it is called, "the cupping.''   A
buffy  coat sometimes  forms  on  the surface, of clots  which are rather
deficient in firmness;  it is,  however, but thin, rather transparent and
produces no "cupping."   It is  mostly  seen  in  rather asthenic condi-
tions of the system, and from its appearance  the blood which  presents
it is distinguished as " sizy."  A very small, firm clot, with a  more  or
less buffy surface, indicates  a diminution of  the  red  corpuscles  and at
least a relative  excess of fibrin.
  The following circumstances1  are favorable to  the formation of  the

  1 Dr. Todd and Mr. Bowman's " Physiological  Anatomy," vol. ii, p. 295.  It must b
remarked, however, with regard to diminished density of the serum, that Mr G  11'
has shown that in serum rendered  thicker, heavier, and more viscid, by the addition^f
mucilage, the red corpuscles subsided not only more rapidly, but  also more completely. 
RED AND WHITE CORPUSCLES.
66
buffy coat:  (1.) Slowness of  coagulation, which gives the red corpus-
cles  more time to  sink.   (2.) Increased weight  of the corpuscles, and
their aggregation together  into  rouleaux.   (3.)  A diminution  in the
specific gravity of  the serum.   (4.) A great diminution in the propor-
tionate quantity of the red corpuscles, or an increase in that  of fibrin.
None of these circumstances, however, seem to us  to  account fully for
the phenomenon in question; and we  are much inclined to believe with
Dr.  Alison, that there exists an absolute tendency  to separation  be-
tween the fibrin and the  corpuscles, somewhat, perhaps, of the nature
of that which prevents the commixture of some dissimilar fluids.   He
remarks: " 1st. That the formation of the buffy coat, though no doubt;
favored or  rendered more complete by slow coagulation,  is often  ob-
served in cases where the coagulation is more rapid  than  usual; and
the  coloring matter is usually observed to retire  from the  surface of the
fluid in such cases  before any coagulation has  commenced.  2d. The
separation of the fibrin from the coloring matter  in  such  cases  takes
place in films of blood,  so thin as not to admit of a stratum of the one
being laid above the other.   They separate from each other  laterally,
and the films acquire a speckled or mottled appearance, equally charac-
teristic of the state of the blood with the buffy coat  itself."  It  does
not  seem necessary to assume that there is any actual repulsion of the
red  particles from the  fibrin, the tendency to separation may  simply
depend on the increased attraction  (which  is manifest) of the respective
parts of each element together.
   The differences  in textural quality which fibrin  often presents, have
been admirably described by Rokitansky and  Mr.  Paget.  _ We will
follow the account given by the former, though it be somewhat in minute
detail, as we may have occasion hereafter to refer to it.  Taking strongly
marked typical examples, he describes, 1st, the fibrin which is found in
the  bodies of healthy persons.   This  forms pretty compact and tough,
moderately adhesive coagula of a  whitish color, passing into  yellow.
They may be torn  into  membranous layers, and exhibit along the torn
surface  a delicate felting.   Microscopic  examination shows a  clear
(hyaline) membranous or flaky basis-substance, and upon  it a thick felt
of very fine, very  elastic, black-bordered, branching fibres, quickly dis-
solved by acetic acid, which project out free at the borders of the speci-
men.   Together with this there are seen on the preparation, appearing
more evident after treatment with acetic acid, round, glistening nuclei,
and  along  with these  a few delicately-granulated, dull-looking, round,
and oval nuclei, and similar cells of the size of a pus-corpuscle.  Of the
same composition are certain soft, brawn-like coagula, termed Pseudo-
fibrin, which Rokitansky regards as a very important transition-formation
as regards healthy nutrition, between albumen and fibrin.
   The 2d variety of fibrin forms coagula much like those  of the preced-
ing, but of  more adhesive quality.  They include often in their substance

than in serum, which was rendered thinner, lighter, and less viscid, by being mixed with
a saline solution.   Mr. Wharton Jones—from whom  we have, in  part, taken the above
passage—believes that the viscid state of the liquori sanguinis promotes the subsidence
of the red corpuscles, by increasing their natural tendency to aggregate together.
        5 
6Q
RED AND WHITE CORPUSCLES.
Fig. 5.
 notable quantities of serum.   Under the microscope they are  seen to
 consist of a flaky basis substance, which divides itself into fibres, either
 flat, or roundish, harsh, and stiff, or resembling those of organic muscle ;
 or the basis-substance may appear  sometimes  membranous, most  deli-
 cately fibred, with a wavy crisping.   On this basis there occur, together
 with elementary granules, numerous round  black-bordered, sometimes
 also staff-shaped or fibre-like, elongated nuclei; and besides these, espe-
 cially in the fluid which trickles out, there are granulated, dull-looking
 nuclei, and similar nucleated cells.   This fibrin, with traces of the pre-
 ceding, is often  combined with  the  other varieties.  Rokitansky  says
 of it,  that it is  often effused, as the result of morbid processes and of
 inflammation, and that it  must be regarded  as diseased,  but to be dis-
 tinguished from  the following varieties by the appellation of plastic or
 organizable.
   The coagula of the 3d kind of fibrin are distinguished by their opacity,
 by a dull-white color, verging on yellowish, or yellowish-green.  They
 often contain, besides serum, red corpuscles also in considerable quantity,
 which  indicate  an  increased  capacity  of coagulation, and more rapid
                 occurrence  of  the  same.  They present  in this  case
                 different  shades of  redness  and  opacity.  Microscopi-
                 cally examined, the coagulum is found to consist of a
                 flaky or fibro-flaky basis mass, or of  a   dull, streaky
                 membrane,  each of which is rendered opaque by a great
                 quantity  of fine punctiform matter.  Besides, there
                 exist  upon  it, and  together with it, in  the  serum, a
                 great  number of nuclear formations, and  developed
                 dull granulated  nuclei,  and similar more or  less de-
                 veloped cells.   Often, the whole coagulum appears to
                 consist of both the last-named elements,  together with
                 some  punctiform substance.  The nuclear formations
                 in  general  show the  ordinary indifference  towards
                 acetic acid.   This fibrin has less adhesive quality.
                   Fibrin  of the 4th kind presents a still  higher degree
                 of the morbid condition of the preceding.   The coagula
                 are in the highest degree opaque.   When they contain
                 no blood-globules they approach more  manifestly to a
                 greenish-yellow.   Often, however, they  contain laro-e
 quantities  of blood-globules, and are reddish-gray,  or  reddish-brown
 which  indicates rapid coagulation.  More closely examined, they consist
 of a thick  finely-punctuated  mass, of nucleus and cell-formations, com-
 porting themselves in various degrees more and  more like the pus-cell
 and pus-nucleus,  which are held together generally by a tenacious, amor-
phous, uniting mass;  no network of fibres exists, and no other fibre-for-
 ^tl0r\' , i ,haS l0St Stl11 more of the  adhesive (soldering) quality.  The
 3d and 4th forms Rokitansky denominates croupous.
   At this point the fibrin approaches close upon that existing in Pysemia •
it  has  the croupous constitution;  the nuclei  and cells inclosed in  the
coagulum are true pus-nuclei and pus-cells.
   Though the above quotation is long, yet the great importance of  the
subject, and the value of the  description given by so high  an authority,
  Corpuscular  un-
healthy fibrin, from
exudation on pericar-
dium. It consists of an
homogeneous granular
basis, imbedding nu-
merous corpuscles. 
RED AND WHITE CORPUSCLES.
67
made us unwilling to omit or  abbreviate it.  Professor Paget, agreeing
closely with  Rokitansky, expresses the same facts  more shortly and
simply.  His description refers, however, to fibrin, as it appears in ex-
udations, while that of the  German pathologist is expressly confined to
the fibrinous eoagula which  are found within the vascular system.   The
                   Softening fibrin from a vein clot.  The dark points are minute oil drops.

        correspondence, however, between the fibrin in and out of the vessels is
        so close, that the characters of the one apply also to the other; and we
        may, therefore, say, that all the varieties of the fibrin of the blood, as
        manifested by the condition of the coagula, depend  upon the predomi-
        nance of one of two forms of structure.  In  healthy fibrin the fibrous
        structure greatly predominates, the whole mass fibrillates more or less
        perfectly, and the included corpuscles  are comparatively few.   This is
        Mr. Paget's fibrinous variety.  Unhealthy fibrin, which tends to  disin-
        tegration, consists of a granular mass, imbedding very numerous nuclei
        and cell-formations; this is the corpuscular variety.  These two corre-
        spond to Rokitansky's 1st and 4th varieties,  and his 2d and 3d are only
        combinations of them in different proportions.
          We shall here briefly notice the metamorphoses which coagula of fibrin
        may undergo: (1.) A more or less perfect development of fibre may take
        place, in which the nuclei are chiefly concerned.   (2.) The coagula may
        fall to pieces, and undergo a kind of dissolution into a pappy or pus-like
        fluid, or in some cases into a fluid which is really  of the nature of pus.
        This  change  may befall coagula of healthy fibrin, in  consequence  of
        their being placed in conditions unfavorable to fibre-development, but is
        more particularly observed in the corpuscular varieties.   It was shown
        by Mr. Gulliver, that the puriform fluid often found in vessels was really
        fibrin which had undergone softening; and it was an important step to
        prove  that  such collections of pus-like  matter were  not  the result of
       phlebitis; but in recognizing their non-inflammatory origin, perhaps, it
       has not been seen clearly how very similar, or even identical, they might
       be with certain forms of true pus.   (3.) The fibrin may part  with  some
       of its natural moisture, and change into a resisting, stiff, dull, translu-
       cent, or also opaque, horny mass.   In process of time it  may  become
       ossified (probably calcified).  (4.) It may undergo fatty transformation,
       becoming converted into a mass of small, oily molecules or drops.   (5.)
       It may gradually be dissolved  and taken up again into the circulation.
*■      Rokitansky mentions as an instance of this the removal of fibrinous
       vegetations from the cardiac valves. 
68         ORGANIC CONSTITUENTS OF THE SERUM.
          ORGANIC  CONSTITUENTS OF THE  SERUM.

  Albumen is the  principal organic constituent of the serum, in which
it exists dissolved in water in the proportion of 63 to 72 parts per 1000
of blood.   The specific gravity of the serum is on an average 1028, and
varies less than that of the entire blood.  The  serum is naturally of a
light yellow color,  which does not appear to depend on the presence of
hsematine or of bile pigment, but to be  special to this fluid.  We have
already expressed  our dissent from the doctrine that the fibrin is  the
sole or chief material intended for the  growth and nutrition of the  tis-
sues, and fully believe that the albumen is quite as much or more applied
to this purpose.  We have no means at present of ascertaining numerous
qualitative variations which  probably affect the albumen of the serum.
Indeed, we cannot  but believe that its composition must be liable to con-
tinual minute changes, as on the one hand nutritive material for various
tissues is drawn off from it, and  on the  other, chyle, scarce yet raised
to the blood-standard, and lymph, containing effete or semi-effete residua
of nutrition, are poured into it.   All such, however, to a certain extent,
are clearly natural; and were our powers of analysis greatly more refined,
we should probably find that it was by the most gradual steps that physio-
logical variations passed into morbid.
  The amount of albumen, according to Andral and Gavarret, is notably
increased  in various diseases; but  this excess does not appear  to be
characteristic of any.  In acute rheumatism, an increase was found vary-
ing from 4 to 24;  in pneumonia, the highest  increase was about 12; in
pleurisy, the extraordinary amount of 34 in excess was once observed;
and several other instances are mentioned of lower degree.   Peritonitis,
tonsillitis, and erysipelas, all furnish cases in which there was more or
less considerable increase of the albumen.  This is the  case also in
tubercular disease  of the lungs, and in simple  and continued fevers.
Bleeding does not  appear to influence the quantity of albumen in a very
constant way; on the whole it tends to decrease it, and this  seems to be
especially the case in  typhoid fever.  In cases of cerebral  congestion
and of apoplexy, generally considered  as  examples of  plethora, there
was found, especially in the former,  a very considerable  increase in
many cases of the albumen.  This amounted once to 24.8 beyond  the
mean.   In the latter there were several instances of marked diminution.
Cases of chlorosis,  in which the globules are so remarkably diminished,
show rarely any diminution  of albumen; and sometimes a considerable
excess, amounting  to 14 or 20 parts per 1000.
  Diminution of the albumen of the serum probably takes place in various
diseases, attended  with defective nutrition and wasting, but has been
more particularly observed in renal dropsy.  It appears as  if the albu-
men of the serum, being drained off in the urine, and in the dropsical
efflux, there remains behind a less quantity in the blood.   This idea is
confirmed by the results of three successive analyses of Andral's in  the
first of which there being much albumen in the urine, the serum contained
only 57.9; in the second, the urine containing less albumen, the amount
in the serum had increased to 66; in the third, the urine being no longer 
EXTRACTIVE MATTERS.
69
albuminous, the quantity in the serum had returned to its normal figure,
72.  It is also in accordance with the circumstance noticed by Dr. Bright,
and others, of low specific gravity of the serum in  this disease.   Still,
this explanation does not accord with the general fact that dropsical
effusions are more watery, and contain less albumen  than the  serum,
which one would therefore expect to find of greater density in such cases.
Probably the supply of such albumen, both from the chyle and  lymph,
is defective in quality and quantity.  Becquerel and Rodier state, that
in diseases of the heart the  albumen of the serum varies but little as
long  as there is no dropsy; then it diminishes, and often considerably.
In the disease called the rot, affecting sheep, which is characterized by
the presences of numerous distomata  (flukes) in the biliary ducts, M.
Andral and  his coadjutors found the albumen of the blood considerably
diminished, as well as the red globules,  while the water was  greatly
 increased.   Sheep are also subject to ordinary anaemia, i. e. to a  defi-
 ciency of  red globules  only in the blood, the albumen  remaining at its
 normal amount; and it is very worthy of remark, that in these latter
 cases dropsy does not take place, while in  sheep affected with the rot it
 is not uncommon.  This seems to point out  that when in cases of cachexia
 and  debility serous infiltrations of the limbs occur,  it is owing to a dimi-
 nution in  the quantity of albumen in the blood.
EXTRACTIVE  MATTERS.
  Chemistry has as yet ascertained too little respecting these substances,
even in the healthy condition, to make any conclusion possible regarding
their variations in disease.  Simon's division  into water extract, proof
spirit extract, and alcohol  extract, is  of no avail for  physiology or
patholoo-y.  As his eminent namesake remarks, what we want is a di-
vision of these matters according to the  organs  or systems of  organs
that produce them.  Still, the recognition of the existence of such mat-
ters in the  blood is important, as showing us the actual  presence ot
principles that are effete, or tending  to  become  so in  this fluid, and
reminding us how often  ill health and  malaise  may  depend  on the
formation of unnatural products  of this kind, which come  at length to
be generated by an almost habitual vice of the system.
  According to Lehmann's estimate, the  quantity of extractive  matter
in healthy blood is 0.25 to  0.42  per 100.  Nasse found a larger pro-
portion in the blood of children and of young animals than in  that ot
adults.  Arterial blood,  according to  Lehmann,  contains  more than
venous blood in the  proportion of  5.374  parts to 3.617.  Portal vein
blood of horses, five to ten hours after food, contained  on  an average
7 422  parts; twenty-four  hours after food the quantity amounted to 10
but it  was always less  than  that  existing  in hepatic vein blood  which
averaged above 18.  The existence of a  larger quantity of extractive
mattef in -terial than in venous blood  may perhaps be accounted for
by the increased oxidation of some of the organic matten  which take
place in and after the  passage of  the  blood  through  the  lungs,  lhe
larger  amount in the  blood of young growing  creatures is  in coire- 
70                OILY MATTER IN THE  BLOOD.
spondence with the greater activity of their circulation,and their nutritive
processes generally.   The  excess  in  the hepatic  vein above the portal
blood indicates that an  absorption of matter from the hepatic cells into
the current traversing  the lobules takes  place.   Sugar, we  know, is
conveyed into the blood from this  source, and there is  equal reason to
believe that extractive matter may be.   Though we  cannot class liver-
suo-ar, or glucose, altogether with extractive matter, as  it is  rather ot
the nature of a secretion, yet we cannot but notice the probable relation
in which it stands to the disease calleddiabetcs,  and the ideas which this
view suggests  as  to various diseases which  appear to have their seat in
the blood.   It seems that one very important feature in diabetes is, that
the sugar formed in the liver, and absorbed into the blood, is not de-
composed,  as it  ought to be, into carbonic acid,  but circulating in the
blood, and arriving at the  kidneys, stimulates them unnaturally, and so
occasions the  profuse diuresis which  exhausts the system.  So, various
ill-defined  extractive matters, intended to be decomposed and eliminated
through the skin, or other channels,  may  fail to  undergo  their normal
changes, and  be, in consequence, more  or less completely retained in
the  blood, which, circulating thus contaminated, becomes a source of
mal-nutrition  and disorder to various parts.  What  more probable ac-
count can be given of the origin of most skin diseases?   Surely, in such
an instance as this the value of a sound pathology is most manifest, if
it be only to open our  eyes to the absurdity of not a few of the  ordinary
remedial measures.   Liebig has particularly described three substances
which appear to belong to the class of extractive matter, creatin, crea-
tinin, and inosinic acid; the two former  seem to be of the  nature  of
 alkaloids,  the latter combines with  bases as an acid.    They are all
 nitrogenized substances, and are found in  the watery extract of muscle;
 the two former  are  present  in  the urine, and  are, therefore,  doubtless
 effete.   They do not seem to have been detected in the blood,  but must
 of course have  passed  through it before being excreted with the urine.
 Creatin, Lehmann states,  is analogous to Thein, an alkaloid, which in
 some trials has produced very  severe  nervous  symptoms, even when
 taken  in  small  doses.   Many  slight changes  in creatin  or the allied
 substances render them capable of producing any similar phenomena.
               OILY MATTER  IN  THE  BLOOD.

  The quantity of oil existing  in  the blood  cannot be estimated only
from the amount  contained in the  serum, for it is  present  also  in  the
red corpuscles, and in the fibrin.   The quantity contained in the crassa-
mentum, which is made up of these two  components, is not much in-
ferior to that in the serum.   The serum of arterial blood contains less
oily matter than  that of venous.  Lehmann gives  0.264  per cent, as
the proportion in the first, 0.393 per  cent, in the latter.1  Chevreul

  1 Lehmann found in 100 parts of dried blood-corpuscles of the ox, 2.249 of oily matter:
arterial blood-corpuscles contained 1.824 parts  of oily matter  per 100 thereof; venous
blood 3.595 parts. 
OILY MATTER  IN THE  BLOOD.
71
states the quantity of oily matter in fibrin as amounting to 4 or 4J per
cent.   Lecame distinguishes a crystallizable and non-crystallizable oily
matter in the blood, the former in the proportion of  1.20  to 2.10, the
latter in that of 1 to 1.30 per 1000 parts of serum.   Cholesterin and
Berolin are two crystalline fatty substances which have been found in
blood;  the  former is of  very common  occurrence  in exudations  in
various parts, and in some  tumors;  it forms the well-known  rhomboid
tablets, by which, when in  a solid form,  it is immediately recognized.
The blood of females, according to Becquerel, contains on an average
more fatty  matter than  that  of men.  In both sexes, the quantity of
cholesterin  increases with advancing years, after the age  of 40 or 50.
It seems established, as was natural to expect, that the quantity of oily
matter in the blood increases after taking food.  A milky state of the
serum had often been observed, but  though it was generally supposed
to depend on the  admixture of chyle, this could hardly be said to have
been proved until  lately.   Dr. Buchanan's  experiments  upon healthy
persons show that the serum "becomes turbid about  half an hour after
taking food, the  discoloration increases  during  several hours, attains
its maximum in about six or eight (after  a full meal), and then becomes
 gradually clearer till its limpidity is restored.  The opaque serum is
 generally milk-white, sometimes cream-yellow, or yellowish brown, like
 thin oatmeal gruel; or it merely loses its limpidity, and  is  like  weak
 syrup.  It always contains solid white granules, smaller than the blood-
 corpuscles, which  are  suspended in it, and which will rise  in  a white

                                                    Fig. 8.
i ^-' °

Cholesterin.
Fat in Blood.
cream to the surface, either spontaneously, or after the fluid has been
saturated with  common salt.   The cream thus obtained is  soluble in
caustic potash,  but insoluble in ether  or  alcohol, and  w considered by
Dr R  D. Thomson as  probably a protein  compound.    lhe  micro-
scopic appearance of milky serum, as I have observed it, has depended
on the presence  of  a diffused finely divided matter,  much  resembling
the molecular  base  of the chyle.  Sometimes, however, distinct oil
drops are observed.  When we remember that the  molecular opaque
matter of the chyle is surely of oily nature  and find that the  opacity
of the serum, which occurs after a meal  of  food  containing fat is_ in
part due to  the presence of protein granules, we can  hardly help enter
 aining the  idea which various other circumstances  confirm, that  the
oly matter  is  actually converted into albumen.  Should this ever be 
72
SALINE INGREDIENTS.
proved to be the case, we should clearly see how in a lowered  state of
the vital powers, nutrition  must be  impaired,  and how the failure of
this, the first of the ascending nutritive processes, would be a  prime
cause of the degeneration of various tissues, or of the accumulation of
adipose tissue,  which are  both  signs  of feeble  general power.  The
general result of Becquerel and Rodier's very careful  analysis of the
blood in various diseases, with regard to the variations  in the quantity
of oil, is that almost from the outset of every  acute disease  the amount
is increased, and particularly that of the cholesterin.   Diseases of the
liver, Bright's disease, and tuberculosis have the same effect.
                    SALINE  INGREDIENTS.

  There remain for our consideration the various salts of the blood, and
the water which holds them in solution.  The amount of salts in the
blood of man is somewhat greater than in the blood of  woman; that of
the former contains, on an average, 8.8 per cent., that of the latter 8.1;
in both sexes the variations  compatible with  health are considerable.
The blood of adults contains more salts than that of children; arterial
blood more  than venous.  The prolonged use of aliments containing
much common salt is said to cause an increase in the proportion of the
latter, and of the other salts generally.   The following  appear to be the
principal saline combinations in  the blood:  Chloride  of Sodium, and
Potassium, Sulphate of Potash,  Carbonate and Phosphate of Soda.   Of
the alterations which the salts undergo in different diseases we have not
much knowledge.  In malignant cholera, the excessive drain tells most
on the fluid  part of the blood, and hence that remaining  in the vessels
is thick and tarlike; hence, also, the extraordinary, though temporary,
effect of injecting saline solutions, which return to the blood the mate-
rial  effused  from it, and revive  all the functions  that  were wellnigh
extinct.  Doubtless, if the intestinal discharges could  be arrested, the
effect would be permanent, but as it is, their effect is soon exhausted.
Henle assumes that in inflammation, when the flow of blood in a part is
retarded, exudation of the  more watery and  saline parts of the liquor
sanguinis takes place, so that that which remains in the vessels becomes
inspissated,  and producing endosmotic  changes in the  red corpuscles
disposes them to adhere together.   This view, however, is merely hypo-
thetical.  Vogel  states that "the salts are increased in scurvy, and it
is very probable that this change influences the condition of the fibrin,
hindering its coagulability, and, perhaps, checking its formation; that
it affects  the blood-corpuscles  by withdrawing their  water, rendering
them granular, and collecting them in heaps;  and  that it thus plavs an
essential part in the disease itself."  However, his statement has "been
contradicted rather than confirmed.  In the cases  of purpura  examined
by  Dr. Parkes, which have been alluded to, the quantity of salts seems
to have been below the average.  In acute exanthemata, in  dysenteric
affections, in endemic agues,  Lehmann  mentions the proportion of  the
salts to be increased, as  also in Bright's disease, in typhus,  and in all
kinds of dropsy and hydremia.  In violent inflammation the salts  are
much diminished. 
WATER.
73
                             WATER.

  Lecame's estimate of the mean quantity of water in 1000 parts of
blood is 790 ;  he found more water in the blood of women than in that
of men, more  in the blood of children and of aged and debilitated per-
sons than in that of vigorous adults, more in the lymphatic than in the
sanguineous temperament.  It is clear that the whole quantity of water
is not contained  in  the  serum, a  certain proportion, which must vary
with the specific gravity of the blood, is inclosed in the red corpuscles,
and holds their coloring matter in solution.  The serum of»arterial blood
and of portal vein blood is said by Lehmann to contain more water than
that of venous blood generally.   It is a very remarkable circumstance,
and strongly  indicative  of wise  provision, that it  is very difficult to
demonstrate by analysis an actual increase of the quantity of water in
the blood after copious drinks have been taken.   Denis and Schultz are
at  issue as to whether  such  an  increase is  detectable or not.  This
seems to show how  exactly the vascular system is kept  at  a certain
degree of tension, so that in proportion as absorption at one part takes
place, excretion at another ensues correspondingly.   The effect of bleed-
ing and  starving which  was before noticed, of reducing the amount of
globules, tells, of course, proportionally, in increasing  the quantity of
water;  this can easily be ascertained, as it is in great measure relative;
the merely positive increase is much  more doubtful.  Andral mentions
a case of confirmed chlorosis, in which the water in the blood  amounted
to 867.9, an increase of nearly 78 parts  per 1000.  Lehmann states,
that in the beginning of most diseases, especially acute ones,  the blood
is found more watery than natural, the serum, however, at the same time
being richer in solid  contents.   He accounts .for this, by supposing that
the material which should  have  been applied to the formation of the
globules, or which  results from  their  decay,  remains  in the serum.
During the first ten days of typhus, the first  stage of scarlet fever, mea-
sles,  and cholera, this increase in the watery constituents of  the blood
does  not appear to take place.
   The condition  which is  commonly called  Anremia should, it would
seem, more properly be named Hydremia, as in most cases it is not so
much a deficient quantity of blood which it is intended to describe as a
defective quality.  Doubtless, a  person reduced greatly by phthisis, or
any exhausting disease,  is really  in a state of anaemia; he has less blood
than natural  in his body, as well as too watery; but a female suffering
from consequences  of  amenorrhcea,  with  pale  lips and  face, is much
more likely to be in a state of hydraeinia, the mass of  blood  not being
diminished", but its red corpuscles replaced by water.
   Having examined the variations which the several constituent elements
 of the blood are liable to undergo, we  next  proceed to make a few re-
marks on certain  abnormal matters which are occasionally present in it.
 Carbonic acid gas, the product of respiration, i. e. of the conveyance of
 oxygen throughout every part of the frame, becomes, if it accumulates
beyond a certain small amount in the blood, the  cause of serious disorder
 and speedily of death. Various diseases of the thoracic viscera, or impedi- 
74
WATER.
ments to the free action of the walls of the chest, prevent more or less
the due oxygenation of the blood, which  is indicated  by the dusky hue
of the complexion, the lividity of the lips, the sensation  of oppression
at the chest, and of dyspnoea.  The larger the quantity of blood which
is circulating in the vessels, and the more vigorous the state of health
and the general activity of the functions, the greater must  be  the ac-
cumulation  of  carbonic acid when any  asphyxiating cause begins to
operate, and the more severely will its effects be manifested.  If, how-
ever,  the mass of blood be greatly diminished by exhausting drains, by
diminution of food, and by non-development  of its  corpuscles, then the
amount of respiratory action may  be also greatly diminished without
producing the symptoms above mentioned.   Thus, if a person in health
should suddenly be deprived of one-half or three-fourths of his breathing
apparatus, he would  quickly die, suffocated;  but a patient  in the last
stage of phthisis, whose lungs are destroyed  to  the  same extent, may
continue to live  on without experiencing any notable dyspnoeal distress.
In the same way, when,  during  violent exertion, a  greatly increased
quantity of carbonic acid  is formed, the  amount  of oxygen introduced
into  the lungs  requires to be increased  in proportion, and  hence the
hurried and panting respiration. A hybernating animal scarcely breathes
at all; its animal heat is not above the temperature of the atmosphere,
and all its  functions are in abeyance; carbonic  acid, therefore, is not
formed, and the inhalation of oxygen is not necessary; life, reduced to
this low ebb, continues in  an atmosphere  which would cause instant suf-
focation if the  animal were  awake.  Man does  not  hybernate, but it
seems highly probable that the system must  temporarily have been in
a similar state in those cases in which life has been restored after pro-
longed immersion for  half an hour  or more.   In persons affected with
the morbus coeruleus,  when, from some malformation,  the pulmonic and
systematic circulations are  no  longer  kept distinct,  we have the best
opportunities for observing the effect of an unnaturally venous condition
of the blood.  The following excellent description is given by Dr. Wil-
liams: "Individuals  thus  affected are  in a lower  scale of animation.
The slower processes of nutrition and secretion seem to  go on pretty
well, but the muscular power  is low, slight exertions bring on symptoms
of faintness, palpitation, suffocation, or insensibility, the animal  heat is
lower than natural, and there is greater  suffering from the influence of
cold.  In  short, all the powers of body and  mind are slender, and are
easily disordered by any circumstances which tax their activity.   In the
fewthat reach mature age there is no sexual  passion.....The
subjects of  cyanosis are said to  be very liable  to hemorrhages,  and
when these  occur spontaneously, or from accidental causes, it is very
difficult to stop  them.   This must be ascribed  to the deficiency of fibrin,
which we have already found to  occur where the changes of the blood
by respiration are imperfect."
  In  what way does accumulation of carbonic acid in the blood prove
fatal to life ?  We find, after death  from  asphyxia, the left side of the
heart comparatively empty, and  its cavities contracted, the  right side
gorged with blood, as well  as the veins  generally; the lungs are also
distended  and gorged  with  dark  blood.   Now, it has been shown that 
WATER.
75
the essential cause of the failure of the circulation is not paralysis of
the heart, or of the brain, though these may have  some influence, but
arrest of the blood in the capillaries of the lungs.
  How this arrest is produced we have not sufficient positive information
to enable us certainly to explain, but we see that it is  a phenomenon of
the same class as that congestion  which has been mentioned as often
occurring when the function of a part is suddenly  put a stop to, or, as
Dr. Carpenter expresses it generally, "the performance of the normal
reaction between the blood and the surrounding medium (whether this
be air, water, or solid organized tissue) is a condition necessary to the
regular movement of the blood through the extreme vesse s.    lne
correctness of this position is almost demonstrated by the following ex-
periment of Dr. Reid's: Having  adapted an hsemadynamometer to a
systemic artery of an animal, and obstructed its respiration, he  tound
that when non-oxygenated blood  was beginning to circulate, as shown
by the commencing supervention of insensibility, the column of mercury
 in the tube was raised, indicating, of course, an increased resistance to
 the onward flow through the capillaries.                .
   In this instance the normal changes  between the non-arterialized and
 the tissues could not take place, and, consequently, the blood could not
 freely pass through them.  The converse of this experiment is presented
 to us in the effect of extreme cold on parts that are exposed to it.  I he
 functions of the part are abolished, the circulation  languishes and at
 last ceases, the vessels remaining congested with venous blood,which is
 not carried onwards.  Hence the blue, or livid color which  he surface
 presents.  In this case, the vital  power of the tissues seems to be para-
 lyzed by the sedative influence of the  cold, and as a  consequence, their
 rfutrition and circulation are also  brought to a stand.  The-res  of he
 pulmonary circulation in asphyxia seems very analogous to the foregoing
 Ltance '/the normal changes in the lung tissue having ceased the blood
  is no longer able to traverse its  capillary plexus freely, but stagnates
  theie and congests the part.   Thus far we simply class together a
  number o? simiL phenomena, and educe from the circumsances com-
  mon to them a kind of law, viz :  that quoted from Dr. Carpenter.  J5ut
       D '.Draper has brought forward  a view which is extremely plausible
  and beautiful,  and appears to us likely to prove  of  the greatee;  va ue
  •  iwLwv and pathology.  It is founded on the  statement, "that it

  r,orous or parenchymatous structure, and have for that tube or structure
  dr^nrchemical affinities, movement will ensue, that liquid which has
  tt most energetic affinity will  move with the  greatest vdoci y and
  mav even drive the other liquid  entirely before it.  The essentia idea
  *Z™ to be this, that the on-coming liquid is attracted, particle by
  ™ ti.le to varous points of the tissue which it traverses, that the at-




  mrnmrn 
76
WATER.
its capacity of being attracted, and is driven on by more arterial blood,
coming up within the range of the tissue's attraction.   In the same way
we may conceive an attraction to subsist between the venous blood and
the air in the cells of the lung, which will, of course, cease as soon as
the change from venous to arterial blood has been accomplished.  The
effect of this nutrition force, a term which we prefer to Dr. Carpenter's
"capillary  force," is,  evidently, to promote remarkably the free transit
of the blood through a part, and there can be no doubt that the arrest
or abolition of this force must tend materially to obstruct the circulation.
Hence, in asphyxia, the attraction probably continuing some time, but
the normal changes which liberate each particle from it not taking place,
the blood continually arrives and stagnates in the pulmonary capillaries.
We have dwelt the longer on this subject, because it appears to us  of so
much importance to recognize the principle that the nutrition of a part
influences so materially the circulation of blood through it, and because
we may often have occasion to refer to the view here enunciated.   The
poisonous influence of carbonic acid is well shown by the following  com-
parative experiment of Rolando.  He tied one of the bronchi in a tortoise,
and found that the animal was not materially injured thereby; but when,
instead of merely cutting off the access of air, he furnished a supply of
carbonic acid to that lung, the other still receiving air, the animal died
in a few  hours.
  When the action of the kidneys is arrested, or seriously interfered
with in any way, their secretion products are no longer carried out of
the system, but remain in and contaminate the blood.   The effects pro-
duced by the blood thus poisoned are  somewhat different, according  as
the secretion is  more or less suddenly and completely suppressed.  When
the suppression occurs suddenly, the acute form  of  uraemia, as  it is
called, manifests itself.   Frerichs describes three varieties of this.   In
the first, after some pain of the head, giddiness, or vomiting,  the patient
soon sinks  into deep stupor, from which in no long while he cannot  be
aroused.  In the second, epileptic convulsions suddenly appear, affecting
the whole muscular system, and returning after occasional intermissions.
The consciousness may remain unaffected.   In the  third  form,  both
convulsions  and coma  occur.  Such cases constitute the disease which
received  a separate name, as ischuria  renalis, but they probably belong
to the same class as the acute anasarca, which occurs sometimes  spon-
taneously, or after scarlet or typhus fever, the  anatomical characteristic
of which is great sanguine engorgement of the kidney.  Uraemia, in  its
chronic form, appears at the close of  Bright's  disease very  frequently.
Frerichs describes it as coming on  gradually and unperceived, occasion-
ing dull headache, or confused sensation, impairing  the mental and
bodily faculties, and producing some dulness  and drowsiness.  These
symptoms  may remit if  the urinary  secretion increases, or they may
progress, and become more intense, the drowsiness deepening  into stupor
and coma.   Vomiting is a frequent symptom in uraemia, and sometimes
amaurosis,  or disturbance of the hearing, is observed.   Diarrhoea some-
times takes place, and seems to avert the dangerous  consequences  of
uraemia; it was a prominent symptom in the animals whose kidneys
were extirpated by Prevost and Dumas, and in those similarly treated 
WATER.
77
by Bernard and Barreswill; in the latter, it was particularly observed
that large quantities of ammoniacal fluid were poured out by the mucous
membrane  of the stomach and intestinal canal;  while these  continued,
the  cerebral functions were impaired, but as soon  as they ceased, the
symptoms of intoxication commenced.  Inflammations of the serous mem-
branes, especially the pleura and pericardium, are very commonly pro-
duced by uraemic poisoning in a less severe form.  Cases of pericarditis
of renal origin are nearly as frequent as  those of rheumatic.   The term
uraemia seems  to imply that the poisoning of the blood depends on the
presence of urea, and such has long been the general belief,  but numerous
experiments and observations of late have done much to  invalidate it.
 The quantity of  urea in the blood, and the intensity of the  symptoms,
 bear no proportion to each other; there  may be much urea in the blood
 and no symptoms,  and  severe symptoms with little or no urea  in the
 blood.  Dr. Rees,  observing this, concluded  that a watery state of the
 blood was  the cause of the symptoms. Dr. Todd, Vauquelin,  and others,
 have injected urea into the veins of animals, or given it by the m0"th,
 without producing  any other effect than increasing very greatly the flow
 of urine.  Still more, Frerichs has repeatedly injected human urine into
 the blood of animals without producing any ill effects.  It seems clear
 then  that it  is not urea, nor any other constituents of the urine, that
 produce, by their presence in the blood,  the symptoms of poisoning.  It
 may be, however, some of their decomposition-products;  and Frerichs
 states that he has proved it to be the carbonate of ammonia, which is
 well  known to result  from altered  urea.  He has repeatedly demon-
 strated the presence of ammonia in  the air expired by the sick,  and by
 animals into  whose veins urea had been  injected after extirpation ot the
 kidneys.   Carbonate of ammonia, he says, can always be detected in the
 blood whenever uraemic symptoms exist, as well as usually traces ot un-
  destroyed urea.   The  two  following experiments  certainly  go  tar  to
  establish  Frerich's theory of uraemic intoxication.  When a solution ot
  urea is injected into the veins of animals from whom  the kidneys have
  been removed, no  symptoms take place for some time ; but after one
  hour and a quarter to eight hours vomiting commences and convulsions,
  or sopor  and coma begin to appear at the same time that ammonia can
  be dSec'ted in the air Spired.   After death, ammonia in large quantity
  was  found in the  blood.  " The brain  and  its membranes  were normal
  Tn appearance,  and the quantity of fluid in the ventricles was not m-
  Seasd " In the second experiment, a solution of carbonate of ammonia
  was injected  into  the veins  of animals.   Convu sions  often very violen
  Tn character instantly ensued, and stupor quickly supervened.   The
  respiration was difficult, the expired breath was loaded  with ammonia,
  and voSng of bilious matter occurred.  While the stupor  lasted  am-
  and \omiting 01 uu                          disappeared the animals
  """rTd their s nSe  That' is the exact cause Sf the inflammations
  ofThserousmeXanes, which often prove fatal in renal degenerations,


    uch effect    French thinks that the impoverished state o  the blood
  I"an adequate cause, but in this we can hardly agree.   *  hile speaking 
78
WATER.
of urea as a substance abnormally present in the blood, it must  not be
left unnoticed, that it is only its presence in anything like considerable
quantity that is abnormal, since it has been clearly proved that a minute
quantity exists  in perfectly healthy blood  of men  and animals.   The
same is the case with another constituent of the urine, viz  : uric acid,
which exists naturally in small proportion  in healthy blood, but accu-
mulates  therein  from defect in the excreting functions of the kidney
just before an attack of acute gout, and also in chronic.  As it is defi-
cient in the urine, Dr. Garrod's conclusion seems just,  that the chalk-
like deposits appear to depend on an action in and round the  joints
vicarious of the uric acid excreting function of the kidneys.   The well-
known effects  of the presence of this gouty matter (uric acid) in the
blood, as the  malaise  and  ill health which precede the  attack, the
inflammation  produced by  its  localization, and  the occasional serious
result of its transfer to more vital parts, illustrate  exceedingly well the
disturbing action of an excretory substance retained in the blood.
  Lactic acid was believed by Dr. Prout  to be  the materies morbi in
rheumatism; he states that it is thrown off in immense  quantities from
the skin during  the perspiration.  Absolute proof of this,  perhaps, is
wanting, but as we know that this acid can  be obtained from muscular
fibre, and exists  in the gastric, cutaneous, and urinary secretions, it is
very probable that this is the case.  In health, lactic acid is, most pro-
bably, rapidly disintegrated in the blood by oxidation, being converted
into carbonic acid and water; in rheumatic and  other diseases we may
suppose this process to be interrupted, and that the acid, therefore, or
its  combinations, accumulates in the  blood, and is thrown  out by an
excessive action of the perspiratory glands.   This  view  is confirmed by
the obstinate nature of many cases of rheumatism, and their  great tend-
ency  to recur, indicating a deep-seated defect in  some of the processes
of organic life.   It is also confirmed by the good effects of  eliminative
treatment  succeeded by tonics, the  object of which is to carry off the
morbid matter that vexes the system,  and  afterwards to invigorate the
general powers, so that the organic functions may be more properly per-
formed.1   Rheumatism  is so manifestly akin to gout, that this conviction
is a  further argument for  believing that the former depends, like the
latter, on a materies morbi.
  Whether Bile, when  present in the blood, is the cause of disorders,
we do not certainly know.   Its gradual disappearance as it passes down
the intestinal canal, is considered by Liebig as a proof that it is absorbed,
but Lehmann is unable  to find any trace of it in the blood of the portal
vein.   It  may, therefore,  be decomposed and not absorbed.   Biliary
pigment is often  present in the blood in considerable quantity without
occasioning much disturbance, but we cannot speak so positively with
regard to the biliary acids.   In that terrible affection of the  liver  called
by Rokitansky acute yellow atrophy, in which the cells of the organ are
completely destroyed, and the whole tissue  deluged with yellow pigment
we are quite ignorant of the exciting cause of the convulsions and coma

  1 This view is the same as that most ably maintained by Dr. Fuller, iu his  truly valuable
work on Rheumatism. 
WATER.
79
by which the disease commonly proves fatal.  No chemical examination
that we know of has yet been made of the blood in this disease, and all
that can be said is, that it seems most probable that the poisonous matter
which produces the cerebral symptoms is none of the constituents of the
bile, since both of them, the pigment  and  the  cholic acid, have  been
found in the blood when none of the symptoms of cerebral disturbance
were present.  It may  be, perhaps,  a decomposition-product  of the
organic biliary acids.   However, though we cannot point out what the
materies morbi in this case is, there is no doubt that the phenomena in
this affection are owing to the presence of  some abnormal matter circu-
lating with the blood.
   In that state of system which Dr. Prout has distinguished by the name
of  the oxalic acid diathesis, there  seems good  reason to believe  that
oxalic acid, or some of its salts, must be present in the blood, and be the
exciting cause of the various symptoms.  It is very probable that imper-
fect digestion often gives rise to the formation of this acid, but in other
instances we are inclined to believe that its origin lies deeper, in a  mal-
performance of some of the secondary assimilating processes.  In not a
few cases, the presence of this abnormal matter in the blood is betrayed
by scarce anything else than  the  existence of  characteristic octohedral
 crystals in the urine; but in others, and, perhaps, the majority, it seems
 impossible not to recognize a connection between the state of the blood
 evidenced by the urinary deposit and the peculiar nervous erethism and
 sensibility which exist.  The circumstance  mentioned by Dr. Prout, that
 those who have this diathesis are very liable to skin diseases, and affec-
 tions of the  nature of boils and carbuncles, also points to the presence
 of a materies morbi circulating in the blood.  It is very conceivable, that
 a small quantity of this  acid formed in, or introduced into, the blood,
 and constantly drained off by the urine, may give rise to no symptoms,
 but, that the presence of a larger quantity, and more especially its non-
 excretion by the  kidneys, may cause great disturbance.   This  is in ac-
 cordance with Dr. Walshe's experience, who remarks: "Observation con-
 tinues to exhibit  to  us  the  frequency of  a deposit  of  oxalate of lime
 crystals, at the period of convalescence of  acute diseases ; so  much so
 that we regard their sudden appearance in an acute disease as  a sign of
 that fortunate change.   This deposit is of temporary (say a few days')
 duration, and not to be confounded with  the  more  or less permanent
 condition appertaining to a peculiar diathesis."1
    The above-mentioned substances, abnormally present in the blood, and
 producing disease, are tolerably well defined, but there  are a multitude
 of others of whose nature we are totally ignorant, and which quite escape
 our means of observation.  The principal of them are the infectious prin-
 ciples of the so-called Exanthematous diseases, including continued fever;
 syphilis belongs to the same category, and various cutaneous disorders,
 especially the squamous and vesicular.   Variola, and  its modification
 vaccinia, are the only instances in which we can at all pretend actually

   i We have observed in a specimen of blood drawn from a man suffering under an attack
 of hemlplegfa  a number of large octohedral crystals exactly similar to those of the urinary
 deposits. 
80
WATER.
 to exhibit the materies morbi, and to transfer it from  one system to
 another; even in these cases, the visible fluid is but the vehicle of the
 poison,  for that  is aeriform, and capable of being received through the
 channel of the lungs.  The venom of deadly snakes, perhaps, may be
 an instance in which the matter inducing the morbid alterations in the
 blood of the  bitten person is manifest and palpable, but even  here we
 have  no knowledge what the  substance is which produces the septic
 effects.   In the case, however, of deleterious gases, and of most  poisons,
 the toxic agent is clearly known, and we can form some idea of its mode
 of operation.  It would be quite beyond our province to attempt any
 detail of the  various poisons and the effects they produce;  we can only
 observe  that they are all referable with tolerable accuracy to three heads,
 or to two of these combined, viz: (1) poisons which act as irritants, pro-
 ducing more  or  less irritation and inflammation of various organs; (2)
 poisons which act as sedatives, causing paralysis, more or  less immediate
 and complete, of the nervous system; (3) septic poisons,  which  seem to
 annihilate the vital power, and induce rapid putrefaction of  all  the
 organic  fluids and solids.
   With  regard to the action of poisons there are two fundamental ideas
 which it seems desirable briefly to refer to.  One is, that when a minute
 portion of virus  is  introduced into the  system, it appears to multiply
 itself immensely, as if it possessed the power of transforming  healthy
 matter into its own  noxious nature.  Such a multiplication must take
 place when an unprotected person is inoculated with the matter of variola,
 the minute quantity of virus introduced reproduces similar properties in
 the contents of the numberless  pustules  which are formed all over the
 surface.   The same is,  doubtless, the case with all  infectious diseases,
 and with syphilis.  In the latter instance, it seems worthy of considera-
 tion whether the  great difficulty of eradicating  the taint from the system
 may not depend on  the less degree of constitutional disturbance which
 the virus occasions, and  its inferior tendency to eliminate itself by under-
 going certain  transformative changes.   May not the action of mercury
 be chiefly to promote these changes, and so render  the materies morbi
 more ready to be eliminated;  this seems both consonant with what we
 know of  its action, and supported  by its superiority over other druo-s
 which are capable of producing much more powerful excretory action.
 Were the action of mercury merely that  of increasing the action of the
 several emunctories, syphilis ought to be curable  as well by sweating,
 purging,  and diuresis, which is not the case.  On this view also we per-
 ceive the reasonableness of not salivating a patient profusely, but main-
 taining for a good while a mild but efficient alterative action.' The con-
 ception now mentioned applies more particularly to certain irritant poisons
 the second to those that are termed septic.  When spongy platinum is
 placed in a mixture of oxygen  and  hydrogen  gases, they quickly unite
 together  and  form water, the  platinum  itself undergoing  no  change
 This is an example of what Berzelius named "catalytic action;" there
are many similar  known instances, and it is very probable that'actions
of this kind are  by no  means  infrequent in the animal  system.  The
solution of the food in stomach digestion is, probably, in part, dependent
on a catalytic  action, or one of a somewhat similar  kind, in which the 
ANJEMIA, SPAN.EMIA.
81
peculiar organic matter called pepsin disposes the alimentary ingesta to
undergo solution in the gastric acids.  A minute quantity of the change-
inducing substance is sufficient to cause the action to commence, and so
it appears a minute quantity of virus is sufficient to induce septic changes
in the blood with which it is  mingled.  The  history of  cases of death
from the bite of venomous reptiles, of the most malignant fevers, espe-
cially scarlatina, and of the effects of the matter of glanders, shows that
the essential and  primary action of these poisons is to lower extremely
the vital powers, and induce putrefactive  changes  in the organic fluids.
If this action be not utterly overwhelming, the system takes alarm, and
manifests resistance and  reaction by setting  up the inflammatory pro-
cess ; but this, it is quite clear, is only the secondary result of the poison,
and not  essential.   In some constitutions  the vital power is weak, and
is seriously affected by comparatively slight agencies ; thus, it is recorded
that very alarming symptoms have been produced by the sting of a bee
and of a wasp.   The state of the blood when affected by septic poisons
will be hereafter described under the head of Necraemia, an appropriate
name which has been assigned to this  state by Dr. Williams.   Pyaemia
is the name given to a certain state of the blood somewhat akin to the
foregoing, in which an unnatural matter, that of pus, is present and  cir-
 culates with it.    The matter itself will be described hereafter when we
 speak of the products of inflammation, and  the condition  will be con-
 sidered as a general disease of the blood.
                     AN.EMIA,  SPAN^MIA.

  There can be little doubt that by excessive  hemorrhage, or exhaust-
ing discharges, the whole mass  of circulating fluid in the vascular sys-
tem can be considerably reduced; that is to say, the result of such losses
is not only to  impoverish the quality (as we know it  does), but to dimi-
nish the  quantity of the whole mass of blood.  The term ansemia, signi-
fying absence or deficiency of blood, is  therefore correct, though if it
were not so commonly received  and  employed, one might wish to  sub-
stitute the  term oligemia.   Spansemia is the name proposed by Dr.
Franz Simon to express a deteriorated quality of the blood {anavo^, poor);
it almost always accompanies the state of oligaemia, or anaemia;  both
may, we are inclined to think, exist not unfrequently as the sole  con-
dition itself, the blood being of normal quantity, but impaired quality.
We will  here  recapitulate shortly the  changes which have been before
detailed  in  the  several constituents of  anaemic and spanaemic blood.
(1)  The red corpuscles are remarkably diminished,  127  being the
average  per 1000;  they have been  known to sink as  low as 27;  they
also appear to contain less haematine, being somewhat paler than those
of healthy blood.  (2.)  The amount of white corpuscles does not appear
to be altered; in some  of our  examinations  they have  been found  as
numerous as in  healthy blood.  (3.) The fibrin is quite unaffected; it
was never found below the normal mean, and in cases where  inflamma-
tion of some  organ was present,  its quantity was  notably  increased.
(4.)  The solids  of the  serum have  not been found specially altered.
       6 
82
ANAEMIA,  SPANAEMIA.
 (5.) The quantity of water is more  or  less increased in proportion to
 the diminution of the globules; in the case above mentioned, where the
 globules were only 27 per 1000, the water was 886.
   The causes which produce anaemia and spanaemia are:  (1.)  Losses of
 blood, whether  natural or artificial,  the  red globules being thus  dimi-
 nished, their place is supplied in great degree only  by the absorption of
 water.   (2.) Profuse discharges of watery, mucous,  or albuminous fluids,
 such as occur in aggravated leucorrhcea, diarrhoea,  or in cases of cauli-
 flower  excrescence.   In these, it seems  as if the  blood-globules were
 melted down to supply the profuse  drain; probably they perish, or are
 not reproduced from want of  a proper nutrient fluid.  (3.)  Insufficient
 food;  the effect of a greatly improved diet in increasing  the amount of
 red corpuscles was very apparent in  a case under our observation, in
 which  iron had been previously administered, with some, but not marked
 benefit; while on the improvement of the diet the amelioration was rapid.
 Too often, no doubt, this  cause operates powerfully in  inducing the
 anaemia so common among young females of the lower  classes.  (4.)  De-
 privation of fresh  air and light; the effect of this can scarcely be over-
 estimated.  Even  the best food will not be converted into  healthy blood
 if light and air are withheld;  while a coarse and  insufficient nutriment
 will not prevent a person from having a ruddy color,  if he be much in
 the open air.  Of this we have frequent  instances among our laboring
 population.   (5.)  An unhealthy crasis of the  blood, in consequence of
 which  the existing blood-globules are imperfectly  nourished, and the
 development of new ones is hindered.   Such is the cause  of the ancemia
 in  persons  suffering from  degeneration  of  the  kidneys,  from  lead
 cachexia,  the cancerous diathesis, perhaps the  tubercular, and in some
 chlorotic  cases.   There can be no question that in  many cases, as is
 well described  by Dr. Williams,  the anaemia is not the cause but  the
 result of the amenorrhcea.   The  suppression of the natural  evacuation
 leaves  the blood in an unpurified  state, which is  unfavorable  to  the
 development of healthy haematine.  In the same way rheumatism may
 prove a cause of anaemia, and in several of Andral's cases, the globules
 at the  first bleeding were found not  to be below the ordinary average.
 Mental anxiety may probably also be considered as a cause of this kind.
 m  The symptoms of anaemia and  spanaemia depend  immediately  on the
 impoverished condition of the blood.   The face is pale  or sallow, accord-
 ing to the natural  tint of the skin; the prolabia are blanched from their
 cherry  red;  even the tongue presents  unnatural  pallor.  The  con-
junctivae, it  may be  remarked, are  clear, which should  always  be  ob-
 served   and may prevent the error that has been sometimes committed
 of mistaking the sallow tinge of the complexion for a bilious, and  direct-
 ing the treatment accordingly.  In some cases there is a show of patchy
 redness on the cheeks, but  this is very different from  the natural diffused
 redness which  is seated in the capillary plexus,  and rather seems to
 depend  on the  congestion of some superficial  thin-coated veins, which
 naturally would not be seen.                                 '
   To the ear the  impoverished condition of blood announces itself bv
 certain  abnormal  noises in different  parts of  the  vascular  system
 lhese,  the so-called inorganic murmurs,  as distinguished from those' 
AN.EMIA,  SPANAEMIA.
83
which  depend  on structural alterations, are commonly heard over the
base of the heart, and at the root of the neck on either side.  The first
are produced at  the origin of the aorta, or of the  pulmonary artery,
and are probably, as Dr. Williams believes, of the nature of ripples, the
natural inequalities  of the surface over which the current passes being
sufficient to occasion in  its dilute and diminished condition " vibrations
and sonorous  gushes,"  which would not occur in  a fluid  of  greater
density.  The latter are generally believed, and no doubt correctly, to
be seated  in  the larger  veins;  they probably depend, partly on the
vibration of  the valves, partly on local compression, which causes  a
sonorous gush, where  the fluid passes from the narrowed channel into
the wider.1   It must not,  however, be omitted, that  these murmurs are
not absolutely a sign of  anaemia; they are also audible, though with less
intensity, in many  young persons, and in  some aged, who present  no
trace of this condition.   As  the impoverished blood runs the round of
the circulation, all  the parts that are dependent upon it for the main-
tenance of their  several powers become more or less injuriously affected.
Those in which the  process of decay and repair is most active, of course
will suffer earliest  and  most.  Accordingly, we find the muscular and
nervous system the  seat of most marked disorder.
    The heart, illustrating the converse of the aphorism, that "repose is
the revelation of power," betrays its feebleness by the weak and thready
 state of the radial pulse, by the coldness of the surface and extremities,
 and by the sudden,  brief,  often palpitating or irregular character of its
 contractions.  The least  bodily or mental excitement  is  sufficient  to
 cause violent palpitation, as if the organ were conscious of its weakness,
 and strove by the frequency of  its action to compensate for the imper-
 fection of it.   Sometimes, even without any excitement, the heart beats
 very forcibly, so much so, that an inexperienced  observer might easily
 be led to suppose  the  organ hypertrophied; but the  sharp knocking
 character of  the impulse is extremely distinct from  the  steady, strong
 heaving  swell of  the  real  hypertrophy.   Such  continued increased
 action of the heart is  as much due to an abnormal condition ot  the
 nervous as  of  the muscular system.  The contractile power ot  the
 muscles  generally  is impaired, and a  slight effort  induces fatigue  or
 even  faintness;  there  is no capacity for any sustained exertion;  the
 bowels are often costive, apparently from want of tone in the muscular
 coat,  which should propel the  contents onward.  The  disorder of  the
 nervous system  is especially manifested by the increase or perversion of
 the natural sensibility.   All causes of pain or uneasiness produce more
 than their  usual effects;  a variety of anomalous distressing sensations
 are complained  of,  some of which are fugitive, or  affect one part after
 another, but one at least locates itself with remarkable constancy in  the
 feft side or hypochondnum.   It is difficult  to say what is the real state
 of the morbid action that occasions these pains, whether it  be in  the
 cen ral organs,  the pain,  according to a well-known law, being referred
 to the Peripheral termination of the fibre, or as we are rather inclined
 to thi^riocated in the  nerves themselves,  their delicate  substance being

    i Kivisch, however,  earnestly contends for the arterial seat of spaneemic murmurs. 
84
ANEMIA, SPAN.EMIA.
 in some degree disordered by the imperfect nutrition  afforded by the
 impoverished blood.   The sympathetic nervous system is  also affected;
 the appetite is lost or sometimes strangely perverted, so  that the patient
 will eat chalk, cinders, sealing-wax, &c.; the stomach becomes irritable,
 and often cannot tolerate substantial food or tonic remedies, or, together
 with the intestines, secretes enormous quantities of gas.   The nerves of
 the kidneys are often so affected, that the secretion of the organs is
 materially modified  for  a  time, and  a copious flow  of  almost aqueous
 urine takes place.   Or, those of the bladder may be  affected, and there
 may  be either inability (supposed) to void the  urine, or  to retain  it.
 The nerves of special sense may be affected, and intolerance of light and
 sound,  flashes before the eyes, and noises  in the ears, may be present.
 The intensified action of the heart has been already referred to.  All
 these symptoms indicate that  condition already described, in which the
 sensibility of the incident nerves themselves appears  increased, and the
 receptive and reactive power of the nervous centres also.  The nervous
 system  in the anemic condition may be likened to a spring, which origi-
 nally was of a certain  strength, requiring a certain impressing, and
 reacting with a corresponding force, but having become much weakened,
 is bent  by a much less force, and reacts also with much  less.   Mobility
 and debility may be said briefly to be the  chief characteristics of the
 nervous actions in the  anaemiated.   Dr. Williams, remarking on the
 nervous excitement of anaemia,  and contrasting the (apparent) increase
 of this  function with the failure of others, is  inclined to account for it
 by the   circumstance, that  the encephalic  bloodvessels, being  less
 exposed to atmospheric pressure than the vessels of other parts, are apt
 to  contain relatively more blood then, under the circumstances, than
 they  should.  This  undue supply  of blood,  if  the  heart's action be
 hurried, or excitement be otherwise induced, may produce an  erethism
 Of the nervous centres, with the  symptoms above mentioned; or if the
 heart's  action be languid, it will stagnate, and  occasion headache,
 relieved by the recumbent posture, drowsiness, impaired mental faculties,
 or even, in extreme cases, coma.  The stagnation probably takes place
 chiefly in the large veins and sinuses.  We confess that we doubt the
 correctness  of Dr. Williams's fundamental assumption,  that  the ence-
 phalic bloodvessels, in the anemic  condition, contain more than their
 due share  of blood.   We have  seen so  often in autopsies  the most
 marked  pallor of  the membranes, and emptiness of the  bloodvessels,
 except the large venous trunks, that we cannot think the peculiar posi-
 tion of  the vessels exempts them at all from  being in a like condition,
 as to fulness or emptiness, with those in other parts  of  the body.   In
 fact, the sub-arachnoid fluid is to them what  the atmospheric  pressure
 is to  others;  and hence an anemic brain is commonly a "wet" one__
 i. e. the  sub-arachnoid fluid is increased.   The real  cause, we believe
 of the nervous excitement which is apt to occur, is the altered condition
 of the nervous matter, both white and gray, in  consequence of its defect-
ive nutrition.  Hence (like the weakened spring) it becomes so suscept-
ible, that it is injuriously affected by even natural and  healthy excitants.
 Perhaps, also, deficient tonicity of the vessels may contribute, in part"
to increase the cerebral excitement.   This would allow of an increased 
ANEMIA,  SPAN^MIA.
85
flow of blood to the brain, and also make it be attended with throbbing,
on account of the flaccid state of the conducting pipes.
  Weak digestion, or apepsia,  is a very frequent  accompaniment of
anaemia, and is  doubtless occasioned  by the debilitated state of the
muscular  coat of the  stomach,  as well as by the deficiency of gastric
juice, which  the follicles are unable to furnish, in consequence of their
owTn nutrient supply being defective.  Hence arises  a  further cause,
which continues  and aggravates the  anaemia.  Healthy chyle cannot,
of course, be formed to renovate the blood, if the digestive function is
seriously  impaired.
   Some of the results of anaemia may next be noticed.   Several  in-
stances have  occurred in which  the nutrition of the heart had suffered
so  much, and the organ  become so debilitated, that sudden  and fatal
syncope was the  result.   The possibility of this should always be borne
in mind in treating a case of severe anaemia,  and the patient should be
enjoined to avoid sudden efforts, and to remain as quiet as possible until
some degree of strength and tone is restored.   It is  a question of much
interest, but  as yet we believe  not determined, whether  the  increased
action of the heart above  described  ever produces  structural change.
It would  be  thought likely that a weakened  hollow organ,  contracting
repeatedly for a  long  time on a  mass of  blood poured into it, would be
apt to yield somewhat to the outward pressure or resistance of the fluid,
and thus  become dilated; but it does  not  seem to have been shown that
this actually takes place.   Some degree  of anasarcous swelling of the
feet and ankles is not uncommon.  When this occurs, we may take it as
a sign, on Andral's authority,  that the albumen of the serum is dimi-
nished.-  Asthenia may advance to such a degree, that it proves fatal by
a gradual failure of the vital powers, like the sinking at the close of
diseases of exhaustion.   The impoverishment of the blood may probably
be the determining cause  of the appearance of  tuberculous or other
cachetic diseases. Dr. Williams describes a fatal termination to anaemia,
which we have  not actually witnessed,  although we have seen  more
than one occurrence  so  closely similar,  that we are convinced of the
correctness of his account.  The importance of the subject makes us un-
willing to abridge Dr.  Williams's description: "A young female becomes
anaemic;  and after exhibiting various symptoms of  feeble general cir-
culation,  with headache, drowsiness,  and impaired sensorial^ functions,
suddenly becomes worse;  passes into a state of stupor, with "dilated
pupils, sometimes varied by slight manifestations of delirium, throbbing
of the carotids,  and partial heat of the head, and dies comatose.   On
opening the head, a small quantity of serum is found under the arach-
noid and in the  ventricles, sometimes with a little lymph (in one case
there was none).  The vascularity of the membranes  is remarkable,
but the vessels most distended are the veins,  and in the larger of these,
 and  in the  longitudinal sinus,  there  is a firm coagulum.   In parts,
 especially at the torcular Herophili,  this coagulum  blocks  the whole
sinus, and exhibits  a  separation  of fibrin, portions  of which  are soft-
 ened  down  into that  opaque  purilaginous matter,  which  was long
 mistaken for pus, but which Mr. Gulliver has shown to be a mere disin-
 tegration of the fibrin,  which  mere  stagnation  in a warm  tempera-
 ture may effect.  These have been taken for cases  of meningitis. # JNo 
86
ANAEMIA,  SPAN.EMIA.
doubt  inflammation may  supervene  in  them occasionally; but  in  two
cases that have fallen under  my notice, there  was no adhesion of the
arachnoid, nor deposit upon it, nor  any other  unequivocal mark of in-
flammatory action; yet the fibrinous and bloody concretions in the veins
and sinuses were most remarkable for their size and firmness."
   In  the cases of similar  nature which have fallen  under our own ob-
servation, the veins  of the lower  extremities,  one or both, have been
affected.  Owing to  the  kindness  of Dr. Cursham, we  had  lately an
opportunity of examining  a very marked case of this kind.  It occurred
in a youth who died in the Brompton  Hospital with empyema  of the
left side, and  tubercular disease of both lungs. The body was emaciated,
exceedingly anaemic, both lower limbs highly anasarcous, and  traversed
here and there by superficial veins, distended with dark blood, and feel-
ing hard and cordy.   One limb had first become anasarcous, and after-
wards  the other; no  symptoms of phlebitis appeared to have existed.
The lower part of the vena cava inferior, and all the veins below, as far
as they were  traced (to below the  knee), were  blocked up by coagula,
of more or less decolorized fibrin.  In many places, the  exterior layer
of the coagulum had almost assumed a membranous appearance, and
was very closely adherent to the wall of the  vessel.  It could,  however,
be completely detached by a little care, and then the coats of the vein
appeared perfectly natural.   They  had  their normal elasticity  and
firmness, and were not even for the  most part  stained with blood.  It
was evident  that their tissue  had not  been inflamed.   The  fibrinous
coagula in several places were somewhat softened, and rendered slightly
spongy or reticular in their interior.  This was due  to a spontaneous
transformation taking place in  the mass.  Instead of presenting a dense
network of fibrils, set  in an hyaline substance, interspersed with a little
granular matter, and with  a few corpuscles, which was  the case with  the
outer  layer of a coagulum found in  the right  ventricle,  the  softening
fibrin from the interior of the coagula in the  large veins consisted of an
immense number of various-sized corpuscles, some quite similar to glome-
ruli, imbedded in a mass of granular  and oily matter, with scarce any
trace of the fibrillar network.  This  change  in  the fibrin  was evidently
not such a mere disintegration as a warm temperature might  occasion;
had it been complete and  general it would have led to the breaking up
of the coagula, and the restoration of the circulation.  In other instances
that we'have  seen, under the  influence  of appropriate treatment, this
actually took  place, and  all obstruction disappeared.  It is very con-
ceivable how anaemic blood, with  its vitality  generally lowered, and
especially deficient in  the organized living cells, shall tend, particularly
when it is propelled in a  sluggish  current by a languid  heart, to pass
into that condition which it spontaneously assumes when withdrawn from
the influence of the living tissues:  and  it is  very manifest how import-
ant it is to be aware of the tendency which exists to such an event, and,
if it occurs, to appreciate its real nature, and not to regard it,  as might
easily be done, as the result of inflammation.   The  nutrition of some
parts in the anaemic may be impaired to  such an extent that ulcerations
form  spontaneously.  The  cornea would appear  especially  likely to
suffer in this way from not being  permeated  with vessels.   Such  in-
stances of morbid action  are very important to notice, as being free 
HYPEREMIA.
87
from complication, and exhibiting, therefore, more clearly the essential
nature of a process.   Ulceration in this case is clearly not produced by
inflammation.  It is rather interesting to remark, that the most lowly
organized and the least essential of all the tissues, viz: the adipose, suffers
less from impaired nutrition in the anaemic state than any other.  It is
by no  means uncommon to see persons, especially females, presenting
a  considerable amount  of  embonpoint,  who  are  manifestly very defi-
cient in healthy  blood.   This is the more easily comprehensible, as  the
fat vesicles really seem to be scarce more than so many minute drops
of exuded oil, included in homogeneous films of protein material.

   The foregoing history of anaemia and spanaemia manifestly relates to
it as a general condition.  It seems very doubtful how far there  can
exist such a condition as partial anaemia, if we recognize a deficiency of
red corpuscles as  an  essential  feature of this state.   Of course,  the
supply of blood to a  part  may be defective  in consequence of various
causes, but  this  does  not involve  any alteration  in  the quality of  the
fluid transmitted to the part.  However, using the term in the  sense of
merely deficient supply of  blood, the consequences of  such a state  will
be generally those of diminished nutrition, or, more properly,  atrophy
 of the part, with more or less considerable impairment of its function.
 If the deprivation of blood be very great, mortification may be the result;
 this has occurred in some cases in which the main artery of a limb  had
 been tied on account of  aneurism, and the collateral circulation did not
 establish itself soon enough.   Even  in cases which have a more favora-
 ble issue, the immediate effect of cutting off the supply of blood is to
 occasion weakness, numbness, and reduction of  the temperature ;  the
 muscles and nerves are, in a great  measure, paralyzed, and the heat-
 producing process fails with that of  nutrition.   When the aorta of an
 animal is tied, its lower extremities,  after a time, become as paralyzed
 as if  its spinal cord had been divided.   The causes of local or partial
 anaemia may be, (1) tumors of various kinds situated so as to press upon
 and obstruct the main artery  supplying the part;  (2) disease often
 atheromatous, of the coats of the vessel  itself leading to deposition of
 fibrinous coagula, and consequent obstruction of  the channel;  (3) spon-
 taneous coagulation  of the  blood in an artery; (4) blocking up  of a
 vessel by fibrinous flakes transported from a  distance, perhaps  from the
 valves of the heart; (5) withdrawal of the nervous influence from a part,
 in consequence  of which its nutrition fails.
    It  may be observed,  that it is difficult in many cases  to say positively
 whether anaemia of an  internal organ exists;  we cannot observe during
 healthy life what amount of blood as indicated by its color it  contains,
 and  he changes in the distribution of blood which may ensue during
 Zf last  houTof life, and  after death, will greatly alter  the natural
 appearance.

                            HYPEREMIA.

    TT^npr^mia  the opposite condition to anaemia, implies, of course, an
    l^^tojrtL*.   The term is commonly applied to accumu-
excessive 
88
HYPEREMIA.
lation of blood in a part, /. e. to local or  partial excess, while plethora
(nx^oj, a multitude) is  that which is used to  signify increase  of  the
general mass.   We will first consider plethora, or general hypcraemia,
and afterwards partial.
  The characters of marked plethora are  strongly expressed, and easily
discernible.   The face is rather full and turgid, and presents a diffused
redness, often of a  slightly purplish  tint; this  is especially observable
in the lips.  The conjunctivae  are redder than  natural, the expression
of the eye sharp and ferrety.  The pulse is full, and more or less strong.
The temperature of the skin is inclined to be hot, and even in the most
remote parts it is fully maintained.   There is  a tendency to  headache,
and not unfrequently there is some degree of drowsiness and disinclina-
tion to exertion.  Persons  in this state have good appetites, and digest
their food well, the secretions all seem to go on naturally, and organic
or vegetative life is in full vigor.   They  often lead sedentary lives, in
consequence of which the  waste of the tissues is diminished, and  the
plethoric state augmented, but  this is not constant.   In many,  a  con-
siderable amount of adipose  tissue  is formed, which, as Dr. Watson
remarks, may serve  as  a  kind of safety-valve  for the diversion  of  the
superfluous blood; no doubt this is true;  and we are  inclined to think
that the peculiar symptoms of  plethora are most marked when there is
no remarkable accumulation of fat.   On account of the increase in the
quantity of blood it is manifest that complete oxygenation  of it must be
more difficult; hence, on any exertion the breath is apt to  be short, and
the action of the heart  laboring;  hence,  also, as Rokitansky observes,
the blood always  presents a  certain degree of venosity, as if never
thoroughly arterialized.  A very just distinction  is made between two
principal varieties of plethora, the sthenic and the asthenic.   Dr. Wil-
liams (whose description of them is  most excellent) considers that  the
difference between them depends chiefly on different proportions of con-
tractility and tonicity; that is, on the different degrees of the vital endow-
ments of the heart and vessels.   Doubtless these are increased in sthenic,
and diminished in asthenic plethora, but we cannot but believe that there
are other differences also.   The quality of the blood in all  probability ia
different, and  the vital properties of the other organs  are also different.
Generally, it  may be said, that in the one  the organic life and tone of
all parts is exalted, in the other proportionately depressed, while in both
the mass of blood is in excess.   Heat of skin, frequency (not, however,
great) of pulse, with fulness and hardness, keen sensibility, mental and
bodily activity and energy, a tendency to gout, bilious attacks, and  dis-
ease of sthenic type, characterize the first form of plethora.   It is
observed in the "young, the active, and those of sanguine temperament."
"Its tendency," according to Dr. Williams, "is to cause general febrile
excitement,  active hemorrhages, fluxes, and inflammations."   Dr. Wat-
son, on the other hand, remarks that the subjects of  plethora are not,
as they might naturally be supposed to be, and as many writers state
them to be,  peculiarly prone to suffer inflammatory complaint.   "There
is general fulness of the vascular system, but  no irregularity, nor any
necessary tendency to irregularity, in  the  distribution  of the blood."
We are inclined to  think Dr. Watson's opinion  the more correct of the 
HYPEREMIA.
89
two.  In asthenic plethora the skin is cool, the extremities apt to become
cold; the pulse  is large, but without resistance;  it is often slow, some-
times irregular.   The venosity of the blood is marked, the lips are often
of a livid tint.  The contractility and tone of  the muscles is deficient,
the spirits depressed, the mental and bodily activity diminished.   It is
most often seen in the aged, in  those who are  exhausted by excesses or
previous disease, "or in whom  the excreting organs act imperfectly."
This latter condition, involving the imperfect  depuration of the blood,
is not a  cause  of the  plethora, at least  not  to any great degree, but
rather of the asthenia modifying the plethora.  The tendency of asthenic
plethora, Dr. Williams says, is to produce congestions and passive hemor-
rhages, fluxes and dropsies, and if continued, structural changes in  some
organs,  as dilatation of the heart,  enlarged  liver, varicose veins, &c.
Most of these effects, in our opinion, imply a  further alteration of the
crasis of the blood than belongs to uncomplicated plethora.   What has
been termed  " excrementitious  plethora," seems  to be nearly the  same
 as asthenic plethora, with impaired action of the excreting glands; this,
 Dr.  Williams  thinks,  may arise  from mere  stagnation,  or imperfect
 motion of the blood, in consequence of which "it becomes  loaded with
 urea, lithic and lactic acid, and other effete materials, which unfit  it for
 its  proper uses, and irritate and  disorder the organ through which  it
 passes."  A more likely cause of  such a state of blood we believe  to be
 the  existence  of unobserved  organic disease of the kidneys or  other
 glands.   The characters of the blood in sthenic plethora are : (1.) The
 increase and amplification of the entire mass.  Of this we have no direct
 measure, but we may form a tolerable idea of the extent to which it takes
 place by observing the effect of bloodletting.  As much as forty or fifty
 ounces may be drawn  at once in some cases without fainting being pro-
 duced and even this quantity has sometimes been exceeded.  Dr. \\ atson
 mentions a case in which seventy-two ounces were withdrawn before the
 patient became  faint.  Not only  does  the system tolerate these  large
 losses of blood, but judiciously employed they are highly beneficial; the
 patients  are relieved  and refreshed by taking off a part of the mass
 which loaded the vascular system.  So conscious are they ot this, that
 those who "make  blood fast," as the popular phrase is, will come and
 request  to be  bled, often at the spring of the year when the  blood-
 making process seems to go on more actively.  (2.) The red globules in
  nlethoric blood are remarkably increased, while the fibrin rather inclines
  to be  somewhat diminished, and  the  albumen, of the serum undergoes
  little variation.  The quantity of water being diminished in proportion
  to the increase of the red corpuscles, it follows that the coagulum formed
  after bleeding will be large, and will be surrounded by but little serum
  The mass of corpuscles in proportion to the fibrin is so great, that the
  latter cannot contract to the degree  it ordinarily does, and hence a larger
  amount of serum is retained within the clot. _  In sthenic  plethora, the
  coacrulum is firm as well as large, in asthenic, its cohesion is diminished.
  (3 f A tendency to deficient arterialization may also be mentioned as a
  character of plethoric blood;  perhaps we may  connect  this with  a den-
  "oductln of fibrin, whi?ch, as we before  statedmay wi h  much
  probability be regarded as  an oxidation product.  Should this  be the 
90
HYPEREMIA.
case, there would appear some ground for accepting  the following view,
which is only offered as a suggestion.
  The perfectly homogeneous aspect of some of  the casts of the renal
tubules which are found in  the  urine when fibrinous  fluid has  been
draining off from the congested bloodvessels, suggest the possibility that
fibrin may be particularly applied to the formation and  renewal of the
various homogeneous membranes, such  as  the  limitary membrane of
gland  tubes, the sarcolemma  of  muscular fibres, the wall of capillary
vessels.   If then in some cases of plethora (the extreme  ones) the fibrin
is much diminished, it is very conceivable that  the  walls of the capil-
laries are less perfectly formed, and consequently less able to resist the
interior pressure of the amplified mass of blood.   This would, of course,
favor the occurrence of hemorrhages, especially such as  capillary apo-
plexy in the  brain.
  Among the causes of plethora, the first place, perhaps, is to be assigned
to a special tendency innate  in the system  to form an undue quantity
of blood,  or, speaking more exactly, to a too rapid growth and multi-
plication  of the red corpuscles.  This, as it  requires, so it may  produce
an increased quantity of Liquor Sanguinis, according to the principle
that the demand induces a supply.  When the tendency to form blood
is  considerable, it will manifest itself even in  spite  of circumstances
that oppose it; but a similar tendency, in much less degree, will  produce
a most highly plethoric state, if favored by an ample supply of rich food
and a sedentary life.  Indeed, these may have  the  same effects,  even
supposing no predisposition  to plethora at  all  to exist.   It  is worth
remarking, however, that they will not produce this result in all cases.
In many  it would be rather dyspepsia, or some  cutaneous  disorder, or
a bilious attack.   Most of the circumstances that promote a robust  state
of health, with the exception  of exercise, are favorable to plethora, and
on the other hand, such as depress the general vigor, or  induce  diseases
of debility, prevent its development.1   Asthenic plethora is probably in
most cases dependent upon an unhealthy state of the Liquor Sanguinis,
occasioned by impaired action of some of the excretory glands, which
itself may depend on some latent organic diseases of the same.
   The consequences of plethora have  already been  in part  alluded to.
They are generally such as result from over-distension of the  vascular
system.   On account of its proximity to the  heart, its delicate structure,
and the large supply of  blood it receives, it  is not  surprising  that the
brain sh<juld suffer from this cause more than most other organs.   Rup-
ture of some of its thin-walled vessels may   take place,  or the blood be
poured out from numerous capillaries; and  this,  of  course, will be still
more likely  to occur, if another consequence of plethora be  present,
viz : cardiac hypertrophy.  It is easily conceivable  how the increase of

  1 There is no doubt that the cessation of habitual  discharges, or their arrest by art,
especially when suddenly effected,  and without any corresponding modification  of the
system, induce  a dangerous plethora. This should never be forgotten, not only in treat-  *•
ing persons who are manifestly of plethoric habit, but even those  who seem and are really
in a different state.  It seems that  the  vascular system, after having been long insuffi-
ciently filled with blood, cannot bear the amount of distension immediately which in the
state of health would only be natural to it. 
HYPEREMIA.
91
the mass of blood shall require and gradually induce an augmentation
in the power and capacity of the organ that keeps it in movement.  In
sthenic plethora the hypertrophy will be more pure and simple, in asthenic
it will be associated, in a greater or less degree, with dilatation.  The great
capacity of the vascular system of  the liver will cause it to be enlarged
by the increased distending force of the blood mass, more, in proportion,
than many other  organs.   This  will be especially the  case  if dilated
hypertrophy of the right chambers exist, and the blood is thrown back
on the venous side of the circulation.  Again, in consequence of hepatic
congestion, the tributaries of the portal vein will also be congested; and
this seems more especially  to affect  the hemorrhoidal plexus of veins,
which become distended into the little tumors, well known as "piles,"
and often give rise to a salutary  hemorrhage.  Another hemorrhage,
not unfrequent in plethoric persons, especially the young, is from the
veins of the nose.  This seems especially to give relief to cerebral con-
gestion.  Menorrhagia may also be dependent on, or at least greatly
increased, by a plethoric state.   The natural determination of blood at
the catamenial periods will of course be  often  attended with a greater
discharge, on account of the increased tension of the vascular system.
Though we consider it at least doubtful whether the plethoric are more
prone to inflammation than others, there  is no doubt that when inflam-
mation is set u|> in them it is more violent, and requires  more  active
treatment.  Dr. Copland states also that the severer forms of inflamma-
tory fever in the West Indies affect young and plethoric strangers rather
than older residents, the  aged, and the  weakly.   Bilious, gouty, and
renal disorders, especially such as belong to the lithic-acid diathesis, are
often considered as proceeding from plethora;  but it may, perhaps, be
questioned whether they do not  rather take their origin in  the causes
of the  plethora itself, the high feeding, insufficient exercise, &c.   It is
not improbable that plethora may  play some part in  producing a vari-
cose state of the veins, but it is very doubtful whether aneurismal disease
is ever occasioned by it.

   We must remark with regard  to Local Hyperemia, as  we did with
respect to local anaemia, that it differs from  general hyperaemia, or ple-
thora, not only in the less extent to which it exists, but in not involving
 any qualitative alteration of the blood.   Local hyperaemia, in fact, is
not exactly local plethora; it  simply implies  that too much  blood is
 accumulated in the vessels of a  part, without taking  any  count of the
nature of this blood.  Hyperaemia  of a  part is a phenomenon which
naturally attracts attention, and has been considered and commented
 on from the earliest  times.  It  exists  in  the most various  conditions,
 from that of increased vital power and functional activity of an organ,
 to that  of cessation of all action in it, its death and decomposition.  One
 of the best examples of a physiological and natural hyperaemia is afforded
 by the female breast during the  period of lactation; the vessels proceed-
 ing to  it  enlarge considerably,  and it manifestly receives much more
 blood than at  other times.   So great is  the flow  of  blood to the part,
 that it  not  unfrequently happens, owing to a deficiency  of secretory
 power, that the healthy hyperaemia becomes excessive, and a cause of 
92
HYPEREMIA.
inflammatory disease.  The limits of physiological hyperaemia are pretty
wide.  It is often striking to observe how much more blood is contained
in the vessels of a part that  is actively employed, than would be  present
there under ordinary circumstances.   Indeed, there is much to lead one
to the belief that it is not so much  the  amount  of  hyperaemia that de-
termines the transition from  the healthy  to the  morbid  state, as the
alteration of the vital condition of the tissues of the part.  In endeavoring
to study the various conditions under which hyperaemia occurs, we cannot
do better than adopt the arrangement proposed by Dr. Williams, and
consider, first,  hyperaemia with  diminished  motion of the blood in the
part; second, hyperaemia with increased motion;  thirdly, hyperaemia
with motion  partly  increased,  partly diminished.   The first of these
states may be designated congestion; the second, determination of blood;
the third, is inflammation.   This arrangement has the advantage of
classing together several conditions, in which hyperaemia is a prominent
phenomenon; but it is not certain, especially as respects determination
of blood and inflammation, that it is correct; or rather,  that it may not
prove a source of error by not being  founded on  that which is the
essential circumstance in these two conditions.   This, at present, is not
possible, from the imperfection of our  knowledge; but it may be  well to
bear in mind the above caution.
   Congestion—employing the term  to signify excess of Jblood in a part
with diminished motion—affects chiefly the small veins of the part, and
the capillaries that communicate with them.  Hence,  its color  is inclined
to be of a dark  venous tint, unlike the more vivid blush of inflammatory
redness.   The part often exhibits patchy, irregularly-distended vessels,
which can be emptied by pressure, but gradually fill  again.   Its  tempe-
rature is not much,  if at all,  increased;  and the pain felt in it is rather
aching or dull than acute.   The degree of swelling varies according to
the cause producing the congestion,  and other circumstances; generally
it is not very great.  Congestion may exist alone, but  often there are
present also some exudations, the results either of it, or of the condition
which gave rise to it.
   The two principal causes which produce congestion are: (1.) Obstruc-
tions of various kinds to the  return of blood through the veins.  (2.) A
relaxed and toneless state of the capillaries  and small  veins.   Of the
first cause we have a good example in  tying up the arm for  venesection;
the current of blood setting  towards the heart being obstructed, and the
artery continuing still to pour in fresh quantities, the capillaries  and all
the veins up to  the obstructed part become distended with blood.  This
is marked by the red or purple color of the part, and its swollen condi-
tion.  The same effects will of course be produced in  all  instances where
the veins of any organ are obstructed  ; obstruction of the juo-ular veins
produces congestion of  the brain, of the renal veins, congestion of the
kidney, and so  on.   The modes in which the obstruction  may be  pro-
duced are very  various; to take the brain as an  instance, the veins re-
turning the blood from it may be pressed on by an enlarged thyroid, or
by a mass of indurated glands, or by an aneurismal tumor.  Temporary
cerebral congestion may also be caused by a prolonged expiration, or by
holding the breath,  especially when muscular exertion  is made at the 
HYPEREMIA.
93
same time.  The arrest of the blood in the veins in these cases depends
partly on the diminution of the capacity of the chest which takes place
during expiration, partly on the suspension of the respiratory movements,
which  cause the blood as well as the air to rush into  their respective
cavities within the thorax during inspiration.   Perhaps the very most
marked  instance of the  effects of this  arrest is manifested by severe
cases of hooping-cough.  The capacity of the chest is narrowed more
and more by the repeated expirations, and the blood not  being drawn
onwards, but thrown back, accumulates visibly in the face, which becomes
turgid;  in the eyes, where ecchymosis sometimes takes place; and simi-
larly,  though we cannot see it, in the brain, where extravasation  may
also occur, or  such congestion  as produces  an  attack of convulsions.
Obstructive valvular disease of  the  heart, throwing the blood back on
the lungs, is the cause of the abiding dyspnoea which characterizes such
complaints.  The condition of the large hepatic veins, and of the inferior
cava where it receives them, shows that the influence of inspiration must
be felt as a powerful  cause in  promoting the circulation through the
 liver; when this, therefore, is impaired, as is the case  in vesicular em-
 physema, or other diseases interfering with the respiratory movements,
 the liver will be congested, and the same will of course occur when in
 consequence of asphyxiating causes the blood does not pass freely through
 the lungs, but accumulates in the  right side of the  heart, and in the
 laro-e veins. Now, in all such instances of congestion it may be remarked
 tha°t there is no evidence of excitement of the part, if we except, at least,
 the occurrence of  convulsions in attacks of paroxysmal cough; the tem-
 perature of the part is not raised, the functional activity is rather  dimi-
 nished  than increased, and exudations from the bloodvessels,  if they
 occur, show no tendency to organization.  Everything indicates that the
 hyperaemia is merely the result of  a mechanical  cause, and that  there
 is no primary and special alteration of the vital endowments of the part.
 The  second  cause of congestion, viz :  atony of the vessels, may  occur
 either primarily or secondarily.   In adynamic fevers, in states of ex-
 treme debility, and perhaps in some persons whose tonicity is naturally
 defective, the vessels of a part become distended with blood, without any
 obstruction existing in the veins which convey their blood away, or with-
 out any previous inflammation or  undue excitement having exhausted
 their natural contractility.  The  whole surface  of  the  body, in some
  fevers  of very low type, is covered with patches of congested vessels, and
  it is  to be noticed that these are chiefly seated in the under parts, the
  blood gravitating downwards, and accumulating  in  this situation.  Hence
  we derive a hint for a precaution well worth observing in continued fever,
  viz •  to alter the  position of the patient occasionally, and not  to allow
  the'blood to gravitate day after day to the posterior parts of the  lungs,
  which  in consequence are especially prone to engorgement and hepatiza-
  tion    Primary atony of the vessels of the choroid coat of the eye seems
  not unfreoSy to  occur, and to  be the cause of the muse* vohtantes
  ?ovhu3l  tie dyspeptic and others are subject.  The vessels of the uterus
  in Das iveMenorrhagia, and  those of the vagina in non-inflammatory
   LcoiToea  are not  unfi'equently affected by primary atonic congestion
  It  s however, much more common that atony, of the vessels  occurs 
94
HYPEREMIA.
secondarily in consequence of some previous excitement or inflammation.
This, in fact, is almost always the case in persons of feeble power when
they are attacked  by inflammation;  when  the disease is subdued there
still remains  behind this congested state of the overstrained vessels,
which being naturally of weak  tonicity, are unable  to resume readily
their proper  caliber.  In persons  of  more  vigorous constitution, the
original tonicity being greater, the vessels quickly recover their normal
dimensions as soon as the strain  arising from determination of blood is
diminished; hence convalescence is  speedy, and the  restoration of the
part complete.  But when the system is naturally  feeble, or when inju-
dicious  treatment  has  rendered  a strong  system so,  then it may be a
most difficult  task to  revive the contractility of the languid vascular
coats, and remove the congestion which necessarily ensues.  A healthy
person may have an  attack of acute bronchitis, or pneumonia,  and if he
is properly treated he will recover completely, and bo scarce any more
liable to the disease than if  he had  never suffered at all.  But how dif-
ferent is it when chronic bronchitis is set up in the aged or debilitated;
the disease  commences generally without very severe symptoms, the
inflammation does not run high, it  may be soon in great measure sub-
dued ; but  after that is  accomplished, the capillaries of the bronchial
mucous lining are unable to resume  their tone, or  they resume it par-
tially, and easily lose it  again when they are exposed  to the slightest
strain, and so  the congestion occurs over and over again,  until the vessels
become mere flaccid channels gorged with slowly-moving blood, and pour-
ing out exhausting exudations of muco-purulent fluid.   It is very appa-
rent that the longer  the vessels  remain congested, the more difficult  it
must be for them to  recover their normal dimensions, and hence we
derive the valuable hint to subdue active inflammation in every instance
as quickly as possible, that the strain upon their walls may be lessened,
and when this is accomplished, to turn as soon as is prudent to remedies
of astringent and tonic character.  This condition of atonic congestion
is often seen in the conjunctiva  after it has suffered an  attack of acute
inflammation,  and  we can scarce  have a more valuable  lesson than the
observation of such cases, and of the Isedentia and juvantia offered us.
A case of this kind is related in  Mr. Tyrrell's work, vol. i. p. 24, which
from the first  time we read it has never passed from our mind;  and
often has the valuable instruction it conveyed been the means of direct-
ing us to successful treatment.   It shows how, besides the local signs of
atonic congestion,  the general condition of the system is also to be con-
sidered, and that, if  this be found in an  enfeebled state, no means will
be  nearly so  efficacious  in removing  the congestion  as those which
impart  tone and vigor to the tissues  generally, and to the vessels in
particular.
  Besides actual inflammation, over-use of a part may occasion conges-
tion of its vessels.   Of this we have an instance in  the congestion of the
choroid, which is so common in  those who exert their  eyes very much
upon minute objects.   An organ which has been secreting with unusual
activity  is  sometimes found  congested  with  blood.  This  we  have
observed in the  kidneys  of  diabetic persons; however, it  is  not con-
stantly the case by any means.   When it occurs, it is presumable that 
HYPEREMIA.                       95
the continued flux to  the  part  had weakened, by the  strain it caused,
the contractility of the vessels.   The influence of cold in producing con-
gestions of internal organs cannot be doubted.  To this we must ascribe,
in part, the prevalence of chest affections during the colder part of the
year, the blood being repelled inward from the surface by the constring-
ing effect of the cold upon the  vessels.  The same cause also must be
the chief agent in occasioning attacks of apoplexy, which have been ob-
served to be greatly more frequent during a very cold season than during
a mild one.  The effect of the  malarious poison  in producing conges-
tions of the internal organs is still more potent than that of cold. With
every paroxysm the  liver and spleen become greatly distended during
the cold stage ;  and to such an extent may this take place, that the lat-
ter organ, extensible as it is, has been  ruptured, and fatal  hemorrhage
ensued.   Posture is a very  efficient cause in  producing congestion.   It
has already been alluded to, when instancing the pulmonary congestions
that occur in fever;  but the most  marked  examples of its effects  are
 seen in  the lower limbs.   Here the returning venous  current has  to
 overcome  the force of gravity, and'though while the vessels maintain
 their tonicity, and  the valves of the veins  are  efficient, this retarding
 force does not produce any effect, yet when the conditions are altered it
 becomes  speedily manifest.  Persons  of feeble constitution, who  are
 obliged to remain for the greater part of their time in an upright posi-
 tion? laboring hard  and living poorly, are  exceedingly liable to a con-
 gested, thickened, and indurated state of the integuments  of the lower
 part of the legs and feet.   The veins proceeding from these parts—and
  esoecially  the  large superficial veins  of the limb—are seen tortuous
  X"edf  distended, and  varicose.  They  are  evidently  gorged  with
  slowl?-moving blood, the column of which, greatly enlarged in bulk  has
  much more difficulty in resisting the force of gravity than in the natural
  state   Such congestions proceed  very soon to  ulceration  which is apt
   oas'sume a slouching form, and which can only be healed by means
  which bring about  a^ore healthy circulation.  These are, of course
  directed to take off the force of gravity by the recumbent  posture, to
  empty the  distended vessels, and  to supply  by external  equable pres-
  sure the defective  tonicity of their walls.  It may, perhaps be ques-
  tioned  whether the class of congestions from this cause should not have
  been inc uded under those arising from venous obstruction,  as the  con-
  dition of the vein itself is such as to  create an  obstruction  to its  own
  current    Withdrawal of nervous influence from a part is sometimes the
  cause of congestion taking place in  it.  Mr. Simon records a case m
  which  after ?he ulnar nerve had been torn across at the inner condyle,
  The two nner fingers of the hand of the same side " had become swollen
    a i  •  with vafcular iniection."  Disease of the trigeminal nerve, de-
  ^X^^^j^ °ften been °bserved  \°r*siz
   Station and ulceration o/the eye, ^^^^J^
  sdiacent   This inflammation,  it  is most  probable, was  ratner  01 uie 
96                        HYPEREMIA.
endowment  of the vascular membranes, and only  capable  of being
affected by the action of the nerves, as well  as by direct stimulus. The
effect of an atonic state of the walls of the vessels is well illustrated by
an experiment performed  by Dr. Williams:  he adapted to a syringe a
tube with  two arms, one of which was connected with  a metal tube, and
the other with a portion of  dog's intestine,  of  the  same  length  as the
metal tube, but, when distended,  double its  diameter.   Water was now
thrown in by the  syringe, and the quantity discharged from the  open
ends of each of the two tubes estimated.  The metal tube in the same
time yielded three times more liquid than the intestine.   Now a vessel,
whose wall is possessed of a proper degree of contractility, may be com-
pared to the metal tube.   The force of the heart communicated by the
fluid to its walls is not lost, but reacts again immediately upon the fluid
and drives it onward.   The vessel, with  atonic flaccid walls, resembles
the intestine, which yielded to the distending force  of the column of
fluid,  and, from not reacting  upon it,  allowed a great part of  the force
to be  lost  as an impelling influence.
  The effects of congestion have already been partially noticed.  They
have reference mainly to two circumstances : one, the  impairment of the
vital actions of the part, the other, the effusion from the overloaded ves-
sels of watery, albuminous, or mucous fluids.   When the arm is tied  up
for venesection, a sensation of numbness, weakness, and chilliness, is
felt after  a  time, showing that the sensibility and  contractility of the
limb are impaired by the  congestion which has  taken  place.   In the
hepatic  and renal congestions, which  often are produced  by  obstruc-
tive disease of the heart, the  secretion of bile and of urine is commonly
diminished, or morbidly affected.   Cerebral  congestion interferes mate-
rially with the  free exercise of the functions of which the  brain is the
instrument.   This impairment of vital  (i.  e.  special) power  depends
partly on  the more increased quantity of blood in the  part, which, being
greater than  is proportionate to its  functional activity, overloads and
oppresses  it.   If it be true—as we shall see  reason  to think that it is—
that the supply of blood to  a part is, in a  measure,  dependent on the
vigor  and  energy  of life which that part possesses, it will not be difficult
to conceive that an over-supply of blood will have an injurious and de-
pressing effect on  the same vital  powers.   But a still  more powerful,
and quite  unquestionable, cause of vital depression  in a congested part,
is afforded by the altered condition of the blood itself, which, semi-stag-
nating in  the capillaries and veins, becomes more venous than it should,
and otherwise unfit for the healthy nutrition  of the tissues.  The slough-
ing ulcers which form in  the congested and thickened integuments of
the lower  limbs, when the veins are enlarged and varicose, are a striking
instance of the lowered condition of the vitality of those textures.  Long-
continued congestion of the liver, from disease of the heart, produces a
very remarkable effect on the  parenchymal cells.  They become very
greatly loaded with yellow matter (which does not appear to be true
biliary, but rather bile pigment); in extreme cases, the majority atrophy,
and are reduced to a mere granular detritus, while the capillary inter-
cell-spaces become enlarged.   These  changes afford  some  explanation
why the  secretion of bile is interfered with, and also  why jaundice 
HYPEREMIA.
97
occurs.   The effusions that take place from  congested  parts  are cer-
tainly the most prominent phenomena of the condition.  They will be
most  abundant, as  a general  rule, when the congestion depends  on
venous obstruction;  so that, while fresh  blood is  being poured into the
part, no exit can be found for it, except that which the exudation affords.
They may also be extremely abundant in some cases, in  which  not only
the tonicity of the vessels is entirely lost, but the texture of their walls
is altered,  so that they no longer oppose  any obstacle to the escape of
their  contents, but allow them (the fluid part) to transude wTith  great
facility.   Such  is, no doubt,  the case in  instances of bronchorrhcea,
chronic diarrhoea, and leucorrhcea,  where large  quantities of fluid are
continually passing  off from the toneless vessels, but where no venous
obstruction exists, or none that is commensurate to account for the dis-
charge.   The effect of remedies in these  cases shows that the discharge
is dependent on the cause we  have  mentioned.   Under the administra-
tion of turpentine or astringents the vessels regain their tone, and no
longer  pour out  their  contents.   Though the  vascular atony may in
such  states have originated in congestion, yet as this is removed by  the
 effusion while the atony  remains, they come at last to be rather instances
 of passive flux, or dropsy.   Chronic  ascites,  in which the  smaller
 branches of the portal vein may be so obstructed that no fluid can pass
 through them, presents  an exquisite instance of effusion depending upon
 venous obstruction.    The fluid effused in the peritoneal sac varies a good
 deal, chiefly as to the relative proportions of water and albumen  which
 it contains.  In the table subjoined at page 116, one  instance is seen in
 which the water amounts to 988 per 1000, and the albumen to  only 0.9,
 while in  another the water does not exceed 704, and  the albumen is in
 the prodigious  quantity of 290.   Not only does a more or less watery
 serum exude, but fibrin not unfrequently accompanies it.  Large flaky
 masses of fibrinous  coagula are not uncommonly found in the peritoneal
 cavity after death in cases of  ascites, and  the same are also seen occa-
 sionally in the  fluid evacuated by paracentesis.  We have  also seen
 blood-globules so uniformly dispersed through the fluid, that there could
 be no doubt that they had escaped from  the  congested sub-serous capil-
 laries, and were not accidentally mingled with the effusion.   The same
 products of congestion  also occur in the  urine when obstructive disease
 of the heart throws back the blood on the veins.   The secretion is albu-
 minous, contains fibrinous casts of the  tubes and blood-globules.  De-
 cided hemorrhage may  also occur, as the result of extreme congestion,
 which  may be dependent either upon venous obstruction or   upon an
 atonic state of the  vessels. Melaena, or hemorrhage from the. bowels,
 is an instance of the  first, passive menorrhagia and epistaxis,  of the
 letter
    We shall  return to  the consideration of effusions proceeding from
 congestion, when we speak of the results  of hyperaemia generally.   It
 is a remarkable and instructive fact,  that  congestion of parts never
 seems to occasion hypertrophy; or, if this should appear to have taken
 place, closer examination  proves  that rather the reverse »  the case;
 that the  hypertrophy is what Rokitansky calls  unreal,  xhus a large
 bacony spleen  or liver may  appear  to  be hypertrophied;  but the in-
        7 
98
HYPEREMIA.
crease in size is not due to the formation of fresh natural tissue, but to
the infiltration  and addition of an unnatural product,  among which the
real structure  is found  atrophied.  In  these  particular instances the
deposits  may not  have proceeded from congestion ;  but they afford an
exact illustration  of what often  takes  place in congestion in a less de-
gree.   It seems also very doubtful whether  simple passive  hyperaemia,
as such, does produce even these unreal hypertrophies, or whether in
all  such  instances the crasis of the  blood is not also altered in some
special manner.  After very numerous examinations of congested livers
from persons dying with heart disease, we have  not been able to  con-
vince ourselves that  the  hyperaemia gives  rise to any new product, or
that it is an exciting cause of the cirrhotic alteration which may also
exist.  We  have already  pointed out the  impairment of  vital  power
which congestion occasions, and the causes inducing it, which seem to
afford an adequate explanation of the non-tendency to growth and de-
velopment which  is  observed both in the affected part itself and in its
interstitial effusions.   The following sentence from Mr. Simon's lecture
recognizes  and similarly explains the same  fact:  "It is true,  that
much blood  is contained in the affected tissue;  but it  is blood that has
insufficient means of renewing itself; and from  its long detention in the
part it acquires, in an extreme degree, the character  of venous blood.
Thus, as regards mere bulk of blood,  the part is over-supplied, but, in
respect of the quality of blood, it may be said to suffer what is equiva-
lent to anaemia: accordingly, the elements of its texture fall into a state
of atrophic softening, which terminates in the formation of an ulcer.  I
think it not  improbable that the same fact may contribute to explain
the continued non-development of those  effusions which arise from  pas-
sive hyperaemia."   It thus appears that atrophy, rather  than hyper-
trophy, is likely to be the result of abiding congestion  of any part.
   The effects  of  congestion  of a part, especially if  it  be one  of some
magnitude, may not be confined  to the part itself, but may affect  the
system generally.   This appears in two respects, one being a degree of
faintness and depression, occasioned by the withdrawal of a consider-
able quantity of  blood, from active circulation;  the other,  an injurious
influence exercised on the whole blood  mass by the  deteriorated  por-
tion, which  slowly and partially returns into it again  from the seat of
congestion.  It is clear that an excess of blood poured into one part, and
detained there, must leave others imperfectly supplied; the local hyper-
aemia, according to  its extent, produces a  degree of  general  anaemia.
That blood which has long been stagnant in a part must be in  an  un-
healthy state is very comprehensible, and that, by its mingling with the
general mass of blood, deterioration of  the same will be induced, and
therewith a  cachectic state.  Thus, when a congested state of liver exists,
there are, frequently, abundant lithates present in the  urine; the blood,
returning from the  liver,  conveys into  the circulation matters  which
induce an unnatural state of the renal secretion and  more or less of
general disorder. 
HYPEREMIA.
99
    ACTIVE  HYPEREMIA. —DETERMINATION OF BLOOD.

   This is the second variety of local hyperaemia  that we have to con-
sider.  The general phenomena of this condition are manifestly different
from  those  of passive hyperaemia,  and convey the idea of increased
activity and vigor in the vital  process.   The flow of blood  to the part
is increased ;  the capillaries, without being greatly  distended,  are well
filled, and give a more or less suffused red blush to the face, very differ-
ent from the duller tint of congestion.  In consequence of this filling of
the capillary plexus, and, perhaps, also  of some slightly  increased  blas-
temal exudation, the turgescence of  the part is increased, and its  tem-
perature elevated.  The arteries leading to the seat of active hyperaemia
often  pulsate with more than ordinary force, so as to have given rise to
the idea  and term of "increased vascular action."   They must  also be
enlarged to  admit the greater quantity  of blood that the part receives,
and this enlargement  becomes permanent; that  is  to  say, the whole
vessel assumes larger dimensions, when  the hyperaemia is a healthy and
natural state.   The veins also  enlarge, but are not  distended  as  they
are in  congestion.  The sensibility of the part is commonly increased;
its function  may be, or may not, and the same is true of  its growth.
   This brings  us to the inquiry, whether active hyperaemia may not be
distinguished into two forms, one to  be  regarded as healthy, associated
with increased vital power  and capacity for  action ; the other  morbid,
attending upon  and promoting unnatural  action, resulting in  disease
and decay.  There are many well-known and oft-quoted examples of
healthy hyperaemia, such  as the female breasts during  gestation and
lactation, the uterus during the period of pregnancy, the gums during
dentition, the mucous membrane  of  the stomach while the secretion of
gastric juice is  going  on, and, generally, it may be  said, every organ
during the time of increased activity and employment.  Now, we think
it may be affirmed, that, in  the above instances, the most  important and
characteristic phenomenon is the  increased functional energy and vigor
of the hyperaemic part; this we believe to  be the main and essential
circumstance of which the increased  blood-flow is a sequel.   Nay, there
are many instances, especially among  secretory  organs, in which  the
great increase of  the product proves that a corresponding  increase of
the supply of blood must have  taken place; a  true  hyperaemia, in one
sense, exists, but it is not apparent,  because of the  active transforma-
tion which  is  going on.   How marked  is  the  difference between  this
condition and congestion !   In  the  one, functional activity and mole-
cular  change at  its  height, with vascular injection more  or less consi-
derable, but not varying in direct, rather in inverse, ratio to it; in the
other, vascular injection  extreme, while the functional activity is  ex-
tremely depressed.  Now, in proportion as  active hyperaemia  departs
from the physiological condition and becomes  morbid—that is to  say,
approaches  towards inflammation—in the same degree  does the vital
energy and  activity of  the  part appear  to be lowered, and  the  hyper-
aemia becomes  the more marked phenomenon.   Thus, a  diuretic drug
shall be administered to two individuals: in the one, the flow of urine 
100
HYPEREMIA.
shall be considerably augmented,  the vital power  of the  kidney predo-
minating over the hyperaemia  excited; in the other, the flow of urine
shall be diminished, and  the secretion become bloody and albuminous,
evidencing the predominance  of  the  hyperaemia over the vital power.
So, too, in fever.  The skin, at one  time, shall be dry, and burning,
and red, with vascular injection, but its vital power  of secretion and
exhalation is in abeyance.  But a change comes, the  tissue regains  its
functions, and pours  out  a healthy moisture on  the surface; and now
the hyperaemia, though it may continue in some  degree, is  no longer
predominant.   How different must be the  condition  of the gastric mu-
cous membrane in the hyperaemia excited  by a few grains of ginger,
and that produced by a few grains of arsenic!  No doubt the one form
of active hyperaemia may pass into the other.  The quantity of blood
which a healthy tissue was able to employ, and which was requisite for
the unusually vigorous discharge  of its function, may become too much
for the same tissue when debilitated by over-use.   A brain ministering
to an active mind,  requires and receives a greater supply of blood than
that of the waterman  " who rows  along thinking of nothing at all."   So
long as the cerebral energy is  not overtasked,  the  hyperaemia will tend
to no injurious result,  but will only supply the necessary pabulum for
the material changes  connected  with thought.   When,  however,  the
time arrives that the delicate organ needs repose, then if the strain be
continued, and the hyperaemia kept  up, it  is manifest  that a morbid
state  will soon supervene, in which  the  hyperaemia may yet further
increase, and the natural energy be still more  diminished, till, together
with symptoms of disordered  and erring action, inflammation,  or some
other result  of hyperaemia,  occurs.   The phenomena  we have alluded
to are of every-day occurrence.  No doubt can exist about their reality,
though different opinions may be entertained  as to how  they should be
interpreted.   We  shall immediately proceed to  consider more  closely
the different views that have been advanced, but we would ask especial
attention to this point which  we have dwelt on, viz: that in one form
of active hyperaemia, the vigor of the tissues for vital action is increased,
while, in the other, it  is  diminished.   In  the  one  the hyperaemia sup-
plies a want, in the other imposes a burden.
   Now, before we enter on the consideration  of the mode in  which
active hyperaemia  is brought  about, let us  refer shortly to one or two
physiological points, which must form the  very basis of all our attempts
at explanation of the  phenomena.  All tissues may be regarded as con-
sisting of vessels, nerves, and the proper elements of the tissue.  The
vessels, it is true, may be more or less closely  woven up with the tissue,
or even may not actually penetrate it, but still they are essential.  The
nerves  convey an influence which may affect the  bloodvessels or  the
tissue.   The elements of the tissue, be they cells, or originally derived
from  cells,  have certain special  endowments, which, when called into
action, increase the flow  of blood to the part; at least, this seems only
another  form of putting the  undoubted fact—that exercise of a part
causes more blood to flow thither.  The bloodvessels consist of arteries,
capillaries,  and veins.  The  arteries have a  truly  contractile coat,
which, under some kinds of stimulation, may  eyen produce obliteration 
HYPEREMIA.
101
of the channel.   This contractile coat  resembles, but is not quite iden-
tical with, organic muscular fibre.  It possesses, so far as we know, no
other property than that of contracting.   There is not the least reason
to suppose that it has any power  of  active dilatation.  The capillaries
have a simple, homogeneous, membranous well, in contact with the tis-
sue proper of the parts.  It does not  appear that this possesses any con-
tractility.   The contractility of the veins has generally been considered
much  more  doubtful  than that  of the arteries.   Weber did not  find
them respond to  the stimulus of cold as the arteries did.   Mr. Wharton
Jones, admitting that they do  undergo some variation in size, in virtue
of the contractility of their outer coat, still expresses himself clearly,
"that constriction or dilatation  of  veins cannot be observed actually
taking place, as it  may  be in the case of the arteries;" and "secondly,

                                Fig. 9.
                   Contracted artery, from Wharton Jones's Essay.

that the degree of constriction or dilatation which the veins in any case
present, is very small  in  comparison with that which the arteries un-
dergo."'   Professor Paget's observation seems conclusive as to the  con-
traction  of both  veins and arteries under a mechanical stimulus.  He
says  "if, as one is watching the  movement of blood in  a companion-
artery and vein, the point of a fine needle be drawn across them three
or four times, without apparently injuring them, or the membrane over
them, they will both presently gradually contract and close; then after
holding themselves in the contracted state for a few minutes, they will
begin again to open, and, gradually dilating, will acquire a larger size
than they had before the  stimulus was applied."   It must be noticed,
that Mr. Paget's  observation has reference to the  wing of the bat, while
Mr  Wharton Jones's conclusion has been formed from examination of
the'web  of the  frog.  The  former, as a warm-blooded mammal, is  no
doubt a better representative of man than the reptile.
   What we can see, by the  microscope, in  parts that are the seat ot
active hyperaemia, in  consequence of the application of a stimulus is
by the very accordant testimony of the best observers as follows:  W hen
a moderate irritant, such  as tincture of capsicum, or a drop of  some 
/
102                        HYPEREMIA.

essential oil, is applied to a transparent part, the arteries speedily di-
late, and a rapid flow of blood through  them  ensues.   This seems to
tell on the  capillaries and veins, which  become dilated  also, so that
vessels, which before scarcely admitted blood-globules, are now traversed
by great numbers.   Sometimes the  dilatation seems to be preceded  by
constriction  of the  artery; but this  does not  constantly occur, and
when it does, is  of brief  duration.    It  has been often said, that the
flow  of blood was accelerated in arteries that were contracted ; but the
reverse seems rather to be the  truth.  It is the dilatation of  an artery
that causes the current to become rapid, doubtless in consequence of the
less resistance opposed to the vis a  tergo of the heart.  Professor Pa-
get writes:  " As the vessels are contracting, the blood flows in them
more slowly, or begins to oscillate; nay, sometimes, even before the
vessels begin visibly to contract, one may observe that the blood moves
more slowly in them,  as  if this were the first  effect  of the  stimulus.
Nor  am I sure that I have ever seen (what is commonly described) the
acceleration of the flow of blood in  the  contracting  vessels.   Such  an
acceleration, however, is manifest, as the vessels reopen; and as  they
dilate, so, apparently  in  the  same  proportion, does  the flow of blood
through them become more free, till  at length it is quite manifest that
they are traversed by  both fuller and more  rapid  streams than passed
through them before the stimulus was applied."   Mr. Wharton Jones's
observation  is to the same effect: " In one case," he says, " the arteries
of the web were more or less constricted, the  circulation sluggish,  the
blood in the  capillaries here and there stagnant.  A  drop of  the solu-
tion  of sulphate of copper with  vin. opii was applied, whereupon  the
arteries immediately became dilated, and the circulation brisk."  Dr.
Williams, in  his work, so often referred  to, had previously maintained
and clearly illustrated the same view.   It may therefore be considered
established,  that in active hyperaemia one principal feature is  dilatation
of the arteries; while in  passive hyperaemia, the veins and the capilla-
ries  opening into them are dilated, and the  arteries  either are riot  en-
larged, or are constricted.   Now, it may very naturally be  asked,  in
what way does the  stimulus applied bring about dilatation of the ar-
teries ?  All that we know of the habits  of contractile tissues, leads us
to believe that they can only respond to a stimulus  by exerting their
Contracting power, and there is no known instance of active elongation.
How is it, then, to be  conceived that a stimulant, applied locally, which
does not affect the action of the heart, can cause dilatation of  the blood-
vessels ?   Henle conceives that the  stimulus,  acting on the  sensory
nerves of the part, excites in them a state, which, being communicated
to the spinal centre,  is reflected on the vascular nerves,  occasioning
them to  become  paralyzed,  and therewith the  contractile coat of the
vessels also.   This theory (the neuro-pathological), though it  has found
credit with many, really  seems only to  shift  the difficulty  from the
bloodvessels to the nerves.  It is just  as contrary to experience that
excitation of a sensory nerve should  paralyze a motor, as that the stim-
ulation of a contractile tissue should make it elongate.  Selling's modi-
fication of the Neuro-pathological Theory, rests on the assumption that
there is a continual reflected influence from the sensory upon the vas- 
HYPEREMIA.
103
cular nerves, so that when the sensory are paralyzed, the vascular are
paralyzed too, and when the former are excited, the latter are also ; but
if, as we know, a paralyzed limb can be the seat of active hyperaemia,
and if, as Mr. Simon has shown,  " the absence of a spinal cord, or the
division of all the roots of the nerves, or the section of the lumbar and
sciatic plexus, will make little or no difference as to the certainty with
which  an irritant, applied to the web of  a frog's foot, will quicken the
circulation there, and subsequently lead  to its retardation and arrest,"
it is abundantly clear jthat all such views  are quite inadequate to account
for the phenomenon in question.  It is to be remembered, that con-
traction and dilatation  of vessels, and increased and more rapid flow
of blood through them, are things that,  by the  aid of the microscope,
we can see;  but the  molecular movements of nutrition and secretion,
which  we believe to influence and modify the circulation through a part,
we cannot see;  they are as real and as potent,  but they are, except in
their results, invisible.   Feeling, however, the importance of ascertain-
ing  every cause  that we  suppose to  be concerned in the  production
of a phenomenon,  to be a "causa vera," we  briefly put together the
arguments which appear to us conclusive, that what we have called the
"nutrition force," and Dr. Carpenter the "capillary," does really exist,
and is concerned in producing the state of active hyperaemia.   (1.)
When a  part is not employed (a limb, for instance)  for  some  time,
it wastes and atrophies.  Its bloodvessels become smaller, and its tem-
perature  falls.  Manifestly, the  circulation of blood  through it  is di-
minished.   (2.) When  a part  (as a limb) is  actively employed,  it en-
larges, its temperature  is increased,  its bloodvessels are more developed,
and the  quantity of blood passing through it is evidently greater.  (3.)
When a  gland is excited  to increased  action, as the mamma of the
female, the flow of blood to it is increased, and the vessels  become en-
larged.   (4.) In plants  it has been observed, among other instances
of the influence  of  local stimuli, that a branch  of a tree,  growing in
the open air, which is brought into the atmosphere'of  a hothouse, will
vegetate during the  winter, and  draw  up sap through the stems and
roots,  while  the  other  branches remain in their ordinary  state.  (5.)
In many of  the lower invertebrata,  the  movement of the nutrient fluid
seems to be  evidently independent of the action of a heart  on the ves-
sels.  (6.) Dr. Houston's case of an acardiac foetus has proved, in the
judgment of those most competent to decide,1  "that a foetus may grow
to a considerable size, and have its various tissues well developed, with-
out any connection with the twin foetus, by means exclusively of a circula-
tion of its own, of  which a heart forms  no portion, or  upon which it
can exercise but a very remote influence."  (7.)  Though the phenome-
non of blushing,  and some other local  determinations of blood, may
be accounted for by an alteration taking place in the caliber of the blood-
vessels,  their channels  being  widened,  and more blood admitted, yet
that of hyperaemia,  excited by  a local  stimulus, appears  to us quite
impossible to explain in such a way.   We would refer more particularly
 to the interesting experiment, recorded by  Mr. Simon (p. 96 of his
1 Todd and Bowman, Phys. Anat. vol. ii. p. 372. 
104                       HYPEREMIA.
Lectures on Pathology), in which hyperaemia was induced by the local
application of a stimulus to a part, which  had lost  all trace of sensi-
bility.   This appears to us to afford conclusive proof, that neither the
action of the heart, nor that of the bloodvessels,  but only the nutritive
force, heightened by  the action of the stimulus,  could  have produced
the local erythema.   This justly eminent  authority adds: "Altogether
we  may, I  think, take it  as an  established certainty, that the first
change which occurs  in  an inflamed  or overgrowing .part, and  which
leads to its becoming  loaded with blood, is not a reflex change operated
through the nerves, but is a direct change, operated by the living mole-
cular structure of the part on the blood which  traverses it, or on the
vessels which convey  that blood."   He compares it  to  "a vortex, es-
tablished in the place of the irritant, causing all  the adjoining stream-
lets of blood to converge in swifter channels  towards it."  Professor
Paget says : " I think I can be quite sure that the  velocity of the stream,
in any vessel of an inflamed part, is not determined by  the diminution
or enlargement of the channel.  Without  change of size, the stream
may be seen decreasing from extreme velocity to complete stagnation.
On  what the alteration of movement of the blood in such a case depends,
I cannot tell; but we have facts enough to justify  such an hypothesis as
that there may be some mutual relation between  the  blood and its ves-
sels, on the parts around them, which,  being  natural, permits the most
easy transit of the blood, but, being disturbed, increases the hinderances
to its passage."
  The foregoing arguments and authorities must be  allowed, though in
opposition to Dr. Williams and Rokitansky, to carry very considerable
weight with them; and the remark will appear justified, that it really
seems far too exclusive and one-sided a view to consider  only the blood
and the vessels as the agents concerned in hyperaemia, the common ini-
tiatory step of inflammation, and  to deny to the  essential elements of
the part any share in the  production  of a state  by which they are so
importantly affected.   We  therefore recognize an increased  attraction
of the blood towards the  part which is  stimulated, as one  cause of
active hyperaemia, and the principal, and we regard the dilatation of the
arteries as  a secondary, but not unimportant.   But the influence which
the  tissues exert on the  circulation,  in  virtue  of their  " nutritive
power," we may  be sure is  not only  an attraction which may be in-
creased or  diminished, but also an  alteration  which the attracted blood
undergoes,  and, having undergone, is either  repelled or pushed on by
the advancing current.  We may illustrate this motive influence by the
example of light bodies, when acted on by  electricity.   Two pith balls,
one  of which  is in a negative, and the other  in  a positive  state, will
attract each other strongly;  but as soon as they both become negative
or positive, they forcibly repel each other.  Some similar relation must
subsist between the blood and the tissues.   The  arterial blood is hete-
rogeneous to the tissue, and is attracted to  it.  Having become venous
it is no longer so, and it ceases to be attracted, perhaps even is repelled.
Now, we may conceive the  attractive force to persist, or even to be ex-
alted, while the change impressed in nutrition may be greatly lessened.
Blood will  then accumulate in the part, from not having undergone that 
HYPEREMIA.
105
vital change which it should, and  the  part will be hyperaemic.  This
would be the case in active hyperaemia of a morbid kind—in that which
forms the first stage of common inflammation, in which  the vital endow-
ments of the part are lowered, and its functional activity lessened.  In
healthy hyperaemia, on the other hand,  the attractive and the changing
influences are both  increased.   The blood does not accumulate, but only
ministers  adequately to  the increased  functional activity of  the  part.
We are anxious  to avoid, as far as possible, speculating  beyond the
limits of actual observation, but we would ask, whether some such inter-
pretation as we  have offered be not necessary to explain the  different
event in two cases of suckling females, one of whom has the  child put to
the breast  early, and by the mental and psychical influence brought to
bear, has the functional  activity of the gland aroused, so that the hy-
peraemia as it arises is converted  into a copious flow of healthy milk;
while the  other, who  has  the  child kept  from her for two days, and
whose mammae are left unaroused and  unstimulated, suffers from  over-
whelming hyperaemia, which issues in inflammation and suppuration.
   We now pass  from the consideration  of  the mode in which active hy-
peraemia is induced, to that of its effects.   These, as already intimated,
are different in  the  healthy and  morbid varieties.   In the  first, the
growth of the part, if the hyperaemia continue long enough, is increased;
it undergoes a true hypertrophy.  Of  this we have the best  examples
in the  muscular tissue.  At the same time, the function is  more vigor-
ously exercised; it has more  capability  for, and it performs more work.
Of this the  brain, under  the  influence of moderate determination of
blood—such as some of our great orators used to induce by pretty free
libations of wine—is a good example.  Similar instances among glandu-
lar organs  we have already noticed.  That of the ovaries and  uterus, at
the catamenial periods, is very remarkable, and is evidently connected
with the reproductive nisus, which manifests itself especially at  these
epochs.  There  seems no ground whatever to  regard it  as originated by
nervous influence, but rather as the result of  a  mode of growth and
nutrient action peculiar to these organs.   The discharges of the ovarian
ovum,  and the catamenial flow, are the results  of this  hyperaemia, but
it is itself  excited by the spontaneous activity of the structures.   Thus
curiously, as we see also in many other instances, are  linked  together
the increased action of an organ, and the increase of its  supply of blood;
in the healthy state, the former usually takes  the  initiative, and pro-
duces the latter, but is itself reacted on  by it, increased, and carried on.
   But it is rather with  morbid hyperaemia that we are concerned as
pathologists.  This is, in a very great  number of instances,  the  com-
mencement of inflammation;  but we shall not speak  of inflammation
as one of its results, but consider it separately.  The effects of morbid
hyperaemia are  generally unnatural excitement, or oppression of an
organ.  The part contains more blood  than it  is  able  to  manage, its
healthy play is  interfered  with, and  it is either  goaded into a  false,
aimless, and exhausting activity, or it is  actually oppressed and enfee-
bled directly.   The chief features of the condition are, probably, in-
creased attraction of blood to  the part, with diminished vital change,
and undue dilatation of the arteries leading to it. 
106
HYPEREMIA.
  If the brain be the seat of determination of blood, in a morbid sense,
there will be throbbing of the carotids and  their superficial branches,
restlessness, more or less intolerance of light and sound, diminution of
the power of attention  and application, dreamy and  disturbed sleep,
irritability of temper, attacks of giddiness, &c.  The face and eyes are
apt to be flushed, and the feet cold.  The uneasy sensations  about the
head are increased by stooping, or the recumbent posture.  The kidney,
in cases of acute anasarca, manifests an excellent  example  of morbid
hyperaemia.  It is enlarged and turgid with  blood, but its  texture is
not apparently altered.   Its secretion  is scanty, loaded with albumen,
and with fibrinous concretions, and epithelium of the tubes.   No doubt
can exist that its  functional energy is gravely impaired.   In active
menorrhagia we  have a third instance in which,  from various causes, a
morbid hyperaemia of a hollow organ lined by a secreting mucous mem-
brane is induced, the results being pain and uneasiness in the region of
the affected part, increased sensation  of heat, tension  and throbbing,
which are  relieved  by the  discharge of a fluid more completely san-
guineous than the natural secretion;  in fact, by an almost real hemor-
rhage.   In such an instance, it is not only the mucous  lining of the
uterus  that becomes hyperaemic,  but  the whole organ, with its thick
muscular walls.  Their tissue is loosened up and swollen  by the quan-
tity of blood admitted, so that the size of the organ is  increased; and
if this hyperaemia should not in  great  degree subside, the result  may
be a permanent  enlargement and congested  state of the uterus.  The
foregoing examples, taken from different organs, will serve as sufficient
illustrations of the effects  of active hyperaemia.  It seems, however,
desirable to allude, somewhat more in detail than has yet been done, to
hemorrhage, flux, and  dropsy, considered as results  of hyperaemia in
general.
  These may  be regarded as the effusions  of hyperaemia,  as distin-
guished from  inflammation.   No  doubt they do  also  occur in cases
where inflammatory  action is  proceeding;  but still they are  not the
special and characteristic products of this state.
  Hemorrhage implies  the  effusion  of blood in mass, not  merely of
some of its constituents; exudations, therefore, which are only colored
by haematin, do  not  constitute hemorrhage.   The best character of  an
hemorrhagic effusion is the presence  of large masses  of blood-globules
imbedded in fibrinous  coagula.   Such may  be  found either from  an
opening in a vessel of some  magnitude, or  from numerous capillaries.
In every case where  blood is effused  in any quantity, the walls of the
vessels must have given way; and perhaps this is the case in every in-
stance where a blood-globule escapes from its channel, though it is not,
to our minds, absolutely certain that there is no such thing  as  the he-
morrhage by exhalation of the older writers.   Hemorrhage  may  take
place either in solid  parenchymatous organs, or in those that  inclose
cavities  and form canals.  In the first case, the substance of the organ
undergoes more  injury than  in  the latter.   An effusion of blood  into
the brain is a most serious thing;  on the surface  of  the  Schneiderian
membrane it is a mere trifle.   When a large  quantity of blood is  sud-
denly extravasated in a solid organ,  it  ploughs up and disorganizes the 
HYPEREMIA.
107
tissue, and forms therein a cavity for itself, where it lies like a mass of
black currant jelly: the  walls of the cavity are usually ragged, and
soon become stained to  some depth by altered coloring matter.   But
the extravasation may  occur in  a  very different manner, affecting a
great number of points at once, and having the appearance of a multi-
tude of red dots scattered about, or of minute streaks.  This is termed
capillary apoplexy, to  distinguish it from  the  other  form ("apoplect.
herd" of  Rokitansky).   It is  often seen  in  the gray matter of the
cerebral hemispheres after death, from concussion of the brain.
   If  the  hemorrhage, though  taking place in the  same way, be more
abundant,  the spots and streaks approach closer together, the  tissue
becomes more swollen, and, at last,  may  become thoroughly red, the
blood having penetrated completely between and among the elements of
the parts.   Rokitansky  enumerates  the following  exciting causes  of
hemorrhage: (1.) Hyperaemia of very great intensity, of whatever kind.
This  may occur in various conditions of the system, but of course the
local strain will  be most  severe when a state of plethora exists  at the
Same time, and the action of the heart is  powerful.  We have seen
considerable haemoptysis take place in a healthy person after very severe
exertion.    This might be considered as an instance of hemorrhage from
intense active  hyperaemia.  The large  evacuations of blood that are
poured out from haemorrhoids, exemplify the  same result from passive
hyperaemia, as also  do  cases of passive  menorrhagia.^  (2.) The hy-
peraemia  that takes place in  some kinds of inflammation which have
 been hence named hemorrhagic.  This tendency is materially promoted
 by the delicacy and  laxity of the tissue  affected.   The  lungs  are
 scarce ever inflamed without  some amount of hemorrhagic exudation
 taking place, viz: the rusty  sputa of pneumonia.   Where scurvy is
 prevalent, hemorrhage  seems more prone to accompany inflammations,
 as might, indeed, be expected.   A form of pericarditis has recently been
 described by Dr. Kyber, which  he terms  "pericarditis scorbutica,"in
 which, after death, large quantities of bloody coagula,  together with
 effusions  of lymph, are found  in the  serous  cavity.   Hemorrhage from
 this  cause is apt to attack morbid growths, especially the softer varieties
 of cancer.  (3.)  The vessels may rupture and pour out blood in  conse-
 quence of  the tissue surrounding them becoming more spongy and lax,
 so that they are not adequately supported.   This appears to be the cause
 of hemorrhage from  the decrepit uterus of the aged.  (4.) Textural
 disease of an organ, rendering it more brittle or soft than natural.  The
 most marked instance  of this is the fatty,  degenerated heart, which has
 often undergone spontaneous  rupture.   (5.) Alterations  of consistence
 of the coats of the vessels, such as take place in atheromatous disease
 or in chronic inflammation; this may affect the  smallest vessels or the
 largest trunks, but is  almost confined  to the arteries, and  may  be  ac-
 companied with dilatation (aneurismal) or not.  (6.) Ulceration  of the
 surrounding tissues may give rise to hemorrhage, by involving some of
 the  vessels.  Severe,  or even fatal,  haematemesis, from ulcers  of the
 walls of  the stomach, is  not uncommon.   The hyperaemia which issues
 in hemorrhage, may be occasioned by obstruction to the venous current,
 as in haemorrhoids from  diseased liver, and pulmonary apoplexy from 
108
HYPEREMIA.
obstructive disease of the heart; or it may be caused by intense irrita-
tion, as when bloody discharges  are  occasioned by  drastic purgatives,
or haematuria by stimulant diuretics.  Posture may prove the cause of
hemorrhage when the tonicity of the vessels is very low.  Thus, stoop-
ing has been known to occasion cerebral, and the erect posture uterine,
hemorrhage.   The influence of malaria and cold has been before noticed.
There seems to be a kind of hemorrhagic diathesis; at least, Dr. Copland
states that hemorrhages are more  common in the offspring of parents
who have suffered from them than in others,  and  that the tendency is
observed in several members of the same family.  Hemorrhage from
the rectum, urinary organs, and uterus,  is said  by Chomel to occur
oftener in cold than in warm seasons, and epistaxis  and haemoptysis to
be more frequent  in  summer than in  winter.  Dr. Prout observed a
peculiar tendency to renal hemorrhage during the time that cholera was
prevalent.   Age seems to have an influence in determining the seat of
hemorrhage.   Epistaxis is most common in children, haemoptysis in  the
early  period of  life,  and  haemorrhoidal discharge  in the  aged.  The
blood,  when effused, may  remain in a  liquid state for some  time,  or
quickly coagulate.   When it is poured out into the substance of a part,
it undergoes, after a time, the changes  which are commonly observed
when a superficial  part has  been bruised.  These  consist in alteration
of the  color of the haematin, which passes  "from a dark red into a blue,
then into a brown, and lastly,  into  a  yellow color, before  it entirely
disappears."   At the same  time the blood-globules, at  least in many
cases,  undergo peculiar changes;  they  become massed  together,  and
sometimes included in a kind of cellular envelop; they waste and shrink
up, until there remain at last only minute yellow or orange-red granules,
which  evidently consist chiefly of pigment.  Such are not unfrequently
found in the straight tubuli of kidneys affected with M. Brightii; they
are the undoubted  records of former hemorrhage.  In  some cases  the

                              Fig. 10.
Haematin crystals.
altered haematin takes the form of crystalloid, elongated,  rectangular
tablets, which  vary very much in size, and are colored more or less
deeply by red  matter.   The formation of these seems to be  promoted
by the addition of water.  They were  extremely  well  seen  in  a case
which we witnessed of cystic disease of the kidney, in which several large
dark clots were contained in a cyst of extraordinary magnitude.  The 
HYPEREMIA.
109
fibrin, and other residue of the extravasation, together  with broken-up
fragments of the tissue, are gradually reabsorbed, the solid  substances
undergoing liquefaction, chiefly in the way of fatty transformation.  A
further  change may take place, not so much in the effused blood, as in
the parts  around it.  These, which are at first ragged and torn, undergo
more or less inflammation, which ends in the  effusion of a  solidifying
blastema; this fibrillates, and passes into the state of more or less perfect
fibrous  or areolar tissue, and thus forms a capsule or cyst, inclosing the
now more or less altered blood.   Rokitansky describes the cyst as being
lined by a colored, soft, gelatinous, loosely-adherent layer, formed from
the coagulum, which, at a later period, by fibrillating, and even develop-
ing vessels, assumes very much the aspect of a delicate serous membrane.
The contents of the cyst may be a gelatinous  or serous fluid alone, or
with more or less traces of a vascularized areolar tissue.   In some cases
absorption takes place completely, and  the  cavity is obliterated by the
adhesion  of the opposite sides, and the  formation of a linear cicatrix.
This, however, is not the most  frequent issue, in consequence  of the
following impediments:  (1) a large size of the cyst; (2) retraction of the
surrounding  tissue, depending partly on its  atrophy, partly on its in-
duration ; (3) the deposition of the fibrin, either as a central lumpy mass,
or as a thickish, peripheral, capsulating layer.  The effused blood-mass
may undergo a different kind of change, in consequence of absorption
of its watery parts, and become, in  this Avay, a kind of tumor, termed
an haematoma.   Dr.  Walshe classes this along with other growths, but
we think  it better to consider it as a simple result of hemorrhage, and
this for three reasons :  (1) that it presents no higher structural character
than that of fibrin; (2) that it is generally devoid of vessels; (3) that it
does not appear to increase by growth in the proper sense of the term.
Dr. Walshe describes an haematoma from  the spinal meninges, which had
been produced by a blow, as of the size of a walnut, of pale  straw color,
and of fine  granular texture when  closely inspected.   "Such tumors
exhibit, microscopically, the qualities of fibrin; fibrils gelatinizing with
acetic  acid, amorphous  fragments, granules, and molecules."   "Their
chemical relations  are those of fibrin."   An epithelial investment covers
the  surface, and makes it smooth, but there is usually no enveloping cyst.
Haematomata occur in serous and synovial cavities, beneath fibrous and
mucous membranes, in parenchymatous  organs, in muscular masses  of
the limbs, in the substance of certain new products, especially encepha-
loid cancers, in cavities accidentally  formed in the tissues,  as in tuber-
culous  cavities of  the  lungs.  An haematoma thus formed, and  being
essentially a fibrinous mass, may undergo certain other changes; saline
earthy  matter may be deposited in  it, inducing a state which is more
correctly named cretification, than ossification;  melanic pigment may
probably also form in it.  It may, perhaps, undergo a  development  to
the somewhat higher stage of fibrous tumor,  and sometimes  even true
bone may be formed within it.   A vascular plexus has been observed in
several instances in tumors of this kind; and  though it may be objected
that this has been developed in superadded exudation-matter, yet it
appears to us very much more probable that the persistent fibrin afforded
the  developmental  nidus from its own substance.  One result of hemor- 
110
FLUX AND DROPSY.
rhage, even in  lesser degrees,  may  be  the persistent discoloration of
the tissues from the presence of brown  or  black pigment, which is dif-
fused among the elementary parts in a  finely divided condition, as one
of the transformations of the effused haematine.  Hemorrhage, like the
hyperaemia from which it results, may be active or  passive, sthenic or
asthenic.   The former variety is associated with the same general con-
dition of the system which characterizes active hyperaemia, the latter,
in the same way,  is connected with  passive hyperaemia.   Rokitansky
says of the condition occasionally observed, in which hemorrhage takes
place to an alarming amount, even from a slight cause, which he terms
Haemorrhophily, that it depends, as  far as we know at present, on an
unusually delicate  construction and vulnerability of  the vascular mem-
brane, together with a thin, watery quality of the blood in general.
                      FLUX AND DROPSY.

  We have  already in part noticed these results of hyperaemia, more
particularly of the passive variety, but it seems desirable on account of
their great importance and frequency to review them separately.  The
term flux may be properly applied to a discharge of various kinds taking
place from a mucous surface, or from a glandular organ connected there-
with ; the term dropsy to an effusion of fluid in serous or synovial cavi-
ties, or in  the areolar tissue.   Fluxes will be active or passive according
to the kind of hyperaemia which occasions them; the same can scarcely
be said of dropsies; the very great majority of them are passive.   It is
necessary  to fix some limitation to the kind of fluid that may be  said to
constitute  flux or dropsy, as there are many exudations which require to
be distinguished on account of their different nature.   A sero-purulent
effusion, on  the secretion of a serous cyst, would not come under the
present head.  Perhaps we shall be nearly correct if we say that a fluid
similar to, but more aqueous than the liquor sanguinis, mingled  in  the
case of flux with  a varying quantity of mucous  secretion or desquamated
epithelium, mature or immature, and if proceeding from a gland mingled
with more or less of its secretion, is that  which properly belongs to this
kind of morbid action.
  Of active fluxes we have a good  example in miniature in a common
sneeze; the peculiar sensation  demanding the reflex expiratory contrac-
tion is no  doubt occasioned by the turgid  state of the bloodvessels of the
Schneiderian membrane  pressing upon the interwoven  nerves; this hy-
peraemia  quickly terminates in a  muco-serous effusion  which the blast
expels, and after  one or  two such acts, all is  quiet again.   More con-
siderable,  and much more enduring is the  hyperaemia in  the state of
coryza, and the serous flux is of course much more prolonged.  In this
instance we have an opportunity of observing a quality of the fluid of a
serous flux which is very common, viz:  that  it is especially acrid and
irritating, so that it will sometimes  excoriate the parts  over which it
flows.  What gives it this quality is not very apparent;  it seems at least
doubtful whether  it is merely an excess of the  natural saline ingredients
of the blood.  We should rather suppose it to be some  organic acid salt 
                        FLUX AND DROPSY.                    Ill

of new formation.   The fluid under the microscope exhibits very little
trace of corpuscles,  and is alkaline.
   Choleric diarrhoea is the extremest example of active morbid flux, the
whole blood  seems to rush to  the intestinal surface, and  pour out its
fluid part, minus the greater part of the albumen and fibrin.  The gruel-
like evacuations consist of water and saline matter, with  some trace  of
albumen in solution, and a large  quantity of columnar epithelium.1  The
reaction of the fluid is alkaline.   The filtering  action of the intestinal
membrane in this instance is very marked, and  well worth noticing;  it
is, indeed, extraordinary, that, while so rapid a rush of blood is going
on to the exhaling  surface,  the effused fluid should be so considerably
altered from that which arrives thither; one would have expected it  to
contain at least  as much albumen as the passive exudation of  ascites.
We would ask whether  the case of choleric diarrhoea, as well as the
similar  condition from drastic purgatives, do not  absolutely prove the
existence of a power influencing the circulation other than the vis a tergo
of the heart with the regulating contractility of the bloodvessels?   Does
it not also demonstrate  that it is this  nutrition  force of the tissues,  as
we have called it, which determines whether an hyperaemia shall issue
in a  flux or in an inflammation?   In profuse salivation arising from the
administration of mercury, or other causes, we have a good instance  of
an active flux, from a glandular organ, although the fluid is in this case
almost identical with the natural secretion.   It is  not unfrequently ob-
served,  that if an active flux be suddenly checked, it will be transferred
to some other part, where  it may, perhaps, produce much more serious
consequences.   The part to which the metastasis takes  place may be a
solid  organ, or a secreting surface; in the first case dangerous hyper-
aemia, and possibly hemorrhage,  may occur; in  the second,  the hyper-
aemia will relieve  itself by a free effusion of  fluid.   Thus arrest of the
menstrual discharge by cold is often followed by determination of blood
to the head,  arrest of an habitual diarrhoea by  the  same result, or by
the supervention of ascites.  The characteristics  generally of active
fluxes are those of active  hyperaemia,  which  is more or less apparent
according to  the  amount of the effused fluid ;  if this be considerable, the
hyperaemia is dissipated as fast as it arises.   Active dropsies are  often
termed  acute, or febrile, and are not always easily distinguished  from
inflammatory effusions.  An almost certain means of  distinction  is,  to
observe whether  the effused  fluid is even slightly turbid with flakes  of
lymph,  or puriform  corpuscles; the presence of  these is decisive of the
inflammatory nature, or at least  of some degree  of coexisting inflamma-
tion.   Acute anasarca affords one of the best instances of active dropsy,
the interruption of the action of the kidneys, at the same time that  it
deteriorates the quality of the blood, and renders it less fit to circulate
in the vessels, diminishes  considerably the separation  of fluid  from it,
so that from  both these causes there arises a tendency to the effusion  of
fluid in the areolar tissue, or in other parts.  The tenseness and firmness

  1 In one case  we examined, the gruel-like fluid contained  feebly formed nuclear parti-
cles, with a few  granular globules and cells, and an abundance of granular matter;  there
was little or no epithelium in the evacuations, and some was found in situ 38 hours after
death. 
112                    FLUX AND DROPSY.

of the anasarcous swelling  in many of these cases lead to the belief
which direct observation has confirmed, that the effused fluid contains
some amount of fibrin, which coagulates among the elementary parts of
the tissue, and makes them more dense and stiff.  The same thing occurs
also in dropsies of serous cavities,  and has been particularly noticed by
Vogel, under the  name of Hydrops Fibrinosus.
  Vogel does not seem to  discriminate between fibrinous dropsy, result-
ing from hyperaemia, and that resulting from unequivocal inflammation ;
and probably it is not necessary.  The one condition is the  inceptive
of the other, and passes  into it by imperceptible grades, or may exist
in various  degrees along with it.  In fact, in this  instance, and  all
through our  study of pathological anatomy, we  cannot too constantly
bear in mind that, though we take, and are justified  in  taking, for de-
scription, certain typical forms of living and acting, yet these are seldom
rigidly defined, but pass easily into each other, or coexist in the  same
part variously combined.  The simple unmixed case is the rare one, the
multiple  and the complex the common.   Having  premised thus that
fibrinous dropsy may be, and often is, the result of  an inflammatory
process, as well as of an active  hyperaemia; but regarding it as  more
properly the  product of the latter than  of the  former, we proceed to
follow the account given of it by the excellent pathologist just quoted.
He remarks that " it may occur either in serous cavities (as in the pleura,
arachnoid,  peritoneum, or pericardium), or may collect in the paren-
chyma of organs."   In both cases, however, it  is essentially similar.
" Examined immediately  on its discharge, the fluid  resembles  in  all
points  that  of serous dropsy.  This either is perfectly clear and color-
less, or else more or  less turbid, opalescent, and  of a greenish, yellow
color; and, examined microscopically in  its  recent condition, exhibits
either no solid particles"  (the case of  pure hyperaemia), " or only such
as may be accidentally present, as occasionally minute amorphous coagula
of fibrin, pus-corpuscles," &c. (inflammatory complication).  " Some time
after its discharge, the whole fluid generally coagulates, in consequence
of holding fibrin in solution, and forms a homogeneous, tremulous jelly,
which, after standing for some time, separates into a partially consistent
colorless, or reddish-yellow clot of coagulated fibrin, and a clear yellow
fluid, analogous to the serum of the blood."   " The coagulated fibrin
appears under the microscope as a perfectly amorphous mass, and devoid
of any traces  of  cellular  structure."   The effused fluid bears a pretty
close resemblance to  the  liquor sanguinis, containing the same saline
and animal matters, but a less proportion of albumen and fibrin.   Vogel
considers that the effusion of fibrinous fluid depends on the transudation
taking place through the walls of the capillaries, while a simply serous
effusion is poured out through the  walls of the  veins.   We cannot join
in this view,  as it seems to us impossible  that transudation  should take
place in any case exclusively from the one or from the other.   All the
capillaries and minute veins in hyperaemia are alike gorged, and  there
is no sufficient difference in the structure of their coats to make it proba-
ble that they affect at all materially the nature of the  exudation.  The
real  cause  of  the difference  between  fibrinous and serous dropsy  we
believe to be the different  quality of the blood, the existence of a differ- 
FLUX  AND DROPSY.
113
ent crasis, to use Rokitansky's term ; in fact, the presence of a greater
amount of fibrin.  Vogel recognizes the dependence of fibrinous dropsy
on  dynamic causes; i. e. its association with active  hyperaemia, while
serous dropsy depends more upon mechanical.  This is true; but  at the
Bame  time we  have seen some amount of fibrinous effusion occur in pas-
sive dropsy, depending upon mechanical obstruction to the  circulation.
The fibrin contained in the fluid may either remain for a long time (days,
or even weeks) within  the body uncoagulated,  and coagulate  after its
discharge, or  it may pass  at  once, while within  the system,  into  the
coagulated condition.  It may also serve as a blastema for organic for-
mations.  This we shall speak of further on, under the head of " Exu-
dations."
   Passive fluxes are of extreme frequency, and are  almost invariably
associated with debility.   Their copiousness,  the aqueous nature of the
fluid,  the frequent pallor, and non-elevated  temperature of the  parts
from whence they proceed, as well  as relaxed conditions of these, may
be  said to be their  general characters.   They take  place, as is  mani-
fest, from mucous surfaces,  or from the  glands that open upon  them,
and are, in  consequence,  mingled, more  or less, with  liquor  muci,
and with epithelial particles, in various stages of formation.  In some
cases, as in bronchorrhose, occasionally they may depend upon venous
obstruction;  but their  most essential cause seems to be a peculiarly re-
laxed and toneless state of the walls of the vessels, and  of the tissues
affected.  This is confirmed by the beneficial effect of astringents, locally
applied. At the same time, there is no doubt that the state of the blood,
and of the  system generally,  has  an influence  upon them, and that, as
the quality (the crasis) of the  former is improved, so the  debilitating
profluvium will  diminish.   It  is reasonable to suppose that in  this way
the walls of the vessels are brought into a condition of  more healthy
tone.   The  peculiar condition of the tissues, as to  their vital endow-
ments, seems to be the only sufficient cause to which we can at all ascribe
the different phenomena  exhibited by the same  tissues, under similar
circumstances.  One person shall have a chronic bronchitis, with puri-
form  expectoration,  while another  person is suffering under bronchor-
rhcea, although the circumstances may be similar, and the two affections
very much alike in  their outset.   When we speak of  a toneless and
relaxed condition of the vessels being the main  cause of the flux,  we do
not so  much  mean to  imply a defect in their contractile power (though
this doubtless exists), but rather such an alteration of their texture, as
that they are  much more transudable by the  aqueous part of the  blood
than  is normally the case.  In health, a certain slight exudation takes
place  from the capillaries, and all the minuter vessels, forming a nutrient
atmosphere, in which the tissues are bathed.  The exact composition of
this is uncertain;  but, as  the following experiment shows, it probably
contains less albumen and fibrin than the liq. sanguinis.   Valentin, hay-
ing made an albuminous solution of a certain specific gravity,  placed it
on a filter of stretched serous membrane, and,  on examining  the fluid
which passed  through, he found its specific gravity reduced; that is to
say, some of the albumen was left behind.  It  is  probable, and  seems
proved  by pathological experience, that increase of  the pressure upon
       8 
114
FLUX AND DROPSY.
the fluid  causes  it to transude  in  a less altered state; so that  this,
whether it be a vis a tergo, from increased cardiac impulse, or caused
by an obstruction in the onward direction, must be one cause of an effu-
sion containing much albumen and fibrin also.  But the common watery
and mucous effusions, which constitute Such fluxes as those of leucorrhoea
and bronchorrhcea,  contain little, if any,  albumen, and  no  fibrin, and
are chiefly remarkable by the quantity of their aqueous and saline con-
tents.   The  same  may be  said  also  of the  intestinal  and cutaneous
fluxes that take place in phthisis, and in other exhausting diseases.1  In
all  these it seems certain  that the natural filtering power of the walls of
the vessels is changed in such  a way that they allow the aqueous and
saline part of the blood to transude with extreme rapidity.  At the same
time,  the  crasis of the blood itself  is altered; it turns, as the popular
phrase is,  to  water; i. e. its corpuscles and its organic matters are not
formed  in due proportion, but, on the contrary, waste and diminish,  so
that the colliquative discharges from the tissues are promoted,  and kept
up  by the (as it were) deliquescing blood.  It is interesting to observe
that the filtrating property of the vascular membrane is capable of being
influenced through  the nervous system.  Thus, after a fit of hysteria, a
quantity of limpid aqueous urine is passed, much more than would have
been voided  had  no such event occurred.   This must depend upon an
alteration of the condition of the Malpighian tufts, and perhaps of the
capillaries of the  tubular  venous plexus. We  have noticed something of
the same kind after a small dose of  opium.  Almost the  only instances
of  fluxes taking place from the  glands, with which we  are  acquainted,
are those  which the kidneys afford.   That of diabetes depends, as is well
known, upon a diuretic substance, sugar, circulating in the blood, and not
undergoing the decomposition which it should  normally.   Diabetes insi-
pidus was believed, until  recently, to depend upon some other and dif-
ferent cause; but  it has been  shown by  Thenard and others that the
only difference is that the sugar which is present, and produces the
diuretic effect, is tasteless.   In cases of polydipsia, where an  excessive
quantity of urine is passed, of low  specific gravity, the flux depends
simply on the injection of an undue quantity of liquid, in consequence
of  extreme thirst.   Discharges, such as those of chronic bronchitis, or
chronic dysentery,  which  were, in their commencement, of truly inflam-
matory nature, but afterwards  become  more of the nature  of fluxes,
often contain a very large amount of muco-purulent matter, and cause
a proportionally  severe drain on the system.  These, however, do not
present the hydraemic condition of the general system, before alluded  to.
   Passive dropsies are the commonest of all; all  the cardiac dropsies,
and most  of the renal that we meet with, are of  this kind.   Their very
aspect excludes the idea of increased action (however the term may be
understood), and naturally suggests that of some obstruction to the cir-
culation, with diminution  of the vital energies.   The surface is  generally
pallid, or of a dull venous hue, the  animal heat is diminished, the ana-
sarcous swellings pit easily on pressure, the effect of gravity upon them

  1 Simon states that he failed in detecting any certain indications of albumen in  the
sweat  collected (by  means of  linen washed with distilled water) from the  breast of a
person in the colliquative stage of tubercular phthisis. 
FLUX AND DROPSY.
115
is  marked, the movements  are languid, the  respiration  often  embar-
rassed, and the mind depressed.   The character of debility is strongly
impressed upon them, and  there  is much correctness  in  the common
feeling, that  when dropsy appears, it announces the approach of decay,
and of the breaking up of the system as it is called.^  One of their most
common, but  as we shall see, probably, not their immediate cause, at
least  in many instances, is, beyond doubt, a mechanical impediment to
the free  course of  the blood.  This was long ago proved by the well-
known experiment  of Lower.  He tied the jugular vein of a dog, and
found that all the tissues of the head and face were infiltrated after the
lapse of  some hours, not  with extravasated blood, as he had rather
expected, but with  clear  serum.   The  analogous instance of ascites
resulting from cirrhosis  of  the liver has been already mentioned.   But
it requires no very long pathological experience  to discover that  there
are cases not unfrequently occurring, in which, although there  exist
abundant causes of obstruction to the circulation, yet  dropsy does not
take  place.   Dr. Walshe, in his  work on  diseases of the lungs and
heart, p. 478, has given a list of most serious diseased conditions of the
heart which  may exist without producing dropsy, and  concludes justly,
that  something beyond all these is wanting  to  insure this occurrence.
What, then, is this ?  Andral shows, in  his  Hematologic, that neither
 diminution of the globules, nor of the fibrin of the blood, is the imme-
 diate cause* of dropsy, but, that this always accompanies  a diminution
 of the albumen.  It is, therefore, highly probable that it  is this altera-
 tion of the crasis of the blood which determines the occurrence of dropsy
 in persons who are predisposed to it by organic disease of the  heart or
 lungs, which causes congestion of the venous system.   It  is not only in
 dropsies of cardiac origin  that diminution of the albumen seems to be
 the most important moment1 in producing the effusion.   This  cause is
 evidently influential in renal dropsy, in which a constant drain  of albu-
 minous serum out of the blood is taking place.  It is remarkable that
 this  may have been going on for some, perhaps a considerable time, and
 yet  no  dropsy occur.   The explanation of this  is  afforded by the cir-
 cumstance  ascertained  by Simon and Christison, that the  decrease of
 the solid constituents of the serum is not always the leading character
 in this disease.  In three of  Simon's analyses out  of  four  of  blood in
 Bright's disease, the  quantity of albumen was decidedly increased—in
 one  instance amounting to  109.4, considerably above the average of
 health.   Cases of dropsy occasionally are  met with, m which,  as  there
 appears no absolute organic disease, but only an hydraemic condition of
 the blood, one is obliged to conclude that  the effusion is dependent on
 this   A female is now under our observation, in St.  Mary's Hospital,
 who has considerable anasarca of the legs and feet, with puffed eyelids
 without any  discoverable albuminuria, or disease of the heart.  Andral
 mentions that, during  a  famine, where the  poorer  classes had been
 obliged to seek a scanty nourishment in roots and herbs growing in tbe
 fields, many persons became  dropsical.  In  this, and similar  recorded

    > We ask leave to introduce this word as a convenient term, signifying an influential
 condition. 
116
FLUX  AND DROPSY.
instances, it is very probable that the proportion of albumen in the
blood was diminished, as  it  is clear  that  the supply of it  ordinarily
derived from the food was so.  When, from cardiac or renal causes, or
both combined, together with altered  crasis of the blood, the tendency
to dropsical effusion is very strong, it  is quite remarkable how universal
the dropsy becomes; the peritoneum, both pleurae, and the pericardium,
may be found full of fluid, the areolar texture everywhere  infiltrated,
the air-cells of the lungs loaded with frothy serum, the tissue of the
brain " wet,"  and the subarachnoid  fluid  considerably  increased.  In
fact, it  seems as  if the  vessels  no  longer presented any  containing
barrier, but permitted the escape of fluid in every part that it traversed.
It is often  observable in these  cases after  death  how the naturally
transparent serous membranes have lost this appearance;  they look
thickened, of  a dull, white gray tint, as it were  sodden in  the  fluid.
There can be  no doubt that  this depends  on a chronic  thickening and
increase of their fibrous layer.
   We have next to examine the composition of dropsical effusions; this
generally approaches more or less closely to that of the serum of the
blood.  The purer  fluids  are clear, tolerably limpid,  and  colorless;
often, however, a marked yellow tint is  observed,  which may either
arise from dissolved  haematin, or from  the presence of an increased
quantity of the natural yellow pigment of the serum;  or again, especially
in the case of ascites,  from dissolved  bile pigment.  If the latter is the
case, it will be rendered evident by the reaction with nitric  acid.   " A
large quantity of  albumen (Vogel says) renders it  (the effused  fluid)
viscid; a very large quantity,  above  twelve per cent., renders it thick,
tenacious, and capable of being  drawn out  in threads, like albumen
itself."  A milk-white turbidity is occasionally observed, which depends
on the admixture of fat (oil), or epithelium scales.  Blood-globules may
be often seen  in great numbers in the fluid of  ascites by the aid of the
microscope:  cholesterin tablets are common in that of hydrocele, and
may be  sufficiently numerous to  constitute a crystalline deposit.   The
reaction of the fluid  is  alkaline; in rare  instances an acid has been
observed; in  Vogel's opinion, probably from the presence of lactic.
We subjoin, from  the  same author, the results of  seven analyses, which
show some remarkable variations in the  amount of the several con-
ltuents. l	2	3	4	5	6	7
Water . . . 905.0	920.0	927	946	956	988.0	704
Albumen . . 78.0 \ Extractive matter 4.2 J	71.5	48	33	29	0.9	290
		101 9/		9		2
Fat ... . 3.8			13	1}		
Salts ... 9.0	8.5	6	8		10.0	4
Blood Serum.	Hydrocele.	Hydrocele.	Ascites.	Ascites.	Ascites.	Ascites.
  The seventh analysis shows actually a larger amount of albumen than
is present in the serum of the blood;  this might  be  supposed to be an
error if other similar instances  had not been observed ; it probably de-
pends upon a quantity of the water of the original effusion having been
removed by absorption, so that the  fluid  became more concentrated.
Urea has frequently been found in dropsical fluids; its quantity is some-
times very small, sometimes amounts  to 6 parts per 1000. 
INFLAMMATION.
117
  This seems to be the most proper place to introduce a short notice of
certain gaseous effusions which there is good evidence to show take place
occasionally in  different parts of the body.  To them the name of Pneu-
matoses has been  given  by Frank and  others.  Frank gives cases to
prove that the subcutaneous cellular membrane, when slightly inflamed,
may secrete air in abundance, and thus  give rise to emphysema.  The
same has been observed after attacks of profuse hemorrhage during life,1
and we are convinced we have  witnessed something  of the same kind
in post-mortem examinations  when there was no  trace of putrefactive
change.   Dr. Graves, whose interesting article on the subject we need
only refer to,  mentions a  case quite conclusive,  as  we think,  of the
secretion of gas to a considerable amount in the cavity of the  pleura,
and we have ourselves observed  a somewhat similar occurrence.  In the
post-mortem examination of a  female, who died with extensive bed-sores,
after symptoms of fever, the right lung was found compressed  against
the V. column, and bound down  by layers of false membrane, which also
formed bands crossing the pleural cavity.  This was empty of fluid, but
must have been filled by air, as a very considerable space intervened
between the lung  and the wall of the thorax.   No vomica was found in
the lung,  or any  evidence of rupture  of the pleura.  The peritoneal
cavity seems also to be the  seat of  gaseous accumulation in rare in-
stances.   The development of gas in great abundance from the  mucous
membrane of the  stomach and intestines is a phenomenon of daily and
troublesome experience;  we speak now  of an actual secretion from the
mucous surface itself, and not of the  result of decomposition of ingesta.
 The influence of certain states of the nervous system upon the develop-
 ment of gas is  often evidenced in hysteric and emotional excitement,
 and also by the circumstance  which we have observed, that it will  take
 place, sometimes, very rapidly from the stomach  after an action of the
 bowels.    The  accumulation  of gas is sometimes  so  considerable as
 to produce alarming or very distressing symptoms; we have  seen it
 even,  in a minor degree, induce or aggravate attacks resembling angina
 pectoris.
    A very remarkable case has  been  recorded by Sir F. Smith, of ex-
 cessive development of gas  from the  stomach, also from the  urinary
 bladder, and from the surface  of the skin.   Respecting the cause and
 mode of production  of  these pneumatoses we are totally ignorant, but
 the fact of their occurrence is  most  important in its relation  both to
 practice and science.


                          INFLAMMATION.

    We proceed, according to our plan, to the third  variety of hyperaemia,
 that in which  the movement  of the blood in the  part affected is partly
 increased, partly diminished.   The truth of this  definition, so far as  it
 goes (though we believe it to be a very imperfect one), is shown—1st,

    i A portion of the liver of a man, who died suddenly with aneurism of the left carotid,
 became so full of gas about two days after death, that it floated on the surface of water.
 Portions of the heart and kidney were not thus affected ; they sank in water. 
118
INFLAMMATION.
as to the increased motion by Mr. Laurence's well-known experiment of
drawing blood at the same time from an inflamed and  from a healthy
arm of the same patient, when three times the quantity of blood flowed
from the vein of the inflamed as from that  of the healthy limb; and,
2d, as to the diminished motion, by looking at an inflamed part through
a microscope when the arrest, or stasis, as it is called, of the blood cur-
rent in the affected part is most evident.
   The general appearance of an inflamed part  is well  described in the
terms handed down from the age of Celsus, as being the seat of redness,
heat, pain, and swelling.  These are the visible symptoms of a  patho-
logical process, which, though continually before our eyes, and  of the
utmost importance in its results, and though it has been  the subject  of
numberless speculations  and careful  labors, we are compelled  to ac-
knowledge we  are still  imperfectly acquainted with.   The redness of an
inflamed  part  is more  or less vivid ;  it is  deepest in  the centre, and
gradually shades off towards the circumference; in this  respect it dif-
fers from an extravasation whose margin is more defined, as also in the
circumstance  that it can be in  a greater degree removed by pressure,
though by no means completely.  The aspect of the redness may differ
according to  various circumstances ;  if the  capillary networks  of the
part affected be a plane, or uniformly extended, the injection will appear
as  an uniform deep blush ;  if, on the other hand, they are  moulded to
the form of villi, or folds of mucous  membrane, the  surface will have
the appearance of a pile of red velvet:  in fibrous structures a streaky
appearance is  observed, and generally the form of the  redness will de-
pend upon the arrangement of the capillaries of the part.  The increased
depth of color is owing chiefly to distension of existing vessels, not in
anywise to the formation of new ones, a process which does not take
place  till a much later  period: the only other cause which at present
exists is the staining of the surrounding tissues with  exuded haematin,
which may occur soon after stasis has been established.  It is necessary
to  distinguish carefully between genuine inflammatory redness, and
that which often simulates it closely in the dead body, viz:  hypostatic,
or  depending  solely  on mechanical causes,  or on the  mode  in  which
death has  taken place.  It is always desirable to  take other circum-
stances into consideration at the same time, but we may generally say
that we should suspect the inflammatory nature of a  redness which ex-
isted solely in  depending parts,  or in those the large veins  of which
were much gorged,  or which coincided with a fluid condition of the
blood, and which was not attended with any  thickening of the  part.
It may also be observed, that after an internal  part  has been exposed
to the air a short time, it assumes a much more marked and brighter
redness, which depends solely on the action of the oxygen in the air.
   The natural temperature of an inflamed part seems to be considerably
increased, and this as well  to the sensations of the observer as of the
sufferer (hence the name "inflammatio," a  burning).   An  increase of
heat is, however, not so decidedly shown by the thermometer; in  some
of Hunter's experiments the difference was  not more  than 1°  and  it
seems doubtful whether the heat of the inflamed part is ever greater
than that of other parts of the body.   The highest temperature we find 
INFLAMMATION.
119
mentioned is llOf; this was in  tetanus, which is not  an inflammatory
disease.   Rokitansky says, that the increased temperature in inflamma-
tion is partly occasioned by the formative processes which take place in
the stagnating blood, but that a very important part in the phenomena
is also played by the excitation of the sensitive nerves.  It is this nervous
excitement, doubtless, which gives rise to the idea of the great increase
of temperature.  The pain of inflammation varies much in degree and
in kind, according to its seat, and intensity, and exciting cause.   That
of inflamed serous membranes is often of a peculiar, sharp, darting kind;
that of mucous membranes more dull and gravative, as it is termed; that
of  dense, unyielding, fibrous or bony textures, amounts sometimes to
extreme agony. The inflammation heightens the sensibility of the nerves,
which are at the same time compressed by the swollen textures and dis-
tended vessels.
   Swelling depends manifestly in great measure upon the distension of
 the vessels  with blood; the bulk of the part is increased just as  that of
 a kidney or liver is when it is injected artificially—its fibres are put on
 the stretch, its vessels strained, and its capsule, if it have one, fully dis-
 tended.  The  effusion of  plasma is  considered by Rokitansky as the
 principal cause of  the swelling; this may be the case at  a later period,
 and in some cases, but is not, we think, so powerful a cause as the vas-
 cular injection.  In loose textures it will be more  considerable than in
 denser.
    We now proceed to  the  more minute examination of the  phenomena
 of the inflammatory process as they have  been disclosed to us by the
 microscope, and we here resume the line of inquiry which we commenced
  during our consideration of active  hyperaemia.   We saw in this, that,
  with  a certain amount of stimulation, the arteries enlarged, and admitted
  a greater quantity of blood, which flowed on more rapidly, and traversed
  with  an accelerated current  the capillaries and veins which  became
  dilated also.   An increased and more rapid blood-flow were then the
  characters of determination of blood.   But if the stimulus is  increased,
  or if it be excessive from  the  first, phenomena of a  very different kind
  present themselves.  The  current slackens, it moves slower and slower,
  and at last ceases; the capillaries are seen distended with a red  uniform
  mass  the veins are also enlarged, and filled with red corpuscles, crowded
  together, which retain more of their distinct form  than  those in the
  capillaries, and move either slowly onwards, or oscillate, or are  quite
  stagnant;  the arteries, which are also distended, exhibit for some time
  a progressive movement onward of their contents, which at first is steady,
  afterwards becomes jerky, or  intermittent, and at _ last  ceases.  I he
  condition  of stasis, as it is called {lcrVuh to stand),  is  now established,
  and therewith, as the sequence of active hyperaemia, inflammation.  In
  the immediate neighborhood of the seat of  stagnation the circulation is
  still  seen  going on rapidly, and not only in the parts adjoining on the
  margins of the stasis, but even within its area capillary streams may be
  seen here  and there rapidly coursing beneath a plexus of channels, which
  are filled  by an uniformly red quiescent mass.   Manifestly,  determina-
  tion of blood prevails  actively all round the focus of arrest of movement
  The stagnant blood in most of the capillaries presents an uniform red 
120
INFLAMMATION.
mass, in which the separate corpuscles are undistinguishable;  here and
there gaps may be seen, as if a fissure had taken  place, and separated
the adjacent portions a little away from each other.   Amid the mass of
blood-globules, appearing as it were fixed together, may be seen occa-
sionally one or two white corpuscles; according to our observation, they
are certainly not to be seen  in the great majority of capillary vessels.
After the stasis has existed some time, they may be seen in  great num-
bers coating  the  walls of the veins, and rolled  along  by the current
passing through them ; and  occasionally they  constitute, together with
transparent plasma, the entire contents of a portion of vessel of some
length,  not remaining absolutely stagnant, but  oscillating to  and fro, or
moving sometimes slowly onwards.   From a vessel thus filled we have
observed  them escaping into a communicating vein, three or four at a
time, and  carried away into the  general circulation.  The diameter of
the distended capillaries, which  are the seat of stasis, has appeared to
us, for the most part, tolerably uniform, but in one instance we observed
numerous constrictions at various points.  These were remarkably abrupt,
and extended across one-third, or one-half, the channel.   Mr.  Wharton

                                Fig. 11.
 a. Colorless globules adherent.  B. Blood-disks, still circulating,  c. Dense, stagnant, homogeneous mass.
    d. Corpuscles in oscillatory movement, becoming detached from the impacted mass.__Williams.

Jones mentions a local dilatation of arteries, but we find no account of
these  local contractions of the capillaries.   The red  globules, for  the
most part, appear to be packed together without any regular arrange-
ment, but occasionally they may be  seen lying together  in rouleaux, 
INFLAMMATION.                          121
like the  corpuscles of human blood,  with their long diameter transverse
to the axis of  the vessel.   The white corpuscles  are not unfrequently
seen  of  a pyriform  shape, dragging slowly along, or actually sticking
to the sides of the vessels;  that they do  possess  some degree of  adhe-
siveness is manifest, but it does not seem to be so considerable or general
as Dr. Williams  supposes. When the inflammation is subsiding, and the
stagnant blood  beginning  again  to resume its course,  all  that can  be
observed is, that the agglomerated  mass of red  corpuscles in a vessel
loosens and breaks up, so that the individual corpuscles are again visible,
while the impulse of the heart makes itself more  and more  felt, and at
last  sweeps away the  accumulation  altogether,  having first  detached
small portions successively.   Fibrinous coagula also form occasionally,
as  Mr.  Wharton Jones describes, and are similarly disintegrated, and
 carried  away by the returning current during resolution of the inflam-
 mation.   While stagnation continues,  a small quantity  of haematin dis-
 solved in the serum exudes, and imparts  to the tissues  bordering  the
 vessels some degree of yellow staining.
    We intend the foregoing  account to serve as a description of what may
Fig. 12.
  An exact copy of a portion of the web in the foot of a young frog, after a drop of strong aleohol had been
placed upon it. The view exhibits a deep-seated artery and vein, somewhat out of focus; the intermediate or
capillary plexus running over them, and pigment-cells of various sizes scattered over the whole  On the left
of the figure, the circulation is still active and natural. About the middle it is more slow the column of blood
is oscillating, and the corpuscles crowded together.  On the right, congestion, followed by exudation, has
taken place, constituting inflammatory action in the part.                               _„-,..,«,
  a. A deep-seated vein, partially out of focus. The current of blood is of a deeper color, andnotsorapidas
that in the artery. It is running in the opposite direction.  The lymph-space on each side, filled with slight y
yellowish blood-plasma, is very apparent, containing a number of colorless corpuscles, clinging to or slowly
moving along the sides of the vessel.                                           .  ,., „  .
  6. A deep-seated artery, out of focus, the rapid current of blood allowing nothing to he perceived but » red-
dish-yellow broad streak, with lighter spaces at the sides.                             resembles  a
  Opposite c, laceration of a capillary vessel has produced an extravasation of blood, winch resembles

"Tr^eron has occurred, and the blood-corpuscles are apparently merged into one ~£™£*
reddish ml, entirely filling the vessels. The spaces of the web, between the capillary j^to-a-tar
and less transparent, partly by the action of the alcohol, partly by the exudation. Tins latter entirely fills
up the spaces, or only coats the vessel.—Bennett. 
122
INFLAMMATION.
be actually observed of the process of inflammation, as it occurs in the
frog's web.   Most of the statements  we have verified by our own exa-
mination, and we believe they are in  accordance with  those of the best
observers.   The question now presents itself, what occasions the stasis?
and this is, in fact, the  great  and unsolved problem of inflammation.
The earlier speculations as to the vessels being in a state of spasm, or,
on the other hand,  of atony, need not  occupy our attention;  nor can
we see that any definite ground is gained by the hypothesis  of Hunter,
that the vessels are in a state of active  dilatation, except that he seems
thereby  to  recognize the  true nature of  active hyperaemia.   Three
opinions, of later date, may be  said to be still sub judice. Two  of them
we have already referred to, when speaking of active hyperaemia.   The
third  is that maintained  by Dr. Williams.  He considers " that an
essential part of inflammation is the production of numerous white glo-
bules  in the  inflamed vessels;  and that the obstruction of these vessels
is mainly due to the adhesive properties of these globules."  With regard
to this doctrine, a reference to  the description we have given will  show
that we agree with  Professor Paget and Mr. Wharton Jones, in reject-
ing it.  Nothing can be more evident, we think, than  that the white
corpuscles play no important part in causing the stagnation of the blood-
current.  But we differ from  Mr. Paget,  and agree with  Rokitansky
and Williams, as to the  increased production of white corpuscles in the
inflamed vessels.  The numbers which present themselves in some of the
small veins, cannot, we think, be brought together merely by accumula-
tion,  especially when we  consider  that  most of the  communicating
capillaries are plugged  up, and that they cannot therefore be trans-
mitted from them.  The neuro-pathological theory of Henle is  the one
which Rokitansky prefers;  but he acknowledges that it gives no  satis-
factory explanation of stasis of the blood.   Henle himself thinks he can
account for it according to his  view as follows:'  " As a physical conse-
quence  of dilatation of  the vessels, there takes place a retarded flow of
blood.  This, together with the relaxation and dilatation of the  vessels,
favors the exudation of serum; the  consequence of which is, that the
plasma  of the blood in the  part becomes inspissated by a preponderance
of protein matter  over the salts.   This inspissation of the  plasma de-
termines endosmotic  changes in the red corpuscle, in consequence of
which they are disposed to aggregate."   Rokitansky, stating that mere
paralysis and dilatation of the vessels cannot give rise to stasis,  gives
the following as his own opinion of  its mode of production: " It pro-
ceeds (a) from the sticking together of the blood-corpuscles, the heaping
up and  wedging together of them in  the  capillaries, while  the plasma
in part flows off towards  the  veins; (b)  from the  inspissation of the
plasma  occasioned by the exudation of  serum through the dilated and
attenuated walls of the vessels, and its saturation with fibrin and  albu-
men ; (c) from the heaping up of the colorless corpuscles—i. e.  nuclear
and cell-formations, together with blood-globules; from their sticking
together,  and  from  the delicate, hyaline, fibrinous  coagula, which
develop themselves  among them.   This  is certainly the most important
' Wharton Jones's Report on Inflammation, April, 1844. 
INFLAMMATION.
123
moment in the inflammatory process, since, on the one hand, it very spe-
cially throws light upon the phenomenon of stasis, and, on the other hand,
comprehends also the plastic processes which take  place  in the heaped
up and stagnant  blood.  It separates in this way the process of inflam-
mation from a merely simple one of exudation.  The elementary forma-
tions above mentioned are not merely swept together towards the demesne
of the stasis, but they originate as new (productions)  in the  stagnant
blood, for this generally presents  remarkable alterations.  .   . _  .  •"
We  believe  the latter paragraph to contain views of very great import-
ance, especially with regard to the effects of local inflammation upon
the  system.  Nor do we doubt that the changes wroughtby exudation,
draining  away  of  Liq.  Sanguinis, multiplication  of white corpuscles,
and coagulation  of the fibrin, may all exercise considerable influence in
prolonging  and confirming the stasis, and determining  its results.  But
we do not  think they are the  primary and causative  phenomena.  It
seems to us a  very important  fact, which Mr. Wharton Jones states,
and which we have observed ourselves, that  " stagnation commences in
the  capillaries, and extends from them to the veins on the one hand,

                                Fig. 13.
     Production of stasis from Mr. Wharton Jones's Essay, Guy's Hospital Reports, vol. vi. p. 35.

and the arteries on the other."  We have seen the blood stagnant in
the capillaries, while  it was moving  on steadily through  an adjacent
artery and vein.  This points to the capillaries  as  the part where the
arrest commences.  Again, it is a very important circumstance that it
a strong stimulus be applied, the stasis takes place almost immediately:
it  seems as if the  blood  were suddenly coagulated in the capillaries.
When  the arrest comes to pass  more slowly, so as to admit ot being
watched, it  is described by Mr. Wharton Jones  as  taking ^e in the
following way: Red corpuscles, more  collapsed and darker-looking than
na aVfi»t adhere to the walls of the vessels, and then other-redcor-
rmscles adhere to them.   "The first adhesion of red corpuscles to the
TaU o?a ve/sel usually takes place  at.a"ion  and %*™%$
fsee Fi». 6): The stream c, striking with force on the wall ot the vessel,
Lt the b furcation A, some of the red corpuscles adhere to the wall of
L: vessel.  Other  'red corpuscles  adhering to them, an'  ^rn^ed
mass results, which is sometimes seen to  be moved along the vessel a
short way by the force from behind; but more red corpuscles adher.ng 
124
INFLAMMATION.
to the mass, the vessel is  at  last wholly blocked up by it at D.   The
stream c, being no longer permitted to pass in part by d, passes off by
E; but in leaving e, the stream strikes on the wall of the  vessel at the
bifurcation B, where red corpuscles  adhere, and  form a  nucleus for an
agglomeration, which blocks up both the vessels  F and g—e and c also
becoming blocked up, and  so  on  the process goes.  Stagnation is  seen
first  to  take place in those  capillaries which are least in  the direct
course from the  artery to the vein.  In  those  capillaries which  lead
most directly from  the artery to the vein, and in which, consequently,
vis a tergo  operates most advantageously, the  blood is latest in stagnat-
ing."   The main  point, that  stasis is produced by the red corpuscles
adhering to the walls of the vessels and to each  other, is confirmed by
others, and by our  own observation.   On one occasion, we distinctly
noticed a single  red corpuscle adhering,  by one  end, to the  wall  of a
vessel, in which  circulation was  returning, while several other red cor-
puscles, in motion one  after another, swept slowly past, brushing against
it, as it waved in the current.   That in the healthy  state  the red cor-
puscles pass on so smoothly and uninterruptedly  within their even rela-
tively narrow channels, that they shun, as is well known, the walls, and
allow  a thin layer of the fluid  in which they float  to intervene, while the
colorless corpuscles show no such tendency, but  affect a preference for
the so-called still layer, and move slowly onwards in it;  that there is
decidedly a tendency of the red globules  to aggregate together in blood
drawn from the body,  while this  seems to be  held in abeyance, while
the blood is within the vessels; that the smallest capillaries,  according
to Wharton Jones, are traversed chiefly by plasma, and  by a few color-
less corpuscles, one after  the other, with only  a single red  corpuscle
now and then;  that the red and colorless corpuscles  show no tendency
to stick together, appear  to  us very significant facts, which  require
some such hypothesis  as that  offered in Wharton Jones's report, April,
1844, viz:  " That  there  exists  some sort of attraction  between the
colorless corpuscles and the  walls  of the vessels, but  an absence  of
attraction,  if not a repulsion, between the red corpuscles and their walls,
as also between the red and colorless corpuscles."  Mr.  Wharton Jones
formerly conceived that it was the nervous influence which prevented
the red corpuscles from aggregating together within the  vessels, as  they
do out of the body, and that stasis depended on  the suspension of this
influence.   It was an ingenious  and probable  opinion, but  is  disproved
by the experiments which he himself has performed,  and which are
related  in  the Astley  Cooper  Prize Essay.   In  these  he shows, that,
after the nerve accompanying an artery had  been divided,  the flow of
blood, though interrupted for  a  short  time, soon returned, and became
quite  free; and also that, after section of the  ischiatic nerve, the arte-
ries of the web  of  the same side are found somewhat more dilated, and
the flow of blood in them freer and more rapid than  in  the web  of the
uninjured side, while stagnation was induced  more readily in the web
of the limb whose nerves were entire, than in that  of  the limb whose
nerves had been divided.   He now adopts the opinion of Henle, though
somewhat  modified, that stagnation  depends on  inspissation  of the
plasma, on its containing  an increased quantity of fibrin and albumen, 
INFLAMMATION.
125
and rests much on the fact that such a condition of the Liq. Sanguinis,
whether natural  or  imitated artificially, is found to increase^ the ten-
dency of the red corpuscles  to aggregate together.   Our limits forbid
discussion ;  and we therefore simply pass  on  to state our own opinion,
so far as we may venture to  offer one on this qucestio vexata.^  We saw
reason to believe that  the tissues, in virtue  of their nutrition power,
exercised an influence on the movement  of  the blood; that in active
hyperaemia  their  attractive  force  was increased; and  we would now
add, that it is through the failure  of this nutrition power that we be-
lieve stagnation takes place.   The exact nature of the influence exer-
cised by the tissues over the blood, which traverses the  capillary chan-
nels, is unknown.  All that we can  discern is, that  it is  such  as pro-
motes its  free passage through  them; and  therefore, when it is  in
abeyance or greatly altered, it is to be expected that the circulation
will be interrupted also.   More  than this  we cannot gather from the
 observed phenomena;  and we would only offer the remark, in  conclu-
 sion, that  in coincidence with  the  establishment of complete stasis,
 cessation of the natural function of the part occurs,  and_ other pro-
 cesses commence—the exudative, in  which the plasma, that in a healthy
 state would have ministered to and  maintained healthy action, is con-
 sumed in wasteful or  even  destructive changes.  Whether the stasis
 depend solely on a persistence  and exaggeration of the attraction of
 the tissues  for the blood which exists in active  hyperaemia, or upon this
 and an abolition of the natural  non-aggregative tendency, or even  re-
 pulsive tendency of  the red corpuscles for each other and for the walls
 of the vessels, must remain uncertain ; but  the coincidence above  no-
 ticed  must be allowed to give  considerable support to the main point,
 on  which we would insist, viz: that  the nutrition power of the tissues
 is chiefly concerned in the production of  the flow of active hyperaemia,
 and tbe stasis of inflammation.
    We must take some notice  of the different varieties of inflammation,
 which depend, partly  on  differences inherent in the subject, partly on
 different exciting causes.  What is  called Sthenic inflammation is that
 which occurs in a healthy person, either spontaneously, or from  ex-
 posure to cold, or the application of some irritant which does not con-
 taminate and  depress the general  system.  The symptoms, if the in-
 flammation is extensive, run high, the febrile excitement is considerable,
 and free depletion is required and borne  well.   The exudations contain
 much plastic matter, and pus, if formed, is of the kind termed  laudable.
 Asthenic inflammation occurs in persons  originally weakly, or  rendered
 so  by the action of the exciting cause, as in  the inflammations of influ-
 enza; the pulse, though frequent, has  no  strength, the fever is of a
 lower type, and the effused matters  manifest little plasticity.    ihe
  terms acute, sub-acute,  and  chronic, have reference mainly to the pe-
  riods of duration of the inflammation, or to the rapidity or slowless ot
  its course. Acute inflammation  is often, but not necessarily, sthenic;
  chronic and sub-acute are often not asthenic.   Many changes are com-
  monly said to proceed from chronic inflammation which probably belong
  more to the class of degenerations: it is, however,  difficult to  draw any
  marked line between the two.   The chief value of the terms lies in their 
126
INFLAMMATION.
affording a kind of scale  whereby to apportion the activity of treat-
ment ;  to the chronic affection we must oppose a remedy of slow and
gradual action : the acute must be met more " heroically."   It is im-
portant to be aware that an  inflammation  may be sub-acute or chronic
from the outset; an acute inflammation cannot well be overlooked—a
chronic, if unpreceded by  acute symptoms, may easily be: such inflam-
mations are sometimes said to be latent.   Congestive inflammation differs
not much from asthenic;  its effusions are of the samekind, but it par-
takes in a considerable degree of the nature  of passive hyperaemia—
indeed, is such originally,  and has, subsequently, inflammation, acute or
sub-acute, grafted upon it.  This must  be remembered in treating it.
The chief character of erythematic or  erysipelatous inflammation is its
tendency to spread and travel over an extensive surface:  this seems to
depend, at least in part, on the peculiar character of the effusion, which
consists,  for the most  part, of serum, or sero-purulent matter, and not
of  fibrin, which  in   phlegmonous inflammations establishes  a barrier
between  them and the surrounding textures.   The general symptoms
are in most cases those  of  adynamic  or typhoid  fever; depletion  is
injurious, and stimulants required at an early period.  There  is good
evidence to show that a peculiar poison, capable of being communicated
by infection, is the  cause of these  inflammations, and that this acts
upon and modifies the system, even  before  the phlogistic process has
made its appearance.   They  are, therefore, with respect to  their ex-
citing cause,  to be ranked together  with  other inflammations, such as
the rheumatic, gouty, syphilitic, &c, which each manifest certain peculiar-
ities, but depend, essentially, upon the presence of some materies morbi in
the blood.   To the same class belong most of the inflammations which
constitute skin diseases, which exhibit very remarkable instances of the
effect of different states of the blood  in determining the kind of inflam-
mation that shall occur.   To this we shall refer again, under the head
of "Crasis."  These inflammations also exhibit very clearly the affinity
of certain parts of the tissues for certain morbid  matters, which are
their exciting  causes; thus,  lepra has  its seat of  election about the
prominence of  the knees and elbows, eczema prefers the side of flexion
of  the limbs  and  the bends of joints,  lichen affects the outer sides.
The same is exemplified in the action of many medicines and poisons;
arsenic, in small doses, produces conjunctivitis—in larger, inflammation
of the stomach and  intestines, corrosive  sublimate inflames the larger
intestines, mercury, the gums, and so on:  in all these cases the affinity
or attraction of the elements of  the  tissue for the  substance is clearly
evinced.  Diphtheritic inflammation  is  characterized by the  early ex-
udation upon mucous  surfaces of a film or membrane of fibrinous matter
of dirty white or grayish appearance  ; this may extend over a consider-
able tract,  commencing often in the fauces,  and thence spreading to
the mouth, the larynx, the air-passages, the oesophagus,  and more or
less of the alimentary canal.  The subjacent mucous membrane is but
little swollen,  of a deep dull red, and inclined to bleed on the removal
of the  exudation.  The attendant fever is of a low kind, and much of
the danger depends upon the insidious,  almost latent manner, in which
the exudation takes place, so that suffocation may be actually threat- 
INFLAMMATION.
127
ened before alarm  is taken.  This  kind of inflammation occurs most
often in epidemics,  and is more frequent on the Continent than in Eng-
land.  It  has been observed in France,  that, during its  prevalence,
wounds and ulcerations assumed an unhealthy character,  and were  in-
disposed to heal.  Its  cause is, evidently,  a peculiar asthenic state of
the system generally,  involving a peculiar crasis of the blood, induced
by atmospheric influences.  Instances of a somewhat similar  kind, but
in which the asthenic  character is much less marked, are occasionally
met with among ourselves; among these we should rank the so-called
bronchial polypi, the pieces of membrane  which are passed  after the
irritation of calomel, and in some other cases of intestinal disorder, and,
probably some of the membranous exudations of dysmenorrhoea.  The
aphthae of children and adults belong  more to the true  diphtheritic
exudations;  they  contain,  often, a large proportion of a confervoid
growth, which has been regarded, indeed,  as constituting  their essential
cause.   This, however, in  Rokitansky's opinion, is  not  the case.  To
this subject we shall  refer again, under the  head  of "Parasites."
Hemorrhagic inflammation  is  another variety;  it  seems chiefly to
occur in individuals predisposed to  hemorrhage, or in  places  where
scurvy is prevalent.   Dr. Williams  has found it associated  with cirrho-
sis  of the liver, and granular degeneration of the kidney.   His opinion
is, no doubt, correct, that it is more dependent on an altered condition
of the  coloring matter,  than on a deficiency  of the fibrin.  Its cha-
racter is decidedly asthenic.  Scrofulous  inflammation is not so much
a distinct variety as some others.   It is commonly excited by the irri-
tation of  existing tuberculous deposit, which is  occasionally mingled
with its exudative products.  These are distinguished  in general by
their aplastic character;  they are  deficient in coagulating fibrin, and
are  often thin and serous.  The vital power of the system, both blood
and tissues, is essentially defective;  and is the  cause, at  once,  of  the
deposit which excites the inflammation, and of the low character of the
process itself.
   We have already alluded to the  causes of inflammation in the fore-
going  remarks, and shall now do  little more than  briefly enumerate
them.   Predisposing causes are almost always debilitating influences ;
a strong part is less liable to inflame than a weak one—a previous attack
of inflammation especially renders a  part more prone  to undergo a
second.   Certain unhealthy conditions of  the blood (of  which that in-
duced by foul air is one) predispose the system to inflammation from
trifling causes,  which  would pass inoperative in a sound state.  Ex-
citing causes  are  either such as act on the part directly which they
inflame, or indirectly through  the  medium of another.   The first may
be mechanical irritants, such as a splinter in the flesh;  or  chemical, as
a strong acid, or acrid salt; or vital, such as mustard, &c, whose opera-
tion oniy affects living structures.   It  is  remarkable that  the urinary
and biliary secretions  which excite  only healthy  action  in the mucous
surface over which they naturally flow,  and which, or at least some of
their constituents,  produce no particular injurious effects  when absorbed
into the blood, act as  the most violent and fatal irritants upon serous
membranes, and the areolar tissue, when infused into them.   This shows 
128
INFLAMMATION.
clearly the important part played by the tissues themselves in the pro-
cess of inflammation:  that which is  a healthy stimulant to one texture
is the cause  of destructive  inflammation  to  another.   The production
of local inflammations from the presence of some substance in the gen-
eral mass of blood, for which certain parts seem to have a special affinity,
has already been noticed, but we may add, that it is in these cases that
we  observe the  interesting phenomena of symmetrical  disease ;* the
corresponding parts of the two lateral halves of the body being affected
almost to the exclusion of others.  Here,  again, we have evidence of
the predominant influence of the tissues,  the parts which are exactly
alike are affected alike, and the materies morbi passes by others.   How
unable is the neuro-pathological theory  to  explain such instances of
inflammation!
  The second class of causes are those which act indirectly on the part
which suffers.  The most common of these is cold, which appears to act
by repelling the blood from  the surface, and causing it to accumulate in
some internal part.   This will be different, according  to the  previous
predisposition; thus one person, as the result of a severe chill, will have
bronchitis, another diarrhoea, a third peritonitis, a fourth renal conges-
tion, and so on.   Malaria, the repelling of eruptions, the arrest of habi-
tual discharges, the sudden healing of ulcers, are also recognized as
causes of internal inflammations, which they probably produce in the
same way as  cold, but the active  congestion of the  incipient process is
more apt to issue in hemorrhage.  It is matter of much uncertainty as
to how many inflammations  originate; they come on, as it seems, spon-
taneously, without the individual being aware of  any exciting  cause.
Both as respects  these, and those which are produced by cold, &c, it
seems to us necessary to recognize some special condition  of the tissue,
which in the  one case converts the congestion into an inflammation, and
in the other, is the  sole and  efficient  cause.  In  ague,  for  instance,
during the cold stage of each paroxysm, considerable congestion of the
internal viscera takes place, but inflammation of these is comparatively
rare.   In healthy states of the system, the surface may remain severely
chilled for several hours, during  which  the blood must accumulate in
the internal organs, but this does not occasion inflammation.   These in-
stances show  that mere repellent  influences  producing congestion are
not adequate to produce inflammation solely by themselves.   Even in
the case of a common catarrh there  is much  reason to  believe that the
inflammation  of the mucous surface  depends  much  more  on some pre-
existing dyspepsia, or unhealthy  condition of the blood, than  on expo-
sure to cold or wet;  and, in fact, many a cold  occurs without any such
exposure.   In such cases, the predisposing cause  becomes the most im-
portant, or may even be the exciting  also.   We have not yet noticed the
nervous influence in its relation to the causes of inflammation.  This is
considered the prime mover in the process by those who adopt the neuro-
pathological theory:  in our view it holds a very secondary place.  That
disturbance of the nervous  force may  prove  a cause  of  inflammation

  1 For a most interesting exposition of the subject of symmetrical diseases, we refer to
Mr. Paget's Lectures for 1847. 
INFLAMMATION.
129
cannot be  doubted: Lallemand (quoted by Dr. Williams) "relates a
case in which a ligature, involving the right brachial plexus, was followed
by inflammation and suppuration of the opposite hemisphere  of  the
brain.   Mr. Paget mentions a case in which a portion of a calculus im-
pacted in the urethra excited inflammation, with deposits of lymph and
pus in the testicle.  Instances of a similar kind, or of active hyperaemia
similarly occasioned, are not  very rare, and  they certainly prove  the
capability of the nervous influence to set on foot the inflammatory pro-
cess.   But we have already given abundance of evidence that it is not
through this channel that the causes of inflammation usually operate,
and for  a summary of the arguments we would refer to Dr.  Williams s
work,  p. 249.   Coinciding, as we completely do, with Mr. Paget, in his
enumeration of four conditions  as necessary to healthy nutrition, and
believing that the derangement of one of these primarily, with secondary
derangement of the others, occurs in  every case of_ inflammation, we
might divide the  various causes which we have  noticed into  such as
affect—(1) the contractility of the vessels ;  (2) the healthy crasisof the
 blood ; (3) the  nervous influence; (4) the life and nutritive actions ot
 the part.                                 .             .
   In strict language, there is only one termination to the inflammatory
 process,  viz: that which is commonly called resolution, in which the
 diseased action ceases to advance, and then recedes by the same  steps as
 those by which it arrived at the condition of stasis.   The microscopic-
 ally visible phenomena have been before described,  and they corre-
 spond to  the subsidence of the general symptom, to the paling of the
 redness, the lowering of the temperature, the lessening of the swelling
 and pain.  The recovery of the part may be complete ; but more often
 some,  it  may be  slight, indications  remain,  for a time, of the  by-past
 malady, and of some deficiency of the vital powers.   These consist, in
 some degree, of  congestion of  the vessels, especially the veins  from an
 enfeebled state of their contractility, in a less  perfect  fulfilment of the
 function of the part, and in a proneness to relapse on the application ot
 slight exciting causes.   Inflammations which arise in consequence of a
 mal-crasis of the blood, rarely undergo resolution, or  if they  do, it
 only  to reappear in another part, and  perhaps  a  more  important,  lhis
   oititutes  metastasis.   A good example of this t-nsfer of inflammation
 from one part  to another is afforded by some cases of  rheumatism and
 occwionaUy by the disease  called mumps.  As long  as the  matenes
 ^continues  to circulate  in the blood, it wil  tend  to excite inflam
 mation in one  part or other;  the best thing that can happen is that it
 Tould locate iLlf in a part where it can produce no serious^effects; from
  interference with important functions, and the*Lr^fla^fmtt not
  crasia is at an end.  One important remark of Rokitansky  must^ no
  be omitted  viz : that even resolution does not, especially if the inflam
  maZ has been extensive, leave the system in as favorabem,^nd^ion
  as before the  attack,  since a large quantity of liquor^ sangum s which
  during the stasis, has undergone certain changes is set; fiee,^ge
  with The general maw of the blood.  This must produee' • oontemin^t ng
  effect until it be eliminated.   Hence the benefit of a  free action ot tbe
  skin, of a free flow of urine, purging,  &c.
         9 
130
INFLAMMATION.
  But in order that resolution may take place, it is absolutely essential
that no considerable amount of effusion should have occurred;  if this is
the case, the affected tissue remains clogged  and otherwise injured by
the presence of solidified matter in its interstices.  This matter and the
tissue may also undergo further changes.  We  thus  come to  the  con-
sideration  of, firstly,  inflammatory exudations;  and, secondly,  of the
changes that take place in the tissues affected by them.  The fluid effused
in inflammation is commonly the liquor sanguinis, more or less modified,
especially containing a less proportion of albumen and fibrin.  An ana-
lysis,  by Simon,  of fluid obtained  by paracentesis thoracis,  shows, in
1000 parts, 934.72 of water, 1.02 of fibrin, 1.05 of fat, 48.86 of albumen
and albuminate of soda, 11.99  of  extractive matter, and 9.5 of fixed
salts.   The quantity of fibrin varies considerably.  Some effusions con-
sist chiefly of it,  others contain very little;  generally, it may be said,
its quantity is in proportion to  the vigor of  the system, and the acute-
ness and sthenic  character of the inflammation.  The fibrin may coagu-
late quickly, or remain  in its  fluid state, for a length  of time, in the
part where it is effused.  Blood-corpuscles, or dissolved haematin, may
be mingled with the exuded matter in various proportions.  Though we
often  speak of serous effusions as the  result of inflammations, yet  the
opinion expressed by Mr. Paget is probably correct, that "  an effusion
of serum alone is a rare  effect of inflammation, and that generally it is
characteristic of only the lowest degrees of the  disease." He mentions
as instances inflammatory oedema of the mucous folds above the glottis,
chemosis of the conjunctiva,  and some forms of hydrocephalus.   The
fluid obtained from blisters contains either distinct fibrinous coagula, or
only a small proportion of  fibrin, together with multitudes of  puriform
corpuscles.
  No doubt, in inflammations of different characters, there must exist
great differences  in the  composition  of the  serous fluid effused,  and in
its particular qualities and tendencies.  There must be great variations

                               Fig. 14.
  Fibrinous exudation on pleura in process of absorption; areolae form in it, and reduce it to filamentous
                                bands.

in the proportion of oil, of extractive and saline matters in the effusions •
but respecting these we have scarce any information.  The chemical
examination of inflammatory  products is very difficult, partly in  con-
t 
INFLAMMATION.
131
sequence  of the impossibility of procuring more than very small quan-
tities, partly because they can so seldom be obtained pure; and  almost
the whole of our knowledge, therefore, has reference to the differences
which are perceptible to the eye and to the microscope in the solidified
and shaped constituents of  the exudation.  These, however, afford very
valuable indications for forming a judgment of the nature and tendency
of the process from which they spring.   We have  already  given  Ro-
kitanky's account  of the varieties of fibrin,  as  seen in intra-vascular
coagula, and stated the important circumstance that they correspond
closely with those observed in exudations; but it still seems desirable to
present an abbreviated sketch of the latter from the same authority, in
order to  furnish a kind of scale  of  varieties, to which observers may
refer different specimens they  meet with, and to elucidate, as much as
possible, a process which meets us at every turn.
   Rokitansky describes two varieties of fibrinous exudation, the simple,
or plastic, and the croupous.  The first appears as a flaky-fibrous trans-
parent blastema, of remarkably sticky quality, tear-
ing, as  a fibrous  felted mass, with numerous nuclei
and nucleated cells scattered over it.  It corresponds
to the second variety of intra-vascular fibrin.   Such
an exudation constitutes the material by  means of
which wounds  are  united  that  heal  by  the  first
intention, and  is  often found forming  the false
membranes upon serous surfaces, or the induration-
matter of parenchymata.   It  may undergo meta-
morphosis ;  (1)  by being  more or less entirely
 absorbed, in which Rokitansky considers the serous
 part of  the exudation  to act as a corrosive or  dis-
 solving  menstruum; (2)  by becoming obsolete, i. e.
 drying up into  a horn-like mass, which  may after-
 wards ossify; (3)  by undergoing a change (of de-
 velopment) into fibroid  tissue.   New_ vessels  may
 from in it more or less abundantly, or it may obtain
 a smooth,  polished surface, like that  of a serous
 membrane, as is occasionally seen in the arachnoid.
 The croupous exudation is,  in general, characterized by a high degree
 of coagulability, a  yellow or  greenish-yellow color, opacity, deficient
 capacity for becoming organized, speedy breaking up, and  diffluence,
 very often  by a  corroding property, which brings the tissues, as it were,
 into a state of fusion.
   The croupous exudation-process and its product are further remarkable
 by (1) the usually excessive, exhausting quantity of the exudation, and
 its extension over  large surfaces  of  tissue; (2) by the acute  occurrence
 of the exudation, since a pre-existing crasis is the fundamental cause of
 the stasis; (3) by the often very slight degree of injection of the diseased
 tissue,  which may depend either on  the blood-corpuscles being concealed
 by the opaque hyperinotic plasma, or on the large quantity of exudation,
 inducing quickly  emptiness and collapse of the vessels;  (4) by a less
 sticky  quality;  (5)  by  a considerable  amount  of fat.    The principal
 alteration which this exudation undergoes  is  the above-mentioned difflu-
 Copied from  Gulliver's
Trans, of Gerber, may be
taken as an explanatory
diagram of  commencing
organization  in effused
fibrin. 
132
INFLAMMATION.
ence, by which it breaks up into a fluid, more or less analogous to pus.
This change especially  affects  the  coagulated solid  part.  When thus
fluidified it may be absorbed, or may leave behind a partial  residuum,
of a cheesy, fatty, pappy fluid, containing granular, cretaceous, and oily
molecules, granule-cells,  and crystals of cholesterin.   Variety  (a) of
the croupous exudation  corresponds to variety (3) of the intra-vascular
fibrin, like it consisting of varying.proportions of felted fibres, punctiform
and oily  matter, and various granular nuclei  and  cells.   Variety ()3)
corresponds to (4) of intra-vascular fibrin.   It consists of a shapeless
basis-substance, containing  a preponderance  of punctiform matter, to-
gether with nuclei and cell-formations, approaching more and more the
character of those of pus.  It is non-adherent to the surface, and quickly
becomes diffluent.  To these two varieties belong the  various exudations
of croup, those in many cases of meningitis, of pericarditis, and phlebitis.
Most cases of pneumonia give rise to exudations of this kind,  especially
those  in which a very abundant yellow, quickly-diffluent material is
deposited, which causes great increase in the  size of the lungs.1   The
corrosive quality of the diffluent exudations manifests a decided tendency
to the early production of abscess and ulceration; it is probably in the
case of such exudations as these that the comparatively rare occurrence
of pulmonary abscess takes place. Variety (?) of the croupous exudation,
Rokitansky distinguishes as the aphthous, or, we may say, the diphthe-
ritic.  It forms a yellow  or greenish-yellow mass, dirty-gray, and opaque,
coagulating on surfaces  into tenacious membranes, and thereupon break-
ing up, and occasioning corrosive  fusion of the tissues.   The affected
tissue may be  simply  corroded, or fused into an ill-looking, stinking,
sanious pulp, or into a tenacious, tinder-like,  dirty scab.  Instances of
this exudation  are seen especially on mucous  surfaces, as in muguet,
diphtheritis, some forms  of dysentery,  of puerperal  metritis,  in  the
ulcerations of typhus, and those of hospital gangrene.   These exudations
are, for the most part, dependent upon  a  special crasis of the blood,
which we shall afterwards notice.   Rokitansky makes a third variety of
fibrinous exudations, viz: the tuberculous, but we shall not notice it in
this place, as we doubt  the propriety of classing it in any way together
with the  foregoing.  There is, however, one form  which fibrinous ex-
udation not unfrequently assumes, which resembles tubercle a good deal,
and might be  confounded with  it.  In this  it  constitutes small, firm
nodules, which consist  of a fibroid tissue, and  do not undergo  any of
those changes which tubercle commonly  does.   They lie sometimes in
great numbers in the sub-pleural, areolar tissue, and are often surrounded
with black pigment.  Rokitansky also describes albuminous exudations,
as distinct from the fibrinous, but the separation scarcely seems to us to
be warranted.   They appear identical with the lower varieties of the
croupous form, but modified, in some degree, by occurring in depressed
conditions of the system; as where the blood is abnormally venous, from
disease of the heart, or impoverished by effusions that have robbed it of
much of its fibrin, or insufficiently renewed, in consequence of marasmus,

  1 Dr. Hodgkin believes, and we think he is right, that this condition of gray or purulent
infiltration is not preceded by a stage of red hepatization. 
INFLAMMATION.
133
old age, kc.   The  stasis, which  gives  rise to these  exudations, is said
to have very often an asthenic, hypostatic  character, and protracted
course.   We have  above  noticed the rather rare occurrence of serous
exudations which contain no  fibrin.   Rokitansky denominates these
albumino-serous, or, if they contain  fibrin, fibrino-serous, reserving the
term "serous" especially for those which contain little or no  animal
matter.   Of these, he says that they are  thinly fluid, watery, clear,
colorless,  or pale yellowish, or even yellowish-red, and of saline taste.1
They may result from inflammation, but afford no proof by their presence
of its having existed.   They are, of course, capable of no organization,
but seem  to exert a deteriorating influence on the tissues where they are
effused, "loosening and puffing them up, paralyzing  their contractility,
and manifesting, after long contact, a surprising  enfeebling influence,
especially upon muscular fibres."
   We proceed next to the examination of certain processes, which are
of extremely frequent occurrence in inflammatory exudations, or which
impress a peculiar character on them, even in their nascent state.   These
are the suppurative, and  that which gives rise to the  granule cell  and
other forms of celloid corpuscles.   We will first describe the products,
and afterwards consider the mode of their production and their import.
There  are many varieties  of pus ; but that which is commonly called
healthy (laudable)  is that which  we shall take for a typical description.
It appears to the naked eye as a creamy, thick, opaque, and homogene-
ous fluid ; communicates  an unctuous feeling when rubbed between the
fingers ;  is of a yellow or whity-yellow tint;  sweetish, or insipid ; and,
while warm,  gives off a peculiar, mawkish smell.   Its specific gravity is
1030—1033.  If allowed to stand some time in a tall, narrow glass, the
fluid separates into a thickish  sediment,  more or less  abundant,  and a
supernatant serum.  This serum, according to Vogel (whose account we
shall use freely) is identical with the serum of the blood, containing
much albumen, extractive and saline matters, and fat.  The reaction is
alkaline; but  it readily becomes acid, from the generation of an acid,
which is commonly supposed to be the lactic.   In some cases, however,
according to Dr. Walshe, it has an acid reaction,  even at the time of its
formation.   A peculiar substance, called pyin,  by Guterboch,  which
Simon considers almost identical with mucin, is said  by Rokitansky not
to be one of the constituents of normal pus, but to proceed from croupous
fibrin,  in  a state of diffluence  mingled with it.   The sediment consists
almost  entirely of small  organized corpuscles, the well-known pus-glo-
bules.   These are of spherical  form, have  a well-defined contour,  formed
by a distinct  homogeneous  envelop, inclosing a mass of  soft granulous
substance, and a varying number of nuclear corpuscles.   These are, in
well-formed pus-globules, for the  most part concealed  by the surrounding
substance; but in the younger cells, even of healthy pus, and  in  all
those of pus of an inferior kind, they are easily perceptible, even without
the aid of acetic acid.  Occasionally, a single nucleus exists;  but more
commonly it is made up of two,  three, four,  or  even five large granules.

  i One of  the best instances of the pure serous exudation (serosity,  as some call it), is
the fluid which  distends the ventricles of the brain in acute hydrocephalus—100 parts
have been found to contain 1 of salt, A of animal matter, and 98.6 of water. 
134
INFLAMMATION.
The single nuclei are always the largest, and indicate, as we conceive,
the most perfect kind of development.  The more numerous the nuclear
corpuscles  are, the smaller do  they become,  so that the opinion seems
very probable, that the perfect  nucleus is formed by a coalescence of the
smaller corpuscles; and that the bipartite, tripartite  condition, &c, is

                               Fig. 16.
                  © %@  © #  ®  €)  ® d

                          Corpuscles from a pustule.
       (a). Large granulous exudation globules.
       (6). Pus-corpuscles.
       (c). Nucleated fibres.
       [d~). Pus-corpuscles, their nuclei brought into view by acetic acid.
       (a'). Granular exudation globules, their nuclei brought into view by the action of water.

an indication of imperfect development.   The nucleus is seated on  the
envelop, or is parietal, as it is termed.   Its diameter is about  g^1^ in.;
that of the entire pus-globule about -g^o in*   Single (complete) as well
composite nuclei, are seen  floating in the  serum of pus;  but they are
not very numerous.  We have also observed, as well as M. Lebert, small
homogeneous, or faintly granular  globules,  about g^uu  m  diameter.
The observer just mentioned describes some globules which often occur,
mingled with those of pus, but  which differ  from them in  several par-
ticulars, being  smaller,  more transparent, and  non-nucleated.   These
he  terms "pyoid."  There  is  generally a small  quantity of diffused
granular matter mingled with the pus-globules.   This is more abundant,
according to our observation, in  pus of low and ill development.   It is
not  to  be  confounded  with the so-called  elementary granules, which
Rokitansky describes as originally  discrete, and, subsequently grouping
together, to constitute the nuclei.  Dr.  Walshe  says, that  the chemical
composition of these granules  is not always identical; that they  are
sometimes  soluble in ether, and sometimes exhibit the reactions of a
protein compound.   The formation of the pus-globule does not appear
to take place in one uniform manner.   The nucleus is generally stated
to be first formed by the grouping together  of  granules, which appear
in a fluid blastema.  Around this there may be first formed the envelop, 
INFLAMMATION.
135
closely embracing the composite mass, so as only to be brought into view
by the endosmotic action of water, or, as we think  is more  frequent, a
granulous deposit forms  round the  nucleus, and afterwards becomes
limited and inclosed by a cell wall.   Lebert describes the pus-globules
as being formed in a different manner, which Rokitansky also seems to
admit, and  which we think actually,  though not constantly, occurs.
According to this view,  minute  granular  globules, forming in  a fluid
blastema, grow and enlarge, granules appear in their interior, and gradu-
ally assume the appearance of the composite nuclei.   The globule is, in
fact, from the first, a miniature of the fully developed one.  It is formed,
in the French phrase, " de toutes  pieces."   The recognition of this diver-
sity in a formative process, is surely an important step.   It  is stated by
Vogel that pus may be formed from a solid blastema of coagulated fibrin.
"The pus-globules," he says, "are  at first  scantily  dispersed  through
the stroma.   Afterwards they become more abundant, and ultimately
occupy the  whole  space, while  the  solid  fibrin  disappears."  In this
way, he states, pus  is formed  in all cases, where suppuration is conse-
quent upon induration, as in the  lung after hepatization, in  solid  exuda-
tions upon serous surfaces, and so on.  In Rokitansky's opinion, these
instances of suppuration really depend on  the original  combination of
 elements of pus with croupous fibrin.  The latter breaks up, and becomes
 a diffluent mass; but yields nothing in the way of nutriment to the pus
 elements, which increase and develop themselves solely out of the sero-
 albuminous fluid, mingled with the fibrin.   The changes taking place in
 intra-vascular coagula, which we  have before described, bear upon this
 question, in connection with which we would also  refer to some excellent
 remarks by Dr. Walshe, in his article on Advent. Products.  (Cyclop.
 Anat. and Phys.)   To us it appears that it must be conceded, that ele-
 ments may form in softening fibrin, indistinguishable from those ot pus ;
 and, indeed, Rokitansky's own description  of croupous fibrin proves that
 such are present from the outset, so that we are inclined to adopt Vogel s
 opinion, that  solid  effusions may undergo actual  conversion into pus,
 iust as we  know they may into fibroid tissue.   The pus-globule is  not
 very remarkably affected by being placed in water.  It becomes some-
 what swollen  and more spherical, but is not destroyed and  burst so
 rapidly as the blood-globule—the nucleus becomes somewhat more appa-
 rent  In blood, urine, mucus, saliva, it is unaltered.  Acetic acid renders
 the granulous contents  translucent,  and  brings out the nucleus more
 definitely.   It renders the envelop also more transparent, but does not
 destroy it.  Other dilute acids have a similar effect.   Caustic and  car-
 bonated alkalies, and borax, convert the whole corpuscle  into a viscid
 mass leaving only very minute  dark molecules,  whose import is uncer-
 tain   Pus, Dr. Walshe says, possesses a  remarkable power of resisting
  decomposition.  At the end of months some corpuscles may still be found
  unchanged among others that are dissolved.  It even retards the putre-
  ?actn ffsubstances which are placed in it; but at the.same.time seems
  to exert upon them a corrosive influence.   Pieces of flesh  put into tresb
  pus gradually lost weight,  and were at last dissolved, without  any evi-
  dencegof putrefaction having occurred.  Mr. H.  Lee  has recently shown,
  that pusPposSesses a remarkable power of accelerating the coagulation 
136
INFLAMMATION.
of blood.   In one experiment the blood, which had pus (healthy) added
to it, coagulated in six minutes;  while that which was left by itself re-
Fig. 17.                             Fig. 18.
Fig. 18. a. Natural appearance of pus-corpuscles, b. Appearance after application of acetic acid.
Fig. 19. Pus-corpuscles, magnified 400 diameters.
Fig. 20. Healthy pus-cells.
Figs. 21, 22, 23. Various forms of pus-cell from phlebitis and pyaemia.
quired twelve.  The pus must, of course, act upon the fibrin; but of the
nature of the change, we have no knowledge.   The following  analysis,
by Dr. Wright, exhibits  the main features of the chemical  constitution
of pus very well.   They apply, of course,  to pus as a whole, not to the
serum only.   The large quantity of fat in  pus is remarkable, as well as
the amount of albumen—the latter sometimes exceeding that contained
in the liquor sanguinis.   This is probably  to be explained by the disso-
lution of some of the red globules, and the blending of their albuminous
globulin with the exudation that yields the pus. 
INFLAMMATION.
137
                 From a vomica.   From Psoas abscess.  From Mammary abscess.
Water    .    .    .    89-4.4          885.2           879.4
17.5 \
 5.4/
11.2             6.1
               28.8            2G.5
                6.1
68.5            63.7            83.6
       Fatty matter
       Cholesterin
       Mucus
       Albumen  .
       Lactates, carbonates, sul- ~|
         phates, and phosphates I 9.7            13.5             8.9
         of soda, potash and lime J
       Iron  ....    a trace
       Loss  ....    3.3             2.7             1.6

  In various unhealthy states of the system pus is formed, which differs
in several respects from  that which we  have now de-
scribed.   Mucin, the peculiar principle of mucus, may
be more or less abundantly  dissolved in  the serum,
which may be recognized by the coagulation produced
by acetic acid and alum.  Small fibrinous flakes, epi-
thelial  particles,  cholesterin  scales,  and  prisms of
triple phosphate may also be mingled with it, as well
as varying quantities of free oil.   The pus-globules
are in such cases  often ill-shaped, feebly formed, con-
veying  the  idea of very defective  formative power; the quantity of
granular matter mingled with them is  much increased.
  One  variety  of pus  has been  called  ichor, and is especially distin-
guished by the paucity of its corpuscles,  which, indeed,  Vogel says, are
absent when it is perfectly pure.   Its color is reddish, or brownish red,
it is alkaline,  and contains a considerable quantity of albumen.  Its
presence indicates an exceedingly depressed state of the vital formative
power.   Certain unhealthy kinds of pus, which Rokitansky comprises
under  the term (Jauche) sanies,  are  especially  distinguished by their
corrosive action upon the tissues, which  he contrasts particularly with
the bland quality of healthy pus.   Their appearance is not at all con-
stantly different from that of the normal  fluid, but they are apt to be
thinner, more  tinged by haematin, of an offensive, or ammoniacal smell,
and to communicate  a sensation of pricking or itching to  the finger
when applied  to them.   Their corpuscles are stunted, and their develop-
ments are  variously  altered, apparently by the "gnawing" action of
the  serum  in  which they  float.    It  seems  to us  very questionable,
whether the dissolving action  which pus is said to exert on pieces of
dead flesh, belongs at all to it in  a healthy and fresh state, and whether
it does not really depend on the  generation  of acids within itself, in
consequence of decompositioji.   Purulent effusions may degenerate into
a semi-fluid amorphous mass, the corpuscles breaking up, and the serum
undergoing chemical changes, often of a putrefactive kind.   They may
also undergo  fatty degeneration, calcareous salts being liberated, or
deposited at the same  time.   Either of  these two changes being pre-
mised, it is possible that  a purulent  collection may be  absorbed, but it
is only  too probable that in the  former  case the result  will be a fatal
contamination of  the blood by the decomposing matters  taken up into
it.   Apparent temporary absorption may be easily produced by means
which, creating a considerable demand  for fluid, withdraw  the serum 
138
INFLAMMATION.
from the pus-corpuscles; but as  these  retain their vitality, they soon
attract a fresh quantity of blastema from the blood, and the abscess
remains undiminished.   This persistent vitality  of the  organized cor-
puscles of a fluid which is regarded as effete in the highest degree, and
incapable of any  further development, is certainly remarkable; one
would rather have expected that they would have disintegrated rapidly.
Pus may be confounded with some other fluid,  and the distinction is
sometimes only to be made out by careful  microscopical examination.
What we have  said  respecting softened  fibrin,  will show that a fluid
having this origin may  approach  very  closely to  the  purulent product
of inflammation;  so much so, that it may be doubted whether it be not
in part identical with it.   It has happened several times, that a quantity
of desquamated epithelium, the  particles being  partly  entire, partly
broken up, has been mistaken for a collection of pus.   Vogel records
an instance of this in the pelvis of the kidney of a person  who died with
empyema.   The pus-like fluid  accumulated in the urinary passages,
was deemed convincing proof that  absorption  of the thoracic effusion
had been taking place with subsequent  elimination  of the same by the
kidneys.   The microscope,  however, showed that the whitish-yellow,
thick, creamy fluid which had been considered as pus by all who saw it,
consisted  entirely  of epithelial debris.    We shall  presently describe
mucus, and will then  point out wherein we believe it to differ from pus.
A caution is  necessary against  a very possible  error which even prac-
tised observers  have committed,  viz :  that  of mistaking  the  colorless
corpuscles of the  blood for pus-globules.    The  two bodies are very
much alike, but the blood-corpuscle is somewhat smaller, generally more
finely granular, and with rather less  definite contour.    The  interior
nuclei of both are identical.
   The granule-cell, exudation globule,  or glomerulus, which was first
described by  Gluge,  and called  by him  the compound  inflammatory

                               Fig. 25.
                         Glomeruli and granulous cells.
                      (1) From ovarian cyst.
                      (2) From cancer of breast.
                      (3) From inflamed lung.
                      (4) From inflamed pia mater.
                      (5) From a case of tuberculous meningitis.
       The opaque cells are the glomeruli, the more simply granulous are the granular cells.

globule, is very frequently present in exudation, and is, speaking  gene-
rally, a valuable  sign of the existence of the inflammatory process, but 
INFLAMMATION.
139
not an infallible one.  The granule-cell is  usually  of large size, from
JZ1TH5—sH inch, mostly spherical, but often oblong, or of  irregular
shape.   By transmitted light they appear  dark,  on account  of their
opacity; by direct,  of a dead white.  Their structure will be best  un-
derstood from the account of their development.   Our own observation
exactly accords with that of Vogel, who states that there are first formed
in the blastema nucleated granular cells, which gradually fill themselves
with  the peculiar opaque glistening  granules characteristic  of  these
corpuscles, until at  last  the nucleus is entirely obscured, and the origi-
nally smooth-cell membrane becomes  rugged,  the granular cell appear-
ing as an agglomeration of granules.   Subsequently the cell-wall van-
ishes,  the  granules  separate  from each other, probably on account of
the dissolution of the uniting  substance,  and the  corpuscle breaks up
into a loose heap of oily-looking granules.  Vogel  says  that caustic
potash and ether sometimes, but not always, dissolve these granules;
Rokitansky regards them as of fatty  nature, and considers the process
of granule-cell formation as one  of fatty degeneration of pre-existing
cells.   He says  that granule-cells do not form in blastemata devoid of
cells,  and that any  cell  may undergo  this  transformation, a cancer-cell,
 a pus-cell, as well  as the cells that form  in  exudations.  There is no
 doubt that blastemal exudations, devoid of  cells, often break up  into
 collections of the  fatty-looking  granules,  and  that  they  may assume
 this form from a very early period; as, for instance, in the coating of
 the vessels in the  gray matter  in meningitis.   Corpuscles also, quite
 indistinguishable from granule-cells, occur in lungs that bear no trace
 of having ever been inflamed,  and this in  considerable numbers.  We
 do not think, therefore, that Rokitansky's view  of the  nature  of the
 process is quite correct, but are inclined to believe that, generally, where
 blastemal exudation has been  poured out  in greater quantity than is
 necessary for the nutrition of the tissue, it may undergo such a change,
 as that  its oil, in combination with a part  of its albumen, separates in
 the form of glistening granules,  while the remainder undergoes absorp-
 tion,  or is otherwise consumed.   The granules  appear to be  attracted
 towards the  interior of existing cells; we have distinctly seen them
 coating the outside of a cell.  One of the  causes  of the different size
 of  the  granule-cell depends  on the  circumstance that  cells of  very
 different magnitude, and cells  in very different stages of growth,  may
 be the seat of their deposition.  Between  the suppurating process and
 that which forms granule-cells, a wide separation exists;  the former, as
 we have seen, gives rise to  a  fluid essentially  effete, rarely,  with  diffi-
 culty or with peril, capable of being absorbed; the latter involves no
 such  deteriorating  alteration of the  blastema; its occurrence,  on the
 contrary, is  eminently favorable to  reabsorption  of an exuded mass.
 It is  to be remarked, in conclusion, that a very  abundant cell-growth
 commonly takes place in exudations, many particles of which are cor-
 rectly denominated granular cells.  These are not to be mistaken in
 descriptions for the granule-cells, into which they often undergo meta-
 morphosis.   The similarity  of the name  is  unfortunate, but the sub-
 joined sketch will make the  distinction between the  two very  apparent.
    The  last inflammatory  product which we  have to notice  is  mucus. 
140
INFLAMMATION.
Speaking correctly, it is only unhealthy mucus which comes under this
head; for it is perfectly clear that several internal membranes secrete a
mucous fluid.   The distinction between this and the morbid product is
tolerably precise, and easy to be ascertained.  The former is a tenacious,
clear fluid, containing only some admixture  of the  epithelium  of  the
membrane producing it, and having no special corpuscles of its own.
The latter is loaded with corpuscles, identical with those of pus, together
with a varying quantity of epithelial debris.   Between such mucus and
pus  it is  evident  that a  close analogy subsists.   Mucus may be dis-
tinguished, like pus, into  a fluid, the liquor muci, and corpuscles.   The
liquor muci, as we find it in the secretion of a membrane which has been
subjected to moderate irritation, is a transparent, tenacious, more  or
less  stringy fluid, of alkaline reaction, and  more  or  less saline taste.
The addition of acetic acid, or  any weak acid, produces a kind of coagu-
lation, and the formation  of a granular precipitate, which Simon states
is  the  mucine, the principal constituent of  the fluid.   This is held in
solution  by means of an  alkali, and  consequently falls on the latter
being taken up by an acid.  Not much is known of this substance,  ex-
cept that it  is a protein  compound.  Albumen or fibrin, treated with
liquor  potassae, forms a transparent, viscous  mass, having much resem-
blance to its solution.  The proper corpuscles of morbid mucus are,  as
we are  fully persuaded, and  as the best observers state, quite  identical
with those of pus.   They are usually mingled with epithelial particles,
in very various stages of  their formation, from a simple  nucleus up  to
a  complete  cell.  It is only in cases  of prolonged and rather intense
inflammation that traces  of epithelium are wanting, and the  so-called
mucous  corpuscles  are crowded  together, and seem to  load the fluid.
In mucus  expectorated by persons  of  very depressed powers, the  cor-

                               Fig. 26.
Separate corpuscles, and two blood-globules.
puscles  may be  seen feebly formed, like  those of pus secreted under
similar  circumstances; the granular  contents  of  the cell are deficient,
and allow the composite nuclei to be  distinctly seen.  It is  often very
observable how the tenacious fluid, in which the corpuscles are entangled,
in consequence of being dragged in one direction, produces an alteration
of their shape; they thus become oval, or even staff-shaped.   Granulous
and oily matter is commonly diffused  through the liquor muci, just  as
it  is through that  of pus.   It is manifest, from what has been stated,
that the difference between mucus and pus consists essentially in the
different nature of the fluids, not in that of their corpuscles.  Both are
exudations;  but the one is poured out directly from the bloodvessels  as 
INFLAMMATION.
141
an albumino-fibrinous blastema, in which special corpuscles (the pus-cells)
are formed;  the other transudes, not only through the capillary walls,
but through the basement-membrane of the mucous surface, with  more
or less of attached epithelium, and in  so  doing experiences a peculiar
modification, which  remains impressed upon it, while the corpuscles
mingled with it are either the natural cell-growth of the surface, or such
as form  naturally in blastemata, that  are destined to  become effete.
Mucus, it is evident, is  effete, like pus.   It is hardly possible that any
part  of it should be absorbed again.  A constant flow of  it becomes,
therefore, a serious drain upon the  system, entailing a loss  of so much
protein matter.   The old question, as to  the means of distinguishing
between pus  and mucus, is manifestly of little moment,  and has, in
general, no interest for the practical physician.  It is sufficient to state
that  the liquor puris is albuminous, the liquor muci not so; that pus will
 mix with water, and mucus will not; that pus is dissolved, in some mea-
 sure, by acetic acid, while mucus is coagulated; and that mucus generally
 contains traces of epithelium, while pus does not.   It may,  however, be
 observed, that if a fluid, secreted under inflammatory irritation, should
 lose  the characteristic tenacity of the liquor muci, and come to contain
 albumen, there would be considerable reason to fear that the texture of
 the mucous membrane  had become ulcerated, and that the albuminous
 exudation,  no  longer modified to  mucus, was  being  poured out from
 exposed  vessels.  Any admixture of  blood with  the  secretion would
 render this still more probable.
    Having considered the effusions of inflammation, we come next to exa-
 mine the various changes that may take place in a part inflamed.  Vs e
 enumerate these as:  (1)  Enlargement;  (2) Atrophy;  (3) Ulceration;
 (4V Gangrene.  The term " enlargement'  is preferable to  that ot • hy-
 pertrophy," which is sometimes employed, because it conveys no  such
  erroneous  idea as that the part is truly increased  in size by addition of
  more of its own proper substance, an occurrence which most rarely, it
  ever is  the result of any  form of inflammation.   The enlargement de-
  fends entirely on the infiltration of the tissue with some form of exuda-
  tion matter, which subsequently undergoes metamorphoses such as we
  have described, and is more or less completely absorbed.   It often hap-
  pens, however  that a part remains behind, and is  converted into a low
  form of fibroid tissue, or a semi-solid blastema, imbedding  multitudes of
  nuclear particles.  This constitutes induration-matter, which resembles
  very much that which forms cicatrices;  like which, its tendency is to
  contract and  shrink,  thus compressing and obliterating the vessels of
   he part, and in this iay, as well as by its pressure  inducing the atrophy
  of the tissues among which it is deposited.   A good instance of primary
  enlargement and subsequent atrophy, resulting  from inflammation  is
  aMed by some cases of cirrhosis of the liver.   Rokitansky describes
  atrophy  the result of inflammation, as depending upon the mechanical
  L urv done to the tissues, in the  seat of inflammation, by the exudation
    J^l as upon their  being deprived by it of their proper amount  of
        ion    "Being thus rendered unfit for the discharge  oftheir■ tunc
SoHeWaTlTo"p eces, and are absorbed, together with the exudation.
-This occurs wkh especial frequency in delicate, lacerable tissues, when 
142
INFLAMMATION.
large quantities of exudation have  been effused, and such as are solid
and capable only of slow reabsorption.   Thus, in the inflammatory foci,
the substance of the brain, of the muscles, of the kidneys, &c.  becomes
lost, while there remains in its place one or more gaps, limited  by cica-
trix-tissue, which, if such gaps are small and numerous, causes a spongy,
rarefied condition of the tissue."
  Ulceration implies that condition of a part in which more or less of
its proper substance has become eroded, and has disappeared,  in con-
sequence of unhealthy action, so that a cavity remains.  This condition
does not most commonly exist alone, but together with a greater or less
amount of  exudative and organizing processes.   These are so far from
being essential to it, that they constitute, in fact, the means by which
its ravages are repaired; the formation of granulations, and the effusions
of pus,  are the characters, not of an extending, but of a healing ulcer.
Instances of pure  and  simple ulceration are to be seen in the  cornea,
and in some ulcers of the walls of the stomach; they penetrate the tissue
more or less deeply, so as sometimes to  perforate it,  without any sur-
rounding thickening from the deposition of lymph.   When the erosion
of the tissue goes on rapidly and extensively, forming  a sore, with very
irregular surfaces  and  margins, and presenting no  trace of reparative
action, the ulceration is said to be  phagedenic.   Many other varieties
of ulcers are mentioned, but they all have reference to the amount and
character of the exudative and reparative processes taking place; and
though they afford excellent indications of the condition of the  general
system, which are well worth  studying, they are not to be  regarded as
containing  anything special in the nature of  the ulceration itself.   Ro-
kitansky considers that the main circumstance determining ulceration,
is  the corrosive quality of the  exudation, the ichor.   We agree with
Mr.  Paget  in doubting the correctness of this as a  general statement;
it is much more probable that, in consequence of altered and defective
nutrition,  the tissue gradually deliquesces  (so to speak)  into  a  fluid,
returning thus, though spoiled and  effete, to the form of the  healthy
blastema,  from  which  it originated.  It is matter  of  some  dispute
whether the tissue, as it decays and  is destroyed, is removed by  absorp-
tion, or is cast off  from the broken surface.   Mr. Paget inclines to  the
opinion that it is  ejected, resting upon  the  analogy of excreting sur-
faces, on the discovery  of fragments of  bone and phosphate of lime in
ulcers of osseous structures, and on direct observation of the commence-
ment of ulcers.  We are also inclined to think that the process of re-
moval is rather by ejection than by absorption,  especially in the case
of open ulcers, yet so that some amount  of absorption also takes place,
varying in  degree  in different cases, and  probably even  predominating
in those where there is no external outlet. The formation of ulcerations
on the surface of  the cervix uteri, has appeared to us to take  place in
the following way, much as it is described by Dr. Baly on the intestinal
surface:  As the first step, in the situation of a  spot  of hyperaemia, a
minute  vesicle is formed, the epithelial layer being  lifted up by effused
fluid, while the tissue beneath is softened, loosened up, and appears less
dense than  natural.  Afterwards the covering of the vesicle is detached,
the fluid escapes,  and the tissue beneath appears  still  more  lax and 
INFLAMMATION.
143
spongy, and  has evidently undergone loss  of substance.  The hyper-
aemia, persists.   In this case, we feel little  doubt that the deliquescing
tissue is partly thrown off in the fluid which escapes from the vesicle,
partly absorbed by the bloodvessels.
   It  seems  desirable  to indicate the difference which  exists  between
ulceration and absorption.   In both, there  may be considerable loss of
substance at some one or more points of the part affected, but in ulcera-
tion there is always an unhealthy state of the nutrition of the tissue, there
is disease of it; in absorption, this is not the case: the part may be dimi-
nished, but cannot be said  to be diseased.  Contrast a bone, carious
and ulcerated from inflammation, with one which has undergone absorp-
tion,  in consequence of the pressure of an aneurism.      _   _
   The last  result  of  inflammation which we have to  mention is Gan-
 grene, or Mortification.   This, indeed, is not a very common  termina-
 tion,  nor is it at  all peculiar to  the inflammatory process.  It more
 really belongs to a deficient condition of vital power induced by various
 causes, which  may of itself be the  cause of the death of some Part> °£
 render it so feeble that it perishes under injurious influences  which
 would otherwise have had no such  effect.   Gangrene may ensue from
 the following  causes: (1) from an absolute and  prolonged stagnation ot
 the blood; (2) from a defective supply of blood;  (3) from a general taint
 or unhealthy  crasis of the  mass of  the blood;  (4) from a local  injury.
 The absolute stagnation of  the blood in  the first case may be the result
 of violent inflammation, especially of an asthenic kind, and occurring in
 debilitated  systems  and organs; or it may be brought about mechani-
 cally, as when a portion of intestine is strangulated.  Rokitansky says,
 that in this case the  blood  stagnant in the vessels first undergoes gan-
  grenous decomposition, and  that, exuding through their walls  in the
  state of gangrenous  ichor, it sets up the  same decomposing  change in
   he  surrounding tissues, which  break up into a dark-colored pulp  of
  as little consistence  as  tinder; diffluent, and excessively stinking.  In
  the  second case,  besides various kinds of  obstruction of the  arteries
  from external pressure, their channels may be blocked up by «ten«ve
  fibrinous coagula, either forming spontaneously, or  in consequence of
  disease  of  the  coats of the vessels.  Gangrene occurring in  aged per-
  sons  without any apparent cause, that from the use of diseased grain,
  Td hlS  gangrene, are instances in which the morbid  action is de-
  pendentC a general taint of the blood, or decay of the whole system.
  Mr  Son suggests that the mode in which ergot of rye produces its
  fotol effect maf be  by causing  such contraction of  the bloodvessels as
  prevents the  flow of Lod into the more  distant parts, which conse-
  £3?f.Umto the condition of dry gangrene   Spontaneous gangrene
  h^  old  nersons or  others, in which after death no obstruction of the
  blodveLeTs I found, can only  depend on an actual and premature loss
   ofvitaSy in the par  affected,  the tissues of which are no longer  able
   £ Jirrv on the actions of vital chemistry,  and yield to those of inorganic,
    ITeUmpot before the death of the  system has actuary =edf
   In  iranerene  from local violence, or from frost-bite, &c.  the vitality oi
   Jh/tSro'f the.pan is  destroyed y the jwp;  one.to. th«. .The .
   general characteristic of gangrene in  all these cases 
144
PY2EMIA.
vital  action;  decay and  death in the  tissues, intense inflammation,
absence of blood-supply, a poison  circulating in its current, senile de-
crepitude, a fearful laceration, may all have the effect of dissolving the
vital affinities which hold together the elements composing the complex
substances of  our organism,  and allowing them to  fall back, as  they
naturally  do, into the simpler compounds of inorganic chemistry.  The
distinctions of dry and moist gangrene, of black and white, of inflamma-
tory and cold, have reference very much to the state  of  the affected
part, with regard to the supply of blood.  If the gangrene  have its ori-
gin in inflammation, there will be a considerable quantity of fluid ichor
effused, and the color of the part will be of a deep red, or almost black.
On the contrary, if the gangrene depend on deprivation of the  supply of
blood,  the part  will be more dry, and of a pale color.   Sometimes,
especially from the effect  of  ergot of rye, a limb dries and shrinks up,
becomes mummified, as it is said, with little change in color.  A black
color is, however, often observed in parts affected by gangrsena senilis;
this, no doubt, depends on alteration of the blood in the vessels, though
there is often no  hyperaemia.   Soft tissues are more liable to mortify
than such as are of a firmer  consistence;  bones, elastic and fibrous tis-
sues, resist  longer than  muscles  and  mucous membranes;  the large
vessels  and nerves  are sometimes  seen completely  exposed  by the
ravages of hospital gangrene, all the tissues being removed from  around
them.
   The constitutional disturbance which often supervenes on gangrene is
easily to be accounted for by the absorption of decomposing  matters into
the blood, which act as a virus  upon it, and render it unfit to maintain
healthy action.
                             PYEMIA.

  Proceeding to consider various diseased states of the blood, we come
next to one, in  which a product of inflammation, viz : pus, is believed in
some way to be mingled with the blood, and, by poisoning it, to produce
both general fatal depression of the powers of life and local purulent accu-
mulations, the  so-called secondary depots, in various important organs.
The phenomena observed in pyaemia are somewhat as follows: A man has
received an injury, or undergone some surgical operation, it may be an
amputation, or  that for fistula in ano;  for a time all proceeds well, but
soon shiverings come  on, with adynamic fever and oppression, he ema-
ciates, pain or  disorder shows itself in some internal viscus, and in a
few days  he  dies  in  a state of  stupor, or  delirium.   On  openino-  the
body, the blood is found less coagulated than is natural;  there are ab-
scesses  more or less  numerous  commonly in  the liver and luno-s,  and
often  in other parts ; there is frequently purulent effusion in the cavities
of the joints,  and sanguineous or purulent effusion in the serous cavities
also.   The question  to determine is, how  these  morbid  changes  are
brought about.   From the almost invariable occurrence of such pheno-
mena  in persons who were the subject of suppuration, or in whom it was
reasonable to believe  that  pus might be formed  in  the seat of some 
PYAEMIA.
145
injury, it was natural to conclude that the pus, making its way into the
blood, was the cause of the mischief.  This was confirmed by Cruveilhier's
experiments of injecting mercury into  a vein, after  which there was
found in the centre of each of the small abscesses a globule of the metal
which thus seemed to  have  been carried in the circulation to the part
where it was deposited, and where it excited inflammation passing into
suppuration  about itself.  The pus-globule was supposed  to act in the
same way as the globule  of mercury; being too large to  traverse the
capillary channels it was arrested there;  and similar obstructions taking
place in other points of the same organ, a number  of separate inflamma-
tions, which soon suppurated, and formed the so-called multiple abscesses,
were thus established.  Another confirmatory fact of the same view was
observed in these experiments, viz : that the mercury was  arrested
almost  entirely in the first  set of capillaries at which it arrived; if it
was injected into tributaries of the portal vein, the abscesses were found
in the liver; if into veins of the general system, the abscesses were
in the lungs.   Pyaemia follows the  same law,  however, less  closely;  it
is very  common to find numerous abscesses in the liver when  pus can
only have been conveyed from the veins of the general system:  on the
other hand, that which is carried by the portal vein to the  liver often
seems to be entirely arrested there.  There is no  doubt that it is the
presence of puriform matter in  the blood which gives rise to the pheno-
mena we are considering, but  it is not yet  fully ascertained whether
perfectly-formed pus circulates  in the blood, or only a pyogenic fluid,
nor how either of these is  introduced within the vessels.  Before we
enter further on these points, we will describe more particularly the for-
mation  of the multiple abscesses.  M. Lebert, whose observations accord
very closely with our own, notices particularly that the parts which are
the seat of purulent effusion are truly inflamed; parenchymata, synovial,
or serous membranes, if examined at all  at an early period, are found in
a marked state of inflammatory hyperaemia.  This proves that the term
secondary  depots, sometimes used,  is  incorrect;  the pus is actually
generated, not only deposited in the part.  The stages of the forming
abscess are as follows : «"(1.) A local and circumscribed capillary injec-
tion, showing little vessels  dilated and  gorged with a dark  red blood,
more or less  coagulated, in which  are seen few 'globules, and very uni-
form plasma, but never pus-corpuscles.   (2.) In this centre of  the vas-
cularization a  yellow point  begins  to be seen, which is  nothing more
than a drop of pus."  The microscope shows in it some well-marked pus-
globules, generally without  nuclei,  and  especially  many  granules, all
floating in a pyoblastic serum.  (3.) The vascularity declines, the puru-
lent collection increases, infiltrating the tissue, the elements of which
are not destroyed.  (4.) The secretion of pus continues, and the puru-
lent inflammation is transformed into an abscess, bounded by a margin
of red injection, and having  its interior, in the case of the larger ones,
lined by a  soft pyogenic membrane.  The larger abscesses have com-
monly a very irregular form, which results from  the  fusion of several
smaller ones together, as they go on increasing in size. As showing the
truly inflammatory character of the pus-secreting  process, we may men-
tion that we have found the texture of  the cartilage  of the knee-joint
        10 
146
PYEMIA.
altered just as it is in common arthritis with ulceration after death from
pysemia of only a few days' duration.  The cartilage in the case referred
to was ulcerated, and the joint contained pus.  M. Lebert has  made
several careful observations, with a view to  discover whether  the  pus-
globules are  actually present in the  blood of the pyaemic;  the result
of these seems to be, that they cannot  certainly be detected; even in
the blood  of animals that died from the effects of pus injected into their
veins, the globules of pus could only once be discovered; and it seems
incontestable, that in the great majority of  cases they are rapidly de-
stroyed after having entered the circulation.  This throws considerable
doubt on the view above noticed, that the pus-globules become arrested
in the capillaries, in consequence of their size, and thus establish nume-
rous foci of inflammation.  Rokitansky also  expresses his opinion very
strongly against it.    He considers that pyaemia  occurs not uncommonly
as a primitive affection;  that is to say, that  pus is actually formed by
and in the blood itself, in consequence of certain changes in the fibrin,
such as occur in the  croupous crasis, which we  shall afterwards notice.
This supposition would account for cases  occasionally met with, in which
there are  multiple abscesses,  yet no source of purulent infection can be
discovered.   The more common case of  consecutive pyaemia,  he states,
may originate in  either of the three following ways,  (a.)  By the ab-
sorption of the serum of pus, either into the lymphatics,  or into the
bloodvessels  directly,  (b.)  By the reception of pus into bloodvessels
which have been in any way opened, especially into those which traverse
solid formations in which the mouths  of the vessels are likely to be held
open,  (c.) Particularly  by  the flowing  off  towards  the  veins of pus,
which has been produced in  a local  process  (capillary phlebitis) within
the vessels.   We  think it important to recognize the possibility of pyae-
mia taking place from absorption of serum alone, because it is  clear that
this may easily take  place wherever capillary vessels are in contact with
puriform exudation.   The' reason why it does not more often  occur is,
we conceive,  that in a tolerably healthy state the fluid absorbed  from
the pus is not adequate to contaminate the mass of the blood; it under-
goes certain chemical changes,  and is soon eliminated as effete matter.
But in a depressed state  of the  vital powers, the  blood cannot resist and
throw off  the contaminating  matter,  and a  pyogenic diathesis is  esta-
blished.  This opinion seems to be confirmed by the experiments which
have been performed  upon animals.  Lebert found  that  rabbits which
had serum of pus injected into their veins, did not survive much longer
than those in which pus  was  injected entire, but that dogs showed no
serious morbid symptom  after  the injection  of serum.  In the experi-
ment performed by Mr. H. Lee, we find  that dogs and asses recovered
from the effects of the injection of pus, or at least were recovering when
the injection  was  repeated.  All this shows that  the weaker the system,
the less it is  able  to resist the poisonous  effects of pus, or its constituent
parts; and should lead us to guard, as far as possible, against the super-
vention of pyaemia after operations on debilitated patients.   The third
mode by which pus comes to  be mingled  with the blood is undoubtedly
the most common, and is believed by Lebert  to  be almost the sole one.
He remarks that, in  the  great  majority  of cases, some trace of inflam- 
LEUCOCYTH^MIA.
147
mation of the veins may be discovered, and supposes that where they
cannot, the veins affected are so small, or so obscured, that the source of the
disease is overlooked.   We believe that in such cases, pyaemia originates
in either of the two other modes.  The injection of pus into the living
blood tends, as  Lebert states, to diminish its fibrin, to destroy its glo-
bules,  to alter its normal cohesion, and to precipitate a part of its fatty
principles.   The blood thus altered tends to form ecchymoses, capillary
hemorrhages, especially in the lobules of  the  lungs.  Rokitansky de-
scribes the  bodies of those dead with pyaemia, as presenting only a brief
rigor mortis, a lax and pale condition of the muscles, especially discolo-
ration and lacerability of that of the heart, rapidly advancing putrefac-
tion, with extensive stains from exudation.  The  lungs are especially
the seat of dark  hypostatic congestion.   The coagula of  the blood in
the heart and large trunks are small and soft, and the inner membrane
of the vessels stained.   It is very intelligible how blood thus vitiated
should tend to stagnate at various points of the capillary plexuses which
it traverses, and to form there minute abscesses, without supposing that
 the vessels  are actually blocked up by entire pus-globules.   The obstruc-
 tion is of a chemico-vital, not of a mechanical  origin.1   The contami-
 nation of the blood when effected, is clearly of such  a  nature,  that it
 determines the rapid suppuration  of all exudations; there  is a strong
 tendency to the formation of pus, a true pyogenic diathesis.   Were it not
 for this,  the formation of the multiple abscesses would not take place so
 quickly.   The fact stated by M. Lebert is interesting, that muco-pus,
 the product of an inflamed mucous membrane, produces, when injected
 into the  blood, the same effect as pus, a further proof of the identity of
 the corpuscles of the two fluids.


                 LEUCOCYTH^MIA — LEUKHJEMIA.

    These terms—the  former  signifying  white cell-blood,  the  latter,
 simply white blood—have been given to a condition of the  circulating
 fluid, which is not  of very common occurrence, and has  only been re-
 cently discovered.   The former name is the more correct, as the blood
 does  not lose its red color, and as the prominent alteration in it is  the
 great increase  of  corpuscles,, resembling  the white or  colorless  ones
 naturally present.   When a drop  of blood, dr,awn  during life, is ex-
 amined  microscopically, the red corpuscles appear  tolerably natural,

    • In the following case, the formation of the secondary depots seems to have depended


 tained several masses, mostly about tbe size 01 a pb*,            fib ■  in stlands, 
148
LEUCOCYTH^MIA.
and often arranged in rouleaux, leaving intermediate spaces, which are
more or less crowded with the white corpuscles.  It is difficult to say
what is the proportion which the  one set of corpuscles bear to the
other.   In the case which we witnessed, we should have regarded  them
as nearly equal, comparing mass to mass.   Dr. Bennett  estimates the

                               Fig. 27.
     Blood in Leucocythwmia—four of the white corpuscles have been treated with acetic acid.
                         From Dr. H. Bennett's work.

white as scarcely one-third the number of the red.   Many of the white
corpuscles are  very much larger  than the  natural size.   They  have
more coarsely granular  contents than the normal ones, with an interior
single,  double, or  tripartite nucleus.   The envelop and nucleus are
brought into view distinctly by the action of acetic acid, which renders
the granular contents transparent.   Occasionally, a crescentic nucleus
is to be seen in the cells, and some  free  nuclei are also  observed be-
tween  them.  The blood, in fatal  cases, is often  found imperfectly
coagulated—sometimes grumous, of a dirty brown color.   The coagula,
where decolorized, have not the aspect of healthy fibrin, but  are  of a
more opaque dull yellow; and, when broken up, resemble thick creamy
pus.  They  contain in  this part very numerous white corpuscles, to
which  the peculiar aspect is probably due.   In  the case where the
blood has been  analyzed, the fibrin exceeded the normal  amount.
Perhaps this increase may be rather apparent than real, in consequence
of numerous white corpuscles  being  included  in the fibrin.  The red
corpuscles  are invariably diminished;  the  solids  of the serum  little
altered. Morbid changes are chiefly observed  in the spleen, the liver,
and the lymphatic glands.  The spleen is often very greatly enlarged,
apparently by a kind of true hypertrophy of its nuclear structure.  It
has, however, been found healthy.   The liver is less  frequently en-
larged.  It  was so  in about half the number of cases.   Its texture  is
more or less altered.  The lymphatic glands  seem to  have  been en-
larged or cancerously diseased in eleven  out of nineteen cases.  The
affection has been more often observed  in males than  females, in the
ratio of 16 : 9.  It seems " to be most common in adult life, and  more
frequent in  advanced age than in youth."   The respiration is often  in-
terfered with by the distension of the abdomen.   Diarrhoea  is a fre-
quent  symptom,  vomiting is less often present.   Hemorrhage,  from
various parts, was observed in the majority of cases, and was attended
with purpura hemorrhagica in one instance.  In about half the number
of  cases observed, dropsy was present, generally dependent  on the ab-
dominal tumors.  Some febrile disturbance  is  not  unfrequent, but not 
NECR^EMIA.
149
to any great degree, or of long  continuance.  Anaemia is commonly
well marked, and emaciation, in the  fatal cases, is said to be extreme.
There seems no reason  to believe  that the affection is at all connected
with ague, or the  malarious poison.   The foregoing facts, relative to
Leucocythaemia, we have taken from the  memoir  of Dr. Hughes Ben-
nett, who offers the following theory of its nature:  He  regards  the
spleen, thyroid, supra-renal, pituitary, pineal, thymus, and  lymphatic
glands, as constituting a great glandular system, whose office it is to form
the blood-corpuscles.   These are  for the most part thrown  off from the
organs mentioned,  and  enter the circulation as colorless nuclei, identical
with the peculiar corpuscles of these glands.   Sometimes, however, the
nuclei proceed to cell development, and appear then as the "white  cor-
puscles."   The nuclei  of these multiply by a process of division, circu-
late  in  the blood with colorless cells,  and subsequently escape  and
become colored blood-globules.  Now, "in certain hypertrophies of the
lymphatic glands," Dr. Bennett believes,  that "their cell-elements are
 multiplied to an unusual extent, and under such circumstances find  their
 way into the blood,  and constitute an increase  in  the  number of its
 colorless cells.   This is leucocythaemia."   Our limits forbid discussion ;
 and we  can only say, that all our observations respecting  the develop-
 ment of the red globules  are entirely opposed to  the view maintained
 by Dr. Bennett; and  that we are fully convinced that, whatever action
 the  glands referred to exert upon the  fluid part  of the blood,   they
 furnish none of its corpuscular elements.   The blood, we believe, forms
 its  own floating cells,  and  these  may, of themselves, become diseased
 and variously altered.   Neither  can we  admit  that the external simi-
 larity of the white granular cells in leucocythaemia to the  natural white
 corpuscles, is a certain proof of  the one being merely further develop-
 ments of the other.   Cells of similar aspect may have the most differ-
 ent properties.  No other conclusions can be  formed at present,  as we
 think,  than  that  leucocythaemia  is  a peculiar  blood  disease, whose
  cause and mode of origin is quite unknown.
NECR^SMIA.
  This term is applied by Dr. Williams to that  condition of the blood,
in which it appears to be itself primarily and specially affected, and to
lose  its vital properties.   It is, in fact, " death  beginning with the
blood"  "The  appearance of  petechiae and  vibices on  the  external
surface, the occurrence of more extensive hemorrhages in internal parts,
the general fluidity of the  blood, and  frequently its unusually dark or
otherwise altered aspect,  its  poisonous properties, as  exhibited mis
deleterious operation on other animals and  its proneness to pass into
decomposition, point out the blood as the first seat  of disorder ; and by
the failure of its natural properties and functions,  as the vivifier of al
structure and function, it is plainly the  medium by which death begms
in the body."....." The blood, the natural source of life to the
whole body  is itself dead, and spreads death, instead  of life.  The
heart's action is faltering and feeble;  the atonic vessels become the 
150
CEASES OF THE  BLOOD.
seat of congestions, and readily permit extravasations.   The brain, in-
sufficiently stimulated after slight delirium, lapses into stupor ; the me-
dulla no longer regularly responds to the "besoin de respirer/' and the
respiratory movements become irregular.  Muscular strength is utterly
lost; offensive colliquative diarrhoea, or passive intestinal  hemorrhage,
often occurs ; sloughy sores,  or actual gangrene of various  parts is very
easily produced;  and putrefaction commences  almost  as soon as  ever
life is extinct.  The track of the superficial veins is marked by bloody
stains ; hypostatic congestion takes  place to a great extent; the blood
remains fluid, and stains the lining  membrane  of the  vessels.   Roki-   (
tansky describes  the  blood  as often  foamy, from the  development of
gas—of a dirty red raspberry-jelly color ; its serum dark,  from exuded
haematin; and  its  globules swollen up  by endosmosis.   Coagula are
either totally absent or are very soft and  small.   The  exudations are
of a dirty red—turbid, thin.   There is scarce any rigor mortis; the
tissue of  the heart and of other organs is flaccid and softened, and
stained by imbibition  of the serum.   Gas is quickly formed in the  ves-
sels and in the areolar tissue, giving rise to  a kind of emphysema.  It
is very remarkable that this necraemic condition, or one closely resem-
bling it, may be brought on by violent shocks  inflicted on the nervous
system, as well as by the introduction of miasmata or animal poisons
into the circulation.   Violent convulsions, overwhelming emotions, the
shock of an amputation, a stroke of lightning, even a severe exhausting
labor, are mentioned by the  German  pathologist as  having produced
this effect.   More common causes, however, are malignant  scarlatina
and typhus, yellow fever, the plague, and the  disease  called glanders.
It may be said, generally, that the  early appearance  of  sinking  and
prostration in any fever indicates that the blood is thus seriously affected.
We are ignorant what is the  exact nature  of the changes which take
place in this condition of the  blood.  Probably  they are more of a vital
than merely chemical kind—that is, they affect the properties of the
blood more than its composition.  The blood-globules do not appear to
be destroyed, but they circulate probably some  time before death, as so
many dead particles prone to  be enlarged and  to stagnate  in the capil-
laries, and to part with their contained haematin.    The fibrin is in
great part destroyed; but how this comes to pass we are ignorant.   We
can perceive, on the whole, scarce anything more than that the powers
of vital chemistry rapidly decay, and those of ordinary chemical affinity
usurp their place.
                    CRASES OF THE BLOOD.

  There are yet several morbid conditions of the blood which are scarce
recognized sufficiently,  at  least among British Pathologists.   These,
Rokitansky describes as so many erases  or alterations of the natural
composition or mixture  of the blood.   They are often chronic, coming
on imperceptibly, and, perhaps, scarcely noticed, until disorder begins
to manifest itself in some particular organ ; in other instances, probably
as numerous, their development and manifestations take place rapidly, 
CEASES OF  THE BLOOD.                  151
and give rise to acute affections.   There is very much reason to believe
that they originate most of the serious visceral diseases which are so
common.   Very many cases of granular degeneration of the kidney, of
cirrhosis of the liver, of contracted orifices of the heart, proceed, in our
opinion, from  slow  and gradual  textural  changes,  dependent  on  an
unhealthy  crasis of the blood.  The importance of being aware of this,
in the treatment of  these affections, is  abundantly manifest.  As, how-
ever, our knowledge of these  conditions of  the blood is yet very imper-
fect, we shall not attempt  more than  to indicate shortly the principal
features of the several erases, as  they  are enumerated by Rokitansky:
A crasis may  occur as the primitive affection, and its local manifesta-
tion, when it takes place, be determined, as to its seat, either by external
influences, or by the operation of the  nervous  system.   Or it may be
consecutive, arising as the consequence of a local,  morbid process, which
has caused infection of the general mass of the blood by matter absorbed,
or having  undergone a  deteriorating  change  within the  vessels.   A
 crasis may terminate, either  by return to the healthy condition, or by
 conversion into another morbid crasis,  or by destruction of life. ^
   The fibrinous crasis corresponds to the condition of blood, which may
 be termed phlogistic or inflammatory.  It is  characterized by an in-
 creased tendency of the fibrin  to coagulation, and  to separation in  a
 solid form, either in some part of the  vascular system, or  as an exuda-
 tion in some of the tissues.  For the  development of this  crasis, Roki-
 tansky considers  it necessary that the respiratory  function should be
 freely performed.   In most  cases, the quantity of fibrin in the blood is
 much increased; but  this is  not so essential a feature as the alteration
 of its quality.  In the croupous  variety of this crasis both the coagula
 and the exudations show less tendency to organization; on  the contrary,
 they  tend to  break up  themselves, and often  corrode, and, as it were,
 fuse down the tissues in which they are deposited.   The mucous surface
 of the respiratory and digestive canals, serous and synovial membranes,
 are the chief  seats of such exudations.  The croup  of early life, many
 pneumonias, many cases  of puerperal peritonitis  or  phlebitis, acute
 rheumatism, and endocarditis, are so many examples of disease  inti-
 mately connected  with this crasis.   Fibrinous erases  often appear
 epidemically.  It may be fairly asked, whether the condition of the
 blood may not be always produced by the inflammation. ^  A\ e are, how-
 ever  quite of Rokitansky's opinion, that while, in many instances, there
 is no' doubt that such is the  case, yet  that there  are numerous others in
 which the local inflammation is  the result of a foregoing crasis.   Ihe
 marked disproportion that is sometimes observed between the hyperaemia
 and the exudation, and the early occurrence of the latter in many cases,
  appear to us  to argue strongly in favor of this view.       _
    Rokitansky recognizes  an aphthous variety of the fibrinous crasis,
  which gives rise to the exudations of  muguet, diphthentis, some dysen-
  teries  and of hospital  gangrene.  These are  manifestly outpourings of
  deteriorated diseased fibrin  on various surfaces rather than products o
  local inflammation.  The alteration  of the blood in  these  instances
  must certainly be primary. 
152
THE TUBEECULOUS CEASIS.
THE  TUBERCULOUS  C R ASIS—T UBE RCLE.
  The product of this crasis, from which  it has its name, is the well-
known substance, which, on account of its frequently spherical shape,
is called tubercle.   This we  have not yet described; and though Roki-
tansky  places it among the organized new formations, yet we think
it will be more convenient to make mention  of it here, in  connection
with our remarks upon the condition of the blood in which it originates.
  Tubercle, or tuberculous matter is, in almost all cases, an exudation
of protein material, which speedily passes into the solid form, and never
proceeds beyond the lowest grade of development.  It very commonly
assumes a spherical shape, which appears to depend partly upon its en-
larging from its original magnitude by successive accretions to its surface,
and partly on the nature of the tissue in  which it is deposited.  There
are two principal varieties of tuberculous matter, distinguished as gray
                      and yellow  tubercle.    The  former, sometimes
                      called gray granulations, are about the size of a
                      millet-seed, roundish, resisting under pressure, of
                      a grayish, semi-transparent aspect.   The micro-
                      scope showTs them to consist  of a  basis-substance
                      (blastematous), which is solid and homogeneous,
                      and serves as the uniting medium of certain cor-
                      puscular elements.   These are granules commonly
                      of  oily aspect, nuclei, oval,  or more elongated,
                      generally feebly formed, and cells, which are, for
                      the most part, very few  in number, and probably
                      not to be regarded as any  essential part of the
tubercle itself.   The globules of tubercle, which M. Lebert describes as
characteristic of this  morbid product, are nothing more than the ill-
Fig. 28.
 Gray tubercle; miliary granu-
lation.
Fig. 29.
Yellow tubercle; crude mass.
developed nuclei just mentioned.  Rokitansky applies to them the fol-
lowing epithets: "anomalously shaped, irregular, as if gnawed, angular,
bent, constricted, rudimentary, stunted."  The elements of the tissue in
which it is  deposited, are often found imbedded in the mass.   This,
however, scarcely applies, except to those which  are not very readily 
THE TUBERCULOUS CRASIS.
153
destroyed, as fibres.   No  vessels are ever found in separate tubercles;
some traces of those belonging to the  tissue may be imprisoned in the
interspaces of several aggregated together.  Yellow tubercle forms masses
of varying size, but generally somewhat larger than those of the gray,
equalling, perhaps, a hemp seed, or a pea, in  magnitude.    They are
from the outset opaque, of a whitish-yellow color, of  rather brittle con-
sistence.  Their microscopic structure is  nearly identical with that of
the preceding  variety, only that they contain more diffused granular
matter.   Their relations, also, to the  surrounding textures, are quite
similar  to those  above mentioned.   The  yellow tubercle, which Roki-
tansky denominates the croupo-fibrinous, in opposition to the gray, which
is the  simple fibrinous, undergoes two metamorphoses of  very great
importance; one is that of softening, the other that of crehfication.
 Softening consists in the texture of the  mass  becoming more lax and
 moist, with  notable increase of size, the change proceeding till it breaks
 up into a yellowish, diffluent, cheesy mass, which finally becomes a thin,
 whey-like fluid, of acid reaction, containing minute floccuh.   I he change
 seems first to affect the homogeneous basis-substance, which dissolves into
 a kind  of fluid, loaded with pulverulent molecules; the corpuscular ele-
 ments in consequence of this are set free, and, at the same time are them-
 selves more or less corroded and dissolved.   The softened tubercle thus
 consists of (1) a fluid loaded with diffusedgranulous matter;  (2) traces ot
 altered  nuclei and cells;  (3) free oil in
 the form of various-sized drops.   It  may
 also  contain  debris of the  tissues.   The
 cretifying change consists in the  gradual
 deposition and liberation of calcareous par-
 ticles  in the  tuberculous  mass,  together
 with simultaneous absorption of the^ animal
  matter, and  consequent decrease  in  size.
  It is said by Rokitansky never to take place
  except in softening, or softened tubercle;            prpt:fipd tubercle
  but this is, probably, too absolute an assertion.  The cretrhed tubercle
  very often remains as a hard, irregular  mass, surrounded by indurated
  Sef and appears to  be insusceptible  of further  change; sometimes,
Fig. 30.
if
oo
Isolated tubercle corpuscles. On the
   right are four blood-globules.
Fig. 31.
'&JB 0

Fig. 32.

Fig. 33.
c^mm

                !  <w™ tho peritoneum  a. The same, after the addition of acetic acid.
Fig. 31. Tubercle corpuscles from the peraoneum. a       ,    tubercular mass in  the lung.  250
Fig. 32. Tubercle corpuscles, granules, and molecules, irom u
       diameters linear.
Fig. 33. Tubercle corpuscles, from a mesenteric gland. 
154
THE  TUBERCULOUS CRASIS.
however, absorption proceeds further, and almost the whole of the de-
posit is  removed.   When this is the  case, however, it is probable  that
Fig. 34.
Fig. 35.
Fig. 36.     Fig. 37.
Fig. 38.

pS
&>
*M9    ®®®
Fig. 39.
Fig. 40.
Fig. 34. Tubercle corpuscles from the lung.
Fig. 35. Pus-corpuscles.  One shows the double granular nucleus after the addition of acetic acid.
Fig. 36. Plastic or pyoid corpuscles.
Fig. 37. Granular corpuscles from cerebral softening.
Fig. 38. Cancer-cells from the uterus.  250 diameters linear.
Fig. 39. Structure of the central portion of a tubercular mass, imbedded in the cerebellum.
Fig, 40. Structure of the external  portion of the same mass, where it was in contact with softened cere*
       bellar substance. 250 diameters linear.
Fig. 41.
absorption had predominated over the deposition  of calcareous matter
                     from the first.  The only metamorphosis, accord-
                     ing to Rokitansky, which the gray tubercle under-
                     goes, is a kind of drying  up into a  hornlike sub-
                     stance, which, in some  cases,  is also the seat of
                     calcareous deposit.  This  he  calls  obsolescence.
                     It  has been very commonly held, since the time of
                     Laennec,  that the  gray tubercle, or gray granu-
                     lation, was the nascent  phase  of the yellow:  Dr.
                     Walshe, after careful examination, maintains  this
                     view ; Hasse and Rokitansky reject it.  The  latter
                     regards the two as essentially distinct, though very
                     frequently combined together in the same tubercle,
                     in  varying proportions; and remarks,  with much
                     reason, that  it  is an error to look upon these dif-
                     ferences in composition as stages of transition, or
                     conversion of one  into the other.   The apparent
softening of the gray  tubercle, when it  occurs, is not  dependent upon
an  alteration  in  its own substance,  but in that of the yellow mingled
with it.   It is very interesting to  remark how  the  behavior of the  two
kinds  of tubercle corresponds  with that of  the fibrin,  from which they
seem to be derived.   The gray resembles healthy fibrin in its  tendency
to contract and shrink up into  an  indurated mass; the yellow, like the
croupous fibrin of coagula and  exudations, tends to soften and break up
into a fluid substance.   Moreover, as the masses of croupous fibrin begin
'wi^
 Fragments of phosphate of
lime, crystals of cholesterin,
and tubercle corpuscles, from
a cretaceous mass in the
lungs. 
THE TUBERCULOUS  CRASIS.
155
to soften in their central part, so we find does the yellow tubercle.  Dr.
Carswell and others consider that inflammation and suppuration  taking
place in the tissues surrounding the tubercles, are the chief cause of its
softening and breaking down.   This Rokitansky denies ; but though we
believe with him that the softening change is one inherent in the tu-
bercle-substance itself, yet we think the hyperaemic  movement taking
place around it must, at least, give an impulse to the process.  As each
tubercle,  or group  of tubercles, undergoes softening, the space which it
occupied  becomes the cavity of a minute abscess, the contents of which,
sooner or later, are evacuated.   The tissue involved in the tubercle  is,
of course, destroyed, together with it, but rather in the way of necrosis
than of ulceration.   The tendency of the tubercle to soften differs very
 greatly in  different cases.   Sometimes it is scarcely deposited before it
 begins to break down, sometimes it remains very  long in its original
 (crude) state.  The influence of the inflammation set up around tubercles
 upon their progress varies very much, chiefly according to the degreeof
 the tuberculous dyscrasia.   If this be very great, the result  of  the  in-
 duced hyperaemia will be  the  infiltration of the bordering tissues with
 tuberculous matter of  the lowest kind, tending to rapid diffluence, and
 involving in its destruction that of the infiltrated tissue.   The increase
 of a tuberculous cavity in this  way may be most rapid.   On  the  other
 hand (and herein is contained a truth of the utmost interest to the prac-
 titioner), if the dyscrasic condition of the blood be slight originally, or
 if it have been amended  by well-directed treatment, inflammation gives
 rise to the exudation of  fibrin, which develops itself into  the so-called
 induration tissue,  or fibroid callus, which either surrounds and capsulates
  the tubercle, or forms a wall  to and contracts the  cavity,  if one  has
  formed.   The surrounding tissues are often much puckered by the shrink-
  ing in of the fibrinous deposit.  There occur occasionally, especially upon
  serous surfaces, small granulations which have much the aspect of tu-
  bercles, but which, in their progress, assume more of a fibroid texture;
  these may be regarded as specimens of an intermediate  condition be-
  tween tubercle and fibrinous exudation, and are, m this light, ot great
  interest.  Tubercle  seems  sometimes to be deposited in the way ot
  infiltration;  that  is to say, it no longer forms  the small  characteristic
  tubera,  from  which its name is derived, but appears as a uniform mass
  which had been effused into the tissue in a fluid state, and had soli-
  dified there   The common  tuberculization of  the absorbent glands is
  very much  of this kind;  it is  seen, however,  most strikingly, in the
  luncrs, a whole lobe or more of which  may appear to be converted into
  a  tuberculous mass.  Sometimes this  appearance depends on  the  part
  being occupied by numerous tubercles,  crowded  together;  but then
  there can always be distinguished on a sec tion  inter Posedlayers°f pul-
  monary tissue which  are not seen in real infiltration   The only doubt
  » to the real nature of apparent tuberculous infiltration arises; from.the
  great similarity between chronic pneumonic consolidation and thi state
  so that Dr. Walshe is  inclined to consider them identtcal.  Ou^own
   belief  is, that in  a person whose blood is in a high  degree affected by
   the  tuberculous  dyscrasia, inflammatory hyperaemia may "^ ^ {^
   exudation of a material which corresponds  closely with tuberculous, but 
156
THE TUBERCULOUS CRASIS.
is less inclined to soften and  break down.   The seat of  tubercle in the
vast majority of cases is  on  the exterior of the vessels, but in their
immediate neighborhood ; its blastema is a true exudation, but, inasmuch
as it coagulates with  great rapidity, it is not able to penetrate for any
distance through the substance of a non-vascularized tissue.   Hence, we

                               Fig. 42.
r   Section of a gray granulation in the lung after the addition of acetic acid, showing the pulmonary
              air-vesicles filled with tubercle corpuscles. 250 diameters linear.

do not  find tubercle in cartilage.  In  very rare instances, coagula of
tuberculous character have  been seen within the vessels;  but these, no
doubt, underwent a morbid alteration  after being formed; and there is
not the least evidence to show that  anything resembling  tuberculous
matter  has even been detected in the blood.   The microscope can dis-
cover nothing peculiar  in  the blood of phthisical  patients, nor has
chemistry detected any characteristic alteration in  its  protein com-
pounds, which we might reasonably expect to  find primarily affected.
The exudation of tubercle-blastema  may take place most gradually and
imperceptibly, with  scarce  a trace  of constitutional  disturbance, or it
may occur in a rapid, tumultuous manner, with all  the  symptoms of an
acute illness; between these extremes the most  various grades  are
observed.  The more rapid the  deposition of tubercle, the more is it
associated with hyperaemia and inflammation.  In  fact,  though  the
production of tubercle be quite independent of inflammation, and though
inflammation, in the great majority  of  cases, is only secondary, and
excited by it, as a cause of irritation, yet, when set up, it has a powerful
effect in hurrying the exudation of tubercle, and that of such a kind as
tends to rapid softening and decay.  Commonly, the  gray tubercle is
the first to appear;  sometimes, however, the yellow, in the miliary dis-
persed form;  afterwards, as the dyscrasia increases, the exudation con-
sists  of yellow tubercle  mingled with the gray;  and, finally, of yellow
tubercle  alone.   Tubercle may be  deposited, we believe, in extravasa-
tions of blood,  or, at least, its blastema may be mingled with  blood;
the  changes  which  the latter undergoes,  suggest to Rokitansky the 
THE TUBERCULOUS CRASIS.
157
Fig. 43.
 Corpuscles mixed with pig-
mentary matter, in a small
tubercle taken from the peri-
toneum, a. Irregular masses
of black matter, which may
be broken down into (6) gra-
nular and molecular matter.
250 diameters linear.
name of pigmentary tubercle, as distinguishing it from the more common
varieties.  Melanic matter, however, is often found, in small quantity,
in the latter also.   The following remarks are of
much interest and importance relative to  the co-
existence of tuberculous disease with other affec-
tions.
   Cystic growths are not  often  associated with
tubercle, and the same is true of cancerous; when
the latter are present together with tubercle, they
are, in  most cases,  of  secondary  origin  to  it.
Rokitansky contrasts the frequency of tuberculiza-
tion  of the lungs with the  rarity of  pulmonary
cancer;  the frequency  of ovarian,  gastric,  and
rectal  cancer, with the rarity of tuberculous de-
posit in these parts.  These and other facts indi-
 cate that the one morbid process tends to  exclude
 the  other.   Typhus and  the  exanthemata, he
 states, do  not  commonly attack  the  tuberculous,
 but they are very apt to be followed by tuberculous disease.   Sufferers
 from intermittent fever, goitrous disease, and rachitis, seem  to  be, pro
 tanto, less  liable to tuberculous affection.   The non-coexistence of aneu-
 rismal and tuberculous disease depends, in Rokitansky's  opinion, on the
 exhaustion of the fibrinous constituent  of the  blood, by the deposits
 taking place on  the inner surface of the sac.   An  especial immu-
 nity against tubercle is afforded  by an abnormally venous condition of
 the  blood, from whatever  cause  this  may come to pass.   Congenital
 malformations of the heart or great bloodvessels;  morbid alterations of
 the same ; deformities of the chest, producing contraction of its cavity;
  annihilation of the function of one lung by pleuritic
  effusion;  abdominal  growths, preventing  the  free
  descent of  the  diaphragm;  chronic pulmonary
  catarrh; emphysema and bronchial dilatation, have
  all been observed as exercising  an unquestionable
  counter influence against the development of tuber-
  cle ; and  in all these conditions the free oxygena-
  tion of the blood  is more or  less interfered with.
  The undoubted effect of pregnancy in delaying the     ,.,,„,.
  advance of tuberculous  disease of  the  lungs, is  explained hj Roki-
  tansky on the same principle  of impeded, and consequently imperfect
  respiration, inducing a venous  condition  of  blood;  and he  refers to
  the  great production of  fibrin, which  takes   place  after  parturition,
  as confirmatory of this view-tubercle being regarded  as a fibriniform
  product  Respecting the identity of tuberculous and  scrofulous matter,
  there can be no doubt.   They have  the  same  elementary composition
  they undergo  the same changes, they are produced in the same way and
  produce the same effects on the tissues  in which  they are deposited
  Generally, it  may be said, that the deposit in  the absorbent glands and
  bTes passes for Scrofulous; that in the lungs or brain, for tuberculous
  ffiatter-both being essentially what we have described as yellow tuber-
  cle.  The name seems to  depend almost entirely upon the form.  In
Scrofulous matter from
 subcutaneous deposit. 
158
THE TUBERCULOUS  CRASIS.
adults, tubercle is  found in the various organs  in  about the following
scale of frequency: Lungs, intestinal canal, lymphatic glands (especially
the abdominal and bronchial), larynx, serous membranes, brain, spleen,
kidneys, liver, bones, and periosteum, uterus and Fallopian tubes, testi-
cles  (with  the prostate  gland and vesiculae  seminales), spinal cord,
voluntary muscles.  In  children,  Rokitansky  states,  the lymphatic
glands and spleen are most often  affected, then the lungs, and after
these the brain, &c.  MM. Rilliet and Barthez assign, as in adults, the
primary place to pulmonary tubercle.  According to them, however, the
lungs are not so invariably affected as M. Louis's well-known law declares
them  to be in adults; as, in forty-seven out of three hundred and twelve
instances, they were  exempt,  while tuberculous deposit was found in
other organs.   It  is to be  observed that  the  above scale of frequency
of the occurrence of tubercle in adults does not express correctly the

                Fig. 45.                             Eig. 46.
®/*s      dffifc                  ?^'<§S
^m
       «©-©w»    warn                  P»

          *> @  J a ®                            ■■*&&
    Scrofulous pus—a large glomerulus is shown, and        Scrofulous pus from a lymphatic
              some oil drops.                     gland. 250 diameters linear.

different tendency of the various organs to primary tuberculosis.  Roki-
tansky places in this respect the lungs and lymphatic glands first, then
                       the  urinary organs,  the  bones,  the testicles,
                       &c.;  while  the  intestines,  the  larynx,  the
                       spleen, and the liver, occupy the lower part of
                       the scale.   The question  as to how far, and in
                       what way tuberculous disease is curable, is of
                       course of the greatest interest.   As an exuda-
                       tion, it  seems credible  that tubercle  should
                       liquefy and undergo absorption;  but it has been
                       very generally doubted whether  this ever ac-
                       tually occurs.  Dr.- Walshe,  whose authority
                       is great on  this point, believes that absorption,
                       under favorable circumstances, may take place,
  pus from a scrofulous abscess.   but acknowledges it to be a rare event.   Pro-
                       bably the most favorable  result  that can gene-
rally  be  expected, after tubercle  is once  deposited, is  either  that it
should cornufy simply without having undergone softening, or that after
this change it should cretify.   After  tubercle  in any quantity has soft-
ened,  and a cavity been formed from which the tubercular detritus is
afterwards eliminated, a cure may still take  place;  but it  is a much
rarer  occurrence than  in  the  two  former  cases, and perhaps  never
attains to the complete closure and cicatrization of the cavity.  This, at
least,  applies to the lungs; in other  parts, there is no doubt that a
tuberculous ulcer may heal up and cicatrize.   The production of  tuber-
 
THE TUBERCULOUS CRASIS.
159
cle sometimes takes place, as observed above, with very great rapidity,
constituting what is  termed acute tuberculosis.  It is remarkable that
the symptoms in this condition very closely resemble those of typhus
fever (v. case in  Dr. Walshe's work on Diseases of the Lungs and Heart,
p. 409).  The tubercle is of  the gray miliary kind, is widely and uni-
formly  scattered throughout the lungs, and is often deposited in other
parts also.

   As a sequel to the foregoing account of tubercle, we may describe here
a somewhat analogous deposit, which is not very unfrequently found in
the organs of those who are the subjects of general cachexia.  It appears
as a solid blastematous mass, infiltrated among the tissues of a part; semi-
transparent, or verging  on a whitish opacity—presenting, under  the
microscope, an  amorphous, flaky basis-substance, together  with scanty
nuclei.  It is  commonly deposited  in a part in considerable quantity,
 and gives rise to the appearance of  hypertrophy, though at the  same
 time the natural elements of the tissue are compressed  and atrophied,
 often to a great extent.   An organ thus  affected  is bloodless, breaks
 with a  sharp fracture, and strongly resembles bacon in appearance, from
 whence the term "bacony" is applied to  the deposit by German writers.
   The formation of this matter is not peculiar to the scrofulous diathe-
 sis  but it is observed in  those who have become  cachectic from  any
 cause- as from  the abuse of mercury, inveterate syphilis, habitual inter-
 mittens, or any severe drain upon the system.   Rokitansky calls the
 deposit " albuminous raw blastema," and believes it to proceed from an
 undue quantity of albumen being present in the blood.

    With respect to  the  real  nature of the tuberculous  crasis, we  have
  scarce any exact knowledge.  It is evidently a special  dyscrasia,  inti-
  mately connected, as we  know, with causes  of debility  and leading to
  the effusion of  a matter, which shows only the feeblest traces of organi-
  zation.  This matter in many respects  comports  itself very differently
  to fibrin; so much so, that the one might almost be regarded as the an-
  tithesis of the  other-supplanting it in  the process of effusion, or itself
  renlaced by it.  Rokitansky, however, shows some weighty reasons for
  regarding (ubercle as a modification of fibrin; and after  a most interest-
  nfdiscission, to which we would particularly refer (t,. p.  522, German
  pdiHon\  concludes that  "the arterial  character—arterial elaboration of
  ^fi^n^on^uls, above all, the cardinal feature of the tuberculous
  crasis "   He also points  out how, in consequence of the  alteration of
  ?he nature of the fibrin, tubercle is continually deposited, even when the
  b oodt very deficient in that constituent.  All the fibrin that is formed
  is soon affected by the peculiar dyscrasia, and is thrown out in the form
  of tubercle   The rapid coagulation of tubercle-blastema, which must be
   ffused in a fluki form, its tendency, when coagulated, to soften-its for-
  maton helnofavored by active arterialization,  and prevented  by a
     \Z InSition of the blood-are circumstances  which indicate  a real
  EC£we«d  fibrin.  When  we  further reflect  that
  various debEing causes are found to increase the quantity of fibrin
  andTlso  tl at the fame are potent in causing the production of tubercle, 
160
THE TUBERCULOUS  CRASIS.
we gain further evidence to the same  effect.  No doubt, however, even
before that peculiar modification of the fibrin has occurred, which leads
to its excretion in the form of tubercle, a special impress is, at least in
many cases, stamped upon the system, which betrays to the instructed
eye the future evil.   The tendency and proclivity to disease is there, it
may be, long before its actual development.  This unexplained proclivity
it is which constitutes the  scrofulous diathesis.

   A condition of the blood, characterized by deficiency in fibrin, excess
of albumen, and for the most part also  of blood-globules, is termed by
Rokitansky  venosity, or  albuminosis.   Simon designates  it hypinosis,
in contrast to hyperinosis,  which implies an excess of fibrin.  Rokitansky
describes under this head  several erases, in which the blood partakes of
the hypinotic character; but we shall  do no  more than enumerate them,
as we think he ascribes far too much  to the apparent qualities of  the
blood, and does not take sufficient count of the unseen but essential de-
rangements: "Hypinotic  blood is  in  general  a thick, sticky,  dark  red
fluid;  contains no coagula, or  only small, soft, sticky, gelatinous  ones,
which include much cruor."   It is apt, under peculiar circumstances, to
undergo various changes,  such as septic destruction of the albumen, in
which case necraemia takes place; or a croupo-fibrinous or pyaemic con-
dition may supervene; or a tendency to the effusion of acid fluids and
acute softening of tissues.   Dark hypostatic  stains, speedy putrefaction,
transitory rigor  mortis, a lax state  of the  solids, are  observed in  the
bodies of those who die with this condition of blood.
   The subordinate hypinotic cases are—(1) plethora; (2) the typhous;
(3) the exanthematic; (4) that existing in certain diseases of the nervous
system; (5) drunkard's dyscrasia; (6) cancerous dyscrasia.
   We may mention, with regard to the drunkard's dyscrasia, that, when
chronic, it presents a remarkable  dark  color, and inspissation of  the
blood, with excessive quantity  of oil.   Fat is formed abundantly in  the
subcutaneous tissue, and  in  other  parts.  The liver, the  muscles, and
even the bones are either  encroached  on by the fat,  or undergo some
degree of fatty degeneration.  The cerebral membranes are apt to be-
come thickened, the brain  itself to  be atrophied.  Chronic fluxes, from
the mucous membranes, especially the  bronchial and intestinal, are very
common.   The crasis often undergoes change to the croupo-fibrinous.
  We would recommend the doctrine of erases of the blood to the careful
thought of our readers.  No doubt it may easily be carried too  far;  but
we  think  cases  will often present themselves, in which  an apparent
inflammation and manifest exudation will be better explained and man-
aged by the ideas which this doctrine suggests, than by the most vigorous
anti-phlogistic proceeding. 
CHAPTER  III.
TEXTURAL CHANGES.
  We  now  come to consider certain  changes,  to  which most  of  the
various organs of the body are liable, in a general way.   These changes
are essentially textural, and result from  various disturbances  of  the
normal degree and kind of nutrition.  They are also for the most part
slow and  gradual in their course, and are thus termed chronic.   They
are intimately dependent  on the condition  of the blood, so that their
consideration  follows very properly on that of the diseases of this fluid.
  Hypertrophy, as its etymology signifies, conveys the idea of increased
nutrition  and  growth in the part affected.  The term, however, is some-
times  applied to parts which are simply enlarged, and  it is  essential
to observe that this enlargement by no means necessarily constitutes
hypertrophy, but may, instead, be attended with the opposite condition.
This makes it necessary to distinguish real from apparent hypertrophy.
In the former, the characteristic tissue of the part is enlarged, and more
developed;  if it be a muscle, the muscular fibres grow larger, and attain
to greater energy of contraction, if it be a  kidney, more renal  tubes are
formed with corresponding  bloodvessels.   The size  of the organ is not
only increased, but its working power too ; the muscle can raise a  greater
weight, and the kidney can produce more  secretion.  But if a  liver or
spleen be enlarged  by ever so great a quantity of the peculiar matter
termed "bacony," which is deposited interstitially between the elements
of the tissue,  their functional power is only thereby lessened,  and dete-
riorated  for the simple reason that the new substance has pressed upon
and caused wasting  of the natural structure.  It is, therefore, necessary
in every  case to ascertain  what is  the nature of the enlargement of a
part before we pronounce it to be truly hypertrophied.  Mere distension
of  a hollow organ,  of course,  is not hypertrophy; a huge  emphyse-
matous lung,  or hydrocephalic brain are not really enlarged, but rather
diminished  in actual capacity.   Great congestion of a part with blood
may give it the appearance of  being hypertrophied, but this again  is
only Another kind of distension.  Real hypertrophy requires a free  sup-
ply of healthy blood, and is commonly attended with enlargement of the
vessels of the part; this is not  the case in apparent. The cause of real
nype  rophy seems  to be always  the increased exertion of the organ
rTre   ILual effort is demanded of it,  and according tc> the law  of
the circulation which we have noticed, more blood flows to the part than
usual   ttr^he  organ  be in a  healthy state, not  only supphe.- s
waste, but furnishes material for increase and development.  The heart
        11 
162
TEXTURAL CHANGES.
in various diseased states of its valves, the urinary bladder in stricture
of the urethra, the remaining kidney when one has been destroyed, the
muscles, and even the solid bones themselves, when  long and  actively
exercised, afford excellent examples of true hypertrophy.
  This process, though in several instances it brings  about an abnormal
state of the part, is yet for the most  part not to  be considered in the
light of a disease.  It is really a compensatory effort made by the sys-
tem, to obviate as far as possible  the evils that arise from some damage
that an important part has sustained.  Thus, if we find the walls of the
heart greatly thickened, and its power proportionately  increased, we
should naturally fear that  such an abnormal increase of power would
prove a cause  of danger to the system, and would  probably induce
hemorrhage in the brain, or elsewhere; but if we know that at the
same time there exists regurgitant disease of the mitral or of the aortic
valves, then, we see, that the hypertrophy, so far  from being attended
with danger, is  useful and  necessary to  enable the  circulation to be
carried on against such impediments.
  Atrophy is the opposite condition to hypertrophy;  and is commonly
conceived of as implying  a  wasting and  diminution  of  the  part.
Atrophy, however, may have  taken place to a great extent, without any
diminution,  but  an increase of size.   These  are the instances of false
hypertrophy, to which we  have above  alluded.   In  a few instances
atrophy is  a natural process, as in the  disappearance of the  thymus
gland when the age of  early infancy is  passed.   Inactivity of  a  part,
obstruction of its bloodvessels, failure of its own vital energy, continued
pressure upon its surface, are all recognized causes of atrophy.  A
muscle, if unused, becomes small and pale, and its tissue degenerates;
the bones of a paralytic  limb lose in density and strength, and  in com-
pactness of  tissue;  the  brain in second childhood shrinks within its
bony case, and leaves a  space occupied by serum.   Obstruction of the
arterial branch leading to a part of the kidney will cause wasting of the
epithelium of the tube in that  part, ligature of the thyroideal arteries
has caused considerable diminution of a goitrous  tumor.  Thinning of
the walls of  the heart, renal degeneration, the fall of  the hair, and the
general decay of advanced  age,  are  instances of  atrophy from failing
vital energy of the tissues.   With  the effect of pressure in  producing
atrophy, all are familiar; it is well exemplified in the absorption that
takes place from the pressure of aneurism, which affects not  only the
soft parts, but the bones themselves.  In most  cases, atrophy i3  an
actually morbid process, and is attended  by  a change in  the  condition
of the elementary parts  of the tissue which attests  the unhealthy cha-
racter of their nutrition.  Atrophy often occurs as a secondary process,
induced by some primary one,  which may have been attended with
apparent hypertrophy.   Of this, the liver in the earlier and later stages
of cirrhosis  furnishes an  instance.
   Induration and softening, are  terms that are commonly employed to
express changes that have occurred in the consistence of various organs,
rendering them more or less firm and dense than natural.   They are,
of course, very general in their meaning, and of themselves tell nothing
as to the pathological condition of the part affected.   This must depend 
TEXTURAL CHANGES.
163
entirely on the causes of the changes in question.  The commonest cause
of induration is the effusion of fibrinous material into the interstices of a
tissue; if this  does not liquefy and become absorbed, it passes into the
state of fibroid texture, and being blended with the elements of the part,
it occasions a more or less considerable increase of density and tough-
ness.  Instances of this are extremely frequent in the lungs around
tuberculous deposits, in the cirrhotic liver, and in the areolar  tissue
around ulcers.  The tissues involved in the induration matter, as it is
often called, are very apt to become atrophied, partly in consequence
of their supply of blood being cut off by obliteration of the vessels dis-
tributed to them,  partly from  the  effect  of  atrophic pressure  itself.
According to its seat, induration may be of trifling consequence, or very
serious; in the general areolar  tissue of the body, it may only cause
slight impediment to the free movements of a part; in the valves  of the
heart  it is a  common cause of secondary  disease, dropsy, and death.
Textures are  often rendered harder and firmer by other  deposits than
simple fibrinous, as by tuberculous, bacony, calcareous, but to these the
term induration is not so strictly applicable.
   Softening of a  part may be  brought about by very various  causes.
 It is almost an invariable effect of acute inflammation actually existing;
 it is also found as  the  result of  inflammation that has in great measure
 subsided; it occurs from deprivation of blood, as a kind of atrophy, and
 probably, in some cases, as  a local result of a general cachexia.   In all
 cases it involves a considerable  deviation from the state of  healthy nu-
 trition, and if it proceeds far, may easily occasion a breaking down and
 destruction of the  tissue.  The distinction of various kinds of softening,
 especially of the red, or inflammatory, has often been considered difficult,
 but may generally be made with certainty by means  of microscopical
 examination, which discovers in the former decided traces of exudation.
 Softening is  connected with the hypinotic  condition of the blood, and
 its subordinate erases, especially the typhous; induration, on the other
 hand, with the fibrinous  crasis.   Softening is more prone to  occasion
 speedy destruction of textures and fatal  disorder.   Induration, to pro-
 duce gradual changes whose effects are slowly and gradually manifested
 Softening  appears as a process of decay, and  affects not only natural
 structures, but new formations, and  even as we have seen tuberculous
 deposits and  fibrinous coagula.   Induration, on the contrary, though
 involving some  degree of atrophy, tends to preserve the parts which it
 affects from entire dissolution.
    Degenerations are  changes of an essentially chronic nature, latent
 in their origin, and obscure in their progress, until they have produced
 such  deteriorations of structure as  give  rise to prominent secondary
 phenomena.   Those with which we  are  most acquainted are the tatty,
 fibrousT and  calcareous.  They  are  of  extremely frequent  occurrence,
 but their nature has scarcely been recognized until oi late
    Fcttu deaeneration consists in the replacement of  the healthy tissue
  of  a Z;  bXps, or molecules of oily nature, which  are deposited,
     it'seemsf instead  of  the natural material   ^t^lleT^-
  guishes it from fatty accumulation, which may take plac  to a great  ex
  tent in the interstices of a tissue so as to  overlay and conceal  its ele 
164
TEXTURAL CHANGES.
ments.   In true fatty degeneration there is always destruction of tissue,
which does not occur when there is merely an increase of oil in the sub-
stance of the part.  A muscular fibre thus  affected shows the  sarcous
elements, the real contractile tissue within the sarcolemma, replaced
by glistening oil-particles, so that the functional power of  the organ is
pro tanto destroyed.   The  hepatic  cells in true fatty degeneration not
only fill themselves with oil, but fuse together with others, and break up
into granulous films, entangling oil-drops; this destruction does not occur
when they simply become loaded with oil from the  presence  of a large
quantity of this substance in the food.   The process by which fibrinous
coagula, or extra-vascular deposits are broken down and dissolved, seems
to be in some measure of the nature of fatty degeneration; there is com-
monly much free oily  matter visible in the  softened  mass, and  the
exudation corpuscles seem  to be thoroughly charged  with it.   Fatty
degeneration is clearly a kind  of atrophy, but not identical with  the
simple form;  we  have  seen muscular fibres  of the heart  which were
simply atrophied, and had lost their transverse striation entirely, which
yet did not  contain a single particle of oil.  The prevalent opinion re-
specting the nature of fatty degeneration is,  that there  occurs a true
conversion of the  albuminous substance  of the tissue into fatty matter,
just as when adipocire is formed out of flesh immersed in water.  We are
rather inclined to  believe  that the  change is effected in the way of an
unhealthy nutrition, oil being deposited in the blood  in the place of
nitrogenized matter.   However this may be, it is important to  distin-
guish the following conditions in which the quantity of  fatty matter in
and upon a part  is greatly increased.  (1.)  Mere  accumulation  of
adipose substance in and around an organ, the tissue  remaining healthy,
(2.) Accumulation of adipose tissue  in the same way, but with atrophy
of the proper  structure.   (3.) Increase of oil in the elementary struc-
ture of a part without atrophy, or  breaking up.    (4.)  True fatty de-
generation,  in which the  structure is more  or less destroyed,  and its
elementary parts converted into oily matter.
  Fibrous Degeneration is somewhat allied to Induration, and is probably
connected with the existence of a  fibrinous  crasis.  It occasions  the
gradual thickening of  serous membranes and  of areolar tissue by the
formation of an imperfect kind of fibrous structure.   This may attain a
considerable thickness, and then by its dead white aspect resemble very
much a layer of cartilage.   The capsule of the spleen is  sometimes thus
altered, and has been wrongly said to have undergone cartilaginification,
for there is no real similarity between this substance and cartilage.   The
white patches formed on the surface of the pericardium and in the capsule
of the liver, are produced in this manner, and so is also  that thickening
of the Glissonian sheaths,  which give rise, in many cases,  to cirrhosis.
The fibres are probably formed, in part, directly out of the  effused blas-
tema, in  part,  also, by  nuclei, developing  short fibres, which unite, as
Henle has described.  This  latter mode of formation is often observed
in the spleen.  The chief difference between induration and fibrous de-
generation  consists in  this, that in the former, a notable  quantity of
blastema is effused, which becomes the induration matter, and compresses
and atrophies the adjacent texture; in the latter, there seems to be scarce 
TEXTURAL CHANGES.
165
any perceptible exudation, as it takes place slowly, and passes at once
into  the condition of fibre.   Induration may affect any  tissue, while
fibrous degeneration is chiefly seen in membranes.   Cartilage, however,
lsliajble to a fibrous transformation of a somewhat different kind, which
will be hereafter  noticed.
   The Calcareous degeneration rarely occurs as a primary change, it is
almost always secondary to some other.  Especially, it seems to be con-
sequent upon a fatty degeneration of the arteries, to  which the term
atheroma is applied, and which may  occur at any period of life, while
the calcareous change is seldom  observed very extensively except  in
advanced age.  We have already alluded to the calcifying process, under
the head of tubercle, as one of the metamorphoses which that deposit
might undergo, and we shall find hereafter that it affects other formations
also.   It is often spoken of  as  ossification, and,  indeed, not altogether
without reason, as the "lacunae" characteristic of bone are found in this
substance also; they are, however, irregularly and imperfectly developed.
The earthy  matters deposited are principally phosphate of lime and
magnesia, and carbonate of  lime;  Rokitansky considers that  they are
not so much new deposits as precipitations from their natural combina-
tions with animal matters.  Calcareous deposition seems generally  to
take  place in  parts  whose vitality has been considerably lowered by
previous morbid processes within them.   Thus it is common, in lymphatic
glands which have been the seat of scrofulous disease, in obsolete croupo-
fibrinous deposits, in the coats of arteries which have begun to be affected
by atheroma, and in the valves of the heart under similar circumstances.
The atheromatous condition, which we shall describe more particularly
when we speak  of  the  diseases of  arteries, may  either terminate  in
softening  and breaking down  of  the  arterial  coats, or in calcareous
deposition; both  of  these changes often coexist, but the latter predomi-
nates in old age.   We think, however, that deposition of earthy matter
may take place to a great extent,  so  as to produce the ossification so
common in the vessels of the  aged, without previous  atheromatous or
fatty degeneration.   The quantity of earthy matter in the bones becomes
greatly increased in later life; it is even deposited  in the so-named per-
manent  cartilages, and  it is,  therefore, not surprising that it should
also affect the walls of the vessels.   This  degeneration probably is oc-
casioned solely by a failure  of assimilative nutritive power in the tissue
itself.
• 
                      CHAPTER   IV.

                       NEW  FORMATIONS.

  It is difficult to give a perfectly exact definition of the class  of new
formations; for we  shall  exclude  from it  many productions which are
not found in the healthy organism, and shall include in it some which
are but the result of the action of parts normally existing.   Thus, we
shall not mention the excessive production of fat-cells, which takes place
in general obesity, as an instance of new formations,  while we shall con-
sider as such the distension of a sebaceous follicle into  an encysted tumor.
This defect,  however, is  common to  all  arrangements.   Nature pre-
sents us readily with distinct types of different classes; but rarely, if ever,
does she  define and separate her groups by any exact limitation, and the
rigid taxonomist wearies himself in the search for that which does  not
exist.  The idea which is conveyed in  the term " tumors," seems, in  a
general way, most descriptive  of the class now before us, which  may be
said to include all new prominent or otherwise apparent local growths.
The character of growing excludes tuberculous and  other deposits, and
concretions.   We shall follow, in  the main, the arrangement of  the
various kinds of new formations  which Rokitansky has adopted,  en-
deavoring to  set forth their distinctive features as far as possible, and
yet recognizing the  frequent  insufficiency of any structural  or chemi-
cal peculiarities that we can observe—to explain, or  even diagnose, the
essentially different natures  of different specimens we may meet  with.
   (1.)  Fibrous Tumors.—These constitute a group with tolerably well-
marked structural characters, but shading,  almost  imperceptibly, into
other species of very different nature.  They are essentially made up of
fibres, more or less closely resembling  those of areolar  tissue, but ap-
pearing,  in very various stages of development,  in different specimens.
Sometimes the fibres are tolerably distinct and separate; more often so
interlaced |nd blended together, or so imperfectly evolved, that they
cannot be  made  out as such.  Sometimes the nuclei, with  which the
structure is loaded,  seem to  be simply imbedded in  a granulo-homo-
geneous blastema, the whole forming a dense solid mass; sometimes the
blastema is divided into fibres, very similar to those of organic muscle;
and sometimes, again, but more rarely, the blastema is broken  up by
fibrillation into bundles of filaments, identical with those of white fibrous
tissue. Yellow elastic fibres are not unfrequently mingled with the white,
and seem to be developed from the elongated nuclei.  Much difference
is observed in the chemical behavior  of tumors of  this class.   Those
which  consist of fully developed fibres yield gelatin, while from those 
NEW FORMATIONS.
167
which consist  of muscle-like fibre, or  of an  undivided blastema, none
can be obtained.1
                                  Fig. 48.
                        Drawing of section of fibrous tumor.

   Fibrous  tumors differ much in their degree of connection with sur-
rounding parts;  sometimes they are quite blended with  them  by con-
tinuity of  tissue;  at  others,  they  are  easily  enucleated.  They have

                                  Fig. 49.
   Fibre-fatty tumor. The upper figure shows fat-cells imbedded in fibrous tissue; the left lower one
           represents a fat-cell capsulated by fibres; and the right some separate fibres.

very few vessels indeed; so  few,  that it is matter of surprise how some
 argYmasIes maintain their vitality.   These tumors develop themselves
in very different parts of the body, usually in  such as normally contain

  > This is Vogel's statement; but ™ have certainly obtained abundance of gelatin from
 umors consisting of undivided blastema. 
168
NEW FORMATIONS.
much fibrous tissue.   The uterus is one of their most common hdbitats,
which probably "depends on the similarity between the undeveloped mus-
cular fibre of the organ and their own structure,  so that a slight altera-
tion in the conditions of nutrition might cause the common blastema to
take the form of fibrous tumor, rather than  of uterine fibre.   Several
fibrous tumors may exist in the same organ; but it is rare that they co-
exist in separate organs.   They are  not liable commonly to any great
degree of change.  Inflammation may occur, characterized by injection
and softening of the part,  and probably by the  presence  of exudation
corpuscles in it.  Cretification is not unfrequent, and may  either com-
mence indifferently at any  part, proceeding until the whole is converted

             Fig. 50.                              Fig. 51.
Fat-cells and granular matter, from a steatomatous     Structure of a fatty tumor removed from the
       tumor of the ovary.—Bennett.           back. Lipome.  a. Isolated cells showing the crys-
                                    talline nucleus of margaric acid.—Bennett.

into a  calcareous mass; or it may be in great measure limited  to  the
peripheral stratum, which it thus converts into a  kind of shell, inclosing
the rest.   The  calcareous degeneration affects tumors  of very different
size, and does not bear any relation to the age of the growth.  Melanic
matter is  sometimes deposited abundantly in fibrous tumors.  Cyst-like
cavities, filled with clear fluid,  are occasionally found in fibrous tumors,
constituting  thus  a fibro-cystic variety.   Another results from their
combination  with  adipose tissue, of which we have figured a specimen.
The form which fibrous tumors  assume is mostly the spherical, with a
more or less  nodulated  exterior.  If, however, they grow  near  a free
surface, they are very prone to become pedunculated.  It is probably
from this tendency, together with subsequent wasting of the peduncle,
that fibrous tumors are occasionally found free in the cavity of the uterus.
In  a case which came under our notice, there was no trace of peduncle.
The tumor, of large size, had greatly distended the uterine cavity,  and
had very  slight  connection with  the  parietes.   The size which  fibrous
tumors sometimes  attain is  very considerable, Some have weighed as
much  as  thirty-five or thirty-nine pounds.   Between proper fibrous tu-
mors and instances of mere hypertrophy of the integument, there exist,
or may occur, every intermediate variety.  In proportion as the texture
of  the formation becomes dense, it  is  more abundantly permeated by
vessels, so that some  of  these growths are highly vascular.   Of  this
 
NEW FORMATIONS.
169
kind is the rather rare Keloid tumor, a specimen of which we have lately
had an opportunity to examine.   It was situate on the back, was well
defined, of a red color before removal, but pale after.   It had much the

                               Fig. 52,
              Fibro-cystic tumor from back: (b) after addition of acetic acid.

appearance of a thick red cicatrix, as if formed by  a kind of transfor-
mation of the skin itself.   The structure, under the microscope appeared
as a dense woof  of  fibrous tissue,  resulting from a pretty thoroughly
fibrillated blastema.  Acetic acid brought into view numerous nuclei,
all more or less elongated, some quite passing into streaks, as  if about
to form nucleus  fibres.   A good deal  of free oily  matter was diffu ed
through the mass.  Another specimen we have lately examined consisted
of a fibrillating but undivided blastema, imbedding numerous nuclei, tor
the most part elongated and streaky.  It involved the conum of  the
skin,  but the epidermis passed evenly over it.  It was  very remarkable
 hat the deeper layers of the epidermis «»™to%^^^g^
cells  and nuclei, while the  upper layers were  of the  usually flattened
 hapeTMs probably depended  on the abnormal fibrefying tendency
hX affectedPthe cefl growth on the free -f "e <»f the W«t mem-
brane   Tegumentary tumors, as  they are termed by Mr. Simon, seem
torProperiy included in the class we are considering, as they consist
essentially of an increased growth of fibrous structure.
   We  may here allude  to a group of tumors  for which Mr  Page
 nronoseTthe name of Recurring  Fibroid.  They are almost identical
 proposes tne name           fh ■   th ;  naked-eye aspect, and in
 Sir S^SXSinVSow a remarkable tendency to return
 aft r ™  It is an ex'tremely important and interesting  circum-
 atter removal.             duced  tumors approximate  much  more in
 stance, that the, later  pro              ^character, than the origi-
 appearance and in behav10r to  x       g        production was hardly 
170
NEW FORMATIONS.
in the circumstance that they form a kind of transition between the so-
called innocent and the malignant formations.  According to our belief,
the circumstance of  structural resemblance to  fibrous  tumors,  is no
hinderance whatever to the possession of malignancy.  A  caudate cell
may have this fatal gift as well as any other kind.

   Epidermic  and epithelial tumors constitute a well-marked class  of
new formations, which are of very frequent  occurrence, and much prac-
tical interest.   Warts and callosities of the skin  are minor instances  of
this group, and consist simply in thickening of the epidermis, produced
by accumulated layers of its scales.   As an increased flow  of blood  to
the part must take  place,  it is not surprising that the papillae  of the
corium beneath should, in some of the more advanced  cases, become
hypertrophied and elongated,  so as to project upwards  into the little
tumor.   In  condylomata, mucous tubercles, and  similar  vegetations,
which are apt to form  about  the  orifices of mucous canals, under the
irritation of syphilitic and other  discharges, the surface is commonly
observed to be tabulated or papillar, the interior  marked  by a vertical
striation, while some vascular ramifications  extend up into each papilla.
The structure of these  is beautifully figured by M. Lebert.  The sur-
face of  each papilla,  as shown in his  plates, is formed by a layer  of
closely imbricated epithelial scales;  while  the deeper parts consist  of
either less flattened cells, or, according to our own observation, of nu-
clei, lying close together in a granulous and amorphous blastema.   This
interior nucleated granulous tissue, we believe, is continued downward
to the base of the growth, and encroaches on the  corium of the skin;
for we have never been able to observe any clear demarcation between
the vascular loops  and  the  surrounding cell formation.   Almost the
very same description applies to those tumors which are most  common
on the lips, and whose cancerous nature one has  often too much reason
                  (A) Papillary prominence of epithelial growth.
                  (B) Epithelial tumour from lip.
                                From Lebert.

to suspect.  These attain a much larger size, and are more  manifestly
vascular than the  preceding, and their papillae are more branched and
grouped together,  so that the surface  resembles somewhat that of a
Fig.
 
NEW FORMATIONS.
171
cauliflower.   We believe it is not always  possible to say, from  the
structural characters of these growths, whether  or  not they are malig-
nant, or whether, if removed, they will return again.   To this point we
shall advert again, under the head of " Cancer."  Horns are epidermic
productions,  which  are occasionally formed upon  the head, the fore-
head, or some other part  of  the body.   They originate in the sebaceous
follicles,  whose  epithelium,  thrown  off  in unnatural  and excessive
quantities, and mixed with the fatty  secretion,  forms a conical mass,
which protrudes from the  orifice in  the  skin, and is  pushed onwards
continually by fresh accretions to its base.  M. Lebert quotes a case in
which the horn was six to seven inches broad at  its  base,  and six inches
long.   A contusion, or ulceration of the skin, preceded the appearance
of  the tumor.
   Melanotic tumors are not unfrequently spoken of by various authors,
and occupy in their arrangements a place with other classes; but there
is  very  great reason to  doubt whether,  properly  speaking, any such
thing ever exists.   This is indeed generally admitted,  and  we now pro-
ceed to show why it is so.   Melanosis (meaning  thereby the deposit of
black pigment) is an extremely common occurrence, and may take place
in  healthy tissues, in those  which  are variously diseased, and  in  new
formations of any kind.   The pigment is in the
 form of minute granules, or sometimes of almost        Fl8- 51
 dust-like molecules.  It very  commonly occurs           H \\ W
 free, though  the particles  may be more or less               ^) {Bj
 closely  massed  together, but  is very often also         || i>~ ^
 contained in the interior of cells. There is nothing      a   %^^
 at all peculiar in these pigment-containing  cells.   <^ ^  W
 They seem to be simply  the natural  cells of the   Mclanic deposit ,n cellg of an
 organ  or of the new growth in which the deposit  engorged lung, some of the
 has occurred.  Pigment  granules are seen in the   ceiis contain oii-drops.
 same part, both free and  contained  in  cells, so
 that it is clear that their presence  in the cells is of no special import.
 Rokitansky gives the following enumeration of localities,  in which the
 melanotic deposit takes place: In  the lungs, both in the air-cells (often
 in their epithelial particles), and in  the connecting areolar tissue.  When
 contained in the air-cavities, it is  in all probability  chiefly inhaled as
 carbonaceous matter, floating in  the  air.  We examined some time ago
 the lungs of a man who had been a worker in a gunpowder manufactory,
 and found them to contain a very  remarkable quantity  of free black
 matter.   In the bronchial glands, its quantity in them being usually in
 proportion to that  in the lungs, it  is rarely contained m cells.   In the
 mucous membrane of the stomach  and intestines, of the uterus, and oc-
 casionally of the air-passages, it is generally the result of the irritation
 of chronic  catarrh, and is derived  from  altered haematin.   In the
 mesenteric glands, coexisting with such  deposits in the mucous tissue
 "produces I slaty gray,  or still darker discoloration spotted or uniformly
 diffused.  In the sympathetic ganglia.  In the skin, either naturally,
 in the  dark races, or as  the  local discolorations, termed "melasma
 in new fo mations  as intravascular coagula, atheromatous patches and
 then cicatrices, in hemorrhagic masses, false membranes of inflammatory 
172
NEW FORMATIONS.
origin, tubercle, especially the hemorrhagic variety, colloid matter, and
cancerous growths.  Lastly, melanotic matter occurs in fluid exudations,
and in the cavities of cysts.  Rokitansky is of opinion, that the deriva-
tion of the black  pigment from the  coloring matter  of  the blood is a
settled point.   We are rather inclined to agree with him  than with Dr.
Walshe,  who thinks " that the relation of true melanic cell-pigment to
the constituents of the blood, is altogether unknown."  It is quite certain
that, in all the instances above mentioned, except that  of the air-cavities
of the lungs, the melanic matter proceeds in some way from the blood;
but the question is, how ?   Is there first extravasation of the blood,  ex-
udation  of its haematin, and conversion of this into the pigment; or is
this produced from the liquor sanguinis, in some unknown way of secre-
tion ?  We are inclined to think the latter is not unfrequently the case,
and for the following reasons: (1.) It seems quite impossible to believe
that the  very considerable quantity of black matter, often found in  the
interlobular tissue of the lungs of old persons, should have proceeded
from  local congestions and extravasations, especially  when there is no
trace  of  previous inflammatory action.  (2.)  We are well acquainted
with the changes which haematin does undergo in the  splenic tissue and
in the renal tubules,  when blood has escaped out of the vessels; and we
have  far most commonly  observed  the color  of  the granules to be an
orange or reddish yellow.   The same is the case in the remarkable pro-
duction of yellow matter, which takes place in the congested centres of
the hepatic lobules.   (3.) We have observed, particularly in the embryo
of the fish, the development of pigment, and seen it  commence by  the
appearance of a minute free particle of intense blackness, smaller than
a nucleus, close by the side of a vessel; so also, in the abundant formation
of black  pigment which takes place in the liver of the frog at certain
times, there is not the least reason for regarding it as specially derived
from the red coloring matter of the globules, but much more for supposing
it to proceed from some of the highly  carbonized matters contained in
the liquor sanguinis.   In this instance,  as in many  others, truth  lies
intermediate between opposite opinions.   The chemical composition of
melanotic matter is not accurately ascertained, and probably hardly  can
be, owing to the difficulty of obtaining it at all  pure, and perhaps also
from  variations in the composition of different specimens.   It is clearly,
however,  a very highly carbonaceous substance—indeed,  that obtained
from the lungs of aged persons, by M. Guillot, seems to have been actually
carbon.   Dr. Walshe mentions that a specimen of softened melanotic
tumor, which he  examined, was not deprived  of  its color by  acids or
alkalies,  only by chlorine.  Strong nitric acid, however, with the aid of
heat, turned  it yellow.   From the foregoing account of melanosis, it will
readily appear that, from the  very commonness of its occurrence, it is
impossible to regard it as giving a really distinctive character to a tumor.
The growth is essentially something else—a cancerous, or sarcomatous,
or some  other formation, and the melanotic tinging is  accidental.

   Fatty  tumors, or Lipomata, as they are sometimes termed, are of  fre-
quent occurrence.  They consist  of normal  fat-cells,  closely packed
together, and invested by a rather  sparing quantity of common areolar 
                        NEW  FORMATIONS.                    173

tissue.  Occasionally, this investment is more developed, and constitutes
a kind of enveloping cyst; occasionally,  also, it dips down, and forms a
cystoid covering  to separate portions of the tumor.   They occur most

                               Fig. 55.
Adipose tissue from a fatty tumor.
often singly, but not unfrequently several exist together in the subcu-
taneous tissue.  They attain,  occasionally, an enormous size, so that
records speak of specimens several feet in diameter, and weighing 20—
40 pounds.   Their most common seat is the subcutaneous areolar tissue,
especially in regions where fat  is apt to collect, as on the buttocks, the
thighs, the back and neck, &c.   They have,  however, been seen in many
other parts, as beneath the scalp, in the submucous tissue of the stomach,
intestines, bronchi, and in the underlying  areolar tissue of the various
serous and synovial membranes.   In  the  knee-joint, especially, tatty
growths have been distinguished by Muller as " lipomata arborescentia,
in consequence of their branching form; this seems to result from their
originating in the areolar tissue, and growing inward towards the syno-
vial cavity.   Lipomata have further been  observed m  the lungs, liver,
and kidneys, and  in the bones.  The  surface of lipomata is commonly
lobulated-their form, for the most part, globular; they have  a peculiar
doughy feel, with some degree of elasticity.   They grow slowly, and
occasion inconveniences only by the pressure they exert on surrounding
parts;  when at last this distension becomes excessive, the  skin covering
the tumor attenuates,  and ulcerates, and  a  sloughing sore may be  thus
produced which may destroy life by exhaustion.  It sometimes happens
CSt.; tumor sLed i/the submucous tissue pushes «it ff^ws Ae
yielding membrane  before it, and thus, acquiring a pedicle, hangs into
L intfstinal cavity.   A steatoma, according  o Rokitansky  s a faO;
tumor, with a preponderating excess of areolar tissue, ™^™f*^
consistence.  Lebert applies the name to collected masses of fatty matter
not consisting of fat-cells, but of concrete  fatty granules. J£-™™
 says, that the steatoma is close in grain, inelastic, opaque,  suet or putty 
174
NEW FORMATIONS.
like, composed of granular, amorphous, and non-vesicular fat.   To this
kind of tumor we think the name most suited.
  Another variety of fatty tumor is  the cholesteatoma, in which a sub-
stance allied to cholesterin is secreted in the  interior of a fibroid cyst,
lined internally by a delicate epithelium, which is probably the secreting
organ.  The contents are of a glistening mother-of-pearl aspect, though
sometimes  of a  dull white; they are  arranged in delicate  concentric
laminae.   The laminae  consist of  superimposed strata of cells, rendered
polygonal by mutual pressure, and resembling, except in size (being one-
half smaller), the cells of sheep's-fat.   Between the laminae there are
numerous crystals, which are of tabular and lamellar shape, and seem to
consist of pure cholesterin.  A similar matter is occasionally found on
the free surface of cancerous and other ulcers.

  Before we proceed to describe  vascular tumors, which constitute our
next class, we shall give some account of the development of new vessels
in inflammatory exudations, and  other blastemata.   Two  opinions are
held at present as  to the mode in which their formation  takes place.
By some, as  Paget, Travers, and Simon,  they are  considered to be
formed by " outgrowth from adjacent vessels."  Small dilatations appear
on the side of a vessel, increase in length, and at last  meet and coalesce
with similar  diverticula in their  vicinity;  in  this way  a new capillary
loop is formed, and the process is carried on in the same way.   On the
other hand, Rokitansky, Vogel, and Dr. Walshe agree in regarding the
new vessels as originating spontaneously in the exuded blastema.  We
strongly incline-to  the  belief  that their view is the  correct one, or at
least that bloodvessels  are formed in the latter as well as in the former
manner.  The following description is taken from Rokitansky and Vogel:
In the substance of the exuded material there appears to the naked eye
small roundish spots full of blood, from which there proceed in all direc-
tions minute streamlets filled with  the same red contents.  These primary
channels are  at first mere excavations in  the blastema, and  have no
lining membrane;  after a time they present the characteristic homoge-
neous coat  of true vessels, and at a later period the external tunics are
added.  The blood-globules originating within their channels are more
irregular in size, less exactly shaped, and  have not the deep red color
of the original ones.  It seems certain that the primary blood-containing
spaces and their offsets are not ramifying cells, for they appear in the
blastema before the formation of cells, or even of fibroid tissue; the
development of blood at certain points seems to be the only determining
cause of  their formation, just  as  it is  in the embryo.  Our  knowledge
respecting  the influence which the nature of the blastema has on the
production of new vessels, amounts to this—(1), that in blastemata under-
going similar  developmental changes, the tendency to the formation of
vessels is much greater in some than it is in others; (2), that in blaste-
mata which remain in their original crude solid state, and  do not break
up  by fibrillation, very Tittle vascular development takes  place.  The
vessels originating as just described, are larger than capillaries, at least
in parts of  their courses, less uniform in caliber, and more delicate;
they communicate with the general circulation by extending through the 
NEW FORMATIONS.
175
blastema till they meet with the vessels of the subjacent membrane, and
anastomose  with  them.   Another variety in  the  mode of development
of new vessels has been observed by Rokitansky in cancerous blastemata.
Parent-cells, such as might have contained a brood of young cells, were
seen filled with red blood-globules ; offsets proceeded from these cells
filled with the same red contents, and  formed anastomoses with  similar
ones from adjacent cells.   The  same special  tendency to vascular deve-
lopment is evidently inherent in some cancerous  and non-inflammatory
blastemata  as in the common; thus, encephaloid growths are sometimes
so  highly vascular as to be considered a distinct variety, the Fungus
Haematodes; in multilocular ovarian tumors, some loculi will be  found,
whose contents are red with blood, while in adjacent ones scarce any
trace is visible.  To say why vascular  formation should so remarkably
predominate in one growth, or part of a growth, rather than  another, is
as difficult as it would be to explain why one organ, or one  part of  an
organ, is naturally more vascular than another; for instance, why muscle
is more vascular than tendon.
   From these remarks upon the excessive  development of  vessels,  we
 naturally pass to the consideration of growths which mainly consist  of
 them,  and  are consequently called vascular tumors.  Of these there
 seem  to  be two kinds, one consisting  of dilated,  arterial,  or  venous
 branches, with a certain quantity of interposed areolar tissue, to which
 the name angeiectoma may properly be applied ; the other  presenting
 a  more  truly erectile texture, i.  e.  spaces  separated by  intervening
 columns of fibrous tissue,  and lined  by an epithelium, which are dis-
 tended by blood in a  greater  or less  degree.  The communication  be-
 tween the cells and the arteries is more or less free; when  the  former
 is the case, the tumor  pulsates  strongly.  Xaevi  are  tumors  of this
 kind  occurring in the skin, which is their most frequent seat; they also
 occur, however, in numerous other parts, even in the interior of bones,
 which become dilated and thinned by their growth.   They are very
 often  congenital,  their  increase  in size  sometimes is very rapid, and
 seems to be favored by a contusion, or any  cause of irritation.   01 the
 non-malignant character  of erectile vascular tumors there can be  no
 doubt; they contain nothing but a fibrous structure interposed between
 their vessels;  but with  regard to some other  growths, more of the
 character of the angeiectomata, there may often be room for doubt, at
 least during life.   Microscopical examination, however, of  the tumor,
 will in  molt  cases readily show whether any elements which  can be
 considered as cancerous are mingled with the dilated vessels.  A simple
 vascular tumor, though it may accidentally burst  and give  rise to
 hemorrhage, does not soften, and ulcerate, and bleed in  the same con-
 tinuous way that an haematoid cancer does.  Little is  positively kno*n
 as to the way in which vascular tumors are formed; the angeiectoma,
 consisting  as it does of dilated vessels, must in some way F^ed from
 a defective contractility of the vascular coats, which yield to.the,  dis-
 tendin- impulse of the heart.   This  defect seems in  some  cases, as in
 STjIPd by Dr. Carswell, to pervade the arterial systemr through-
 out or at  least in a considerable extent, instead of being  localized in
 one part(v fig. 3, plate iv. in his work), where  the common iliac arte- 
176                      NEW FORMATIONS.

ries  and  their  divisions  are strangely  contorted and expanded into
pouches and dilatations.   Erectile formations must  acknowledge some
other cause more deeply affecting the  original  formative process, but
we do not think with Rokitansky that  their  cells originate as  excava-
tions in a  solid blastema.   The  rapidity with which, when imperfectly
removed,  they often  return  again, also indicates  a special modification
of the laws which determine the formation of tissue.

   Enchondroma.—-This name was applied by Miiller to certain tumors
Fig. 56.
                  Enchondroma ; microscopic structure—after Lebert.

essentially consisting of cartilaginous structure, whose real nature was
first discovered by him.  They must be carefully distinguished from all
Fig. 57.                 Fig. 58.             Fig. 59.
Fig. 57. Thin section of the circumference of an enchondroma from the pelvis.
Fig. 58. Corpuscles from tbe softened part of the same tumor.
Fi^. 59. The same, after the addition of acetic acid.—Bennett.
those dense white fibrous  thickenings which present very much the ex-
ternal aspect of a  layer  of cartilage.  Enchondroma forms  usually a 
MYELOID  TUMORS.
177
globular tumor, with a smooth or somewhat tuberiform surface.  Inter-
nally, a section displays a number of loculi of very irregular roundish
shape, filled with  a firmly gelatinous, or rather pellucid substance.  The
walls of the loculi consist of a whitish fibrous tissue, more or less closely
resembling that of fibro-cartilage ; in some much rarer cases, this is re-
placed by an amorphous, firm,  intercellular substance, very similar to
that of  true cartilage.   The gelatinous matter consists  of roundish or
elliptic  cells, varying from ^^h— g^th inch in diameter, containing
granular nuclei, or secondary nucleated cells in their interior.  Enchon-
droma,  by boiling, generally yield  chondrin, the same  substance  as  is
obtained  from ordinary unossified  cartilage; occasionally, however,  it
yields glutin.  Tumors of this kind  sometimes originate in the interior
of  the bones, which they expand so as to form a thin capsule covering
their surface;  this is sometimes absent entirely, or may be deficient  at
certain spots.  In the interior of the mass there often  remain inclosed
portions of the cancellous tissue of the bone.  Vogel states that enchon-
dromata may originate also on  the surface of bones, especially the flat;
in  this  case they are of course  invested only by periosteum, and not by
any bony capsule.  Enchondroma is occasionally observed in soft parts;
 it contains  then  no bone, and its structure is more purely that of hyaline
 cartilage.  The  chosen seat of  enchondroma is in the bones,  especially
 in  the  phalanges of  the toes and  fingers; out of thirty-six  cases the
 metocarpus and phalanges were  affected twenty-six  times,  the tibia
 three,  the ilium  one, the cranium one, the ribs one.  In the four other
 cases, the testicle was in two the seat of the disease, the parotid in one,
 the mamma of a dog in one.   Rokitansky mentions having seen it also
 in the  subcutaneous cellular tissue,  and  in the  bony.   It occurs most
 often in the young, but sometimes has not appeared until an advanced
 period of life; when this is the case  it is often associated with exostoses
 and osteophytes. Enchondroma is of slow growth, and does not usually
 attain  a large  size;  one instance, however, is  recorded, in  which the
 tumor  weighed nine pounds and a half.   They  do not  contaminate the
 system, and only become dangerous  if they inflame and ulcerate, and
 pour out a copious discharge.   Cartilaginous tumors  are prone to ossify,
 and in this instance the term is not misapplied, as true bony structure
 is really found.  The ossific  change sometimes seems  to  have com-
 menced at the root of the tumor, at its bony attachment, and to extend
 outwards towards the circumference, following the progress of the car-
 reformation, just as it does during the growth of the shaft of a long
 bone  In this way a cartilaginous tumor is converted into an exostosis.
 In other cases ossification commences from numerous  independent cen-
 tres, from which bony fibres radiate in all directions,  and would, after
 a  time, become  confluent.


                        MYELOID  TUMORS.

    In his eighth lecture, Mr. Paget has described, with  his usual ability,
  a class of  umor with which pathologists  have but recently  become ac-
  quainted   They are  termed'myeloid, from their being usually deve- 
178
OSSEOUS TUMORS.
loped in or upon bones, and  from the  similarity  of their structural
elements to certain  corpuscles found  in  the marrow (pvs\ov) of young
bones. The tumor may either be inclosed in a capsule of expanded bone,

                               Fig. 60.
Remarkable example of ossification of enchondromatous tumor.
or only by a periosteal investment.  They are, for the most part, rather
firm, but brittle, compact, of spherical or ovoid shape when invested by
bone, more irregular and lobulated when growing upon bone.  The cut
surface is smooth, uniform, shining, succulent, with a yellowish fluid;
commonly variegated by blotches  of dark or livid crimson, or various
shades of red upon a greenish or grayish white ground.   The structural
elements characteristic of myeloid  tumors are  large, round,  oval, or
irregular cells, and  cell-like masses, of clear,  or dimly granular  sub-
stance, 3^—toW mca diam.; and  containing from two to ten or more
oval, clear, and nucleolated nuclei.  With these occur caudate and fibre-
cells,  and free nuclei, and the whole are imbedded in a dimly granular
substance, mingled with  more or less of molecular fatty matter.   The
history of these tumors, as far as  is  known, is nearly as follows : They
usually occur  singly, are  most frequent in youth, and very rare after
middle age; they are of slow growth, cause no pain, have no tendency
to ulcerate, and are not  apt to  recur after complete removal.   To the
naked eye they may closely resemble malignant growths, but they have
not any of their essential characters.  For further details  and illustra-
tive cases, we refer to Mr. Paget's work, p. 212, from whence the above
summary has been taken.


                     OSSEOUS  TUMORS.

   These may be divided into exostoses, osteophytes, and osteoid tumors.
Before proceeding to describe them,  we shall mention some of the vari-
ous parts and tissues which have  been observed to be the seat of  true
osseous formation.  Articular cartilages rarely, if ever; the laryngeal
and costal very frequently, especially in advanced age,  and under the
irritation of adjacent tuberculous ulcers, undergo ossification.  The an- 
OSSEOUS TUMORS.
179
terior vertebral ligament occasionally ossifies, so do the tendons, fasciae,
and aponeuroses in various parts.   Dr. Walshe  enumerates the follow-
ing instances of the formation  of  bone in areolar  tissue, in the sub-
mucous tissue of the gall-bladder, in the sub-serous  of the  pleura, the
sub-retinal, the  intramuscular,  the  parenchymatous of the liver.  He
mentions also ossification of muscular fibre and of the crystalline lens
as having occurred.
   An exostosis is an osseous tumor, proceeding from  the bone or its
periosteum, and, according to Rokitansky, homologous in texture, when
fully developed, with  that of its  base  and point  of  origin,  whether
that be  compact or spongy.   Its form varies—being  sometimes broad
and flat, sometimes round and  prominent, with  a narrow neck, some-
Fig. 61.
Fig. 62.
Fig. 62.  Pack view of same preparation.
 Fi-. 61. Remarkable osseous tumor of os innominatum.
                 Front view.

t;m», Ninons   They do not often attain a size above that of a Ws
 'g7 sCetimes the£ are sing!e; but often several «£; toget  er.n


Z^tlL" to the Po-sityof ordinary canoe lous«.   Th. 
180                     OSSEOUS TUMORS.

as dense as ivory."  "When they  are  minutely examined, the num-
ber of peripheral laminae  is  found  to be very  considerable,  and the
corpuscles  lying  amongst them are long.  The  Haversian canals are
small and far apart," and the corpuscles in some parts are quite absent,
in others are  closely crowded together.  "The  spongy exostosis pro-
ceeds from a circumscribed rarefaction or expansion of the bony tissue.
It forms  a tumor of cellular texture, abounding  with marrow,  which is
surrounded by a  compact layer or rind."  It may originate from the
compact  outer layer of the bone, or  from its spongy interior.   In some
cases a tumor  of this kind contains in its interior a well-formed  me-
dullary  cavity, communicating  with that of the bone.  The spongy
exostosis may remain in the same condition, or become indurated and
more similar to  the compact, by the deposition of more earthy sub-
stance.   If, as occasionally happens, a bony tumor grows inward into
the medullary canal of a bone, it is termed an Enostosis.   Exostoses
often arise without any obvious cause; sometimes they appear to develop
in consequence of  a blow or  strain.  "In most cases the  periosteum
covering them is in its natural  condition;"  sometimes it is thickened
and  unusually adherent.   They are  not peculiar  to  any period of life;
those of  the spongy kind have been  observed even in new-born infants.
Spongy exostoses are sometimes destroyed by caries; and in a few cases
the ivory exostosis has become necrosed, and  been thrown off.   This
change  must  proceed, no  doubt, from  obliteration of the Haversian.
canals, and consequent cessation of  its nutrition, and would be similar
to the shedding of the antlers  of the stag.
   Osteophytes.—To this  class belong a great variety of bony growths,
which form, for  the most part, in inflammatory  exudation, are pretty
widely spread, in many cases, over a bone, and are rather easily separa-
ble from it.  In these  respects, and in their greater irregularity,  they
differ from  exostoses, which are to  be regarded  as outgrowths from a
bone, while osteophytes seem only to be produced under the influence of
a bone.   Osteophytes, of warty or  stalactitic shape, are very  common
in the neighborhood of diseased joints, where the articular surfaces are
affected with caries. They result, doubtless, from ossification of the ex-
udation,  derived from the adjacent hyperaemic vessels.  In front of the
vertebral joints and some  other synchondroses,  pretty long styloid or
lamellar osteophytes frequently are  produced, so as even sometimes to
form a kind of bony capsule around them.  " They arise from a chronic
inflammation of the bones," and while these are atrophied, are often of
dense hard texture.  Sometimes the osteophyte is said to be foliaceous,
consisting of beautiful delicate lamellae, arranged parallel to  each other,
and  running transversely vertical to the axis of the bone.  The flat
osteophyte is sometimes an extremely thin and delicate layer (like hoar
frost); sometimes it is one or two lines in thickness.   It is composed of
delicate fibrils and lamellae, and at first  has  scarce any attachment to
the bone upon which it lies.  "At a later period the osteophyte is found
attached to the bone by some intervening minute round pillars and plates.
After having become gradually compact, it unites with the bone."  To
this  variety belongs the  puerperal osteophyte, to which attention has
of late been particularly  directed.  An account of this will  be  given in
the chapter on the osseous system. 
CYSTOID TUMORS.
181
  Osteoid tumors, in Rokitansky's opinion, are simply cancers, in which
the stroma  has undergone  true  ossification.   This view is favored by
the fact, that similar tumors are very apt  to  develop themselves  in
other and internal parts, whether the original growth has been removed
or not.  Lebert, however,  distinguishes them from  cancer,  and, from
the accounts which  are  given  of their structure, not without reason.
They are described as tumors of  irregularly protuberant surface, some-
times of rapid, sometimes of slow growth, occasionally attaining a very
considerable magnitude, and originating (the  primary ones) from some
bone.   In structure, they consist of a cancellous bony tissue, which is
plunged amid a  grayish white,  vascular,  fibrous  material, in which  a
sparing quantity of cells and  nuclei are  discernible.  This  substance
seems to  be similar  to the ossifying basis  of the cancellous tissue, and
yields, on boiling,  neither  gelatin  nor chondrin.   The bony skeleton
 of an osteoid tumor may predominate more  or  less, so that  the struc-
 ture may be like compact or spongy tissue.   Varieties in this  respect
 may be observed among the different  tumors in  the same  individual.
 Osteoid tumors have been found in the cellular tissues, the serous mem-
 branes, the lungs, the lymphatic glands, and in the interior of the great
 vessels.  From these and other facts, Lebert arrives at the rather vague
 conclusion, that the cause of the appearance of  these  tumors  is a
 general osteoplastic diathesis.   This does not  advance our  knowledge
 much, and, besides, we doubt whether it touches  the  principal point,
 which is, to know whether the  tumor is  essentially a bony  tumor   the
 fibrous part serving only as an  ossifying basis,  or whether the bony
 formation, though constant, is secondary  and inferior in importance to
 that of the soft matter?  Further observations must determine this
 We may mention, that the name osteosarcoma is given to encephaloid
 tumors, originating from bone, and receiving into their mass  long thorn-
 hkTor stalactitic or radiated  offshoots of bone, from the  natural tissue
 in the vicinity.  These, in some cases,  may resemble very much  the
 arrangement of the bony portion of osteoid.
CYSTOID  TUMORS.
  These constitute a very large and important class of new formations.
Thevagree  n  the  one general  character, that they form receptacles
whbhafe  filled with various contents, but in other respects  they pre-
Tenfverv  great diversity.   We shall separate them at the ou set into
sent very  great oivers  y         Cysts, which result from the distension

formations   Under the first head we notice:  (1.)  The  common  so




a^tirance  and tne names of meliceris, hygroma, atheroma, gummy 
182
CYSTOID TUMORS.
cally, epithelial scales, free fatty matter, tablets of cholesterin, crys-
tals  of  triple  phosphate, and  small  hairs in various proportions,  the
epithelium, however, usually predominating,  are found to constitute the
contents of these cysts.   The cyst itself appears as a thin fibrous layer,
lined on its inner  side with epithelium.  We have seen  one case in
which the epithelium in several tumors had accumulated in a very thick
layer on the interior of  the true cyst, giving rise to the appearance of
a thick-walled cavity  with contained matters of the ordinary  kind;
microscopic examination, however, showed that there was no real thick-
ening of the cyst itself.   The scaly particles of epithelium seem  to fill
themselves occasionally with a pellucid refracting matter, apparently of
oily nature; they are mingled in some cases  with granular globules, not
unlike pus-corpuscles, or if inflammation has occurred, with pus  itself.
This, at least, is the case with comedones, which  are of a similar  na-
ture.   (2.) Mucous encysted tumors; these are  essentially similar to
the preceding, and are formed by obstruction of  the duct  of a mucous
follicle,  or small conglomerate gland.  They contain usually a glutinous
mucous  fluid.   They occur in the lips, the mouth, in  the  cervix  uteri,
the Meibomian glands,  and in  the  vagina.1  Ranula is an  exactly
analogous affection  of the duct of the sublingual gland.  (3.)  Some of
the renal, and mammary, and probably  most of  the hepatic cysts  are
produced in the same way, by local obliteration of  the duct canals at
two  points, and distension of the  intermediate  portion.   (4.) Single
cysts in the ovary are  perhaps formed by dropsical distension of  the
Graafian vesicles;  this may also be the  origin  of others which  are
afterwards compound.   (5.)  Cysts in the thyroid  gland are, no doubt,
often formed by simple expansion of  the normal vesicles.   (6.) Certain
bursue (not of  new formation) become distended by a persistent increase
of their secretion, and constitute cystic tumors.   Mr. Simon states that
the contents of these, instead of being fluid, are occasionally solid,  the
albuminous secretion having been replaced by a fibre forming (probably
fibrinous) blastema.
   Under the  second head, we  notice:  (1.) Simple serous cysts,  and
synovial bursae.  These  arise in some cases evidently from the effect of
pressure or friction, in others  without any such cause.   In the former
case, we observe that a kind of condensation takes place in the areolar
tissue of the  part, making out the  limits  of the commencing bursa;
within this the fibrous  bands are  gradually  absorbed, while a secretion
at the same time of fluid takes place, and at last  the cavity is  lined by
a more  or less perfect epithelium, and the new formation  is complete.
We can discern the purpose for which  such cysts  are formed, the  end
they serve, but we have  no idea  of the  nature of the action which de-
termines their formation.  With regard to  the  others, which form in
situations removed from  pressure, as in the broad ligament of the ovary,
the cause of  their production is utterly unknown.   They consist of a
wall of  fibrous tissue, varying in thickness in some measure, according

   We found the contents of an encysted tumor of the eyelid, operated on by Mr. White
i.V>oner, to consist of a colorless, translucent matter, made up of multitudes of  delicate
granulous globules, imbedded in a clear fluid,  which was coagulated in some measure by
acetic acid. 
CYSTOID TUMORS.
183
to the size of the cyst, condensed so as to form  a smooth surface in-
ternally, and lined by a  thin  layer of epithelium, which has generally
appeared to us  to consist of nuclear particles, with imbedding granulous
matter, and not of perfect cells.   The import of this condition of epi-
thelium appears to have reference to the rapid secretory action which
takes place.  The fluid contents of these cysts  may be poor or rich in
albumen, may  contain abundance of cell forms,  or very few, and may
be either loaded with cholesterin, or devoid of it.   We can confirm the

                               Fig. 63.
                     O©00@©©@@)©OG>©


                                -o
        Simple serous cyst, and epithelial particle's from its interior—from vicinity of ovaries.

statements of Mr. Simon, that the granule-cells, which are sometimes
very numerous, are the seat of the color of the dark coffee-ground-like
matter which is sometimes present in large quantity.   Some of these
simple  cysts contain quantities  of fat, hair, teeth, and even bone, so
that some good authorities have expressed  their belief that they were
the  remains of a partially  absorbed foetus.  This is certainly not the
case, but their occurrence is of extreme interest, and being peculiar to
ovarian  growth, suggests very strongly that the  normal  reproductive
function of this organ exerts itself by the development of these pro-
ductions within its germ-bearing cavities, under the influence of some
unnatural stimulus.   This, of course, applies  especially  to  the cysts
alluded to under the first head, as developed from the Graafian vesicles;
but  it is Rokitansky's opinion, that cysts of new formation may develop
like products also.   Mr. Paget states, that in  these cases the_ wall of
the  cyst acquires in  some  part  the  character  of true skin,  with hair
follicles, sebaceous,  and sometimes perspiratory glands; and infers that
" the structures and secretions formed on this portion of  the cyst are
shed into its cavity, and there accumulate; and  that they remain, when,
as often happens, the cutaneous  structure on which they are produced
has  degenerated and disappeared."   Several  simple  cysts may exist
together in the ovary;  this,  we should consider most likely  to occur
when they result from development of the Graafian follicles.  Simple
cysts not unfrequently  occur in  the  mammary gland, or  rather in the
dense areolar tissue investing it;  they have a wall of condensed fibrous
tissue, and according to Mr. Birkett,  are  lined by a characteristic epi-
thelium, consisting of hexagonal particles.   Their contents  are either
limpid  opalescent, non-albuminous  fluid, or a tenacious, slimy, opaque,
variously  colored, and concentrated solution of albumen.   When com-
bined with a peculiar growth  of gland tissue advancing into their cavity,
these tumors  constitute the  sero-cystic  sarcoma, of  which  we shall
speak more particularly when we  come to the morbid anatomy of the
mammary gland.   Cystic formation may take place in various kinds of
tumors,  in fibrous, carcinomatous, sarcomatous, and may he a more or
  ess prominent phenomenon.   (2.)  Compound cysts.  The chief seat of 
184
CYSTOID TUMORS.
these is in the ovaries, where they present  two principal modes of de-
velopment.   In one of these the parent cyst, which, for the most part,

                               Fig. 64.
Diagram of compound cysts. In the left figure, the secondary cysts ore seen growing on the inner surface
                of the parent. In the right, they have filled up the cavity.

continues to predominate in size, gives origin to a second generation of
cysts, and then  again to  a third, and so on.   The consecutive  series of
cysts are developed in the walls of their parents, but do not grow in-
ward and occupy their cavities;  the result is a multilocular mass, made
up of numberless cysts, which are filled with very  various  contents.
These may be tolerably limpid and clear, or very  viscous and greenish;
may contain a very large number of celloid particles, or very few; may
be variously colored by  blood-globules of new formation,  or  even re-
placed by  a solid blastema loaded with developing  blood; fat,  hair,
teeth, and bone may also occur in these, as well as in the simple cysts.
The partitions between the various cysts sometimes give  way,  and thus
a  tumor  is  produced, which internally seems imperfectly divided into
compartments.   In the other mode of development, the secondary cysts
grow inward into the cavity of  the parent, which  they fill up  more or
less completely, a tertiary race behaves toward them in  the same way,
and so on.   This form may be  combined with the preceding.   Roki-
tansky describes a kind  of villous, or cauliflower growth,  which origi-
nates on the wall of the secondary  or  parent  cyst, and may increase
so as not only to fill the  cyst cavity, but to break  through its wall, and
vegetate in the  cavity of the peritoneum.1   The impression left on the
mind of the observer after a minute examination of the compound cysts,
is, that they are of the lowest  type of organization,  resulting, appa-
rently, from a depraved,  degenerate formative action,  which, withdraw-
ing blastema from its proper uses in the system, hurries it with a waste-
ful expenditure into  useless  and  injurious  elementary  shapes.   How
precious is the stringency of the law of our organic constitution, which
is  comparatively seldom infringed by such terrible aberrations !   It may
be remarked, that the tendency to  cyst formation  most often appears
in the existence of several together; it is certainly far more common to
find several, whether of new formation, or resulting from distension of
natural cavities, than to find a solitary one.   This indicates some spe-
cial modification of the normal organic action; but we cannot think it is
such as Rokitansky points out, when he ascribes all cyst  formation, ex-

  1 In the Report of the Pathol. Society for 1851-52, there is  an account, at p. 404, of a
growth on the interior of an ovarian cyst which seems to be of  this kind.  It consisted of
"vast numbers of pedunculated, clavate, clustered growths, formed apparently of a sim-
ple basement membrane inclosing cells." 
CYSTOID TUMORS.
185
 cept  that arising from mere  distension, to the extraordinary develop-
 ment of a primary cell.
   Sarcomatous tumors constitute a group, which, it must be allowed, is
 very ill defined.  We may describe what we regard as the characters of
 a typical specimen; but we shall seldom find them all present  in any
• given instance; and, frequently, they will approximate so closely to those
 of other classes, that we shall remain in some degree of doubt.  The
 fibrous group on the one hand, and the carcinomatous on the other, are
 the territories which border  on the  debatable land of sarcoma.  The
 characters attributed to sarcoma are  the following:  It occurs as a local,
 for the most part solitary formation, not affecting the constitution.  If
 removed completely, it does not return.   In shape it is well defined,
 roundish, with uneven  or lobulated  surface, often also branching  and
Fig. 65.
                       Pancreatoid sarcomatous tumor.

                               Fig. 66.





                         Structural elements of same.

extending itself between the adjacent tissues.  Its size varies from that
of a hazel-nut to that of a cocoa-nut (Walshe), or perhaps may be still
greater   It  seems  to have  no  particularly  determined site;   both
maxilla;  (especially the upper), the  interior  of  bones, glands, muscles,
fibrous membranes, submucous areolar  tissue, even  the bram, are all
mentioned as being affected by it.  It belongs to an earlier period of
life than carcinoma.  Softening and breaking down do not necessarily
occur in the progress of sarcomata; but if they are exposed, by sloughing
of the parts which cover them, they may inflame and saniate, or slough.
   The commonest variety of sarcoma is that which Rokitansky calls the
albuminous fibrous tumor, on account  of  its yielding, on boiling, no
gelatin, but an albuminous matter.  The  fibres are of various kinds,
scarcely different from those of ordinary fibrous tumor.   They lie in a
diffused albuminous  blastema, and  are  interwoven with a more or  less
abundant vascular plexus.   Another variety is the gelatinous sarcoma,
the same which Muller has named  " collonema."  It is sometimes very 
186
CYSTOID TUMORS.
 soft, clear, tremulous, like jelly, scantily supplied with  vessels.   In
 structure  it  presents, in  different specimens, varying proportions of
 fibres, white  or elastic, of celloid  particles, elementary granules, and
 fibrillating blastema.  In other instances the structure is more firm and
 resistent, of lobulated aspect,  consisting of white  filamentous tissue,
 intermingled with caudate nuclei and cells.  In others, again, the inter-
 cell substance is firmer, more stiff and amorphous, so that the structure
 approaches that of enchondroma.   Some sarcomatous tumors present a
 not very distant resemblance to the conglomerate gland structure, their
 mass dividing into lobes and lobules.  To such, the name of pancreatic
 sarcoma has  probably been applied.   It  is, however, pretty certain,
 that the same kind of structural arrangement exists in some cancerous
 growths.  M. Lebert has examined sarcomatous tumors very carefully,
 and designates them as fibro-plastic.  By this term,  he seems  to  imply
 that they constitute a transition stage towards fibrous tumors;  and the
 excellent detailed descriptions  he gives of their  structure, are, on the
 whole, confirmative  of the same view.   Nuclei, circular, and elongated
 cells, and fibres, make up the chief part of their structure—the fusiform
 cells being generally the most numerous.   It is to be regretted that
 the tumors he  examined were not tested, so as to ascertain whether
 gelatin could be obtained  from them in quantity.  If this had  been
 the case, their fibrous character would have been  decided.   Among the
 tumors we have ourselves examined, those which  seem to deserve best
 the name of sarcoma, as being unlike either  to fibrous and carcinoma-
 tous growths, are certain enlarged lymphatic glands,  whose structure
 consisted of multitudes  of  nuclei, set in a fibroid stromal substance.
 With these we should class  certain separate tumors, entirely new forma-
 tions, which are rather soft or lax, of a whitish gray or light pinkish
 color, either smooth on  the surface or lobulated,  so as to resemble the
 pancreas.  In structure, these are found to consist of myriads of nuclear,
 with a few celloid, particles, and some  trace of fibroid stroma mingled
 with a large proportion of faintly granulous matter, and more or less
 oily.  These tumors contain notable quantities of gelatin and protein.
 Generally, we should conceive that  a  growth, consisting of cells or of
 nuclei, set  in  a  non-fibrillated homogeneous blastema, would not yield
 gelatin, but albumen; while one  which  consisted of fusiform cells  or
 fibres, would have  more  or less  completely undergone the chemical
 change which  an albuminous blastema experiences in passing into the
 state of gelatinous fibre.   The former, we should,  therefore, consider to
 be properly termed a sarcoma, i. e. a simple growth, of like composition
 to flesh, or the albuminous blastema, effused from  the blood, not having
 attained  in its development any very special structural  character.  In
 proportion  as  it passed into the condition of a fibrous tumor, it would
 lose its sarcomatous character.   Cyst formation, combined with sarcoma,
 constitutes cysto-sarcoma.   This is said by Rokitansky to occur in three
 forms: (1) simple cysto-sarcoma; (2) cysto-sarcoma proliferum, in which
 young cysts grow on the inner surface  of the parent, and are either
 sessile or pedunculated ;  (3) cysto-sarcoma phillodes,  distinguished by a
growth of vascular, laminated, or watery  or cauliflower-like excrescences
projecting into the interior of the cyst.   The structure of these growths 
CANCEROUS TUMORS.
187
is  sometimes more  fibrous, sometimes more similar to that of gland
tissue.   In both cases, the foliated terminal portions are invested by a
distinct  limitary membrane, within which  an epithelium is sometimes
discernible.   Cysto-sarcomata mostly occur in  the female breast and in
the ovary.
                      CANCEROUS  TUMORS.

  In attempting to give a sketch of cancerous or malignant tumors, we
think the best plan will be to take a typical specimen, which presents
all  the  characters  of the genus  strongly developed, and to point  out
what  these characters are.   We  shall afterwards  notice  the several
species, and endeavor to show how the distinguishing features gradually
become effaced, until the formation,  as often  happens, is, or appears,
almost  identical with those  of a benignant  nature.   A  tumor, of the
species  called encephaloid, is certainly the *apaofiy/ia of  cancer.   It is
of rapid growth, often attaining in a short time a very large size.   Its
Fig. 67.
 Encephaloid —The first and the last three of the sets are from the liver, the second is from a bone, and the
      third from the vertebral column. The great difference of the cell forms is very apparent.

aspect, resembling very closely that of the medullary cerebral structure,
has obtained for  it the name just mentioned, as well  as others of simi-
lar import—medullary  sarcoma, medullary fungus.  Its color is an
opaque white, often,  however, varied in parts  by patches of deep  red,
from vascular injection or hemorrhage.   Its consistence is often so  soft,
that it  seems  semi-fluid, and gives the sensation  of fluctuation. ^ In
structure, it appears  on  section often almost  homogeneous, sometimes
with a locular or fibrous arrangement.   Microscopic examination shows
that the main mass consists of celloid particles and cells,  contained in a
sparing quantity of  filamentous tissue, which forms  a kind of stroma.
Such a tumor is seldom solitary, but coexists with other similar ones m
the same  and in different  organs.   If  extirpated,  it is  sure to return, 
188                    CANCEROUS  TUMORS.

and  probably diffuse itself  more  widely than  before.   It poisons  the
lymphatic current  passing from it, and induces growths of like nature

                                Fig. 68.
            Simple and compound cancer cells from cancerous duodenum.—Bennett.

in the  glands which that  current traverses.   It  affects  the general
system with a peculiar cachexia, marked by languor, emaciation, debility,

                                Fig. 69.
Cells from Encephaloid of Tongue (rapidly growing).
and a sallow complexion.   It is very apt  to infiltrate adjacent textures
with its own substance, and, by absorbing their  nourishment for  itself,
to occasion their atrophy; and, lastly, it tends, when exposed, to break 
CANCEROUS TUMORS.
189
down by a kind of decay, and to pour out profuse, exhausting discharges
of serous, sanious, or bloody fluid.   Such is cancer in its most malignant
form.   Of the above-mentioned characters, those which seem to us most
nearly pathognomonic, are the tendency to infiltrate adjoining parts, to
affect the glands traversed  by the issuing  lymph-current, to reproduce
similar growths in distant parts, and to return after removal.   If these
Fig. 70.
Fig. 71.
Fig. 72.
Fig. 73.
Fig. 74.




 Figs. 70, 71, 72.  Cancer-cells before and after the addition of acetic acid, also the structure of the reticula-
tum from encephaloma of the testicle.
 Figs. 73, 74. Young cancer-cells before and after the addition of acetic acid.

four  characters are  decidedly  exhibited  by any tumor, there can be
scarce any doubt of its malignant nature.   It is to be remarked that all
these characteristics  are dynamic and not structural.  They result from
the invisible qualities of the new formation; its mode of vegetation, dis-

                                 Fig. 75.
           Fungus nematodes.  Fungoid, bleeding, and blood-like. From the mamma.

semination, and  reproduction  not  from  any peculiari^  ^ form «
arrangement of its particles.   Whatever these might be, a tumor, wnicn
Tehaved as we havePjust described, would proclaim its cancerous nature. 
190                    CANCEROUS TUMORS.

This point we shall illustrate further on.   We now proceed  to speak of
the other varieties of cancer; first, however, noticing the sub-varieties
of encephaloid.   The  name mastoid is given to a kind of firm growth,
which  is  thought  to resemble on  section the  boiled udder of the cow.
That of solanoid (potato-like) designates other hard cancers, resembling
that vegetable when sliced.   Dr. Walshe says they are a pale yellow-
ish, of unctuous crisp  look, and  almost  homogeneous.  Milt-like has
evidently reference to  a soft, pale growth, containing scarce any blood.
The surface of a section of Nephroid cancer presents a resemblance to
that of a  kidney, owing to the peculiar arrangement of its fibres, which
are themselves of a delicate gelatinous transparency, so that Rokitansky
calls the growth hyaline cancer.   The term Hsematoid expresses a much
more important  feature than any of the preceding, as it implies  that the
growth is unusually vascular, is the seat of excessive development of
vessels, and perhaps of blood, and is prone to pour out those alarming
hemorrhages which often cause  fatal exhaustion.  When the haematoid
character is strongly marked, the name of Fungus Haematodes  is appli-
cable.   Melanoid cancer is, in the great majority of cases, encephaloid
structure, with  the  addition  of black pigment.  The   cell-growth of

                                Fig. 76.
    Cells more or less loaded with black pigment, from a melanotic tumor of the cheek.—Bennett.

encephaloid may consist of large free nuclei, of  caudate cell-particles,
of granulous globules much like those of  pus, but unaltered by acetic
acid, of cells of most various  shapes, often irregularly caudate, and of
pellucid vesicles.   All these may be  mingled in various proportion, or
some may constitute the chief mass  of  a growth.   The annexed cut,
page 187, exhibits cell structures of various kinds ; and for more minute
details we must refer  to the trustworthy descriptions  of  Mr.  Paget,
page 368, vol. ii., of his published lectures.
  Scirrhus or hard cancer  commonly appears  as a knotty, or uneven,
pretty distinctly  limited, very hard (stony) tumor.   Its surface  or sec-
tion is of a bluish or grayish white, and often presents a peculiar glossi-
ness;  scarce any trace of vessels is  ordinarily  visible, except in spots,
which are inflamed and softening.  The  adjacent tissues, especially the
skin, when the growth is subcutaneous, are more  or  less involved, and
drawn inwards towards the tumor.  In structure, it consists essentially of 
CANCEROUS TUMORS.
191
a blastema, or basis substance, more or less advanced in fibre-development,
in which very various forms of cell-growth are imbedded.   Of the latter,
Fig. 77.
Fig. 78.
Fibroid stroma of a scirrhous tumor of Pylorus.
Scirrhous tumor of cerebrum.
A—Cells.
B—Section of firm stroma.
it is  utterly impossible to  give any general account, except to correct
the common idea  that  they  are  of fusiform shape,  they may be bare
Fig. 79.
Fig. 80.
                                                 Fig. 82.              Fig. 81.

  Fig. 79. Portion of the section from a carcinomatous tumor of the breast; consisting of fibrous tissue and
cysts, inclosing cancer-cells and granules.  A compound granular corpuscle is also visible.
  Fig 80. Another portion of the same section treated with acetic acid.  The fibrous tissue is rendered more
transparent, and elongated nuclei are visible scattered through it.  The nuclei of the cancer-cells are un-
changed, while their walls are transparent.  A compound granular corpuscle is seen at the upper part of the

6gF J'si. Cancels from the cream-like juice squeezed from the tumor. Numerous granules, and a com-

pound granular cell, are seen.
  Fig. 82. The same, after the addition of acetic acid.—From Bennett. 
192
CANCEROUS TUMORS.
nuclei, cells of most various aspect, vesicles;  granular globules; with
these oil and diffused granulous matter are mingled in varying quantity.
Glomeruli are often seen in fattily degenerating, or in inflamed parts;
and  parent cells, containing  a secondary generation, are  occasionally
present.   The disposition of the fibres is very various, sometimes parallel
Fig. 83.         Fig. 84.     Fig. 85.
   Fig. 83. Dense fibrous and elastic tissue, in which cancer-cells are infiltrated from cancer of rectum.
   Fig. 84. Cancer-cells scraped from the surface, in the same case.
   Fig. 85. The same, after the addition of acetic acid.—From Bennett.

to each  other, sometimes radiating, often crossing at right  or acute
angles.   An alveolar arrangement sometimes exists ; it proceeds, accord-
ing to Rokitansky, from the development of the parent cell.   Scirrhus
yields  some gelatin on boiling;  less albumen and oil, but more saline
matter, are contained in it than in encephaloid.   The growth of scirrhus
is slow, the more so in proportion  as its  fibrous element predominates;
it may then exist long without inducing the constitutional cachexia, or
reproducing itself in any distant part, or even affecting the lymphatic
glands.  The most common seats of  scirrhus are the female breast, the
pyloric extremity  of  the stomach, the rectum; it is usually the original
formation in these or in other parts ; but gives rise to secondary encepha-
loid growths.   A  tumor of this kind does not, even when most defined,
possess a true cyst; often, it extends itself by infiltration among adjacent
tissues.   It rarely attains a large size, it is not often  seen so large as
an orange.   Various names have been given to some peculiar appearances
occasionally presented by scirrhous tumors; of these, we shall only men-
tion the  napiform, applied to certain tumors whose cut surface presents
a number of concentric lines, resembling those seen in the interior of a
turnip; and the apinoid,  or reticulated, in  which spots or streaks of  an
opaque oily matter are apparent upon a grayish field, and thus occasion
the appearance of separate patches, or of a network.   It is ascertained
that this latter condition  indicates a commencing fatty  change.  The
surface of an ulcerating cancer is irregular, of a grayish or faint reddish
aspect, covered with a thin watery sanies,  or with a layer of sloughing
detritus; the margin  of the surrounding skin is commonly elevated and
everted.
   Colloid cancer,  the next variety we  notice, is  also  called alveolar;
other cancers  may present more  or  less of an alveolar arrangement,
hut it never constitutes the prominent feature of  their structure.  The
walls of  the alveoli consist of a fibroid  tissue, sometimes extremely deli-
cate and translucent, sometimes, and especially  in  the deeper  layers, 
CANCEROUS TUMORS.
193
strong and firm.  The contained loculi vary in size from that of a grain
of sand to that of a pea; they are round or oval;  occasionally adjacent
Fig. 86.
Fig. 87.
Colloid cancer of a lymphatic gland.
                                      Of the two smaller  figures, one exhibits the
                                    circular loculi as they  appear on a section; tbe
                                    other shows the compound spherical character of
                                    the malignant growth itself.

ones communicate together by solution of the interposed  wall.   The
ielly-like substance in their cavities is  of a greenish yellow, semi-trans-
parent, and  clammy; "it  yields no gelatin  on boiling, but seems  to
consist of a  peculiar substance, identical with that naturally occurring
in the cavities of the thyroid, and in some cysts    Cells, nucleated and
non-nucleated, caudate,  and fusiform, nuclei, and  elementary granules
occur  in this substance,  and,  under circumstances probably connected
win  softening changes  granule-cells, and fat-molecules.   Endogenous
production of the cells within parent-cells is sometimes observed  Colloid
may present itself as a distinct solitary tumor," or may infiltrate the
tissues which it infests,  when  it occurs on serous membranes;  there are
often small scattered nodules  of the growth in the vicinity of the larger
Rokitansky  mentions the two following varieties  of colloid: (1.)  The
intents of  the loculi increase, so that their septa are in grea measure
a?Sd and lost, and  the mass presents the  aspect of  a tremulous
 •eTvP  (2.)  The  superficial alveoli  enlarge  considerably, and attain a
Smous  size   The favorite  habitat  of  colloid is the stomach and
LeS-     a so  occurs  in  the ovaries,  the  bones,  the  kidneys, the
  TZl Tnd  the snleen   Its growth is often rapid, and it may attain a
 v rvlar.e^sze, exceeding  that  of a  cocoa-nut.   The contents  of the
 a ve^liTare som  times of pearly aspect, probably from the  presence  of
 chdeste^omatous  matter.   Cruveilhier  has described an areola,• pu -
 ^S in which  the loculi contain an  opaque, yellowish tal-
 W hke  matter having the chemical constitution of  casein.    This
 we bel eve, "2 RokitLsky,  to  be  a condition in which fatty^trans-
 format oTof the gelatinous  matter is  taking place analogous  to that
 nXnlticulfr scirrhus   Colloid may exist combined  „      *-
 rLna  „nA   „ian  with encephaloid; in the  latter case,  uie   f
 Si become occupied by  soft encephaloid matter.  Tbe  mal.gn.nt

        13 
194
CANCEROUS TUMORS.
character is less marked in colloid than in  the  other kinds of cancer ;
it does not induce such marked cachexia,  does not  reproduce itself  in
distant parts, does not contaminate the lymphatic glands, and is less
prone to softening and decay, or to inflammation and saniation.
  Epithelial cancer seems only recently to have  been admitted among
the varieties of this disease; it is not mentioned by Dr. Walshe in his
elaborate work, and yet its cancerous nature in many cases is unequivo-
cal and strongly marked.   It occurs almost  solely  on  tegumentary or
mucous surfaces, the lips  and cheeks are  among the parts most com-
monly affected by it.   Rokitansky mentions  having once observed it in
the liver, and Dr. Bennett has met with it as a secondary growth in  the
                             lymphatic glands.   On mucous surfaces it
          Fig. 88.            appears as a cauliflower-like growth, of a
                             more or less red tint from vascular injec-
                             tion,  of various degrees  of consistency,
                             and easily separated  into  parts by press-
                             ure.   On the general tegument, its appear-
                             ance is most often that of a low, tolerably
                             well-defined tumor, of hard feel, having  an
                             irregular  nodulated surface,  covered with
                             minute  watery  papillae; when ulceration
                             and softening take place,  the surface  be-
                             comes injected,  a watery  and  serous dis-
                             charge  is  poured  out, and  gradual  de-
struction of the part  proceeds.   In structure, these tumors  essentially
consist of an alteration of the integument, the corium and subcutaneous

                                Fig. 89.
 Appearance of section of cancerous tumor of the cheek,  o. Epidermic scales and fusiform corpuscles on
the external surface.  6. Group of epidermic scales,  c. Fibre-elastic tissue of the dermis,  d. Cancer-cells
infiltrated into the fibrous tissue, and filling up the loculi of dermis.  (From Bennett.)
                                                        I
areolar tissue  being converted  into  a fibroid  substance,  the papillae
greatly hypertrophied, as well as the epithelium resting upon them.  In
the last specimen we examined, which was from  the lower lip, a vertical
section displayed an external whitish layer,  about one-third inch thick,
marked by vertical striae, and resting  upon some areolar tissue, fat, and
muscle.  Its surface showed but slight traces of subdivision.   Its ex-
tent in depth  appeared to  be most  accurately limited  by  the lower
margin of the whitish striated layer, but, upon examination, the areolar
tissue immediately  subjacent, and for some depth, was found thoroughly
 
CANCEROUS  TUMORS.
195
infiltrated with nuclei and granular  matter.   Sections of the altered
integument showed papillary elevations, completely overwhelmed and
blended together by an enormous growth of scaly epithelium, which, in
some parts, showed a tendency to fatty change, and here and there the
capsulating arrangement mentioned below.   If glands  exist in the part
affected,  their  epithelium  may also accumulate within  their canals,
and thus add to the size of the  tumor.   One  peculiarity  is very  com-
monly observable in the arrangement of  the  cells  of epithelial cancer,
which does not seem to occur in  other growths;  this is, that here  and
there the scaly particles are arranged in lamellae around a central cir-
cular space, which appears  to be a largish  cell, containing a younger
cell-growth.  The malignant  character  of epithelial  cancer is  mani-
fested in its extending from the  superficial textures  first involved to
the deeper seated, even to the bones;  the  laryngeal cartilages  have
often been involved by it.   It seems, however, to have less tendency to
contaminate the lymphatic glands, and the system generally, than other
varieties  of cancer.   Rokitansky  describes a variety  of cancer,  which
he calls villous, from its consisting  of  a kind of delicate fibrous stalk
 branching  at its end  into  villous  processes,  with  somewhat bulbous
 terminations.   These contain encephaloid substance, and  are extremely
 vascular.   Hemorrhage often takes place spontaneously from them, and
 is easily  excited by the slightest lesion.   The only specimen at all cor-
 responding to  this which we  have  examined, was one  of cauliflower
 excrescence of the uterus:  it was not in a suitable state for  accurate

                                Fig. 90.
Epithelial cancer-four of the loculi are shown, and some of the flattened cells, one of which is curved,
                   having probably been arranged round a loculus.

investigation, but we saw that it  consisted in great  measure of  large
vessels!  covered with  a thick layer of lowly  organized cell-growth.
Rokitansky mentions a case of this kind, in which the growth sprang
from  an  evidently  encephaloid  base.   A  cystic  growth sometimes
occurs in  combination  with  one or other of the species of cancer,
chiefly with encephaloid:  the  cysts  may  be  simple or  compound.
The  cysto-carcinomatous  growth  is usually of  large  size.   Ihere
mav  be  probably,  other varieties of cancerous  tumors, or, to  put
ntherwfse  turners possessing more or less  of. cancerousness;  bu
we have  now sketched the  outline of  the  principal  forms  that  are
usually met with, and we feel  convinced  that it is far more important 
196
CANCEROUS  TUMORS.
for the student and the practitioner, to contemplate steadily the great
characteristics of cancerous  disease, than to load his memory with de-
tails of the incidental and trivial.   Partly on this account we have not
attempted to give any very minute description of the structure of can-
cerous tumors, for our own examinations have most thoroughly convinced
us of the non-existence of any special structural character, absolutely
and in all cases distinctive of cancer.  This point, which is in accordance
with the teaching of the best authorities, seems far from being correctly
understood  in the present day, and we cannot but think that there is
still much tendency to over-estimate  the microscope as a means for the
diagnosis of cancer.   It  is  our  opinion  that the  cases are very rare
indeed, where the  microscope will avail to  detect cancer with any cer-
tainty, where the  naked  eye features are insufficient.  On the  other
hand, we have more than  once seen unquestionable cancers made up of
substance which we should have been led, from microscopic examination
alone, to consider as of a  simple nature.  What may be said relative to
the distinguishing of cancerous from other tumors, by their mere physical
characters,  and not by their living actions, amounts  to this:  If a tumor,
on  being incised and  compressed, yield a whitish, milky juice, (the so-
called usue cancereux,'")  it is probably malignant; we have, however,
failed to obtain this sign from actual encephaloid.  If the cell-growth of
a tumor  is what may be called exceedingly multiform, i. e.  one particle
unlike another, the field of view being filled with other varieties of shape
and construction, there arises a strong presumption that the structure is
malignant.   If a tumor consist of an abundant  cell-growth lying in a
basis substance of slight consistence, and  containing very little fibre, it
so far bears a close resemblance to encephaloid.  If, on the other hand,
a tumor  consist chiefly of fibre or fibrillating blastema, the presumption
of its cancerousness diminishes; we have, however, seen a growth in the
liver, which had all the aspect of a scirrhous formation, and probably was
so, which yet consisted solely of fibre-forming solid blastema. If a tumor
infiltrate adjacent parts, it is probably malignant, but all cancers have not
this character.  The presence of large  cells, containing several nuclei,
similar to those figured by Lebert1 and Bennett,2 would be a strong ar-
gument for  the cancerous nature of the tumor, from whence they pro-
ceeded.  So also we should regard the development of  a nucleus into a
large granulous globule or vesicle, or into any structure very dissimilar
to its original  condition, or  that of the nuclei of natural  tissues.  In
concluding these general remarks, we may state, we  think, the following
position with some  confidence, viz:  that,  starting from encephaloid as
the representative of cancer par excellence, we find  the cancerous cha-
racter gradually declining as we pass  through a series of formations,
such as we have above described,  until we come to those of whose inno-
cent nature there is no question.   The exact limit, we believe, at which
cancerousness is lost, cannot be marked by any characters  of  a growth
itself.   The vessels of cancer, for the  most part, we believe, are of the
ordinary kind,  derived from those of  the natural tissues by the process

            1 Phys. Patholog. PI. xxi. fig. 5.
            2 On Cancerous and Cancroid Growth.  Figs. 69 and 117. 
CANCEROUS TUMORS.
197
of extension or  growth; sometimes, however, it  seems that blood and
vessels are  formed in  the  blastema of a tumor, as we have described
them to be in exudation matter;  this we consider is most  likely to be
the case in growths of the haematoid character.   The blood  contained
in the developing vessels is seen,  as it is said, to oscillate in them before
they have anastomosed with those of the general system.   No special
formation of lymphatic vessels or nerves, seems to take place in cancer-
ous  tumors.  The lymphatic vessels of  the part  affected, no  doubt,
act as absorbents  of the redundant blastema, as is amply shown by the
special contamination of the glands, to which those vessels  immediately
proceed.   The nervous filaments traversing or distributed to the part
which  is the  seat of the cancerous growth, are often involved in the
mass, and becoming injuriously pressed on, or otherwise injured, occa-
sion the most frightful  pains.  There is scarce anything accurately de-
termined, respecting the chemical composition of cancer.   Encephaloid
is said to consist chiefly, if not entirely, of albuminous matter; Scirrhus
to contain gelatin also, while colloid  jelly seems to be a principle quite
sui generis.  Possibly, there may be some special cancerous virus,  as
there is a variolous and syphilitic, but as yet chemistry knows nothing
of it, and we only infer their existence from the effects they produce.
   [The subject of cancer and its microscopic diagnosis being one of deep
interest, we present here  the illustrations  of  cancerous structure from
the  valuable paper of Dr. Francis Donaldson, of Baltimore, Maryland.
 See Am. Journ.  of Med.  Sci., vol. xxv. p. 43.
   " It is improper," remarks Dr. D., "to attempt to divide cancer into so
 many species, as they all have the same common pathology.  The variety
 of aspect,aconsistence, volume, coloration, and vascularity, is caused merely
 by the amount  of fibrous element, of fat, or of gelatinous fluid present;
 all of which are purely accidental, and in no way essential to constitute
 the growth.  The density, softness, &c, may also vary according to the
 organ involved; the breast and  the pylorus take generally the form of
 scirrhus; whereas the bladder,  the kidneys, &c, are more likely to be
 affected with encephaloid.   Compare the physical characters of cancer
 with those  of the simple tissues, such as the muscular, areolar, dartoric,
 osseous, &c, or with those of the compound, as the glandular, the syno-
 vial, the mucous, &c, and the difference  will be  very apparent.  Its
 greater or  less  firmness, its homogeneous fibrous  aspect with its lacte-
 scent  infiltrated  juice, are very characteristic.  The presence  of this
 peculiar fluid is of itself a point of differential diagnosis of great value;
 the microscope always detecting in it, when found, the presence of cancer-
 cells, &c.   No matter  what organ is the seat of the disease, this fluid
 can generally be  scraped from the cut surface, or squeezed out by gentle
 pressure.   It is  particularly abundant in  encephaloid, and frequently
 oozes out in drops having a white cloudy appearance of the consistence
 of cream, and very much of its color, being slightly tinged with yellow.
 It may sometimes, on superficial inspection, be confounded with  light-
 colored  pus, which has, however, with  the yellow, a slightly  greenish
 tinge   If from the conditions of its formation, there can  be any doubt,
 an appeal to the microscope will  at once settle it by giving  us the charac-
 teristic pus-globule.   (See Figs. 99 and 100.) 
198
CANCEROUS TUMORS.
   "The cancer juice forms readily an emulsion with water, and in  this
differs from tubercular matter and from that pressed  from sebaceous
tumors.  The color of this juice is of course modified by the mixture of
other fluids with it;  thus, when the vascularity is great, it is often red-
dish ; when from a  deposit of dark  pigment, we have what  is called
melanotic  cancer, it becomes  of a  dark  brown.  When  mixed  with
much fat, it is more consistent;  in colloid, it is  thicker and sometimes
grumous."
   "In  the accompanying figures, we have," says Dr. D.,  "attempted
to arrange (under several divisions), into groups, the different forms of
the cancer-cell we have met with.  In making the selection from  the
numerous drawings we have collected in our album, we have thought it
better, instead of giving only the types,  so  to  speak, of  the  several
shapes under which we desired to include all the various modifications,
to show as many  as possible of the numerous varieties.   For the rude-
ness of the designs themselves we ought, perhaps, to apologize, but they
are, as  far as we could make  them, exact representations of what we
saw in the field of the instrument.   We will  first describe  the  proper
elements separately, and then speak of  the  objections offered  by  Dr.
Bennett, and some others, to their distinct characters as pathognomonic
of cancer,  giving drawings  of other  elements confounded  with them.
The points of dissimilarity we will call attention to with a view of fixing
the differential diagnosis.  The mode we have employed has been simply
to place between two pieces of glass a drop of the juice, obtained either
from gentle pressure, or by scraping the cut surface with a  scalpel,
diluted with a little water.   The cutting off of small slices with Valen-
tin's knife, and examining the whole mass together, will exhibit, almost
invariably, more or less fibrous structure, but necessarily the lens em
ployed must be much feebler, and the cell is not seen to the same advan-
tage ; moreover, the fibrous element is purely accidental, and is found
in a vast number  of  tumors.   The  instrument used is a first-class one,
manufactured by Nachet.  The power we have habitually used in study-
ing  cancer element  has  been  one of 555 diameters (Nachet's No. 6).
Mr.  Bennett used, in his researches, one  of 250, which he recommends
to others.  We state this for the purpose of explaining why it is he  has
omitted some characters of the element which we believe are of great
importance.  The element of cancer consists of three parts, cell, nucleus,
and nucleolus, all of which are peculiar to it.   We will consider—
   "1. The cancer nucleus, as  inclosed in a cell, or as floating free by
itself.
   "2. The polygonal,  or more or less spherical and ovoid cell.
   " 3. The caudated cell.
   "4. The fusiform cell.
   "5. The concentric cell.
   " 6. The compound, or mother cell.
   " 7. Agglomerated nuclei connected by amorphous tissue.
   "In all the varieties of cancerous tissue, nuclei are to be found either
enveloped by a cell, or floating free, generally more or less of both ; in
some specimens, there exists a  large number of free nuclei with only an
occasional cell.  The form and appearance of  these nuclei is the most 
CANCEROUS TUMORS.                   199
constant and unvarying of all cancer elements.   They are, Fig. 91, a,
ovoid, or  more or less round;  the  latter are found more particularly
when the eye or the lymphatic glands are  the organs diseased.   Some-

                                 Fig. 91.
 Free cancer nuclei, a. Type form. b. The same, with a piece nicked out of the side accidentally,  c. Shows
a free nucleus, in which the molecular granules are very minute, often met with in perfectly fresh specimens.
d. A nucleus, in which larger granules have commenced to form. e. The characteristic nucleolus with its
dark contour and bright centre,  h. Fine molecular granules,  i. The second variety of granules, or gray
granulations, j. Fat granules.

times (as in b), we find little pieces of the wall of the nuclei apparently
nicked out;  but evidently  it is purely accidental, and  the proper  shape
can easily  be recognized.  They have, ordinarily, in width, a diameter
of from l-100th of a millimetre, or (a millimetre being equal to .039th
of  an inch) of .0039th  of an inch, to  l-66th of a millimetre, in one
instance we met with one as  wide as l-38th  of  a millimetre;  in length
they  measure  from l-133d  to  l-100th of  a millimetre.   Their con-
tour is dark and well defined,  with the interior  containing very minute
dark  granulations; indeed, when the specimen is perfectly fresh, they
have  a  homogeneous aspect, the granulations being  so small as to give
the appearance of a mere  shading (as in c);  if the  specimen is kept a
day or  two, we find the interior filling up with larger granulations (as
in  d).   Within  these  nuclei,  when they have  not  been obscured  by
granular or fatty degeneration, there is found habitually a small body,
or  nucleolus,  averaging in  diameter about  l-500th  of a  millimetre.
These nucleoli have  somewhat of a  yellowish  tinge, with a  brilliant
centre  and  dark  borders, refracting light  like the fat-vesicles.   We
would call attention, particularly, to the peculiar  brilliancy of the cen-
tres of these nucleoli, which, we think, is characteristic; it can be almost
invariably noticed, if the focus is varied.  Their  large size, in  propor-
tion to  the nuclei, should also be noticed, together with the great varia-
bleness of their position, sometimes being near the centre, and again in
close contact with the  walls (see e).   Ordinarily, in other elements, they
are found almost constantly  in  the  centre.  Very frequently, two^  or
three nucleoli  are found within the same nucleus.   M. Robin1 mentions
the action  of acetic acid upon  cancer nuclei and their nucleoli, as differ-
ing from that  on other elements, particularly epithelial;  it renders the
nucleus gradually  paler, together with the cell, destroying neither—but
1 MS. notes of his Cours de Histologic, 1850. 
200
CANCEROUS TUMORS.
the nucleolus is perfectly untouched by it;  whereas in epithelial cells,
where generally in those of the skin the nucleoli are wanting, the action
of acetic acid destroys the cell, leaving the nucleus unaltered."
   " It is of primary importance for the proper examination of the cancer
nucleoli that the specimen should be fresh.   Such being the case, we do
not remember ever having found these peculiarities wanting."
   " We have examined some specimens in which free nuclei were in great
abundance, and where,  after long-continued diligent  search, we were
unable to discover any cells.  More particularly is this the case in can-
cer of the liver, of the pylorus, and of the lymphatic glands; more rarely
in that of the eye.  In the breast, many full-formed cells are found with
more  or less of free nuclei floating in the blastemic fluid.  It  may be
well to remark  here  that we find  also  free nuclei of  fibro-plastic and
epithelial cells, of the finest bronchial ramifications,  each with their
peculiarities.   Mr. Bennett appears to us to have confounded them  all
together  in speaking of what  he calls  fibro-nucleated tissue.
   "In regard to the cells themselves of cancer, although we stated their
forms as very variable, yet many of them are modifications of the poly-
gonal, which may be considered the type.  In explanation of the theory
of the shape  and size of  various  cell-membranes, we would refer the
reader to Professor Schwann's views;1 undoubtedly, as he supposes, the
close  crowding together, and the processes of endosmose and exosmose,
may be the producing cause.   Thus, we observe that in hard firm tumors,
particularly those of  the breast and ovaries, the cells found are  exceed-
ingly  irregular, sometimes nearly triangular, Fig. 92, /.   The ovoid or
spherical are more frequently met with in soft or medullary cancer, Fig.
:>2, g, where there is but little pressure, although its juice appears often
to be  but one mass of cells.  It  is rare, however, that perfectly round
cells are  met with, but very generally the angles  are  well rounded in
those  which appear to be derived directly from the polygonal form, the
diameter of which  is very variable, ordinarily from ^5th to  2]5th of a
millimetre.  One peculiarity of this, as of the other forms of cancer-cell,
is the presence of the granulations of different  sizes in their interior;
whereas, in epithelial cells, the interior is  generally, when fresh, of
course, homogeneous.   In cancer, we  find the three varieties of granu-
lations given by M. Robin ;3 first, the  very fine  black dots found in  all
organic elements, and named by the French, very appropriately, pous-
siere  organique;  secondly, the  gray granulations, a  form"  somewhat
larger;  and, lastly, the fat granulations distinguished  by the refraction
of the light.—This first variety of cells contains nuclei, having in their
interior invariably one or more nucleoli, both of which retain the charac-
teristic points described above.  The large size of the nucleus, in pro-
portion  to the diameter of its cell, will at once  strike the eye of the
careful observer.  The variable position, also, of the nucleus within the
inclosure, appears to us to be  peculiar to cancer ; in cells of other struc-
tures, the rule  is to find the  nucleus  very nearly in the centre, except
with fibro-plastic cells, where the nuclei appear to have a peculiar affinity

  1 " Microscopical Researches into  the Accordance in the Structure and Growth of Ani-
mals and Plants," by Th. Schwann.  Sydenham Soc. edit.
  2 Tableaux de Anatomie, &c, par  Ch. Robin. Paris, 1851. 
CANCEROUS TUMORS.
201
for the walls.  All varieties of cancer-cells contain very frequently two
or more nuclei;  whereas, the epithelial, more particularly those found
 Forms of cancer-cells derived from the polygonal or type variety, g. Spherical cells,  a. Dark contour of
inclosed nucleus, e. The nucleolus, k. A nucleus with its contour pressed out of shape. I. A form of cell
frequently seen, where there is a deficiency of part of the wall. /. From pressure rendered triangular.

on the surface of the body (where there is most danger of confusion and
doubt), but rarely have more than one.   Moreover, the cell of epithelium
is much larger than  that  of cancer, yet the cancer nucleus is twice as
large as that of epithelium, as is also the nucleolus, compared with that
found in epithelium.
  " Caudulated Cells.—This variety of cancer element appears to be
considered the cancer-cell by persons unfamiliar with the  microscope.
The French  pathologists  speak of it as la cellule en  raguette, Fig.  93.
Its  general aspect is the same as that of the preceding, the only difference
being the prolongations, one, two, or three in number, branching off from
the body  (so to speak) of  the  cell;  sometimes  there are as  many as five
projections.   There  is  no regularity about them,  as the reader may
perceive in the plate; indeed, they frequently take the most  grotesque
shapes.
  "This form is met with more or less  in all cancerous tumors, but in-
variably in those of the bladder; cancerous degeneration of the parotid
often contains them in considerable abundance.
  "Fusiform Cancer-Cells.—(Fig. 94.)  This shape is caused by a swell-
in o- in the centre, with the  ends pointed,  forming often a very acute
angle.   It is found mixed with the other forms in all parts of  the body;
but always more numerous in cases where the disease has attacked  the
bones.  M. Robin1 says that he has never examined cancer of the bones
without finding this variety.  It is this form which Mr. Bennett  confounds
1 MS. Notes of his Cours d'Histologie, 1850. 
202
CANCEROUS TUMORS.
with fusiform fibres of fibro-plastic tissue (Fig. 95), making no distinction
between them, but describing them together under the name of fusiform
  Caudated cancer-cells,  to. The most usual forms. «. Cells containing double nuclei; cancer of the bladder
                              invariably contains this variety.

corpuscles.   Except  some  similarity of shape, we cannot see how  they
could be  mistaken for each other.   We  ask the reader  to compare the
Fig. 94.
Fig. 95.
  Fusiform cancer-cells, found in  great abund-
ance in cancerous disease of bones,  a. The nu-
cleus, which, in this variety of cell, is almost con-
stantly ovoid. The transverse diameter of the cell,
and the size of the nucleus in proportion to the
cell, together with the characteristic nucleolus,
distinguish this variety from  the fusiform fibro-
plastic element.
  Fusiform corpuscles of fibro-plastic tissue.  4. The
narrow and long fusiform cell, containing a nucleus
(5) with a small dot in its centre for a nucleolus; ave-
rage length of cell l-12th millimetre.  (Magnified 555
diameters.) 
CANCEROUS TUMORS.
203
Fig. 96.
drawing of these two things, and he will at once see that the cancerous
is double in width and length; moreover, its nuclei are much larger, and
the nucleolus is much smaller in  the fibro-plastic, where the  absence of
the clear bright  centre, &c, may be noticed.
  The Concentric Cancer-Cell, Fig. 96, is formed of an ovoid or spherical
body, surrounded by concentric rings, so  as to give the peculiar appear-
ance of circles around a centre, increasing  in size as they get further
out.  The centre resembles in every respect the ordinary cancer nucleus,
and sometimes other nuclei appear between
the circles, and occasionally a nucleus is seen
pressing against the outside of the cell wall.
It is not known how this variety of  cancer
constituent is formed, and we forbear giving
any of the conjectures in regard  to  them.
Sometimes a mass  of epithelial cells are
pressed together, and present somewhat this
appearance.  This cell is met with but rarely,
and but few in a specimen; it is more  likely
to be  seen, says M.  Robin,  in  the uterus,
breast, and ovaries, than elsewhere; it never
forms  the  basis of  the tumor,  but is merely
accessory.  According to Robin, it exists more frequently in the form of
cancer tissue, which, in consistence, is  between scirrhus and encephaloid.
   " Having ourselves but one drawing of a  distinctly marked specimen
of this cell, we borrow for  our plate one from M. Lebert.1
   " The Compound or Mother Cell of Cancer, Fig. 97, is of very varia-
 Two concentric cancer-cells,  a. The
cancer nucleus, the size of which is al-
ways in proportion to the innermost cir-
cle, e. The brilliant nucleolus.
Fig. 97.
Compound cancer-cells, containing three or more nuclei, a. Nucleus; when there are more than one nucleus
            within a cell they are smaller than the single nucleus, o. From Lebert.

ble shape, as  the drawings show.   They have received this name from
the views  entertained by some  authors, more particularly Kuss and
' Physiologie Pathologique.  Atlas, Plate XVIII. 
204
CANCEROUS TUMORS.
Fig. 98.
 Bruch, of their splitting up into smaller  segments and  multiplying by
 division.   They contain often three, four, or  more cancer nuclei.   We
 ourselves have never seen more than seven within  one cell, although
                      Lebert gives a drawing of one containing as many
                      as nine.   Some consider that secondary cells  are
                      formed within the parent one, and  are let out by
                      the rupture  of the  outer wall.  It  is, however,
                      mere  conjecture.—The  last  form  in  which these
                      elements are exhibited is where a number of nuclei
                      appear to  be glued together, as  it were, by  the
                      amorphous blastema in which they are generated,
                      without  there  being any recognizable cell-wall
                      around them.   M.  Robin1 calls them  plaques a
                      noyaux multiples.   The  size of the envelop about
                      them  prevents them from  being confounded with
 anything else.   These agglomerated nuclei (Fig. 98) are nearly as rarely
 met with as the concentric  cell.
   " All these varieties of cancer element can be seen in the same speci-
 men, although, as we mentioned  in  speaking of each, they have sepa-
 rately organs of selection.  Cancer-cells, of course, like homomorphous
 elements  of the organized animal or plant, have their periods of growth,
 and development, and decay;  their  progress to maturity may be some-
 times arrested,  and account to us in some measure for the great variety
 of appearance,  structure, and  size.  For some interesting remarks, in
regard to the retrograde metamorphosis of all tissues, both normal and
pathological, we would refer the reader to an article by Dr. Burnett.2
   "Out of the body, cancer elements change very rapidly, more so than
  Agglomerated nuclei, a. Nu-
cleus, p. amorphous uniting
tissue.
Fig. 99.
Fig. 100.
 Pus-corpuscles, magnified 833 diameters, q. Type
form before the addition of any reactive,  r. Outline
of nucleus seen surrounded by thick granulations.
  The same after the application of acetic acid. s. The
irregular contour of the corpuscle freed from the
granulations, leaving the nuclei clear,  t. Character-
istic nucleus without any nucleolus, u. Free nuclei,
the walls having been destroyed.  Diameter of pus-
corpuscle varies from  l-100th to l-80th millimetre,
that of the nucleus l-333d.  v. Remnant of contour.
'  Tableaux d'Anatomie, 1851.
2  American Journal of the Medical Sciences, July, 1851. 
CANCEROUS  TUMORS.
205
any one element we have met with.   Often, in the  course of the first
day, they  become degenerated by the appearance of fatty granulations,
which often hide their distinctive characters.   Unfortunately, they can-
not be preserved in any fluid.   Alcohol coagulates the albuminous cell-
wall.  Mixed up with what we have designated cancer elements are often
found crystals of cholesterin and of  triple phosphates of ammonia  and
magnesia, filaments, fat-globules,  crystals  of margarine, pus (Figs. 99
and 100),  &c.  Wherever there is  inflammation, especially of a chronic
character, we are  apt  to find  fibro-plastic elements; consequently, we
must not hastily conclude, because we find them in a tumor, that there is
nothing else there.  The importance, therefore, of examining thoroughly,
as far as  possible, each  portion of the specimen, cannot be urged too
much.   If but one cancer-cell be  found, it is conclusive.   That which
has been  designated melanotic cancer, is  merely a  mixture, with true
cancer elements, of free pigmentary granulations, or of the peculiar cells
of pigment."
   "We give,  however, that others may compare  them, the histological
elements with which Mr.  Bennett thinks cancer can  be confounded.

                                                  Fig. 103.
  Fig. 101. Young epithelial cells (from Lebert's plate), w. Cell-wall filled with few and small granules,  x.
The nucleus, very small in proportion to cell, and containing no nucleolus.
  Fig. 102. Tessellated epithelium, y. Nucleus without nucleolus, diminutive in proportion to cell.  2. The
cell with homogeneous minute granulations filling up the centre. Diameter of the cell when taken from the
skin l-10th millimetre.
  Fig. 103. Buccal epithelial scales, magnified 555 diameters, to showmore clearly their dissimilarity to cancer
elements.  11. Irregularly polygonal contour. 12. The characteristic nucleus without any appearance of a
nucleolus, which is rarely met with in epidermic cells, or in those coming from the buccal surface.

   "Fibro-plastic elements possess a peculiar interest  in being  the only
ones where there is any ground for seeing  a resemblance to cancer ele-
ments.   They were first defined by M. Lebert, who thought them always
the product of disease.  Further  researches have convinced  him that
such  is  not the  case.  In the  healthy subject, they are found in the
bladder, ovaries,  liver, mammary gland,  uterus, &c.   According to
Robin,1 the internal membrane of the Graafian vesicle is the only mem-
brane, in the state of health, which is formed altogether of it."

                   1 MS. Notes of his Cours d'Histologie, 1850.
Fig. 101.
 
206
CANCEROUS TUMORS.
Fig. 104.
<w
#
   "We  give the true  fusiform corpuscle (Fig. 95)  of this  tissue, the
length of which is often as much as from Jgth to ^Tst 0I" ,a millimetre.
The narrowness of their width, the smallness of their nuclei, the nucleo-
lus,  and, indeed, the whole aspect, would prevent, we should think, any
                             one who is familiar with microscopic inves-
                             tigations, from confounding them with any-
                             thing else.   The fibro-plastic cells and their
                             free nuclei (Fig. 104) could be mistaken for
                             cancer by a superficial observer.   They are
                             ovoid, and sometimes polygonal, varying in
                             diameter from j^th to g'gth of a millimetre.
                             The appearance, however, of the  nucleus
                             itself with the nucleolus, differs very widely
                             from  cancer, the granulations in their inte-
                             rior are very much finer, and of more uni-
                             form size  than those found in  cancer.   The
                             free  nuclei  of fibro-plastic  tissue are  so
                             much smaller as  to  be easily known when
                             met with."
                                " Mr. Bennett tells us, that when enchon-
                             dromatous tumors become softened, and the
                             cells escape from the cavities, they resemble
very closely cancer.  It has never been our good fortune to meet with
any such cases; but we confess we cannot understand  how, even if the
cells were free, they could be taken for those of cancer.   Compare them
(Figs. 105 and 106) with any  or all of the varieties  of  cancer element,
and remark  the difference of shape, &c.
 Spherical fibro-plastic cells, found in the
uterus and in other organs in the healthy
subject; also as the result of chronic in-
flammations ; and forming, with the pre-
ceding variety, the basis of true sarcoma-
tous tumors. 6. Well-marked ceU. 7 and
8. Nuclei inclosed in cells or floating free;
transverse diameter l-200th millimetre.
Fig. 105.
Fig. 106.
 Cartilage elements taken from the condyles of the
femur.  13. Hyaline tissue. 14. Excavated cavity.
15. Cartilage cell. 16. Nucleus. 17. Nucleolus very
frequently drowned by the fatty granulations.
Costal cartilage.  18. Hyaline substance. 19. Car-
    tilage cavity. 20. Cell. 21. Nucleus.
   "In Fig. 99, we have given a drawing of pus, before the addition of
any reactive, and, in Fig. 100, we have given the same corpuscles, acted
upon by acetic acid.   It will be noticed  that with a  high power, fre- 
CANCEROUS TUMORS.
207
quently a dim outline of the nuclei can be seen when the corpuscles are
unmixed with any reagent.  We  are glad to have the support of Ben-
nett and Robin in stating that there is no mucus-corpuscle.   What has
been so called was either pus, so easily produced on mucous membranes,
or epithelial nuclei.
   " Thinking it would be not uninteresting to the reader to compare the
element of tubercle with that of cancer, we give (Fig. 107) several cor-
Fig. 107.
 Corpuscles of tubercle (833 diameter?). 1.
cles found in softened tubercular matter; a i
regularly formed globular body, with neithei
nor nucleolus, measuring l-142d millimetn
meter. 2. Interior granulations. 3. Free loos
lations.

puscles found in a specimen of softened tubercular lung handed to us
while copying off these remarks ; from the first preparations examined
we could have given almost any number, but the few we have drawn are
perfect type specimens."]
   The origin of cancer is a subject of the deepest interest, but the first
and most important step of the process is entirely concealed from  us.
M. Simon views a cancer as  "substantially a  new excretory organ," a
growth which arises for the purpose of eliminating from the system an
unhealthy matter which is generated within  it.  Such a function, how-
ever, is  surely not fulfilled by all instances, even of encephaloid, and
still 'less of the other species.  It rather seems that we should recognize
in cancer a grave alteration of the normal formative powers; those real,
but occult influences which determine that—here bone, and there muscle,
and there nerve shall be produced.   We know  something of the  dis-
turbances of nutrition occasioned by unhealthy conditions  of  the blood
quoad its chemical  composition; we know something of the  origin  of
rheumatism, and gout, and syphilis, and of the  effects they  produce,
but they are very  different from the  phenomena  of new formations.
Surely,  the  arising of a fibrous tumor, an  enchondroma,  or  a cancer,
implies a very different kind of action to  that  which is observed in  any
blood disease.  We certainly believe the blood to be  affected, probably
in its chemical  composition,  as well as, and  most  importantly, in its
Fig. 108.
Corpus-    Cylindrical and ciliated epithelial elements, found
imall, ir-   in the nasal fossee, trachea, Eustachian tubes, in the
nucleus   intestinal canal below the cardiac orifice. 9. Hair-
j in dia-   like extremities, which, during life, are constantly
b granu-   in motion. 10. Nucleus clear in the centre. 
208
CANCEROUS TUMORS.
vital endowments, but we do not think  it is the only seat  of primary
alteration.   Were it so, how would it be possible to account for the
constant preference manifested by scirrhus, and by other  tumors, for
particular sites ?  We conceive, then, that  in the  case  of  cancer, the
blood and the  general  system, but  especially some particular  part,
having suffered some unknown deterioration or perversion of their vital
power, a minute quantity of blastema, exuded in the specially weakened
part (perhaps in consequence of a blow or other injury), commences to
develop cell and fibre structure, which soon constitutes  a new growth,
endowed with  powers of assimilation and vegetation to an almost in-
definite extent.  The tendency to  cancerous disease, that is to  say, the
deterioration of the blood,  and of the assimilative powers, may exist
for a long time  before it expresses itself in  the  tangible  reality of a
tumor;  but when this is  formed it  becomes an engine for multiplication
of similar tumors, and intensification  of the cancerous diathesis.  We
have spoken of cancer as  resulting  from the development of effused
blastema, and this, there is good  reason to believe, is  invariably the
case ; in the vast majority of instances, the growth manifestly originates
in the interstices of textural elements;  in some few it has  been  found
in the coats of the  veins, but  in none has  it been certainly proved to
have originated in  the blood.  Cancerous  growths have, indeed, been
seen within  the veins, but this has been the result of perforation of
their walls by formations external  to  them.  Development  proceeds in
cancerous blastema just as it would  do in  healthy; nuclei and fibres
seem to arise in the same way.  The  former are produced,  we believe,
with great rapidity, not by any slow process  of building up by coalescing
granules, but by the  formation, at once, of a small spherical  body,
55^00" mcn *n diameter,  which subsequently enlarges, and presents the
sharply  defined envelop and  the  clear  central cavity  with nucleolar
spots, which characterize all nuclei.   Often, however, the abnormal na-
ture of the formative process displays itself in the irregular forms which
the nuclei assume, becoming largish vesicles or  granular globules; or,
if they have become included  in a surrounding cell, enlarging, so as to
represent a cell themselves,  while secondary nuclei appear  in their
cavities.  The encasement of several nuclei in one  cell is not  unfre-
quently observed, and is a wide departure  from the ordinary plan of
healthy  cell-growth.   Fibres  are  formed partly by  development from
nuclei, which are often seen elongated,  partly, and in greater degree,
from the blastema,  by splitting up and  division; they  are rarely as
perfect as those of healthy tissue.  An  albuminous fluid,  in varying
quantity, is diffused through  a cancerous mass, and beyond all  doubt
partakes of the qualities of the solid  structure; in it the bloodvessels
may be said to lie bathed, and by  it, in consequence, the blood travers-
ing the organ must be  contaminated.   This same fluid is also taken up,
in part, by the lymphatics, and thus readily communicates its own can-
cerousness to the nearest lymphatic glands.  The  growth of a cancer-
ous tumor will be more rapid, in proportion as its structure is mainly
composed of cells,  and contains but little fibre, and is also  so situated
that it has room to expand freely.  Encephaloid, in which cell-structure
always  predominates, is, notoriously, of  most rapid growth, but even 
CANCEROUS  TUMORS.
209
its progress is comparatively slow, while it is confined within unyielding
walls, a3 in the globe of the  eye.  Laennec supposed  that all cancers
were originally hard, and that in the process of growth they gradually
became softer; this is not so; cancers may be quite soft at their  com-
mencement; but still, they do generally appear to diminish in consist-
ence as they advance in age.  Tumors, however, of the" same  date may
differ very greatly in consistence.  Inflammation may affect cancerous
tumors; it is commonly excited by their exposure to the air after they
have  made their way through  the covering parts.  It  powerfully  ac-
celerates softening  and decay.   Suppuration  may take place as  the
result of inflammation, but  the  pus is an  ill-formed  sanious  product,
mingled with detritus.   Cancerous formations  sometimes mortify spon-
taneously, sometimes in consequence of inflammation; in the  first case
a cure has  been  known to take place, and  to  attain this  artificially is
the object of various escharotic applications.   It is evident that it is
only in instances of cancer,  whose powers of vegetation are feeble and
sluggish, that such  a  proceeding  can be successful.   There  are two
other changes which cancer  occasionally undergoes, and which may re-
sult in a cure.  One is that called Saponification, by Rokitansky, which,
however, seems to be simply fatty degeneration.  It is this change, in
an early stage, which constitutes Carcinoma reticulare;  it occurs with
formation  of granule cells, or  independently of them.  The  other
change is a shrinking and contraction, a kind of drying up of the can-
cerous growth with deposition of calcareous matter, analogous to cretifi-
cation of tubercle.
   The term primary is applied to cancerous growths, originating for  the
first time in the system, secondary to those that are in  someway derived
by dissemination from the primary.  We have already alluded to one mode
by which secondary cancers are established, viz:  that through the medium
of the lymphatics; and we have stated that it is the cancerous blastema
which is absorbed, and which gives the impulse to cancerous develop-
ment in the glands.   This, there can be no doubt, is equally capable of
propagating the  infection as any solid germs to which it is in  fact equi-
valent.   If in some instances it does not do so, it is because the natural
assimilative power of the gland tissue resists the infectious tendency of
the blastema, and perseveres in its  own normal mode of nutrition  and
action.   In the same way, we believe that the  bloodvessels traversing
the cancerous mass readily  imbibe  through their delicate parietes  the
diffused blastema, and that the blood thus contaminated, when it arrives
in  a  suitable nidus, deposits there a blastema, which,  under favoring
circumstances, gives rise to a secondary tumor.  The nidus is most often
the next capillary plexus at which the blood arrives; thus, cancer of the
breast occasions  cancerous tumors in the lungs  in  almost  all cases in
which it also affects the liver, but it often produces cancer in the lungs
without any occurring in the liver; cancer originating  m the stomach
occasions similar disease in the liver to which its veins  proceed, before
it produces any in the lungs.   It is easy to understand that a suitable
nidus is requisite, and that, if the organ first traversed by the blood pro-
ceeding from the infected part does not afford such, the  material will be
effused'in vain, the seed will not germinate in a soil unsuited to it.   Ine
        14 
210
CANCEROUS  TUMORS.
recognition of the efficiency of cancerous  blastema to  produce similar
formations is of some importance, as it does away with  the  difficulty of
supposing that solid germs are introduced  into  the circulation through
some breach  in  the walls of the vessels.  These may, doubtless, some-
times make their way into the blood, but there is no proof that they do;
and we are certain, on mere physical grounds, that the blastema must.
The analogy of pysemia is in favor of our views ; Lebert has shown that
the serum of  pus produced like effects to the entire fluid, and that the
globules of pus were not the special cause of the multiple abscesses by
being arrested  in  the  capillaries,  as they were  soon destroyed in the
blood.   Cancerous  blastema, or germs,  may be communicated  also in
another way, viz:  by actual contact of the diseased with other parts;
cases are  mentioned by Dr. Budd, and Mr. Simon, wdiich may be con-
sidered to prove this,  though there is no improbability whatever in it.
Fluid blastema might easily be imbibed from a growth by a soft tissue in
frequent contact with it, just as a solution of some salt would be.  Germs,
that  is, nuclei  and  cells,  might  also be similarly transferred, if  any
breach of surface in the growth had occurred.  Pathologists are gene-
rally agreed  in  attaching little credit to the results of the experiments
which have been made relative to  the production of cancer by inocula-
tion, or injection of the cancerous matter.   Some few are said to have
succeeded, but the  great  majority have failed;  in this there is nothing
surprising; we quite agree with Dr. Walshe, that the non-production of
cancer by inoculation proves conclusively "the absolute necessity of
constitutional predisposition" for the development of the disease.  A
healthy system  will resist and overcome by an assimilative  force the
cancerous poison, just as it  will in the case of a  dog that of pus, while a
weaker system might be infected by it, as the rabbit is by the injection
of pus.   What  has been called the metastasis of cancerous tumors has
occasionally been  observed; see a case  quoted  by Dr. Walshe, p. 110,
from Recamier ; in this, it must not be supposed that the tumor existing
in one part is removed molecule by molecule to another, but that either
a small pre-existing tumor was excited to rapid  growth  by  the wasting
and absorption of  the other, or that absorption  being induced by some
local condition,  blastema, or germs, were carried  in  the circulation to
the new nidus,  where they commenced to germinate and  develop afresh.
Were such cases of transfer frequent, they would constitute a considera-
ble objection to the plan of  causing absorption of  a tumor  by pressure
upon it.  It might be reasonably conceived that  the  structure of  the
locality in which cancerous blastema was deposited, would influence the
kind of tumor that was therein developed, and  such does appear to be
the case,  at least to some extent.   Thus scirrhus  is far more common
than encephaloid in the female breast, which abounds in fibrous tissue;
and  encephaloid is most frequent in the  liver, which contains little of it,
and  chiefly consists of cells; the  muscular walls of the stomach  are
commonly also affected by scirrhus, as  well  as those of  the uterus, and-
both these consist  mainly of fibres.   On the other hand, there are excep-
tions in the case of the lungs, and of the meninges which are most often
attacked  by encephaloid.  The  species of  cancer termed  epithelial,
seems certainly to  be determined by the peculiarity of its  site, as  it 
CANCEROUS  TUMORS.
211
seems almost invariably to be developed on free  cell-bearing  surfaces.
It is generally true that the greater the proportion of fibre in a tumor,
the less is its  malignancy; especially intending thereby its tendency to
contaminate the system, and  to destructive  ulceration.   On the other
hand, the more  it  abounds in cell-growth, and  in fluid  blastema, the
greater is its  malignant  capacity.  M. Simon says, "in proportion as
the blastema has suffered  itself to undergo a fibrous transformation, in
such measure  I cease to recognize that which is  distinctively cancerous
and malignant."   Believing this to be in great part true, we must  still
remember that the abolition of a truly scirrhous growth may be followed
by the development  of encephaloid ; the inactive fibroid structure is still
the expression of the comparatively quiescent  constitutional infirmity,
which may at any time  be roused to  its  more  severe manifestations.
There  is much probability in the common opinion, that cancer is an
hereditary disease.  Dr.  Walshe acknowledges his belief  in the  disease
having thus originated in some cases which  he witnessed; and,  indeed,
most persons might adduce confirmative testimony. Still, actual  statisti-
cal proof has  not yet been afforded.   Cancer is, on the whole, a disease
<if advancing age; it does, indeed, exist occasionally at every period of
life; both scirrhus and  encephaloid  have been observed in the foetus,
and encephaloid is not uncommonly seen in infants and children of ten-
der years; but the  researches of  Dr. Walshe show that  the  mortality
from cancer " goes on steadily increasing with  each succeeding decade
until the eightieth  year," so that, taking the mean of  both sexes, it
attains its maximum between  the ages of seventy and eighty.  In males
the ratio of increase is more uniform  than in females; in them,  there is
a great and rapid increase of mortality between  the ages of thirty and
fifty, which " lends support to the current belief respecting the  con-
nection of the development of uterine and mammary cancer with declin-
ing activity and cessation of  the  genital functions."  The influence of
sex upon the development  of cancer is  very  striking; Dr. Walshe's
tables show that in  six  years an absolute  number of deaths  from this
disease, in males, was only 3495, compared with 10,146 in females, al-
though the mean rate of mortality in the male exceeds that in the female.
A sanguineous temperament is considered, by several who have  paid at-
tention to the question, to predispose in some measure to  cancer.  More
powerful are  the effects of mental distress, and of the refining, but ener-
vating influences of civilized life ; at least, such  are  the conclusions to
which the evidence that can be obtained at present seems to point.  A
fact of a rather opposite import which  Dr. Walshe establishes, is that  a
town life has no greater  influence than a country one, in promoting the
development of cancer; in  fact, a greater number die of cancer in the
country, than in the towns;  this applies to the mean of both sexes, but
taking the females  separately, the mortality from cancer among them
is greater in the town than in tbe country.
   An  injury  to a part (the observation  is  most  common in the case of
mammary cancer) seems to  be often  the exciting cause of  cancerous
development, and it is probable enough, and accordant with the analogy
of o-rowth, that a weakened part should offer the least resistance to the
localization of constitutional disease.   However, the immunity from can- 
212
CANCEROUS  TUMORS.
cer observed in the Parisian prostitutes,  and the result obtained  by
Andral, with regard to cerebral carcinoma, as  following injury, show
that but little is to be attributed to this as an exciting cause.   Habitual
irritation of the stomach by alcoholic  liquors has no effect in inducing
carcinomatous disease of this organ, though it may have sometimes pro-
duced a state of simple induration, which has been mistaken for scirrhus.
It is, however, not to be denied, that  irritation may in some cases de-
termine the formation of a cancer; as, for instance, in the  scrotal cancer
of chimney-sweeps, which certainly seems to be  called  into existence
from a latent predisposition by the  irritation of soot.
   In concluding this subject, we may offer a few remarks with reference
to the effects of removing cancerous tumors by operation.  In the first
place, it is quite clear that the disease is manifestly constitutional, and
that no sound, real cure can be expected from  merely removing its ex-
ternal development.   Secondly, it  is  matter of  experience, that in not
a few instances surgical interference with  one tumor has provoked the
speedy appearance of several others.   Thirdly, any attempt at removal
is useless;  nay,  may be absolutely injurious, unless  every particle of
cancerous structure is taken away.   Fourthly, epithelial  cancers seem
least prone to return after removal;  encephaloid  invariably does, and
mostly with great rapidity; scirrhus may be checked in its progress, but
its return can very rarely be prevented.   The check which may be given
by operation to the progress of cancer depends  on  the  circumstance
before stated, that a tumor, once formed, becomes an instrument for the
multiplication of similar tumors and intensification of the  diathesis.   It
must require a combination of favorable circumstances,  or a great  in-
tensity of the diathesis, to insure the development  of  effused blastema
into an heterologous growth; but when  this has taken place, then the
very growth and vital actions of the structure will constantly generate
fresh supplies of cancerous blastema, and thus promote the formation of
secondary  cancers.  The  destruction, therefore,  of the growth, which
thus reacts so evilly upon the system, may be  reasonably expected, if
it do not aggravate, to delay the cause of the disease.  But the misfortune
is, that, as  above stated, it does sometimes aggravate, and that fearfully,
a previously indolent cancerous diathesis.  Dr. Walshe says, "excision
of a tumor seems to awaken a dormant force, cancers spring up in all
directions, and enlarge  with a power of vegetation almost incredible."
Why this should happen, we do not know; but we  may conjecture that
when the original diathesis is slight, the formation of a tumor may tend
in some degree to localize it, and leave the system in a somewhat healthier
state, provided the tumor itself be chiefly fibrous, and  produce but a
small amount of blastema.  The removal of the indolent  tumor may be
analogous to the cure of fistula in ano in a person of phthisical tendency.
The two principles referred to of the cancerous tumor, in one case acting
as a cause, increasing the force of the disease, and in another retarding
it, are not contradictory, though opposite;  they will prevail in different
degrees in different instances, according to the kind of tumor and other
circumstances. 
CHAPTER  V.
  Foreign bodies of very various kinds are not uncommonly found in
the living  organism, having made their way in through  the natural
orifices, or having been introduced through wounds.   They often occa-
sion a great deal of irritation, excite inflammation and suppuration, and
in this way become eliminated.  At other times, they remain for  years
without producing any symptoms, and are only discovered  after death.
When  this is the case, they are generally inclosed  in  a  fibroid  cyst,
which  isolates  them  from the adjacent  textures, and prevents them
causing irritation.  We recently found a bullet thus capsulated in the
abdomen of a  cat, close to the left  kidney;  the  animal  was in per-
fect health.   Dr. Walshe quotes a case in which  an  ounce  of arseni-
ous acid was swallowed without producing any fatal  effects ;  after the
lapse of a year the  suicidal  attempt was repeated,  and with success.
The arsenious  acid  of the former attempt  was found  inclosed  in  a
cyst, which had evidently prevented it from exerting its  poisonous
influence.
                           PARASITES.

   These are organized formations existing in a living organism, but not
connected with it by any continuity of tissue, and  possessed of an  in-
dependent life.   In these respects  they differ from the class of new
formations.   They have been often supposed to be produced in a spon-
taneous  manner, originating  as  by a  kind of  necessity from morbid
products; but the  progress of inquiry has proved,  almost completely,
that this is not the case; that they are  developed from sporules or ova,
just as beings of  a higher rank are;  and that the cause of their appear-
ing  in certain localities, under  certain  morbid  conditions, is,  that  in
such cases the germs find a suitable  soil or nidus wherein they can be
dOveloped.   We believe  that  recent researches  have  also rendered  it
very probable, if not certain, that the same  species  of parasite  may
develop itself very differently in different localities ; so that some, which
were formerly  regarded as distinct species, are now considered to be
only varieties of  the same.
   Vegetable Parasites.  These are  microscopic growths belonging  to
the lowest class of the vegetable kingdom.  They are found most com-
monly on diseased mucous surfaces, sometimes  in  exudations, but  it
cannot always be clearly determined whether they are the cause of the
diseased  state, or whether (as is more probable) the  diseased tissue has 
214
PARASITES.
merely afforded a suitable nidus for their development.   We enumerate
those which have been observed,  after Rokitansky, as follows: (1.) The
mycoderm of favus.  It consists of minute, transparent, round  or oval
vesicles,  often united in branching threads.  This  arrangement  results
from  their mode  of growth  by  elongation and division of the cells.
                   M. Lebert has observed a  rotary movement  of the
     Fig.  109.        separate or united  cells similar to that which  has
                   been detected in other cryptogamia.   The vegetable
                   growth  is  inclosed in a kind  of  capsule, which is
                   marked on the surface  by a funnel-shaped depres-
                   sion, and is of a sub-conical shape beneath, where
                   it is implanted in the skin.   Experiments  to repro-
 Drawing of Mycoderm of  duce the disease by inoculation with the mycodermic
Favus — partly from he-       .,       "   ,              -, ■,   .
bert                sporules have  scarcely ever  succeeded;  it  seems
                   therefore probable that they do not  constitute  the
essence of the disease.  (2.) A similar fungous growth has been found
in the sheath surrounding  the root of the  hair  in  sycosis.   (3.) In
porrigo decalvans,  a  growth  of very minute fungi has been  detected
within the roots of the  hairs.  (4.) A  similar  one has been  found  in
the hair roots in  plica  polonica.   (5.) Also, in pityriasis versicolor.
Croupous, aphthous, and diphtheritic exudations upon the mucous surface
of the mouth,  pharynx, oesophagus, intestine, and larynx,  are often
found  to contain minute  fungi very similar to those  of favus,  except
that they are longer and more slender, and  more distended by reproduc-
tive granules at their terminal extremities.   They have also been  ob-
served in gangrsena oris, in sputa from  a patient affected with  pneumo-
thorax, in the sordes of the teeth, &c.
   Animal Parasites.  Infusoria  (vibriones  and vorticellse) are not un-
frequently found in pus, and probably in other fluids.  Dr. Bence Jones
has discovered vibriones in the urine of a child the moment after it was
passed.  The following insects are known  as human  parasites: the
common  flea (pulex  irritans), the chigoe  of the  West  Indies  (pulex
penetrans); the pediculus capitis; the p. pubis; p. vestimenti; p. tabe-
scentium; the common bug (ciroex lectularius).   To these may be added
the harvest bug, which, like the chigoe, burrows into the skin probably
for the purpose  of  laying her  eggs.  Among arachnida, we  find two
species of acari, that frequent, the  one the epidermis, and the other the
sebaceous follicles.   The acarus scabiei (sarcoptes hominis) is a minute
whitish creature, about T fo—^ in. in size; it has  no  true head, but is
provided  anteriorly with  proboscis-like  mandibular organs  furnished
with four bristles.  There are eight legs, " four anterior are  inserted
into the thorax by the side of the proboscis, are jointed, and furnisned
with hairs and bristles, the last joint of each terminating in an adherent
disk.   The posterior legs, without adhering  disks, terminate in very
long bristles."   (Vogel.)  The animal  burrows in the  epidermis, and
forms minute channels, at the end of which it may often be discovered;
it does not inhabit the vesicles or pustules which  constitute the  erup-
tion, and are simply excited by the irritative proceedings of the acarus.
The acarus folliculorum is proportionally much longer, about  T}5—Js
in. long.  5j-n in. broad; its  head  has two lateral palpse with an inter- 
PARASITES.
215
vening proboscis;  its thorax is  supported  by four  pairs  of very short
legs with terminal claws;  its long abdomen gradually diminishes to the
end, and contains  some granular matter and oil-vesicles.   It  inhabits
the hair follicles and sebaceous glands in any region of the skin, where
it may be found in the healthiest persons.   It doep not appear to excite
any disease.  The  following Helminthic parasites infect man : (1.) Fila-
ria medinensis, the Guinea worm, from six inches to twelve  feet long,
about as thick  as  a piece of packthread.   It makes  its way into  the
subcutaneous tissue of the lower limbs and  some other parts, where  it
remains a variable time without exciting any particular symptoms; but
when its  progeny are  approaching  the period  for their extrusion, it
makes its  way out, or  is extracted by hand.   The symptoms  of  this
period are sometimes slight, sometimes very severe.   If ruptured during
extraction, the young escape into  the cellular texture and excite an
unhealthy suppuration.   (2.) Filaria oculi humani, discovered in the
surrounding fluid and in the crystalline lens.  (3.)  Filaria bronchialis,
once  found in diseased  bronchial  glands.   Other filaria have been
found  in  the blood and  in the urine (spiroptera  hominis, dactylius
aculeatus).   (4.)  Trichina  spiralis  is a  minute round  worm, 3]T to
g'g  inch long, with  an  intestinal  canal and distinct oral  and  anal
openings.  It occurs inclosed in a transparent  cyst,  which is situate
in  the interior of the fibres  of voluntary  muscle, separated by  the
sarcolemma from all surrounding textures.   Sometimes there  are  two
or three worms in one cyst.  Sometimes the cyst contains calcareous
matter, in which  case  the worm is  most commonly dead.  The patholo-
gical significance of this worm is not very  apparent; it has often been
found in persons who have  died of  different diseases, and even in those
who perished while in health and vigor.  (5.)  Tricocephalus dispar, a
thin filiform worm, one and a half to two inches in length.  Its  anterior
two-thirds are quite capillary, and pass rather suddenly into the thicker
posterior portion.   The sexes are distinct; the  male  has a long penis
invested with a proper sheath.   The female produces numerous ova, few
of  which are probably developed.   The worm  is found  chiefly in  the
ccecum, adhering by its head to the mucous membrane; it is sometimes
solitary, sometimes occurs in great numbers; it does not appear to pro-
duce  any remarkable symptoms.   (6.) Ascaris  lumbricoides, a round
worm, pointed at both ends, from six to fifteen inches long, of a grayish
and sometimes red color,  sufficiently translucent to  allow the viscera to
be  seen, marked  by two lateral lines corresponding  to  the principal
vessels,  and by  two others  less  distinct, and  corresponding  to  the
nervous  cords  on the dorsal and ventral surface.   The  head  is sepa-
rated from the  body by  a  slight constriction;  at  its  extremity is the
mouth,  surrounded by  three  tubercles.  The anus is situated  on  the
under surface, near the extremity of the tail.   The reproductive organs
consist, in the male, of a  single seminal tube, three feet long, terminat-
ing in a  reservoir  about an  inch in  length,  which communicates with the
base of the penis: in the female, they comprise the vulva, situated at the
junction of the anterior and middle thirds of the body; a vagina, five or
six lines long;  a uterus, which divides into two long, tortuous  oviducts,
gradually diminishing to capillary ovarian tubes, which are conspicuous 
216
PARASITES.
by their whiteness, as they are coiled around the intestinal canal.  They
inhabit chiefly the small intestines, but roam about occasionally up into
the gall-ducts, the  stomach, the oesophagus, and have even made their
way into the nostrils and into the mouth, as  happened  in a girl under
our care.  It  seems ^t least  doubtful whether they ever perforate the
coats of the intestine and get into the peritoneum.  Sometimes they are
very numerous; one patient passed as many as four hundred and sixty
in a fortnight, but this is not common; however, one would rather be
inclined to expect, from the appearance of one, that there were others
remaining  behind.   They have been known to accumulate so as to ob-
struct the intestines;  more commonly, they produce  only some amount
of irritation, or even no  symptoms at  all.  We think we have seen a
case of convulsive paroxysms depending on the presence of these  para-
sites in the bowels.  (7.) Ascaris vermicularis ; a  minute, white, thread-
like worm, of separate sexes; the male about one and a half lines in length,
the female five or six; the former has a spirally coiled tail, the latter a
straight, tapering, and very delicate one.   There is a transparent tube-
rosity on  the  head, with a kind of alar membrane on each side.  They
inhabit the rectum in vast numbers, and may crawl out and get, in females,
into the orifices of the adjacent canals.  They occasion very distressing
irritation, perhaps in consequence of their restless disposition, which has
obtained for them their name of ascarides (afl*api£W, to leap).  (8.) Stron-
gylas gigas, a  formidable large round worm, which  attains sometimes
three feet  in  length, and is of a blood-red color.  The male, as usual,
is the smaller, is marked by circular striae and  " shallow longitudinal
furrows;" at its posterior extremity it has a funnel-shaped pouch, from
which a slender penis protrudes.  The female has astraighter and more
obtuse tail, and at one or two inches' distance from it the vulva.  It in-
habits the kidneys, and causes more or  less destruction of this organ.
Among the trematoda, we are acquainted  with three  species of distoma,
which have been  found, though rarely, in the human subject.  The d.
hepaticum and d. lanceolatum are  both flat, lancet-shaped worms, of a
yellow-white color,  with two suckers, one of which situated at the head
forms the mouth; the other is on the abdomen, and is imperforate.  The
orifice of the  sexual organs lies between these two.   They are herma-
phrodite.  The d. hepaticum is the larger, being  eight to fourteen lines
in length, and from one and three quarters to six lines  in breadth;  its
intestinal canal is ramified.  The d.  lanceolatum is only two to four lines
long and one  broad;  its intestine is bifurcated.   They have been found
in  the gall-bladder and ducts, and in  the v. porta?  and its branches.
Distoma oculi humani is of minute  size, and has been found in the fluid
surrounding a cataractous lens.   Cestoidea.—Two very common para-
sites of the human subject belong to this order,  the  taenia  solium  and
the taenia lata.  They are both  flat-jointed worms, of a whitish-gray
color, and attain, very  often, an  immense length.   Their joints, laden
with ova,  frequently separate, and are  discharged from the system,
while fresh ones  are formed in succession behind the head.   The  one
do not appear to be developed in the organism inhabited by the parent
worm.   The  head of  the taenia solium  is at   the  anterior  smallest
part of  the worm;  it is provided  with four lateral suckers,  between 
PARASITES.
217
which is a circle, sometimes supporting a double  row of hooks; in the
centre of this circle there is a minute opening, that of the mouth.  " The
anterior segments," ^Professor  Owen  says, "are feebly represented by
transverse rugae;  the succeeding ones are subquadrate, and as broad as
long."  Advancing posteriorly, the segments still increase in length and
Bize;  the anterior  part of each is  overlapped by the broader posterior
Fie. 110.
Fig. 111.
Taenia solium. Head and joints.
Tania lata. a. Marks the generative orifices in both.
         From Owen's Lectures.
part of the preceding.  At about the middle of the margins of the joints
is situate the orifice of the generative canals, which is in successive joints
on alternate sides; this constitutes a distinction between the taenia solium
and  the taenia lata, in which the genital orifices are in the middle of the
ventral surface of the segments.  The alimentary canal in both taeniae
seems to commence as a  single minute tube, which soon bifurcates and
forms two divisions, which run throughout the length of the worm,_ at a
little distance from the margins. The generative apparatus is very highly
developed  in each joint,  consisting of a large branched ovarium and a
seminal tube, which terminates as a  small rudimental penis, situated just
anterior to the opening of the ovarian canal.  The head of the taenia lata,
or Bothriocephalus latus, forms an elongated, sub-compressed enlarge-
ment, with an anterior  obtuse prominence, perforated by the mouth, and
havino- two lateral sub-transparent parts separated by an opaque tract;
these °have been  regarded as depressions (Mp^), whence the generic
name.  There is no trace of joints  within 2| inches of the head;  these
are, at first, feebly marked, then the  segments expand posteriorly, and
slightly overlap the succeeding ones; their length  nearly equals their
breadth.   The generative apparatus repeated in each segment, as in the
taenia solium, is still more developed, and occupies, especially in the
hinder  segments, by far the greatest part of the space.  It consists  of
complicated tubular ovaries, and a convoluted uterus, on the one hand;
and  of a laro-e glandular testis, vas deferens, seminal receptacle, and
penis on the°other.   Certain glands, which seem to furnish a matter 
218
PARASITES.
to protect and  cement together the ova, open into the uterus, near its
termination at the vulva.   The multiplication of the joints seems  to
take place by division of the  first, that immediately succeeding to the
head, the two  parts subsequently enlarging.  The substance of the
joints in the tasniae consists of very minute nucleated cells, which doubt-
less obtain nutrition by absorption of chyle through the delicate integu-
ment.   There are two layers of muscular fibres, a transverse and longi-
tudinal.   The  ova are most matured in the  posterior segments, which
are, of course, the oldest.   It  is extremely  remarkable, and a most mer-
ciful provision, that the ova do not undergo development in the intestine
which  lodges  the parent;  otherwise, their enormous multitude would
speedily exhaust  the individual infested by them.  The further progress
of the ova has not been  determined,  but it is most probable that after
extrusion they (that is, such as do not become abortive) light upon some
suitable nidus, where they  attain a  certain stage of development before
they are again transferred  to the intestine  of some hospitable  recipient.
The taenia solium is a native of Britain, Holland, Germany, Egypt, and
the Levant; the  taenia lata, of Russia, Poland, Switzerland, and East-
ern Prussia, and  of Middle and Southern  France: it is clear that it is'
some  peculiarity  in the  localities, and  not in the human inhabitants,
which  determines this limitation, as a visitor to a foreign  country may
be attacked by a  different  parasite to  that which is indigenous in his
own land.   Cystica.—There seems to be good reason to doubt whether
the animals contained in this order should be separated from the pre-
ceding; the formation of the head in both is identical, or nearly so, and
the different shape of the  body may very  possibly depend on its being
placed under different conditions of development.  Cysticercus cellulosa
has a conical, glistening, white, transversely wrinkled body, and a  cau-
date vesicle, which assumes various shapes, according to the pressure of
surrounding parts.  Its  size  is about that of a pea or bean, in most
cases, but when  situate  in open cavities, as  the  cerebral ventricles, it
may attain the size of a hazel-nut.   The body and head can  be  drawn
into the vesicle, and when  there may escape notice.  The head is some-
what larger than the neck,  of a quadrangular shape, with a round sucker
at each' angle, and provided  in the middle, at  the  base  of  a conical
proboscis, with a  double  circle of hooks, amounting in number to about
thirty-two.  In structure,  the body and globose  tail consist  of a well-
marked homogeneous membrane, which is  covered over internally with
a  layer of highly-refracting celloid particles.  These are very closely
packed together  in the  body, but  are less numerous in the  neck, and
disappear by the  caudal appendage; they have very much  the aspect of
fat- cells, but are  shown, by the action of acid, to contain carbonate of
lime.  ^ They lie upon  a stratum of dark, finely-divided molecular matter,
which is also spread over the surface of the interior of the caudal pouch.
A neutral, slightly albuminous  fluid distends this  cavity moderately.
When  the cysticercus lies  in the substance of an organ, it determines
the formation of  a kind of fibrous cyst around itself;  this is wanting
when it lies in a  natural cavity, as the ventricles of the brain.  After
the death of the  animal the  body collapses,  and degenerates, more or
less  completely,  while  calcareous  deposition  at  the  same time  takes 
PARASITES.
219
place, so that there remains at last only a chalky mass surrounded by a
fibrous  cyst.   This parasite occurs in  the  brain, and in the voluntary
muscles; it is sometimes solitary, sometimes in  great numbers.   Echi-
nococcus hominis is a minute, but very interesting and not uncommon
parasite, which inhabits, in great numbers, the interior of  those large
globular sacs which are  called acephalocysts or hydatids.  One of these
consists of  an external  enveloping  cyst, composed of condensed fibrous
tissue  closely  in contact with the  tissue of the  part  in which it lies,
traversed by some  vessels, and lined on its interior, according to Vogel,
by an  epithelium.   Within this is a second cyst of nearly milk-white
aspect, nearly  brittle,  and yet,  elastic in  some degree, without  any
organic connection whatever with  the  inclosing cyst,  and filled, itself,
with a pellucid serous fluid, in which are often numerous secondary cysts,
either free  and floating, or attached to  the wall of the parent.   These
secondary cysts sometimes  contain a tertiary, and the tertiary again a
fourth generation.  The younger cysts are tensely filled with a fluid like
that of the parent, which spurts  out on an  incision  being made, while
the membrane curls  outwards.   They are sometimes so numerous as to

                                Fig. 112.
A. Echinococcus, the head retracted.
B. Echinococcus, the head and cornet of hooks facing the observer.
c. Echinococcus, the head extruded.
D. Section of wall of acephalocyst, with blastematous layer, in which are seen several Echinococci.
occupy great part of the parental cavity; they vary, also, much in size,
from that of a small seed to that of a goose's egg, or even more.   Their
membrane is precisely similar to that of the parent; it is  beautifully
seen when a thin vertical section is  placed in the field of the microscope,
to consist of a very great number of  laminae, which are arranged con-
centrically, and vary in thickness, from uo1^—2cn5o inch, according to
a recent observation which we made.   The  substance of the membrane
has the chemical properties of coagulated albumen, or fibrin, and there
can be no doubt that it is the result of the  effusion of liquor sanguinis
from the  external cyst, which solidifies as it is effused, layer by layer; 
220
PARASITES.
 and thus, somewhat  after the fashion  of an aneurismal sac, is formed
 an interior laminated cyst.   But little is known as to the mode  of form-
 ation of the secondary cysts; what we have ourselves observed amounts
 to this: On the interior of  a primary cyst, a number of whitish opaque
 spots, of the size of  a  pin's head, were seen; these were produced by
 the existence of a number of circularly disposed laminae, identical with
 those  of the membrane itself, and  apparently inclosing a cavity.  A
 little more  elevation  and isolation of these spots would have produced
 a secondary cyst; not indeed detached, but sessile, as they often are
 found to be.  The transparent fluid contents of the cysts have a specific
 gravity of 1.008—1.013, are neutral, or slightly alkaline, contain very
 little albumen,  if any, some  extractive and fatty matter, and some salts,
 especially chloride of sodium.   With respect to the echinococci, whose
 habitation we  have  now described, they seem to form in  a  stratum
 which lies on the inner  surface of the parent cyst.  This  is of opaque
 oily aspect, and consists of imperfect celloid particles, irregularly shaped,
 non-nucleated,  a little larger than pus-corpuscles, and with faint granu-
 lar contents, lying imbedded in  an oily and granular matter.   In this
 kind of blastema there  lie numerous echinococci, which, as  in  the in-
 stance referred to, may be separated, or aggregated together in  groups.
 The groups are  sometimes inclosed  in  a spherical sac, attached  by  a
 pedicle to the wall, or the individuals of the group are connected to-
 gether only by a  short  branching pedicle,  which  sends  a division to
 each.   The  echinococci are about 2Jy in.  — ^ in. long, and  ^ —
 Tin in. wide; they have a head  much  like that of a  taenia, provided
 with four lateral suckers, and a double row of hooklets, situate at the
 extremity, around an  orifice.  The head is  separated by a contraction
 from a  thicker roundish body, at  the  posterior extremity of  which is a
 transverse depression, into which  a  short delicate pedicle is inserted.
 Ihis pedicle is  the same before mentioned  by which the  animal  is at-
 tached to the cyst membrane.   The echinococcus is most  commonly
 seen with its head inverted, and, as  it  were, doubled inwards,  so  that
 the animal appears of an oval shape, with an orifice  at the part oppo-
 site to the attachment of the pedicle, and a narrow canal leading from
 thence  downward  to  the middle of  the interior,  where  the  circlet of
 hooks is now seen  marking the position of the extremity of the head.
 It consists of a strong,  homogeneous  membrane, which  is covered  over,
 internally, by a soft granulous substance, in which are imbedded  several
 retracting, probably calcareous, celloid corpuscles.  There is no appear-
 ance of reproductive  organs  in the echinococci; the young seem to be
 produced in the blastematous layer we have  already noticed.   They are
 described by Mr  Erasmus Wilson as originating in certain transparent
 ce s, some of which are, however, more opaque.  Both  contain smaller
 cells, but these  are more defined in the latter, and are mostly nucleated.
 Ihe inclosing membrane of the primary cell ruptures, and  the included
 cells are diffused " in  the form of a small opaque patch in the substance
 ot the internal  membrane of the  acephalocyst."   The cells multiply,
and form a small globular prominence on the surface of the membrane
while one larger and more transparent cell is to be seen in the interior
ot the mass.  As the  germinal patch increases in size, other protrusions 
PARASITES.
221
take place around the base of the original one, and develop in the same
way.   The formation of the echinococcus from  the mass of cells seems
to take place by their coalescence, and retiring from the centre so as to
leave a tubular canal, which Mr. Wilson believes  to be  modified, so as
to form in the body the  retractor muscle of the head, and  exterior to it
the peduncle.
   A ciliary movement has been seen by M. Lebert in the interior of echi-
nococci;  it does not, however, appear to be a constant phenomenon.  We
have never seen it ourselves.  Among the multitudes of living echinococci,
some are found which are shrivelled, altered in shape, more opaque than
the others, and filled with an opaque granular mass.   These are  doubt-
less dead, and, at the same time, traces of others, which have completely
decayed, are discernible in  the shape of detached hooklets.   When, as
occasionally happens, a cyst, such as we have above described, is entirely
barren of  echinococci,  it is properly termed an acephalocyst.  This is
much  more frequently,  we think, the case with  the  secondary and ter-
tiary than with the primary cyst.   We cannot hesitate for a moment to
regard the cyst  productions as  simply results of a peculiar  exudative
process,  and not  as in the least partaking of the character of animals.
The exterior envelop is derived from the natural tissues of the affected
part;  the  interior, which can alone be considered as proper to the ace-
phalocyst, can scarcely be said to be organized, not, we think, certainly
so much as the successive layers of false  membrane, which are  formed
upon an inflamed serous surface.  Neither can we consider  the acephalo-
cyst as a " gigantic organic cell," as all we  know of its origin is entirely
opposed to such an idea.  Its relation to the echinococci is, in all  proba-
bility, that of affording a suitable nidus for their formation and develop-
ment; but it is by no means clear why, in some acephalocysts, the  animal
 cells are wanting; or why, in others inhabited by them,  no  secondary
 cysts  are  produced.   Perhaps it may be  found that the development of
 echinococci  and  secondary cysts takes place in an inverse ratio to each
 other.   The  cysts, both primary and secondary,  are subject to degene-
 rate ; they become less  tensely filled, their walls softer and  more gelatin-
 ous, their  contents turbid  with diffused granulous matter  and debris of
 echinococci.  At last they  shrivel up into a caseous mass,  which is often
 the seat of calcareous deposit.  A  variable  number of its  progeny may
 decay in this  manner,  without the parent cyst  itself being similarly
 affected.  Inflammation of the external enveloping cyst is  the chief
 cause of the destruction of the primary formation in contact with it;
 this is sometimes very  acute, and leads to the formation of an abscess,
 which subsequently opens externally, or into some of the  adjacent cavi-
 ties or  canals.  The debris of the  acephalocyst  and  its  contents may
 be evacuated in this way,  and as the cavity contracts and closes a cure
 is effected.  When the inflammation is more chronic, the exudation which
 is poured out into the cavity of the primary cyst seems to derange the
 nutrition of the  included ones, so  that  they shrink up and degenerate
 into mere laminae, of  cheesy consistence;  these, together with  an  oily
 calcareous residue of  the  fluid contents, which are gradually absorbed,
 remain  in the interior of the primary  cyst, which itself wastes  and
 shrinks  like  its included progeny.   In this way, another kind of cure of 
222
PARASITES.
the disease takes place, as the degenerated mass may remain for an in-
definite time in the substance of a part, without giving rise to any symp-
toms.   Such degenerated  acephalocysts  have,  it would appear,  been
mistaken for tubercle.   The following organs are occasionally the seat
of acephalocysts.   The liver, xar' t%oxnv, the peritoneum, and the under-
lying areolar tissue, the muscles, the brain, the spleen, the  kidneys, the
lungs, the bones.   They not uncommonly occur in several parts at the
same time.  The  only injurious effects ordinarily caused by acephalo-
cysts, are such  as  result  from pressure on important parts.  It may,
perhaps, happen that they  cause exhaustion when very numerous.
   It  may be well  to add a caution, with respect to Pseudo-parasites, as
they  are termed.  These are either  real animals, which are mingled
with the excretions by impostors, or substances which are really produced
in the body, but are not  animals  at  all.  It may sometimes require a
more than ordinary acquaintance with parasitic animals to arrive at the
truth. 
THE  PATHOLOGICAL ANATOMY  OP THE
                NERVOUS  SYSTEM.
                     CHAPTER  VI.

                  GENERAL  OBSERVATIONS.

  In no organ or system of the human body is there such an apparent
want of accordance and definite relation between the symptoms of dis-
ease and the structural derangements and changes produced by it, as in
the nervous system  at  large.   This is due to various  causes.   In the
first place, our physiological knowledge of the laws governing the action
of the nervous system  is not on a par with our acquaintance with the
processes operating  in  other organs;  chemistry,  physics, mechanics,
can be  called to aid in the investigation of the healthy and diseased
states of the bones, the soft tissues investing them, the thoracic or ab-
dominal viscera; and the structure of these parts is more analogous to
what meets the eye of the scientific observer in other departments of
nature.  The only agent to which nervous functions can  be  compared,
eludes  our  senses, except in  its manifestations, as much  as  the opera-
tions of the cerebro-spinal energies themselves; we can judge of gal-
vanism  and electricity by the effects they produce, but we do  not see
their modus operandi;  and we have not even succeeded in demonstrat-
ing, as yet, the existence, in  the  brain or spinal  cord, of a structure
which may legitimately be  concluded to generate a force, in a manner
similar  to the production  of that  powerful agent, which is  now meta-
morphosing the human race.   It is, then, manifestly impossible, if we
are imperfectly acquainted  with the laws governing the nervous system
in health, that we should be able, sufficiently, to define and  appreciate
the deviations from  the healthy standard; and, in  many instances, we
must be satisfied to refer for explanation of the symptoms we meet with,
to hypothetical analogies, or confess our entire incapability of account-
ing for the phenomena before us.   A correct appreciation of the symp-
toms of disease is a point which next may be fairly demanded of us, if
we  attempt to explain or seek for morbid phenomena after  death;
thanks to Sir Charles  Bell,  Flourens, Marshall Hall, Romberg, and
other distinguished inquirers of the present age, much has been cleared
up, which previously appeared an impenetrable mystery ; but  our means
of physical diagnosis are still but scanty; we  are  left, in a large num- 
224
GENERAL OBSERVATIONS.
ber of cases, to form our opinions from the subjective statements of the
patient; and where  these  fail us, as in early childhood, or in certain
forms  of disease, the greatest empirical experience may be inadequate
to offer an explanation  of the  symptoms, or even to determine their
exact relation to cerebral lesions.  The peculiar connection of the brain
with our mental powers  and the soul,  will, necessarily, ever place it in
a different position, in regard to physical research, than other organs
of the  body, and  in  no department of natural science is  the caution
more necessary, that we  should  not  mistake  that which is unattainable
to science, and  that which the  Creator has  allowed to be within our
reach;  and, valuable  as  are vivisections,  and other experiments, made
upon the lower animals, in reference to neurology, we  must never for-
get,  on the one hand, the disturbance to the ordinary laws of action
likely to be produced by the injuries themselves; and on the other, the
chasm which intervenes between the  brute creation and the  human spe-
cies.   We cannot allude  to the subject  of the diagnosis of nervous dis-
ease, without dwelling, forcibly,  on the necessity for availing ourselves
of those means which, limited as they  may be, are  yet not used as uni-
formly  and perseveringly as they are  applied for  the  investigation of
other morbid states of the body.  A close examination by the eye and
by the hand should be made of the cranium, the spinal column, and the
courses  of affected nerves;  the thermometer  and the dynamometer
should be brought into more frequent  use, and more  accurate tests of
the sensibility and mobility, and other  functions of the nervous system,
ought to be employed than have hitherto generally prevailed.
  The  researches  of Bright, Frerichs, and  others, have demonstrated
the close relation of the state  of the blood  to cerebral  disease; and
science has shown,  what, previously, was purely  hypothetical, that
the most fatal conditions may be thus induced without any palpable
changes being wrought in the cerebral tissues.   It does not, however,
follow that, because we see no changes, none have taken place.  The
poison that we know to be in the blood may  elude our chemical tests,
and  yet cause death.  Then, seeing how limited our knowledge of the
nervous system is, it is not to be wondered at that, although the mani-
festation of altered  function  is  so  great as  to  force the belief in its
altered  constitution, it is not in our power  to  prove  the latter to the
perception; but, as Dr. Watson remarks, " whatever may be the nature
of the unknown, and, perhaps, fugitive physical conditions of the nerv-
ous centres, thus capable of disturbing, or abolishing their functions,
it is  useful to keep in our minds  a distinct and clear conception of the
fact, that there must be some such physical conditions."
  In examining  the pathology of the  nervous system,  we shall  adopt
the  succession usually followed  by medical writers, and consider, first,
the  brain and its  membranes;  next,  the spinal  cord, with its mem-
branes ;  third, the cerebro-spinal nerves, and  the subject will be con-
cluded by a summary of what is known with regard to the sympathetic. 
CHAPTER  VII.
                       THE DURA  MATER.

  The intimate relation existing  between the dura mater and the cra-
nium  renders it peculiarly prone to sympathetic affections propagated
from the bone, and from its proximity to the latter it is most likely to
be involved in injuries of a traumatic nature.   As on its external sur-
face the close contact with the  cranium favors  a communication of dis-
ease from without, so the relation of its internal surface to the arachnoid
induces a liability to communication of morbid action from within.  The
amount of idiopathic disease discoverable in the dura mater in the dead-
house is not great;  though we are justified, by its character as a fibro-
serous membrane, in assuming that it is frequently affected during life;
thus,  the headaches complained  of by patients  affected with chronic
rheumatism may  often fairly be set down to a diseased condition of the
dura  mater,  both from the resemblance which its symptoms  offer  to
those occurring in rheumatism of other fibro-serous  membranes, and
from the success resulting from an anti-rheumatic treatment.   It is not
the general character of rheumatism  to cause marked  or extensive dis-
organization when attacking membranous expansions, and there are  no
especial reasons to expect  a deviation from  this rule in regard to the
fibrous covering  of the brain.  A considerable difference exists in the
adhesion between the dura mater and the cranium at different periods
of life, independently of disease ;  the connection is lax in childhood, and
is rendered more intimate and firm with  advancing age, as the sutures
become ossified and the bones lose their resiliency.   It is especially in
the latter period  that external  injuries  are liable to implicate the dura
mater as well as the bone, and  one of the most common effects of blows
or concussions is a forcible separation of the  membrane, with hemor-
rhage between it  and the bone.  The clot may, as elsewhere, be partially
or entirely absorbed, and we  accordingly meet with it in the various
stages of metamorphosis.  One form of hemorrhage in this region is
connate, and is termed cephalhaematoma;' it is produced  by the pres-
sure exerted during parturition, and is generally found in the form of a
tumor, varying in size from a walnut  to a child's head, on the parietal
bone, presenting  during labor.  As this, however, is rather an affection
of the pericranium, we shall revert to it when speaking of the morbid
anatomy of the bones.   We  may state  that nature adopts the same
process of limitation and absorption in the case of the external as in the
internal hemorrhage.

            1 Deriv. xs<j>«x»i, head;  and alparupi, sanguineous tuaior.
       15 
226
THE DURA MATER.
  Inflammation of the dura mater presents the features of inflammatory
action in fibrous tissues generally; it is never of a very active character,
and in many instances of contiguous inflammation, the membrane seems
to act as a barrier, to intercept  its progress.   In the first stage the
membrane presents a pinky  hue, which  is irregularly diffused, and evi-
dently has but little tendency to spread.  The injection causes the dura
mater to assume a more lax  and pulpy condition, and it is more readily
detached from the adjacent parts.   A stage of infiltration and suppura-
tion, or of effusion of lymph  may follow; the latter is the more frequent
result of idiopathic inflammation of the dura mater, and may give rise
to induration, firm adhesion, thickening, or to new formations, such as
the production  of bone.   In fibrous tissues generally the tendency to
lymphatic effusion is rather  on  the surface, causing an attachment to
adjacent parts, whether  bone or muscle;  in the  dura mater, however,
interstitial effusion is more frequently met with,  on which account the
latter is more likely  to  show the traces  of inflammatory action  than
aponeurotic  or fascial expansions.   When apparent adhesions occur be-
tween the dura mater and the arachnoid, which are not unfrequent, they
are rather the effect of inflammatory action and deposition of lymph on
the latter than on the former.  In such a  case the removal of the dura
mater cannot be effected without laceration of the arachnoid or the sub-
jacent gray  matter, or connecting bands or shreds are found to be drawn
out as the membranes are separated.   The reparation  of solutions of
continuity in the  dura mater is not effected with the same rapidity and
vigor that we see in more vascular tissues.   From  its contiguity to the
skull it is very liable to  be implicated  in  external  injuries, which may
assume the character of the  injury to the bone, being cut, punctured, or
bruised;  or, we occasionally meet with laceration of the dura mater from
concussion at a distance from the point  at which the force was applied.
The same causes  that give rise  to  hemorrhage  between the periosteum
and bone elsewhere, frequently induce extravasation between the dura
mater and the inner table of the skull;  but they are all of a mechanical
nature.  A  form  of inflammation that we very commonly meet with in
the dura mater is that  resulting from  inflammation occurring  in the
internal auditory passages and the cells of the  mastoid  process.   This
form is not only secondary,  but also of  a dyscrasic  character; it is met
with chiefly in childhood and in scrofulous individuals.   As infants may
be affected with otitis, it often becomes  a matter of difficulty to form a
correct diagnosis  at the  commencement of the disease, when remedies
are most likely to arrest it and  prove beneficial.   The  disease may be
initiated in the mucous membrane or the bone, and as the morbid process
extends towards  the cavity of the cranium, effusion  of lymph or pus
takes place under the dura mater, and the brain itself generally becomes
involved.  The dura mater is often found  black and sloughy, especially
over the diseased portion  of bone; and  it is a curious fact, illustrating
the propagation of disease  from  one tissue to another without actual
contact of the morbid process, that there need not necessarily be a per-
foration of the pars petrosa to induce the inflammation of the dura mater.
Mr. Toynbee has found that disease communicated to the encephalon in
this manner more frequently induces morbid action in the cerebellum 
THE  DURA MATER.
227
than in the cerebrum.   The same affection, purulent otorrhoea, when of
long standing, is liable to induce inflammation in the sinuses of the dura
mater; though other injuries, accompanied by purulent discharges, may
also give rise to it.  This  particular form of phlebitis is mainly, if  not
exclusively met with in early life; when the sinuses become inflamed in
manhood, it is the result of external injury.   The dura mater in such a
case is found more closely adherent to the skull in the line  of the inflamed
sinuses and their vicinity than elsewhere, and the contents of the sinuses
are  fibrinous coagula, while their  lining membrane  is  thickened and
deprived of its  lustre and smoothness, as in other  cases  of  phlebitis.
More  or less adhesion is generally found to exist between the dura mater
and the visceral plate of  the arachnoid, when the former has  suffered
from inflammation.                    4
   A gradual absorption of the dura mater from within,  and consequent
thinning and perforation, is occasionally observed  to follow the growth
of tumors, from the brain, or inner membranes; it may also result from
an unusual increase in the size and number of  the  Pacchionian bodies.
Of these we shall have occasion to speak, when considering the relations
of the arachnoid.
   Little  is to be said concerning heterologous products occurring in the
dura mater;  the same cause which accounts for the comparative rarity

                                Fig. 113
 A portion of dura mater, exhibiting a mass of bone-like substance of low conical form, attached to the side
of the falx cerebri. The patient, 28 years old, had been subject to severe headaches from boyhood. A fort-
night before death acute  headache supervened, followed by delirium, partial paralysis, and insensibility.
There was copious effusion of lymph in the cerebral membranes and ventricles.
 * Lateral view of the same. St. Bartholomew's Museum. Series vi. No. 46. Catalogue, vol. i. p. 201.


of idiopathic inflammation  in this membrane, suffices to explain why it
is less frequently  the seat of adventitious growths, than the other  en-
velops of the brain.  Fibroid tumors are not unfrequent in connection 
228
THE DURA MATER.
with the dura mater, from  which they are more prone to arise than
from other structures within the cranium;  according  to  the  prevailing
law, that the physiological properties of a structure are liable to influence
the morbid growths springing from it.   In many instances these tumors
would come under the head of hypertrophy, rather than of heterologous
products.
   Both on the internal and  external surface of the dura mater we fre-
quently meet with small laminae of  bone, which, in many  instances, may
be owing to chronic inflammatory action, of which no other  trace is left.
Some writers deny that the ossifications found on the inner surface of
the dura mater  are  the  products of this  membrane; they view them
rather as growths  belonging to the arachnoid, an opinion  to which we
demur, both on account of the position in which these bone deposits are
found, and from the  general endowment of periosteal  tissues, to  which
class  the  dura  mater undoubtedly  belongs, to generate  bone.   These
ossifications, which are easily separated from the dura mater, and  are
generally met with along the falx, must not be  confounded with  the
hypertrophy of  the  frontal  and  parietal  bones,  said  to occur during
pregnancy, and hence termed,  by  their discoverer, Rokitansky, puer-
peral osteophyte.  The most remarkable instances  of  genuine ossifica-
tion, or  of osseous deposit in the dura mater, are occasionally met with
in chronic hydrocephalus, where it seems to indicate an effort of nature
to afford extra protection to the diseased brain.   A delineation of this
affection is given in Dr. Bright's medical reports.
   Cysts of a lipomatous  character  are occasionally found attached to
the dura mater.
   We have already seen  that the dura mater is frequently subject to
secondary inflammation, owing to  the extension of scrofulous or tuber-
cular inflammation from adjoining bones; it may  thus, as  also by exten-
sion of tubercular disease from the cerebral tissue,  become the seat of
tubercular  deposit; but  the primary deposit of tubercle in  the dura
mater is, probably, never seen.   Tumors  of a cancerous nature more
frequently grow from the dura mater; and, although the  term  " fungus
of the dura mater" may occasionally have  been falsely applied to car-
cinomatous formations within the cranial  bones, still, morbid  anatomy
supplies numerous instances of undoubted cancer of the dura mater.
It occurs either in the form of an infiltration of the membrane; in con-
sequence of which the  dura mater becomes thickened, and  may, by
degrees, communicate the carcinomatous infection to the arachnoid, or
the bones; or it assumes the form of a rounded tumor, which generally
consists of medullary cancer, and pushes its way through the adjoining
bone.   It is commonly very vascular, and generally  occupies a situation
near the vertex.  When it forces  its way through the  osseous parietes,
these form a ring round it, and the external table  of  the cranial bone
will present a  smaller opening than the  internal  table.  Its growth
becomes very much more rapid  when it has passed the  bounds  in  which
it  is first kept by the skull, and the soft parts  soon  become involved
and perforated.
   The dura mater rarely exhibits any malformation or defect, beyond
those  spoken of, except that the falx  is occasionally  found cribrated, 
THE DURA  MATER.
229
and that in old people the dura  mater presents slits in the vicinity of
the longitudinal sinus, varying from two to four lines in length, through
which the Pacchionian glands have forced their way.
   The records of the Pathological Society of London contain the account
of a very rare defect of the falx cerebri, exhibited by Mr. Shaw.1   Dr.
Bright2 also gives a  similar case, in which no trace  of  the process was
visible anterior to the tentorium, and it was assumed that  the defect,
which occurred in a lady thirty years of age, had existed from birth.

              1 Reports of the Pathological Society, 1847-48, p. 178.
              2 Medical Reports, vol. i. p. 150. 
CHAPTER  VIII.
              THE 'ARACHNOID  AND PIA MATER.

  The traditional doctrine of anatomy, that the arachnoid is a serous
membrane  of  the  same character as the pleura  or  pericardium,  has
found powerful opponents in  Doctors Henle and Kolliker, who have
shown that the external lamina is nothing more than an epithelial layer
investing the dura mater.   It  must also be  remembered that the arach-
noid is entirely dependent for  its supply of blood upon the pia mater;
and  that, consequently, in health as well as disease, the condition of
these two structures necessarily bears a very intimate mutual relation.
The pathologist has, instinctively as it were, adopted this view; inasmuch
as the term meningitis is generally understood to comprise inflammation
of the arachnoid and the pia mater,  to the exclusion of inflammation of
the dura mater, which  is not implied in the name; while arachnitis is
commonly used to designate disease of the arachnoid, as well as the pia
mater, although etymology would not sanction sucn  an interpretation.
The  best authorities of our own country, on subjects connected with the
pathology of the brain and its membranes, as Doctors Watson, Aber-
crombie, and Bright, are opposed to over-refinement in these distinc-
tions, and  are inclined to deny the  limitation of disease to one  or  the
other of the structures under consideration.   It  certainly is more prac-
tical, and less likely to mislead the student, if we treat of the morbid
appearances of the arachnoid and pia mater under one head, pointing
out as we  go on those cases and diseases in which the one or the other
may appear exclusively or mainly implicated.  The arachnoid depends
solely for its supply of blood upon the pia mater, which may, therefore,
fairly be regarded as its matrix ; in fact, it is very doubtful whether the »
former  contains any bloodvessels of its own ; and, although it is com-
monly assumed that the arachnoid possesses the power  of secretion,  this
would seem rather to be of a mechanical than of a vital nature.
   Though the traces of active congestion or hyperaemia of the arachnoid
are not visible to the eye after death, we constantly meet with changes
in the physical characters of the membrane which are  the result of
increased action, though the history of the  individuals  fails to show the
occurrence of actual inflammation; opacity and thickening of the arach-
noid, especially on the surface of the hemispheres, is so frequent after the
middle period of life as almost to merit being classed under the changes
of involution,  but it is most marked in habitual drunkards;  in delirium
tremens, it is  often the only disorganization to be found in  the cranial
cavity.  This opacity is commonly  accompanied by more or less serous 
THE ARACHNOID AND PIA MATER.
231
effusion, which fills the sulci, and raises the membrane from the surface
of the brain.   Instead of being transparent, and allowing the vessels of
the pia  mater to shine through, the surface looks milky to a greater or
less  extent, and more  particularly on  the surface of the  hemispheres.
Owing to the  obliteration of the sulci by the serum, the affected portion
of the cerebrum often looks as if the convolutions were compressed, but
on removal of the serum the cause of this appearance at once becomes
evident.  The subarachnoid effusion may be independent of any affection
of the arachnoid, and be solely due to congestion of the pia mater; we
should then find no  adhesion between the tissues, the arachnoid retains
its transparency, and the fluid is more prone to follow the laws of gravi-
tation,  and form pouches at the dependent portions of the organ.
   It may fairly be questioned whether the subarachnoid fluid is, in any
way, due to the action of the arachnoid membrane.   Whenever we find
serum between the  layers  of  the arachnoid,  and in the  ventricles, to
adhere  to the received terminology,  it is right to refer  it  to that mem-
brane ;  but the vicinity of a congeries of vessels, and the known laws
of transudation, certainly favor the view that subarachnoid  effusion is
attributable to the pia mater only.  Congestion of the vascular network
contained in this membrane is extremely frequent, though we are more
frequently left to infer it, during life, than that we find it after death.
It is the very nature of congestion to  disappear  in  articulo mortis.
Still, there is a sufficient number of affections in which the vessels of
the  pia mater have been shown to be  gorged with blood, without any
further accompanying morbid conditions of  the  adjoining structures;
thus, we meet with  it in cases of pertussis, of fever, of capillary bron-
chitis, or disease of the heart.   The congestion may, in the latter case
more particularly, attain an extreme degree, so that, the blood not having
room in the veins, we find dark venous-colored blood even in the larger
arteries.
   There  is no doubt that, occasionally, the  subarachnoid fluid is attri-

                               Fig. 114.
 Subarachnoid effusion on the upper surface of the anterior lobe, causing an apparent obliteration of the
interstices between the convolutions, and accompanied by increased vascularity.
 * Enlarged Pacchionian bodies. 
32          HEMORRHAGE INTO THE ARACHNOID.
 butable  to  cadaveric changes;  it is, therefore, necessary to be circum-
 spect in at once attributing its presence  to  antecedent morbid action.
 The amount and  position, and, more  particularly, the concomitant ap-
 pearances of the pia mater and arachoid,  must assist us in determining
 the question in the individual case.
   It is not  yet decided whether the small nodules, which are found in
 almost every brain, but become more numerous with advancing age, and
 have received the name glandulae Pacchioni,1 are pathological products,
 or normal constituents.  A superficial examination suffices to show that
 they are not what their first discoverer assumed them to be, conglobate
 lymphatic glands.  They consist of an irregular fibrous network, contain-
 ing some albuminous granular matter, and generally occupy the vicinity
 of the' mesial line of the surface.  They often cause perforations of the
 dura mater, and may thus appear to belong to this membrane, when the
 brain  is taken out in all its envelops.  Their development, at times, is
 so considerable as even to  induce absorption  and thinning of the skull-
 cap.   The  term  arachnoid granulations, applied  to  them by Louis, is
 probably as correct a designation as any that has been given them, and
 we should be inclined to attribute  to them no higher importance  than
 that belonging to warty indurations on the surface of the body. Luschka,
 who has especially investigated the Pacchionian bodies, confirms this
 view, and describes them as cactus-like projections from  the arachnoid,
 of a fibrous organization, vascular, and covered by a scanty epithelium.
 He regards them  as  normal constituents  of  the membrane, but states
 that the hypertrophy to which they are liable may be the  cause of death
 by the pressure they occasion.
   The arachnoid is occasionally found to present an unctuous sensation
 to the  finger, without any marked  morbid changes being discoverable
 in its vicinity;  though there is  generally considerable disease in some
 part of  the brain, which would account for a change of nutrition and
 secretion in a membrane like the arachnoid.   This is  the case  in  four
 out of five cases in which Dr. Bright applies the term  to the  arachnoid.


            HEMORRHAGE  INTO  THE ARACHNOID.

  We  come now to the consideration of hemorrhage into the cavity of
 the arachnoid, a subject which presents a  peculiar interest, from being
 the form  of cerebral sanguineous  effusion most common  in childhood;
 the reverse condition obtains in adult life,  when hemorrhage within the
 cerebral  tissue is  the prevailing form.  In  neither case do we generally
 succeed in tracing the mouths  of the vessels  from which the discharge
 has proceeded; though it is easier to do so than in most other  hemor-
rhages.  In fact,  Dr. Watson2 lays  it down  as a rule,  that, while the
hemorrhages occurring in the lungs,  and other organs  of the body, are
due to exhalation, those occurring within the  cranium are attributable
to the actual rupture  of a  larger vessel.   We have already  alluded to

  1 Ant. Pacchioni Dissert. Epistolaris de Glandulis Conglobatis Durse Meningis. Romse,
1705.
  2 Lectures on the Practice of Physic, &c. vol. i. p. 494. 
HEMORRHAGE  INTO THE ARACHNOID.          233
one variety of hemorrhage occurring in the tissues of the head in the
new-born infant, which we stated  to  be the result of the mechanical
pressure exerted during  parturition; the  same cause may give rise to
arachnoidal effusion, which then commonly and speedily proves fatal.
In this case, we find a larger or smaller quantity of fluid blood investing
the upper surface of the brain; but, if the child survives the  immediate
shock  of the  apoplectic  seizure,  the  effused  blood will  undergo that
series  of changes, which indicate the tendency of the natural processes
to restore the parts to  their normal condition.   The first  step is the
formation of a coagulum; the fluid portions are first, absorbed, then, by
degrees, the coloring matter passes through various changes till it also
disappears, and we  then  find, in the place  of  the  original coagulum, a
membranous  formation, which is  more or  less organized, and may be
shown to contain a  capillary system of its own.  It is a singular act in
the  pathology of the disease, to which MM. Rilliet and  Barthez were
the  first to  draw attention, that, unlike  cerebral  hemorrhage  in the
adult, it rarely gives rise to paralysis in the  child; a circumstance ex-
plained  by Dr.  West,1 upon  the  principle of the blood in  the latter
instance being almost invariably effused into  the cavity of  the arach-
noid, in consequence of which, the effects of the pressure act more uni-
formly  upon  all the  contents  of the cranium.   The  changes in the
effused  blood  may, however, assume another form than the one above
described, and it is important  to be aware of the circumstance, as it
may stimulate hydrocephalus.  Instead of the serum being absorbed,

                                Fig. 115.
 This drawing represents a portion of dura mater divided from above, and showing a sac which was filled
with coagulated blood.  The coats of the sac presented nearly the same thickness as the dura mater.—St.
Bartholomew's Museum. Series vi. No. 25.

it may become, inclosed in a false membrane, and remain as a persistent
sac,  exerting an amount  of constant pressure upon the subjacent brain,
sufficient to cause the flattening  of the surface, and to induce,  as  they
generally do, a  considerable impairment of the intellect.   When these

  ' Lectures on the Diseases of Infancy and Childhood. By C. West, M. D.( London,
1848, p. 40. 
234
ARACHNITIS.
cysts are once formed they have a great power of passive  resistance,
and rarely diminish in size.
  Three interesting and instructive cases of  superficial hemorrhage
occurring in the adult, are given by Dr. Abercrombie;1 and we also find
a few instances recorded by Dr. Bright.2   In the former, nothing was
found either in the brain or the other viscera to account for the effusion ;
in one of the cases contained in the Medical Reports there was a hyper-
trophy of the heart; in another, the hemorrhage was due to the rupture
of a small aneurism; in a third, no lesions were found; and in two others
the hemorrhage was attributable to a fall, and the viscera do not appear
to have presented any disorganization.
                          ARACHNITIS.

  Arachnitis is a term used synonymously with meningitis, to designate
inflammation of the arachnoid and the pia mater.  The nosologist may
at the desk draw numerous fine  distinctions, and classify symptoms so
as to produce a uniform system of morbid processes;  but nature does not
bind herself to laws of this description.   This remark applies forcibly
to the attempts made to dissever inflammation  of the visceral plate of
the arachnoid from inflammation of the subjacent pia mater.   Whether
in the course of  pathological research we shall be justified in  establish-
ing more systematic  divisions than we  are  now able to do, is not the
question ; but we deem it especially our duty, throughout this work, to
place before the  student of pathology facts which he may recognize in
the dead-house,  from their  having been previously  observed by trust-
worthy inquirers, rather than to show him amaze of systems which have
long been the opprobrium  of scientific  medicine.   The subject imme-
diately before us is a stumbling-block  to the practitioner, as  much or
more than it has been to the pathological anatomist.  The  former has
allowed early and traditional impressions of the  necessity of  employing
powerful antiphlogistic treatment in all cases where heat of surface,
restlessness, a tendency to,  or actual convulsions, the drawn-in thumb,
and other well-known symptoms, seemed to indicate inflammatory action;
and many a child has been sacrificed at the altar of school-science, where
the avoidance of injurious influences, or a strengthening regimen, would
have succeeded in restoring the patient.   Similar observations apply to
much of our treatment in cerebral affections of adults, in whom cephalic
symptoms are, even at the present day, too uniformly looked upon as
the legitimate excuse  for the application of our entire  antiphlogistic
apparatus.^  These remarks have suggested themselves  by the great
difference in the causes and course of several diseases, which are each
due to, or connected with, inflammatory conditions of the pia mater and
arachnoid; and there is also one disease which must  be classed with the
former, which with  symptoms resembling those of  meningitis  leaves no

  1 Pathol, and Pract. Researches, &c. p. 242.
  2 Medical Reports, &c, p. 266.  See, also, Mr. Prescott Hewett's paper in the Medico-
Chir. Trans., vol. xxviii. 
ARACHNITIS.
235
trace of inflammatory or morbid action.  Under the first head we class
simple meningitis and tubercular meningitis; under the second, we allude
to hydrencephaloid disease, to which Marshall Hall1 first drew attention,
and the analogue of which is presented to us in the adult, m that form
of cephalic disease, termed somewhat indefinitely, serous apoplexy.  In
a case of simple acute  meningitis, three points especially deserve atten-
tion:  the vascularity  of the membranes, the  adventitious membrane
formed between the arachnoid  and the pia mater, and the effusion ot
serum or pus in the same position.  We may, according  to  the stage
and duration of the disease, meet with either  of these appearances, or
they may be combined in the same individual.  If the patient has died
 in the early stage of the disease, we find, on removing the dura mater,
 that  the subjacent membrane shows a great increase of vascularity,
 which may be so intense as  almost to resemble the effusion ot blood;
 the eye  and the touch will, however, speedily detect the real nature ot
 the discoloration.  The congestion spreads more or less over the surface,
 or  appears  in circumscribed  patches;  on removing  a portion ot the
 arachnoid, we shall find the congested vessels dipping down with the pia
 mater between the convolutions.   If effusion of lymph has taken place,
  a membranous expansion will  be found here and  there to intervene be-
  tween the two meninges, causing a sort of marbled appearance, or bands
  stretching from one convolution to another.  The effused lymph attams
  the thickness of  a wafer and more, and most  commonly occupies the
  upper portion of the hemispheres.   The lymph itself dips down into the
  convolutions, and presents the same variations of density and consistency
  that  this product  of inflammation offers elsewhere m  proportion  to  he
  date of  its  effusion.   Some serous effusion beneath the arachnoid of the

                                Fig. 116.
              v, i i,omi«nhprP of a vouns woman, aged 27, with purulent effusion under the arach-

convolutions.

base especially about the optic chiasma, which causes the part to re-
sembhX appearance of jelly, and a small amount of similar• flmd (fr m
two drachms to an ounce) in the ventricles, are often found in this form

      • On Diseases and Derangements of the Nervous System.  London, 1841. 
236
ARACHNITIS.
of arachnitis,  though it is by no means a necessary accompaniment.
The brain, in these cases of simple meningitis offers no appreciable de-
rangement of  structure, though the symptoms during life  may  have
shown very manifestly that its functions were involved.  The formation
of pus in the course of arachnitis is not an occurrence of frequency, but
it is necessary to bear in mind that it is a pathological fact.  A remark-
able  instance  of this occurred under  our  observation recently, at St.
Mary's  Hospital, in a young woman in whom  sudden  and unexpected
coma  supervened, and terminated, after thirty-six hours, in death.  She
had previously suffered  from otorrhoea;  but on her admission gave no
evidence of cephalic disease, nor was any direct connection traced after
death between the affection of the  ear  and the meningitis which was
found to have  caused her death.  Here two  yellow patches were dis-
covered on each parietal surface of the brain, owing to  an  accumulation
of pus spread  out under the meninges; the microscopic examination of
the fluid satisfactorily demonstrated the characters of pus.
  Cases of meningitis are now and then met with, in which the  arach-
noid appears perfectly transparent and  normal, while there  is vascularity
of the pia mater with subarachnoid effusion.   We should here  be in-
clined to assume an idiopathic  affection of the pia mater, and it  cannot
be denied that the evidence in favor of primary and independent disease
in that membrane, is stronger  than any arguments adducible in favor of
the same disposition in  the arachnoid.  We  cannot blind  ourselves  to
the fact that the latter  differs much in  its behavior from the  serous
membranes of the thorax and  abdomen, in the  rarity  of  inflammatory
effusion occurring within what  we must term the sac of the arachnoid,
if we continue to look upon it  in the same light as a serous membrane.
It is highly desirable that anatomists should settle its normal relations,
in order that the deviations occurring in morbid processes  may receive
the correct and proper  estimation.   Thus, with regard  to the effusion
occurring within the ventricles of the brain, which are commonly taught
to possess an  arachnoideal  lining, it  evidently  offers  many relations
different from  the arachnoideal effusions occurring on the surface of the
brain; nor is it quite intelligible why the secretion  into the  cavity of
the ventricles  should so  rarely be found to communicate with  the super-
ficial  arachnoideal space.   Kolliker,1 whose  profound knowledge  of
anatomy and physiology renders him an  authority in the matter, says:
"Those who state  that the arachnoid lines  the ventricles  of the brain,
and the processes of the pia mater contained in them, suppose a thing
that  is  impossible, viz., that  the  arachnoid passes through the  pia
mater, and invests the  surface of the plexuses, which is actually an
internal one."
  If we examine the inflamed  pia mater under the microscope, we shall
find the smaller vessels  studded with exudation matter, in  the shape of
minute oily-looking vesicles; we have seen it as in the  adjoining draw-
ing, so bounded by the outline of the vessel, that it seemed to lie within
its coats;  there is no a  priori reason why it should not  be formed in
the vessels. We also see numerous  so-called  inflammation corpuscles,

        1 Mikroskopische Anatomie von Dr. A. Kolliker, 1850, vol. ii. p. 501. 
ARACHNITIS.
237
which would appear rather to be a peculiar aggregation of the exudation
matter  than  distinct formations; they are  sometimes possessed  of a
delicate envelop, at others they  are  devoid of it; they may be  appro-

                                 Fig. 117.
 Meningeal vessels invested and surrounded by exudation matter, and glomeruli or exudation corpuscles,
from a young man, aged 34, who died in consequence of injury to the head, followed by meningitis; magn.
270 di.

priately compared to a mulberry—they generally, also, offer a brownish
tint.   We owe the knowledge of  these corpuscles to Professors  (jluge
Fig. 118.
Fig. 119.
          Further specimens of the microscopic appearances of the vessels in meningitis.

and Bennett;  the former was the first  to show their  connection with
inflammation generally,  the latter drew attention to  their  presence in
inflammatory affections of the brain and its membranes.
  Much confusion has arisen from the misapplication of the term hy-
drocephalus, as  it has been  used to  designate  a  variety  of diseases,
simply on account of their resembling one another in a  comparatively 
238
ARACHNITIS.
accidental feature; and we would, therefore, follow in the steps of those
authors who  limit the term  to  the dropsical  effusion  of serous fluid
within the cranium, unaccompanied by marked  symptoms of inflamma-
tory action during life.   We  have  already seen that an accumulation of
serum beneath the arachnoid, or  within  the ventricles, is a  common
feature in both acute and chronic meningitis; and though  an  affection
of serious import, we have  abundant  evidence of  the value  of  thera-
peutic proceeding in arresting and completely removing the disease and
all  its effects.  Not so with  what  is  commonly called  chronic hydro-
cephalus,  or what  ought exclusively  to  receive the name  of hydro-
cephalus, while certain forms of meningitis should designate the disease
acute hydrocephalus ;  nothing is more liable to mislead  the student, or
to perpetuate error, than a want of precision in our nomenclature.  We
must never forget that the effusion of serum  is only a product of mor-
bid  action ; and that inflammation,  mechanical  obstruction, anasmia,
blood-poisoning, scrofulous   cachexia, diseased conditions essentially
differing from one another, may each  of them give rise to a  secretion
of fluid into serous cavities.   It is erroneous, and likely to lead to  the
most injurious practice, if we apply a name to a symptom, by which it
becomes identified with the most opposite diseases.
  Whether we look upon the arachnoid as  a  serous  membrane or not,
and whether or not we continue to consider the lining of the ventricles
as a prolongation of the external arachnoid, there  is no  doubt of the
close resemblance between the structure of the latter, with this  differ-
ence, that while the superficial arachnoid overlays the pia mater, the
lining of the ventricles is in  direct opposition with  the  gray matter of
the brain.   In examining the  pathology  of the brain, we shall have
occasion again to allude to the ventricles,  but it seems advisable to ad-
vert to some changes which occur in them at this part of  our inquiry.
Here, as in the superficial arachnoid,  we  see no  traces of active con-
gestion, even where we have  the undoubted  evidence of inflammatory
action. Hemorrhage  into the ventricles is invariably the result  of in-
jury to or disease of the brain, and the effusion of blood into them is
stated by  Dr.  Bright to be the most rapidly fatal of any kind of apo-
plexy.  It has already been  mentioned that in  meningitis it is common
to find an increase in  the ordinary amount of secretion of the ventricu-
lar fluid;  but while this may be measured by drachms, the fluid accu-
mulating in hydrocephalus reaches to several  pints, and is  commonly
the result of defective action, not  so much in the membrane  as in the
cerebral and general circulation.  Though we fail to find a  congested
state of the vessels in the ventricular lining membrane, it often pre-
sents an indurated, thickened, and  granular  condition, indicative of
previous inflammation.   The  septum lucidum,  and the commissura
mollis, are generally involved in the morbid processes occurring  in the
ventricles : the former is  more particularly liable to suffer in chronic
hydrocephalus from distension ; and yielding to the mechanical pressure,
it becomes perforated, and allows of free communication  between the
two cavities.   The granulations of the arachnoid  occasionally become
prominent, and even pediculated ;  at  other times the inflammatory pro-
duct is rather of an adhesive character, and the opposite  sides  of the 
TUBERCULAR MENINGITIS.
239
ventricles, especially the corpora striata, may then become  agglutinated
to one another.
   It must be considered as one of the great goals which this and future
generations of scientific inquirers have to pursue, in how far these and
similar changes in the membranous  or parenchymatous structures are to
be attributed to dyscrasic conditions.  The combined modes of research
represented by the microscope and the test tube, must assist in solving
many  of the  problems that yet  puzzle the physician; and if there are
various  cachectic  conditions  differing essentially in  their  character, of
which we have no doubt, we must hope to succeed eventually in demon-
strating them more palpably than has yet been done, both in the living
and the dead subject.   That the rheumatic and  gouty diathesis  should
produce their definite lesions within the  cranium, as well as externally,
can scarcely  be  denied;  but we do not possess  sufficiently satisfactory
evidence.   Purpuric spots are occasionally seen  on  the arachnoid,  indi-
cating a scorbutic crasis; but none of the  erases  have hitherto  been
shown to have such  decided traces  within the cranium as the scrofulous
or tubercular.   The frequency of meningitis  in  childhood  is in a great
measure due  to this fact; and to it we may also in a measure  attribute
the great prevailing fatality, owing to the misconceptions that the  term
inflammation gave rise to; and  which, therefore, seemed to necessitate
antiphlogistic treatment of as active a character as if we  had to deal
with sthenic  inflammation.
                   TUBERCULAR MENINGITIS.

  The deposit of tubercle on  the pia mater of the brain occurs  in the
shape of small  miliary granules, resembling the Pacchionian bodies in

                                Fig. 120.
 Deposit of tubercular matter in the Sylvian fissure of the brain of a child, aged 19 months, who died ten
days from the first appearance of head symptoms, which were treated antiphlogistically.  The white circular
spots represent the tubercles, which were surrounded by highly congested bloodvessels.  The white deposit
examined by the microscope showed granular matter and granular corpuscles varying in size.


appearance, but differing from them both in their site and in their micro-
scopic relations.  They are not seen on  the free surface of the  arach- 
240
HYDROCEPHALUS.
noid; and, in  fact, seem in no way connected with  this membrane; a
point which establishes a marked difference between it and the serous
membranes of the thorax and the abdomen.   They are found most fre-
quently deeply within the  Sylvian  fissure, in  the convolutions  of the
brain, and at the base;  they are of the size of pins'  heads,  and appear
in the form of gray granulations, imbedded among a vascular network;
they are very rarely found upon the cerebellum.  A careful examina-
tion is necessary, to prevent their being overlooked;  but in  a therapeu-
tic point of view, it is most important that their presence should be duly
appreciated, and that they  should be taken as an indication of a state of
the blood, requiring a different line of treatment from what  ought to be
adopted  in meningitis, unconnected with  the  pathological condition of
the fluids that tubercle implies.  It is only by the aid of the microscope
that we have been able positively to determine the real nature of these
granulations, for they closely resemble a  mere puckering of the mem-
brane ;  seen  under a power of three or  four  hundred  diameters, their
elements resolve themselves into the corpuscles peculiar to tubercle,
possessing a faint outline,  with  granular  contents, and surrounded  by
granular matter.   The tubercular  corpuscles  must not be  confounded
with epithelium, which may be seen under the same  field, and which is
to be distinguished by the nuclei it contains, within which, again, one or
two nucleoli are visible.
   This form of  meningitis is  generally met with in  connection with or
secondary to tuberculosis of other organs; though we see it occasionally
in the idiopathic form,  as  in  the instance from which our  delineation
was taken, where no tubercular deposit was found in any of the viscera
beside the brain.  In the former case, the tubercular deposit may take
place so  insidiously as to offer no marked inflammatory symptoms during
life; and it is only on the dissecting-table that the  physician becomes
aware of the cerebral disease.  It must, therefore, be borne in mind
that scrofulous  children have a tendency to become  afflicted in this
manner; and  it is an additional reason for watching them with care,
and avoiding such debilitating measures as would be  likely to encourage
the dyscrasia.  It is not our province to enter into the  consideration of
nosological or therapeutic inquiries, but we  cannot avoid  remarking
that the frequency of tubercular deposit in the pia mater in children is
a strong argument against those powerful depleting measures which
inflammatory symptoms presenting  themselves in the head  of  a  young
subject, are generally calculated to provoke.
                       HYDROCEPHALUS.

  The irritation of the  tubercular deposit is very liable to induce the
secretion of serum, either beneath the arachnoid membrane, or in the
cavities of  the brain, and this leads us to the consideration of that for-
midable disease of childhood, hydrocephalus.
  The etymology of the term indicates the main feature that character-
izes the morbid condition, and, provided its application be limited to the
class under consideration, it is not likely to mislead the practitioner, as 
HYDROCEPHALUS.
241
it implies no theory.  It  is truly a dropsy of the brain, and it is  an
affection which, like dropsies in other parts of the animal  economy, is
favored by a relaxed and soft condition  of the surrounding tissues; the
anatomical peculiarities of the foetal and infant head at once indicate a
probable  reason why it should commence  at  those  periods;  while the
mal-nutrition upon which it is based, and  the further impairment of the
important organ in which it occurs, is a sufficient ground for  explaining
its great  fatality, and the infrequency of  the child affected with  it sur-
viving to  reach manhood.  Instances are, however,  on record, of indi-
viduals in whom the parts accommodated  themselves  to the morbid effu-
sion, and life was  prolonged far  beyond the period of  childhood.  The
most celebrated case of this kind is that of James Cardinal,1 who  at-
tained the age of  twenty-nine, though he had been hydrocephalic from
within a fortnight after birth; the circumference  of  his skull measured
at the period  of his death thirty-two inches and a quarter.
    The accumulation of serum frequently commences in the ventricles,
 which are the most ordinary seat of hvdrocephalus, or on the surface of
 the brain, during  the last months of foetal life;  it  may become a  cir-
 cumstance for the consideration of the accoucheur  during parturition,
Fig. 121.
  . ^ ^    v. it „v„n from a rfrl aeed 11 years: the enlargement of the skull is effected by its elongation,
 A hydrocephalic f^7^^fdits Jase.  An increase of width appears to have been prevented by
^S^^^^^^'^M'atm-  Tnecoronalsuture^ndthatbetweenth^ronU!
W anTthe suture, also of the splenoid, are wide open.  The superior walls of the orbits are pressed down.
wTds  The bones generally are thin and light. St. Bartholomew's Museum, sub series *, 2.

not so much from the increased size of  the head presenting  an obstacle,
because  there is even a greater compressibility than usual but from the
head beinp so soft as not to offer a sufficient fulcrum for the labor pains
to act upon, or, in case of operative interference, for the instruments to
obtain a sufficient purchase.   The child may, however, be born appa-
rently without a  blemish, though  it does  not thrive well, and a  few
weekl after birth, or  at  least within  the  first three  years  of  Me, Ae
head appears to increase unduly in size, and the ossification of  the ton-
Lnelles^  retarded.   Dr. West states,* that  out  of  fi ^^^
toms of  hydrocephalus were observed in forty-six  before they were six
          ■ Dr. Bright's Medical Reports, p. 431.
          2 On the Diseases of Infancy, 1848, p. 84.
16 
242
HYDROCEPHALUS.
months old, and in twelve of these the malady was congenital, and that
in nineteen more it came on before the completion of the third month.
The accumulation of fluid may amount to as much as ten pounds.   The
increase in  the  quantity is  greatest during the  first months, and dimi-
nishes or  even remains stationary if the child survives; the circumfer-
ence of the head corresponds to these relations; thus, it is not uncom-
mon to find the circumference to attain  as  much as  twenty-six inches
and more, during the first three months, and to vary but little subse-
quently.
   The immediate pathological effect of this secretion is to compress the
parts  within the skull, and to distend  and prevent the due ossification
of the cranium; the frontal bone is made to protrude, and the parietal
bones, from their yielding character,  bulge  out  considerably  on each
side, while the intervening soft parts present fluctuation.  Ossification
takes  place, though irregularly,  and at  a  much later  period, and we
have already seen  that  a succedaneous deposit  of bone is occasionally
effected in the dura mater.  The sutures of  the  cranial  bones are not
formed as in the healthy skull, but are less serrated, and therefore more
ready to yield to pressure from within, which they occasionally do, after
they have closed, in the event of a sudden increase of  the fluid.   The
ossification does not  proceed with the normal regularity, but numerous
centres form, and thus we meet with more or less ossa triquetra in the
line of the sutures.  In an almost similar ratio,  we shall find the brain
altered in its relations.  If the accumulation has been confined to the
ventricular cavities, the  entire brain will be distended, and  its  tissue is
generally found softened and pultaceous, from the fluid having infiltrated
the cerebral tissues.  The distension may be so  excessive as to reduce
the hemispheres to the thickness  of a sheet of  paper; but more com-
monly the parietes give way,  and allow the fluid of the two sides to
combine;  and the  pressure may then, as in the case of  Cardinal, sepa-
rate the hemispheres, and unfold them, "like the leaves of  a book."
   Occasionally the fluid is limited to one side, and thus gives rise to an
unilateral distension  or  obliquity.  When the superficial arachnoid  is
the seat of the dropsy, the brain may,  at first sight, appear altogether
deficient; but, on raising the sac, we shall find it pressed downwards and
forwards, and presenting a state of extreme  atrophy.
   It is usual to meet with some abnormal conditions of  the vessels and
the membranes in hydrocephalus, but we are unable  to determine the
relation that they bear to the morbid  product—whether  they are to be
considered in  the  light of cause  or  effect;  though we find both  Dr.
West  and MM. Rilliet and Barthez agreeing that hemorrhage  into the
cavity of the arachnoid may occasionally be the fons  et  origo mali.
Rokitansky  attaches  more importance to hemorrhage,  as occurring in
the course of the  disease.   A thickening  and  opacity of the lining
membrane of the cyst, with  granular  deposits,  are the  most  common
post-mortem appearances found in the arachnoid, while occasionally the
formation of a new membrane, and the deposit of fine granular matter,
causing a roughness of the surface, present themselves  to  the anato-
mist.   The occurrence of the latter suggests that there  has been inter- '
current, subacute inflammation, and should warn  us to remove all causes 
HYDROCEPHALUS.
243
of irritation from an individual thus circumstanced.   The vessels sub-
jacent to the arachnoid are frequently enlarged, varicose, and congested.
   The fluid of hydrocephalus is of  a limpid and transparent character,
or more or less yellowish and opaque ;  of a specific gravity rather lower
than that of the serum of the blood, and containing, therefore, a smaller
amount of solid constituents.  When there is any opacity, this is found
to be  due to  granular  and nucleolar  matter, mingled  with epithelial
debris.   The  fluid,  when tested by heat and nitric  acid, presents  the
characters of a solution of albumen, and is found to contain chloride of
sodium, soda, and traces of  salts of lime and potash;  and also, accord-
ing  to Dr. Bostock's investigation, urea.  The results  of his analysis
of the hydrocephalic fluid of Cardinal are  embodied in the following
table:—
        Sp. gravity 1011.38
           Water.........982.6
           Albumen  .........   6
           Chloride of sodium  .......   7
           Soda.........1.4
           Urea and osmazome  .......   3
           Sulphuric acid, lime, potash.....a trace
                                                     1000.0

   The fact of urea being found in hydrocephalic fluid has not met with
 any attention on the part of other pathologists ;l  but if it should prove
 to be  the rule, it places  this disease  on  a par with  the uraemic cases,
 which are intimately connected  with  certain forms of renal disease, to
 which Drs. Bright  and  Christison first drew attention.  The state of
 the kidneys is a point which  merits #iore consideration in this disease
 than has hitherto been  devoted to it, or we may say in infancy gene-
 rally.   It is to the generic  development of an  affection  like hydroce-
 phalus that we must look for the attainment of a means of cure; for
 its  products,  though interesting to the  pathologist, are unfortunately
 not of a character  to yield  either to the vis  naturae or to medical treat-
 ment.   From the early appearance of its symptoms  it  especially chal-
 lenges  our attention to the  state of health of the  progenitors ;  and
 though in many of the  recorded cases it is expressly stated that  the
 mother's constitution had been sound, we must bear in mind how vague
 such data generally are, and that the  hereditary influences are as inti-
 mately connected with the father as the mother.   We know more of
 the relation existing between hydrocephalus and tubercle ; for the  two
 are very commonly found  associated.   Scrofulous  children  very  fre-
 quently present  a  very considerable  amount  of serous  accumulation
 within the ventricles, without even having manifested any symptom of
 cerebral disease.
   We have  spoken  of  hydrocephalus  throughout  as of  a  disease ot
 childhood, and it is to early life that it mainly belongs.   Several cases
 are, however, on record of the affection having supervened in the adult
 when there was no trace of previous  cerebral disease.   If it be found

   '  Dr. Garrod has stated to us in conversation, that he has also found urea in hydroce-
 phalic  fluid. 
244                     CHOROID PLEXUS.
that the diathesis upon which the disease is engrafted belongs equally
to infancy and manhood, we shall easily  be  able  to explain why the
more prominent symptom of dropsical accumulation  does not present
itself frequently in the adult.  The firm connection of the cranial bones,
and the compression which they consequently exert, offer a mechanical
impediment to the effusion, which can only  take place at the expense of
some other contents of the skull.   The very congestion of the veins,
which for instance exists  in cases of uraemia, would  militate against it.
  Several instances of  an accumulation of serum in  the  cavity of the
arachnoid or in  the ventricles, and  not  offering  any marked traces
of active hyperaemia or inflammation occurring in  advanced life, may
be found in the works of Professor Golis, Dr. Baillie, and Dr. Watson.
They have received  the name  senile  hydrocephalus, and  such are the
cases to which the nosological term of serous apoplexy ought  to be re-
stricted.   The  fact of Dean  Swift having  died of this affection, may
serve to fix the subject in the memory.  The immediate cause to which
this may be most justly attributed is an atrophic condition of the brain,
which gives rise to a vacuum, and hence to  a discharge from the vessels,
of that part of the blood which most readily transudes the coats;  the
effused serum  is  peculiarly clear, and its  quantity  varies, according to
the extent of cerebral atrophy, from  two to six ounces.   When we ex-
amine into the morbid anatomy of the brain, we shall discuss the origin
and causes of atrophy;  we have here only to do with one of its  pro-
ducts ; but it is apparent that in the present instance, as well as in the
hydrocephalus of infants, the effusion is a  symptom of a deeper-seated
malady, and  not truly an idiopathic affection.   In  senile as well as
infantile  hydrocephalus, the soft commissures,  the  septum, fornix, and
adjoining  parts, are commonly round softened ; but it is not always
easy to form a positive opinion, whether this is  a primary  or secondary
condition.  Before  dismissing this subject,  we have to advert to a form
of congenital hydrocephalus  which has received the  name of hernia
cerebri, in which, owing to a deficiency in  the  cranial walls, a portion
of the  brain and its membranes are protruded.   It  is analogous to the
spina bifida.
                       CHOROID PLEXUS.

  The venous rete mirabile of man, known by the name of the choroid
plexus, appears in a measure to possess a vitality independent of the
membrane, the pia mater, of  which it is an appendix.  It is impossible
to doubt that it plays a most important part in equalizing and balancing
the circulation within the cranium, within the limits of health, and that
equally its peculiar relation to the cavity in which it is suspended must
give rise to important variations in disease; the physical laws of exos-
mosis and endosmosis may, without any  stretch of hypothesis, be  sup-
posed to  operate with peculiar  vigor, and it  is  not  unreasonable to
assume in the choroid plexus  a powerful agent of secretion and absorp-
tion.  The amount of blood in the plexus found after death varies much
—at one time it is full, and the vessels stand out in relief; at others it 
CHOROID PLEXUS.
245
is collapsed, and contains scarcely enough blood to color it.  There is no
necessary relation between the amount of vascularity or exudation, and
the congestion or inflammation of the pia mater; thus,  we may find the
surface of the brain covered with a highly vascular pia  mater, while the
choroid plexuses  present  an exsanguine appearance ;  a  circumstance
which rather confirms our  view of  the  physiological character of the
latter.  The greater density of  the coats of the vessels in the choroid
than  in other parts, may account for the  rarity of their being the source
of hemorrhage; indurated yellow bodies are, however, occasionally found
in them which are referable to  former effusion.  The  morbid  appear-
ances most  commonly found in the plexuses are round or oval bodies of
a yellowish tinge, apparently formed of  concentric laminae, which only
become more apparent on the addition of acetic acid.   They are  ordi-
narily microscopic,  but are often found  in considerable  numbers, and
occasionally accumulate into masses  of the size of a  pea  or small nut.

                                Fig. 122.
 The upper figure represents a choroid plexus with several small tumors at * * *, supposed at first to
have been tubercular; they proved to consist of aggregations of concentric corpuscles, cholesterin, and pure
oil, united by areolar tissue; the concentric corpuscles which are shown below the plexus are magnified 100
diam.

It is  evident that they are phosphatic connections  enveloped by layers
of organic material.  Acetic acid acts very slowly upon  them, destroy-
ing their opacity, but not altering their configuration.   Muriatic acid
destroys their opacity by removing the phosphate of lime, and  leaves
transparent rings of animal matter.   They are not found in  early in-
fancy, but occur so  frequently in advanced life that they almost appear
to be'a  normal  constituent  from  their  behavior with reagents.   Vir-
chow calls them corpora amylacea, but the term concentric corpuscles,
suggested  by Dr. H. Jones, is  more  appropriate.  Similar formations
are met with in other parts of the  body: thus, we have seen them in an
adventitious  membrane  formed in  the kidney.   Cysts of  the choroid
plexus are more frequently mentioned by authors on account of their
being visible to the naked eye ;  they are minute,  transparent  vesicles,
varyino- in size from a poppy seed to a  small pea;  and we generally
meet with them in brains,  in which we also find evidence of inflammation 
246                      CHOROID PLEXUS.
of the lining membrane of the ventricles.   They sometimes contain a
milky fluid,  and  may  present incrustations  of a sabulous character.
They have been erroneously regarded as hydatids, but there is no evi-
dence of their belonging to  this class of  parasitic  formations ;  they
would rather seem to be due to a condensation of the epithelial covering
of the plexus, and  an  accumulation of  fluid beneath it, limited by an
effusion  of plastic  matter.  An  hypertrophy of the  epithelium, which
covers the choroideal vessels, is  very  commonly observed  in advanced
age—though we have  not been able, as yet, to  trace  any  definite rela-
tion  between this condition and certain  forms of disease.   The choroid
Fig. 123.
 Portion of a choroid plexus, exhibiting a fatty degeneration of the epithelium, from a female aged 45, who
for 14 days previous to her death was subject to convulsive fits  and various cerebral symptoms. No morbid
condition was observed in the brain, but considerable deposit of oil in the choroid plexuses; in one, there was
a small lump of fat. A. The loop of the plexus dotted with oil, 120 diam.  B. The epithelium, containing oil-
drops, magnified 360 diam.

plexus  is frequently found of  a  fleshy consistency, probably owing to
some interstitial  effusion  having taken place;  and we also find  small
fatty tumors on the  plexuses, as well as a microscopic deposit of fat in
the shape of minute oil-globules, dotting the surface of the vessels, but
for the most part inclosed in the epithelium. 
CHAPTER  IX.
            THE BRAIN.—GENERAL OBSERVATIONS.

   The question that meets us at the threshold of an inquiry into  the
pathological conditions of the brain, is whether  the amount of  blood
contained within the cranium in the adult, can vary.   There is no diffi-
culty in determining the question in the child, for there, as long as  the
fontanelles  are  unclosed  by bone,  the cerebral circulation necessarily
obeys exactly the same laws as rule  the general circulation; when  the
skull is completely formed, the pressure of  the atmosphere is in a mea-
sure withdrawn  from the  contents, and the variation in the amount of
blood contained in the cerebral vessels is very much lessened.  Still, in
applying the law of atmospheric pressure to this  subject, we  must  re-
member that the column of blood reaching  from the heart to the  brain
is not like  the barometer, a single  tube, with  a  vacuum at the closed
end, but that the vessels may be  compared  to a curved tube, both ends
of which are equally under the control of this law.   If it were not so,
respiration could not, independent of the heart's  beat, exert  any influ-
ence upon the cerebral  circulation.   The presence of the ventricles, and
of serosity in the cavities and subarachnoid  fluid of the brain and spinal
canal, is a further indication that there is a provision to meet this species
of variation—for it is in obedience to this very law of atmospheric pres-
sure, to assume  that these fluids mutually assist one another, and as  the
walls of the cranium Gannot collapse, keep  up the balance of the  circu-
lation by vicarious action.  We have already seen that nature shows  her
horror vacui in  senile hydrocephalus, where, if our explanation is cor-
rect, the effusion is mainly due to the atrophy of  the brain.   While we
admit, therefore, that the constriction placed upon  the vessels of  the
brain and the peculiar character of the  cranial  contents, prevents  as
great a variation in  the amount of  the fluid contents as takes place in
the thoracic or abdominal viscera, we feel assured that a variation does
take place,  and sufficient to account for  many of the phenomena of
nutrition and disease.   It is important to place  this question on a pro-
per basis, as it is one that constantly suggests itself to the pathologist;
without a satisfactory explanation, we  shall be constantly at a loss to
find the proper terms for  morbid conditions, and they would  themselves
appear to contradict our theories.  We cannot enter further into this
question, but we hope that the suggestions just thrown out may serve to
reconcile some conflicting views on the subject.  The positive  denial of
various physiologists, of any variation in the quantity of blood  in  the
brain, apparently supported by such experiments as those of Dr. Kellie, 
248
THE BRAIN.
has served not a little to confuse the student.  Dr. Burrows1 has inves-
tigated this  question fully, and  from experiments  and  physiological
considerations, arrives  at  the  conclusion, which seems  unavoidable to
the practitioner of medicine, that the quantity of the blood within the
cranium is extremely variable at different times,  and  under different
circumstances.  There is a peculiar  feature in the white matter of the
brain,  which  constantly forces itself on the notice of the  microscopist,
by impeding  his  investigation, and which has a  strong  bearing  on the
matter—it is the great elasticity of the medullary tissue; this resiliency,
among others, is a counterpoise to the rigid structures  enveloping the
brain.   All inquirers are agreed  that the relative  amount of blood in
the different sets of vessels, in  the veins and arteries, varies considera-
bly; and on this point Dr. Kellie's experiments appear to afford conclu-
sive evidence, though the  examination of a few bodies would suffice to
show the same thing.
  The importance of the study of the morbid phenomena met with in
the brain is self-evident, both from the rank of the organ in the economy,
and from the great frequency of cerebral disease.  Thus we find, on re-
ferring to the Registrar General's valuable  statistical reports, that the
deaths caused by  diseases of the brain rank fourth in order of fatality.
The average  percentage of mortality in London from zymotic, tubercu-
lar, pulmonary, and cerebral disease, appears from analysis of the deaths
in ten weeks, selected promiscuously throughout the year 1851, to  be
respectively 19.9, 18.3, 15.5, and 12.1.
  We  frequently make post-mortem investigations in  cases where all the
symptoms indicated that  death  proceeded from cerebral  lesion,  and
where, nevertheless,  we are unable to discover any disorganization  such
as would appear to justify the conclusion that this was the  case.  A cer-
tain amount of hyperaemia in some of the cranial contents may be all
that presents itself  to  us, and even this may be absent.   Sir Astley
Cooper's experiments2 upon rabbits, in which the vertebral arteries  were
alternately compressed  and relaxed, after the carotids  had been  pre-
viously tied, have sufficiently demonstrated the influence of the circula-
tion upon the functions of  the brain.   The compression  invariably pro-
duced  an instant arrest of respiration, convulsions, and apparent death,
and when the finger  was removed from the artery the animal gradually
recovered.   The  symptoms closely resembled those  of epilepsy in the
human subject, to the illustration of which  disease  they are frequently
applied.   We have yet to  determine  the ratio in which mere pressure
influences the cerebral functions, as compared with the frequency in
which  disturbance is excited, and a fatal  issue produced by a poisoned
condition of the blood, as in uraemia, resulting from granular degenera-
tion of the kidneys.

            1 On Disorders of the Cerebral Circulation, London, 1846.
            2 Guy's Hospital Reports, vol. i. 1836, p. 465. 
CONGESTION.
249
                           CONGESTION.

  When the congestion of the brain is considerable, the entire  organ
may present an increase of volume and turgidity.  On slicing it, the gray
matter may exhibit a deeper tinge  than usual, but its  natural hue pre-
vents the alteration of  color from  being very perceptible.   The white
matter shows an increase of the red  dots  indicating the bloodvessels,
and may, as it does particularly in children, assume a  general  pinky
tint from the same cause.   This must not, however, be  confounded with
the color imparted to it by  the knife as it divides the bloodvessels, and,
according to the amount of blood contained in them, smears it over the
brain surface;  by carefully wiping or scraping it, we shall be enabled to
determine to which cause the color is due.  Scipion Pinel1 dwells very
forcibly upon the occurrence  of congestion of the gray  matter of the
brain as the main  pathological feature accompanying mania.  He de-
scribes the inner layer of the cortical tissue, as presenting  a lively red or
violet tint, the white matter being less altered in this  respect, but also
offering a livid hue, with occasional blackish patches, or more or less
extended ecchymoses.   Congestion of the  meninges is more frequently
found independently of congestion of the brain than the converse; but
we  must look for the latter more especially in cases in which death has
taken place in consequence of poisoning from opium, in epilepsy and
apoplexy, in bronchitis, hooping-cough, in  fever accompanied by  coma,
and in hypertrophy of the heart and granular kidney.   In a therapeutic
point of view, the relation of congestion to cerebral symptoms is important,
and the proceeding of Mr. Parry,2 to  compress the  carotids  in epilepti-
form and other affections, probably  dependent upon this derangement,
is a practical application of the doctrine to therapeutics.   The patho-
logical effect of arresting the circulation in  the vessels of the head is
illustrated by cases like those referred to by Dr. Abercrombie,3 in which,
accidentally or intentionally, these vessels  were closed, and  animation
temporarily suspended, until the constriction was removed. The frequent
fatality of apoplectic affections, without leaving any appreciable  trace,
has been the  cause, as the same  author most justly  observes, of the
number and variety of speculations on the subject, which have certainly
not tended to clear up  the  difficulty.   Turgidity of the bloodvessels in
the membranes and brain has been observed in the majority of lunatics,
independent of other lesions; thus, Dr. Webster, in analyzing the records
of Bethlem  Hospital, finds this the case in eighty-nine out of one hundred
and eight.
  Local congestions are occasionally met with limited to individual por-
tions of the encephalon.  There can  be no doubt that an anaemic con-
dition of  the brain, as well  as a cachectic state of the blood circulating
in it, may induce, in a similar manner, disease and a fatal issue without
offering any perceptible lesions.  In these cases, the fibrous tissue  of the

     1 Traite de Pathologie Ce're'brale, p. 193.  Paris, 1844.
     2 Collections from the Unpublished Writings of the late C. H. Parry, 1825.
     3 Diseases of the Brain, &c, p. 211.  Edin. 1845. 
250
HEMORRHAGE.
brain presents a  more deadly  white, and fewer red spots than in the
normal condition, but we possess no means as yet of determining these
relations by actual measurement; and in many instances where no organic
change  has taken place, the tonicity of the  arteries  may, in articulo
mortis, restore the balance of the circulation in such a manner as really
to remove all post-mortem effects.
                         HEMORRHAGE.

  Congestion is a transition state to numerous  cerebral lesions which
leave sufficiently perceptible post-mortem effects.   The first of these that
we shall consider  is  hemorrhage, the most  frequent cause of cerebral
apoplexy, and an affection  peculiarly belonging to advanced life;  the
disposition to it increasing in a direct ratio  with  the years of the indi-
vidual.   The greatest fatality, according to Dr. Burrows, exists between
the age of sixty and seventy, while it is also found to occur more  fre-
quently in males than in females.  The following table, which has been
compiled by Dr. BurroAvs, clearly exhibits the progressive ratio of apo-
plexy with advancing age.
OBSERVERS.	u o CO o o CM	8 S o CO	d 3	© CO o	d ©	d CO a ©	d CO > o <	3 c El
Dr. Abercrombie Dr. Bright Dr. Andral Dr. Rochoux Dr. Hope Dr. Burrows	3 4 3 2 2 2	4 4 3 8 2 9	6 8 4 7 9 6	7 4 6 10 6 8	7 5 5 23 7 7	1 1 1 12 11 1	0 0 0 1 2 1	28 25 26 63 39 34
Total in periods of 10 years,	16	30	40	41	54	30	4	215
  This corresponds in the main with the results obtained from the Re-
gistrar General's reports.   To explain the apparent diminution after
the age of seventy, we must remember that the total number  of living
is very much reduced, and that hence the relative number of apoplectic
cases is probably even larger than at an earlier age.
  The amount  of hemorrhage varies from a spot of the  size of a pin's
head to an  accumulation of many ounces; the former,  which may be
termed capillary hemorrhage, is  frequently observed in connection with
effusions  of  a more  extensive character, but may often  be  assumed to
have occurred  during  life,  where  trifling apoplectic symptoms have
rapidly passed  off under appropriate  treatment.   It is  not generally
easy to trace the vessels from which the blood has  been effused, and
there is also much obscurity as to the actual nature of the morbid action
which induces the hemorrhage.  All parts  of the encephalon may pre-
sent apoplectic  effusions,  but the parts most frequently affected are the
anterior lobes, and especially the vicinity of the corpora  striata.  As a
rule, the  gray structures, including the convolutions of  the brain, ex- 
HEMORRHAGE.
251
hibit the  greatest proclivity to the  affection, which is in  consonance
with the  known  vascularity  of these  tissues.   The  structures most

                                  Fig. 124.
                 Apoplectic effusion upon the left side of the pons varolii.

removed from the  gray matter, as  the corpus callosum and the fornix,
are least  liable  to it.   Apoplectic effusion is not very frequent in the
cerebellum, but  it is  found to be more rapidly and invariably fatal when
it occurs here than elsewhere.   Andral's extensive  sphere of  observa-
tion  has  only  presented him with six cases  of hemorrhage  into the
cerebellum, and in three of these it was associated  with hemorrhage
into the cerebrum.   In the causation  of apoplectic effusion three  ele-
ments come into consideration;  the condition of the blood, the state of
Fig. 125.
 Hemorrhage into the right lateral ventricle and right hemisphere, in a man aged 65. He was Drought
into *t Mary's Hospital in a state of profound coma, and died two hours after admission. There was a large
ra^ed' cavity in the hemisphere, communicating with the ventricle, from which about 4 oz. of black fluid
blood escaped  The corpus striatum and thalamus opticus of right side were much softened.  There was no
apparent disease of the arteries.

the coats of the vessels and  that of  the tissues surrounding them.   The
first, though the most important, as  necessarily influencing  most mate- 
252
HEMORRHAGE.
rially the two latter, we  do not as yet possess sufficient data to speak
otherwise than hypothetically of.  It is not difficult to conceive that
stasis in individual vessels, the  formation  within them of  exudation
matter,  or an alteration in the  density of the liquid,  may mechanically
and vitally influence the  origin of this morbid state.   The  fact of the
occurrence of sanguineous effusion, as a sequel  of renal or cardiac dis-
ease where no  disorganization of the brain  is traceable, is  a further
point corroborative of the position.   We may also mention that Messrs.
Andral  and Gevarral are  of opinion that an essential connection exists
between cerebral hemorrhages and a diminution in the amount of fibrin
in the  blood with an increase in the quantity of blood-globules.   In
eight venesections, performed upon seven apoplectic subjects, they found
the fibrin below the normal standard in five, and the globules above  it in
four cases.  With regard to the coats of the vessels, the  influence of
chronic arteritis in causing pulpy softening or in giving rise to calcareous
or atheromatous deposits, and thus rendering them  unfit  to  bear  the
pressure of the blood-current, is  a  subject  of frequent observation,
though  disease of the bloodvessels is not a necessary  accompaniment of
apoplectic  effusion. t  In  the same way  as  this pathological  condition
induces local affections in the  thoracic and abdominal viscera, it causes
aneurisms  or ossifications  of  the arteries of  the brain, and in both in-
stances  affects nutrition,  and is liable to be followed by rupture and the
effusion of blood.   Such alteration in the nutrition of the  nerve-tissue
as diminishes its  resistance  to the impulse it  receives  from the  san-
guineous current,  is the  third element to which we have  alluded.   We
shall  consider the main  characters of softening more in detail further
on;  but it is necessary to mention here that  it occurs in two forms,
which appear to be essentially different,  the one being due to a state of
hypersthenia or active inflammation, the other to an impaired or cachectic
nutrition of the tissue.   We  cannot always in the dead subject demon-
strate the  sequence or the relation which these conditions  bear to one
another; but  an extended knowledge of morbid processes elucidated by
vital dynamics, the microscope, and animal chemistry, wtil undoubtedly
clear up many difficulties connected with  cerebral  disease,  as  it  has
already done in diseases  of other organs.
   In the present state of our knowledge, and of physical examination,
the proximate causes of cerebral apoplexy frequently elude the inquirer;
but it is difficult to assume that  it can occur without previous disease
within the cranium of the nerve-matter, as well as of the vessels; the
fact that apoplectic effusion is not met with in healthy individuals who
have died  from strangulation, alone  affords  sufficient evidence that a
mere arrest of the current of the blood  is incapable  to produce it; for
in these cases the vertebral arteries may fairly be assumed to convey
blood to the brain after its return by the veins has been arrested.
   The apoplectic effusion is  not  necessarily fatal in  proportion to the
amount of blood discharged from the vessels; but the rapidity of the
issue appears to bear a relation to the vicinity of the hemorrhage to the
medulla oblongata.  The effusion of blood into the  ventricles is  also
marked by being very rapidly fatal. Much, probably,  also depends upon
the amount of laceration of the cerebral tissue accompanying the hemor- 
HEMORRHAGE.
253
rhage, inasmuch as the curability of apoplectic effusions seems to be in
the ratio of the interstitial character of the discharge.   Thus, Messrs.
Foville and Ollivier have pointed out, both with regard to the encepha-
lon and the spinal cord, that the cure of paralysis resulting from rupture
of the  nerve-tissue  is never  complete; but that where  the  patient is
restored to perfect  health, the hemorrhage has  mostly separated  and
compressed the cerebral or spinal fibres.
   The processes that occur in the blood itself, after  it has been effused
within the brain, are: the formation of a coagulum, the gradual absorp-
tion of the fluid parts of the blood, the formation of an organized mem-
brane around the clot, and the continued absorption of thelatter.  The
rapidity with which these changes occur differs considerably, and depends
greatly upon  the  healthy condition  of the surrounding parts.  Thus,
while Dr. Macintyre1 has  recorded a case of apoplexy, in which, thirteen
days after the seizure, the cyst was found fully formed, organized,  and
nearly  empty, a French physician, Moulin,2 mentions one of seventeen
years' duration, in which  a cyst was  found containing  four  ounces of
sanguineous fluid. When the effusion occurs in the cavity of the arach-
noid, we have seen that  cysts  also form, but we do not meet with them
in the cavity of the ventricles, though there is reason to suppose that
the blood may be  absorbed from their surface also.  According to  the
degree  of absorption, the clot changes its  consistency and  color.  The
clot first assumes  a  deeper color and becomes of  a chocolate hue, and,
from absorption of the serum, is rendered hard; the coloring  matter is
more and more absorbed, a  light-colored fibrinous mass is then seen,
much contracted from the original dimensions of the clot, and finally
this too may disappear,  leaving no remains of the hemorrhagic effusion
but the contracted empty cyst, the walls of which are  frequently con-
nected  by fibrous  beads.  The cyst itself, in  its turn, shrinks up,  and
finally nothing may remain but a cicatrix.   The haematoid crystals, first
discovered by Sir Everard Home, and more recently described by Vir-
chow, are occasionally found  in  apoplectic clots, together with orange-
colored granular  matter.  Virchow3 states that the  earliest period at
which he has discovered  them was seventeen days after the injury; their
not  occurring in  recent effusions  has been urged as a positive proof
regarding the age of a clot.
   It is manifest that no effusion can take  place into the cerebral tissue
without a certain  amount of disruption of the nerve-matter, portions of
which may be generally traced within  the fresh clot; the greater the
previous cerebral softening, the more we shall find the brain comminuted.
The danger to life, as the recorded  cases teach us, is in proportion to
their cerebral disorganization ; for the tax made upon the powers of the
constitution, to repair the injury done, is  necessarily greater, the more
inflammatory reaction is set up ; for, though  the clot possesses in itself
a  tendency to form a cyst without inflammation, and thus aids in the
process of reparation, this cannot suffice to repair  the injury done to the

  1 Report  of Pathol. Society, 1847, p. 11.
  2 Traite" de l'Apoplexie, ou Hemorrhagic Cer^brale, &c. Paris, 1819.
  3 Soe an article on Blood-Crystals, by Dr. Sieveking, in the British and Foreign Medico-
Chirurgical  Review, Oct. 1853. 
254
WHITE SOFTENING — (EDEMA.
cerebral tissue.  After the absorption has come to a stand-still, the cyst
or the cicatrix may be borne for years without exciting any new symp-
toms; and thus, if  the individual has suffered from a repetition of apo-
plectic attacks, we shall find one or more such residuary appearances, in
a state indicative of the period from which they date.   As we occasion-
ally meet  with  a recent apoplectic effusion that has been effected near
the surface of the brain, marked by  fluctuation, we find,  after  the
absorption of the fluid, a slight depression in  the superincumbent nerve-
tissue, or a supplementary effusion of serum  into the ventricles.


                 WHITE  SOFTENING —OEDEMA.

   The converse of  the condition which  we have just been  considering,
anaemia, is undoubtedly one  of considerable  importance,  and one that
may be assumed to be the cause of numerous morbid conditions;  but
we have a still  greater difficulty of determining its existence than that
of congestion of the  brain.   Where it exists, the  brain presents  a
generally  pallid  appearance, and  especially the white  matter  is re-
markably  deficient  in red spots, and more dead-white than  normally.
It is an important element in the diseases termed white  softening and
oedema of the brain, which, therefore, especially  as in their turn they
may give rise to apoplectic effusion, may appropriately be treated of in
this place.
   In estimating the degree of  white softening, it  is important  to bear
in mind the physiological  variations in the density of the  brain, accord-
ing to the age of the individual.1  It is naturally very soft in infancy,
and progressively becomes firmer with  the advance of years; and, in
old age, as we  find a  tendency to  rigidity of the soft tissues, and to
ossification  of  the  cartilages,  we discover  the  brain to  present  the
physiological  extreme  of  density  and  toughness.   The  diminished
density of a portion of, or the entire brain,  constitutes the disease in
question;  at times, it appears to be due to an increased  infiltration of
serum, in  the cerebral  tissue,  in which case it  may  be  considered as
identical with  oedema.  It  is common  in children,  complicated with
hydrocephalus, or as a product of arrested  or perverted  nutrition, or
exanthematic fevers ; the affected portions  of the brain  often  being
entirely diffluent.   In adults, it is found in connection with phthisis.
   White softening is characterized by a  loss of cohesion, varying in
degree, and is chiefly met with in the parts most remote from the gray
matter, as one  would expect, if the etiology, as given  above, is correct,
because they are provided with fewer bloodvessels.   Rostan,  who  was
the first to  draw attention to cerebral  softening, which has since been
extensively studied by pathologists,  admitted the presence  of an in-
flammatory and a non-inflammatory form ; but we owe  to Gluge  and
Bennett the means of discriminating the  two with  physical  accuracy,
inasmuch  as they have shown, that an essential feature in inflammatory
affections  of the brain is  demonstrated by  the   microscope.   The in-

  1 See a paper by Dr. Sankey on the Specific Gravity  of the Brain, in the British and
Foreign Medico-Chirurgical Review, Jan. 1853. 
INFLAMMATION.
255
flammation corpuscles or cells, produced by the disintegrating  changes
which  accompany the phlogistic process, are  invariably found in the
cerebral tissues, where there is inflammation; and it is characteristic of
the non-inflammatory softening, and of oedema of the brain, that these
corpuscles are not  met with.   The  microscope only exhibits the  mere
debris of nerve-tissue, in a state of greater or less  destruction, without
any trace of new formations or products.  The entire absence, then, of
inflammation  corpuscles in a softened portion of brain, serves to confirm
the  opinion  of  its  non-inflammatory  character.   According  to  Dr.
Todd,1 white softening is  characterized  by organic globules, or large
cells, containing oily matter,  from which he infers  that  the disease is
accompanied  by  an active process  during life, although he  regards it
essentially  as an  atrophic condition.   Abercrombie and some other
writers attribute the  form of  softening just described, under the  term
of  cerebral softening, to inflammation ;  an analysis  of the cases given
by Abercrombie himself,  will be found to support the view of the exist-
ence of white softening  without the  physical signs of inflammation.
The microscopic discovery  of the  product of  inflammation  will, in
future, aid the pathologist in determining  the question  in individual
cases.
   (Edema of the brain is a common  condition of  the organ met with
in ataxic conditions,  such as typhus, or  puerperal  disease, in exanthe-
mata,  heart disease, and anasarca.   It is common  in  insanity.  Pinel
describes it as the pathological  condition characteristic  of stupor, or
acute dementia.   He states,2 that if the medullary tissue of  an  cede-
matous brain be torn, a peculiar feature  presents itself;  at the  summit
of  each rent, and at the  angle formed by the  separation of  the fibres,
whitish  filaments  may be  perceived with the naked eye,  which are
nothing but capillaries, strongly injected with serosity; they pass from
side to side, and when torn, allow a  small quantity of serosity to  es-
cape;  in the  normal state, these capillaries are filled with colored blood.
 On cutting into  a brain thus  affected, the tissue \s found pallid, and the
water drips from it, showing  a complete oedematous imbibition.   The
infiltration causes  an enlargement of the brain, and consequent flatten-
ing of the convolutions.
                         INFLAMMATION.

  We now return to the examination of one of the sequelae of conges-
tion, which, in some  of its forms and  products, constitutes a  class of
very fatal diseases.  Inflammation of the brain occurs in the various
forms,  and gives  rise to the same products that we find in other organs,
modified, of course, in  their characters  by the  anatomical relations of
the organ.   We find it as an acute and as a chronic disease.   Acute
inflammation of the brain is not frequently met with in the dead-house,
in the early stages, nor is idiopathic encephalitis a disease of common

                  1 Clinical Lectures on Paralysis, &c, 1854, p. 99.
                  2 Traite de Pathologie C6rdbrale, p.  257. 
256               INFLAMMATORY SOFTENING.

occurrence, and many of the cases recorded by older writers resolve
themselves into cases of meningitis.  It is  not our province to inquire
into  the causes of the peculiarities of diseased action;  but we  may
allude to the circumstance of the brain being so completely withdrawn
from physical  influences  acting immediately upon  it,  as one  of the
reasons why idiopathic inflammation should not  set  up  in it,  with the
same frequency and  violence that it exhibits in organs that  are more
exposed.  It is brought on by exposure  to  the  sun's rays in  hot  sum-
mer days or in tropical climates, and may be so rapidly fatal as to pro-
duce death before the purulent stage has supervened.  Other instances
of idiopathic encephalitis are, however, met with  in  the early stage, in
which no such direct exciting cause is traceable.   In  a case of this  kind
we find a more or less circumscribed dusky  redness in the substance of
the brain; the spot generally occupies  the upper  part  of the hemi-
spheres, and, on section, drops of blood may ooze out from the divided
surface: there  is no necessary change in the consistency of the spot,
though  it is frequently somewhat softer than the healthy tissue;  as the
disease  advances, the exudation of lymph and suppuration  ensue, and
the color and  consistency of the affected part are modified in propor-
tion.   These products are much more frequently the result of chronic
and of  secondary, than of acute and primary, encephalitis.   So much
so, in fact, that softening, which is the  most common effect of inflam-
matory action, has  been  treated, by  many authors, as  an idiopathic
disease.


                INFLAMMATORY SOFTENING.

  The consistency of cerebral  tissue may be altered by  inflammatory
exudation alone, or with the  supervention of  suppuration.  In the

                               Fig. 126.
  VcBsels fcon the brain of a female aged 40, who died hemiplegic, in consequence of red softening of the
                            right hemisphere.

former case, we shall find traces of congestion, giving  to the  affected
part a  reddish  hue; and  in the softened  tissues, the microscope will 
INFLAMMATORY SOFTENING.
257
show, besides broken-down nerve-matter, a large number  of  exudation
corpuscles ;  while, as soon as suppuration has occurred, there is a change
of color,  and we may expect to find pus-cells in  addition to the former.
Exudation matter may, however, be found where there is no perceptible
change in the consistency of the tissues, or  other  palpable lesion, and
it is "here  that we feel the  great advantage of the  microscope in assist-
ing our views on the pathology of disease,  because it often  serves  to
account for symptoms that  otherwise  are not to  be explained.  The
vessels, especially, appear covered with, or to contain, the molecules of
exudation matter, without the presence of the exudation corpuscles and
masses, which are evidently a  further  stage  in  the  exudation process.
The absence of  pus-cells would not be  an absolute proof that suppura-
tion had not occurred; for they are not  always  present-1 in undeniable
abscesses, where molecular granules and pyoid  bodies may be the sole
objects detected by the  microscope.  We are further borne out in this
view by Dr. Bright,2 who  expressly states that  we can hardly restrict
the term, abscess of  the brain, to those very rare cases in which well-
formed pus is found in the substance of the cerebral mass.
   Suppuration  occurs in three forms:  we find it occupying  the convo-
lutions in the shape of a ragged ulcer, varying in size from a  fourpenny
piece, or  less, to that of half a crown;  or the pus  is infiltrated through
a large extent  of cerebral tissue, causing what Dr. Bright  terms the
diffused abscess; or again, the pus becomes limited, as in other parts of
the  body, by a membranous expansion, and we  then have to deal with
the encysted abscess.  The consistence and color  of  the parts in which
exudation and  suppuration have  been effected, vary according to the
extent to which the tissues are involved;  the softening may be scarcely
sufficient  to mark a  difference between  the healthy and the  diseased
portions,  and it may reach such a degree that  the  latter are perfectly
diffluent; the discoloration, in the same way, will be more or  less straw-
 colored or reddened, according to the amount of suppuration, the injec-
 tion of the bloodvessels, and the accompanying exhalation of blood, or
 its coloring matter.   We have  already alluded to the presence of exuda-
 tion  corpuscles, which are detected by the  microscope in inflammatory
 affections of the encephalon.   They will here be  found in large num-
 bers,  and will   assist  in  establishing  our  post-mortem  diagnosis, in
 addition  to the evidence, afforded by  the microscope,  of the presence
 of true pus-corpuscles.   The  necessary disorganization of the cerebral
 tissue, which must ensue in each of these cases, causes the presence of
broken-up nerve-matter, which the microscopic  specimens will be found
to contain.  When we  have  to do with red or apoplectic softening in
 which hemorrhage has occurred, we shall also  detect  blood-corpuscles
 in a more or less altered state.  A rough way to determine the presence
 of softening  is, to allow a gentle  stream of water to fall upon the sus-
 pected part; the softened  parts will more or less readily give way and
 break up.

   1 Lebert, Physiologie Pathologique, vol. ii. p. 303.
   2 Reports, p. 171.  See also Bennett on Inflammation of the Nervous Centres, Edmb.
 Med. and Surg. Journal, 1842-43.
        17 
258
INFLAMMATORY SOFTENING.
  With regard to the locality of red or inflammatory softening, authors
are not agreed as to the preponderance of its occurrence in the gray or
the white matter; while Gluge and Durand-Fardel are of opinion that it
is more frequently met with  in  the former, Dr. Bennett's researches
lead him to assert, that the white matter is the chief seat of this morbid
action.   French physicians  look  upon softening of  the superficial
laminae of the convolutions as peculiar to dementia, and state that it is
characterized by portions of the gray matter adhering to the  meninges
when they are removed.
  It follows, from what we have stated, that some of  the distinctions
which authors have laid down with regard to the varieties of  softening,
as characterized by their color, are not essential differences, but rather,
different  stages of  the same  inflammatory process.   The structure of
nerve-matter would, a priori, lead  us  to expect  that  the products  of
inflammation would assume  an appearance  different  from what  they
present in  other tissues of the body, and  as we  advance in our know-
ledge of  cerebral disease, we shall  probably succeed in reducing it still
more to the  general type of morbid action.   Dr.  Abercrombie has sug-
gested that  ramollissement of the  cerebral substance is analogous  to
gangrene, occurring in other parts of the body; but; though obliteration
of the small  arteries of the brain may give rise to this change, it is by no
means an essential cause; and we may sum up  the prevailing views  on
the subject, in Dr. Bright's classification of the causa proxima of soften-
ing ; he attributes  it—(1) to an impediment  in  the circulation; (2) to
congestion;  and (3) to inflammatory action.  The reader will  gather
from  our remarks,  that we do not concur in  the view of Dr. Aber-
crombie ; an additional argument  against it is,  that aneurism  of the
cerebral arteries is  not commonly followed by softening; and, if  any-
where, we should expect to find it in  this case most  uniformly, if the
process is identical  with death of the part.  Those cases of ramollisse-
ment which we have attributed to mal-nutrition, or a cachectic state of
the blood, as opposed to those resulting from  inflammation, would  be
more appropriately classed under the head of gangrene;  and under this
head may also be placed the cases of softening resulting from ligature of
the carotid artery;  but we are not justified in assuming the presence of
gangrene in  parts  which, though  seriously diseased, are by no means
withdrawn from the range of vital  processes.   An important physical
symptom of gangrene is remarkably absent  in softening of the brain,
viz : a fetid  odor.
  Softening of the  brain is looked upon as an essentially fatal disease,
though there is no inherent  reason why the process of resolution and
absorption should not be carried out within  the brain as in other organs.
It is probable that, as our means  of diagnosis become more perfect and
more refined, our knowledge of this subject will also enlarge; at present,
we deal rather with the last stages of the disease than with its incipient
and  more curable  features.   One  reason  why inflammatory  softening
appears less tractable than analogous  processes elsewhere, is  that the
brain does not possess a great power of isolating  the disease;  encysted
abscess is a very unfrequent  occurrence in cerebral  pathology.  The
greater number of cysts  containing pus,  that we  meet with, are the 
INDURATION—HYPERTROPHY.
259
result of external injury, involving the bone, as if nature only cared to
protect the brain  from  contact with the external  atmosphere.  It was
already observed by Dr. Baillie, that abscess  on  the  surface of the
brain was  almost  constantly the effect of external  violence, but that it
was  often  independent  of  this  cause when formed at  a considerable
depth within the brain, and that the former was by far  the more com-
mon form.   The cyst itself presents  in  either case various degrees of
thickness and density;  the former may amount  to half  a line, and the
latter  increase  to  the  consistency of leather.  The cysts themselves
have a laminated fibrous structure, and they are lined with a layer of
the pyogenic membrane.
   With regard to the cause of softening, as of cerebral disease gene-
rally, it must be mainly sought for in changes directly and  primarily
affecting the brain; but  that peripheral affections may  be followed by
central disease, is forcibly illustrated by  the case  published  by Lalle-
niand1 of a soldier, who had been operated upon for aneurism of the
right axillary artery.   In applying the ligature, the nerve was inclosed,
cerebral symptoms followed on the  seventh day,  and death  ensued on
the eighth: the post mortem showed an  abscess  in the left  posterior
cerebral lobe.  The case is  also of interest, as  affording proof of the
uniformity of the law of crucial conduction.
   In phlebitis and  purulent infiltration, which are commonly associated
with cerebral symptoms, we do not generally discover any marked trace
of disease  in the brain.   Metastatic abscesses appear limited to the great
organs of depuration; but while we rarely, if ever, discover metastatic
abscess in  the brain, in  consequence of phlebitis in other parts of the
body, it is not uncommon to find metastatic abscess in the  liver or spleen,
after idiopathic phlebitis in the veins of the brain.
                 INDURATION —HYPERTROPHY.

   The  converse of  ramollissement  or induration, appears, like the
former, to be an occasional result  of  a phlogistic process ;  but, like it,
we must in many instances attribute it to a non-inflammatory change in
the nutrient  sphere.   We find portions of the brain both at the surface
and in the deeper-seated parts presenting no material alteration beyond
an increased density  as compared with surrounding parts.   This is dis-
tinct  from the hardened cicatrices  resulting from the absorption of
apoplectic effusions.   A general hardening of the brain, accompanied by
a livid earthy hue,  and an increase of the  entire volume of  the organ,
is  met  with  in chronic  lead poisoning;2  the convolutions are found
flattened, the ventricles are compressed, the tissue is dry ;  and a chem-
ical analysis  will detect  the presence  of sulphate of lead in the brain.
Tanquerel des Planches  records two cases in which this was done.  It
is  also found in cases of acute lead poisoning.3   A  similar state  of in-

  1 Recherches Anatomico-pathologiques sur l'Encephale, &c, vol. i. 123.
  2 Tanquerel des Planches, Traite des Maladies de Plomb,  Paris, lbo'.i, vol. ii. p. -Ob.
  3 Alfred Taylor on Poisons, &c, p. 133. 
260
INDURATION — HYPERTROPHY.
duration and hypertrophy  of the  white substance, is stated by Ferrus
and Parchappe to be found in epilepsy.   Laennec and others have also
directed attention to hypertrophy as simulating hydrocephalus.  We
must also be careful not to confound cases of tumefaction of the brain
from softening with hypertrophy; thus  we find, in Andral's  Clinique
Medicale, the account of a post-mortem,  in which, owing to this cause,
the left hemisphere was so much swollen as to push over the mesial line
to the left side.   A similar instance is preserved in the museum  of St.
Thomas's Hospital.
   In a case of hypertrophy,  on removing the skull-cap, the brain seems
to expand, as  if it had  been previously confined in too narrow a space;
the membranes are thin, the convolutions are  flattened by being com-
pressed against the  bone, and the  ventricles are found to contain very
little or no fluid.   On making a horizontal section, the gray matter is
not seen altered,  and the  naked-eye  view displays an  increase in the
amount of white  matter;  this, according  to Rokitansky, is owing, not
to an augmentation in the number  of nerve-tubes, or their  dimensions,
but in the excessive  accumulation of the intervening and nucleated sub-
stance.   We have not  ourselves been able to confirm this  statement,
nor have we found corroborative evidence in other writers.   Hypertro-
phy appears to be due  to a  lymphatic constitution,  and it is met with
chiefly in early childhood.  As  long  as the  fontanelles are not closed,
it does not in  itself involve danger, and even the intellect continues un-
impaired ; but as  soon as the  fontanelles have closed, the undue pressure
gives rise to numerous cerebral symptoms, none of  which,  however, are
characteristic  of  this disease.   It  belongs essentially to the family  of
scrofulous affections ; the frequent coincident distortion of the bones, the
swelling of the lymphatic glands, and the general torpor of the system,
suffice to establish its relationship.   The bloodlessness and dryness of the
tissues must assist us in deciding, in a doubtful case, whether we have  to
deal with hypertrophy of  this character,  or with hyperaemia, hydroce-
phalus,  or oedema, conditions which also may cause the brain to appear
too large for  its case,  and produce  a flattening of the convolutions.
Nor would it  be  just to consider  as diseased a brain, which, though
larger than the average at the age of the individual, exhibits no morbid
relations such as  those  described.
   Individual parts of the cerebrum are very rarely found hypertrophied
by themselves.   Dr. Mauthner1 records a case  of  hypertrophy of the
thalamus opticus  of  the right hemisphere in a  child of three years  of
age, which, till within  three weeks  of its death,  had enjoyed  sound
health.   She  then fell from her chair, striking the occiput, and became
paralyzed on the  left side.   Shortly before death scarlet  fever super-
vened, she became delirious, and died comatose.  The thalamus  is de-
scribed as enlarged to the size of a hen's egg,  of a lardaceous, dead-
white appearance on section,  without softening of the adjacent parts  or
effusion;  except that the  testes were very vascular  and the left  optic
nerve enlarged,  no  abnormity  was discovered. Dr. Mauthner  is  of

  1 Die Krankheiten,  des Gehirns, und Ruckenmarks, bei Kindern, von L. W. Mauthner
Wien, 1844, p. 189, 
ATROPHY.
261
opinion that the organic malady had remained latent,  until the occur-
rence of the fall.  The same author gives an interesting table, showing
the weights of the brains of fifty children aged fifty months and under,
who died of various diseases; he concludes that all inflammatory affec-
tions have  a tendency to increase its weight, and that this increase is
mainly due to the greater amount of blood contained in  the cerebral
vessels.


                            ATROPHY.

   The converse of hypertrophy is a condition which, as we have already
had occasion to remark, is the result of- a natural  process in old age;
but it is also the effect of disease; or of an arrest of development.   In
consequence of long-standing, exhausting illness in children, Dr. West
informs us that the  brain is found far from  filling up the cavity of the
skull, so that a knife may be passed, in many places, between it  and the
cranial walls.   The same appearance is met with in the adult, and the
consequence is that serum is effused between the brain and its envelops,
in order to supply the defect; the convolutions become thinner, and they
are separated by broader sulci.  There is some discoloration of the tissue,
and the veins of the pia  mater are observed to present a varicose ap-
pearance, owing to the loss of  the support which they experience.  We
also meet with partial atrophy; this is generally of a secondary character,
owing to pressure exerted upon individual parts by tumors or other ad-
ventitious growths, apoplectic cysts in the arachnoid or peripheral lesions.
The absorption induced by the effect of pressure is accompanied by in-
duration of the adjoining layers of the cerebral tissue.   The atrophy
that is found as a result of arrest in the functions of a peripheral nerve,
as in the case of the optic thalamus in amaurosis, is a marked  instance
of the influence of functional derangement upon nutrition, propagated
to a distance.
    In idiots, we have congenital atrophy of  the entire, or of portions of
the brain; in the brain of old insane persons it is common, according to
Neumann's statement, who has examined fifty cases of the kind, to find
the posterior lobes  and their  convolutions  more atrophied than  other
parts;  Sir Charles Bell,  Cruveilhier, and Lallemand record  cases  of
epilepsy and hemiplegia, accompanying congenital  atrophy of one hemi-
 sphere, though not necessarily associated with a destruction of the in-
tellectual powers. 
CHAPTER X.
               THE  BRAIN—MORBID  GROWTHS.

  The products of a perverted state of nutrition and of a cacoplastic
condition of the blood, which are found  in  other tissues of the body,
also ,occur  in the brain, though for the most part in a secondary form;
associated with  or following upon their deposit elsewhere.  They have
certain features in common, owing  to the  anatomical relations of the
brain; thus, they all  generally assume a rounded shape, owing to the
uniform pressure to which they are subjected on all sides; they are not,
as for instance  in the lungs, received into a mould  by which  their ex-
ternal configuration is in a measure determined; they do not proceed to
a similar degree of development from the early danger to life which they
induce; they are liable to produce softening of the tissues in the imme-
diate vicinity, and, owing to the impairment of the circulation, are com-
monly accompanied by an effusion  into  the ventricles.   The last two
circumstances  are those to which we may probably refer the symptoms
observed during life;  for the presence of tumors in the brain is  often
not discovered until the death of the patient from disease of some other
organ, and where they had maintained this quiescent state, the cerebral
tissue in the vicinity exhibits no traces of degeneration.  Thus, Messrs.
Tonnelley  Le'veille', and others, who have devoted especial  attention to
the occurrence  of cerebral tubercle, conclude that the tubercles in them-
selves do not give rise to any symptoms, but  that the cerebral symptoms
accompanying them are exclusively due to the intercurrent inflammation.
The difficulty of early diagnosis, and the fact of adventitious growths in
the brain occurring almost exclusively in the secondary form, place them
more  especially in the range of the morbid anatomist; they are even less
amenable  to therapeutic treatment than when they have found a nidus
in tbe abdominal or thoracic organs.  The form in which we most fre-
quently meet with them is tubercle and cancer.
                           TUBERCLE.

  Tubercle, as we have already had occasion to see, is a frequent con-
comitant or source of meningeal inflammation.  Tubercular  deposit in
the cerebral tissue,  like the former, is  equally a  disease peculiar to
childhood; but the two are not necessarily associated together.   Tuber-

  1 See Rilliet and  Barthez,  Traits Clinique des Maladies  des Enfants, torn. xiii.
p. 552, seq. 
TUBERCLE.
263
cle in the brain may affect any part of the organ; it occurs in the shape
of rounded nodes varying in size from a pin's head to a walnut or hen's
egg; the deposits are not generally numerous, and their size bears an
inverse ratio to their frequency.   It is most common to find only one or
two, and of an average  size of a chestnut.  Dr. Baly has recorded a
case in the reports  of the Pathological Society1 of a young man who
died in the Millbank prison, and in whose  brain tubercles were found;
only two were discovered in the left hemisphere, but the number in the
right are estimated to have been as  many as fifty, varying in size from
a grain of pearl  barley to that of a barley-corn ; the same case  is also
instructive as showing the  great  rapidity with which  the deposit  may
occasionally take place  under circumstances favoring  the  disease; for
the patient was admitted into the prison  on  the 30th December as  a
healthy subject; after  a few days  was  attacked with headache,  and
on the lfJth. of January following, he died  with all the symptoms of an
acute  cerebral affection.   The case  appears to disprove  the dictum of
Rokitansky, that cerebral tubercle never occurs in any but the chronic
form.
   The tubercle presents the appearance and consistency of soft yellow
 cheese, and while miliary granulations are peculiar to  the meningeal
 form,  the yellow tubercle is  the variety almost invariably met with in
 the brain.   We  are unable to determine whether the deposit takes place
 in this form; the more extended application of the microscope will best
 decide the question; since the microscopic characters  of  tubercle are
 sufficiently  determined  to give a positive answer.   Rokitansky is of
 opinion that tubercle in the brain, does, in part at least, commence in
 the gray translucent form, for portions of  a tubercular mass are some-
 times found in that state.  In any case, however, he  adds,  it may con-
 tinue for a short period only in that form,  and soon pass into the  stage
 of the yellow cheesy tubercle.   The microscopic elements are the same
 granulated nuclear corpuscles of an ovoid  or  somewhat irregular shape,
 interspersed with granular blastema and particles of oily  matter found
 elsewhere ;  according to the  amount of inflammatory action exerted in
 their vicinity we shall also find more  or less glomeruli, with other traces
 of its effects.   The tubercle is generally surrounded by a delicate cyst,
 and when, which occasionally happens, the tubercular matter  proceeds
 to the stage of softening, the superficial observer may mistake the morbid
 appearances for those of a simple abscess of the brain.  The concurrence
 of tubercle in other parts, together with the  aid of the microscope, will
 assist in fixing the real character  of the  affection.  The frequency ot
 tubercle of the brain in children is a point not to be forgotten in the
 treatment of their diseases, and is one of the reasons why the overstrain-
 ins of the mental faculties of  a delicate child is so much to be repro-
 bated   Physicians who have had the most extensive experience in these
 matters agree as to the rarity of its occurrence in the adult; thus, Cru-
  veilhier never met with a single case, and Lugol, in  the large  hospital
  of St. Louis, has only seen eight instances, in none of which any symp-
  toms of the disease were manifested during life.
i Session 1850-51, p. 34. 
264
CANCER.
  It is a  singular fact, which we gather  from the  statistics of MM.
Rilliet  and Barthez,  that  sex appears  to  exert a marked influence
upon the  occurrence of cerebral tubercle; in each variety, the  males
are considerably more  liable to the affection than females; of forty-four
cases, we  find twenty-nine occurring in boys,  and fifteen in girls.   The
fact is confirmed by the statistics of our own  medical writers: an ana-
lysis of fifteen cases reported by Dr. Abercrombie and others, establishes
a similar  proportion;  ten of  these cases were males, and five females.
It is, however, right to state  that  Dr. Hennis Green's1 statistics con-
tradict this fact ; his observations were made at the  same hospital  as
those of MM. Rilliet and Barthez, and, of the thirty cases which he has
collected,  fourteen occurred in boys and sixteen in girls.
  The deposit of tubercular matter sometimes occurs in  patches of irre-
gular shape and size, on the surface of the  brain, beneath the pia mater,2
but commonly, as we  have already seen, it forms nodules within the
cerebral tissue.   It is  often met with both in  cerebrum  and cerebellum
at the same time; the number of  cases in which it occurs in one or the
other alone is about equal;  the pons varolii is, in rare  cases, the only
seat of  the deposit.
  In  the  lungs, we  frequently meet with satisfactory evidence  of the
power of  the system to reject and cure tubercle; we are not possessed
of similar proof with regard to the brain; the  only analogous  process
is that in  which the vitality of the deposit seems utterly destroyed, and
cretification results; this is a metamorphosis which  sometimes, though
rarely, takes place in cerebral tubercle.   We must not confound with
cretification of tubercle, certain gritty or  sabulous masses found in the
brain; thus,  our notes contain the history of a  case, in which, on a
vertical section of the  cerebellum, the knife grated upon some calculous
formations, imbedded in the tissue, and intimately adherent to it; there
proved to be,  on each  side, three or four irregularly crystallized masses,
which broke up easily on pressure, and were not affected by either liquor
potassae or acetic acid.  There was no other  perceptible disease of the
cerebral tissue, but the choroid plexuses were covered with concentric
corpuscles.   Andral3 gives, as a great curiosity, an analogous case,  in
which, however, the "ossifications" were inclosed in a cyst.


                              CANCER

   Next in frequency to tubercular deposit we find the various forms  of
cancer,  all of which, excepting  the epithelial variety, are met with in
the brain.  There are no symptoms peculiar to the disease, beyond the
effects resulting from pressure; and even they do not appear to  be  in
any way commensurate with the size  of the  deposit.   The form which
it assumes is that of infiltration,  without any  definite limits,  or of a
tumor surrounded by a cyst;  in the  former  case, there seems  a con-
tinuity of tissue between  the cancerous mass and the nerve-tissue. The

                   1 Medico-Chir. Trans, vol. xxv. p. 192.
                   2 See Mr. Dunn's case, ibid. p. 209.
                   3 Clinique Medicale, t. v. 719. 
CANCER.
265
same law, with regard to the  predominant liability of the  cerebrum
compared with the cerebellum,  applies in the present instance; thus, in
forty-three cases of  cancer of the nervous centres alluded to  by An-

                                Fig. 127.
 Cancerous tumor, occupying the upper portion of the posterior cerebral lobe of a man aged 54, brought
into St. Mary's Hospital comatose and hemiplegic, in which state he remained until death.  The central
portion was dense and fibrous, of a yellow color, and consisting of fusiform fibre-cells: the external portion
soft, cream-colored, or pink, composed of a variety of compound cancer-corpuscles. The whole was sur-
rounded by a red vascular margin.

dral,1 we  find thirty-one occurring in the  cerebral hemispheres, and five
in the cerebellum ;  the  remainder were  thus distributed:  three were
found in the pituitary gland, one in  the corpus  callosum, and three  in
the  spinal  cord.   The same author, by an  analysis  of the cases col-
lected by him,  establishes, numerically, the relation commonly found to
prevail with regard to the frequency of primary cancer in the nervous
centres;  in ten of  the forty-three cases only, or less than one-fourth,
was there any  carcinoma in  other organs.  As a result  of local injury,
we meet with a species of fungoid growth of the. brain, which has been
termed hernia  cerebri, but which is  very  different from  the hernia cere-
bri to which allusion has been made, in the section treating of congenital
hvdrocephalus.  In  consequence  of a fracture  of the  skull, the brain
appears to sprout forth  in the  shape of a vascular, medullary growth.
It appears as if the brain, released  from its confinement, luxuriated in
its newly-acquired liberty.   Extensive suppuration is  generally found
accompanying  this form of hernia,  within  the brain   We  are  not in
possession of  any  microscopic examination showing the exact nature ot

*  In addition  to tubercular and cancerous  deposits  we  also meet with
melanotic, fatty, and fibrous growths, and cysts m the encephalon.
    It was long doubted whether  melanosis ever occurred  in the brain
 and it certainly is rarely found in this locality.   Sir Robert Carswell
 howeverrgives^  specimen  of two  tumors  of  this description,  which

            i Clinique Med. t. v. p. 633.                 ..
            2 Pathological Anatomy, 1838, Art. Melanoma, pi. u. 
266
FIBROID TUMORS—CYSTS.
were located in the right hemisphere of the cerebrum of a man; they
were of the size of a hen's egg, and  penetrated into the ventricles.
Melanotic deposits were also found in other organs of the same subject,
and the veins passing from the tumors in the brain, were observed  to
contain melanotic matter in a fluid  condition.  Dr. Hooper's work on
the brain also contains a plate representing this disease ; and, recently,
Dr. Clendining brought  a  case of the  kind before  the  notice  of the
Pathological Society.1
  The simple fatty tumor is only found in the choroid plexus, where  it
does not, however, attain any great size.   The fatty growths most fre-
quently met with in the brain  are those which are  termed cholestea-
toma ;  they are formed  of  concentric layers,  and  present  a  metallic
lustre;  they consist of membranous layers, ordinary fat-vesicles, and
cholesterin plates, and are  inclosed in a capsule.  They attain the size
of a walnut or goose's egg.


                        FIBROID  TUMORS.

  We have searched in vain for the evidence of fibrous tumors occurring
in the cerebral tissues, though their  existence is admitted by Rokitan-
sky.  None of the pathological works that we have consulted record a
case of  the kind;  we are, therefore, inclined to assume  that  they are
limited  to  the dura mater, and that fibroid  tissue only occurs  in the
metamorphosis of old cysts or envelops of the heterologous growths
found in the brain.

                              CYSTS.

  Cysts of various kinds present themselves in the brain ; those resulting
from apoplectic effusions are the most common, and present, as we have
seen, various stages of development.  It is probable that, in many in-
stances, their formation may be due to the same process  as that described
by Mr.  Prescott Hewett, as  giving rise to the inter-arachnoid cysts, viz:
a formation of a false  membrane, subsequent to the effusion from  the
sanguineous clot.   The firmness and thickness of these cysts will serve
to distinguish them, even when they only contain  serum,  from  the true
hydated cyst.   The microscope, by determining the presence of entozoa,
or the parallel lamination of the envelop  peculiar to hydatid growths,
will further assist our diagnosis.  The only parasites hitherto discovered
in this  locality,  are  the ecchinococcus and the  cysticercus cellulosae,
which,  however,  are not to  be viewed as essentially  distinct.  The
acephalocyst occupies the  peripheral, more frequently than the  central
portions of the hemispheres, and is found to present no connection with
the surrounding tissues.   When met with in the  brain,  there is gene-
rally a coincident development of  the same parasites in the liver, a fact
first pointed out  by Aran,2  who has  analyzed  forty-seven  cases  of
this kind.

         1 Report of the Pathological Society of London, 1847, p. 15.
         * Schmidt's Jahrbiicher der Medicin, vol. xxxiii. p. 136. 
THE PITUITARY BODY.
267
                     THE PITUITARY BODY.

  The pituitary body presents morbid conditions, which, generally, are
rather pathological curiosities, than that they offer any peculiar points
of general interest;  in a  physiological point of view, tumofs or cysts
occurring in it attract attention, from their not producing those symp-
toms which are generally attributed to  pressure upon the encephalon,
and this is supposed to be due to the  force  acting in an upward direc-
tion.  Thus, they are rarely accompanied by paralysis, though acquiring
an extent sufficient to  displace the lateral ventricles with the thalami
and corpora striata, a circumstance presenting, as Dr. Romberg remarks,
an analogy to  the different  effect produced upon  the conduction of a
nerve by a tumor, according  as the nerve is gradually distended or forci-
bly compressed.   Neither Rokitansky, who treats  diseases of the pitui-
tary body in  detail, nor Engel, who has written a monograph  on the
subject, corroborates the observations of Joseph Wenzel, that disease of
the pituitary body is an essential feature in epilepsy.   The pathologists
of our own country have not observed a relation of the kind.  Epilepsy
is met with as a result of the most various degenerations, or morbid pro-
ducts within the brain, independently of any marked disease of this ap-
pendix cerebri; it is not constantly associated with any one lesion, and
in the cases of disease of the pituitary gland, given, for instance, by Dr.
Bright, we find no epileptic  seizures during life; or, conversely, we see
epilepsy1 occurring without any disorganization  of this part.
   The pituitary body does not seem to bear any definite relation to the
manifestations of the mind.    Dr. Bright2 gives  an instance in which it
was absent; the patient was a man who  died at the age of forty-eight,
of softening of the left corpus  striatum; but he had  enjoyed thorough
good health until five months previously.
   In the course of our account of cerebral morbid anatomy, we have had
occasion to allude to the occurrence of aneurism  of the  cerebral arteries;
the  subject will meet with a fuller consideration  when we  treat of the
 diseases of the vascular system ; but we  could not  dismiss the pathology
 of the brain without pointedly remarking upon  their importance in the
production of cerebral  symptoms, and as a more or less direct cause of
 death.   The  diseases of the arteries play a most important part in the
 production of cerebral  disease, and in many of the morbid conditions
 which  we have passed in review they may be viewed as one of  the main
 elements.

   1 Reports, &c, case cxlii.                       ...    ,  ,  .   .   .  .,
  2 An interesting case of disease of the infundibulum and  pituitary body is given in the
 records of the Pathological Society of London for 1849, p. 19. 
                     CHAPTER  XI.

          THE SPINAL  CORD  AND ITS MEMBRANES.

  We must commence this section with the ungratifying confession that
it is a subject upon which  our knowledge is very limited. This is partly
owing to the various baseless hypotheses which the pathology of the spinal
cord has admitted, and still more to the mechanical difficulty which pre-
sents itself to the investigation of its derangements, during life, as well
as after death.  The depth of muscle which invests the spinal column on
the dorsal surface, the tediousness of the  procedure of sawing through
the arches of the vertebrae, and the routine system of conducting post-
mortem investigations, militate against the frequent examination of this
organ. Nor can we hope that any great amelioration will take place in
this respect, until our hospitals and medical schools are able to endow
the curatorships of morbid anatomy in such a manner as to secure the
undivided services of men  of science, for a series of years.   So long as
the spinal cord was considered only as an  aggregation of nerve-fibres,
serving to conduct influences to or from the brain, it was natural that its
pathological changes should be regarded as of a secondary importance ;
but since the researches of Dr. Marshall  Hall have shown its claim to
be considered in the light  of a central organ of the nervous system, en-
dowed with powers independent of the brain, the morbid anatomy of the
spinal cord has also acquired a higher dignity.   As our knowledge of its
physiological endowments, and of its structure, is enlarged, and as our
means of physical diagnosis are improved, we may hope to see its morbid
anatomy better understood and appreciated.  At present, we can scarcely
be said to have advanced beyond  the very threshold of this department
of science.
  We shall follow the same order we adopted in treating of the morbid
anatomy of the brain, and  examine successively the post-mortem appear-
ances of the dura mater, the arachnoid, and pia mater, and then of the
cord itself.  In all cadaveric  examinations of the spinal  column, it  is
particularly to be borne in mind that the position of the body after death
may influence  the post-mortem phenomena, independently of morbid
action, owing to the gravitation of the fluids to the depending portions,
and their secondary effect upon the nerve-tissues.  How important it is
to attend to this point, is illustrated by some observations, made by Mr.
Curling,1 of tetanic cases.  On examining the  body of a man who had
died of tetanus, which had been  placed on its face immediately after
death, Mr. Curling found that part of the pia mater covering the ante-
rior columns of .the medulla spinalis remarkably vascular; a  circum-
1 On Tetanus, p. 48. 
THE SPINAL CORD  AND ITS MEMBRANES.        269
stance which would necessarily induce a conviction in the mind of the
pathologist, that  an essential lesion had been discovered, by which the
exaltation of motor action could be  satisfactorily explained.   Unfortu-
nately for the conclusive force of the observation, in three other instances,
where the bodies were suffered to remain in the usual position, the vessels
on the posterior parts  only were observed to be turgid.
  This influence  of position is more likely to affect the spinal cord than
the brain, owing to its being less excluded from atmospheric agency. It
is also important to remember that the relation of the envelops of the
cord differs from that existing between the investments of the brain and
their contents in  various material points.  The movements of the osseous
case of the cord  would have rendered a close adhesion with the mem-
branes a source  of frequent danger; we may fairly assume this as a
reason why the dura mater  of the  spinal column is  only very loosely
attached to the vertebral canal;  on which account it allows of an accu-
mulation of fluid  on its external surface, such as we but rarely meet with
in the brain.   Owing to the firm attachment of the dura mater to the
occipital foramen, fluids accumulated on this part are prevented passing
into the cranial cavity, while there is a free communication between the
arachnoidal spaces of the  two cavities. This fact is one that must not be
overlooked in  morbid affections both of the spine and the encephalon;
independent of the protection that  the  arachnoidal fluid affords to the
cord,  it  is an evident means of securing a balance in the circulation in
the nervous centres, while,  on the other hand, a derangement in its
quantity and site may be alone sufficient to  produce serious symptoms,
which the morbid anatomist would be unable to measure by physical tests.
   We possess  no evidence of the occurrence of idiopathic disease of the
 spinal dura mater, though it can scarcely  be supposed that a fibrous
 membrane, situated as it  is, should not suffer from  the rheumatic dia-
 thesis.  In all cases of injury of the vertebral column it is  liable to be
 affected, and scrofulous disease  of the vertebrae and the  extension of
 psoas abscess  may involve it.  In the congenital affection termed spina
 bifida, which is analogous to the form  of hernia cerebri, occurring in
 infants  as  a result of non-closure of the cranial bones, the dura mater
 extends into the cvst that shows on the dorsal surface of the column;
 but it is occasionally found deficient at one point, so that the contained
 fluid  is only retained  by the thin  meninges.  This  pathological  state
 differs from that to which we have  compared it in this, that the fluid  is
 entirely external  to the nerve-tissue, and that the cyst at no  time pre-
 sents a layer  of medullary matter.
    The tumor  varies in size from that of a small nut to that ot a child s
 head- it generally is solitary, and occupies the lumbar or sacral region;
 when'occurring  in the back we may expect to find another tumor of the
 same description lower down.  The swelling is of  a semi-globular, or
 ovoid shape, and may appear pediculated, owing to a constriction at its
 base  The thinness of the cutaneous covering passing over the tumor, has
 induced some  pathologists to deny its presence; this however is an error.
    The rarity  of the occurrence of idiopathic diseases in the  dura mater,
 annlies equally to adventitious products.  Encephaloid, and other forms
 of carcinoma, undoubtedly  occur primarily  in the  dura  mater, but  in 
270         THE SPINAL  CORD AND ITS  MEMBRANES.
many of the instances on record, it is manifest that the disease extended
from the bones to the theca vertebralis.   The same is true with regard
to tubercular deposits; in both cases, however, the membrane is liable
to become secondarily involved, by  extension of these diseases  either
from within or without the canal.
   An  instance  of melanotic growth  apparently proceeding  from  the
dura mater of the cord, is to be found in the Report of the Pathological
Society for 1847.  Dr. Williams discovered it in a patient, aged forty-
six, who, three years previously, had suffered from  hemiplegia of  the
right side, following the extirpation of the  right eye, for  fungus.   The
patient recovered from this, and in the summer preceding his death was
attacked with epilepsy: weakness and numbness of  the lower extremi-
ties, and inferior portion of the  trunk,  soon proceeding to  complete
paraplegia, supervened.   The  brain and its  membranes were  found
healthy; within the spinal canal,  closely adherent to the  theca extern-
ally, there  existed an irregular  encephaloid mass, mottled with  dark
spots, extending  from the third to the sixth dorsal vertebra, the bodies
of which were carious  and infiltrated with cancerous matter;  the por-
tion of the cord beneath the tumor was flattened, soft, and wasted.  In
connection with this subject, we may also be allowed to mention  the very
rare occurrence of an accumulation of fat, a genuine fatty tumor, within
the spinal  column, in contact with the dura mater; an instance of this
kind was  brought before the  Pathological Society,  in 1852, by Mr.
Obre', in which death was produced in an otherwise healthy child by the
                               Fig. 128.
 Part of the dorsal portion of the spinal cord of a young man who died paraplegic.  A thick layer of lymph
and tuberculous matter was found surrounding the dura mater, and slightly compressing the cord.  It wan
manifestly an extension of disease from the adjacent vertebrae and intervertebral cartilages. The cord and
the dura mater appear healthy in texture. From St. Bartholomew's Museum, Series vii. No. 10.

mere mechanical pressure exerted by a deposit of this kind.   The  lipo-
raatous growth was two and a half  inches  in length,  the breadth of the
canal, and about half  an inch in thickness, composed of the ordinary
spherical fat-cells: it  did not  differ from fat usually met with in other
situations, excepting that the cells seemed  to contain  fat in a more  solid
and granular state.   It lay between the theca and the bodies of  the last
cervical and first dorsal vertebrae. 
CHAPTER  XII.
THE  ARACHNOID  AND PIA  MATER  OF  THE  SPINAL CORD.

  Although  the anatomical connection  between these membranes is
somewhat different from that obtaining between the cerebral meninges,
it does not appear that their  relation  in disease differs materially from
what we have  found  to prevail in that locality; we shall, therefore, con-
sider them together.
  The absence of valves in the spinal veins, and their peculiar distribu-
tion, cause the circulation of  the spinal cord to be very sluggish,  and,
therefore, prone to congestion and stagnation; to this,  Ollivier attributes
the great number of dilatations which we find in the  different points of
its  extent, in  individuals advanced in  years.   He adds, that he  has
generally remarked that the  quantity of serum in the vertebral canal
was so much the greater, according as there was a greater congestion in
the veins of the spine, and of the membranous coverings of the cord;
thus, the slowness and difficulty of the course of the  venous blood may
be here the causes of a dropsy, which is independent of inflammation of
the spinal membranes.  These effusions of serum will, according to the
exciting causes, be of a chronic or acute character; in  infancy, irritation
frequently gives rise to a more rapid accumulation of fluid, while in old
age a slow effusion is frequently met with, which Rokitansky attributes,
in part,  at least, to a secondary congestion, arising from atrophy of the
medulla and  the roots of the nerves.   The fluid exhaled  under  such
circumstances will follow  the law  of gravitation, and  accumulate at the
lower end of the spinal cord, and thus assist in exciting and perpetuating
paraplegic symptoms of which we may be unable to detect a sufficiently
satisfactory reason after death.  The occurrence of sanguineous apoplexy
of the meninges, in any form, is very rarely met with; Dr. Abercrombie
gives a single instance, which occurred under his own observation, in a
child, aged seven, in whom, after an  illness of three days, death ensued
after violent convulsions.  A long and very firm coagulum of blood was
found  external to the cord, extending the whole length of  the cervical
portion.  An interesting  case of hemorrhage under  the pia mater, but
external  to the  cord, is  also quoted, from Dr. Stroud's  notes, by Dr.
Bright  (p. 340).  Numerous instances of spinal  apoplexy occurring in
children are given by Dr. Mauthner, but as no post-mortem appearances
are recorded,  the inferences are solely derived from the symptoms, which
do  not enable  us to  state positively  the  exact nature of the effusion.
We possess more satisfactory  and copious evidence  regarding the in-
flammatory affections of the spinal meninges, and it appears that it is a 
272  THE ARACHNOID AND PIA MATER OF TnE SPINAL CORD.

very frequent cause of  death in new-born  infants; thus, Billard found,
that in thirty cases of convulsions, there was meningitis of the cord in
twenty, only  six of which  presented inflammation of the cerebral me-
ninges.  It is much less frequent in the adult, and is  here almost invari-
ably associated  with, or consequent upon, cerebral inflammation.   As
a result of an acute inflammation of the membranes, we find lymph, or
pus exuded, to a greater or less extent.  Either  may invest the entire
surface of  the cord, or  it may be  limited, as in a case that fell under
our own observation, in a child of four years of age, to a space of an
inch and a half in length.  But we must be careful in  at once concluding
that we have to deal with a case of spinal meningitis, because we find
the theca vertebralis lined with pus, for it may find its way from without
into the cavity; thus, in a case of psoas abscess, given by  Dr. Bright,
the sudden supervention of  fatal symptoms was  manifestly due to this
cause; a probe could be easily passed from the intervertebral foramina
into the adjoining abscess.   In  the chronic form of  spinal meningitis,
the traces of the disease consist in greater or less opacity and thickening
of the arachnoid, which frequently is found closely adherent to the spinal
cord, and corrugated.
   The symptoms of spinal arachnitis are met in trismus neonatorum, in
the shape of congestion of the spinal arachnoid, with an effusion of blood
or serum into its  cavity; and Dr West1 also states  that,  in the three
cases which he examined, he found  effusion of fluid or coagulated blood
in the cellular tissues surrounding the  theca of the  cord.   This is not
necessarily  at variance  with the statements of  Dr  Scholler2  and Dr.
Colles,3 who attribute trismus to inflammation of  the  umbilical arteries,
as this may, and is, found to coexist with the former.  Symptoms of
inflammation of the spinal membranes have also been met with in tetanus;
but in by far the greater number of cases examined after death, no uni-
form or adequate cause,  to  which the  symptoms were referable, could
be discovered.   The importance of  the predisposing causes is, probably,
as great in tetanus as it is shown to be in trismus;  atmospheric states
have a manifest influence in this  respect, and an irritation set up in any
part of the body,  and propagated  to  the nervous centres, under such
circumstances, induces the disease.   The  same absence  of uniform  pa-
thological data exists in another disease, which we  cannot but refer to
the nervous centres, hydrophobia; congestion  of the cerebro-spinal mem-
branes  and nerve-matter, and  some occasional effusion, is all that is
generally met with in the shape of post-mortem effects; we need not add
that these  appearances cannot be  considered  as characteristic of  the
disease in question.  Mr. Youatt, whose extensive experience of hydro-
phobia in the brute creation, justifies our referring to him as an authority,
states  that the  appearance of inflammation  of rabies  is of a peculiar
character in the stomach, but that no conclusion can be drawn from the
state of other organs.  In discussing the changes occurring in the spinal
cord itself, we shall have occasion once  more to recur to the subject of
tetanus.

  1 The Diseases of Infancy and Childhood, p. 125.
  2 Neue Zeitschrift fur Geburtskunde von Busch, D'Outrepontund Ritgen, vol. v. p. 477.
  3 Dublin Hospital Reports, p. 285. 
THE ARACHNOID AND  PIA MATER  OF THE SPINAL CORD.  273
  In cases of long standing paralysis and paraplegia, we find evidence
of chronic meningitis of the cord in the corrugation, opacity, and close
adhesions of the membranes  to one another, and to the cord.   A good
illustration of this is afforded by a case given in Dr. Bright's  Reports
(page 380);  here, the dura mater of the cord was unusually firm and
thick, and, as far  as the  middle of the back, closely adherent to  the
pia mater, from which, in most parts, it could not be detached without
lacerating the cord.   On  attentive examination, it was found that  the
apparent thickening of the dura mater  depended chiefly on a layer of
membrane, of almost cartilaginous thickness, beneath it;  and was, pro-
bably, rather the  diseased arachnoid, or an adventitious deposit, than
the dura mater itself.   These appearances may be associated with fur-
ther lesion of the cord, or with adventitious growths of the vertebral
column or arachnoid.   The only growths of this kind that  are of  fre-
quent  occurrence, are formations of bone on the visceral  side of the
latter membrane.   In this respect, we perceive a characteristic  distinc-
tion between the head and the spinal column; for while, in the former,
ossific deposits are  common in  the  dura mater, and are scarcely ever
met with in the other membranes, in the spinal  column they are found
to prevail in the  arachnoid, and not to affect the dura mater.  A re-
markable  instance  is recorded by  Herbert Mayo, in  his  Outlines of
Human Pathology, of osseous concretions surrounding the posterior
roots of the nerves, and proceeding to the lower extremity.   This, un-
doubtedly, belonged to the  class of pathological products under con-
sideration ; and the  case has a special interest, from its bearing upon an
important law of nervous conduction.  The pains suffered by the patient
were so limited to the lower extremity, and were so  excruciating, that
the surgeon performed amputation of the limb, though with what results
need scarcely be stated.
   Cartilage also  forms, though less frequently, on  the arachnoid.  A
good instance is recorded in the Reports of  the Pathological Society of
London, by Dr.  Quain,1  who describes  the laminae as  composed _ of a
transparent matrix, in which  were deposited  small  cells,  containing
nucleoli, and numerous small amorphous granules.
   It does not appear that there is a liability on the part of the spinal
 pia mater to tubercular deposit, as we find to prevail in the cerebrum.
 Rokitansky remarks on the subject, that he has  never  had occasion to
 suspect the exudation formed on the pia mater  to be of a tuberculous
 nature and that this observation accords with the fact that  spontaneous
 spinal meningitis so commonly coexists with that form of cerebral menin-
 gitis which produces similar exudations.  An acute tuberculosis, he adds,
 he has never observed in it.

                         1 Reports, &c. 1849, p. 25.
18 
CHAPTER   XIII.
THE  SPINAL  CORD,
  The forms of disease and their  effects, which  present  themselves in
the spinal cord, closely resemble those we meet with in the brain.  The
spinal cord does not appear to be so often attacked as  the encephalon,
and as we have already pointed  out, it  is the  part which is generally
left unexamined, unless attention is forcibly directed to it by the pre-
vious symptoms  of the patient; for both reasons  the records  of its
pathological  states are  much more scanty than those regarding the
brain, and future  inquirers have yet  a large field  to explore.  The
evanescent character of congestion  rarely allows of its  being demon-
strated after death; though it is impossible to  believe that there should
not be accumulation of blood in  the  cord, in those  instances  in which
                   the symptoms demonstrate  intense  irritation of the
     Fig. 129.        part, as  in tetanus; a case  of hydrophobia  is  re-
                   corded by Dr. Bright, in which a blush of redness
                   was perceived  in  the cineritious part  of the  spinal
                   cord  opposite the  second  and  third cervical ver-
                   tebrae.   An  anaemic condition of the cord is as dif-
                   ficult to  demonstrate at its converse, though here
                   too the practitioner will not fail to suggest  instances
                   in which its existence may  be fairly assumed during
                   life.  Both  states manifest  themselves in the  se-
                   condary  effects  of  hypertrophy  and  atrophy.
                   These may be general or local; the former affection
                   belonging chiefly to early  life, and the latter, like
                   the  corresponding  condition in  the  brain,   to  old
                   age.  Atrophy of the spinal cord is one of the  pa-
                   thological conditions met with in the disease known
                   as tabes dorsalis; in this case it is  more of  a local
                   character, involving only  the lumbar segment of
                   the cord and the nerves passing off from that part.
                   The separate divisions of the cauda equina are often
                   found entirely deprived   of their  medulla,  and
                   nothing but  the neurilemma  may remain.   A local
                   atrophy,  as  the  effect of  the compression exerted
                   by morbid growths  or displacement of the vertebras
 is frequently met with, and in these cases it is of peculiar physiological
 interest to observe the limitation of the symptoms of nervous affection
 according to the extent to which the pathological condition involves  the
  Part of a spinal cord
from a case of paraplegia,
with angular curvature of
the spine, in a lad aged
eighteen.  Opposite  the
contracted part of the cord,
a short process of bone
projected from the angle
of the curvature into the
spinal canal. — From St.
Bartholomew's Museum,
Series vii. No. 7. 
THE SPINAL CORD.
275
medulla.  Numerous instances are recorded by writers on the subject;
among whom we would particularly refer to Ollivier, Longet, and Rom-
berg.  Both in atrophy and hypertrophy of the spinal cord, the  tissue
is commonly indurated and firmer than in the normal state.
  Cases of  the termination of myelitis, or inflammation of the cord, in
the first stage, like those of encephalitis, are scarcely ever met with; it
becomes the question whether, owing to the peculiarity of the nervous
structures, the first onset of inflammatory action is not at once accom-
panied by those changes, which in other tissues are looked upon as the
secondary products of inflammation.  An essential difference appears
to prevail between the brain and spinal cord with regard to  one of the
results  of congestion, hemorrhagic effusion.   The frequent occurrence
of apoplexy of the encephalon is familiar  to all; its idiopathic  occur-
rence in the spinal  cord is  extremely rare,  and when  brought on by
external lesion, such  as fracture of the vertebrae, or penetrating wounds,
it is commonly associated with hemorrhage on the surface.   The  cases  -
collected by Dr. Abercrombie all appear to be instances  of  effusion be-
tween the meninges and the cord itself.   The rarity of the occurrence
may justify our extracting the following observation from the Report of
the  Pathological Society for 1849, p. 28 :—
   "A gentleman, aged 44, who, with the exception of occasional at-
tacks of gout, had previously enjoyed good health, was suddenly seized
one  evening with violent spasm in the stomach, and found that he had
lost all sensation and power of motion in  the lower half of the body.
Mr. Curling found him an hour later with complete paraplegia  below
the  third ribs, and strong priapism ;  no  excito-motory movements were
producible,  and the mind was perfectly clear.   The priapism  subsided
in about twenty-four hours; there was no extension  of paralysis, ex-
cept a feeling of numbness of the hands, and at last imperfect power of
using them.  During the first eighteen hours after the  attack, scarcely
any urine was secreted, and it  subsequently became scanty in amount.
The patient died four days after the seizure.   The spine was examined
seventeen  hours  after death.   The muscles of the back  were much
loaded  with blood—no fluid escaped on  opening the theca vertebralis,
the  head being in a depending position.   The vessels on the surface of
the  cord were a good deal congested.  An incision was made above the
front of the  medulla, commencing  at the part  corresponding to the
third cervical vertebrae, and terminating at the  last dorsal; two  small
clots of blood, amounting together to about  a  drachm, were found in
the  interior of the medulla, occupying about an inch and a  half  in ex-
tent and situated between the origins of  the second and third pairs of
dorsal nerves.  The  substance of  the cord around the  clots was some-
what soft;  the medulla was more  or less infiltrated and stained with
blood from  the site of the clots upwards as high as the third cervical
vertebras, and downwards as low as the last dorsal."
   No microscopic examination of the parts appears  to have been made;
future observation must determine whether atheromatous, or other dege-
neration of the arteries, or previous derangement in  the nutrition of the
adioinino- tissues, is  the causa proxima of spinal, as it so frequently is of
cerebraUiemorrhage.  The above case does not tally with the statement 
276
THE SPINAL CORD.
of Rokitansky, that, when hemorrhage occurs in the spinal cord, it is in
the cervical portion.
  The product of inflammatory action most commonly discovered in  the
spinal cord is  ramollissement, a condition which, however, like its ana-
logue in the brain, is equally attributable to other pathological states,
each of which may be recognized by the naked  eye, and the aid of  the
microscope.  The  degree of softening varies from a slight diminution of
consistency, as compared with  surrounding parts, to a state of pulpy
diffluence;  the extent of cord affected differs equally.  In paralysis, we
very frequently meet with no other trace of disease but a trifling soften-
ing in the lumbar, dorsal, or cervical regions, manifestly the result of a
slow inflammatory process.   The microscopic products of inflammation,
the inflammation corpuscles and granules, spoken of in considering  the
similar conditions  of  the brain, are also found in the present instance ;
and where  any doubt prevails as to the  nature  of the  softening, these
microscopic appearances will aid our judgment.   MM. Rilliet and Bar-
thez have invariably found that, in children,  the softening of the white
matter of the cord coexisted with  inflammation  of the membranes, and
that the extent of the former was in  the  exact  ratio of the amount of
the latter.
  The softening affects the gray matter, and especially that belonging
to the lumbar and, brachial swellings more than  any other part;  and a
case is given by Ollivier, in which  the entire gray substance of the cord
was converted into a pulpy mass, leaving the white matter in a compara-
tively healthy state.  We meet with diffused suppuration in the cord as
in the  brain;  circumscribed  abscess is also, though very rarely, found
within the medullary matter.   Dr. Abercrombie1 gives a case  of this
which occurred in  a woman aged fifty-six, who was affected with sudden
loss of power of the limbs of the left side, followed by death in a week.
The brain was sound, but in the centre of the right column of the spinal
cord, in  the middle of  the cervical portion, there was a cavity three
inches long, and two or three lines  in diameter; it was full of a soft
matter, like pus, which  became more  consistent  towards the parietes of
the cavity.
  It appears that the softening invariably proceeds from the gray to
the white matter in myelitis.   It is probable that where the process is
a result of exhaustion,  mal-nutrition, or degeneration, the  reverse will
be found to obtain ; as the former would be favored by the presence of
a large number of bloodvessels, the latter would spread more in a part
not copiously supplied with them.   The tint of the gray matter is deep-
ened, and a rose-blush pervades the white matter in the red form, while
this hue is  replaced by a more or less yellow tinge when the suppurative
stage has set in.  A form  of white softening  occurs in the spinal cord
which is analogous to the white softening met  with in the brain, as a
result of the effusion of serum or oedema,  which is in no way connected
with inflammation.
   Another product of myelitis is induration of  the cord; this is found
coexistent  with  ramollissement, or by itself.   It is more  frequently

                 1 Diseases of the Brain, &c, 1845, p. 355. 
THE SPINAL CORD.
277
brought on by chronic or cachectic inflammation than softening, and it
is not unfrequently complicated with hypertrophy of the affected part.
When the induration is very considerable, the nerve-tissue resembles, as
Ollivier observes, in  consistency, density, and appearance, boiled white
of egg;  it is a  condition that Esquirol  has repeatedly met with in epi-
leptic subjects.  Gluge,4 in adverting to the extreme difficulty of a minute
analysis of all the elements of disease occurring in nerve-matter, alludes
to the coagulability of the contents of the tubules as a point  of great
importance,  though he admits the obstacles that oppose themselves to
a determination of such relations in  disease.   He  is inclined  to think
that the coagulation  takes  place in  certain diseases, such as  tetanus,
 during life.   That a change in  the contents of the nerve-tubules must
 materially affect their conducting power, is  too  manifest  to require
 enlarging upon theoretically; still, the proof has, as  yet, evaded our
 means of demonstration.
   Softening of the  spinal cord occurs,  as in the brain, as a  sequel ot
 morbid growths,  such as carcinoma,  or tubercle.   Neither of  them is,
 however, frequently met with, though they are oftener seen  in the cord
 itself than  its membranes.   Ollivier, whose work  contains  the largest
 collection of cases of this kind on record, denies the occurrence of me-
 lanosis affecting  the cord, nor have we  been able to discover any other
 instance but the one already alluded to, in which  the melanotic tumor
 was attached to the dura mater.
    Acephalocvsts are also  met  with in the  spinal cord.   Rokitansky
 states that he has repeatedly met with the cysticercus  in  the cervical
 portion of the spinal marrow;  but his  experience  agrees with that ot
 Ollivier, that they do not occur in the substance of the medulla.  Iney
 in  most instances are  situated externally to  the  dura mater.  In this
 case, it is manifest that they had been first developed outside the column,
  and had forced their way in through the  intervertebral foramina; they
  have, however, also been found within  and underneath  the arachnoid.
  It is a curious fact, for which we can offer no explanation that the cases
  of acephalocyst occurring  in the spinal column have all been  females.
     In concluding the subject of the  pathological  anatomy of  the spinal
  cord and  its  membranes, we  must again express our regret that our
  knowledge of the morbid changes occurring  in it are in no way com-
  mensurate with the  importance and  dignity of the organ   With refer-
  ence to no other part of the body are we so often at a loss  to explain
  the connection which  exists between the symptoms of disease, and the
  actual pathological  condition of the organ   The hyperaesthesia of the
  spinal cord (which is manifested in  so marked a manner in tetanus, hy-
  drophobia, hysteria, and poisoning by strychnine) is a palpable derange
  ment of its functions; and yet the anatomist can discover no satisfactory
  reason to satisfy his desire for establishing the etiological  relation.  A
  comparison suggests itself between  these cases of diseased  action which
  anneaiayet  to be out of  the reach of science, and those  calamitous
  Sents oJn ou  railways which generally seem to be due rather to some
• Atlas der Pathologischen Anatomie, Lief. xx. p. 
278
THE SPINAL CORD.
Deus ex machind, than to those physical laws which are  generally sup-
posed to  rule  mechanical appliances.   Had we desired to  enter into
theoretical discussion,  either regarding the  brain or the  spinal cord,
much more might have been said on the subject; and we have carefully
abstained  entering into the debated  ground of hypothesis, as, for in-
stance, with regard to the participation of these organs in fever, as we
should thus have outstepped the limits which the practical character of
this work  seems to impose upon us. 
CHAPTER  XIV.
                          THE NERVES.

  It very rarely happens that individuals die of an affection residing
solely in the nerves; consequently, we are left to surmise their morbid
appearances in those diseases in which they are manifestly affected, from
analogy.  At the same time, we must never forget that the nerves  are
not central organs,  but that they are the telegraphic wires  destined to
convey intelligence to and from the central organs.  When, therefore, we
have to deal with a nervous symptom, we must first  inquire whether it
be due to a centric or to a peripheral cause; or, in other words, whether
the nerve is propagating a morbid impression from the  brain, the spinal
marrow, or the sympathetic ganglia which may simulate peripheral  dis-
ease,  or whether it is giving evidence  of local disease by producing
in the brain the consciousness of that  affection.   In the  majority of
instances of irregular  or painful action of the  nerve, we should be as
much in error in seeking for the cause of the derangement in the nerve
itself, as if, when our galvanic battery does not act, owing to the trough
containing no acid, we sought to  remedy the defect by changing  the
conducting wires.
   The nerves have repeatedly been made the subject of inquiry in  dis-
eases, in which either local symptoms predominate, or  in which, from
the known physiological action  of the nerves, controlling the parts
affected, the morbid phenomena could fairly be sought  in  an _ individual
nerve; thus, the sciatic has  been subjected to examination in individuals
who had been affected with sciatica, and the vagi have  been explored as
the hypothetical excitants  of hooping-cough.  ^ Pathologists have, in
neither case, succeeded in demonstrating a relation between the malady
and an uniform alteration in  the  respective  nerves.   A case has  long
been  transcribed, and has thus acquired traditional importance, by which
Cotugno, the first who wrote on  sciatica, is  made  to affirm a lesion,
oedema of the nerve, as the  causa proxima of that malady; but although
he records a case of the kind, he  himself would certainly not have ap-
proved of the  interpretation which has  been  given  to it, since  he  dis-
tinctly states that he  attributes no importance whatever to  the circum-
stance.   With regard to hooping-cough, we find instances  recorded of
the vagus having been reddened and swollen, indicating inflammatory
action, but  the large  majority of  cases in which the point  has  been
attended to have presented no such change.  Thus, Dr. Albers examined
the va«-i  in  forty-seven children who had died of  hooping-cough, and
found &them  perfectly normal in forty-three ;  Dr. West, who has  also 
280
THE NERVES.
paid especial attention to the subject, has, only in one case out of eigh-
teen, met with any change in  the nerves ;  in  this case  they were de-
cidedly redder than usual.   We are inclined to conclude, with the latter
                        author, that an appearance so frequently absent
                        cannot be one of much moment, and that, like
                        Cotugno's famous case, to which we have just
                        referred, it may be set  down  to a  cadaveric
                        change.   In  our examinations  of nerves, sup-
                        posed to be diseased, we must be careful to dis-
                        tinguish between the neurilemma and its altera-
                        tion, and the nerve-tubes ; thus, in the stump
                        of an amputated limb, we commonly  find the
                        nerve terminating in a button; this is owing to
                        the effusion of plastic  matter, which serves as
                        a protection to the divided nerve, and not  to an
                        hypertrophy  of  its tubules.
                          The morbid condition most commonly seen in
                        the nerves throughout the body is atrophy; this,
                        however, can rarely be said  to be a  primary
                        affection ; it is brought on by the  influence of
                        pressure, acting  immediately upon the nerve,
                        and causing gradual, and even entire absorption
                        at  the point upon which the pressure acts; this
                        we find occurring in the  case of aneurism, or
                        enlarged glands, lying in the vicinity of nerves.
                        Atrophy of the  nerve results from the part to
                        which it is supplied ceasing to perform the func-
                        tions  for  which it  receives the  nerve;  thus,
                        atrophy of the optic nerve may follow destruc-
                        tion of the eye, by mechanical  injury; or the
                        nerve of an extremity wastes, when the muscles
of the part are condemned to inactivity.  A case  is related by Swan,1
in which, however, other nerves, the  vagi, appear to have been idiopa-
thically affected with atrophy.  An individual had, for eighteen months,
been  unable to  satisfy  his  appetite;  the food  was vomited four   hours
after  being taken, without showing any signs of digestion; respiration
became laborious  and sibilant;  emaciation and  death ensued.  At the
section, the lungs were found normal, but the vagi, from the middle of
the neck, were atrophied, and their terminations in the  oesophagus red
and thickened.   The left was found smaller than the right.   Mr.  Swan
adds that, in two  consumptive patients, he found the vagi smaller than
usual.   In cases of atrophy and degeneration of the spinal cord, the
nerves passing from the diseased portion are, necessarily, in an atrophic
condition : thus, in an instance given by Cruveilhier,2 in which the dis-
organization of the cord was  limited to the posterior strands, extend-
ing from the lower end to the cerebellum, the posterior nerves were en-
tirely atrophied and converted into transparent threads, which contrasted

      1 Treatise on Injuries and Diseases of the Nerves. London, 1834, p. 174.
     1 Anat. Pathol. Livr., xxxii. p. 19.
Fig. 130.
 Portion of a cerebrum with the
optic nerves and remains of the
left eye.  The cornea is opaque,
and the coats of the eye are col-
lapsed.  The  left optic nerve is
considerably diminished in size be-
tween the diseased eye and the op-
tic commissure. Behind the com-
missure, the nerve on the right
side is rather smaller than that on
the left, but the thalami appear to
be of equal size. From St. Bar-
tholomew's Museum, Series viii.
No. 5. 
THE NERVES.
281
strongly with the normal appearance of the anterior nerves.   It would
appear that an idiopathic atrophy is met with in the nerves of sense,
at least the acoustic and optic nerves have been found atrophied, in cases
of blindness and deafness, where none of the ulterior causes alluded to
were  traceable.  Rokitansky states that, under  certain circumstances,
nerves which are extremely atrophied acquire a grayish, translucent ap-
pearance, especially within the skull, and that the coloring is produced
by the presence of a blastema filled with numerous nuclei, which, at
first gelatinous, and afterwards tough and elastic, takes the place of the
nerve-tubes as they disappear ; it becomes more distinctly visible, as the
original  neurilemma of the affected nerve diminishes.   He adds, that
the vessels of  a nerve in this condition are often palpably dilated.
   Whether true hypertrophy of the nerve  ever occurs is a matter that
scarcely bears direct proof; a priori, we may assume that  a nerve en-
larges in proportion to the functional  activity of the organ to which it
belongs •, an hypertrophied muscle is only enabled to manifest its power
if its nerve be also hypertrophied.  In such  a case, there is  probably
an increase in the nerve-tissue itself.  Enlargements of a different kind
are found  in nerves which are traceable to the neurilemma, or to a fibrin-
ous deposit within  the latter, as in the case of tumors of the nerves,
following  injury or  division.   After  our  preliminary remarks on the
pathology  of the nerves, we need say little about the  appearance pre-
sented in congestive  or inflammatory states;  it is questionable whether
they are ever subject to any idiopathic affection  of  the  kind, and when
the surrounding parts are involved, these invariably attract much  more
attention than the  nerve itself.   Moreover, the statements on record,
though but scanty, do not  agree;  thus, to return  again to the vagus,
which has always been the pet nerve of pathologists, probably owing to
its size and superficial site, we find that Kilian has  observed it to be in-
flamed fifteen  times, in pertussis, while Breschet  has only met with the
occurrence twice, a relation that is  the more surprising when  we recol-
lect that the sphere of observation of  the former  is a small German
provincial town, and that of the latter, the capital  of France.  Auten-
rieth, also, states generally that he has found the vagi inflamed,  in per-
sons who have  died of spasmodic cough.   The neurilemmatous  sheath
is the part mainly  affected in inflammation ;  it presents an increase of
redness, of more or less  intensity;  the infusion of  serum induces a ful-
ness and swelling of the nerve, and the nerve-tubules themselves become
separated, and, as  it were, unravelled.  The exudation of fibro-plastic
matter  follows, and, by  compression  of the fasciculi, may cause  their
obliteration; or, if resolution ensues, the  nerve may be restored to its
primitive  condition, or again the  part may accommodate itself to the
change, and the nerve remain permanently enlarged and somewhat no-
dose.   After partial or total division of a nerve,  these changes are liable
to occur, and in an irritable constitution the deposit of lymph  continues
to act as a source of irritation, and induces intense pain.  The occur-
rence of suppuration within  the  sheath necessarily gives  the nerve a
yellow color, and causes  the tubules to be broken up.  In all inflamma-
tory affections of the nerves, the cellular  tissue surrounding them will
likewise be found  inflamed.  Two  cases of inflammation of the nerve 
282
NEUROMA.
are given by Mr. Curling,1 in his treatise on tetanus, in which healthy
spots were found, between  which the nerve-tissue  appeared inflamed.
M. le Pelletier2 has also published several cases, in which  the inflam-
mation  appeared propagated along the injured nerve, to the spinal cord,
in the  same  disease.  The  most complete investigation, however, has
been made by Froriep ;3  in seven cases of  tetanus, in which injury of a
nerve had preceded, he has discovered a uniform lesion, resembling that
indicated by Mr.  Curling, and consisting in a tumefaction and redden-
ing of isolated tracts, extending from the wound to the spinal cord; he
has not found it in other cases, in which no tetanic symptoms prevailed.
We have already had occasion to observe that there is no uniformity in the
post-mortem appearances in the central organs of the nervous system in
tetanus; it is satisfactory,  at least,  to  know  of one symptom  which
appears to be established, and which, at the same  time,  may afford an
indication with regard to the necessity of local treatment, in  preventing
the propagation of the irritation from  the peripheral parts to  the central
organs.

                             NEUROMA.

   Of the morbid growths found in nerves,  the so-called  neuroma is the
most common.   In the  idiopathic form, it  is  a growth which  occurs

              Fig. 131.                            Fig. 132.
 A stump of the upper extremity, showing the     Neuromata of stump, after amputation of the
bulbous termination of the median, internal    arm. A large neuromatous mass at a; opposite 6,
cutaneous, musculo-spiral,  and musculo-cuta-    the tumors are more defined.
neous nerves;  the circumflex passes behind
the teres major and its termination is not seen.
—From St. George's Museum, A. 35.
within the sheath of the nerve, but  does not in any way fuse with the
nerve-tubules; it forms on the neurilemma, and, by gradual expansion,

    1 A Treatise on Tetanus, 1836, p. 72.
    2 Revue Me"dicale, 1827, vol. iv. p. 183.
    8 Neue Notizen aus dem Gebiete der Natur und Heilkunde, 1837, vol. i. No. 1. 
NEUROMA.
283
separates the  nerve-fibrils  from one another, which, with care, may
always be traced from the upper to the distal part of the trunk of the
nerve.  We have already alluded to one  kind of neuromatous forma-
tion—the button  found  at the termination  of the  divided  nerve
in
Fig. 133.
 Section of a neuroma; three nervous trunks
terminating in it. The fibrous arrangement
shown, as observed by the naked eye.—Smith.
 Fibrous structure of neuroma; from the case published
by Dr. Smith, of Dublin.  After immersion in spirit'
which has caused corrugation of the granules and cor-
puscles.—From a drawing by Dr. Bennett.
stumps.   In this case, the  nerve necessarily  ends in  the tumor, the
fibrous tissue of  which the swelling is  composed blending with nerve-
tissue, which it is destined to protect from external injury.  If this view
is correct, and we are supported in it by Mr. Langstaff, the  swelling can
scarcely be looked upon as morbid, but rather  as the evidence of the
curative efforts of nature.   The idiopathic neuroma occurs without any
known  cause, in the shape  of  a round or  oval  tumor, varying in size
from a grain of wheat to that of a pumpkin, and  in number from one to
several   hundred.  It must  be classed among  the non-inflammatory
growths.   The tumor is generally solid  throughout, though occasionally
it  contains  a cavity.   It has a tendency to increase in size,  and the
nerve-fibres are  proportionately distended  and  separated.  They may
generally be easily detached from the nerve.  On section, the texture is
found to be dense and homogeneous, closely resembling that of a fibrous
tumor in other parts of the body; presenting  under  the microscope a
fibro-cellular structure, the fibres  being arranged in bands or loops, in
which oval or elongated nuclei become apparent on  the addition of
acetic  acid.   Sometimes the tumor is  of  an atheromatous character.
Dr. Smith1 has published two cases  of  neuroma  which are  instances of
the occasional extravagant production of these growths; in them, almost
every spinal nerve was closely studded  with neuromata, which  did not,

  1 A  Treatise on the Pathology, Diagnosis, and Treatment of Neuroma.  By A. W.
Smith, M. D., &c, Dublin, 1849. 
284
NEUROMA.
however, give rise  to  much  uneasiness;  in  fact,  it  appears,  as  also
noticed  by the same author,  that they are  rarely productive of much
pain when  in great numbers; whereas  the solitary neuroma, which is

            Fig. 135.                       Fig 136.             Fig. 137.
 Fig. 135 —A posterior tibial nerve, in which there is a circumscribed oval tumor, composed of a soft grumous
Bubstance. The component fasciculi of the nerve are separated and spread out around the tumor, the pero-
neal nerve is adherent to the surface of the neurilemma, extended over the tumor.—From St. Bartholomew's
Museum, Series viii. No. 1.
 Fig. 137.—A median nerve, in which is imbedded a small tumor, over which the filaments are spread out.
St. Bartholomew's Museum, Series viii. No. 13.

generally known by  the name of painful subcutaneous tubercle, is cha-
racterized  by agonizing  pain.   Other  adventitious  growths  do  not
appear to affect the nerves of the spinal system primarily; they are
involved in cancerous degeneration, by the extension of the disease from
adjoining tissues; and  in the nerves of the senses  we also meet with the
primary formation of  cancer.   In  the  retina, medullary carcinoma is
not unfrequently  found  unassociated  with cancerous  growths in any
other part of the system.
• 
CHAPTER   XV.
                 THE SYMPATHETIC SYSTEM.

  A few cases are on record in which the ganglia of the sympathetic
system were found more or less  deranged and altered in structure.  It
is probable that a series of nervous centres, like that presented in the
sympathetic, are much more frequently diseased than we have it as yet
in our power to demonstrate.   We can  scarcely conceive that the so-
called functional derangement of the heart, for instance, can continue
as it does, for a series of years, and the nerves controlling its action not
be or become organically altered;  in  the same way, long-standing de-
rangement in the nutritive and secretive functions of the abdominal vis-
cera may be assumed to  give rise to material changes in the cceliac and
semilunar ganglia, as  the numerous diseases  of  the generative organs
can  scarcely exist without a similar  influence being exerted upon the
spermatic plexus.   The  anatomical disposition, as well as the physio-
logical manifestations of the range  of action of the sympathetic, justify
our  belief in its  great  and powerful  agency in disease; the actual
demonstration of the fact is, however,  yet reserved for future inquirers.
Bichat1 repeatedly examined the nerves of the viscera in different dis-
eases without discovering any lesions.   With  the exception of a single
case, he' has found  the semilunar  ganglion intact in  canqers of the
stomach.  In a case of periodic mania, he found this  ganglion of the
size of a small nut, with a cartilaginous centre.
   Several authors have reported cases in  which one  or  more of the
ganglia of the sympathetic were found congested and inflamed in tetanus.
Swan2 has noted this condition  in each of the three cases in which he
made a post-mortem examination of tetanic individuals ; in the first, he
found  a very distinct inflammation of the  semilunar ganglia; in the
second, it is described as a remarkable  redness, which appeared, through-
out  to  be produced by  a very minute injection  of the cellular tissue,
interspersed between the small grains of which the ganglia are composed;
and in the third, he  states that there was an enlargement, and a greatly
increased vascularity of all  the ganglia of the sympathetic nerves, in
the  chest and also of the semilunar ganglia;  in  several of those in the
abdomen, the same  appearance  existed, only in  a less degree; but in
some there was neither the least redness nor enlargement.
   That  this, however, is not a  uniform lesion, and  not noted because
overlooked, or not attended to, is proved by a case of traumatic tetanus,
given in Dr. Bright's Reports.  (Case  cclxxvi.) A boy had been injured
i Anatomie Ge"ne>ale, u 225.
2 On Tetanus, p. 325. 
286
THE SYMPATHETIC SYSTEM.
in the heel by a circular  saw, and had  suffered a fracture of the left
humerus; a week after  the  accident  he  was seized  with  tetanus, and
died, forty hours from the first appearance of this affection.   The post
mortem is stated to have been conducted  with the greatest care by Mr.
Bransby Cooper and Mr. Key, twelve  hours after death, and  there were
no diseased appearances discoverable;  the brain was most minutely exa-
mined, as was the spine, through its whole course; the same attention
was  paid to  the sympathetic, the nerves and  the ganglia of which,
throughout, appeared healthy and white.  The nerves  were turned  down
to the wound in the leg,  and were also found healthy.  We have given
this case in detail, because  it bears upon all the points  already discussed,
regarding the pathological anatomy of tetanus; and while it proves that
none of the morbid appearances pointed  out by various observers are
essential, it also bears strong evidence to the non-inflammatory nature
of the disorder.   At the  same time, it does not destroy the value of the
testimony which we have found in favor of frequent physical alterations
in the nervous centres, only it alters the interpretation which we might
otherwise put upon  them.   In tetanus, the  equilibrium of the forces,
whose balance is necessary to the due performance of the functions of
the nervous system, is destroyed, and it  is quite compatible with our
knowledge of pathology and  of physiology, that  this should occur,  with-
out any primary change  in the  circulating organs, while, on the other
hand, we are equally justified in assuming that a state of congestion and
inflammation may react upon the nervous system in such a manner as
to entirely alter its normal relations. In the latter case, we should, under
such  circumstances, still be at liberty to view the  morbid  appearances,
induced by the vascular system, either as  the cause or the result of the
changes in the balance or polarity of the nervous sphere.
  It  appears that the  sympathetic system may also, though very rarely,
be the seat of neuroma.  Dr. Smith gives an instance of it occurring in
the cervical ganglia, and figures it; it is, probably, the same case which
is described  by Cruveilhier,1  as a case of fibrous transformation,  and
enormous development of the cervical glanglia, and the nerves of com-
munication passing  between  them.  One  of the tumors was  two and a
half inches long by one in breadth.  Both authors state that their sub-
ject was accidentally discovered in the dissecting-room  in Paris, and that
no history of the case  was  obtainable.
  Dr. Smith, in alluding to this remarkable degeneration of the cervical
ganglia, states that, according to Schiffner and  Bischoff, this  condition
of the sympathetic frequently coincides with idiotcy and cretinism ; it is
a point which requires further confirmation.
1 Anat. Pathol. Livr. PI. iii. 
PATHOLOGICAL ANATOMY  OF  THE  ORGANS
                   OP  CIRCULATION.
                    CHAPTER  XVI.

                  GENERAL OBSERVATIONS.

  Until a very recent date, the pathology of the heart was one of the
most obscure departments of medical science, and the ignorance of the
profession on the subject was veiled by terms which implied hypothetical
views of the derangements which appeared most certainly referable to
this organ. The most prominent among these were angina and hydrops
pericardii; the one supposed to represent the climax of functional  dis-
eases, the other of organic changes.  What the discovery of the circu-
lation, at the beginning of the seventeenth century, by our great country-
man,  Harvey, contributed, to illustrate the  uses of the heart and the
vessels,  in a  physiological point of view, may be said  to have been
equalled in pathology by the application of the  physical method of re-
search in disease and at the dissection-table, introduced into the science
of medicine during the present century.   So long as we did not possess
definite means of  tracing morbid action in the living, it was impossible
to correctly appreciate the phenomena  presented in  the dead subject.
And thus we find that the two studies, mutually assisting and elucidating
one another, have gone hand in hand.  Far as a modest estimate must
as yet admit pathology to be, from that to which an augmented know-
ledge of  morbid processes may lead future inquirers, it is impossible to
look back to the history of this branch  of science without a feeling of
congratulation; for, while every step in advance raises the intellectual
standard of the profession, and diminishes the skepticism which even its
most distinguished members are occasionally observed to express with
regard to its actual capabilities, the mass of  mankind are no less bene-
fited both by the increased means  of avoiding and preventing morbid
influences, and of checking their  progress wThen once they have fixed
upon  the system.   But while we have succeeded in  determining more
uniformly and positively the  locale of disease involving the central
organ of the circulation, we have also discovered what may be called a
type of the relation existing between the poisoned condition of the blood,
to which we are justified in referring the great majority of pathological 
288
GENERAL OBSERVATIONS.
processes, derangement of function, and disorganization of structure in
a part of the economy.   The  doctrine of metastases, a favorite hobby
of some of the older writers,  has  been  materially modified  by an ex-
tended knowledge of this relation ; and at the same time an enlightened
humoralism has simplified the  theory of disease, and has tended to bring
us nearer to  the causa proxima  of numerous processes which other-
wise offer no analogy or rationale.   The morbid anatomist must never
forget that he has to deal, not with disease itself, but only with its pro-
ducts; and while it is of extreme importance that he should not isolate
a single morbid phenomenon found in  the corpse, but take the entire
complex of derangements that  present themselves, before he ventures to
analyze and draw his conclusions as to their origin and connection with
one another, and with the symptoms produced during life, he must also
remember that the  very cessation  of life  must  alter  the  conditions of
disease, and that there will always remain much that bears upon its in-
telligence, which neither scalpel, microscope, nor reagent, will be able
to detect when the vital spirit has fled.   A certain amount  of hypothesis
must, therefore, be  had recourse to, to establish and satisfy the legiti-
mate demands of science; but this  theory must be based upon the entire
range of our physical knowledge,  and only proceed within those limits
which are placed by the laws of rigid induction.   It is by  pursuing this
system of research that  the proclivity of the heart to be affected in rheu-
matism has been established, that we have determined fatty degeneration
of the heart to be a frequent consequence of depraved nutrition, or that
the close relation between renal and cardiac disease has been ascertained.
The post-mortem examination  alone would probably have  established
these facts as  little as clinical  observation taken by itself; but the two
combined and practised by the master-minds of our century have led to
results which, indeed, form an  epoch in the annals of medicine.   It is
our duty to deal mainly with the cadaveric phenomena, but it is impossi-
ble to treat them intelligibly unless, as we have throughout sought to do,
we keep  in  view the vital relations  of the various organs  in disease.
After these brief preliminary remarks, we proceed, first, to consider the
morbid  anatomy of the fibro-serous  investment of the heart, the  peri-
cardium. 
CHAPTER  XVII.
       THE MORBID  ANATOMY  OF  THE PERICARDIUM.

  The diseases affecting the pericardium partake of a double character,
owing to the two constituents which enter into its tissue, the fibrous and
the serous layer; on the one hand they are allied  to the affections of
fascial and  tendinous formations, on  the other  to those of pure serous
membranes.   The morbid process  that  commences in the one  may be
propagated  to the other, and the effects of disease occurring in one may
be manifested by the products  peculiar  to the other.  We deem it the
more important to insist upon  this  point, as  it bears strongly upon the
difference between the various post-mortem appearances, and because it
aids us in appreciating the pathological  distinctions  between pericardial
and endocardial  disease.  These are particularly manifested in their
relation to the erases ;  while the morbid products  found in the pericar-
dium are  generally evidence of active disease, the endocardium almost
serves as an index for the amount of crasis prevailing in the system;  at
least, no membranous structure so frequently presents alterations in those
constitutions which we have elsewhere  considered as characteristic of
blood erases.
  The frequency of morbid alterations in the pericardium increases with
ao-e, a proclivity which is not marked in  the same degree with regard to
the internal lining of the heart, which is much more prone in childhood
to take on diseased action, than we should be inclined to assume a priori.
Congenital  affections of the pericardium  are very rare, and though cases
of its entire absence are recorded by observers like Baillie and Breschet,
the majority of  instances that  have  been classed under this head, have
been shown to be only apparent anomalies, owing to intimate adhesion
between the two  surfaces of the sac giving rise to  the semblance of the
defect.  A  case  of  undoubted absence  of the  pericardium, where the
heart lay  in the  same serous sac with the left lung, has recently been
observed by Dr.  Baly, in a man aged thirty-two.1   It appears that an
hypertrophic  condition of the pericardium may  occasionally occur  so
early in life as to seem congenital; we allude to  the so-called milk spots,
which  are yet considered by various authors  as results of inflammation
exclusively.   This is the view  of Mr. Paget, while Dr. Hodgkin is  in-
clined to  look upon  them as the product of  attrition only, as they are
almost universally found on the anterior  surface of the heart, at the
point most in contact with the anterior walls of the thorax.   The dis-
crepancy is  probably reconciled by the  observation  that there  are two

                  ' Report of Pathol. Society, 1S51, p. 60.
       19 
290
PERICARDITIS.
kinds of white spots, as was well laid down by M. Bizot ;*  the one, pro-
bably, owing to an inflammatory, the other to a non-inflammatory con-
dition  of  the pericardium.   They  are cream-colored opacities of  the
visceral layer, varying in size from that of a sixpence, to that of a five-
shilling piece, and  more; which may  at times  be  detached from  the
subjacent  serous membrane, to which they are then connected by cellular
adhesions.  In other cases they are mere  thickening of the pericardium
itself, or rather of the  subserous cellular tissue, and  cannot in that case
be detached  from it.  The former, to  use  the  accurate  description of
M. Bizot, present at their commencement the form of small transparent
elevations, aggregated together with circumscribed edges, and but slightly
adherent to the serous membrane.  They soon lose  their transparency,
becoming  white and opaque, but still capable of being removed without
injury to the subjacent serous membrane.  They occupy every portion
of the heart, but lie chiefly in the direction of  the  bloodvessels.   The
second variety have no circumscribed margin, they are peculiarly white,
and their  greatest thickness is in the centre from where they are bevelled
off in all directions;  these are essentially  identical with the pericardium
itself, and constitute a  true hypertrophy of the membrane.  It is import-
ant to arrive at a definite conclusion with regard to their origin, since
their great frequency influences our views in  regard to the prevalence
of inflammatory affections of the membrane, and assists in determining
our choice of treatment.  Dr. Latham includes them in his table on the
relative frequency of pericarditis in rheumatism,  and thus  establishes a
ratio different from what we should arrive at if they are proved to be of
non-inflammatory origin.  We are ourselves of opinion that they are to
be viewed as resulting from two causes; and that while they are in
many instances  the results of  previous  inflammation, they may also
represent  a simple hypertrophic condition resembling the horny thick-
enings of the cutis.   The great frequency of the occurrence of milk
spots2 in Bright's disease  of the kidney, tends to  prove their connection
with a blood crasis, which would  favor  a  non-inflammatory fibrinous
deposit.

                         PERICARDITIS.

   The first effect of inflammation in the pericardium is to produce a
reddening and pulpy thickening of  the  membrane, by  the congestion of
the bloodvessels and interstitial effusion of serosity.  A beautiful reticu-
lation of minute vessels is visible to the naked eye, and still better under
a low power  of the microscope ; both on the internal and external sur-
face of the  pericardium exudation on  the  free surfaces  then follows,
which, according to the constitution of the  individual, is of a more or
less plastic character.   In the most active forms, the effused matter  is a
semi-fluid, organizable  material of a yellowish hue, forming a reticulated
or villous  appearance, which must be attributed to the movements of the
heart.   Laennec has very correctly compared the appearance thus pre-

  1  Memoires de la SocieHe" d'Observation, vol. i. p. 347.
  '  See Dr. Taylor's paper on the Causes of Pericarditis, in Medico-Chir. Trans., vol.
xxviii. p. 468. 
PERICARDITIS.
291
sented, to that we see  on quickly separating two  slabs  of marble, be-
tween  which a layer of  butter was  interposed.   This plastic material
gradually becomes organized, and we find minute red vessels projecting
Fig. 138.
 A heart covered with plastic exudation, investing both the parietal and visceral layer of the pericardium,
which has been cut open and reverted.  An incision has been made through the false membrane over the left
ventricle, to turn it back and show the subjacent muscular tissue. The lymph fringes the right auricle and
coats the root of the aorta.

into if and as this process proceeds the two surfaces become intimately
adherent to one another; the lymph loses its fluid constituents; it is con-
verted into firm bands, connecting more or less loosely the visceral and
parietal pericardium, which, according to  their density and  tenacity,
indicate the period  of their formation.   If adhesion does not result
absorption  may remove these  appearances, and nothing but  a general
opacity or thickening of the pericardium remains;  or again, the active
condition may be arrested after the formation  of villi, and without  the
supervention of adhesion they may continue in a passive state, and pre-
sent  the appearance termed  the hairy heart,  the  cor villosum.   It is
customary to quote as an  instance of  this  a classical name; the  great
enemv of Sparta, Aristomenes, was captured  and  killed  on  his  third
entrv into Lacedsemon, and  his  heart is stated by Pausamas to have
been found covered with hair.   In a less sthenic  constitution the  effu-
sion resulting  from pericarditis will be of a more serious character; and
we then find the pericardium more or less distended with a straw-colored
fluid in which flakes of lymph  are discovered,  while traces of lymphatic
exudation are seen attached to the membrane with thin free ends waving in
the fluid  We have seen the pericardium mount up from this cause to the
second rib, and the quantity of serum varies from half  an ounce to two
quarts.   In this case, as in the former, absorption may take place,^leav-
ing but  comparatively slight  traces  of the previous disease andthe
pericardium itself appears to adjust itself to the reduced quantity of its

C°nA tiitr'd form of exudation met with is of a purulent character, which 
292
PERICARDITIS.
is of a more atypic nature than the last.  It is the least frequent, and
is always associated with a large amount of serous effusion.  It is chiefly
met with in  protracted cases, though Dr. Hope  avers that even in  the
first stage  a degree of milky opacity is  observable in the serum, Avhich
may be  attributed to an admixture of  real pus.  Hope  is of opinion
that even pus  may, if not exceedingly  copious,  be sometimes partially
absorbed, leaving only its solid parts to  undergo ulterior changes.
  The serous effusion just spoken  of must not be  confounded with  the
dropsical accumulation of fluid, to which we should restrict  the term
hydropericardium, and which is a frequent accompaniment of general
dropsy.  In many cases of wasting disease we find a few  ounces  of
serum in the pericardium, which we must refer to mere want of tone in
the vessels, and which appears to  be eliminated shortly before death.
It is not associated with symptoms of inflammatory action; and  the
fluid itself  is a clear, amber-colored serum.   In  long-continued  dropsy
of the pericardium  the  heart  is generally found  contracted, and  the
muscular tissue anemic and  of light-brown hue.   Occasionally, an atro-
phic condition of the sarcolemma results, which  is  characterized under
the microscope by an absence of the striation seen in healthy muscle.
  In the exudation resulting from  acute inflammation we  occasionally
meet with  a small  quantity of blood.   Hemorrhage, independently of
this cause of mechanical  injury, or of rupture of the muscular tissue of
the heart,  is not met with  in  this locality as it is  in  the sac of  the
arachnoid.   As regards  the extent of the phlogistic process in the peri-
cardium, it generally involves the  entire surface of the membrane  in
acute cases;  the chronic form, except as a sequel of the former, has a
tendency to limitation, and its residuary effects are seen in the form of
circumscribed white patches, either  on the  visceral or parietal portion,
or of partial adhesions or isolated bands of false  membrane.
  Pericarditis is not often an idiopathic disease.  Dr. Latham, who was
the first  to notice its frequent complication with the rheumatic diathesis,
has rarely  met with it except in this connection.   Andral gives six cases
of pericarditis not connected with rheumatism, of which three were un-
complicated with any other  morbid affection ; while Corvisart only met
with five independent of rheumatism,  which were all,  excepting  one,
complicated with disease of other  parts.  The rheumatic complication
is one found at all periods of life.   Messrs.  Rilliet and Barthez and Dr.
West look  upon it as essential in young children; and all writers on the
subject concur  with regard to its frequency  in adults, though the statis-
tical results arrived at are not perfectly uniform.  A further powerful
predisposing cause is to be found in renal disease, and more especially in
that form known as Bright's disease of  the kidney.   Dr. Taylor gives
the following results of the  analysis of the  causes  of thirty-eight cases
of acute  pericarditis:—
     There  was rheumatism in.......20 cases.
     Bright's disease in     .    .   .     .   .    .   ,   .    10   "
     Bright's disease doubtful, or other form of renal disease, in .     5   "
     Cyanosis..........1 case.
     Extension of inflammation from adjoining tissues in             1   "
37 
TUBERCLE.
293
  It follows that in examining the dead subject, we should, in all cases
of pericardial disease, be particularly careful not to omit looking to the
condition of the  kidneys, even  if the symptoms during  life  were not
such as to draw the physician's attention to these organs.   Considering
the degenerative character of Bright's disease, and its chronic  course,
we  are justified  in regarding it as a powerfully  predisposing cause to
inflammation of serous membranes, and particularly of the pericardium.
The fact of the relation of  the two  diseases  being established, will also
assist us during life in discovering one  by the indications of the other,
as has already been the case in regard to rheumatic pericarditis; for the
subjective symptoms of the latter are occasionally  so slight, that but
for our knowledge of the predisposing influence of rheumatism, we might
not be induced to look for the evidence of heart  disease.   This remark
applies with almost greater force to affections of the endocardium, which,
as  we shall have occasion to see, offers a  yet  greater proclivity to the
morbid influence of the rheumatic diathesis than the external investment
of  the heart.
   The false membranes remaining after an attack of pericardial inflam-
mation, may, unless absorbed, become the  seat of similar  changes, as we
find them undergoing in other structures  throughout the body.  They
present a metamorphosis into fibrous, cartilaginoid,  and  osseous tissue.
The deposit of the latter occurs in smaller or larger patches; they may
be numerous and distinct from one  another,  or they may unite  to form,
 as  in a preparation contained in Guy's Hospital (No. 1,448), a complete
 ring encircling the base of the heart.
TUBERCLE.
  The relation  of pericardial  inflammation to definite dyscrasia? is
evinced negatively, by the absence of any  proclivity of the membrane
to be affected in tubercular disease.  On theoretical grounds we might
have been inclined to assume that the vicinity of the  diseased lungs in
phthisis,  as well as the more immediate  relation which would  seem to
exist between the blood circulating in the pulmonary and cardiac vessels,
would have been a frequent source of disease in the latter, and the parts
supplied  by them.  But while the meninges of the brain and the peri-
toneum are constantly found to be the  seat of tubercular deposit, the
pericardium is remarkably free from it.   Louis1 has only found evidence
of pericarditis three times in phthisis; and he details one case in  which
some semi-transparent gray granulations were found under the serous
lamina of the pericardium, to which he attributes the pericarditis  under
which  the patient  was laboring.   Dr. Hope  states that tubercles are
sometimes developed in the false membranes of pericarditis ; but neither
does he himself  give any  positive evidence to that effect, nor have we
succeeded in finding proofs of it elsewhere.   It does, however appear
that the  false membrane may itself become subject to simple inflamma-
tion, which, from its known vascularity, is in accordance with the general
theory of inflammation.
1 Memoire sur la Pericardite, &c, 1826. 
294
PNEUMOPERICARDIUM.
                          CARCINOMA.

  Carcinoma affects the pericardium more frequently than tuberculous
disease; it occurs only in connection with a general cancerous cachexia,
and a formation of  similar growths in other organs; the only variety
met  with is  medullary  carcinoma.   According  to  Rokitansky, this
secondary mass spreads itself in the form of an infiltration of the fibrous
layer of the pericardium over a large portion of its surface, and presses
upon and into the tissue itself, where it becomes developed into roundish,
or flattened, or teat-like nodules.
                        FATTY  DEPOSIT.

  It is not uncommon to meet with an excessive deposit of fat upon and
within the pericardium;  it occurs in conjunction with general obesity, as
well as in cases where there is  little subcutaneous fat; nor is it neces-
sarily associated with true fatty degeneration of the muscular tissue of
the heart, though we may at the same  time find fat insinuating itself
into the heart, so as to separate the muscular fasciculi from one another.
It will be observed that accumulation upon  the heart is largest in the
horizontal sulcus, and that its distribution appears to bear a relation to
the arrangement of the bloodvessels.
                    PNEUMOPERICARDIUM.

  A condition of the heart rarely found until after  death, and termed
by Laennec pneumo-pericardium, consists in an effusion of air into the
sac.   Laennec  states that he was able to diagnose its presence during
life from the unusually clear sound yielded by percussion in the region
of the heart, and by a  sound of fluctuation accompanying the move-
ments of the heart and of respiration. In the majority of cases, it is due
to post-mortem decomposition of the pericardial fluid.   The vital gene-
ration of gas in the sac must be an occurrence of extreme rarity, since
Rokitansky does not appear to have met with an instance.   M. Briche-
teau is  quoted by M. Bouillaud1 as having met with a case of hydro-
pneumo-pericardium,  in  which a murmur resembling  the  noise  of  a
water-wheel was heard during life, evidently connected with the alternate
movements of the heart.   The pericardium was found to contain a  fetid
effusion, and, on incision, the contained gas escaped with a lisping noise.
During  the  present year (1852), a case of perforation of the oesophagus,
which had formed adhesions to the pericardium, occurred in St. Mary's
Hospital.   The  patient was a  young  woman under  the care of Dr.
Chambers, in whom the admission of air into the pericardium occurred
shortly  before death through the perforation; the pericardium was found
much distended from this cause, when the post-mortem examination was

                  1 Traite Clinique, &c, vol. ii. p. 472. 
FIBRINOUS CONCRETIONS IN THE PERICARDIUM.    295
made; and it was owing to this circumstance that the fibrinous layer,
which had been deposited between the surfaces of the pericardium, had
not given rise to any friction sound during life.1
     FIBRINOUS  CONCRETIONS  IN THE  PERICARDIUM.

  To complete the subject of the morbid contents of the pericardium, we
have yet to advert to the presence of free bodies, which Rokitansky has
met with in a case of pericarditis.  He describes them as fibrinous, soft,
yellow concretions, of the size of beans or almonds, and similar to the
latter  in shape;  which, he adds, would no doubt have eventually been
converted into elastic, tough bodies of fibroid tissue. ^  None of the
authors whom we have been able to consult, record any similar case; we
may therefore assume that the actual occurrence of free  bodies is a cir-
cumstance  of extreme rarity, and the above  seems rather to be due to
an accidental agglomeration of fibrinous flakes than to  any other  new
production of tissue.

        1 The case is detailed in the Report of the Pathol. Soc. for 1852-3.
r/
 i 
CHAPTER   XVIII.
          THE MORBID ANATOMY  OF  THE  HEART.

  The close  relation existing  in  disease between certain affections of
the pericardium and endocardium would be a sufficient excuse for taking
the affections of the latter into consideration at once.  But  it appears
more convenient to follow the anatomical sequence, both because there
is  an undoubted  relation between  many morbid  states of the serous
envelop and  the muscular substance, and because the pathology of the
endocardium  is a natural transition to the morbid anatomy of the car-
diac valves and the bloodvessels.   Much has been done of late to pro-
mote our knowledge of cardiac disease, and the main result has been to
withdraw  many so-called functional diseases of  the organ from this
category, and to classify them with the known lesions met with in other
tissues of  the body which are more accessible to  examination in life.
It is more particularly in the sphere of degenerative changes, and their
effects, that the advance has taken place; much yet remains  to be done
in the demonstration of the simple and primary forms of disease.
  Congestion of the heart may be assumed  to exist in  the early stages
of several affections with which we become acquainted, when  they inter-
fere with the vital functions.  We frequently find the heart of a  dark
color, and the veins overcharged with blood,  as secondary effects of dis-
turbance in the circulation;  in the same way, we  see an anaemic condi-
tion of the organ  manifested by pallor, and a  flabby condition of the
muscular tissue, in the train of long standing and debilitating  disease.


                            CARDITIS.

  Genuine carditis, ulceration, and abscess of the heart, are conditions
of which  but few cases are  recorded.  Of the former, Dr.  Latham1
details a remarkable instance.  It occurred in a  boy, aged twelve years,
who presented all  the symptoms of acute cerebral  disease, without any
indications of the  disorganization  found after  death.   No  vestige of
morbid action was discovered in the brain, but the  heart was the seat of
the most intense inflammation, pervading both  the heart and muscular
structure.   There was the ordinary evidence of recent pericarditis, and
when the heart was itself divided, the muscular fibres were dark-colored,
almost to blackness, loaded with blood, soft, and loose of texture, easily

             1 Lectures on Clinical Medicine, &c, 1845, Lect. xxv. 
CARDITIS.
297
separated, and easily torn by the fingers, and at the cut edges of both
ventricles small quantities of dark-colored pus were  seen among the
muscular fibres.   The internal  lining was  of a  deep red color, without
any effusion of lymph.  A case which resembles the one just detailed,
and which occurred in the  practice of Mr. Salter, of Poole, is detailed
in the twenty-second volume of the Medico-Chirurgical Transactions.
It affected a man aged fifty, who  died after a short illness,  in which the
main symptoms were oppression  and distress at breathing, inability to
lie down, and  a dull, heavy pain at the  sternum.  The  pulse at the
same time was eighty, and regular, and the action of the heart seemed
natural.  There was no serous or other  effusion  into the  pericardium,
nor any signs of disease in the valves or endocardium.   The heart itself
was somewhat larger than  natural, and its substance of moderate firm-
ness.   The great deviation from  the normal condition  of the heart was
to be found in the muscular condition of the left ventricle.  Excepting
a few lines  in thickness on either surface, the left ventricle had entirely
lost its muscular color; it was of  lightish  yellow hue, but  still preserv-
ing the fibrous character of muscle.   From all the cut surfaces purulent
matter could  be scraped;  in  some  parts  absorption had  taken place,
leaving small cavities  in  the muscular substance, varying  from the size
of a pin's head to  that of a small  pea;  these  were all filled with pus.
A third case of the  same kind is related by Mr. Stanley in the seventh
volume of the Medico-Chirurgical Transactions, p. 323, which occurred
in a boy aged twelve.   In purulent infection, when deposits of pus are
found in the parenchyma of every organ of the body,  the heart rarely
 presents similar appearances.  It is a common thing to find the muscu-
 lar  tissue in severe pericarditis  of an  abnormally dark  color, and it
 seems  probable that, in the cases alluded to, the primary disease lay in
 this membrane.  In those rare cases in which an ulcer is found in the
 substance of the heart, and an abscess occurs in the muscular tissue, we
 may fairly assume local inflammation to have preceded, and in the cases
 which are presented by the records of pathological anatomy the appear-
 ances  are generally mentioned as indicating such a process.  In a case
 of general hypertrophy of the heart, accompanied  by  enormous dilata-
 tion of the mitral  orifice, and diseased  aortic  valves, which was exhi-
 bited"  at the Pathological Society in 1847, by Dr. J. R. Bennett  an
 opening of the size of a quill was found in the  ventricular septum; this
 was surrounded by ulceration, warty roughness, and thickening, and
 there  were distinct traces of inflammation round the opening.  Hemor-
 rhage into the substance of the heart is  occasionally met with in small
 spots, in connection with  pericarditis; but in cases of genuine cardiac
 apoplexy as Cruveilhier terms  effusion of blood into  the substance ot
 the heart,  which  must be considered in the same  category  as sponta-
 neous rupture  of the organ, we  almost invariably  find fatty degenera-
 tion at and near the point, which has destroyed the uniform consistency
  of the organ.                                      ...      ...
    Before  entering into the examination of this morbid  condition,  we
  must mention one undoubted residue of inflammation, which presents the
  appearance of fibrinous deposit, or an interstitial deposit of lymph. We
  meet with  this in rheumatic subjects.  The heart presents a feeble, flabby 
293                 FATTY DEGENERATION.

appearance, and spots of an irregular shape and a pale yellowish hue
are found  scattered through  the tissue.  The circumference of these
spots is tolerably defined, or the deposit appears to follow the direction
of the fibres.   It may itself be associated with fatty degeneration, but
the microscope sufficiently serves to distinguish  it from this condition.
It is found to consist of granular matter, within which nuclei and fibroid
cells  are imbedded, and oil-globules.   This  is entirely external to the
muscular fibre, which  commonly exhibit an atrophic condition  in the
immediate  vicinity of the deposit.  Dr. Hope1 recognizes three varieties
of softening occurring in the heart as  a result of inflammatory action :
a red, whitish, and yellow form.   The red, he says, corresponds to the
first stage of carditis, and is analogous  to the inflammatory engorgement
constituting the first degree of peripneumony; the whitish corresponds
with a more advanced  stage, analogous to the second and third degrees
of peripneumony, when a pale tint is produced by the absorption of the
red particles of the blood, and by the presence  of lymph and  pus in
variable proportions.  The yellowr variety he  considers rather the result
of chronic inflammation.  These views  are supported by Laennec, Bouil-
laud, Corvisart, and other continental authors, who at the same  time
admit the distinct character of a fatty degeneration.   The  microscope
has of late contributed  much to unsettling these  doctrines, inasmuch as
the naked-eye view has been almost superseded, and, in some instances,
we fear, to the  detriment of true science.  For,  valuable  as it is in
analysis, if used exclusively it  prevents that general coup d'ceil which
embraces more than one morbid phenomenon, and which is necessary to
the due appreciation of disease in its totality.  We are induced to make
this warning remark, because, in analyzing the records  of the post-mor-
tem appearances of heart-disease during the  last  six years, we find  that
almost invariably a  fatty degeneration  of the organ, or of individual
parts, has been discovered; and this  condition is one which is by no
means limited to a  certain well-defined disease, but is found to prevail
so extensively that we cannot but look upon the molecular disintegration
implied by it as a mere symptom of various elementary morbid  states.
It is undeniable that the appearance of minute vessels, e.g. of the brain
in a state of  fatty degeneration,  as  found  in the vicinity of apoplectic
clots, or in connection  with atheroma  of the larger arteries, closely
resembles the appearance presented by vessels of the pia mater  sur-
rounded by or containing so-called exudation-matter in  meningitis.   In
both  instances, microscopic globules, of a highly refracting character,
are the characteristic symbol.   The fibre of the heart, when affected in
this manner, presents a similar appearance.
                    FATTY  DEGENERATION.

  The degeneration may be traced through  various stages.   It com-
mences as an atrophic condition, in which the fibre loses its sharp edges,
and the striae, so well seen in the  healthy heart, disappear.   One or

           1 A Treatise on Diseases of the Heart, &c, 3d edit. p. 333. 
FATTY DEGENERATION.                   299
more oil-globules successively appear, until the whole fibre is occupied
by them; its outline is broken, and in the highest development the fibres
appear almost fused together into a confused, more or less opaque, mass,
in which nothing of the original tissue can be traced.   This molecular
deposit of oil  in the fibre  is  often accompanied by a generally adipose
condition of the organ, and a layer of fat on the surface; but not neces-
sarily so, and we must be careful not to infer that the heart is in a state
of fatty  degeneration because it is surrounded by adipose tissue.   The
fat may insinuate itself between the muscular fasciculi and fibres, and
yet no change in the latter take place.  The large circular fat-cell, with
its  sharp boundary of  ^^th of an inch in diameter, when  seen under
the  microscope, occupies  the former position, and cannot be mistaken
for  the minute  oil-globule,  which  varies  from  a microscopic point to
^^(jth of an  inch, and is confined to the  interior of  the sarcolemma.
   The heart affected with fatty degeneration has lost the firm muscular
appearance which characterizes it  in  health,  and presents  a pale, yel-
lowish,  buff  color,  either throughout  or limited  to individual parts.
When  cut into, a greasy stain is  often left  on  the knife,  though the
absence of this circumstance must not be looked upon as an indication
that the  heart is not degenerated.   The left ventricle and the columnse
carnese are most liable to be  thus  diseased; next in  order the  right
ventricle and  right auricle,  while the left  auricle is  least  frequently
involved.  Dr. Quain,1 to whom we are indebted for a clear resume, of
the whole subject  of fatty degeneration of the heart, has found that in

                                 Fig. 139.
 Specimens of fatty degeneration of the heart.
 a. Heart-fibres taken from the columnae carnea? of the mitral valves of a young woman, set. 30; the fatty
degeneration was scarcely observable in the ventricle, where the fibres still retained their striae.
 b. An extreme case of fatty degeneration, showing an entire conversion of the muscular fibre into oil-
molecules, still retaining a linear arrangement. It is taken from the right ventricle of an old gentleman,
who had Bright's disease of the kidney and pulmonary phthisis, and was affected with fits during the last two
years of his life.
twenty-two cases, in which the seat of the  disease was expressed, the
two ventricles were affected in ten, the left alone in eight, and the right
alone in four.   Rokitansky describes three forms of fatty degeneration
of the heart;  the first two are varieties of fat-deposit upon and within
1 Medico-Chir. Trans, vol. xxxiii. p. 121. 
300
FATTY DEGENERATION.
the heart, external to the muscular fibre to which we have alluded above,
and to which, with Dr. Quain, we would apply the term fatty growth,
while the term fatty degeneration should be  confined to that change in
the muscular fibre which we have just described, and which constitutes
Rokitansky's third form.   The deposit and the degeneration may coin-
cide, but  there is no definite  relation  between the occurrence  of  the
two.
   The frequency with  which  fatty degeneration of the heart  occurs
among the patients that present themselves in  a  London hospital, may
be inferred from the circumstance that Dr. Ogle has met with it in 100
out of 143 post mortems, in which he noted the microscopic appearances
of the organ; a circumstance sufficient to rivet the attention of nosolo-
gists upon the heart, in order to determine with more accuracy than we
at present can bring to bear, the incipient  morbid conditions to which
this state is due.   It  is essentially a disease of  middle and  advanced
life; and is, we may say, invariably associated with a fatty  condition of
other organs, more especially of the liver,  the  spleen, and  the arterial
system;  in this is borne out the observation of Dr. Latham, that  ex-
cepting those cases in which the  damage done to the  heart could be
clearly traced to some distinct  attack of accidental disease, his records
of dissections do not supply him  with a single instance of a person  re-
puted to die of disorganized heart and its consequences, in whom, after
death, other  parts  were not  also  found  disorganized.  And, he con-
tinues, the kind of  disease  in other parts has been such as could  in  no-
wise have been derived from  the heart, but must have grown  out of
special morbid processes within themselves, whether prior or subsequent
to, or simultaneous with, the disease of the heart.
   Dr.  Quain  concludes, from  the  circumstances, that when  muscular
tissue is  exposed to certain influences, such as  a  stream of running
water or the action of dilute nitric acid, it assumes appearances identical
with those of  fatty degeneration,  that  the  processes occurring  in  the
dead meat and the living heart are identical.  We are willing to  admit
the analogy, but we are of opinion that the uniform evidence of a  de-
generative tendency throughout  the system, accompanying  the fatty
heart, is a strong proof of the ultimate cause residing in  the  organs
and function of nutrition.   The  circumstance  of  the coronary arteries
being' almost invariably atheromatous, or in a state of ossification, is
rather corroborative of the view, for we are not justified in  assuming a
primary  and idiopathic affection of these  vessels.  Whatever may be
the theory of  the disorganization, its existence and frequency is suffi-
ciently established, as well as the fact of its being the cause of further
changes in the muscular tissue of the heart, which are a common  source
of suffering and death.   Syncope and angina  pectoris  during life,  are
among  the effects  of fatty  degeneration  of the heart and diseased
coronary  arteries;  apoplectic effusion into the  substance of the organ,
rupture,  dilatation, and aneurism of the heart, are  found in constant
connection with this affection. 
APOPLEXY AND RUPTURE OF  THE HEART.       301
          APOPLEXY AND RUPTURE OF THE  HEART.

  Without a knowledge of this change, which  has taken place  in the
tissue, and precedes the occurrence of these accidents, it is impossible
to offer any rationale for them;  but now that we  are acquainted with
the fact that the muscular fibre is degenerated  at  certain  parts of, or
throughout the organ, it is easy to understand that, under given circum-
stances, requiring an unusual effort in the heart, the weakest point will
yield, and give rise to effusion of blood.  It is difficult to offer an ex-
planation for those cases in which the rupture appears to have  occurred
during  perfect rest; but it is not unreasonable to suppose that, when
patients have died from this cause, while reposing in their beds,  a sud-
den movement of the body may have been the immediate cause  of the
accident; much in the same way as we see, in syphilitic  and other  ca-
chectic states, the bones become so friable as to be  fractured from the
same trifling cause.  There is no essential difference between those
cases in which the hemorrhage seems  confined to  the muscular  tissue,
and those in which, owing to a laceration of the pericardium and endo-
cardium,  a passage is established by  which  the  blood flows  into the
serous sac.   In the latter case, we find the pericardium, on  opening the
body, distended with fluid blood, or, if the individual has survived some
time after the accident, the blood is partly coagulated.   The rent varies
from  an inch in length to a minute orifice; it frequently runs  into the
septum, and occasionally we  find  an  accompanying rupture  of the
columnse  carnerje.  The left ventricle  is by far  the  most frequent  seat
of these disruptions ;  we find that six of the seven cases of spontaneous
rupture of the heart, detailed in the Reports of the Pathological Society
of London, occurred in  the left ventricle, and  only one in the right.
An analysis of  these  cases  also  shows  that the  prevailing impression
that the anterior surface is more  liable than the  posterior to become
lacerated, is erroneous;  five having occurred on the  posterior, and two
on the  anterior  walls of  the heart.  In all there was fatty degeneration,
most marked at the seat  of injury ;  the coronary arteries  were found
in an atheromatous or ossified condition, in the five  cases in which they
were examined  ; the average age of  the sufferers was  69^ years.   A
rather  different result is obtained by an analysis of  cases of rupture  of     •
the  heart,  following  mechanical injury, without  penetrating  wounds ;
here, there is  no suspicion of fatty degeneration, and  a  different  ex-
planation must  be sought for, to account for the  seat of the  rupture,
which appears to vary as much as the injury itself.  We  find that  of
five cases of this description, in all of which there  was no penetration
of the  heart's  substance from without, one  occurred on the  posterior
surface of the  left ventricle, one on  the posterior surface of the left
auricle, two  on  the anterior surface of the left  auricle,  and one  on  the
anterior surface of the right ventricle.  Here, the left auricle was three
times  affected,  and each of the  ventricles  once.   From what has  pre-
ceded,  it  may be gathered that we do not take Dr. Hope's view, that
ulceration is the main cause of rupture of the heart; a solution of con-
 tinuity of the lining membrane of the heart from this cause, is, as we 
302       APOPLEXY AND RUPTURE OF THE HEART.

shall have occasion to  mention, when considering endocardial disease,
an occurrence of extreme rarity, and it does not appear to bear any
direct ratio to rupture, though it may give rise to gradual perforation.
  Rupture of the heart is  generally immediately fatal;  instances  are,
however, recorded, in which the patient recovered from  the first shock
and survived for several hours; in these cases, nature is found to have
made an effort at repair, in the shape of a film of lymph, exuded between
the torn surfaces.
  Gangrene  of the heart is a subject alluded  to by pathologists,  but it
does not appear that any authentic cases of its occurrence are recorded.
Dr. Copland looks upon it  as manifestly a post-mortem alteration, acce-
lerated by a  depraved habit of  body.   We may, therefore, at once pass
to the  consideration of  two conditions which are very  frequent, and
which  are nearly allied to one another, hypertrophy and dilatation  of
the heart.
• 
CHAPTER  XIX.
                HYPERTROPHY OF THE HEART.

  In determining  the existence of hypertrophy of the heart, we must
attend to two preliminary points; first, we must ascertain whether there
is  an absolute  increase  of  the total bulk, as  compared with hearts of
healthy individuals of the  same age and conformation ; and secondly,
whether the relative size of the walls of the different cavities has altered.
Next, it will be well  to inquire into the relation  existing  between  the
walls of the cavity and its capacity, and it is also necessary to remove
the contents, fluid or consistent,  that may distend  the cavities, before
we form our estimate.  Laennec suggested that the doubled fist of  the
individual might be taken as a rough measure of the size of his heart, as
he found, that, in health,  the two corresponded  in  their  dimensions;
there is no objection to retaining this indication, to assist our judgment,
when more accurate determinations are not at our command.   The weight
of the  healthy adult heart varies from eight to  ten ounces, while, in
hypertrophy, it is found to rise to as much as five pounds.
   At the same time, we must also bear in mind the  fact, sufficiently
well determined by Bizot,1  that there is a progressive increase  in  the
dimensions of the  heart, from infancy upwards ; a circumstance that does
not, at  first sight,  appear to tally with the  general law of involution, but
will, in many instances,  probably, find an  explanation in so-called fatty
defeneration.  The following table shows, at a glance, the results arrived
at by that inquirer :—
V MALES.					FEMALES.				
Age.	DQ o P o <* a "s'§ g X 1° P	a u p	O . as s a ha	u A o v 00 .2 li H	Age.	"■ a ° a t. a P	.9 1 "S.2 a" P. 3	o . 11 <e 9 s-s P a u o .a a	si A H
1—4 5—9 10—15 IG—29 30—49 50—79	7 3 3 18 23 19	22f 31} 34 42 A 432s3 45}f	27 33 37 45 }§ 47JS 52^	10f 12f 14 1713 18A	1—4 5-9 10—15 16—29 30—49 50—89	8 10 5 14 27 19	22f 2Gf 29f 38f 41A 42A	25$ 29 31} 42A 44,V 40 H	10i Hi3<j 121 17* 14i* 16ft
1 Memoires de la Socidte d'Obscrvation, torn. i. p. 262. 
304
HYPERTROPHY OF THE  HEART.
  According to this table, there is an uniform increase in all the dimen-
sions of the heart,  from infancy to old age,  with one exception, viz:  in
females after the age of 30, where there is a falling  off in the thickness
of the organ, the other dimensions continuing to increase.   The heart
appears, subsequently to recover itself, and  again to follow  the general
law, but not sufficiently to attain a thickness proportionate to that  in
the male heart of the same age.   Mr. Bizot's  measurements are taken
vertically, from the apex to the base, round the base at the junction  of
the auricles and ventricles, and at the thickest part of the left ventricle.
  The part most commonly affected with hypertrophy is the left ventri-
cle, and even when  other portions  of the heart have acquired an increase
of size, there is  still an increase  upon the relative dimensions of the
walls  of the  left ventricle.   Bouillaud1 gives the   following measure-
ments  of  an adult normal  heart, weighing  between eight  and nine
ounces:—
                                                         Inches.
       Average circumference at base    .    .    .   .     .   .  8 to 9
         do.   longitudinal and transverse diameters   ...     3£
                                                         Lines.
       Average thickness at base of left ventricle    .   .     .      6 to 7
         do.     do.    do.    right do.      ....     2£
         do.     do.    do.    left auricle     .   .     .   .     1 £
         do.     do.    do.    right auricle    ....     1

In health, the relative proportion  of  the thickness of the left and right
ventricles is as 1 :  3; if we bear these facts in mind, they will assist  us
in determining any relative changes, and  the weight of the organ will
establish the fact of an  absolute augmentation of bulk.
  Hypertrophy occurs  in three forms, to  which Bertin was the first  to
draw attention, and his classification has been adopted by subsequent
writers.  In the first, which is termed simple hypertrophy, the walls  of
the heart are thickened, while the cavities  retain  their normal dimen-
sions ; the second, eccentric  or aneurismal hypertrophy, presents an
augmentation both  of the lumen of the cavities and  of the substance  of
their parietes ; and in  the third, which has received the name of con-
centric  hypertrophy, the former  is reduced, while  the latter is  alone
increased.   The  last variety, probably, has  no existence as^a morbid
condition, but is, according to the  showing of Cruveilhier and Dr. Budd,
a post-mortem effect, an evidence,  simply, of the powerful tonic contrac-
tion of a robust heart.   The  former writer observed that it occurred  in
almost  all  persons decapitated by the guillotine,  and the latter has
pointed out that in all concentrically hypertrophied hearts the ventricle
may be easily dilated by means  of  the fingers, and always dilates  of
itself, when the rigor mortis goes  off.   The  simple and eccentric  forms,
then,  are the two which alone constitute actual cardiac disease.
  A priori, we should expect to meet with the former, very frequently,
as a mere effect of stimulated nutrition, since the  heart's action is  so
constantly  abnormally increased, and its powers unduly taxed; and also
because, according  to Bizot, there is an uniform increase of the heart
from birth  to the grave;  but such cases are  the exception, while, in the

       1 Traite* Clinique des Maladies du Coeur, vol.  ii. p. 559.  Paris, 1835. 
HYPERTROPHY OF  THE HEART.
305
majority of instances, some lesion may be  discovered in the heart, or
the larger  bloodvessels, which, by impeding the  current  of the  blood,
gave rise to unusual efforts on the part of the heart, and thus to hyper-
trophy of its tissue; in the same way as we  see the coats of the urinary
bladder enormously augmented in bulk, when a long-standing stricture
has daily called for violent contractions for  the removal of the obstacle.
   The left ventricle in either form  of hypertrophy is  the  part that is
most frequently affected; next in order, the right ventricle, and,  lastly,
longo intervallo, the auricles.   There is  not necessarily a relation be-
tween the increased thickness of the walls of a cavity and of the columnse
carnese; the former may be themselves only thickened in  some parts,
while,in others they retain their normal size; and again, we occasionally
find the  trabeculse much  enlarged, while  the proper walls present but
little  variation.   Hypertrophy of the heart necessarily alters, more or
less, the relation between the thoracic viscera, a  point of importance to
the practitioner, as  it also  gives rise to modifications in the form and
direction of the organ, which generally  becomes more globular and
spherical, while its apex is tilted up, and  the long diameter occupies a
more transverse direction than in health.
   In uncomplicated hypertrophy, where we have  to deal with no morbid
product, but that of an increase in the amount of muscular^fibre, the
muscular tissue is  of a  deeper red than usual,  and its  consistency  is
increased;  but  the  hypertrophy  may be  the result of a degenerative
process, or a degeneration may have set up in the organ, subsequent to
the hypertrophy having been established; the color  may then be of a
brownish tint, or present yellowish or fawn-colored spots,  while the con-
sistency is generally reduced.  In the former case, we find the characters
of voluntary muscular fibres more strongly marked than usual; the trans-
verse striae are more defined, and the edges have a sharper outline; in
the latter, these characters are more or less altered, and we meet with
further  traces of the  specific alteration.    An analysis of the cases of
fatty degeneration collected by Dr. Quain,1 shows that the prevailing
condition of the heart accompanying this state  is one of hypertrophy,
whether primary or secondary we are not prepared to determine, though
it appears very probable that the change known as  fatty degeneration
is the result of various  morbid processes, inducing a disintegration  of
tissue.   In the thirty-three cases of Dr.  Quain's first  series, the heart
is stated to be enlarged  in twenty-one; in six the organ was of a normal
size-  in  four the dimensions are not stated;  in one there was dilatation
without hypertrophy, and only in one was  the heart decidedly smaller
than usual.                                  #             .
   The causes inducing hypertrophy  are essentially of  two kinds ; " in
the one  kind," to use Dr. Watson's  terms, "there is some  mechanical
obstruction to the exit of the blood  from one or  more of the cavities; a
constricted state of the orifices is the most  common  condition.   In the
other kind without any such mechanical drain or bar to the fluid, there
is something to hinder the  free and sufficient play of the organ, an ad-

                      1 Medico-Chir. Trans, vol. xxxiii.
        20 
306
HYPERTROPHY OF THE HEART.
hering pericardium, it may be, or mal-position of the heart.   The causes
of hypertrophy  may, therefore, be situated within the heart itself, or
without and beyond it;  but in all those cases in which the effect of the
hinderance or obstacle is to detain the blood in  one or more chambers,
the hypertrophy will be likely to be accompanied  by dilatation, and
generally speaking the hypertrophy and dilatation result from disease
in some part, which lies beyond the affected chamber in the order of the
circulation."  The largest  hypertrophied heart, however, which we have
met with, was one of the latter class, in which  no such obstacle could be
discovered.   The specimen, which was  taken  from a middle-aged  man,
is preserved in the St. George's Hospital Museum, and weighed, when
removed from the body, 5 lbs.; the left ventricle is enormously hyper-
trophied,  and very much  dilated  at the same  time;  but  beyond  this
increase in the size of the heart, no morbid appearances are perceptible
or on record; the valves are all perfectly healthy.
  Insufficiency of the valves, by whatever cause produced, is one of the
most  frequent excitements of hypertrophy; and as the former lesion
prevails most  on the left side, it agrees with the fact that the left ven-
tricle is the part  most commonly affected.   Indirectly, the passage of
the blood from the right side  may be thus influenced, and an increase of
the walls of that part result.   Impediments occurring in  the course of
the arterial system at a greater or less distance from the heart act in
a similar manner, but, as may be supposed, in the ratio of their proximity
to the heart.  It is thus that we account for the complication of hyper-
trophy, more especially of the left ventricle, with aneurisms.  Obstruc-
tions  in the capillary circulation, though less  frequently,  give rise to
hypertrophy; this cause is found  to obtain chiefly on the right side of
the heart, partly, we  may fairly conclude, on account of the greater
vicinity of an  extensive capillary system in the  lungs to this portion of
the organ than exists in relation to the systemic side. The most marked
case of hypertrophy of the right ventricle which we ourselves have wit-
nessed, occurred  in a child of  one  year and a half, who had been long
subject to pneumonic attacks; and in whom,  after death, the whole of
both lungs were found studded with small lobular  abscesses.  The sub-
stance of the right ventricle was increased in thickness by one-third, as
compared with the left ventricle.  An undeniable influence must be also
attributed  to  inflammatory affections of the endo  and exo-cardium, as
well as to chronic inflammatory conditions of the muscular tissue  of the
heart; though the actual demonstration of the latter is a point yet  to be
effected, unless we assume that fatty degeneration  may be  the result of
a phlogistic process.  The manner in which pericarditis gives rise  to it,
is by causing  partial or general adhesions, and thus preventing the free
contraction of the muscular tissue.  Endocarditis most commonly  gives
rise to hypertrophy, by inducing changes in the valvular apparatus, and
thus affording impediments to the sanguineous current.
   In the thirty-fifth volume of the Medico-Chirurgieal Transactions,
Dr. Barclay publishes a list of ninety-two cases of heart disease, taken
from the post-mortem  records of  St. George's Hospital, of which we
have  made an analysis with regard to the relation of frequency of hyper- 
DILATATION OF THE HEART.
307
  trophy and dilatation; and we find that while the muscular tiesue of the
,  heart presented a state of hypertrophy only in  twelve  cases, there was
  hypertrophy combined with dilatation in forty-six, and only  fourteen in
  which the latter condition was observed alone.
                  DILATATION  OF THE HEART.

   If  in  hypertrophy of the heart we  in  many cases see an  effort of
nature to adapt the organ to peculiar requirements entailed  upon it by
morbid conditions, and therefore would, a priori, expect to find it fre-
quently  accompanied  by dilatation, we  fail  to  discover this tendency
where the latter condition  occurs  by itself.  This form  of dilatation is
necessarily associated with an attenuated state of the muscular  parietes,
and may, therefore, be considered as synonymous with  atrophy of the
organ.   Hypertrophy, with  dilatation,  corresponds  to the condition to
which the older authors applied the term active  dilatation; while dilata-
tion,  associated with a diminution  of the fleshy parietes, was known as
passive dilatation. The two conditions have also been respectively called,
by Corvisart, active and passive aneurism  of the heart.   These various
terms show that the subject itself  has not  been  established on  a settled
basis ; and they certainly only tend to increase the embarrassment of the
student.   The less our nomenclature involves disputed theories the better,
and as long as  we are unable to base our terminology upon a knowledge
of the proximate causes of disease, it is wiser to employ  names that are
derived from the most prominent symptom. In the present instance, we
shall  continue  to use the term dilatation to designate a distinct class of
morbid changes in the heart, and  we shall separately consider  the two
varieties under which it occurs, the general and  the partial form.
   When, as Bouillaud remarks, the blood ceases to exert its stimulant
and irritant influence upon the heart, and there are causes tending to
enlarge its cavities, we find dilatation without hypertrophy; the blood in
that case does  not augment the molecular nutrition of  the  organ, but
appears  to act  simply according to the laws of hydrostatics as a forcing
power.   That it should, however,  at any time be able to  cause a change
in  the cardiac  cavities, necessarily presupposes  an alteration in the
power of the heart, and  in the  cohesion of the muscular tissue.  The
ultimate cause of these conditions may be supposed to reside in the nerv-
ous or vascular system, or in both conjointly.
   The parietes of a dilated heart  may  be  attenuated to  an extreme de-
gree ;  the thickest part of the left ventricle may be reduced to two lines
in diameter, while at the apex the  muscular substance may have disap-
peared entirely, so that the endocardium and pericardium are in opposi-
tion ; at  the same time, we find a corresponding diminution in the
thickness of the columnse carneoe.  In one point there is a characteristic
difference between hypertrophy and dilatation,  independently of the
nature of the lesion.   This is in regard to the part affected.   The left
ventricle  is most frequently attacked with  hypertrophy,  while we meet
with dilatation  most commonly in the right ventricle.  It has been stated
that the  female sex are most  prone to dilatation, and males to hypertro- 
308
DILATATION OF THE HEART.
phy;  we do not find this to be the case.   On analyzing  the ninety-two
cases  of heart-disease collected and reported in the Medico-Chirurgical
Transactions, by Dr. Barclay,1 with a view to determining this question,
we find that, of fourteen cases  of dilatation, six  occurred in  females,
and eight in males;  of  sixteen cases of  hypertrophy alone, seven were
women, and nine men;  of forty-six cases of hypertrophy combined with
dilatation, seventeen were females, and twenty-nine males.  On a rough
average it therefore appears that in each variety there is a preponder-
ance of about one-third on the  side of the  latter.   Dilatation, as Dr.
Hope remarks, takes  place more in the  transverse than in the longitu-
dinal  direction of the ventricles,  and it accordingly communicates to the
heart an unusually spherical form, the apex being rounded off in such
a manner as frequently to  be scarcely distinguishable.
   Dilatation affects the auricles more frequently than  hypertrophy ;
however, we must be careful in not hastily  assuming a diseased condi-
tion, where its semblance is owing merely to distension.   This  is par-
ticularly the case with the  right auricle,  which very commonly appears
much dilated,  owing to the accumulation of blood taking  place on this
side of the heart in articulo mortis.   If  on removing the contents the
cavity presents  its normal appearance, we  consider  it to have  been
merely mechanically and temporarily distended;  if the enlargement  is
persistent, we may look upon  it as the result of morbid  action during
life.  A  dilatation  of  the  right side of  the heart is met with in con-
nection with  patency of the foramen  ovale.  A case  of  this  kind was
exhibited  by Dr. Lloyd,2 before  the Pathological Society.  It occurred
in a boy aged sixteen, who had been  subject to bronchitis, with tempo-
rary cyanosis.  The right auricle was much  dilated, and the right vent-
ricle was  dilated and hypertrophied, while the left side presented the
normal appearances.
   The preceding remarks apply mainly to general dilatation; partiai
dilatation, or aneurism of the heart,  is, according to Rokitansky, whose
views  on this subject are particularly lucid, a condition depending espe-
cially upon an inflammatory state of the  endocardium and the muscular
tissue at  the point affected.  The following abridged view of this writer's
opinions  is the best account of the matter that we have to offer to our
reader.    Rokitansky assumes the existence  of two distinct  forms  of
cardiac aneurism.   The first—the acute  and rarer form—depends upon
a laceration of the diseased endocardium, and adjoining muscular tissue,
through which the blood  passes ; and the power of resistance being
diminished at the point,  a pouch is  established, a fringed margin  of
endocardium is found at the entrance, and the blood deposits  itsfibrin
within, while the margin becomes fringed with vegetations. Rokitansky
has never seen a case in which the walls of an aneurism, formed in this
manner,  had become consolidated  into a fibroid, callous tissue.   In all
the cases examined by him, the aneurismal formation was of recent date,
having existed only a very inconsiderable period after the endocarditis,
during the continuance of which it  had originated.   The second form

                1 Medico-Chir. Transact, vol. xxxv.
                2 Reports of Pathological Society, 1848, p. 223. 
                  DILATATION  OF THE  HEART.               309

is the more remote effect of an inflammatory condition of  the investing
or lining  membrane, or  of the  muscular parietes  of the  organ.   This
induces the development  of a  fibroid  tissue, replacing, or, we should
rather say, causing  the absorption of, the muscular fibre.  The new
tissue contracts, the parietes lose  their power of resisting  the pressure
of the blood, and a circumscribed  dilatation ensues.
   The aneurism varies much in size, from  that of a pea to that of the
heart itself; it does not necessarily present an enlargement at the sur-
face, nor  does  it appear to possess an inherent tendency to increase ;
thus, in a case presented to the Pathological Society by Dr. Jenner,1 in
1848, an  aneurism was found of the size of a filbert at the apex of the
left ventricle.  Though  there was no  muscular  substance over the ex-
tremity of  the sac, it did  not project  beyond the external wall of the
ventricle.  The existence  of the  aneurism  in  this instance was traced
back to two years  previous to the death of the  individual.  A few old

                               Fig. 140.
Series xii. No. 53.

slight adhesions binding the  apex of the ventricle loosely to  the  free
pericardium, indicated a previous inflammatory condition at the affected
point.   It appears that the  healthy tissue  of the organ possesses in
many instances an inherent power of neutralizing the evil effects which
might be expected to result from a local loss of resisting power in the
parietes;  otherwise, it is difficult to understand  how a cavity can be
hollowed  out  in  their  substance without seriously impairing  the  con-
tractile power.  We sometimes  find cases in which the thinning is not
quite so definitely circumscribed as Rokitansky describes it, and where
it  yet proceeds to an  extreme  degree.  Thus, we have seen a case of
enormous dilatation of both  ventricles without hypertrophy, in which
the apex of the left ventricle was thinned to the  size of a sixpence (bt.

               ' Report of the Pathological Society, 1848-9, p. 89. 
310
ATROPHY OF THE HEART.
George's Museum, 1842-62).   Partial aneurisms  are not necessarily
solitary, but there may be two  or three, which may, as they progress,
intercommunicate.   Next to the apex of the  left  ventricle we find its
base, and, third in order, the septum ventriculorum liable to  be  thus
affected; in the latter case the bulging is towards the right side of the
heart.   Considering that there is  a point in the upper part of the sep-
tum, at  which normally there  is no muscular tissue  to maintain the
separation of the two cavities, we should be led to expect the occurrence of
aneurism more frequently at this point; but in ordinary circumstances
the balance of the circulation suffices  to prevent this result.  When this
form of aneurismal dilatation extends to  such a degree that an opening
and communication between the ventricles results, we have to deal  with
what Dr. Thurnam has termed the varicose  aneurism ;  it is a condition
analogous to a congenital state,  not unfrequently met with, in which the
ventricular septum is more or less defective.
  The contents  of the cardiac  aneurisms vary; we find  in them  fluid
blood, more or less decolorized, sanguineous  coagula, or laminated fibrin-
ous deposits, resembling those found in arterial aneurisms, and present-
ing similar microscopic appearances.
  The male sex and mature age offer a greater proneness to aneurism
of the heart than the female  sex and youth; the proportion with regard
to sex is about 1 to 3; Hasse states that  of  forty-seven cases thirty-five
were men and twelve women; and of forty-two cases,  ten referred  to
individuals under thirty, and thirty-two to older persons.
                  ATROPHY  OF  THE  HEART.

  In introducing the subject of dilatation, we observed that it was essen-
tially an atrophic condition.   Atrophy of the heart is also met with in
the shape of a mere  reduction of size, either as a result of wasting dis-
ease or as a congenital vice.   Three  extreme cases recorded by Burns
probably belong to  the latter variety; in  one  instance, he found  the
heart of an adult as small as that of a new-born infant, and in another
the heart of a female, aged six-and-twenty, was  no larger than of a
child  of six  years.  Bouillaud  describes a case  of an  old woman of
sixty-one minutely,  who died of acute  peritonitis, in  whom  the heart
was a third smaller than in the normal condition,  or about the size of
the heart in a  child of ten or twelve.  The surface was furrowed  and
presented milk spots, the  remains of former pericarditis; the cavity of
the left ventricle was scarce large enough to contain a pigeon's egg, and
its parietes were only three lines in  thickness.  In phthisis, there is a
uniform diminution in the size of the heart; in no other maladies is this
so much the case, as  illustrated by the following measurements given by
Bizot1  of the heart in the adult:—

             1 Me"moires de la Socidte" d'Observation, vol. i. p. 277. 
MORBID GROWTHS.                    311
MALES.				FEMALES.			
Age 1C to 79	"?!	■8 8	DQ is	Age 16 to 89			c i
years.	C OS	8&1 .So*		years.	D a h3 J	.1 1 a	1 Thic of h lines
57							
Phthisical.	42ft	47A	15H	—	39|	41^	15ft
65							
Non-							
Phthisical.	45^	50|T	"if	—	43	47H	16&
                        MORBID  GROWTHS.

  The adventitious and heterologous  products  found in the muscular
tissue of the heart are almost all pathological curiosities, with the ex-
ception of the fatty metamorphosis to which we  have already alluded.
Acephalocysts are occasionally met with, as also the cysticercus  and
echinococcus.  A well-marked instance of the  latter was presented to
the Pathological Society by Mr. Ward, in 1847,  and the preparation is
still preserved in the Museum of the London Hospital.1  In this case
no trace of the entozoon was discovered in other viscera.  A remarkable
case in which a cyst containing hydatids was found in the substance of
the heart, is recorded and delineated by Mr. Evans in the seventeenth
volume of the Medico-Chirurgical Transactions.  It occurred in an un-
married female, about forty years of age, who,  during the winter  pre-
ceding her death, had been subject to  palpitation and angina  pectoris.
The cavity of the pericardium was found to be  coated with  a  layer of
coagulable lymph over a small extent of its front surface; the apex of
the heart was lost in  a considerable tumor, apparently an elongation of
the heart*itself, and covered  on all sides by pericardium.   The  new
growth was found to project into the cavity of the  right ventricle, was
smooth,  globular, and about three inches in diameter.   It contained
numerous hydatids from the size of  a pea to a pigeon's egg;  their in-
terstices being  filled  up by a soft, curd-like,  yellow substance.  The
hydatids were  precisely the  same  as  those found  in  the  liver.  The
trichina spiralis has not been met with in the  heart.  Ossific deposits
are recorded, but they seem invariably to proceed from the endocardium;
and we shall return to the subject in connection  with the diseases of this
membrane.  Both Corvisart  and Hope give cases of portions  of the
heart  being converted into cartilage:  we should be inclined to  assume
that if these cases had been subjected to microscopic examination, the
tissue would have proved fibrous rather than  cartilaginous.   Tubercle
and cancer occur in the heart, but only when the  respective dyscrasiae
are verv strongly marked; the centre  of the vascular, in this  respect,
differs much from the centre of the nervous system.  Of the two, cancer
is the more frequent;  it occurs in  the medullary and melanotic varie-
1 Report of Pathol. Soc. 1847-8, p. 225. 
312
MORBID GROWTHS.
ties, and either by infiltration or in the form  of isolated tumors.   An
exceptional case, as proving the occasional  evolution of cancer in the
heart, is recorded by Mr. Travers.1  On the anterior apex of the heart
of a gentleman, who died suddenly with  symptoms of angina pectoris,
and whose body he examined with Mr. Parrott, of Claphara, he found a
fungoid growth, elevated, and of the diameter of a shilling;  it had the
true pulpy character.   There was no ulceration, nor any correspond-
ing appearance in the loose pericardium or elsewhere.   The  internal
membrane was  unchanged,  except some earthy deposits about the aortic
valves.

     1 On the Local Diseases termed Malignant. Med.-Chir. Tr. vol. xvii. p. 354. 
CHAPTER   XX.
         MORBID ANATOMY OF THE ENDOCARDIUM.

  It has required the multiplied observations  of numerous laborers  in
the field of pathology to establish the true nature  and importance  of
endocardial affections;  Laennec and J. P. Frank were among the first
to draw attention  to inflammatory  conditions  of the  endocardium, but
we  owe the more correct appreciation of the subject to Bouillaud and
Dr. Hope.   The pathology of the endocardium is as significant in re-
gard to its primary, as it is with regard to its secondary lesions.   The
membrane is analogous to that lining  the bloodvessels; it consists of a
layer of epithelium, investing a fibrous tissue, between which and the
muscular fibre of the heart there is a layer of elastic cellular tissue; it
is in the latter that bloodvessels ramify, and through them the nutrition
of the surface-laminae becomes affected, in disease as  well as by the  direct
influence of the blood contained in  the cavities of the  heart.   It is
necessary to bear this double relation in mind, as,  without a due per-
ception of these facts, we shall  find it difficult to harmonize our general
knowledge of morbid changes with  the apparent exceptions  that  endo-
cardial disease brings to our  notice.
  A  careful  examination of the endocardium is necessary, before  we
determine positively that the  appearances we find are due to pathological
alterations;  the earlier observations lose much of their value from post-
mortem staining  having  been mistaken for  inflammatory  reddening.
When the change  of color, which naturally is of the  palest white, and
translucent, is due to inflammation, the redness cannot be washed off,
nor is it rapidly destroyed by maceration;  the membrane is  pulpy and
thickened, and in  an advanced  state,  further products of inflammation
are found beneath, or upon the membrane.   Where the redness  is the
result of mere imbibition, we find the blood in the cavity fluid, and it
occurs in cachectic individuals.   The later the post-mortem examination
is made after death, and the  warmer the weather at the time, the more
likely are we to find the lining  membrane of the  heart and  arteries
stained with blood.  We rarely have  an opportunity of seeing endocar-
ditis in its first stage.   Rokitansky and Hope describe  inflammatory
redness of the endocardium as  mottled.  Dr. Hope states it  to be less
characterized by streaks, patches, isolated  unstained spots, and abrupt
ed^es, than non-inflammatory  imbibition.   The  discoloration is  more
perceptible in the arteries than in the cardiac cavity, owing to the sub-
jacent tissue serving as a better foil in the former  than in  the latter.
On the other hand, the  next  change, that of opacity of the lining mem- 
314        MORBID ANATOMY  OF THE  ENDOCARDIUM.

brane, for the same reason shows more distinctly in the heart than  in
the arteries, where a transverse section will be required to demonstrate
the increase of thickness.   This alteration  in  the appearance  of the
endocardium also changes it in other respects ; it loses its glaze, and be-
comes dull, relaxed, milky, and velvety.  The redness of imbibition  is
darker in proportion to the period the blood  is in contact with the pari-
etes of a cavity, and for this reason it is observed, as pointed out by
Hasse,1 in the following descending order: darkest  in the right auricle;
paler  in  the right  ventricle, with the exception of the valves  of the
pulmonary artery, which are as deeply colored as the auricle ; still paler
in the left auricle; whilst the left ventricle often retains quite its natural
tint,  except that the aortic valves are darker. In the great vessels, the
posterior surface is strikingly dark, in comparison with the anterior.
   In  rare cases, an adhesion has been found  effected between opposite
points of the parietes.   When the inflammatory process extends to the
valves, the consequent change in their relation to  the blood-current,
gives  rise to those physical signs which are  of so much value  in the
diagnosis of cardiac affection.  The laxity of tissue induced by the in-
flammatory process offers more or less impediment to the circulating
fluid,  and may even be the cause of  a laceration of the cardiac  lining,
or of  the extension of the membrane to the valves  and arteries.
   The first effect of inflammation of the endocardium is the exudation
of lymph on its free surface; where, however, it is rarely to  be found,
on account of the current washing  it  away; its absence was an argu-
ment  used by Laennec, against the assumption that the endocardium was
liable to inflammation.  In how far the fibrinous vegetations on the
valves are the product  of inflammation of the  part, or a deposit of lymph
exuded within the heart, or again, an elimination of fibrin directly from
the blood, is a matter not absolutely  decided.  It  appears to us that
there  is no difficulty in reconciling the conflicting opinions, by assuming
that the  valves may become the seat of these deposits, in each  of the
modes alluded to.   We know that, if a thread be  passed  through a
healthy artery, a coagulation  of fibrin attaches itself to  the foreign
body; and we also know that inflammation increases the tendency to a
separation  of fibrin from the blood.    There  is,  therefore, no necessity
for the intervention of the coats of the capillaries  to produce the effect
of exudation, although the term certainly implies a transmission through
a membranous expansion.  We are satisfied  that we have seen what  is
called exudation  matter, within the small vessels  of the pia mater,  in
meningitis, and, though the number of our observations are not sufficient
to base any positive conclusions thereon, the fact may, quantum valet,
aid in the present inquiry.   Besides, the  circumstance of the great
tendency to valvular  growths prevailing in rheumatic  constitutions,
supports the view of the frequent occurrence of deposits being effected
directly from the  blood.  Rheumatism, more  almost than any inflamma-
tory condition, presents the character  of a blood disease, and, consider-
ing the  preponderance of fibrin in  the  elements  of the blood which

  1 An Anatomical Description of the Diseases of the Organs of Circulation, Syd. Soc.
Ed. p.  128. 
           MORBID ANATOMY  OF THE  ENDOCARDIUM.       315

characterizes it, and the frequent complication with heart disease, it offers
a further  corroboration of the view just advocated.  It is, in fact, the
same as that expressed by Dr. Hope, when he says that the vegetations
on the valves are caused by inflammation inducing either an effusion of
coagulable lymph, or by its imparting to the blood in  contact with the
inflamed part,  a morbid tendency to coagulate.
  If the discovery of lymph on  the inner surface of  the  heart  is an
unusual circumstance, it follows d fortiori, that we still less frequently
meet with  a  purulent effusion resulting from endocarditis.   Rokitansky
remarks on the subject, that although the recognition  of the  seat and
position of pure pus, as a free product, is, in most cases, impracticable,
it is not difficult to prove the extreme probability of  the existence of
such a  process.  The loosening  of the tissue,  the want of polish, and
the felt-like  character of  the endocardium, are very strongly marked in
the centre of inflammation, and hence lacerations frequently occur.  In
these cases, a purulent product mixed with the blood  is generally  found
infiltrated into the tissue,  if not at the surface of the endocardium;  whilst
abscesses  are occasionally found  to have spread themselves  over a vari-
ous extent of surface below the endocardium, in the cellular and adjoin-
ing muscular strata, deep in  the tendons, and in the tissue of the valves.
   One of  the effects of endocarditis is ulceration; it  is met with on the
parietes of the heart, but more frequently on the flaps of  the valves,  where
it gives rise to perforation and rupture.  Perforation  of the septum ven-
triculorum occasionally results from this cause.   A free communication
may thus  be established, or the  muscular wall  may be completely de-
stroyed; but an exudation of fibrin having taken place on the distal side,
the intermingling of the contents of the two cavities  may be prevented.
We find the two  lesions associated, as for instance in Bouillaud's1  sixty-
sixth case; the subject, a man aged thirty-seven, was seized with rheu-
matism, upon which  pericarditis  and endocarditis supervened, causing
death on  the thirty-first day of his illness.  At the cadaveric inspection,
a cauliflower excrescence of fibrin  was found upon the ventricular sur-
face of one of the aortic semilunar valves ; upon which, besides a  fringe
of  lymph  along its free margin, two perforations were discovered, one
at the middle of the flap,  the other lower down,  and communicating with
a cavity in the muscular  tissue large enough to contain a bean; to the
right of this flap there was a red spot of three  lines  in diameter,  in the
centre of which was a small  circular ulcer, sufficiently large to admit the
head of a  pin.  Bouillaud also gives two instances in which endocarditis
was followed by gangrene, a conclusion, however, which some have cavilled
at.  The following is an abstract of the most satisfactory of the two: The
patient, a robust individual,  aged fifty-six, after exposure  to a draught
while much heated, was seized with endocarditis, and death ensued in six
weeks.  The post-mortem was made thirteen hours after death, and two
of the aortic valves were  found indurated at their base, and adherent to
one another so  as  to interfere  with the current.   The endocardium
covering their base was  red, thickened, and presenting an  abrupt red
fringe, at  a short distance from the  free margin.  The  remainder  of the
1 Traite Clinique des Maladies du Coeur, vol. ii. p. 29. 
316        MORBID ANATOMY OF THE ENDOCARDIUM.

valve was ulcerated, soft, friable, of a dirty gray, and eroded;  one pre-
sented a perforation.   The two  flaps, says M. Bouillaud,1  closely re-
sembled the appearance of gangrene of  the  cutaneous surface, with a
red line of demarcation.  Dr. Copland, as we have  already seen, is  of
opinion that gangrene will only supervene when internal carditis attacks
a cachectic habit of body, or when there is a septic tendency induced in
the system, by a depraved state of the circulating fluids, or by impaired
vital power.
  A frequent concomitant of endocarditis, appears  to be, according to
the statistics of  Bouillaud,  who has  met with a larger number of fatal
cases of  endocarditis than any  English physician, the coagulation, dur-
ing life, of the blood, and the  organization, in the  clot,  of  new blood-
vessels ;  the coagulum is found adherent to the parietes of the cavity,
and  requires some force for its  removal.   It  is  colorless, elastic, and
glutinous, and closely resembles the buffy coat  of inflammation, or false
membranes themselves.  The symptom  by which  Bouillaud recognizes
this occurence before death, is, a want of accordance between the pulse
and the heart in point of force ; the heart presenting evidence of violent
excitement and action, while the pulse is small and evanescent.   Gluge2
describes organized fibrinous coagula under the name of hsematoma, and
gives an  interesting instance, with the minute anatomy of the clot, which
occurred in a female,  aged fifty-two.   The left  auricle was filled with
a red tumor, surrounded by a delicate membrane, in the interior  of which
he distinctly traced capillary vessels, forming a retiform plexus.   Simi-'
lar instances may be also found in the records of the Pathological Society,
and in Dr. Hodgkin's Catalogue of Guy's Hospital Museum.  The cases
in which organized clots or fibrinous coagula have been found by English
observers, were  generally connected with a cachectic condition, analo-
gous  to  what Rokitansky  terms the fibrinous crasis.  The surface is
found more or  less intimately connected with the  endocardium, while
the interior of the clot may, in its turn, be undergoing further changes
of an inflammatory or  degenerative character.   The fibrin is seen  to
be breaking up  into a  granular  condition; exudation or  inflammation
corpuscles and fibro-plastic cells  may be exhibited  by the microscope.
This does not necessarily apply to  the  pus  that  is  occasionally found
within the coagulum, which is to be regarded rather as the cause  than
the  consequence of the coagulation.   The pus  may be derived from
various sources; Cruveilhier3  observes  that it may be generated at a
distance, and be carried to the heart by  the blood-current; that it may
be the result of  inflammation occurring in the coagulum, or that it may
be the product of endocarditis;  in which  case it is absorbed into  the
coagulum, by capillary attraction.   Tuberculous  concretions have also
been found in the clot; however they gain the position, it must be before
death ; changes affording sufficient proof of the independent vitality of
the concretion.   The older pathologists attributed a much greater  im-
portance to fibrinous coagula,  or, as they termed them,  polypi, in the

         1 Traite" Clinique dee Maladies du Coeur, vol. ii. p. 87, Observ. 87e.
        1 Atlas der Pathologischen Anatomie, Lieferung 11.
        * Anat. Pathol, livr. 25. 
           MORBID ANATOMY OF THE ENDOCARDIUM.       317

heart, than they now obtain, owing to their being regarded as the im-
mediate cause of death.   It is only in rare cases that we shall be justi-
fied in looking upon them as products formed during life; in the majority
of instances they are merely the first evidence of the arrest of vitality,
and the incipient influences of the metamorphoses of decay. When formed
during the agony, or after death, there is no adhesion to the parietes ; the
polypus is moulded to the  cavity which contains it, and a straw-colored
fibrinous layer invests a blood-clot, similiar to the buffy coat covering the
coagulum of blood obtained by venesection.   The view we have taken of
the organized polypi is supported by Hasse,1 who observes that the seat
of morbid action giving rise to them is, in the  majority of  instances,
remote from the heart.   Under certain circumstances the blood retained
after the systole in the ventricles, and impelled into the network of the
columnar carnese, acquires the  opportunity to coagulate; and one fixed
point being given, it is easy to understand how constantly fresh deposits
are made on the surface,  causing a laminated appearance, and  aiding
in the process of organization.
   A second form of fibrinous concretion is  described by Rokitansky,
under the name of globular vegetations, as round masses, varying from
the size of a pin's head to that of a nut, attached by  means of rami-
fying cylindrical or flat appendages or bands, which entwine themselves
among the trabecule of the heart, and are of a more or less  uniformly
dirty grayish-red or white color.   He states  them to be hollow  in the
interior, and to contain, within a wall of  irregular thickness, a dirty
grayish-red or even  chocolate-colored fluid, resembling cream or pus.
One or more of these concretions very frequently burst, when the fluid
may be seen effused into the cavity of the heart, and distributed over
the recent coagula, which have been formed either in the death-struggle
or shortly  after death.
   Rokitansky establishes a third concretion, under which he  comprises
all vegetations of the valves of the heart, presenting a  shaggy appear-
ance, resembling villi, forming shaggy pedicled excrescences, or offering
a  cock's-comb or mulberry-like appearance.  They affect the free mar-
gins of the valves, the tendons  of the papillary muscles,  and also  attach
themselves to the endocardium. They float in the blood, and necessarily
lie in the direction of the current.
   It appears that we have sufficient evidence to  believe that  they may
occasionally become detached and be carried by the force of the circu-
lation as  far as  the first angle of a vessel offering an  impediment,  or
until they reach a channel which  is too small to permit of their trans-
mission.   Dr. Kirkes,2 in an interesting paper presented to the Medico-
Chirurgical Society, has carefully investigated the  circumstance, and
recorded several instances  in illustration.   The part more immediately
affected depends, according to this author, in the first instance, upon the
circumstance of the fibrin being detached  from the right or the left side

  1 An Anntomical Description of the Diseases of the Organs of Circulation and Respira-
tion, Syd. Soc. Ed. p. 1-7.
  2 Mcdico-Chirurgical Transactions, vol.  xxxv. p.  281. 
31.8        MORBID ANATOMY OF THE ENDOCARDIUM.

of the heart.  In the former case, the pulmonary, in the latter, the sys-
temic circulation will become affected.   When the mass of  fibrin  is
detached from the left side, the lodgement is most commonly effected in
one  of  the middle cerebral arteries, a circumstance  explicable by the
anatomical relation of these vessels.  The arteries  of the spleen  and
kidneys appear to be  liable,  next in order, to  similar  deposits, on
account of their receiving their arterial supply by large vessels directly
from the heart.  That the plugging up of an artery must induce a change
of nutrition in the part to which it leads, scarcely requires to be dwelt
upon;  while it  causes  coagulation  of the  blood behind, it  acts  as a
foreign body, exciting inflammation and exudation, or degenerative  pro-
cesses,  as  softening and gangrene.  In how far such  an occurrence is
remediable is very doubtful, though Dr. Kirkes suggests that a breaking
up and absorption may  take place, or that, by a dilatation of the blood-
vessel,  the current may be enabled to pass it; in the latter  case, we
should  imagine it more  probable that the  plug would be propelled, espe-
cially as one characteristic of this variety  of deposit  is that it enters
into no close adhesions to the inner coat of the vessels.  Twenty-one
cases have been analyzed by Dr.  Kirkes, in which these deposits were
found,  and in every one but two he found disease  of the valves and of
the interior of the heart.   One of these was a case of  cholera, in which
 a "doubtful mass of capillary phlebitis existed in the liver; the other was
 a case  of  aneurism of the aorta, which the author looks upon rather as
 favoring his views. In fourteen out of the remaining nineteen, fibrinous
 growths were noted on  the surface of the left valves, or the interior of
 the left cavity.

   Note.—Since the above has been in type, we have seen that Dr. Todd is not inclined to
 adopt Dr. Kirkes's view, but would refer the coagulum found in the distant artery to an
 altered nutrition of its wall—to arteritis—and connected with a rheumatic or other morbid
 Btate of the blood.  (Clinical Lectures on Paralysis, &c, 1854, p. 176.)
\ 
CHAPTER  XXI.
         DISEASES OF THE  VALVES  OF  THE  HEART.

  The  estimates  of different authors,  with regard to  the influence
exerted by inflammation in producing valvular  disease, have varied con-
siderably.   Bouillaud attributes nearly all  changes  occurring in the
valves, such as altered consistency and form, fibrinous concretions, cal-
careous and  ossific deposits, to inflammatory action, terming them the
third stage  of  the inflammatory process ; while Rokitansky, and many
with him, are of opinion that they are only in part the product of endo-
carditis, but that the majority are the result of slow changes of nutrition,
not connected with inflammatory action.
  The most manifest direct results  of endocarditis are white opacity and
thickening of the endocardium  and the lining membrane  of  the valves,
and  adhesion between the latter.   Adhesions are most commonly found
in the aortic valves, and this lesion must necessarily constitute a perma-
nent and very  serious obstacle to the circulation,  in its turn giving rise
to further disorganization and  derangement, such as hypertrophy and
dilatation, asthma and anasarca.   In dealing  with this species of  mal-
formation, it is often very difficult  to determine whether it is congenital
or the  result  of disease, especially when, subsequent to adhesion,  an
absorption of the partition  separating the two pouches is effected, and
the double valve thus converted into one.   Dr. Peacock1 has  analyzed
fifty cases  of  malformations of the  pulmonary  and aortic  semilunar
valves, among  which he found  forty-one of defective, and nine of ex-
cessive development.  Of the former, nine were found at the pulmonic,
and thirty-two in the aortic  orifice.   The varieties which the  fusion of
the  valves with one another, or their adhesion  to the^ walls of the heart,
may present, are very numerous.   In all  cases an insufficiency of the
valves must result, which both offers an obstacle to the free discharge of
the blood from the heart, and fails  adequately to close the orifice during
the  diastole, so as to prevent regurgitation.   The left side of the heart
generally, and especially in regard to inflammation, offers by far the
greatest proclivity to disease.   Very few cases are recorded in which a
phlogistic process could be demonstrated on  the right  side.   Gluge3
gives two observations in which the tricuspid valve was  thickened and
rendered insufficient by this cause.  We also find two instances reported
in  Dr. Hodgkin's Catalogue of the Museum  of Guy's  Hospital (Nos.
1401 and 1402), in which the curtains of the  tricuspid were thickened.

  ' Reports of the Pathological Society, 1851-52, p. 292.
  * Atlas der Pathologischen Anatomie, 1850, Lieferung l. Beobachtung, 12 and 12a. 
320        DISEASES  OF THE VALVES  OF  THE HEART.
In one of these there was also shortening of the tendinous cords.  While
the arterial valves are more subject to this species of lesion, we find the
mitral valve more prone to  an hypertrophy  of its fibrous tissue, which
is especially liable to present itself in the shape of nodulated masses,

                               Fig. 141.
Fibroid thickening of the mitral valve.
fringing the curtain, and in some instances closely resembling accumu-
lations of fat.  The microscope at once determines their real nature, as
it exhibits, instead of fat-cells, a fibroid structure, containing nuclei and
elongated nucleated cells. In connection with hypertrophy of the endo-
cardium, we find the lining membrane of the valves also thickened; by
which means  it appears  that, independently of inflammatory action, a
secondary adhesion may  be effected between the flaps.  Here  the aortic
valves are more liable, though it is not at all unusual to find the curtains
of the left auriculo-ventricular orifice opaque throughout, from the same
cause.
  We have already alluded to perforation of the  valves, as a result of

                               Fig. 142.
 Fibroid thickening of a pulmonary valve, extending symmetrically on both sides of the curtain, and con«
sisting of a soft fibrillating deposit.  It was found in a man who had a broken spine.

endocarditis.   Another  form in which the same lesion occurs is in con-
nection with  atrophy.  This  is  manifested, in the first  instance, by 
DISEASES OF THE VALVES OF THE HEART.       321
attenuation, and increased transparency of the valves ; as this advances,
one or more openings  are effected, which may be sufficiently numerous
to induce a cribriform appearance.  It is only when the perforations are
large or numerbus  that  they interfere, to any serious extent, with the
circulation.   Thus, in  the case of a man who died recently at St. Mary's
Hospital, after an operation for popliteal aneurism, the cause of  death
being extensive pneumonia, there was much  fibrinous  deposit on the
aortic valves, with  two valve-like perforations, apparently the result of
ulceration, which had given  rise to murmurs  of a peculiar character
before  death, but  not,  apparently, inducing  any other symptoms of
cardiac disease.  Dr.  Kingston,1 who was the first to draw attention to
this  point, observes, that atrophy may be defined a simple shortening
of the valve, and, in the first instance, a mere atrophy in  the direction
of the length.   He speaks of the cribriform appearance in the flaps as
also resulting from  the  same process, and has found the two conditions
chiefly in the mitral and tricuspid valves.  In this, he differs from other
authors.  Rokitansky, for instance, has  only met with the lesion in the
arterial valves.  Dr.  Kingston, out of  about  thirty cases of valvular
disease, found  the lesion  to be atrophy  in ten.  The mitral valve was
shortened in five, the  tricuspid in five; both in two.  In one the mitral
valve was cribriform,  in two the tricuspid, and  in one  both the  aortic
and pulmonary valves were so.
   The lesions of the valves hitherto  spoken of  may be variously com-
plicated with one another, or with  heterologous growths.  Pathological
records  contain  instances of a great variety  of changes  of form, the
result of morbid processes or accident.   Thus,  the individual flap of the
semilunar valve may be  reverted  or  inverted,
the valves of the aorta may become detached at
their bases, and thus lose the fulcrum by which
they resist  the impetus of the blood, or the
tendinous cords  of the mitral  may induce  a
deficiency of the valve  by a  shortening  and
thickening, a lesion which Dr. Hope  considers
as  constituting one of  the  worst  varieties of
disease of the  valves.
   Among the anomalies of consistence, Roki-
tansky describes, besides the increased density
of  thickened and shrivelled valves, and the
softening that  results  from  inflammation,  a
gelatinous condition of  the valve which he has
found in the  valves  of  the left  side  of the
heart exclusively.   There is a  loss of fibrous
tissue,  for  which  a  gelatinous, non-adhesive
substance is  substituted,  causing the  valve
throughout, or only in  parts,  to  become  soft
and pliable while its color is converted into a pale yellow or reddish hue.
The author is of opinion that there is  no effusion  of new matter, but
that the gelatinous substance is merely  the disintegrated fibrous  tissue
Fie. 143.
 Aortic valves of a child aged four
years; they are opaque and thick-
ened, and their free margin curled
backward towards the artery. Two
of the valves are closely united hy
their adjacent margins.—St. Bar-
tholomew's Museum.  11th Series,
52.
21
1 Medico-Chirurg. Trans., vol. xx. p. 90. 
322
DISEASES OF  THE  VALVES  OF THE HEART.
of the valve itself.  It appears that while  on the one hand this condi-
tion may lead to lacerations,  especially of the valves of the aorta, pre-

                                 Fig. 144.
 Atheromatous deposit in the valves of the aorta of a man aged 26, with rupture at the point marked by
*; there was also congenital union at the point (marked by f) of two of the valves.  The case is described
in the Reports of the Pathological Society, vol. iv. p. 100.

senting the fissured appearance of true rents, to  distinguish them from
the perforations resulting from atrophy, it is also susceptible of cure by
a reconversion into fibrous  tissue.
  Fibrous and ossific deposits,  which we have seen to be not uncommon
on the surface of the heart, are  very rarely met with under the  endo-
cardium except in connection with the valves. To the former, which are
often rather hypertrophied states of the normal fibrous tissue, we must
attribute many of the lesions already adverted  to,  consisting of malpo-
sition, eversion,  and inversion,  of the valves; the fibro-cartilaginous and

                                Fig. 145.
  Aortic valves of a man set. 47, rendered perfectly rigid by calcareous deposit. The patient was affected with
granular kidneys and cirrhosis of the liver.

cartilaginous induration spoken  of by Bouillaud  and others, may be
referred to this head.   The  calcareous or ossific deposit is a distinct new
formation.   It presents the  most varied forms, which may be compared
to the fantastic shapes assumed by molten lead when poured into water;
sometimes resembling stalactitic projections, at others forming irregular
rounded eminences, stretching across the orifices of the heart like rigid 
           DISEASES OF THE VALVES OF THE HEART.       323

bars, maintaining the valves in a state of permanent erection or disten-
sion, and inducing symptoms both of obstruction  and of regurgitation.
A single flap or  curtain may be rendered rigid while the others retain
their natural pliability: the valves of one side of the heart may be more
or less intimately united by the morbid growth ; but whatever forms
the lesion may assume, it is scarcely possible to occur without a perma-
nent narrowing of the orifice.  Kreissig and Bouillaud refer the disease
uniformly to inflammatory  action; and Dr. Watson is also of opinion
that it is somehow certainly connected with inflammation of the internal
lining of the heart.  But we must not  overlook the important fact of
the natural tendency existing  in  the arterial system generally, as well
as in other tissues of the body, to induration and ossification with ad-
vancing life;  and though we are far from looking upon  ossification of
the valves  as a  physiological process, we are justified by analogy, as
well as by the positive fact of the very chronic nature of these deposits,
in looking upon them in many cases  as of a non-inflammatory character
allied to the general species of degenerative disease.   Lobstein's view,
that these  concretions are intimately allied to the  gouty diathesis, is one
that must not be lost sight of; though he perhaps erred in restricting
them too closely to  this particular constitution.  Although we have used
the term ossification in accordance with common usage, to designate the
change under consideration, it is  important not to confound the process
with the one in which genuine bone is formed : cretification or calcareous
deposition  M*ould be a more appropriate term, for there is no resem-

                               Fig. 146.
 Ossification of the aortic valves; a thick calcareous deposit has taken place between the valvular mem-
branes, interposing a rigid and almost imperforate diaphragm between the cavity of the heart and the
vessel.
                       a. Upper surface, b. Under surface.
                     From St. George's Hospital Museum, E 18.

blance between the morbid product and true bone.  It consists essentially
of carbonate and phosphate of lime deposited in irregular,  amorphous
nodules, and resembling more  a chemical precipitation than  an organic
formation.  The material is more or  less friable, and is  connected by
the remains of the fibroid, or atheromatous matter, in which it formed.
It is soluble in the mineral  acids.  It is often difficult, when  we meet
with an advanced case,  to determine in what part the deposit first takes
place ;  whether beneath or on the surface of the lining membrane.  The
opinions of different  writers differ with regard to this  question.   The
most  common form  undoubtedly is the conversion of  atheromatous  or
fibroid deposit underneath the lining membrane analogous to  what we 
324       DISEASES OF THE VALVES OF THE HEART.

see occurring in the arteries ;  and as  this enlarges, the membrane be-
comes softened and  destroyed, and  the ossification then  projects free
into the sanguineous current.  It is not the mere increase of the deposit
which determines this solution, but an element in producing this result
is undoubtedly a morbid affection of the lining membrane itself, in which,
even in early stages of degeneration  of the  subjacent  tissue, we have
observed disintegrating processes, of which we shall speak further when
discussing the diseased conditions of the arterial  system.   One of the
most  extreme cases of narrowing  of the aortic orifice in an adult, that
we have met with, is the one delineated (Fig. 146), in which the continuity
of the lining membrane  was preserved entire over the ossific deposit.
The passage was contracted to the size of a pea.
  Rokitansky is of opinion that we may establish three  varieties of con-
cretions: the first is similar to the form just described,  but he terms it
exclusively ossification of the fibroid tissue developed in the interior of
the valve by inflammation;  he calls  the second  form, ossification  of
endocardial deposit, on the surface of the valve;  and he describes the
third as an osseous concretion in a stalactitic form, or as a  rough calca-
reous agglomeration, which constitutes a metamorphosis of the  vegeta-
tions  on the  valve.   These stalactitic osseous masses, he says, occasion
and promote the continued formation  of new vegetations;  and are con-
sequently very commonly surrounded by them.   Calcareous concretions
and morbid affections of the valves generally follow  the law which de-
termines the great prevalence of disease on the left side of the heart  as
compared with the right side:  ossification, especially, is so rare on the
right side that it has been denied altogether.   Hasse, however, has seen
partial  ossification of the pulmonary artery; and Dr.  Hodgkins1  also
reports a case of thickening and bony  deposit in  the pulmonary artery
close  to the valves.
  A condition of the valves remains to be pointed out, which was first
demonstrated by Dr. Thurnam;2 it  consists in a saccular dilatation,
which he attributes to a  gradual  distension, and hence  terms aneurism
of the valves.  It  is met with in the aortic and tricuspid, but most
commonly in the mitral valves.  Dr. Peacock3 has also recorded a simi-
lar  affection  of the valve  of the foramen ovale.  We find that the dila-
tation may exist without  any lesion  of continuity in  the  tissue; the
endocardial lining being traceable throughout  the pouch.   This, in the
case of the mitral valve, projects into the left auricle, and is often filled
with a clot of blood.   This form would correspond with what is termed
true aneurism of  the arteries.  A second variety is that resulting from
inflammation of the valves, by which a solution of continuity is effected
in the lining membrane.   Rokitansky states that he has found it occur
either as a fissure brought on by softening of the membrane, or by dis-
integration of the subjacent tissue ; or again, by ulceration of the endo-
cardium resulting from an abscess proceeding from  the lowest  part  of
the valve.   Thus, he continues, when  the valve has been perforated  to

  1 Catalogue of Guy's Hospital Museum.  No. 1403.
  2 Medico-Chirurgical Transactions, vol.  xix. p. 162, vol. xxi. p. 187, vol. xxiii. p. 323.
  3 Pathological Reports, 1850-51, p. 80.  Several instances of valvular aneurism are
detailed in the same volume, pp. 72, 77, and 78. 
          DISEASES OF  THE VALVES  OF THE  HEART.        325

a greater or less extent, the blood which impinges on  it penetrates into
its parenchyma and causes more or less extensive infiltration.  We give
this explanation in deference  to  the authority from whom it emanates;
Fig. 147.
 Aneurism of the mitral valve; a pouch projecting into the cavity of tbe left auricle about three-quarters
of an inch high, and half an inch wide. It has burst by an irregular rent on one side.  St. Bartholomew's
Museum, 12th Series, 62.

we cannot, however, deny that the evidence in favor of the prevailing
cause of valvular aneurism being dilatation of the  coats, rather than a
rupture of the membrane, appears to us to be the stronger.  The form
of the aneurism is  almost invariably  that of a circular cup, varying in
size from a pea to a walnut; nor does  it appear from the  cases which
we have  analyzed, that the affection  so uniformly terminates in lacera-
tion as Rokitansky affirms.
  We have for the sake of convenience reviewed the diseases affecting
the individual tissues  of the  heart  separately;  but before proceeding
further, it  may be well to dwell for a brief space upon their complica-
tions with  one another, and  with  morbid  phenomena in other vital
organs.  The fact of the intimate connection between a rheumatic dia-
thesis and  pericardial  and endocardial inflammation, has  already been
alluded to.  We cannot show the relation better  than by extracting
from Dr. Latham's  Lectures  on Clinical Medicine, the statistical facts
illustrative of the subject, to which  that  author's large experience had
led:  The number of cases of acute rheumatism which occurred to him
were 136, out of which  90 presented  symptoms of heart  disease; of
these 63 were diagnosed as affecting  the endocardium alone, 7 the peri-
cardium alone, and 11 both endo and pericardium.  ^ Out of the total
number only three proved fatal;  they were men, and in them both sur-
faces of  the heart were inflamed. In all cases of  heart disease other
organs will be liable to be affected  in  proportion,  as different parts of
the circulation are more immediately involved.   While disorders  of  the
arterial system more directly induce deranged  action  in the brain,  the
spleen,  and the kidneys; the lungs,  the  liver, and  the  chylopoietic
viscera  suffer  chiefly  in derangements  acting  immediately  upon  the
venous system.   As a matter of  course this distinction is one that can-
not be always demonstrated, as in an advanced stage of cardiac disease
of either side of the heart, or of any one portion, the entire circulation
must of necessity be impaired.   On  the  arterial side we find that more
particularly a  complication between  granular degeneration of the kid- 
326
CYANOSIS.
neys with heart disease obtains; thus, Dr. Bright has shown that in a
hundred cases of this  disease, the heart presented lesions  in  at least
thirty-five, a number which would probably have been increased if the
condition of this organ had been noted with  the same care in all.   This
proportion has been confirmed by the researches of Dr.  Taylor.1  The
secondary effects produced by the  dislocation  of  lymph from  the left
side of the heart, in the brain, the spleen, and the kidneys, by blocking
up the arteries, and  thus  altering the nutrition of the  parts to  which
they lead, we have already alluded  to.  The influence of valvular dis-
ease in producing hypertrophy is a point of great importance, and  its
connection with  pericardial  and  endocardial  inflammation has  been
especially dwelt upon by Bouillaud.  Its influence in affecting the cir-
culation in the brain is undeniable, but it is probable that the frequency
with which it induces hemorrhage, either in the lungs or in the brain,
has been overrated.  In many of. the cases  on record of cerebral apo-
plexy connected with cardiac  hypertrophy, the result was  more  justly
attributable to the  coincident arterial  disease  than  to the increased
impulse of an enlarged heart.  Pulmonary apoplexy appears rather to
be connected with the obstructions to its circulation presented by mitral
disease than by an hypertrophic  condition of the heart.  With regard
to the liver, we find that in fatty degeneration of the heart it commonly
presents a similar concomitant affection, not to speak of  the congestion
to which it is almost invariably subject when the return of the blood to
the heart is in  any way impeded; more than  any other organ it is
enabled by its size and elasticity, as well as by its functions, to serve
as a  species of reservoir where  the balance of the circulation  is dis-
turbed,  a reservoir  which may be frequently overcharged, but from
which we are more able to draw off the surplus without too  much debi-
litating the system  than from any other organ.   Congestions of the
venous system of the entire  body are frequent in cardiac  disease, and
manifest themselves by lividity of the cutaneous surface and  of the
mucous membranes: and the secondary effects of stasis are shown in
these  tissues by oedema and  hemorrhage, while in the  serous cavities
they are evidenced by an effusion  of serum—one form of passive dropsy.
Of the latter, we find the peritoneum chiefly prone  to suffer, a circum-
stance which we may fairly attribute to the absence of any compression,
such as we find normally exerted upon all the other serous sacs.   With
these  few remarks on a subject which belongs rather  to the domain of
the history of disease  than the records of morbid anatomy, we pass to
the consideration of  the conditions with which cyanosis  is found asso-
ciated.

                            CYANOSIS.

   Cyanosis is a term applied  to a livid, purplish hue of the cutaneous
surface, which is found to accompany some  organic and congenital dis-
turbances in the central organ  of the circulation, of a more intense
character than the slaty tinge which the complexion is very frequently

                1 Medico-Chirurg. Trans., vol. xxviii. p. 536. 
CYANOSIS.
327
observed to assume in acquired disease of the heart.  It was formerly
attributed, on theoretical grounds,  solely to one lesion, a permanent
patency of the foramen ovale;  and although this occasionally gives rise
to the affection,  by allowing  an intermixture between the blood of the
two sides of the organ, and causing it to be circulated through the sys-
tem, without having undergone the purifying process to which it ought
to be subjected in the lungs; it is satisfactorily demonstrated, both that
the foramen ovale may remain open, to a considerable degree, through-
out life, without inducing any serious  disturbance of the circulation;
and on  the other hand, that various other irregularities in the  heart
may give rise to cyanosis.   Bizot found the foramen ovale more or less
open in forty-four out of 155 subjects, in none of whom there was a
trace of the morbus cceruleus.  Two openings  have been found in the
ventricular septum, and no cyanosis resulted; a marked instance of this
kind in  an individual who attained to the age of eight years, was brought
before the  Pathological Society, by Dr. Quain, in 1847.  In such a case,
we are justified in assuming that the forces of the two sides of the  heart
are so exactly balanced as not to disturb the circulation ; and the orifice
of the  pulmonary and systemic  arteries  being  patent, the contents of
each side pass into their proper channel.   That this is a prevailing law
for many cases of cyanosis, is shown by the fact that it frequently does
not manifest itself unless there is some  further cause for derangement of
the circulation, such as  a bronchitic affection,  to which, it  may be  re-
marked, cyanotic individuals are peculiarly subject.
   The lesion that appears to be most constantly associated with cyanosis,
and which  may  be regarded  as its  primary cause, is  a contracted state
of the pulmonary artery ; and, as in that case more than usual pressure
will continue to  be exerted upon the foramen ovale, this will necessarily
remain  patulous, and allow a passage of blood from the right to the left
auricle; in such a case it may be almost looked upon as a safety valve.
Gintrac1 has analyzed fifty cases of cyanosis, and among them found
obstruction at the pulmonic orifice in twenty-six;  the proportion is stated
to be still greater by other authors.  But  the blue disease is not neces-
sarily the result of an admixture of the contents  of the two sides of the
heart;  anything causing an arrest  in the return of the venous blood to
the heart  is sufficient to give rise to it.   In  the  first volume of the
Pathological Reports (1847,  p. 25), we find a case of marked cyanosis,
recorded by Mr. Ebenezer Smith, in which the foramen ovale was per-
fectly closed, and had  evidently been so for some time  before birth;
there was  no inter-ventricular communication, the pulmonary artery was
large, but  the left auriculo-ventricular opening was  small, and the left
ventricle was almost obliterated; the walls were  contracted on a  small
cavity at the base, not exceeding two or three  lines in diameter.   The
aortic opening was also very  small,  being about two lines wide; and the
arch was much smaller than the pulmonary artery.   The mitral  valve
was altogether defective in structure, consisting only of two small bands
without  any curtains.   Here, then, there was an evident arrest at the
aortic orifice, which reacted upon the pulmonary circulation, and through
1 Sur la Cyanose, Paris, 1824. 
328
CYANOSIS.
that upon the systemic capillaries.   The lungs were  too much charged
with blood to perform  the duty of aeration effectually, and a congested
or cyanotic condition of the surface resulted.   Similar instances of the
cyanosis being due to  contraction at the aortic orifices are on record,
but it may also happen without  this symptom.   Dr. G. A. Rees  pre-
sented the heart of a child  to  the Pathological Society, in  1847,1 in
which the aortic was much smaller than the pulmonic orifice, and there
was no cyanosis.   The ductus arteriosus  continuing  open, allowed the
blood to pass from the pulmonic artery, directly to the aorta, so that the
blood distributed to the lower part of the body  must have been almost
entirely venous.
  One of the most palpable instances that has occurred to us, proving
how little we are able to account for cyanosis theoretically, was that of
a child that lived to  the age  of nine weeks,  and whose heart, after
death, was found  to present  no auriculo-ventricular opening,  on the
right  side,  while there  was scarcely any inter-ventricular septum at all.
Here there had been no cyanosis, although  a thorough intermixture of
the venous and arterial blood must have necessarily taken place.
  Bouillaud2 is of opinion that the communication between  the two sides
of the heart, and the consequent admixture of the arterial and venous
blood, has, comparatively, little  to do with the purple hue of the com-
plexion, which he considers to result, mainly, from the coincident obstacle
offered to the circulation by a malformation of the arterial orifices of the
heart.  The numerous  cases on record,  in which not only the foramen
ovale was patulous, but in which there was further evidence of the actual
passage of the blood, directly from one side of  the heart  to the other,
shows, as Dr. Peacock3 has remarked, that there is a want of just rela-
tion between the amount of venous blood entering the general circulation
and the degree of cyanosis.   The lesions that are found in connection
with  this symptom, consequently, require  to be carefully analyzed,
before we can determine the exact part that each bears in its produc-
tion.  They may shortly be enumerated as a patulous condition  of the
foramen ovale, from the valve not entirely covering the orifice; with this
a defective involution of the  Eustachian valve is  commonly combined;
permanent patency of the ductus arteriosus;  contraction of the arterial
orifices;  a deficiency in  the intra-ventricular septum;  and the malfor-
mation in which the aorta springs from both ventricles.  The effect upon
the heart itself in these cases is to produce hypertrophy and dilatation,
more  especially of the right ventricle.
  Cyanosis is a disease which generally shows itself  at or immediately
after  birth.  The circumstance that it occasionally makes its appearance
later  in life, has induced  Meckel and  Abernethy to assume that the
foramen ovale may reopen, an hypothesis which is unnecessary, as we
now know how frequently a eommunication exists between the auricles,
without producing cyanosis, and  that this lesion  may, under certain cir-
cumstances, as in diseased states of the lungs, induce a disturbance  in

                   1 Reports, 1847-48, p. 203.
                   2 Traite" Clinique, &c. vol. ii. 690, seq.
                   8 Pathol. Reports, 1848, p. 202. 
CYANOSIS.
329
the balance of the circulation, sufficient to force  the blood through the
auricular septum.
  Stress has been laid  by several authors upon  the circumstance that
the fingers of cyanotic individuals are found clubbed.  We only advert
to it, to mention that it is by no means diagnostic of this form of heart-
disease, or, in fact, of any distinct malady.  A more important  point,
is an observation that Rokitansky concludes his remarks on the subject
with; to the effect that cyanosis is incompatible with tuberculosis, against
which he states that  it offers a complete  protection.  We do not deny
that this is the  prevailing  rule,  yet it is not as absolute as the author
quoted asserts.   In the Report  of the Pathological Society for  1848
(p. 200), we  find a case presented by Dr. Peacock, which refutes the
universality  of  the law.   There  the  post-mortem  examination of the
individual, a young man, aged twenty, established  the following  facts:
The right lung was extensively permeated by tubercle, and towards the
apex exhibited several small cavities; the  left lung contained much solid
tubercle; the heart was hypertrophic; the pulmonary artery exhibited
a complete diaphragm, formed by adhesion of the valves, leaving  only a
small triangular aperture; the foramen ovale was very widely patulous.
There had been cyanosis during  life,  but  not in  a very marked degree.
   Besides the malformations of which we have just spoken, we find other
congenital affections  of the central organ of the circulation which are
compatible with life,  to which we must briefly turn our attention.  Those
hitherto mentioned have all been instances of an arrest of development;
an excess of development  is rarely met with in the heart, except as an
acquired condition.   In all the  varieties  of congenital arrest, we see  a
tendency to  return to the primitive type of a single pulsating cavity; in
itself a sufficient proof, if any be needed, that the organ is not  a com-
bination of two originally distinct hearts,  but that it arrives at its perfect
state by a subdivision of a single cavity. As the growth proceeds through
its different  stages, from the simplest condition of  the pulsating vessel,
 to the complex mechanism of the perfect heart, we see close resemblances
 between temporary conditions of the human heart, to permanent  condi-
 tions of the heart in the lower animals.  Thus, the type of the piscine
 heart is presented in those cases where, in a man, we only find a single
 auricle and ventricle.  Here, an aorta proceeds from  the latter, from
 which the lungs are  nourished by the ductus arteriosus, while both venae
 cavse and pulmonary veins discharge into  the  auricle.   Children  are
 known to live several months with this defect, without necessarily pre-
 senting any marked symptoms of deranged circulation.  In the next
 degree  we find an analogy with the  amphibious heart, the septum ven-
 triculorum being absent, or imperfectly developed, while  there are two
 auricular  cavities.   A  defect in the ventricular septum is commonly
 associated with that  malformation of the aorta, in which it communicates
 with either side of the heart, the pulmonary artery being displaced, or
 altogether absent.   The defect in  the inter-ventricular septum may
 present various degrees, from a mere rudiment at the  apex, to a full
 development of the partition, with the exception of a minute orifice near
 the base.                                                   .
    A very curious anomaly, a  genuine  freak  of  nature, consists in a 
330
CYANOSIS.
transposition of the pulmonary artery and the aorta, the former arising
from the right, the latter from the  left ventricle; an accident which is
attributable to an abnormal division being effected in the arterial bulb,
at the  period of intra-uterine life, when  the branchial arches are being
converted into the arteries of the upper  extremities  and head, and into
the pulmonary arteries.   Again, we are  informed by Tommasini1 of an
instance occurring in a female, aged twenty-five,  who had not been
cyanotic until the last days of her  life, and had enjoyed general good
health, in whom a circular orifice in the parietes of the left ventricle,
established a permanent and free communication between this cavity and
the pulmonary artery.  Other varieties, in the configuration of the heart
and the distribution of the vessels, are recorded in the works of Meckel
and Geoffroy  St. Hilaire, which contain a full account of everything
relating to the subject.   We have adverted to those most frequently met
with.   The valves of the heart, in these various malformations, generally
present  some alteration,  being thickened,  corrugated,  or otherwise
changed from their normal constitution.   An  alteration in the caliber
and form of the parietes  of the  heart is not less frequently  found to
accompany the arrest of development spoken of; hypertrophy of one or
more parts is  a very common accompaniment.   The valves frequently
present a congenital arrest, or excess of development,  sometimes inde-
pendent of any other malformation of the heart, but commonly associated
with further lesions.  In reference to the arterial orifices, Dr. Peacock2
observes that  the aperture may be defended by a single valve, protruded
forwards in the course of the circulation, a condition seen chiefly in  the
pulmonic artery, or only two valves appear, owing to two having united
at their edges; or again, there may be  two  fully developed semilunar
valves, with an abortive valve intervening.  Of forty-one cases of defect
in the number of the valves, Dr. Peacock found the malformation at  the
pulmonic, in nine; in thirty-two, at the aortic orifice.   Of fifty cases of
malformation of the semilunar  valves examined by the same observer,
nine were examples of excessive development.   Of these, he found that
eight were cases in which the  pulmonic  valves  were in excess, and in
one only was there more than the natural number of valves at the aortic
orifice.   " In  some cases, the excess in the number of valves  seems to be
due to  the division of one  of  them into  two, such divided valves being
smaller in size than the others.   In others, there are  three valves of
nearly equal size, with a smaller supplementary valve interposed between
two of them.  Occasionally, the aperture is provided with four valves,
gradually decreasing in size, and in the  other cases there may be four
valves of nearly  equal size, and natural form."   Similar defects are met
with in  the tricuspid and mitral valve, but more rarely.

                1 Quoted by Bouillaud, vol. ii. p. 674, 1841.
                2 Report of the Pathol. Soc, 1852, p. 292. 
CHAPTER  XXII.
                      THE BLOODVESSELS.

   In estimating the morbid lesions occurring in the bloodvessels, we
must bear in mind that they are mere conduits for  the fluid, by which
nutrition and the metamorphoses  of the  tissues  are effected, and  that
they therefore bear a very different relation to disease fr»m that  pre-
sented by the central organ of the circulation, or by the blood itself.
It is the more necessary to urge this,  as so much that has been written
with regard to the  main  pathological condition, which we are  able  to
excite and observe in the  living tissues, inflammation, appears to have
originated in the view that the coats of the bloodvessels were the most
essential elements in the production and maintenance of the  phlogistic
process.  This is owing to the experiments having been necessarily of a
character to irritate the vessels from without, and produce rather a phy-
sical than a  vital effect.   We cannot in this way imitate  those consti-
tutional  causes  of inflammation to which we must  generally attribute
its production, and in which it is impossible not to recognize the state of
the blood as constituting the first element in the production of the phe-
nomena in question.   These remarks apply  more  particularly to the
capillaries, but we shall have occasion to see that they also bear upon
many of the symptoms met with in the  larger vessels.  The difference
in the direction of the current,  in  the composition of the  blood, in the
velocity and force of the circulation, and in the structure of their coats,
are points that must not be  overlooked  in forming  an estimate of the
diseases of the two great classes of vessels, the arteries and veins.  The
manifestations  of disease  in its  primary and secondary form are essen-
tially different in the two, as we find their physiological and anatomical
relations to be  widely apart.  The arteries exhibit between their lining
membrane and cellular coat a  dense  fibrous  layer, which  contains no
vessels, and  therefore removes  the vasa vasorum, which ramify in the
cellular coat, much further from the lining membrane than is the  case
in the veins, nor can any vessels be  detected on the lining coat, or between
it and the middle tunic. To this circumstance, and not to any difference
in the supply of bloodvessels,  we must  attribute the fact that, while
irritation of the lining membrane of the veins rapidly and easily pro-
duces inflammatory  reaction, it is almost  impossible to produce such
effects in the arterial lining membrane.   Hasse1 is of opinion that the
latter, in both instances, at first merely yields to the alternations of en-
1 Pathological Anatomy, Syd. Soc. Ed. p. 11. 
332
THE ARTERIES.
dosmosis and exosmosis, and does not suffer any organic change until a
later period.  In arguing on the effects of inflammation in the arteries,
we must not forget that  the laws of exosmosis and  endosmosis apply
chiefly to fluids occupying the opposite side of the same membrane.  In
the arteries, we find deposits chiefly between the middle and lining coat,
and  of a character to forbid our believing that  they can be derived
directly  from the current circulating in the  vessel.  Here,  then, the
exudation from the vasa vasorum has traversed the dense fibrous  coat;
and  there appears to be no reason for refusing to admit that, eventually,
the lining coat may be involved in a  similar process.   Without entering
further into these considerations, we may observe that we are unable
to join those who  look upon the reddening of  the  internal  coat accom-
panying its thickened condition, which  cannot  be attributed to  post-
mortem action, to  mere imbibition; but that there  must be some change
in the nutrition of the parts analogous to inflammation in other parts.
            0

                         THE ARTERIES.

   To proceed systematically, we shall first examine the morbid conditions
of the arteries.
   We have  seen that it is a subject of debate whether the middle and
lining coats of the arteries are subject to inflammation; as  they possess
no bloodvessels of their own, we can scarcely assume  them to present
symptoms of the primary phenomena of inflammation;  but that  they
may be secondarily involved in inflammatory affections proceeding  from
the  cellular sheath, cannot  be  doubted.   A  most interesting case of
acute arteritis, in a previously  healthy individual, a gentleman,  aged
twenty-nine, is recorded by Dr.  Romberg,1 where sudden  pain mani-
fested itself in the right femoral artery, affecting the distribution of the
artery in the limb, then  mounting up to the  aorta,  passed to the left
iliac and its branches.  Endocarditis followed, and inflammation of the
arteries in the' left upper extremity;  the  entire illness lasted from the
20th October, 1844, to the 5th December, of the same year.   The post
mortem was performed by Professor Froriep  thirty hours  after death,
and  the following  appearances were found in the  arteries:  A pale red,
firm  clot was discovered in the abdominal aorta, close to its division;  it
blocked up the artery, and adhered closely to its lining membrane, which
was  smooth  and not reddened.   This coagulum extended into the two
iliac arteries, gradually became thinner, and terminated in a point.  At
the point at which the left external iliac is given off, there was an equally
firm  but  lighter-colored exudation.  The left external iliac,  as far as
Poupart's ligament, was filled up with a  thinner  coagulum containing
much cruor; it  could be  easily detached from the lining membrane,
which was thickened, reddened, and friable, and could be easily detached
from the fibrous  coat.  The  middle and external coats were also thicker
and  more friable than in the normal state.   Between the  membranes

  1 Manual of Nervous Diseases, Sydenham Society's Edition, vol. ii. p. 238. Since the
above was written, a very similar case has occurred under the care of Dr. Sibsuii, at St.
Mary's Hospital. 
THE ARTERIES.
333
there was an exudation of lymph, which was also distinctly perceptible
in the cellular tissue surrounding the arteries.   The latter was particu-
larly inflamed under Poupart's ligament, and the neighboring lymphatic
glands were tumefied and reddened.  The crural artery contained a firm
coagulum at the point  at which the profunda is given off, which could
only be detached with difficulty from the dark red lining membrane, and
which extended into the profunda.   Further on, the  crural artery was
filled with a grumous coagulum, and the lining membrane was villous,
rough, and much reddened.  Then  came a free spot, but at the part
where it passes through the adductor, it was again  closed by a firm  co-
agulum, and the corresponding lining  membrane was much reddened,
softened, and pulpy.   The tissues here were in a state of gangrene, the
right internal iliac was unaffected.   A firm, pale clot, strongly adher-
ing to the lining coat,  was discovered in the external iliac close to the
point at which it is given off by the common iliac artery.  The crural
artery of the same side was narrow and contracted;  the lining mem-
brane thrown into folds, containing a solid plug at  the  site of the pro-
funda;   the lining and other  membranes  being much reddened  and
thickened.  A similar coagulum was found  in the left branchial artery
at its division, extending into the  radial  and ulnar.  The  heart was
hypertrophic, and a roundish excrescence  was found attached to the
mitral valve, which was proved by Professor Miiller to consist of fibroid
tissue, and to be subjacent to the endocardium.  The same author con-
firmed the fact that a thin layer of  plastic exudation matter was found
on the arterial coagula, which at many points  also  invested  the lining
membrane.   For further particulars, and for the author's views on the
case, we must refer the reader to Dr. Romberg's work.   We have ex-
tracted so much of it as refers to the subject  under consideration, and
because it offers a combination of  all  those  phenomena which writers
attribute to acute  arteritis, and which are found in the inflammations of
other parts  of the system as a result of a peculiar derangement of the
circulating fluid.  In this respect, the case quoted might form an appro-
priate text for the development of  the whole  theory of the phlogistic
process.  Bizot1 describes as  the  result of acute inflammation of the
arteries, an albuminous exudation of greater  or less thickness, of the
consistency of jelly, transparent,  smooth,  sometimes rose-colored, at
others colorless, covering the  lining membrane.  It  is occasionally so
transparent as to escape attention unless very carefully examined.  It
occurs in patches, solitary or numerous, and diminishes the  caliber of
the vessel;  in one case, Bizot saw it entirely plugging up the  anterior
tibial artery.  In the aorta, this exudation is formed mostly at the orifice
of the arteries arising from the arch, at the mouth of the cceliac, mesen-
teric, and renal  arteries, and at its posterior surface,  so as to block  up
the mouths  of the  intercostal arteries.  An  instance of acute inflamma-
tion of the  aorta  is recorded  by Mr. Hodgson;2 it is to  this effect: A
man was seized with violent pneumonia, which proved fatal in five days;
the cadaveric inspection exhibited all the thoracic viscera in the  highest

             1 Me'moires de la Socie'te' d'Observation, vol. i. p. 311.
             2 On the Arteries, p. 5. 
334
THE ARTERIES.
degree of acute inflammation; the aorta was also involved; its internal
coat being of a deep red  color, and a  considerable  portion  of lymph
being effused into the cavity.   The effused lymph was very intimately

               Fig. 148.                             Fig. 149.
           Plastic deposits in aorta.             Plastic plugs occluding the axillary artery.

connected with the internal coat of the  vessel, and a plug of it had ex-
tended into the left subclavian artery, and nearly obliterated the cavity
of that vessel.  In reference to this subject, some experiments performed
by Gendrin1 are of considerable importance in demonstrating the capa-
bility of the coats of the artery giving  rise to inflammatory exudation
in the strict sense of the word.  He found that  on injecting an irritant
substance into a portion of an  artery included between two  ligatures,
and deprived of blood, a deposit of coagulable lymph took place, which
arrested the internal coat, and at last formed a plug filling up  the
channel.   The lining membrane at first was only slightly discolored,
and through it a network of injected capillaries  might be distinguished
on the adherent surface  of this tunic to the  middle coat.   Whe/i  the
K
1 Histoire Anatomique des Inflammations, vol. ii. p. 13. 
THE ARTERIES.
335
inflammation had advanced, this was no longer seen, the external coat
having become pulpy, rugous, and dull.  The suppuration that followed
did always coincide with ulceration of the inner coat; the pus, however,
was not  necessarily deposited in the vessel, but infiltrated into the cel-
lular sheath, forming small abscesses.  We may reasonably conclude that
in arteritis the morbid  products are  derived from  the vasa vasorum as
well as from the contained blood.   To sum up: The symptoms of acute
inflammation of the arteries are more or less extensive, reddening, soft-
ening, thickening, and  detachment of the  lining coat which exhibits an
opaque,  plicated condition; the middle coat becomes hypertrophied and
friable, and in the external coat we find distinct signs of congestion and
exudation.   Within the vessel, a coagulation of fibrin and the deposit ot
coagulable lymph from the  blood  is seen, and as secondary effects we
have to  deal with  ulceration, laceration of the coats, hemorrhage, and
gangrene of the distal parts of the system.
 = From the time of J.  P. Frank,1 who  first drew attention  to the sub-
ject of arterial inflammation, to the most recent periods, various patho-
logical conditions have been attributed to it; the acute forms have been
repeatedly asserted to be the cause  of trismus  neonatorum, a disease
which at present is one of very rare occurrence among  ourselves.  Dr.
West denies this cause, but Dr. Collis,2  and recently Dr. Scholler3 satis-
fied themselves of  its real existence.  The latter  found inflammation ot
the umbilical arteries in fifteen out of eighteen cases of  trismus neona-
torum.   There was tumefaction of the umbilicus,  reddening and con-
 gestion  on the external surface; the channel contained pus, and  the
 lining membrane was eroded and invested with an albuminous exudation.
 Dr, Scholler has carefully examined these parts  in all other new-born
 children who died shortly after birth, and has never succeeded in  dis-
 covering similar lesions.  It does not appear that traumatic tetanus in
 the adult, to which we may compare trismus neonatorum, is accompanied
 by similar  lesions.                                               .
    The formation of a coagulum in  the  artery is a well-known physiolo-
 gical effect of the laceration by mechanical or other means of the lining
 membrane,  and the atrophy or gangrene of  the part nourished by the
 artery is an illustration of  the  effects  following similar obliteration of
 the channel from disease.   We have alluded to  the cerebral affections
 resulting from an arrest in the arterial circulation; senile  gangrene is
 another morbid condition which has been  ascribed, by Dupuytren and
  Cruveilhier, to arteritis.  In this there is a marked distinction between
  inflammation of the two  sets of vessels; that phlebitis induces secondary
  deposits and oedema, while these occurrences are not  met with  in arte-
  ritis.   It is even doubted whether  the  latter ever gives  rise to suppura-
  tion' but, independently of the cases  of suppuration in the  umbilical
  artery  quoted from Dr.  Scholler, Andral and Hodgson's4 authority5 de-

    ' De curandis Hominum Morbis, vol. ii. p. 363.
    2 Dublin Hospital Reports, vol. i. p. 285.
    3 Neue Zeitschrift fur Geburtskunde, herausgegeben von Busch, d Outrepont una tut-
  gen, vol. v. p. 477.
    ♦Anat. Pathologique, torn. n. p. <J<9.
    & On the Arteries, p. 10. 
336
THE ARTERIES.
termine the question affirmatively, for these authors state  that actual
idiopathic suppuration does occur in the artery.
  The spontaneous coagulation of the blood in the arteries is not, how-
ever, the result of inflammatory action only.  It may occur in conse-
quence of a low ataxic condition, which does not permit the vital powers
to resist the chemical tendencies that  normally ought not to come into
play until after death.  This spontaneous coagulation is especially met
with in the pulmonary arteries, where  the occurrence of the inflamma-
tory symptoms has, as yet, not been met with. Mr. Paget,1 in describing
a case of the kind, says, that nearly all the branches beyond the  primary
divisions of the pulmonary artery contained clots of blood, which, from
a comparison with  those found in tied arteries, he judged to be from
three to ten days old.  The clots did not commonly extend continuously
from any large branch of the pulmonary artery  into many of its succes-
sively  subordinate  divisions, no branch of the  pulmonary  artery less
than half a line in diameter appeared to contain any of these clots, and
the pulmonary veins were healthy and empty.  The  case under consid-
eration proves that a large portion of the pulmonary  circulation may be
arrested for a considerable period without immediate danger to life, a
circumstance explained by Mr. Paget,  by assuming a retardation of the
circulation in the  systemic vessels, in  order to  allow the quantity tra-
versing them in a given time to be equal to  the  reduced quantity which
in the same time traverses the lungs.  In order to keep up the necessary
balance, the systemic circulation is as much less rapid than the  remain-
ing pulmonary circulation is  more rapid than  before the obstruction
took place.
  The formation of a coagulum in the  artery does not necessarily block
up  the entire passage, but may leave a central  opening by which  the
circulation yet continues to be carried  on.  But after the formation of
the clot,  it in its turn  undergoes  various changes; it may  become
absorbed, or it softens or breaks up into granular matter, and is carried
into the  capillary circulation, or it  is capable of organization, and  we
then find in it a network of fine bloodvessels.   The last point serves to
elucidate the observations of the passage of an artery occasionally seen
in old coagula formed after the application  of a ligature.  Lobstein, as
we are informed by Hasse, met with an arterial vessel of the caliber of
the stylo-mastoid artery running lengthwise through the femoral artery
obliterated two years previously  by tying.   Blandin and Barth have
met with  analogous instances, to which may be added those cases in
which, after the complete obliteration  of arteries by ligature, new ves-
sels  have been found  shooting  from  their  extremities.  The  general
infection of the  blood from breaking  up of arterial coagula, is a very
rare occurrence; a circumstance which establishes a marked  distinction
between  arterial  and venous  disease; it is  referred by Rokitansky to
the greater susceptibility of the arterial blood for taking up inflamma-
tory products, which speedily give rise to coagulation and obturation of
the vessel, and to  the circumstance that  their reaction in the  arterial

  1 See Mr. Paget on obstructions in the Pulmonary Arteries, Medico-Chirurgical Trans-
act., vol. xxviii. p. 533. 
CHRONIC  ARTERITIS.
337
current,  being exhausted towards  the  capillaries  in  ordinary cases,
hinders the general infection of the blood beyond the limits of those
vessels.

                      CHRONIC ARTERITIS.

   With regard to chronic arteritis, the opinions of writers are yet more
divided than in reference to the acute form.   The same difficulties in
determining the relation of cause or effect in this subject has been felt
by most of the writers on the subject, and have not yet met their  com-
plete solution.  The older authors attributed the appearances of chronic
arteritis to syphilitic taint or mercurial poisoning; some of the more
recent, among whom we  may mention Corvisart,1 have held a similar
opinion, and Hodgson2 supports  it on the ground that he has  observed
aneurism,  and those  organic  alterations which  generally attend the
formation  of  aneurism, to prevail in subjects  that have suffered from
venereal disease, and who have taken large quantities of mercury.
   While the majority of  authors are of opinion that fibrinous depos.it,
atheroma, ulceration, ossification, and aneurism  are the result of a chro-
nic inflammatory process, Hasse absolutely denies its primary existence,
and only admits its occasional occurrence as a secondary effect of the
degenerative processes alluded to.  On the other hand, Rokitansky looks
upon chronic inflammation of the arteries as an essential constituent of
morbid deposits on the inner coats of the vessel, and its metamorphoses,
but is of opinion that it is primarily manifested in the cellular sheath of
the arteries, where it produces hypertrophy, thickening, and condensa-
tion, followed by a secondary disturbing  action upon the normal relation
 of the inner  arterial coats,  the  fibrous  and true lining membrane.  It
 is very certain, however, that we very rarely meet with traces of this
 superficial cellular inflammation of arteries, except as a result of their
 implication in morbid processes  of  the surrounding tissues, as in phleg-
 monous erysipelas, or in  tubercular destruction of  the parts;  while we
 constantly have occasion  to examine deposits underneath the lining mem-
 brane in their incipient stages. Here, we almost uniformly find an accom-
 panying tumefaction and reddening, affecting the entire thickness of the
 inner coat, which  is distinctly perceptible on  making  a section of the
 artery.   This change is  accompanied by a  puckering and plicated con-
 dition, and extends to a greater or less distance beyond the circumference
 of the deposit.   The reddening, though persistent, is not due to the
 formation of new vessels;  the microscope fails to detect them.   The
 softening, which we find  to be a common result of inflammatory action,
 affects the entire caliber of the artery, and in that case may give rise
 to a  uniform dilatation, or to what has been termed true aneurism.  The
 deposit which invariably takes place in  the first instance, between the
 middle and internal coats, is of a yellowish tinge, and forms slight ele-
 vations, in circumscribed dots or patches; as the disease advances, these
 coalesce, and may thus affect the vessel to a considerable extent.  We
 are not prepared to state, nor  are we of opinion, that the chemical

   1 Essai sur les Maladies du Coeur, p. 319.              * On the Arteries, p. 9.
        22 
338
CHRONIC  ARTERITIS.
character  of the primary deposit  is  in all  cases identical;  this would
not be  in  accordance with what we know of the elimination of  morbid
constituents of the blood.   But there is no  doubt that in a majority of
cases the atheromic deposit is a secondary fatty degeneration of  fibrin.
We are inclined to suggest that the more purely inflammatory the cause

                                 Fig. 150.
 Incipient atheroma and fatty degeneration of an iliac taken from an aged female. The lining membrane is
much puckered, owing to the irregular deposit of fibrin between it and the middle coat. A. Naked-eye view
of the artery, b. Microscopic appearance of the fibrinous deposit, dotted with oil-molecules, o. A longitudinal
section of the artery taken between *—*; j, the inner coat with subjacent deposit; m, middle coat unaltered;
o, the external coat.

of the  disease, the more presumption there  is of a fibrinous  deposit in
the first instance.   The fibrin seen by the naked  eye presents little  or
no distinction from actual atheroma;  but, on examination by the micro-
scope, we see the delicate fibrillse characteristic of this matter; and we
also detect in it glistening particles of oil, which show the transition to
atheroma.   The fibrin is itself deposited in distinct laminae, which may
Fig. 151.                              Fig. 152.
Fatty deposits in internal coat.                    Early stage of atheroma.
easily be separated from one another in the plane of the vascular coats;
there  is no arrest of the coat investing it  on the minor surface of the
artery, but  this  may be peeled off to an indefinite extent  beyond the 
CHRONIC ARTERITIS.
339
deposit,  showing that  in  the earlier stage there is no solution of con-
tinuity of the lining membrane, a point of some importance in reference
to the doctrine  expounded by Rokitansky.   This author, who treats of
the diseases in question as a new formation of the lining membrane from
the blood, does not appear to have recognized this form of deposit, which
we have  delineated, and which is clearly subjacent to the inner coat. Dr.
Hope, who does not, however, appear to have confirmed his view by a
microscopic examination, looks  upon the fibrinous deposit as  the first
stage of  the metamorphosis; and, until further investigations confirm the
views  of the Viennese  Professor, we adhere to the doctrine just adverted
to, in preference to what we cannot but  regard as a forced explanation.
It is, however, but due to the high reputation of Professor Rokitansky,
that we should allow him to speak for himself
in this question, in order that further investi-          Fig. 153.
gation may  determine the point;  he says:1
" The most frequent form of disease affecting
the arteries is an excessive formation and  depo-
sition  of the lining membrane of the artery,
derived from  the mass of the  blood, and at
the  same  time constituting hypertrophy of
this  membrane.  In a highly developed form
of this affection, we find  the inner  surface of
a large  artery, as  the aorta, covered with a
foreign substance, spread over it at separate
points or  in  large patches, and forming  a     Atheroma from old patch.
stratum  varying in thickness, by  which the
inner surface  of the vessel is commonly rendered uneven; this substance
is, in some places, either  grayish, grayish-white, faded and translucent,
or, in others,  milky white, opaque,  and similar  to coagulated albumen;
in some rare instances it  is colored by the imbibition  of haematin, over
various extents  of surface.  Its free surface is at the same time smooth
and  shining, or dull, and, as it were,  wrinkled.  It is soft,  moist, and
succulent in the translucent parts, and dense, dry, tough, and elastic in
the more opaque portions; resembling a cartilage or fibro-cartilage, with
which it  is usually  compared, and for which it  is still occasionally mis-
taken.   In the latter condition, it adheres  internally to the circular
fibrous coat."   Hasse considers that when chronic arteritis  is induced
by degenerative processes, we find  a  deep, dingy, brownish-red color,
extending to the middle tunic, a densely injected state of the vasa vaso-
rum  of the cellular sheath, and a deposition  of plastic material in the
caliber of the vessel;  these deposits accumulating in masses, adhering
to the  arterial parietes, and consisting of imbricated layers.
  We  occasionally find a general  thinning of the coats  of an  artery
without any appreciable change in  their composition,  in the same way
as we also find an  hypertrophic condition of the same character.  In
either  case it appears  generally to be  at the  expense of the middle
fibrous coat.  But, in  the  great  majority of  instances, we  shall,  on
careful examination, succeed in detecting some existing, or some ante-
' Pathol. Anat. vol. iv. p. 261.  Sydenh. Society's Ed. 
340
ATHEROMA.
cedent, morbid  deposit  to  which  the condition  is attributable.   The
most  important of these is what is commonly called  the atheromatous
process.

                            ATHEROMA.

  Atheroma,1 or, as it has  also been called by Baillie and others, stea-
toma  of the arteries,  is not, as we have already seen,  necessarily a soft,
pulpy deposit; but appears, in the first instance, as a series of fibrinous
layers subjacent to  the  inner coat of the artery, formed by a process

         Fig. 154.                               Fig. 155.
                                     Fatty granules, with crystals of cholesterin,
                                    from atheromatous deposits in  the aorta.—
     Steatomatous degeneration.              Bennett.

analogous to secretion from the blood.   Small  oil-globules are early
seen in the fibrin, and in the course of time the latter may become  com-
pletely converted into oil and a fatty crystalline matter, termed choles-
terin, which appears in flat, rhomboidal, crystalline laminae, with sharp
outlines;  the oil occurs in small globules of a highly refracting charac-
ter, more or  less aggregated in masses, and soluble in ether.  In  this
state it presents  a pulpy diffluent  condition, and, owing  to its yellow
color, it may, as  it occasionally has, be  mistaken  for  pus.   This con-
version does  not necessarily follow at stated  periods,  for it  is probable
that the fibrin may continue unchanged for a long time, until such a
tendency  prevails in the constitution of  the individual of a cachectic or
degenerative character,  as  to give rise  to the secondary process.  The
lining  membrane  of  the artery investing  the atheroma, in  the  first
instance,  becomes  thicker,  and assumes a darker color, and is capable
of considerable distension by the morbid product.  This at first occurs

  1 Atheroma is derived from itHipn, wheat-grits, a pap made of them, hence adhftafjia, an
unclassical  term, a pulpy substance.
 
                  OSSIFICATION OF ARTERIES.               341

in small points, and, by gradual extension, may occupy surfaces of one
or more inches in circumference, and of irregular though definite out-
line.   The liability1 of the arterial system to be affected, is in a ratio
with the proximity to the aorta, this vessel presenting the greatest pro-
clivity.  In no disease does the general law of symmetry, which prevails
in morbid as well  as in  physiological growth, manifest  itself with  so
much exactness, as in the one under consideration; the existence of an
atheromatous patch in an artery, may lead us safely to infer the presence
of an analogous change in its fellow.   And this applies equally to those
lesions which are consecutive to the  primary deposit, as softening and
ossification;  thus, to quote  a single  instance from Bizot's memoir,  he
examined thirty-four cases in which the crural arteries were the seat of
patches, and  in  thirty-three the law of symmetry  was  observed;  in
twenty-four cases of consecutive lesion of the same vessel, there was  no
exception to the law.   Even in the aorta we are able, in the incipient
stages of the disease, to trace the same law; the patches being found
symmetrically placed  round the orifices  of each pair  of  intercostal
arteries, or forming parallel lines across  the main  vessel.    The two
sexes do not differ in any marked manner with regard to the frequency
of the occurrence of the patches.   The only exception from this is, the
well-ascertained  proclivity on the part of the female sex to disease of
the inferior mesenteric and the abdominal aorta;  the ratio of  its occur-
rence  in  males and females  is nearly as  one to four.   On the other
hand,  age exerts an undeniable influence in its production; so much  so,
that, while it is scarcely ever met with before puberty, we rarely open
the  body of a person  in advanced  age without finding  some arterial
lesion of the kind.  The liability increases in the exact ratio of the age
of the individual, so much so that we can scarcely refuse to look upon
the  change in a measure as essentially connected with the  process of
involution.   Mr. Hodgson2 gives two instances  of the  deposit of cal-
careous matter in the arteries of infants, but they are extremely rare,
and thus only add force to the rule laid down.
                 OSSIFICATION OF ARTERIES.

  The second  change which  the  arterial  patches undergo, is that  of
ossification;  a  process  in which phosphate of lime is  deposited in an
amorphous condition;  it contains  no bone-corpuscles or canaliculi, and
hence, though the proportion between the animal and earthy matter is
about the same as that prevailing in true bone, it is by no means identical
with it.  As the process advances, the internal arterial coat is generally
destroyed, and the mass projects, in the most varied and fantastic forms,
into the current of the blood; thus, in its  turn, giving rise to further
deposits in the  shape of fibrinous coagula; or the bony deposit advances
under the lining membrane, till it encircles the artery and converts it
into a rigid channel, inducing that condition which is found to accom-

         1 See Bizot, Memoires de la Societe d'Obscrvation, vol. i. p. 388.
         2 On the Arteries, p. 23. 
342               OSSIFICATION  OF ARTERIES.
pany senile gangrene, fatty degeneration of the heart, cerebral soften-
ing, and other  morbid processes.   The frequency with which  different
arteries are  affected, follows  the general rule  already laid down, that
                          i
               Fig. 156.                                 Fig. 157-
                                             Annular calcification; it principally oc-
                                            curs in arteries of the third maguitude,
                                            such as the popliteal and the femoral. It
                                            commences by the deposit of granules of
                                            calcareous matter, a, which are arrange''
                                            in lines running transversely to the axis
                                            of the vessel;  the  lines gradually increase
                                            in breadth until  they coalesce laterally,
                                            the intervening spaces being filled up, and
                                            the vessel being  converted into a rigid
                                            tube, b.

the liability bears a certain ratio to  the proximity of the vessel to the
centre of the circulation.   This, however, applies  only to  the systemic
circulation;  and  here, too, there are some marked  exceptions, for the
cosliac, the hepatic, and the mesenteric, gastric, and hypogastric arteries
are scarcely ever found ossified, while the splenic presents this condition
very commonly; we must assume that the nature of the contained blood
exerts some  influence upon the process.   Lobstein, who has made out a
list showing the comparative frequency of the affection in the different
arteries, places the pulmonary arteries last.   He also includes branches
of the umbilical  artery, and the vessels of the  placenta.   Very small
arterial twigs present gritty deposits  in their coats;  but ossification has
not been met with in the capillaries.
   One of the secondary effects of atheroma and ossification is, a perfo-
ration of the  lining coat of the artery, causing, in  some instances, an
appearance of ulceration;  Rokitansky and Gluge deny  the existence of
Calcareous deposition. 
OSSIFICATION OF ARTERIES.               343
ulceration  in the arteries, on the ground that  there  is  no essential
analogy between the atheromatous  and ulcerous process, and that the
deposit itself is not an  inflammatory product; but  the former  author
adverts to  a peculiar appearance in  highly diseased arteries not  spoken
of by other writers, which he characterizes as minute openings or fora-
mina,  interspersed  between  the deposit, resembling  the contracted
mouths of small vessels.   They lead into canals which penetrate the
deposits to various  depths, and serve to convey the blood into  it and
into the circular fibrous coat.   The description would lead the reader to
suppose that the object of the atheromatous process was to  produce this
condition, instead of its being a mere result of disintegration.
   A remarkable fact  in  connection  with  the  forms of  arterial  disease
just discussed  is, that it appears to confer an immunity from tubercle,
while it is closely allied to fatty degeneration ; the  latter  is a point to
which  attention has been especially  directed of late among  ourselves; it
is one  that Rokitansky most pointedly alludes to  in the first edition of
his  great work.  There  does  not appear to be  sufficient ground for
adopting  the doctrine of the older writers, and which Dr. Copland1
sanctions and enlarges upon,  that ossification of  the arteries is derived
from the same sources as  the morbid deposit of stone and gout.   The
only analogy appears  to  be that they originate  in  the blood; but the
crasis giving rise to it, as well as the chemical  nature of  the product,
are essentially different.   We have already alluded to the circumstances
of  atheroma inducing aneurism.  This disease is one that  has long
attracted  the serious attention of medical practitioners  in  its advanced
stages, in which it becomes not only irksome to the patient, but a source
of  great  danger.   Important as the  surgical  aid is, that  in many
instances may  be rendered, it is easy to understand, from  the constitu-
tional  character of one of its causes, why operations so frequently fail.
1 Dictionary of Medicine, vol. i. p. 121. 
CHAPTER   XXIII.
                           ANEURISM.

  Aneurism,1 or a dilatation of an artery, is connected with two lesions,
according to which, from the days of Scarpa and John Bell, downwards,
two classes of aneurismatic disease have been adopted by most writers
—true and false aneurism—though we shall find grounds for assuming
that spontaneous aneurism is in  all instances traceable to one ultimate
cause—a morbid state of the arterial coats, which may produce accidental
varieties in the arterial tumor.   The definition of true and false aneu-
rism, ordinarily accepted, is that, in the former, we have to deal with a
dilatation, partial or  entire, of  a certain extent of  an artery, without
laceration of any of its coats, while in the latter, the dilatation is accom-
panied by the laceration of  one or more of the coats.  The distinction
is not, however, one based upon a difference in the morbid process; the
laceration, except in traumatic aneurism, being an accidental coincidence.
The effect of the atheromatous process is to destroy the normal cohesion
of the artery, the lining and middle  coats  are weakened, and the latter
may become  much  atrophied, in addition to being  in a  degenerative
condition.  The column of blood acting upon a point thus weakened,
necessarily causes the coats to protrude, and  the protrusion will  corre-
spond in size and extent to the amount of previous disease in the artery.
Several small dilatations occurring near one another, may, in the course
of time, unite and thus form one large pouch.  Dr. Peacock2 has shown
that, in these cases, there is an entire continuity of the lining membrane
in the sac, and that, while all  three coats may present the normal rela-
tion at the orifice, the middle coat becomes so much atrophied as in some
cases to disappear altogether at the distal point of the aneurism, so that
the  internal  and external coats come into contact with  one another.
This is the form which Rokitansky considers  identical with the hernial
aneurism of authors or with Scarpa's aneurisma spurium.   In the sim-
plest form of dilatation the entire caliber of  the artery is affected, and
the fusiform variety results, or the aneurism  is  confined  to one side of
the vessel, and it then assumes the saccular character, with an opening,
which is more or less patulous, and may be so  constricted as to resemble
mere pedicle.   It is  to the latter that Mr. Hodgson, and some  other
writers, confine the term aneurism; but there are not sufficient grounds
in the nature of the morbid change to sanction this  view.  Scarpa, fol-
lowing  Sennertus,  limits the  term  to  those  aneurismal  tumors which

         1 The term is derived from avtvpviae, I dilate ;  avtupvi-fta., a dilatation.
         2 Patholog. Reports, 1850, p. 2U1. 
ANEURISM.
345
result  from rupture of the coats.   This is almost invariably found in
large aneurismal sacs, and appears to be a  main cause of that stratified
coagulation of  blood met with  in them, the clot  forming by that  law
Fig. 158.
 Section of the arch of an aorta, with an aneurism arising from its upper part. The cavity of the sac is
nearly filled by laminated coagulum, the internal membrane of the artery is thickened. The sac presses
against the trachea, the arteria innominata, and the right carotid and subclavian arteries.—St. Bartholomew^
Museum, Series xiii. No. 11.

which enables the human economy to  protect itself against dangerous
and noxious influences.   A solid deposit is less frequently met with in
aneurisms formed by simple dilatation of the coats of the vessel.
   The form of sacculated aneurisms is generally globular, but they may,
partly owing to accidental  conditions in the coats of the affected vessels,
partly from the pressure exerted by surrounding tissues,  assume an oval
or more or less irregular outline.  Upon the original  aneurism, an evolu-
tion of secondary dilatations is sometimes met with, and  these may even
give rise  to a further  or  tertiary multiplication of the disease,  so as to
induce  a  sort of mulberry appearance in the tumor; it is the variety to
which Cruveilhier has applied the term " ane'vrisme  sous l'aspect d'am-
poules & bosselures."
   The  laceration of the internal  coats of the artery may occur at the
early stages of the disease, and be the first  exciting cause of the aneu-
rismal tumor.  The aorta of a lady, whose case is detailed by Mr. Hodg-
son,1  illustrated this mode  of  the formation of aneurism.  The coats of
the'vessel were diseased, and presented at the arch  a transverse  rent,
about an  inch in length, which had penetrated to the middle coat.  The
blood had insinuated  itself between the middle and external coats, the
latter of  which was elevated into a tumor, about two inches in circum-
ference.   A similar appearance was found  in the body of  George II.
We see* no difficulty in regard  to this view of the  occasional origin of
aneurism.   That the  early stages should  not often be presented to us m

                      1 On the Arteries, pp. 39 aud 63. 
346
ANEURISM.
the dead subject, is easily accounted for by the rapid distension that will
take place after the first laceration, and the equally rapid laminated
deposit of the defensive fibrin.   Rokitansky, however, denies this mode

               Fig. 159.                             Fig. 160.
                                     Aneurism of the posterior tibial artery, with the
                                    nerve spread over the back part of the pouch; the
                                    sac is entirely obliterated by concentric  layers of
                                    fibrin, growing paler towards the surface.—St. George's
                                    Museum, F. 41.

of origin altogether, stating that no such rent is ever detected.  Another
question is, whether laceration of an artery ever  occurs without some
previous derangement in its coats, in what is termed the traumatic form
of aneurism, without a penetrating wound.   The extreme pliability and
elasticity of the arterial system, compared with all the tissues that sur-
round it, might alone suffice to answer the question; but the direct phy-
siological experiments performed by Mr. Hodgson and Mr. Hunter, and
Sir Everard Home,1  as  well  as  the pathological  observations by the
former,2 positively determine the  point in the  negative.  Mr. Hodgson
states that he has repeatedly tried, in imitation of Richerand, to produce
a laceration of the internal and middle coats of the popliteal artery, by
violently extending the leg upon the thigh;  but that he has never lace-
rated the coats of the  artery unless the degree of violence was sufficient
to rupture the  ligaments  of the knee, an event which certainly does not
generally accompany  those accidents to which patients attribute  the
origin of aneurism.
   The  contents of aneurismal sacs are  fibrinous  coagula, which form
in successive layers, and accordingly present a concentric arrangement,
like the annular rings in perennial plants.   The  resemblance may be
traced still further in  the gradual condensation of  the  outer or external

  1 Transactions of a Society for the Improvement of  Medical and Surgical Knowledge,
vol. i. p.  144.
  2 On the Arteries, p. 64.
Aneurism of the Brachial Artery. 
          %                 ANEURISM.                         347

layers,  owing to absorption and compression.   These  also lose their
color, and become fawn-colored or white;  while towards  the interior we
continue to recognize the dark color  of the blood.   The accumulation
may proceed to such an extent as to obliterate the cavity, and thus es-

               Fig. 161.                            Fig. 162.
 , Further growth of aneurism prevented by coagulum      Spontaneous cure of aneurism of the
becoming adherent to the artery around the opening of    femoral artery by the sac being filled with
the sac.—From Hodgson.                      coagulum; the vessel remaining pervious.
tablish a spontaneous cure.  A considerable amount of organization is
observed to take place in some deposits, manifested by the formation of
fibres.  The existence of a distinct membrane is assumed by most writers
to envelop the coagulum.   It is a point to which Bizot particularly drew
attention, and upon which Hasse dwells forcibly.  The latter states that
he has never met with an aneurism in which this adventitious membrane
was not present.  Mr. Bowman has observed that  the membrane en-
veloping the coagula in an aneurism, though apparently of exactly the
same  nature as that lining the arteries, differs from it in not presenting
any epithelium.  We  would not lay any  stress upon this distinction,
inasmuch as the presence of epithelium in a healthy artery is often, to
say the least, extremely doubtful.  The coagula form in proportion as
the sac is cut off from the rest of the circulation, the more shallow it is,
and therefore the more exposed to the force of the current,  the less the
liability to the formation of fibrinous laminae,  and the less, we may also
add, the coincident danger of perforation of the coats of the vessel.   It
is through the agency of this deposit that a spontaneous cure may take
place, either by an obliteration of the sac, or by pressure upon the artery,
and consequent obliteration of  its channel.  The  coagula may subse-
quently undergo secondary metamorphoses, such as a conversion into 
348
ANEURISM.
cholesterin, or cretaceous matter.  But  it does  not always form, and
we may meet with  a series of aneurisms on the same vessel, some of
which present the deposit, while others are empty.   In number and size
there is a great diversity, as also with regard to the liability of different
arteries to be affected, as well as in respect of sex.   The following table
contains an analysis of sixty-three cases, examined  by Mr. Hodgson,
which illustrates the last two points.   It shows at once the great liability
of the male sex, and the prevailing tendency of certain arteries to be
affected:—1
                                               Males.
      Ascending aorta, innominata, and arch of the aorta    16
      Femoral and popliteal......14
      Inguinal    ........12
      Descending aorta      ......     7
      Subclavian and axillary   .....     5
      Carotid........2

                                                66     7     63

  Bizot's statistics  agree closely with those of Mr. Hodgson as to the
different liability of the two sexes; out of one hundred and eighty-nine
analyzed by him, one  hundred and seventy-one  occurred  in men, and
eighteen in women, which is even more in favor of the latter than Mr.
Hodgson's table.  The proclivity to aneurism is also determined by the
age of the individual;  it is unknown to childhood; the greatest tendency
to the disease exists at the middle period of life, as shown by the follow-
ing analysis of one  hundred and  eight cases:
Females.	Total
5	21
1	15
0	12
1	8
0	5
0	2
From 10 to 19 years
" 20 '	' 29
" 30 '	< 39
" 40 '	' 49
" 50 '	' 59
" 60 «	' 69
" 70 '	' 79
" 80 " 89	
 1 subject
15 subjects
35
41
14
  As an aneurism enlarges it necessarily displaces the adjoining tissues,
and causes an absorption of  those that offer any resistance.   The dan-
ger of an aneurismal tumor depends upon its site, and upon its vicinity
to vital  organs whose functions are liable  to  be interfered with by
pressure.   It is thus that aneurism occurring in  the thorax and in the
regions of the  neck threatens life, before the  arterial disease has put
on any dangerous appearance, by narrowing  the trachea, by compress-
ing the oesophagus or other  vessels.  The extent to which absorption
prepares a passage to an advancing aneurism is  in some cases extraor-
dinary; an aortic aneurism by this process may pass through the thorax
or eat into the  vertebral column.   In these cases, as  Rokitansky de-
scribes, not only the bone is  destroyed  but the aneurismal  sac itself
becomes fused with the periosteum, and the other fibrous structures that
usually invest the  bones.  In this  way the exposed  vertebral  column

  1 The table is essentially the same as that given by Mr. Hodgson, but differentlv
arranged.  It excludes aneurisms arising from wounded arteries, and aneurisms by an-
astomosis. 
ANEURISM.
349
may constitute a portion of the aneurismal wall.  Hodgson1 has pointed
out, that, as the aneurism advances to the surface of the body, it induces
Fig. 163.                            Fig. 164.
 Fig. 163 exhibits a front, and Fig. 164 a back view of an aneurism of the arch of the aorta, which burst
into the trachea. The opening into the aneurism from the artery, and the atheromatous patches between
the coats of the latter, are well shown.

sloughing of the integuments, and an eschar forming on the tumor itself,
its discharge  gives rise to fatal hemorrhage;  the same is the case when
Fig. 165.
 Aneurism of the aorta, which induced caries of the vertebrae, and fatal compression of the spinal cord.

the aneurism opens into a cavity lined with  mucous membrane.  But a
different result takes place when the sac projects into  a serous cavity;
in this case  the membranes do not slough, but the parietes of the tumor
become softened  and thinned, and a laceration is effected.   If a rupture
' The Diseases of the Arteries, &c. p. 85. 
350
ANEURISM.
of the internal and middle  coats alone  takes place, the  external coat
remaining entire, the blood may separate the latter to a greater or less
extent without forming a sac; it then causes what has been termed, by

            Fig. 166.                             Fig. 167.
Front view of aneurism of aorta.     falling into the artery.
Laennec,  the dissecting aneurism.   We  sometimes meet with small
ecchymoses under the lining  membrane of the aorta in the dead body,
which indicate the commencement of this form of aneurism.  A minute
and sometimes imperceptible  fissure in the inner coat allows of the per-
meation of a small quantity of blood, and the first step having occurred,
a succession of similar deposits may soon cause a greater accumulation,
and necessarily a coincident separation of the coats.   Nothing has been
added by later writers to the observations of Mr. Hodgson on the sub-
ject of the spontaneous cure  of aneurism;  we cannot do better than to
extract  his own terse summary of the subject; first, the  whole tumor
may be  removed by sphacelation, in consequence of extreme inflamma-
tion  excited by the  distension of the surrounding parts;  secondly, the
tumor, as we have already  had occasion to observe, may assume such a
position as to obliterate, by its pressure, the superior or inferior portion
of the artery communicating with  the  sac; and thirdly,  the gradual
deposition  of fibrin in the sac and the artery leading to it, may render
them impervious, and allow a subsequent process by which the tumor is
removed.   In the latter cases a gradual absorption of its contents takes
place, the tumor becomes harder  and smaller, and the establishment of
a collateral circulation restores the balance of the circulation.
  Before quitting the subject of aneurism, we  must allude  to certain
peculiarities in connection with its occurrence in different parts of the
arterial  system.   We have seen  that aneurisms are almost  limited to
arteries of  the  largest size;  in smaller arteries, as in  the radial and
ulnar or tibials, they are  rarely  met with.   They are altogether ex-
tremely rare in the upper  extremity; they here almost invariably arise
8755 
ANEURISM.
351
from  carelessness in venesection, especially if, as  on the continent, a
spring-lancet is employed.   In such .a case the result generally is a
communication between the brachial artery and a cubital vein, espe-
cially  the basilic, forming  what  is called  varicose aneurism.   The

                              Fig. 168.
                              From Liston.

smallest  arteries in which spontaneous aneurism  is  met with are the
coronary of the heart and  the cerebral.   An instance  of  the former,
which is extremely rare, is reported in the Records of the Pathological
Society for  1848; it  was discovered by  Dr. Peacock in a man  aged
fifty-one, who had presented no  symptoms of cardiac  disease before
death.   The tumor occupied  the  left coronary artery, and  was about
the size of  a pigeon's  egg, containing lacerated  coagula, which  were
intimately adherent to the lining membrane.  There was some atheroma
in the aorta.  Aneurism of the  cerebral arteries,  though not common,
has of  late been shown to be more frequent than was at one time sup-
posed.   It is generally seated at  or near some part of the circle of
Willis; it may attain the size of a walnut, and  more, though it  is com-
monly  smaller; it  is met with  chiefly between the age of forty and fifty.
Here,  too,  the  male sex presents a much greater liability than the
female; showing that the former manifestly possess  a  marked aneu-
rismal  diathesis, and that the increased tendency is not due to accidental
circumstances.  We find two good instances of aneurism of the  cere-
bral arteries in the Reports of the Pathological Society, presented  by
Dr. Hare1 and Dr. Roe;2 the one in the left posterior communicating
artery, the  other  in  the anterior cerebral; this  one of unusual size,
being  as  large  as a hen's egg, had caused  partial absorption of the
sphenoid bone upon which it  rested, and  a flattening of  the adjoining
portions of  the brain.   Both the cases alluded  to occurred  in females;
and Dr. Roe's case was still further remarkable from its affecting the
patient at the early age of twenty-one.   Dr. Brinton,3 from an analysis
of about forty well-authenticated cases of  cerebral aneurism, finds that
three-eighths terminate in rupture, one-eighth from simple loss of func-
tions by pressure,  one-eighth by convulsive attacks, one-eighth by con-
gestion or hemorrhage of the brain, one-eighth  by inflammatory condi-
tions of the brain, and one-eighth by coincident disorders or accidents.
In three instances  Dr. Brinton found  the  aneurisms more than one in
number; in  one instance three were found; in one, the opposite carotids
were symmetrically affected.

  1 Report, 1849-50, p. 169.       2 Ibid., 1850-51, p. 46.         3  Ibid., p. 48. 
352
ANEURISM.
   The pulmonary artery and its  distributions are not subject to aneu-
rism, beyond an occasional dilatation of the orifice adjoining the heart.
The mechanical injury of an artery may cause the effusion of blood into
the surrounding parts, which constitutes what has been  termed diffuse
false aneurism.  It generally produces gangrene ; but inflammatory re-
action may be set up, and establish definite limits, and thus lead to the
formation of an aneurismal sac.   It is  manifest that  this, as well as the
aneurismal varix, of which we have already spoken, has no pathological
relation to the disease of which we have been treating. 
CHAPTER   XXIV.
                            THE VEINS.

   The physiological relations of the veins, as well as their anatomical
 structure, would lead us to assume that  their diseases differ in many
 points from those affecting the arterial system.  The absence of an elas-
 tic coat, their greater collective capacity, the direction of the contained
 current, their frequent superficial position in the body, the nature of
 their contents, and the absorbent power of these vessels,  are elements
 which influence their morbid states materially.   Some of the most viru-
 lent manifestations of disease that we are acquainted with are symptoms
 of diseases of the veins, and it is most probable that in the great majority
 of cases of poisoning, whether the toxic  agent be introduced by the
 stomach, by the  skin, or  by inhalation, they are the medium by which
 it is conveyed  to the central organs and  prostrates the vital energies.
 It is in the study of this subject that the value of pathological  inquiry
 has been particularly demonstrated.   Hunter was the first to open the
 way, and since that period the  scalpel has shown that many previously
 unintelligible malignant conditions are attributable to phlebitis.
   Phlebitis may be acute or chronic.  Inflammation of a vein is charac-
 terized by a reddening of all the coats, owing, on the external surface,
 to capillary congestion in the lining membrane, to a transudation similar
 to that found in the coats of the arteries.  It is only when we find other
 concomitant symptoms of inflammation, that we are justified  in setting
 the latter down to that cause.  According to  Lebert,1 the  nutrient ves-
 sels of the veins, which in the normal state are scanty, during inflamma-
 tion become excessively  developed, forming large anastomosing net-
 works.   As the inflammation advances, a second vascular network ex-
 tends from the former, and is described as passing to the surface of the
 lining  membrane of the  veins.   Lebert states this evolution  of new
 vessels to be identical with what is perceived in other  phlegmasiae, and
 to be a uniform accompaniment of incipient phlebitis.   The color of the
 lining membrane fades at the  margin of the inflamed  portion into the
 pale, healthy tissue, and itself presents various subsequent modifications
 of tint, becoming more or less mottled, violet, or fawn-colored.   An
 exudation of serum is next perceived in the coats of the vein; they
 become thickened, so that when cut across the vessel may remain patu-
 lous  like an artery.   A deposit of fibrin in the channel of the  vein
 follows, and it  will depend upon the character of the deposit, and this
in its turn upon the constitution of the individual, whether it suffices to

                  1 Physiologie Pathologique, vol. i. p. 272.
       23 
354
THE VEINS.
Fig. 169.
arrest  the disease and  render it a  mere local affection, or whether it
becomes a fresh source of contamination.  The more intense the phlo-
gistic process, the more thoroughly we shall find it  affecting the coats
of the vessel, so  that the latter, as Gendrin  observes, may appear to
form a dark red cord surrounded by and closely adherent  to a friable,
red cellular  sheath filled with bloody serosity, and intimately attached
to the surrounding tissues.   Gendrin has demonstrated that the lining
membrane  of veins possesses  the  same power of exuding lymph into
their cavity as that  of  arteries; we must not, therefore, look  upon the
coagula found in the veins in phlebitis as resulting solely from a chemi-
cal elimination of the contained blood.   Lebert describes  the adhesive
fibrinous exudation as  being  effected by the new-formed capillaries
between the coats, but he  regards it  as the  rarer  issue of phlebitis,
while he attributes its very  fatal character to  the prevalent suppurative
character of the disease.
   It is probable that the first effect of phlebitis  is to cause the forma-
tion of  a layer of exudation matter on the lining membrane,  and that
                    this in  its turn gives rise to the  deposit of further
                    coagula from the blood ;  the concentric lamination
                    which  may generally be  traced in the plug,  and
                    the firmer connection between it and the  vessel in
                    phlebitis, than in those cases of spontaneous coagu-
                    lation of the blood  from  other causes, confirm  this
                    view.   The coagulum itself may extend considera-
                    bly beyond the primary  seat of inflammation,  and
                    it terminates in a conical point;  the plug generally
                    reaches as far as the next main vessel with which
                    the inflamed vein communicates, while  the smaller
                    branches, which contribute to its formation, become
                    choked with lymph.  A cure may take place at this
                    stage,  either by a permanent obliteration and con-
                    traction of the vein, as we see  in favorable cases
                    of operations for varicose veins, or by a disappear-
                    ance of the coagulum and a restoration of the vessel
                    to its   normal condition.   Hasse was fortunate
                    enough to  experience this event in his own person,
                    after the whole system of the  saphena up to  its
                    junction with the crural vein had  become blocked
                    up;  he attributes the dispersion of the lymph not
                    so much to absorption as to its resolution and lique-
                    faction,^ an opinion  which is rendered  probable by
                    the position of the deposit as well as by the absence
                    of chemical changes which render it hostile to the
                    vital powers.
                       This, however, is not  the usual termination of
phlebitis, which more commonly leads to a suppuration of the clot,  and
secondary phenomena of the most destructive  character, resulting from
this process. In this case, a soft, straw-colored spot forms in the centre
of the coagulum, the lamination of the latter disappears, until the whole
is converted into a grumous  mass.   When portions of this mass are pro-
 Fibrinous  Phlebitis,  a.
The femoral vein, occluded
by solidified contents. At 6,
the saphena  enters; and
consolidation ends abruptly
there. 
THE VEINS.
355
pelled  into  the  circulation, the symptoms of poisoning result, and we
find the individual particles of the morbid product occasioning coagula-
tion  of the  blood, or  the formation of  abscesses at  distant points.
Coagula resulting from this cause are most  commonly met with in the
right side of the heart, and in the distribution of the pulmonary arteries.
They are laminated, and are softened  in the interior, where  there may
be a nucleus of  pus.   The introduction  of pus into the circulation  is
generally accompanied with symptoms of a general prostration of the
powers, of the most intense character, which are due rather  to the  in-
fection of the blood, or pysemia, than to the local results  in the  shape
of lobular abscesses, or secondary purulent deposits in  distant viscera.
Cruveilhier is of opinion that, after the occurrence of suppuration, what
he terms  a sequestration  of  the  pus may take place, and prevent the
general infection, by the formation of fresh  coagula in advance of the
point of suppuration, in consequence of which  the pus may be absorbed
or be discharged externally, in the shape of an abscess.
   Authors of our own  country were the first  to  trace  the  connection
between secondary deposits and  local injuries.   Morgagni and Desault
had particularly alluded  to  abscesses in the  liver following cerebral
lesions, but it was reserved for Arnott1 and  Davis2  to show the  actual
physical connection between these occurrences, and to establish the real
nature of phlebitis.  The latter was the first  to demonstrate that it is
the  pathological phenomenon constituting  phlegmasia alba dolens,  a
malady  accompanying the  puerperal state, which had  previously been
attributed to a  reflux of the lochia, to  milk depots,  or to obstruction
of the lymphatics.   He showed, by a post-mortem examination of four
fatal cases, that it  resulted from inflammation  of one or more  of the
principal veins within, and in the immediate  neighborhood of the pelvis,
producing an increased thickness in their  coats, the formation  of false
membranes on their internal surface, a gradual coagulation of their con?
tents, and occasionally a destructive suppuration of their whole texture.
Dr. Graves,3 though "he  admits that the veins are involved in this dis-
ease, looks  upon their inflammation  as  secondary to a  general inflam-
mation of the  tissues, produced by a morbid  impression  made on  the
ultimate ramifications of  the sentient nerves of the extremity; on  the
 other hand, Gendrin considers the swelling accompanying phlegmasia
 dolens to be a  mere accidental concomitant  of  the  phlebitis.   Many
 cases  of puerperal fever are mainly due to phlebitis of  the uterus, and
 secondary inflammations induced by the former.  This  appears to have
been more particularly the case  with the frightful endemic of puerperal
fever, which used,  until very recently, to rage in the  great hospital of
Vienna.  Dr. Semelweiss made  the discovery  that it mainly was  due to
the  introduction of poisonous matter into the vagina and uterus of par-
turient women,  by  the medical men and students, who had recently been
handling post-mortem specimens.   The proper precautions  that have
 since been adopted have almost  banished the  disease.4  Thus, while in

   > Medico-Chir. Trans., vol. xv. p. 1.               2 Ibid., vol. xii. p. 419.
  s Clinical Lectures, &c, vol. ii. p. 290.
  « See Dr. Routh ou the Endemic Puerperal Fever  at Vienna, Med-Chir. Trans., vol.
xxxii. p. 27. 
356
THE VEINS.
1846 there were 459  deaths among 3354 females, in  1848, after  the
employment of chlorinated solutions by the medical attendants for their
own purification, had been introduced, the deaths in 3356 patients had
sunk to  the  comparatively small  number  of 45.   In many cases  of
phlebitis resulting  from venesection, the effect has  been traced to a
similar cause,  viz : the introduction of poisonous matter into the vessel,
either by the lancet,  or by the  use of foul  sponges.  It was from its
occurrence after phlebotomy that the attention of John  Hunter was first
drawn to the subject.
  For a  long time the liver was supposed to be the only organ in which
metastatic abscesses, as secondary deposits used to be called, were found,
and then only in connection with  injuries of the  brain.   It was  first
shown by Arnott that no organ of the body is exempt from this lesion,
though it occurs more frequently in the liver and  the lungs, and next
in order in the kidneys, the  spleen, the heart, and superficial tissues,
while it is met with but rarely in the brain and the cavities of the eye.
The abscesses  vary in number, but when found in one  organ,  we may
expect to find them in others also, and it is rare to meet with a  solitary
secondary deposit.   Thus, in a case that occurred at St. Mary's Hos-
pital, in  a boy, in whom  crural  phlebitis was brought  on by an acci-
dental contusion,  and death occurred within six days of the injury, and
three of  the occurrence of any alarming symptoms, secondary deposits
were found in  the lungs, the heart,  and the kidneys.  Velpeau1 relates
the case of an  individual, in whom, from fifteen to twenty abscesses were
counted in the brain, from eight to ten in the lung, and purulent depo-
sits were also found in the kidneys, the spleen, and the  liver.
  We find the law  of symmetry prevailing in the  present as in other
diseases; thus in the viscera, as  well  as  in  the  superficial tissues, ab-
scesses,  resulting from phlebitis, are constantly met with, at points most
closely corresponding with one another on the two sides of the body.
  The introduction of a deleterious agent from without is not the sole
cause of phlebitis, nor is absorption of pus necessarily  followed by the
serious consequences to which we  have adverted;  we  must, therefore,
assume, that in those cases in which it occurs, there is  a predisposition
determined by a cachetic condition in the blood, to which it is attribut-
able.  Rokitansky treats of a definite form of phlebitis, depending on
coagulation of the blood, in which the coagulation  within the vessel is
the primary phenomenon, whilst the inflammation of its coats is merely
a secondary affection.   When the coagulum is once formed, which may
take place at different points and at different distances from the centres
of infection, the inflammation of the coats follows.  To this class  we
must refer cases of phlebitis recorded as having supervened upon invete-
rate lues, or varioloid disease,2 or upon catarrhal or rheumatic affections.
  In addition to the cases  of inflammation of individual  veins,  already
treated of,  there are others to which it is right that we should especially
advert.   An inflammation  of the umbilical vein in infants is mentioned
by Kiwisch,3 as occurring  almost epidemically; and Dr. Lee  has also

         i Revue Medic, vol. x. p. 442, 1826.
         2 See Puchelt, das Venensystem, vol. ii. 88, 1843.
         3 Die Krankheiten der Wochnerinnen, Prag. 1840, vol. i. p. 112. 
THE VEINS.
357
met with it coincidently with the epidemic occurrence of metro-phlebitis.
The affection generally commences between the second and fourth days,
and is followed by peritonitis and  icterus.   In the adult, we meet with
inflammation of the vena portae, which may occur idiopathically, or by
extension of inflammation from  the mesenteric veins.  It has been seen
resulting from a fish-bone penetrating through the coats of the stomach,
into  the superior mesenteric; and the cases in  which no  such lesion
could be discovered  have been set down to metastatic irritation, to the
irritation produced  by spirituous beverages, suppressed haemorrhoids,
gout,  or erysipelas.   The occurrence is marked by the appearance of
what exactly resembles the formation of numerous abscesses in the sub-
stance of the liver,  but which, on close examination, prove to be accu-
mulations of pus in  the branches of the vena portae.   The cases of this
disease that are recorded are so few  that we are induced to quote the
following instance, which fell under our own observation ; it  is the more
remarkable as it presents the only instance of apparently idiopathic
ulceration of the trunk of the vena portae, that has been published.  It
occurred in John Wright,1 a laboring man, a patient of Dr.  Alderson's,
at St. Mary's Hospital, who, seventeen days previous to admission, was
seized with  a  shivering fit;  since then he had  suffered from rigor, fol-
lowed by heats and perspirations at  irregular intervals.  On the 1st of
October, 1852, a fortnight after admission, the skin is first  reported to
have been somewhat jaundiced, the  pulse eighty-eight, tongue  coated,
loss  of appetite, a burning  sensation at the top of the sternum, with
great  depression of spirits.  The  yellow  tinge  of  the skin continued,
and  the fits were fewer in  number.   On  the 11th, the dulness of the
hepatic region was  found increased,  and the stools  are noted to have
been dark.   On  the 18th,  the  skin was less yellow, the percussion of
stomach and colon was tympanitic—no pain—no increase in the hepatic

                               Fig. 170.
      Section of liver exhibiting the appearances presented in inflammation of the Vena Portae.

dulness.  The shivering fits  now returned  more  frequently, pleuritic
symptoms  supervened, the  patient became more and more weak, more
jaundiced,  and drowsy, and sank on the 24th of October, 1852.  In the

         1 The case is abridged from the Records of St. Mary's Hospital. 
358
THE VEINS.
thorax, the deposit of fresh lymph on the lower edge of the right lung,
was all the evidence of recent disease to be  found.  The  lungs, the
heart, are noted as being healthy, so  also the  kidneys  and the brain.
The liver  was found  much enlarged and dark colored,  feeling soft at
many points ;  on removing it from the body, about two or three ounces
of purulent matter escaped from the portal vein ; the organ, at the same
time, shrinking under the hand.  On incising the liver, numerous bright
yellow circumscribed spots appeared, closely resembling abscesses ; they
varied in size from a  pin's  head  to a walnut.  They proved to be  all
connected, occupying the ramifications of the portal vein, gorged  with
pus, of a perfectly laudable appearance.  On  examining the  portal vein,
it presented close to the point at  which the spleen and superior mesen-
teric met, a puckered, ulcerated appearance of its inner surface, extend-
ing for about  an inch  towards the liver; the ulceration was found to
have penetrated through the  inner coat, the  edge  of which was turned
up, and well defined towards the  healthy part of the vein.   The ducts
and the hepatic  vein were found healthy, as also the orifices of the me-
senteric and splenic veins.   The surface of some of the portal branches
was smooth, and these only seemed implicated as receptacles for the pus,
while, in others, the lining membrane  was  destroyed, and  a pyogenic
layer  substituted.  The hepatic  cells proved  everywhere natural, the
lobules were loaded with yellow pigment in  the middle,  and there was
marked hepatic venous congestion, which it  may be observed, closely
resembled congestion of the inter-lobular plexuses.   Mr.  Blyth, who
analyzed the organ, found it to contain neither sugar nor cholic acid,
nor did the bile  obtained from the gall-bladder contain either of these
constituents;  it follows, that the  pigment in the hepatic cells was  not
biliary matter.  The intestines  were only partially examined, but so far
appeared healthy.  This case contradicts the assertion of Rokitansky,
that  inflammation of the vena  portae invariably induces purulent and
ichorous abscesses in the liver,  and abscesses  in the lung, with a  very
highly developed pyaemia.  No abscess was discovered either in  the
hepatic  or pulmonary tissue, nor was there any evidence of pyaemia ;
the suppuration was limited, in  the  most remarkable manner, to  the
trunk and branches of the vena portae.
   In the cranium, we meet with  inflammation and suppuration of the
sinuses of the dura mater as a consequence of direct injury, and not
unfrequently as a result of otorrhoea and caries of the fibrous portion of
mastoid cells of the  temporal  bone.   Cerebral phlebitis is necessarily
commonly associated with meningeal inflammation.   It appears that the
sinuses of the dura mater are liable to  a chronic form of inflammation
in children, leading to their obliteration and conversion into fibrous cords.
Such a condition has been found by Tonnelle', and by Gintrac,  in cases
marked by symptoms of cerebral  congestion and apoplexy.  The latter
author1 gives the following case in illustration of this condition:  a child,
aged four years, was liable from its birth to  a temporary suspension of
voluntary movement.   There were no premonitory symptoms, and the

  1 Recueil d'Observations, Bordeaux,  1830.  Quoted by Andral, Clinique Medicale, torn.
v. p. 266. 
DILATATION OF VEINS.
359
attack occurred equally in the erect and recumbent position; the intel-
lectual  faculties were maintained, but the  power of  articulation  was
suspended.   The child died  of pneumonia, supervening upon variola.
The post-mortem examination exhibited  the superior longitudinal sinus
converted into a hard cord, the  veins in  connection  with which were
filled  with coagulated blood.  The walls of the sinus  were thickened,
dense, and of a yellowish color;  it contained a solid  clot; no further
lesion was discovered in the cranium.
   Among the local cases of phlebitis not followed by general infection
of the blood, those of the haemorrhoidal veins are the most frequent,
though it is a complication much to be feared in all operative proceedings
directed to their cure, as well as to that of varicose veins of the legs or
spermatic cord.
   Rupture of the large veins is an event very rarely met with; Haller1
quotes  a case of rupture of the vena cava inferior, attributed to eating
ice; but most of the instances recorded2 were brought on by mechanical
injury.  The rupture of smaller veins often  occurs as a result of sudden
and forced distension.   Thus, small ecchymoses are frequently brought
on in the conjunctiva by  violent coughing.   The veins of the lower ex-
tremities have been found ruptured by spasm of the muscles of the calves.
The hemorrhage that constitutes epistaxis, the menstrual and haemor-
rhoidal discharges, is rather analogous to the process of exosmosis than
a result of  actual rupture, and therefore is rather more  immediately
connected with the capillary than  the venous circulation.  A spontaneous
rupture of larger veins occasionally results as a secondary consequence
of varices.   The sanguineous tumors in  the  labia of pregnant and  par-
turient women,  are attributable to this cause, as  also the  laceration of
varicose veins of the extremities,  with or without coincident ulceration.
                     DILATATION OF VEINS.

   Dilatation or varicosity of  the veins is a subject which has attracted
the attention of pathologists from the days of Hippocrates, who already
distinguished between two kinds, which he termed haemorrhois and cirsus.
   The affection is also treated of by writers  under the generic term of
phlebectasis.   It consists mainly in an enlargement  of  the caliber of
the vessels, and may or may not be accompanied by an  alteration in
their coats.  Briquet3 avails himself of these  differences for establishing
his classification. He assumes three varieties—simple dilatation; uniform
dilatation, accompanied by thickening of the coats; and irregular dilata-
tion, with thickening or attenuation.  The distension  is generally owing
to some impediment being offered to the return of the blood to the heart;
and we therefore most  commonly meet with it in  parts  in  which the
surrounding tissues  are lax, and consequently  do not offer a sufficient

  1 Elementa Physiol, vol. i. p. 130.
  2 James Kennedy has collected all the known cases of rupture of the vena cava inferior,
in London Medical Repository,  vol. xx. 1823.
  3 Histoire des Inflammations, vol. ii. p. 9, seq. 
360                  DILATATION  OF VEINS.
resistance to the pressure of the blood.   Hence, varicose veins are most
commonly met with in the vicinity of the  rectum and  pudenda, and in
the lower extremities.   The veins swell, and assume a nodulated appear-
ance and tortuous course, while the  increased local pressure gives rise
                                  to  an hypertrophy  of the  coats.
             Fig. 171.              Gendrin1  and Briquet attribute the
                                  latter  to chronic inflammation.  A
                                  necessary consequenee of the dila-
                                  tation is  an insufficiency of the
                                  valves, which  no longer  close the
                                  passage to the regurgitating current.
                                  They suffer a solution of continuity,
                                  and may  become partially or wholly
                                  obliterated.    The  occurrence  of
                                  phlebectasis  is  connected with  a
                                  peculiar  constitution, which  Hasse
                                  terms  a morbid predominance of the
                                  venous system, a  venous habit of
                                  the body, which may be  character-
                                  ized as one of general laxity of fibre
                                  and want of bone, associated with
                                  a  tendency  to local  congestions.
                                  Age exercises  a marked influence
                                  upon the  occurrence and prevalence
                                  of the  affection.  It rarely manifests
                                  itself in any form until puberty, and
                                  is most common during  the prime
                                  of life, as the tendency  to  it gra-
                                  dually ceases with advancing years.
                                  An  hereditary  predisposition may
                                  very frequently be traced.   There
                                  is also a  marked  difference in the
                                  two sexes in regard to  their pro-
                                  clivity to certain forms of the dis-
                                  ease.  Thus,  the haemorrhoidal form
is peculiarly an affection of the  male sex, and its  symptoms in many
instances induce  an impression that it is an  analogue  to the menstrual
secretion in the female, from the  periodicity of its  occurrence, and the
relief the flux affords to the system.   In some rare cases, recorded as
curiosities  by various authors,2  a dilatation  of  the large veins in the
cavities of the trunk  has been observed.   We  must content ourselves
with alluding to the fact, and pass to the consideration of the ordinary
forms of the disease.
   Varicocele, or  cirsocele, affects the male  sex  commonly at the com-
mencement of  puberty.   It consists in a dilatation of  the veins of the
spermatic cord, and prevails more on the left than the right side—a
circumstance attributed to the more circuitous route taken by the left

           1 Archives Ge"ne>ales de M&lecine, vol. vii. p. 200 and 396.
           1 See Puclielt das Venensystem, vol. ii. p. 378, et seq.
Varix of the veins of the leg. 
DILATATION OF VEINS.
361
than the right spermatic vein.  How rarely  it affects the right side is
shown by the fact that, in one hundred and twenty cases operated upon
by Breschet, all but one occurred  on the left.  It is important, on ac-
count of the atrophy of the testicle, which it is likely to induce, from its
causing haematocle, by hemorrhage into the tunica vaginalis, and from
the influence which, in common with  all sexual diseases, it exerts on the
mind of  the patient.   The form of varicosity in  the female sex,  corre-
sponding to varicocele in man, is enlargement of the vaginal and pudendal
veins, which, especially during the advanced  periods of pregnancy, are
the cause of  much suffering, an'd may, during labor, give rise to very
Bevere hemorrhage.
   Haemorrhoids, or  piles, consist in  an  enlargement and varicose con-
dition of the veins surrounding the  anus,  and may occur in terminal
branches of the inferior mesenteric, a tributary of the portal vein, or of
the internal iliac.  They protrude in  the form of bluish nodes, or form
flat sessile tumors.  From their position, and  the frequent pressure and
congestion they are subject  to when  once formed, they are liable to
inflammatory attacks;  in consequence of which the surrounding cellular
tissue condenses and hardens.   Small  cysts are formed  in the latter,
into which blood is effused, and they then  exhibit a complex  structure,
which has been the source of much disputation.   Abernethy and Kirby
have even gone so far as to deny that  they were owing to varicosity of
the veins, and have asserted  them to be mere sacculated  prolongations
of the condensed  submucous tissue.    The  sequela: to which they give
rise are hemorrhage, ulceration, and  prolapsus  of the  rectum.   The
periodical character that is often  observed in the sanguineous flow, is
one that peculiarly deserves  the attention of the physician.   In man
the affliction is common in persons of  the middle of life, who have  fol-
lowed a sedentary pursuit; in women they are more apt to occur during
pregnancy, and as a substitute for the menstrual discharge at the period
of the climacteric.
   Of all forms of varix, none is, probably,  of  so frequent occurrence as
that which affects the superficial veins of the lower extremities, and more
particularly the ramifications of the saphena.   It is not  peculiar to either
sex, but is decidedly more common in females than males.  This remark
does not appear to apply to  the continent, however, for we  learn from
the statistics of Briquet, as well as from the statements of Hasse, that,
with them, the male sex is the most liable.   Another statement of Bri-
quet's, that it is more frequent in the right than in the left leg, is  not
confirmed  by British experience.  Hasse  observes that, in men,  the
dilatation generally arises from the trunk,  or the principal branches of
the saphena, while he states that, in women, it commences in the minute
twigs.   It is especially at the ankle, and at the inner side of the popliteal
space, that the veins are seen and felt, in the shape of an accumulation
of tortuous vessels, of a more or less resistant feel.
  A varicose state of  the veins of the pia mater is a condition upon
which Rokitansky lays  some stress,  as found after repeated attacks of
delirium tremens.   Oculists treat of  dilatation of  the veins of  the eye
in various forms; and instances of varix in  other parts of the upper half 
362
DILATATION OF VEINS.
of the body are recorded by authors.   Thus, Cruveilhier1 delineates two
cases of varix affecting the arm.
   Varicose veins may prove dangerous, by  giving rise  to  hemorrhage,
in consequence of ulceration or rupture.  They are not, like the arteries,
subject to  atheromatous disease, though occasionally they become ob-
literated by the  formation of a coagulum, or spontaneous inflammation
and cohesion of the parietes.
   An obliteration of portions of the venous system, from  spontaneous
coagulation of the blood during life,  is a not unfrequent occurrence,
either from the pressure exerted by morbid growths, as aneurisms or
cancerous tumors, or without such mechanical causes, from sheer cachectic
debility, as, for instance, in a case of empyema that fell under  our notice,
in which, from the inferior cava downwards, the veins were plugged up
with a fawn-colored coagulum.   They are not, however, limited  to the
veins of the inferior half of the  body,  though most frequently met with
in the vena cava  inferior, and the portal vein.   Dr. Bright2 records a
case in which the  longitudinal  sinus was  filled in  a child  of twenty
months, another of a female aged seventeen, in whom  the left jugular
and  subclavian veins were  plugged with  a  firm coagulum, terminating
abruptly just as. they entered  the cava, and a third, in a  female aged
twenty, in whom a white, fibrinous coagulum was found in the subclavian
vein, extending  two or three inches up the jugulars.   In both the last
cases the hardened veins were traced during life;  the subjects were all
in an extreme state of exhaustion.  In these cases, the coagulum can be
easily removed from the channel of the vessel, and the coats of the latter
present no evidence of inflammation in the shape of thickening or inter-
stitial deposit, or roughening of the lining  membrane.  Another form
of obliteration is that resulting  from a chronic inflammation  and conse-
quent adhesive process,  set  up by the  advance of degenerative disease,
such as tubercle or  cancer.  Thus Dr. Lee records two cases of abdo-
minal phlebitis resulting from  malignant disease  of  the  uterus;  and
another of inflammation of  the  iliac veins in a man, from carcinoma, is
related by  Mr. Lawrence.   Tubercle  never  directly affects the vessels ;
it is not found deposited in  the  coats,  nor is it found in their channels.
Carcinomatous matter, on the  other hand, is very frequently discovered
within the veins, either as an immediate extension of the disease, external
to them, or as an absorption of the morbid product.   Thus, in cancer of
the stomach  and liver, it has been found in the vena portae;  in  renal
cancer, in the corresponding vein and the vena cava inferior ; in uterine
cancer, in the vena cava and its branches.   Few of the  observers of the
cases on record  have verified the  fact of the  cancerous nature of  the
contents of the vessels by microscopic examination, and in many instances
fibrinous coagula have been mistaken  for cancer, when coincident with
the latter.   Langenbeck3 has, however, established the possibility of the
occurrence of cancer within the  vessels, by observing cancer-cells in  the
blood of individuals affected with malignant disease of the  uterus.  We

         1 Anatomie Pathologique, Livr. xxiii. and Livr. xxx.
         2 Medical Reports, p. ii. pp. 60, 64, 65.
         3 Essai sur 1'Anatomie Pathologique.  Par. 1816, vol. ii. p. 70. 
ENTOZOA.
363
must not, however, regard the presence of any one variety of cell as
essential to  determine the malignant character of a morbid growth.
The inherent tendency of  a certain blastema or matrix is to lead to the
production of appearances which are commonly denoted as tubercle, or
as cancer, but that blastema in itself need not present any microscopic
signs to distinguish it from  healthy albuminous or fibrinous deposits.
Hence it is not absolutely necessary that we should meet with what are
commonly called cancer-cells  in the cancerous contents
of the veins, in order to justify the conclusion as to their
malignant character.  Ossification very rarely affects the
veins, but cretaceous deposits are occasionally discovered
under the lining coat, as  in  the case of which we  have
given a delineation.   Cruveilhier1 relates the case of an
old man who died of gangrena senilis, in whom the veins
accompanying  the  popliteal  artery were studded with
phosphatic  deposit.   This must  not,  however,  be con-
founded with that  variety of  concretions  termed vein-
stones, or phlebolithes, which are met with  free in the
cavity of the vessels.   These  are  formed of concentric
laminae, of which the internal are  hard and brittle, while
those forming the  outer layers present a softer consist-
ency.   They closely resemble the concentric corpuscles
so frequently met with in the choroid plexus,  where, how-
ever, the formation is external to the vein.   They are found most fre-
quently in the pelvic veins, and in varices, and appear to result from a
stasis in the blood, first giving rise to a coagulum of fibrin, within which
a process of cretification takes place;  chemically they are found to con-
sist  of phosphate  and carbonate  of  lime, bound together  by  animal
matter.  The theory of their formation agrees with the mode of expla-
nation which suggests itself for other concentric corpuscles, and is con-
firmed by what we  occasionally see in diseases.  Thus, in a case of a
large cyst in the kidney, containing, within  an inner sac of false mem-
brane, a large black coagulum of blood, we found concentric corpuscles
in the false membrane, of  exactly the same character as those observed
in the brain.  Here, too, it seemed reasonable  to assume  the primary
deposition of fibrin, and the secondary precipitation within its laminae
of the phosphate of lime.  It is not impossible that  phlebolithes may
in some instances be the residuary traces of former phlebitis.   Dr. Lee
observes,2 that in the spermatic and hypogastric veins  of females ad-
vanced  in life, calcareous concretions  and disorganizations of various
kinds have frequently been observed, which must have been the conse-
quence of attacks of acute inflammation at remote periods.
 Calcareous deposit
in the coats of a vein.
—St. George's Mu-
seum, F. a. 12.
ENTOZOA.
  Before quitting the  pathology of  the veins, we have to allude to the
presence of entozoa,  and of gaseous contents  within  them.  Of the
1 Medico-Chirurgical Transactions, vol. xvi. p. 418.                2 Ibid. 
364
AIR IN THE  VEINS.
former, instances  are  recorded by various of the older authors, from
Pliny the elder downwards.  This writer states, in his Historia  Natu-
ralist, that animals form in the blood of man, and destroy his body. The
most recent observation of parasitic animals in the blood is recorded by
Dr. Bushman;1 but it is liable to objections which tend to invalidate the
conclusions  arrived  at.   The observation of the  presence of distoma
hepaticum in the trunk of the vena portae in a man aged forty-nine, by
Duval,2 is more valuable and trustworthy.  Andral3 recounts the only
instance known of hydatids found in the venous system.   They occurred
in the pulmonary veins of a man aged fifty-five, and twenty-three occu-
pied  the  small ramifications  shortly before  their transition into the
capillary network.   They varied in  size from a pea to a nut, and were
symmetrically distributed through both lungs.   They had all  the cha-
racters of acephalocysts.


                       AIR IN THE VEINS.

   The  entrance of air into the veins is one of  the most formidable
occurrences complicating operations about the  neck, that  the surgeon
has to deal with.  Death ensues rapidly, and atmospheric air  is found
in the right side of  the heart.   Air has been traced in  some  of these
cases in the aorta, the crural arteries, the arteries of the brain, the in-
ferior cava, the iliac veins, and the coronary veins of the heart.4  It has
been  suggested  that, in some cases of sudden death  after  delivery, the
cause might be found in an introduction of air  into  the  circulation by
the open mouths of the veins,  when the uterus  contracted imperfectly.
Another question is the possibility of the spontaneous evolution of gas
within the veins during life.   Many of the cases on record  are undoubt-
edly mere instances of rapid putrefaction; but we are justified both by
the constitution of  healthy blood, and by post-mortem  observation, in
admitting the reality of such a change before death.  Numerous authors,
among whom we would mention Dr. Baillie,5 have met  with  air  in the
veins of the pia mater in cases of apoplexy, before any traces of decom-
position were to be  perceived.   Dr. Bright6 attributes the presence of
air in these cases exclusively to  accidental injury of the veins, or to in-
sipient putrefaction.  The evolution of gas during life, though difficult
of absolute proof, is entirely within the  range  of probability, when we
consider that venous blood contains an excess of carbonic acid gas, which
is discharged on reducing the atmospheric pressure, as demonstrated by
Magnus.  "Perhaps," as Professor Puchelt remarks, "it happens more
frequently than we  are aware, that  a bubble of air forms in  the  venous
blood, and again disappears.  I am  acquainted with at least one variety
of palpitation, which produces the sensation; and, I am almost inclined

   1 The History of a Case in which Animals were found in Blood drawn from the Veins
of a Boy, London, 1833.
   2 Gazette Medicale de Paris, 1842, No. 49.
   * Magendie, Journal de Physiologie, vol. iii. 69.
   4 See Puchelt, das Venensystem, Liefing, 1843, vol. iii. p. 328.
   s Morbid Anatomy, p. 430.
   « Medical Reports, vol. ii. p. 668. 
THE CAPILLARIES.
365
to assert, the noise, as if a  bubble passed through  a fluid.  It occurs
generally with but one beat of the heart, and I  have  met  with  it in
venous subjects with an hemorrhoidal tendency, and a liability to  flatu-
lency."

                       THE  CAPILLARIES.

   The importance of the capillary circulation in its  bearings upon dis-
ease, and the relation borne by the blood to the coat of the vessels, and
by both to the nervous terminations and other surrounding tissues, can
scarcely be over-estimated;  and yet we are  inclined to think that in
most of the experiments  performed with a  view  to  determining  their
functions or ascertaining the part they bear  in disease, as in inflamma-
tion, the most important of all morbid processes, the share taken by the
vessels has been regarded more than the changes occurring in the circu-
lating medium itself.  A great physical difficulty  presents itself in the
examination of the ultimate  radicles of the vascular system in most of
the organs of the body, from our  inability sufficiently to isolate  them.
Where we are able to do so,  as in the brain  or pia  mater, we may, in
inflammation, trace the evolution of the morbid product in the shape of
minute molecular spherules, but the coats of  the vessels must be looked
upon rather as the passive agents  of percolation, than as the  active pro-
moters of the diseased action.   Calcareous deposits are also  seen, as in
cases of cerebral  apoplexy,  upon very  minute vessels, but we do not .
possess any means of determining in  how far the  vascular coats are
liable to anything like an idiopathic morbid  condition.  We need not
enter into the question of the part played by the capillaries in nutrition
and  inflammation, as that is discussed in the general pathology.  There
are few morbid processes in which they are not involved, though at the
same time we must not forget that they are  not  essential to diseased
action, and that, as  many healthy changes of the  body are affected by
metamorphoses directly from the blood,  or through  the intervention of
non-vascular tissue, so, in disease, the capillary system is one of several
of the agents of the  morbific influence.  We  must here allude to a form
of inflammation which, from presenting somewhat peculiar characters,
has  been termed  by Cruveilhier, capillary phlebitis.  It depends  upon
the same causes as those to  which we  have traced metastatic abscesses,
or purulent deposits, viz:  a poisonous infection of the blood, and hence
is most commonly met with in organs to which there is a great afflux of
blood, as in the lungs, the spleen,  the kidneys, and the liver.   The form
in which it appears,  is that of a circumscribed patch of injected and in-
flamed tissue, which, by itself, may pass through  the various stages of
inflammation; or it  may, in its  turn, excite active inflammation in the
surrounding parts, which will present different features, in color and
consistency, by which  the  two may be  distinguished.  Rokitansky ob-
serves that capillary phlebitis is not essentially a true inflammation, but
that it consists in a  coagulation of the blood in some  portion of the
capillary system, and is analogous to  the phlebitis  caused by coagula-
tion.  He states that the coagulum at first appears as  a dark red in-
farctus of the affected parenchyma; that it  subsequently may undergo 
366
THE CAPILLARIES.
various processes, either breaking up and commingling with the blood,
or undergoing a retrograde process, leading to obliteration and atrophy
of the part affected, or passing  into purulent or  gangrenous fusion.
Rokitansky also expresses it as his opinion that the capillaries may be
affected in a similar way as he describes the arteries to be, by an exces-
sive deposition of "lining  membrane," only that the  anomaly is  here
less in degree, owing to the arterial portion of the blood being expended
in the  process of nutrition.
   Among the chronic forms of  disease which are attributed more par-
ticularly to the capillaries, and to which  we have not had occasion to
allude  elsewhere, is the affection which  Mr. John Bell, and  English
writers following him,  have  termed aneurism by anastomosis, or the
Germans, more  classically, teleangiectasis.1   It  is  also known by the
simple term, erectile tumor, which is probably the best, as it implies no
theory. The affection is commonly congenital, and presents itself in the
shape of a  cutaneous swelling of a  circumscribed form  and bluish-red
color, liable to considerable variations of distension,  according to the
state of the circulation.   The tumor commonly, though not always, offers
a pulsation to the touch isochronous with the arterial pulse.  Bell described
the tumor as consisting of  a  congeries of vessels, between which  were
cavities and cells communicating with the latter; others have attributed
the affection solely to a distended condition of the vessels, among whom
may be mentioned  Syme and Pelletan;  it is, however, extremely pro-
bable that both conditions may occur, as in the analogous case of hemor-
rhoidal tumors ; and that while one erectile tumor contains only vessels,
another consists of both vessels  and cellular cavities.  This explanation
would aid in understanding the difference  in the symptoms presented by
this species of tumor.

  1 Teleangiectasis—literally, expansion  of the remote vessels; t>?Xe, distant, remote;
ayyos, a vessel; IxteiW, I distend.  See also page 175. 
CHAPTER  XXV.
                   THE LYMPHATIC  SYSTEM.

  Our knowledge of the diseases of the lymphatic system  is not com-
mensurate with the importance we attribute to it in the animal economy
on physiological grounds.  We may infer, from the close relation which
it bears to the metamorphoses of the tissues, that it must be morbidly
affected in all diseased conditions of individual parts, while its anatomi-
cal bearings assist in accounting for the difference which prevails between
diseases specially affecting the lymphatic vessels and the veins. A morbid
product, or  a poison that  has found its way into a vein, meets with no
impediment, and, unless adhesive inflammation be set up at the point of
introduction, speedily taints the  whole system; the force and direction
of the blood-current materially facilitate the propulsion  of  any foreign
matter that  has  entered the vein.   In the lymphatic vessel we have no
such powerful and continuous stream, nor do the channels enlarge in the
same uniform manner  as  in the former; on the contrary,  we find the
passage every now and then blocked up by a sluice, in  the shape of a
lymphatic gland, the obvious object of which is to submit the contents
of the afferent vessel to a process of purification.  By this means, fur-
ther security is provided against the ultimate introduction into the blood,
by the thoracic duct, of deleterious matter, which may have penetrated
the lymphatics.   Hasse1 observes  that the lymphatic vessels, being ex-
clusively devoted to the purposes of absorption, can contain  fluids of
very  various, and even morbid  admixture, without detriment to their
internal membrane, and that it is  not until the fluids in  question have
reached the lymphatic glands that inflammatory reaction becomes esta-
blished.   He instances the conveyance of miasmatic and contagious
matter through the lymphatic system, as  in typhus, the plague, &c,
where the lymphatic vessels never exhibit any morbid alteration, although
the glands  are  found  more or less  disorganized.  We must, however,
demur both  to  the fact and to the conclusions drawn by Hasse;  for
although undoubtedly the  mere presence of noxious  matters, either in
the blood or in the lymph, does not necessitate inflammatory reaction in
the  coats of the  vessels, the fact of lymphatics presenting all the symp-
toms  of inflammation between the seat of irritation and the next chain
of glands is  one of too frequent occurrence  to establish it as a rule that
the  morbid manifestation only takes  place in the latter.  The metamor-
phosing and eliminating power of the lymphatic glands is one that exerts

         1 An Anatomical Description, &c, Sydenham Society's Ed. p. 2. 
363
THE LYMPHATIC  SYSTEM.
a most important influence upon the preservation of health, and, where
it is weakened, as in scrofulous individuals, we see that every species of
disease  makes  an easy ingress, and  is with difficulty expelled.  This
circumstance offers a satisfactory explanation for the great variation in
the susceptibility of different individuals to the action of morbid agents;
as we see in the undoubted exposure of several  subjects to  the same
infectant;  when, for instance, the same venereal female  receives a suc-
cession  of visitors, we have good grounds for assuming that each of the
men came into contact  with the syphilitic  poison, we  may  find one
enjoying an entire immunity from evil effects, while the  other  becomes
the subject of secondary and tertiary symptoms.
   Inflammation of a lymphatic  is manifested  by redness, painfulness,
and swelling, in its course; the coats become thickened and infiltrated,
and exudation and suppuration may occur in their channels.  A resolu-
tion is  the most common termination of the process.  The presence of
pus in the lymphatics does not necessarily demonstrate the existence of
inflammation of the vessels; it may be introduced into them by abrasion
or  ulceration  of  lymphatics communicating with  an abscess.   Suppu-
rative  inflammation gives rise  to small  isolated  abscesses along the
course  of the  lymphatic vessels, forming, as it were, stations of the
disease, each  of  which appears to serve as a  fresh  focus of morbid
action.   The inflammatory process more or less affects the surrounding
cellular tissue from  the commencement.  With the advance of the in-
flammation, the lymphatics are blended with it, and  suppuration  and
the formation of  abscess involve the entire mass.  A chronic inflamma-
tion of lymphatic  vessels is met with in  scrofulous, tubercular, and
cancerous disease.   Their coats  are  found indurated  and thickened,
and their channels  are  blocked  up with the morbid blastema of the
heterologous growth.  The frequency with which  this occurs,  appears
to be in a ratio to the softened condition of the  deposit in the organ
from which the affected  lymphatics take their origin.  Thus, in a case
of encephaloid cancer of the stomach, in an aged female, that  occurred
under our own observation, the plexus of  lymphatics  occupying the
lesser curvature of the organ were gorged  to  the size of crows' quills
with the cancerous matter.1  In the majority of instances, we meet with
no  such filling up of those vessels, and the subacute inflammation which
coexists in their glands appears to be either the result of irritation pro-
pagated to  them from the primary seat of  the  lesion, or of idiopathic
disease  set up in  them as the purifying agents of the blood.  Sir Astley
Cooper2 reports three cases of obliteration of the thoracic duct, two of
which were connected with tubercular, the third with cancerous disease.
In  the  first, the obstruction  was  produced by the  thickened valves, in
three distinct parts, adhering to one another, the lowest still allowing of
a partial transmission of fluid, the upper arresting  it entirely.   Scrofu-
lous matter was found  deposited between the laminae of the valves.  In
the second there was considerable thickening and ulceration of the duct;
two fungous growths occupied the channel; and in  the third, which

            1  Report of Pathological Society, 1847-48, p. 195.
            2 Medical Records and Researches, 1798, p. 87. 
THE LYMPHATIC SYSTEM.                369
occurred in a man who had died in consequence of malignant disease of
the testis and  the lumbar glands, the thoracic duct was found  much
thickened, and filled with a pulpy mass, composed of broken, coagulable
lymph.   Opposite the curvature of  the  aorta, the vessel was lost in a
swelling as large as a moderate-sized walnut, beyond which it was nor-
mal.  The paper from which these cases are derived, contains various
experiments upon the thoracic duct in animals, of physiological interest.
One of the main conclusions arrived at by the author in reference to
this point is, that the circulation in the lymphatic system may be kept
up  by dilatation of collateral vessels subsequent  to the  occurrence of
obstruction in a trunk, as in  the vascular system at large.
  A varicose condition of lymphatics is  occasionally met  with in atonic
habits,  causing  them to resemble hydatid tumors.  It affects parts of
the system, and especially the thoracic duct is liable to dilatation ; occa-
sionally the entire system is found  in this condition, and an extreme
instance of this, occurring in a young man, aged nineteen, which hap-
pened in the practice of M. Amussat, is given in the works of Breschet
and Carswell.   Cruikshank1 alludes  to  and delineates a similar case.
Here, the lymphatics of the groins had reached a size sufficient to permit
of the introduction of a straw by which  air was blown into them;  the
iliac ganglia had entirely disappeared, and were  replaced by the lym-
phatic vessels.   A corresponding enlargement of these  vessels was traced
through the  abdomen into the thorax; none of the  other viscera pre-
sented any marked pathological changes.   The depurating functions of
the lymphatic  glands while  they render these  organs safety-valves to
the system, also induce in them a frequent  liability  to disease, which is
characteristic of what  is familiar to us as the lymphatic constitution.
The irritation to which their affections are traceable, may proceed from
some local lesions, from which it is carried to  the  neighboring glands
by  the connecting lymphatic, as in the case of a sore on the prepuce,
inducing bubo,  or of porrigo of  the head, causing  tumefaction of the
cervical glands; or, it may be excited directly by the morbid condition
of the blood circulating in the capillaries of the glands.
   Simple acute inflammation  is manifested by tumefaction, softening,
and a  highly vascularized state  of  the  organ, causing  it, on  division
with the knife, to distil blood, while its color is changed from a reddish
gray  to a dark red or crimson tint.   If  suppuration has ensued, yellow
spots first appear in different parts, and eventually the entire gland may
be destroyed by the process, and be converted into an abscess, in which
the surrounding cellular tissue is more or less implicated.   The chronic
form  is, however, the  more common;  a species of  plastic  matter is
effused  interstitially, and induces gradual enlargement and induration of
the gland.  This condition may  be  perpetuated, and  the resulting hy-
pertrophy exhibits a conversion of the effused  matter into the ordinary
cell  structure, displayed by the  microscope as constituting the  gland
tissue.   On the other  hand, a  reabsorption of the interstitial deposit
may occur, as we have frequent opportunities of observing, as the effect

  1 See Carswell, Patholog. Anat. Fasc. ix. pi. iv. fig. 4; and Breschet,  Le Systeme Lym-
phatique, 1836, p. 260.
       24 
370
THE LYMPHATIC SYSTEM.
of a suitable dietetic  and medicinal regimen, in consequence  of which
the parts regain their normal size and appearance.
  Hypertrophy of the glands, whether simple or complicated, with the
tubercular  diathesis, is  peculiarly prevalent in  childhood,  at  the time
when the  vegetative development of the  animal economy makes the
greatest  claim upon  the organs  of nutrition and  metamorphosis;  an
atrophic condition is met with  in  advanced age, after the period of in-
volution has commenced, and it is stated by Rokitansky particularly to
affect the mesenteric glands as a result of typhous infiltration,  in con-
sequence of which the parenchyma of the gland is absorbed, as  well as
the product of the process.   The inflammation of the mesenteric glands
accompanying typhous  fever, is  a point upon which  Rokitansky1 lays
great stress.   He considers it as an  integral  part of ileotyphus, and
states  it particularly to attack the chain  of lymphatic glands  corre-
sponding to the affected part of the intestine.   He looks  upon it as a
substantive affection of the glands, allied to the morbid condition which
they present in  the Oriental plague.  The reader will see that, in regard
to the lesions of the  mesenteric glands  in fever, there is  a wide differ-
ence of opinion between Rokitansky and Drs. Stewart and Jenner, who
on very satisfactory evidence have shown that typhus and typhoid fevers
are distinct  forms of fever, one of the characteristic features  of the
latter being the intestinal ulcerations and disorganization of the  mesen-
teric glands, while no such affections are met with in typhus.2


                            TUBERCLE.

   Few parts of the body are more exposed to the deposit of tuberculous
matter than the lymphatic glands.  It occurs in them either in  a pri-
mary or secondary form, as the  result  of direct elimination from the
bloodvessels, or owing to the conveyance of tubercular matter from the
organ from which the lymphatics are derived.   We see  it  in the shape
of yellowish masses, interspersed among the gland tissue;  and as the
morbid  deposit  increases, encroaching more upon, and  ultimately en-
tirely destroying all traces of,  the normal tissue.  The tubercular mat-
ter is observed to go  through  the same  processes of softening and sup-
puration, or  of  induration and cretification, that we  find it  liable  to
elsewhere.    Children are peculiarly prone  to tubercular disease of the
glandular system; but there is  a considerable difference in the proclivity
of different sets of glands to be affected.  All  authors are agreed that
the bronchial are pre-eminently endowed  with this  tendency.  The
analysis of one  hundred post-mortem  examinations of tuberculous chil-
dren, by Dr. Lombard,3 showed that
            the bronchial glands were affected in 87 cases.
            the mesenteric       "       "       31  "
             the cervical         "      "        7  "
             the inguinal        "       "        3  "
  1 Pathological Anatomy, Sydenham Society's Edition, vol. iv. p. 390.
  2 For the further details we must refer to the original papers of these authors, which
are contained in the Medical Times (1851) and the Edinburgh Medical and Surgical Jour-
nal (1840).
  3 Andral, Precis d'Anatomie Pathologique, vol.  i. p. 425. 
CARCINOMA — MELANOSIS.
371
  In the case of the bronchial glands, a communication is occasionally
established between their  contents  after they have  softened  and the
channel of the bronchi, and may be thus evacuated, by expectoration.
The chalky concretions find  their way out occasionally in the  same
manner.   A remarkable instance of death being caused by the impac-
tion of the cretaceous contents of a bronchial gland in the bronchi, is
detailed by Dr. Tice, in the twenty-sixth volume of the Medico-Chirur-
gical  Transactions.


                           CARCINOMA.

   The lymphatic glands are very commonly the seat of malignant dis-
ease; it  affects them either  primarily  or  secondarily, but  more  fre-
quently in the latter form.   It is probably owing to  the implication of
the lymphatic system that we may, in part, at least, attribute the symp-
toms  of  cancerous cachexia in  an advanced state, as influencing the
process of nutrition and assimilation.   No other part of the economy
is so liable to secondary cancerous deposits as  the  lymphatic glands;
the immediate cause of their becoming the  seat of the heterologous
growth  being the  introduction of cancer blastema from  the  affected
organ, or an irritation set up by the proximity of the gland to the latter,
which, in its turn, excites a fresh separation of cancer matter from the
blood.   The second explanation is probably that which obtains in  most
cases; for we find the parenchyma  of the  gland to  be the  prevailing
seat of the  disease, both  in primary and  secondary carcinoma of the
lymphatic glands.  It commonly appears in the shape of a general in-
filtration, and rarely in isolated nodules or islets.  The encephaloid or
medullary variety is the form which carcinoma generally presents in the
glands.   In a case of pancreatic  sarcoma affecting the thoracic muscles
of the right  side, which fell  under  our own  observation, there was a
development of  a similar morbid growth in the  anterior mediastinum,
evidently involving, if not proceeding from, the bronchial glands.  The
tissue was made up of fibres and fibroid cells and circular corpuscles,
containing oil-particles.    The lungs  and other viscera presented no
trace  of  a similar disorganization.   In  another instance, occurring at
St. Mary's Hospital, in which the bronchial glands were converted into
a mass closely resembling a malignant growth, though the microscope
only exhibited granular corpuscles, resembling the forms seen in tuber-
cle, the lungs were free from substantive disease, though the spleen was
both disorganized and hypertrophied, and presented in its tissue deposits
resembling those found in the bronchial growth.


                           MELANOSIS.

  An affection to which the glandular system, and especially those parts
in relation to the respiratory  organs, is  very prone,  is melanosis; it is
scarcely, however, to  be looked upon as a morbid process in itself, but
rather as  an evidence of the depurating functions by which they assist
in eliminating the superfluous carbon from the blood.   We have shown 
372
ENTOZOA.
elsewhere that melanosis does not, in itself, constitute a malignant disease,
and that it does not consist of a new formation, but that it is mainly a
secretion of normal constituents of the blood, though frequently compli-
cated with malignant affections.  While it is unusual to find black matter
in the lymphatic ganglia of the abdominal or inguinal regions, we con-
stantly meet with it in the glands surrounding the bronchi.


                            ENTOZOA.

   The only instance on record, of entozoa being found in the glands, is
recorded by Rudolphi.1   It was found by Treutler, in a  person  worn
out by syphilis;  it was an inch in length, tawny in color, semitransparent
at one end, presenting two hooklets at its anterior extremity, and hence
termed hamularia bronchialis.
1 Entozoorum Historia Naturalis, vol. ii. p. 82. 
THE PATHOLOGICAL ANATOMY  OE THE
         ORGANS  OE  KESPIBATION.
                  CHAPTER  XXVI.

                 GENERAL OBSERVATIONS.

  We learn from the registers of mortality that the most prevalent cause
of death at various ages is to be found, in our climate at least, in morbid
conditions of the organs of respiration; if  it were possible to estimate
the amount of  disease introduced into  the system through the  lungs,
though manifested in other organs, we should enhance  the importance
of an intimate  acquaintance with their pathology still further.   While
the lungs serve the purpose of affording to the blood the means of effect-
ing  the changes of assimilation and metamorphosis,  this very function
renders them, by their extent of surface, and by their intimate relation
to the capillary'circulation  throughout the body, more  than  any other
organ the portal of disease.  The impalpable  poisons borne on the air
enter the human economy chiefly by  this entrance, and the system,
debilitated by the various influences that wear out its strength, is attacked
at this point by irritants of all kinds, introduced directly from without,
palpable and impalpable.  Thus, the lungs and their accessory parts are
subject  in various ways  to  suffer primarily or secondarily from  causes
that  scarcely affect other organs; no  age  is exempt; no sex or rank
offers any immunity; the common air is the common danger, and the
sanitary measures necessary to anticipate or remoye it, confer im-
measurable benefits upon all, though the boon may be  but scantily ac-
knowledged.
  We shall examine the pathological conditions of the different parts of
the  respiratory system  in  the  order in which they naturally present
themselves, as we proceed  from the orifice  downwards ; commencing
with the larynx and  its appendix the epiglottis, we shall descend to the
trachea, the bronchi and their ramifications, the pulmonary parenchyma,
and the'pleura.  Though a definite relation exists between these different
parts, which is more intimate in some than  in others, they are each sus-
ceptible of isolated  morbid states; and though  the continuity of the
mucous membrane lining the entire  passages frequently induces a  pro-
pagation of disease from one part to the other, this is by no means uni- 
374
THE EPIGLOTTIS.
versally the case, and the catarrh or croup affecting the larynx or trachea
need not cause any pathological changes in the adjacent mucous mem-
brane, or the other tissues of  the affected part itself.  The absolute
importance of the morbid condition to the individual, does not necessa-
rily bear a direct relation to its  intensity, but depends a great deal upon
the part affected; a point which the physiological  laws regulating the
different sections of the respiratory organs render sufficiently palpable;
thus, a trifling amount of inflammatory swelling of the glottis or epiglottis
threatens danger, while much more intense inflammation of  the pulmo-
nary parenchyma, or of the bronchi, may run its course without causing
more  than  a temporary inconvenience.   The features  of  the  morbid
condition may be identical, while their bearings upon  the existence of
the individual are widely dissimilar.
                        THE EPIGLOTTIS.

  The epiglottis is, notwithstanding its exposure, not very liable to dis-
ease, a circumstance due in part to the dense fibro-cartilaginous tissue
which forms  its substratum.   The mucous membrane which invests it,
may be affected with  acute or chronic inflammation,  in which case the
vessels enlarge and become tortuous and congested, and the light  pink
hue is converted into a streaky, or more  or  less uniform redness.   The

                               Fig. 173.
 Acute ulceration of the epiglottis and surrounding parts in a man, caused by taking a large dose of bichlo-
ride of mercury.  Death followed after nine days; there were pneumonia, ulceration of the stomach, and
inflammation of the entire intestinal tract.

acute form  is commonly the result of mechanical injury or  chemical
irritation; while the chronic form accompanies old standing  catarrhs of
advanced age, arthritic  or  syphilitic cachexia, and  other conditions
resulting from general atony.   The  former is met with as a result of
the action of irritant poisons, which may thus cause death without pass- 
THE EPIGLOTTIS.
375
  ing the fauces; and  as Dr. Marshall Hall1 has pointed out, in conse-
  quence of children, as frequently happens among the poorer orders,
  drinking boiling water from the spout of the kettle or tea-pot.  In these
  cases there is also rapid and extensive oedema, giving rise to a mechanical
  impediment  to the admission of air into the lungs.  In one of the in-
  stances detailed  by Dr. Davis,2 suffocative dyspnoea supervened within
  three or four hours, and when at  this period the attempt was made to
  apply leeches, the  child, a  little girl of three  years of age, was  much
  terrified,  and screamed so violently, that they could not be applied.
  From this moment, however,  respiration became easy, and a speedy
  recovery  took place, owing  most  probably to a rupture of the  bullae
  which had formed in consequence of the irritation.   The remedy which
•  in such a case relieves the  immediate symptoms, and may thus be the
  means of saving life, is the  operation of tracheotomy, though,  as in the
  instance from which the delineation was taken, not  always successful.
     Ulcerations of the epiglottis are not unfrequent, more especially as
  complications of phthisis;  they are generally limited  to the inferior
  surface of the valve and to its mucous covering; though they  occasion-
  ally penetrate to  the  fibro-cartilage.   They are not generally accom-
  panied by much  tumefaction or reddening  of the  surrounding tissue.
  Louis3 states that in all the cases that fell under his  notice, he only once
  observed ulcerations on the lingual surface; he found the breadth of the
  ulcers to vary from about one  to two lines;  though in  some cases the
  laryngeal surface of the epiglottis  was  entirely deprived of its mucous
  membrane:  in four cases  the edge of the fibro-cartilage was destroyed,
  as well as the surface ulcerated,  so as  to  give  the part  a festooned
  appearance;  in a fifth  case  the epiglottis was totally destroyed.   The
  proportion of phthisical cases in which the epiglottis is affected, appears,
  according to the same author,  to be about one-quarter.  These ulcers
  are not,  however, the  result of a fusion of tubercular deposit, which is
  not met with at this point, but of sympathetic irritation and inflamma-
  tion; they, like other affections of the mucous membranes  of the  air-
  passages which have been mistaken for tubercular deposit, often  originate
  in occlusion  and sebaceous enlargement of the numerous solitary follicles
  scattered about the respiratory mucous membrane.   These vary in size
  from  an  almost imperceptible point to a pin's head, and even to that of
  a bean;4 and closely resemble miliary granulations, surrounded  by a halo
  of bloodvessels, as they appear for instance  in the pia mater.   The
  microscope,  however, reveals  their  structure; showing the basement
  membrane of the follicle lined  with epithelium, and containing  oily mat-
  ter.  The cheesy particles coughed up by many  people, are formed partly
  in the follicular structures of the tonsils;  and probably also in  the  folli-
  cles of which we have just  spoken.  The epiglottis is  liable  to  suffer
  from  syphilitical ulceration, by an extension  of the disease from the
  fauces: it very rarely passes beyond to  the larynx and trachea.  In
  smallpox and other eruptive fevers, the peculiar poison of the disease

               1 Medico-Chirurgical Transactions, vol. xii. p. 1.
               2 Ibid.
               3 Researches on Phthisis, Sydenh. Soc. Ed. p. 42.
               4 See a case detailed in Dr. Bright's Reports, ii. p. 644. 
376
THE  LARYNX.
often sets up its action in the fauces and the respiratory passages;  the
former may give rise  to  pustules  on the glottis, accompanied by more
Fie. 175.
Fig. 176.
 Fig. 174.—(Edema of the epiglottis, brought on by drinking scalding water, and causing the death of the
child, a boy aged three years and nine months, in two hours. The uvula, which is seen a little above and to
the right of the epiglottis, was also oedematous. No other feature was observed, except some reddening of the
bronchial mucous membrane, and congestion of the lungs.  Tracheotomy was performed.
 Fig. 175.—Q5dema Olottidis.
 Fig. 176.—Acute CEdema Glottidis; exposed from behind.

or less redness and serous infiltration;  in the latter, ulcerative destruc-
tion and cedematous swelling occur.   It is  to an affection of these parts
that more  particularly the danger of  the retrocession of the cutaneous
affections is attributable:  there is frequently an  inverse ratio between
the force with which the external and internal symptoms are manifested.
                           THE LARYNX.

   The mucous membrane of the larynx presents the same changes that
we meet with in the mucous  membrane investing  the entire respiratorv
tract.   In health it has an almost colorless, slightly pink hue, and con-
sists of a uniform epithelial surface, overlaying a basement membrane,
underneath which the vascular network ramifies.   The surface is broken
only by the minute follicles which open upon it.   In congestive and in-
flammatory states  this vascular network becomes  much distended;  the
membrane  is rendered thick  and soft by mere  repletion in the first
instance,  and subsequently by interstitial  effusion.   The more lasting
and chronic the inflammatory action, the more this  thickened condition
is  established, and thus a permanent hypertrophy of the membrane is
effected.  The color of an inflamed respiratory mucous membrane varies 
THE LARYNX.
377
according to the  intensity, and  also according  to the character of the
inflammation, from a bright crimson or scarlet, to deep purple or dusky
redness.  The hyperaemia is often found to be  entirely local;  this  is
chiefly the case in chronic affections: thus, we may find it limited to the
larynx, the trachea, or the bronchi.   The character of the inflammation
necessarily determines the nature of the products which occur upon and
beneath the membrane.   The most acute form is probably that in which,
from the contact of a powerful irritant, such  as boiling water, an  in-
stant effusion of  serum takes  place in the submucous tissue,  causing its
distension or  oedematous swelling.  We  have already alluded  to the
cases in which children  have met with their death  in  consequence  of
drinking the hot  contents of a kettle from its spout.   In some of these
it appears that the oedema rather  affects the  parts below the epiglottis
than the epiglottis itself.  Here, it is rather the mechanical effect of the
tumefaction of the loose tissue  at the  glottis than the intensity of the
pathological process, that produces the fatal issue.  In catarrhal inflam-
mation of the larynx, the dyspnoea, and affection of the voice, depend
mainly upon the  amount of tumefaction of the rima glottidis; during
the first stage there is, as elsewhere, in the mucous  membrane a sense
of titillation, roughness, and  pain; and as  the stage of secretion super-
venes, these symptoms subside and are  relieved by expectoration.  This
presents various  appearances to the naked eye;  at first, it  is a glairy
viscid mucus, which subsequently assumes a greenish  or yellowish color,
losing its adhesiveness and forming into opaque  rounded pellets.  If a
blennorrhseic state supervenes,  the discharge assumes a purulent cha-
racter.   Under the microscope these varieties  can  scarcely be distin-
guished.   In each, we find mucous corpuscles and epithelium; and if the
inflammation has  been of sufficient intensity to cause  hemorrhage, we
shall also  discover blood-corpuscles.   Idiopathic laryngitis  appears
generally to be the  result of atmospheric changes; it runs  a rapid
course, and it  is one of those affections in which  the performance  of
tracheotomy may become the  means of  saving  the  patient's  life.  The
disease acquires  an historical interest, from  the circumstance  that  it
proved  fatal to Washington.   Rokitansky describes, under the name  of
gonorrhoeal catarrh  of the larynx,  a variety which he attributes to me-
tastasis; he considers it  important on account of its  leading to a con-
traction of  the passage.   He states it  to attack the mucous  membrane
of the  epiglottis  and the duplicatures of the  glottis,  converting the
mucous membrane and subjacent areolar tissue into a  fibro-lardaceous
white resistant structure of tolerable thickness,  thus giving rise to con-
traction of  the rima glottidis  and the cavity of the larynx.
   In children, catarrhal  inflammation  of the larynx may produce all
the symptoms of  croup; in which case,  though, as Andral observes, the
passage of air through the contracted rima gives rise  to the well-known
sound of croup, the post-mortem examination will only exhibit a slight
tumefaction of the mucous  membrane,  without any trace of the mem-
branous exudation, which Bretonneau, Copland, and others consider  as
characteristic of  the disease.   On  this subject, the  morbid  anatomist
still  continues at  issue with the nosologist, a  circumstance which must
be attributed to the unwillingness, not to call  it by a  stronger term, of 
378
THE LARYNX.
the former to recognize any other proof of disease  than that discovera-
ble by the scalpel.   It appears difficult  to avoid seeing that the pecu-
liar disposition existing in infancy to spasmodic affections, dependent
upon great  irritability of the excito-motor system, may  convert the
most trifling irritant into a cause of danger and death, which would not
be demonstrable by our present means of examination; even in marked
cases of diphtheritic  exudation, the child does not  always die of the
mechanical obstacle, but by the indirect influence it exerts in producing
glottic spasm.  The variations presented by croup are numerous, and
depend upon atmospheric  causes, or upon peculiarities  of living, regi-
men, and residence.1
   The larynx is the most frequent seat of croupy exudation, and though
occasionally found to extend even into the smaller bronchial  ramifica-
tions, the deposit in the trachea  and  bronchi appears  invariably to be
continuous with the laryngeal exudation.   On the continent, more com-
monly than with us, the exudation also  forms on the velum palati, and
in the fauces and  pharynx; according  to Bretonneau's8 observations
during an epidemic at Tours, the exudation occurred simultaneously in
the gullet and air-passages, in fifty cases, while in  one only the former
was unaffected.   Six or seven  times he found that the membranous
concretion extended  to  the  smallest  bronchi, and in one-third of the
entire number it reached beyond the main division of the bronchi; in all
the rest it terminated at different points of the trachea.  In this form
it has received the name of diphtheritis, or pellicular inflammation.  The
exudation itself is of an albuminous character,  of  greater  or  less con-
sistency—we have  seen it of a translucent jelly-like character, scarcely
adherent to the parietes—though commonly it presents the appearance
of a thin and tolerably firm layer, moulded upon the mucous membrane,
varying in thickness from a mere film to a coat  a line and a half in
diameter.  It then exhibits the ordinary appearance of fibrin; of a light
yellow or cream color; more  or  less intimately attached to the mucous
membrane; from the latter it may, however, always be separated, leaving
its surface entire, and generally  of a bright red.  The functions of the
mucous membrane appear to have undergone an entire revolution; the
secretion resembling rather that  of a  serous membrane in tenacity, ad-
hesiveness, and coagulability.  It  is  deposited  in  patches, which may
gradually coalesce, and thus form  rings or channels of greater or less
extent; they send off small prolongations into the follicles scattered over
the mucous membrane, by which they are secured in their place until a
suppurative  process underneath, loosens  them, and allows them to be

  1  The reader is particularly referred to the  nineteenth  and twentieth Lectures in Dr.
West's work on the Diseases of Infancy,  &c.
  Croup is a disease known by a great variety of names, which are calculated to embar-
rass the student.  Cynanche is the oldest term, under which it is described by Paulus
./Egineta, as a well-known affection (see the Sydenham Society's Edition of his work, vol.
i. p. 464); modern writers  term it promiscuously cynanche, angina, trachitis, with the
epithets merabranacea,  polyposa, stridula,  diphtheritis, pellicular inflammation, asthma
acutum infantum, ccc.   The English name croup is of Scotch  origin, and was first, we
believe, introduced into general use by Sir Everard Home.
  8 Des Inflammations Spe"ciales du Tissu Muqueux, &c, par P. Bretonneau. Paris 1827
p. 32. 
THE LARYNX.
379
thrown off, if the patient retains  strength to do  so.  No chemical or
microscopic difference has hitherto been shown to  exist between croupy
exudation and the product of acute inflammation of serous membranes,
or of the fibrin of the blood.  The hue of the subjacent tissues in cases
accompanied by great  disturbance of the circulation, or with typhoid
symptoms, becomes dusky and livid.  There rarely are  any abrasions
of the mucous membrane of the trachea.   If there  is more than usual
difficulty in removing the false membrane from the larynx, this depends,
as Dr. West1 remarks, upon the more extensive alterations which this
part of the air-tube  has undergone.  It is generally red and swollen,
especially about the edges of the rima glottidis, the  arytenoid cartilages,
and the openings of the sacculus laryngis.  It is in the former that we
occasionally find small aphthous  ulcerations.  In that  form  of croup
which succeeds to measles, we are informed by Dr. West, that there is,
in many instances, a condition of unhealthy inflammation, and aphthous
ulceration  of the mouth and gums; a slight speck of ash-colored false
membrane covering each little ulcer.
   The diseases with which croupy inflammation is  most frequently com-
plicated are bronchitis and pneumonia; though we very commonly meet
with no other symptoms of morbid action  than those found in the part
affected; nor is there any doubt that these may be so slight as altogether
to escape observation, in the post-mortem examination.   We must here,
as elsewhere, be careful not to mistake the pulmonic congestion, resulting
from the suffocative influence of the malady,  with inflammatory action.
   The disease  which we have  just  considered is  almost exclusively a
disease of  early childhood.  The  aphthous ulcers found as a result of
aphthous stomatitis, or muguet, are equally peculiar to infancy.  It is
not so with the ulcerations which constitute an affection termed phthisis
laryngea, which accompany tubercular phthisis of  the lungs, and rather
belong to puberty and the later periods of life.   It has been long thought
to constitute an idiopathic disease, but morbid anatomists are now agreed
that it occurs only as a sequela of tubercular disease of  the lungs, and
also that it is very questionable  whether it is ever preceded by the
deposit of  tubercle in the larynx itself.   With regard to the latter point
we must not, however, overlook the statement of Rokitansky, that it is
deposited  in the form of gray granulations in the submucous  areolar
tissue, or as yellow caseous matter, infiltrated into the mucous membrane.
He has found it constantly and exclusively in the  vicinity of the trans-
verse muscles and the  adjacent arytsenoid cartilages.  His experience
is strikingly at variance with  that of  Louis, who has not in a single
instance met with tuberculous granulations in the substance,  or on the
surface of the epiglottis, larynx,  or trachea.   Dr. Watson attributes
these ulcers exclusively to the acridity of the sputa; but, although the
sputa manifestly exercise an influence in their production, there must be
some further cause, as they are by no means constant accompaniments
of phthisis, and as they do not form at some points, e. g. the ventricles
of the larynx, in which a lodgement of sputa must constantly take place.
Louis states ulcers  in the larynx to have occurred in a fourth part of
his cases.
1 Lectures on the Diseases of Infancy, 2d ed. p. 221. 
380
THE TRACHEA.
Fig. 177.
  In children, ulceration of the air-passages is scarcely ever met with;
Dr. West1 has only seen it once in early life; on that occasion, several
small excavated erosions were found, just above the chordae vocales, in
a child of twenty months, besides a general redness of  the bronchial
tubes.   In the  larynx, their  site  is generally at  the junction of  the
vocal chords, on the vocal chords themselves, and  on the  arytenoid
cartilages.
  Ulceration of the mucous membrane may extend to the cartilages of
the larynx; or these may be primarily the seat of inflammatory action,
as the result of deep-seated cachexia, such as  syphilis.   To this cause
we must also refer the epithelial formations or polypoid growths, which
                           are occasionally  found springing from  the
                           mucous lining of the  larynx.   Cancer  no-
                           dules of the medullary variety are also met
                           with  in  these parts, and Rokitansky  de-
                           scribes, as a very singular form, a cancerous
                           degeneration of the  arytenoid cartilages.
                           These affections  are generally accompanied
                           by symptoms of chronic laryngitis, consist-
                           ing in reddening and serous infiltration and
                           hypertrophy of the surrounding tissues;
                           with wasting and degeneration of the laryn-
                           geal  muscles, and  occasionally the forma-
                           tion  of abscesses in the submucous layer.
                             The laryngeal cartilages have a "tendency
                           to ossify in  advanced life in obedience to
                           the general law affecting similar structures;
                           but this metamorphosis is also produced by
                           disease; and it is probably in  those cases of
                           chronic laryngitis  chiefly, which are con-
                           nected with a rheumatic diathesis and origi-
                           nate in the perichondrium, that this meta-
                           morphosis takes  place.   The larynx is not
                           so liable to be affected by tumors or foreign
                           bodies pressing upon it as other parts of the
respiratory system, on account of the greater rigidity of its walls, and the
capaciousness of its interior.   Foreign bodies arrested in the oesophagus
generally become impacted behind the larynx ; when introduced by the
glottis,  they may become fixed in the chink; but if they pass the portal
they necessarily drop through  the wider cavity of  the  larynx,  and
become fixed at  some lower point, or play up and down in the trachea.
Ulceration of the larynx.
THE TRACHEA.
  Many of the observations which we have had occasion to make on the
pathology of the larynx  apply to the trachea.  The congestion of the
mucous membrane presents similar characters; it is  generally observed
1 The Diseases of Infancy, 1st ed. p. 71. 
THE TRACHEA.
381
to be most marked in the membranous interstices, between  the  rings
and at the posterior part.  Occasionally, it is bounded  by a sharp out-
line;  thus, where the hyperaemia of the trachea is associated with disease

                                Fig. 178.
 Enlargement of follicles of mucous membrane of the trachea, closely resembling miliary granulations, and
accompanying pulmonary phthisis. The drawing on the right is an enlarged view of a single follicle, sur-
rounded by enlarged and congested vessels.  The glandular structure was distinctly apparent when examined
under a higher power.

of one lung, it may be seen on the corresponding half of the former only,
the mesian  line forming the division between the normal pale tissue and
the portion that presents  increased vascularity.  A similar observation
has been made with regard to the occurrence of ulcers, viz: that when
following unilateral  pulmonary disease, they are confined  to the corre-
sponding side of the trachea. Otherwise, the point of divergence of the
bronchi  and the  posterior mesian line are  the most frequent seat of
tracheal ulcers.   They may  often be traced to follicular inflammation,
in the same way as obstructed solitary follicles put on the appearance
of tubercular deposit.  The essential connection between  ulceration of
the trachea and pulmonary phthisis is even more firmly established than
in regard to the relation  between  the  latter and  laryngeal ulceration.
Louis1  found that, of  190  phthisical  subjects,  seventy-six presented
ulcerations in the trachea; while in 500 non-phthisical subjects, carried
off by chronic diseases, examined by  the same pathologist, not one pre-
sented any tracheal  or laryngeal ulceration.   A  curious  circumstance
connected with  this question  is the different ratio in which the two sexes
are affected; thus, Louis has shown that, while only about one quarter of
the  females who  succumb to pulmonary consumption exhibit ulcers in
the trachea, they are found in  half the male subjects  similarly diseased.
   Croupy inflammation of the trachea presents no characters which differ
from the phenomena exhibited by the disease when affecting the larynx
alone.
   The  rings of the  trachea,  like the cartilaginous  structures  ot  the
» On Phthisis, Syd. Soc. Ed. p. 42. 
382
THE TRACHEA.
larynx, are liable  to  become  abnormally ossified, a condition which
does not in itself exert any material  influence on the  health  of  the
                 individual.   The functions  of the  trachea are more
     Fig. 179.      liable  to  be interfered with than those of the upper
                 portion of  the  air-tubes, by pressure  exerted from
                 without;  encysted tumors,  hypertrophy, and other
                 diseased conditions of the thyroid gland, aneurismal
                 tumors of the carotid or subclavian arteries, or of the
                 arch of the  aorta, enlarged cervical glands, tumors,
                 and foreign bodies in  the  oesophagus, phlegmonous
                 erysipelas and diffuse abscesses  in  the vicinity, may
                 each induce compression of the windpipe to such an
                 extent as to cause death.    The practical question
                 which arises in these%ases regards the propriety of
                 performing laryngotomy or tracheotomy; it is also
                 one that requires  great judgment in connection with
                 disease of the mucous membrane, and the presence
                 of foreign bodies within the tube.
                    Diverticula are described as occasionally forming
                 in the trachea, by a  dilatation  of  a portion  of  the
                 posterior  wall,  and consequent  protrusion into  the
                 oesophagus between the ends of the tracheal rings;
   brane in croup.    they have been  attributed,  by Rokitansky, to an hy-
                 pertrophy of the  muciparous  glands.   The  dilated
duct of the hypertrophied cysts may be discovered  in the  pouch; which
confirms the explanation of its origin.  When met with in the trachea,
a similar condition  is sometimes traceable in the bronchial tubes.
   The presence of  extraneous matters in the air-passages is always an
occurrence of very serious  import;  but,  unless the substance becomes
impacted in the rima glottidis, it is  not immediately fatal;  the  mucous
membrane  of the lower  portions being less irritable and less liable to
produce spasmodic action.   The more rough the surface of the  foreign
body, the sooner inflammation is  likely to supervene;  and,  unless it be
removed by coughing, or by an operative proceeding, the issue is certain
death.  If of a globular form, and  too large  to enter into the bronchi,
it will pass up and down in the trachea, giving rise to a variety of  sounds.
Cherry-stones,  buttons, coins, teeth, morsels of food, portions of bone,
and other things, have thus found their way into  the  trachea,  and re-
mained there or got impacted in the bronchi.   One case is recorded by
Mr. Liston,1 as a solitary instance, of a piece of bone having lodged in
the right bronchus (which, from its size and relation to the  trachea, gene-
rally becomes the receptacle for foreign bodies), and having been dis-
covered and removed during life.   A triangular piece of mutton-bone
had, six  months previous to  the  operation, become entangled  in  the
glottis, and shortly  after slipped down the trachea.  A perfect recovery
resulted.
   The upper portion of the air-tube is also liable to fatal injuries inflicted
accidentally or intentionally.   In those cases in which life is not imme-
1 Practical Surgery, 3d ed. p. 412. 
THE TRACHEA.
383
diately destroyed by hemorrhage, the  injury may prove fatal  by the
secondary inflammation and tumefaction  of the mucous membrane, or
by coagula obstructing the passage of  air.   The latter is  particularly
likely to happen as a consequence of hasty surgical interference,  in pre-
maturely sewing up the wound, and thus preventing the necessary escape
of the blood. The trachea is less frequently subject to become the seat
of condylomatous  and epithelial growths than  the larynx; the same
applies to cancer, though carcinomatous affections  of the neck occasion-
ally make their way into the trachea. 
CHAPTER  XXVII.
                    THE BRONCHIAL TUBES.

  The diseases of the bronchial tubes affect the  individual very differ-
ently, according as the larger or smaller divisions are the seat of the
morbid  action.   Thus, the same amount of tumefaction which, in the
mucous  membrane of  the bronchi near the trachea, will  scarcely give
rise to any inconvenience, will,  in the finer ramifications, be  the  cause
of intense dyspnoea and danger.  The terminal points of the respiratory
system,  in this respect, resemble each other; an acute tumefaction about
the aperture of the larynx, and at  the opposite  end  of the bronchial
tree, may equally induce suffocative symptoms.   Moreover, it is not
always easy to determine the limits  of bronchial and  parenchymatous
disease  of the lungs; and it is scarcely possible that inflammatory affec-
tions of the latter can take place without involving the smaller bronchi.
Hyperaemia of the bronchial mucous  membrane is a phenomenon of
every-day occurrence, accompanying catarrh, gastro-intestinal, hepatic
or cardiac affections, and manifested in its most marked forms by hemor-
rhage.  Haemoptysis  is rarely idiopathic as a mere result  of plethora,
but commonly associated with a deeper-seated morbid affection; a crasis
subsequently manifesting itself by further disorganization, or an organic
disease, which has already been discovered.  Pathologists have not yet
succeeded in demonstrating the exact manner in which capillary hemor-
rhage takes place; in a few instances of advanced tuberculosis, patulous
vessels which were eroded by the progress of the ulceration, have been
discovered, to which  pulmonary hemorrhage could be  attributed; but
the common process by which  the blood is  discharged, is  undoubtedly
analogous to the "sweating" of blood  by which the menstrual flow has
been observed to be effected; it is rather by exhalation or secretion that
the overloaded vessels relieve themselves, than, as the term hemorrhage1
implies, by laceration or rupture.   The hemorrhage is not  a  mere pas-
sive occurrence, resulting from a retardation of the vascular current, or
we  should find it accompanying hypostatic congestion,  which it does not;
it must  be looked upon as an evidence of further disease of an active cha-
racter, as a symptom calling for our careful attention, but only to be
treated  in reference to a fundamental affection.   Hemorrhage from the
lungs by exhalation  rarely proves fatal in  itself, though  at times the
amount of blood lost is very considerable.  Dr. Copland quotes the case
of a patient who lost about 192 ounces in twenty-four hours, and  reco-

    1 Hemorrhage, etymol. *Tf*a, blood; fiywfjii, I rupture; fnykt,  a cleft, a fissure. 
THE BRONCHIAL  TUBES.
385
vered.  The frequency with  which it is associated with  phthisis, has
been determined by Louis to be about two-thirds of all the cases;  a re-
lation which is confirmed by recent observers, and one which, taken with
other circumstances, casts much suspicion on the nature of the cases of
so-called vicarious hemorrhages,  whether they take the place of the
menstrual or hemorrhoidal discharge.  With regard to the former, we
cannot overlook the very frequent derangement of the ovarian function
in company with tubercular disease of  the lungs; and if we add to this
the demonstrated connection between haemoptysis and phthisis, it is diffi-
cult to  avoid  seeing  that  vicarious menstruation of this  character is
almost necessarily indicative of a tubercular tendency.  The difficulty
of explaining the mode in which  haemoptysis takes place, is as great in
regard to the  stages  of softening  as in  the earlier stage  of crudity;
the vessels become obliterated in  the former instance as the  tubercular
matter and pulmonary tissues  deliquesce,  and we are rarely able to dis-
cover the open mouths of lacerated vessels.   At a future page, we shall
also have occasion to  see  that the hemorrhage  into the  tissue of the
organs constituting pulmonary apoplexy, is  distinct from that bronchial
hemorrhage with which haemoptysis is  commonly associated.   In either
stages, therefore, of tubercular disease, it remains for us only to assume
that the congestion takes place on the bronchial mucous membrane, and
that the discharge which ensues, is a symptom of the blood crasis rather
than of the local affection to which  it  has given rise.   The  relation of
haemoptysis to the different stages of phthisis,  is  one to which Dr.
Walshe1 has especially directed his attention; the results of an analysis
of the cases which had occurred  at the  Hospital for  Consumption at
Brompton, in  reference to this question, are as follows:—
	Number of cases.	Frequency of Haemoptysis.	
		Absolute.	Per cent.
	39 20 69	28 18 57	71.79 90.00 82.61
   The proportion changes somewhat, when the analysis is made for each
of the sexes; we then find  that the increase of haemoptysis during the
second and third stages is considerably greater in men than in women,
which may fairly be explained by the greater bodily labor, and increased
tax upon the pulmonary circulation, in the former than in the latter; it
rather tends  to show that the exciting influence of the tubercular ca-
chexia itself, in  producing the hemorrhage, is greater  than that of its
secondary results.   The following is the table illustrating this point:—

                 1 Medico-Chirurgical Review, vol. iii. p. 225.
25 
386
BRONCHITIS.
	MALES.	HEMOPTYSIS.		FEMALES.	HEMOPTYSIS.	
	Number of cases.	Absolute frequency.	Per cent. frequency.	Number of cases.	Absolute frequency.	Per cent. frequency.
First stage 2d and 3d stages	18 56	12 49	60.66 87.50	21 33	16 26	76.19 78.78
  We forbear entering into a further disquisition of this point, as it
would carry us beyond our prescribed limits; we cannot, however, avoid
pointing out, that it bears most immediately upon  the question  of the
treatment of the early stages of phthisis, for if, as we would conclude,
the hemorrhage is a local symptom of the general cachexia, the indica-
tions would be to remove the local congestion by non-debilitating counter-
irritation, while we correct the constitutional taint by the remedies which
we know to be capable of doing so.   Neither, alone, would be likely to
suffice, nor would anything  appear more objectionable than the employ-
ment of remedies applicable to a state of plethora and general vascular
excitement;  we  allude more particularly to venesection and mercurials.
BRONCHITIS.
Fig. 180.
   In inflammation of the bronchi we find the same variations of injection
 and secretion that are presented to us in similar conditions of the upper
 portions of the air-conduit; but the nearer we approach the terminations
 of the subdivisions, the more the bronchules will be found filled with the
 fluids poured  into them,  corresponding in  character,  in  a  measure, to
                       the sputa seen before death, but with  a greater
                       admixture of air, the less viscid and tenacious the
                       secretion.   The post-mortem appearances  may
                       be limited  to mere  redness of the mucous mem-
                       brane.   In the smallest subdivisions, we must be
                       careful to discriminate between the injection of
                       the bronchules, and the redness  resulting from
                       the translucency of their tissue, allowing the color
                       of the subjacent pulmonary parenchyma to shine
                       through.   The  redness is  generally tolerably
                       uniform in   the part affected, fading off at  the
                       margin into the healthy tissue; we do not com-
                       monly meet with that arborescent or punctiform
                       injection in the bronchi,  which is  seen  in inflam-
                       mations of  other mucous membranes, as that of
                       the stomach.   Sometimes the affection resides
                       exclusively  in the larger bronchi, fading off in
                       the smaller divisions; at others it occupies  the
                       reverse  relation; the danger to  the individual
                       increasing  with the number of small tubes af-
uniteu by transverse inoscuia-  fected; the tumefaction and loss of elasticity in
                       which,  necessarily  exert a  great  influence  in
 Injection and stasis in the ves-
sels of the bronchial mucous
membrane, in bronchitis, seen by
a low power.  The vessels were
disposed in longitudinal clusters 
                           BRONCHITIS.                        387

producing dyspnoea.   The actual sense of the difficulty of breathing,
as well as the real absence of proper aeration of the blood, shown by
the lividity of the patient, has  appeared to us to be greater  in these
cases of capillary bronchitis than  in  pneumonia.  The more  asthenic
the form of bronchitis, the more the redness of the bronchial mucous
membrane  approaches a  livid purplish tint; it is generally found of
this hue in  the  chronic forms.   The  secretions will  vary according to
the stage and character  of the disease, from a viscid  glazy mucus,
to a  genuine purulent discharge of a  more  or less diffluent character.
Occasionally, death is the result of a  sudden effusion of liquid into the
bronchi, constituting what  is called suffocative catarrh, which is  met
with more frequently in the infant  than in  the adult.  Long-continued
purulent expectoration may, however,  have  existed during life, without
any appreciable lesion being discovered after death; in these cases, the
bronchial mucous membrane, as Andral1 observes, need not even present
a trace of redness.  In examining  the lungs, we must be careful to com-
pare  different portions, before arriving at  definite conclusions; for it is
often difficult to determine to  which part  the fluids belong which exude
on section.   The surest way to  ascertain  the state of  the parietes and
contents of the bronchi, is to follow them from the larger trunks with a
pair of scissors,  carefully avoiding to admit more extraneous matter into
the tubes than we can help.
   Croupy inflammation  may  affect the bronchi, as it  does the upper
respiratory passages, though  it does so with less frequency;  complete
moulds of  portions of the bronchial tree present themselves to us; the
influence they exert upon respiration  depends  partly upon  the obstruc-
tion they themselves offer, and partly upon the tumefaction of the sub-
jacent mucous membrane.
   The mucous membrane of the bronchi, like the mucous membranes of
the urino-genital organs, occasionally exhibits a chronic  affection,  in
which,  without  marked  symptoms of an  inflammatory character, the
membrane pours  out a plastic exudation,  which forms what has been
termed bronchial polypi.   Their microscopic characters have not as yet
been determined, but, if  a surmise may be hazarded, we should expect
to find them consisting of epithelium, matted together by an unusually
viscid mucus.  Dr. Watson observes,  that though it  is surprising  that
patients should  recover from  the affection, it  never  in itself  seems  to
prove fatal.   Dr. Reid3 has reported two cases of tubular expectoration
from the bronchi, occurring in the adult, with delineations, which closely
resemble that given by Dr. Baillie, in his work  on morbid anatomy.  In
one,  the patient, a married  lady, aged  twenty-eight, affected with  a
chronic cough,  consequent upon  an  attack of bronchitis,  frequently,
after  suffocative  attacks, coughed up  arborescent  membranous  sub-
stances  resembling casts of the  minute  bronchial  tubes:  the second
case  occurred in a gentleman, aged  forty-four, and closely resembled
the former, except that there was  more manifest congestion,  and that
the casts were more of a  sanguineous character, and their rejection each
1 Precis d'Anatomie Pathologique, ii. 481.
2  Medico-Chirurgical Transactions, vol. xxxvii. p. 333. 
388                       BRONCHITIS.

time accompanied by some hemorrhage.  It appears to be more frequent
on  the continent of  Europe, where the affection has carried off several
distinguished individuals, among whom the Empress Josephine  is the
most eminent.
   Other morbid states, besides those already alluded to, may give rise
to a constriction or stenosis of the bronchial tubes; it may be produced
by  an actual hypertrophy of the submucous  layers,  as  a  result of
chronic bronchial irritation, or by serous effusion,  as in dropsical states
of  the system.   The physical symptoms in these different cases may be
identical, being produced by analogous structural alterations ;  but it is
manifest that the constitutional basis upon which they  rest may differ
very considerably, as also the influence they exert in  living subjects
upon the further production of morbid conditions.
   The pulmonic symptoms  accompanying  typhous and  typhoid fevers,
is set down by Rokitansky1 among the class of catarrh  of  the mucous
membrane; he states it always to  appear as an intense diffused conges-
tion ; the mucous membrane is of a dark, almost violet tint, swollen and
succulent,  and yields a  secretion  of a gelatinous and sometimes dark,
blood-streaked mucus.   The disease, according to this author, is most
commonly developed in the bronchial ramifications of the lower lobes;
it is always limited to the stage of typhous congestion, and  never gives
rise to any apparent production of a  secondary formation on the tissue
of the mucous membrane, such as  is produced in immense  quantity in
the intestinal follicles in cases  of abdominal typhus.  He based his
diagnosis of a primary broncho-typhus, in which the disease is localized
here to the exclusion of all other mucous membranes, upon the peculiar
stasis and swelling of the spleen, and at the cul-de-sac of the stomach,
the remarkable character of the blood, the typhous nature of the gene-
ral  disease, and especially the  altered condition of the bronchial glands.
The last  lesion of the bronchial mucous membrane which  remains for
our consideration  is, ulceration;  as in the  larynx and trachea it is
mainly, if  not exclusively, a concomitant of phthisis.  It has been ob-
served by few authors, probably on account of the care requisite in the
examination,  to  discover an abrasion  in these parts.  Louis, who ex-
amined the bronchi of forty-nine phthisical subjects, with special regard
to this point, found ulcerations in  twenty-two.  Dr. Copland is of opi-
nion that ulcers  occasionally  perforate the bronchial tubes, and thus
occasion abscesses in the pulmonary parenchyma.
  The submucous tissues may be variously affected in the bronchi, as in
air-passages already considered.   The cartilaginous rings may undergo
a process of softening or the opposite condition of ossification;  in this
case, they become brittle, and  break;  they then either project like fish-
bones,  as Andral observes, into the bronchial cavity, or, becoming de-
tached, are expectorated.
1 Pathological Anatomy, vol. iv. p. 23, Syd. Soc. Ed. 
DILATATION OF THE BRONCHI.
389
                 DILATATION  OF THE  BRONCHI.

  Many of the  lesions which we have  adverted to  may co-operate  in
producing a morbid condition of the bronchi, to which Laennec was the
first to draw  attention, and which,  though of extreme importance  in a
nosological point of view, has hitherto been rather treated as a question

                                Fig. 181.
Dilated bronchi, from a female aged 52, who had suffered from chronic pneumonia and bronchitis for three
        years; the pulmonary tissue intervening between the bronchi was much condensed.

affecting the pathologist than  the  practitioner.   It is dilatation of the
bronchi  or bronchiectasis.1  By Laennec, it was attributed exclusively
to an accumulation of mucus in the ramifications of the dilated portion ;
but, as Dr. C. J. B. Williams justly  observes, if this were the cause we
should not, as we do, hear the air penetrate freely into  the dilated por-
tions.   There may, undoubtedly, be various efficient causes  at  play in
the production of this diseased state,  both of a mechanical and of a more
dynamical character.   The most palpable instance of the former is pre-
sented to us in the case of an  enlarged bronchial gland, whether it con-
tains cretaceous or  simply scrofulous  matter, compressing a bronchus.
Here, the free  exit of the respired  atmosphere  being prevented,  an
accumulation of air might be supposed to  take place behind the narrowed
portal, the channels being prevented ever collapsing to the same extent
as a healthy lung.   Any impediment to the entrance or exit of the air
into the  lungs will produce irregular and forcible breathing, and throw
a greater strain upon those parts especially, which are in the vicinity of
the obstacle.
   One point having yielded,  it is  quite  intelligible that the distension
should gradually progress, while,  at the same  time, it  must, in a cor-
responding ratio, compress  and gradually obliterate the  surrounding

  i Etymology—&royxta*tne bronchi, and ?itT<*a-ic,  dilatation, from sxtk'vw, I stretch.   We
may take this opportunity of remarking upon the distinction which  some  authors have
lately made between bronchia and bronchi; it is a source of some confusion, and scarcely
warranted by their etymology of the words;  if a  diminution is required, the term bron-
chule is more convenient, and not liable to be mistaken. 
390
DILATATION OF THE BRONCHI.
pulmonary tissue.   In the majority of instances a diseased condition of
the bronchial parietes, if not, as Corrigan has suggested, of the pulmo-
nary  parenchyma  itself,  precedes  the occurrence  of  bronchiectasis.1

                                Fig. 182.
   Cretaceous enlargement of a bronchial gland compressing the right bronchus, which is much dilated
                             beyond the point.

When the  changes  have taken place in  the tissues which are likely to
give rise to it, any violent effort  to distend the lungs,  as  in catarrh,
bronchitis, or hooping-cough, may  be  the exciting cause.   The  three
forms  which Laennec* describes have been successively adopted by sub-
sequent writers, though none have been satisfied with his  rationale.  In
the first  there is a solitary cystic dilatation—in  the second, a series of
distinct dilatations of a more or  less circular form, commonly affecting
bronchi of the third and fourth order;  these two forms  are essentially
the same,  and they generally present  considerable attenuation of  the
dilated portions, while the intervening  parts  of the bronchi remain nor-
mal.   Laennec's third form differs entirely from those just considered,
and consists in an almost uniform or cylindrical expansion of a single
tube,  or  an  entire section of the bronchial  tree.   Here it is we meet
with thickening of the parietes,  tumefaction of the mucous membrane,
which may be thrown into folds  resembling those of the small intestine,
and a proportionate  increase in the subjacent fibrous tissue.   When  the
dilatation affects the apex of the  lung, it may proceed  to such an extent
as to resemble a tuberculous multilocular cavity.   The  perfect continuity

  1  Corrigan views the condition of the pulmonary tissues, giving rise to bronchial dila-
tations, as analogous to cirrhosis of the liver; he considers it the result of the formation
of an unyielding fibrous tissue, to which  the bronchi become attached, and therefore inca-
pable of collapsing.
  2 See Laennec's Traite de 1'Auscultation Mediate, &c, 1826, vol. i. p. 206. 
DILATATION OF THE BRONCHI.
391
of the mucous lining with that of the adjoining bronchi, and the smooth-
ness of  the tissues, will aid in determining the nature of  the  lesion, if
there is any doubt.  The explanation offered  by Hope1 of the mode in
which bronchitis, the most  frequent exciting cause of bronchiectasis,
gives rise,  is so satisfactory,  that we give it in his own words: First, the
air-passages are stripped of  their epithelial lining in the ordinary man-
ner; their  canals  becoming  loaded in  part with a  mucous secretion, in
part plugged with fibrinous exudation.  This  latter occurrence takes
place chiefly within certain of the lesser twigs, occasioning a collapse of
the adjunct air-cells.  The space thus set free,  is sought to be filled up
by the expansion of the neighboring parts, giving  rise, in the majority
of cases, to  empl^sema;  where, however, the collapse does not occur
close beneath the surface of  the lining, but at a greater depth, and near
a larger bronchial tube,  and  when it comprehends a larger tract  of pul-
monary  substance, the result is bronchiectasis;  these circumstances do
not, however, suffice for  the formation of a bronchial cavity, the parietes
of the involved bronchial tube must needs have previously suffered  the
changes pointed out by Stokes—namely, loss of elasticity in  the longi-
tudinal,  and of contractile power in the annular fibres, with consequent
incapacity on the part of either to resist  the  mechanical influence of
forcible  inspiration or of violent cough.
   It appears from Dr. West's description, that  in children the fusiform
variety of bronchial dilatation is rarely, if ever found, while the cylindrical
form is a common result of  bronchitis.   On  one occasion, however, he
saw a case in which, in addition to  a general cylindrical enlargement of
the tubes,  many of them presented a marked dilatation, about half an
inch from  their termination  the tube expanding into a cavity big  enough
to hold half a large nut.  The lining mucous membrane  presented an
extraordinary degree of thickening.
   Tubercular deposit in the  bronchial tubes is an affection spoken of by
Rokitansky alone among authors; he  describes it, under the term of
bronchial tuberculosis, as an infiltration of the mucous membrane with
yellow, lardaceous, caseous matter,  into which the former at last appears
to be converted;  the bronchial tube becomes enlarged, its channel finally
obstructed by tubercle, while its fibrous sheath  is infiltrated with larda-
ceous matter, callous and thickened.   He states that it occurs second-
arily to tuberculous abscesses, but that the primary form, commencing
in the ultimate ramifications of the bronchi, and extending backwards
into the larger tubes, is by far the more  important form.  The latter
may be found unassociated with genuine  pulmonary tubercle, and  it may,
by softening  and breaking  down  of the bronchial  walls, give  rise to
abscesses resembling those of  vesicular  tuberculosis;  at the same time,
the author admits that this mode of the formation of abscesses is infinitely
less frequent than that commonly known.  The primary form of bron-
chial tuberculosis, Rokitansky describes as most common  in childhood,
being usually associated  with all the tuberculoses of other organs peculiar
to  this  period of life, and especially with intense tuberculosis  of  the
bronchial glands.
1 Pathological Anatomy, Syd. Soc. Ed., p. 297. 
392              DILATATION OF THE BRONCHI.

   In  addition to the varieties of mucous,  purulent, and hemorrhagic
sputa, and to the foreign bodies occasionally introduced  from without,
to which we have already alluded, we occasionally find  in the bronchial
passages calcareous concretions, derived from obsolete tubercular deposits,
bile or  bile-tinged pus, derived from a  fistulous opening through the
diaphragm, communicating with the liver fragments of pulmonary tissue,
recognizable by the elastic fibres shown under the microscope, and cysts.
The latter are extremely rare, and are probably always derived from the
pulmonary parenchyma,  or  the  liver.   We  have not seen  any case
recorded of their formation in the bronchi.   Hasse1 states, that  he has
seen a pellucid vesicle, of the size of a hemp-seed, on the left vocal cord,
and he  mentions cases recorded  by other observers  of  hydatids  in the
same  region.
1 Pathological Anatomy, Syd. Soc. Ed., p. 378. 
CHAPTER  XXVIII.
                           THE  LUNGS.

   Having in the foregoing pages considered the diseases of the respira-
tory passages, we now arrive at the investigation of the morbid changes
which occur in the lungs themselves; in  the tissues aiding in the pur-
poses of oxygenation, the ultimate vesicular terminations of the bronchi
and the  interlobular tissue.   The bronchules, long before their termi-
nation,  are deprived of their cartilaginous rings;  these are reduced to
mere  flakes before  they cease altogether, and all  trace of them disap-
pears, according  to Messrs. Todd and Bowman,1 in tubes of  less than
one-sixth to one-tenth  of  an inch in diameter.  The  tracheal  muscular
fibres are described by these physiologists as being continued even to
the terminal bronchules, but instead of merely filling up the gap in the
cartilaginous framework, they form a uniform layer encircling the canal,
but excessively thin. Within the muscular layer is that of the longitudi-
nal or elastic fibres;  the ciliated epithelium and  basement membrane
of the mucous tissue descend into the terminal bronchules.   The air-
vesicle itself  is described as formed of one coat only, resulting from a
fusion of the  elastic coat and basement membrane, and it is stated to
contain no epithelium.  Whether  the latter point is correct or not, the
extreme tenuity of the vesicular coat is an undoubted fact; nor could it
be  expected  otherwise, when we consider  that the part  it plays is to
prevent the air from being diffused into the interstitial tissues, and that
the exchange of the oxygen of the atmosphere, and of the carbonic
acid of the blood, could only be effected with sufficient rapidity through
an  infinitely delicate  texture.  We  premise so much of the healthy
anatomy of the lung, in order to render it evident that  the  difference
in its  texture would produce different morbid symptoms, as well as differ-
ent post-mortem results,  than those exhibited in  diseases of the air-
passages.  While the latter possess their  own peculiar secretions, which
tend to  modify or relieve the perverted action of their constituents, the
effect  of disease upon the true pulmonary tissues must  be, to cause  a
more  immediate interference with the vital functions, by altering the
caliber of the air-) eservoir from without or from within.  The air-vessels
themselves are solitary globular sacs, terminating  a minute bronchule,
and arranged along a larger bronchule like a bunch of currants, or pre-
senting  a corymbose or racemose appearance more analogous to a bunch
of grapes.  The vesicles are never angular or polygonal, until subjected
1 Physiological Anatomy, chap. xxix. 
394
THE LUNGS.
to pressure resulting from some pathological process.  When intravesicu-
lar effusion is limited to a few scattered vesicles, the globular appearance
is only rendered more conspicuous; and in no case has it appeared to us
that the human lung offers, in its ultimate terminations, any resemblance
to the honeycomb arrangement seen in the lungs of the lower animals,
and  produced by a  reduplication of the basement membrane, so as to
form septa, projecting into the cavity of the vesicle.
  The anatomical characters of the vesicular structure, and the little
support it has  compared with the denser tissues of the bronchi, easily
explain the first  morbid condition to which we shall advert—Vesicular
Emphysema.   Dr. Baillie, though unable to suggest the means of dis-
tinguishing the disease  before death, was one of  the first to show its
true nature in  the dead  body.  It consists essentially in a dilatation of

                               Fig. 183.
  Portion of emphysematous lung—the cavities are either formed by simply enlarged air-cells, or by the
             coalescence of groups of cells.—St. Bartholomew's Museum, xiv. 11.

a larger or smaller number  of air-vesicles, and may be produced by any
cause exerting a great strain upon them.   The effect is to diminish the
specific gravity of the part affected, so as to render it more buoyant
than the healthy lung tissue in water; to cause the lung to become less
crepitant on compression, giving it a doughy or woolly  feel, to prevent
its collapse  on  the thorax being opened, and to render it more or less
dry and  exsanguine.   The  emphysematous portion, if  superficial, pro-
jects above  the surface of the unaffected part;  and large bullae  may be
visible on the surface of the lung, from  the gradual  obliteration of the
intervesicular tissue, allowing  several vesicles  to unite.   The  loss of
elasticity in the pulmonary tissue, whether primary  or  secondary, pre-
vents the usual collapse  of the  lung at the period  of  expiration; the
vitiated air  is not expelled as it ought to be;  hence arises a great want
of oxygen, and the patient, on the slightest aggravating cause, is seized
with a fit of asthma;  the consequence of this  permanent  dilatation of
the organ necessarily affects  the thoracic parietes; if one  lung only
is affected, the corresponding side enlarges, and  becomes less movable
than  its fellow; the adjoining viscera are more or less displaced; the
intercostal  and supraclavicular spaces  swell out; the  ribs,  instead of
slanting downwards, stand  out horizontally from the vertebral column,
and are almost immovable, giving to the thorax  that barrel-shaped form, 
THE LUNGS.
395
which alone is considered indicative of emphysema.  In horses, this is a
very common disease, and constitutes the vice termed "broken wind,"
which veterinary surgeons state  to  be chiefly due to overworking after
a full meal of green meat.   Veterinary surgeons have observed  that it
is hereditary in  horses,1 which tends to confirm the like remark made  by
Dr. Budd, Louis, Hasse, and others,2 as applied to man.   Dilatation of
the bronchi is a pathological condition  frequently associated with vesi-
cular emphysema, and may  be attributed to the same cause.
   Mr. Rainey, in one of his interesting papers in the Medico-Chirurgical
Transactions,3 has attempted to prove,  that emphysema is the result of
over distension of the air-cells, brought on  either by their  mechanical
distension, or of the pulmonary membrane undergoing a fatty degenera-
tion, which enfeebles it, and causes  it  to give way under the ordinary
pressure  of  inspiration.  Dr. Gairdner, as  we  shall see,  denies either
mode of production  in  the  sense of Mr. Rainey, and only  admits the
occurrence of fatty or granular deposits in emphysematous parts as ex-
ceptional.  The microscope confirms what is palpable to the naked eye,
that the bloodvessels are very scanty.   They become compressed in the
interstitial tissue by the enlarging air-vesicles, and are entirely obliterated
in the progress  of the disease; hence, the emphysematous portion is ex-
empt from those morbid affections which are associated with congestion
or inflammatory conditions, such as hemorrhage, pneumonia, or exudative
processes.  It was  formerly supposed  that  vesicular emphysema was
mainly due to rupture of the interstitial membrane; we have  shown that
this is  not the prevailing  circumstance ;  still,  actual laceration does
occasionally take place.   The largest dilatations are seen along  the
ulterior margins of the lungs, probably owing to these parts  being least
supported.  The bullae individual sometimes attain a very considerable
size.   If the dilatation of  the air-cells is more  generally diffused,  the
lung presents, as Dr. Baillie first observed, the appearance of the lung
in amphibious animals.
   It is the more important to  be well acquainted with the  features of
this malady, as much may be done to anticipate and prevent it, while
we have little control over it when it is established; the advantage of the
study of pathological anatomy, as an illustration of morbid processes in
the lining, is rarely shown in more marked instance than here:  the
knowledge of the actual lesion giving rise to  the  phenomena  of asthma,
if not in  all,  yet in the  majority  of cases, is  a warning to  those who,
from indolence  or carelessness, are too prone  to  be  satisfied with attri-
buting spasmodic symptoms exclusively to deranged nervous action.  The
credit of  offering the first rational  explanation of asthma, and its con-
nection with emphysema, is  due to Dr. Floyer,4 though the priority of

  1 See Mr.  Youatt's work on the  Horse, art. Broken Wind.
  2 Med.-Chir. Trans, vol. xxiii. p. 37.
  » Vol. xxxi. p. 297.
  1 In his little work on Asthma, published in 1698, Dr. Floyer says: " The broken wind
results from  the rupture or dilatation of the bladders of the lungs, by which the air is too
much retained in the bladders or their interstices, and thereby produce a permanent flatu-
lent tumor in the whole substance of the lungs.  It is not easy to explain the production
of a permanent flatulent tumor in the lungs by a strain in running, but by supposing tlie
bladders  of the trachea too much distended, and the muscular fibres which constringe them 
396
THE LUNGS.
the discovery  is commonly  attributed to Laennec.   The  views of the
latter, in regard  to  the  production of the disease, though difficult  of
comprehension, have long been accepted by the profession.  He conceives
that any obstacle to  the discharge of air from the lungs may give rise to
it; he especially attributed it to "dry catarrh;'' in  early life, hooping-
cough, by inducing  an over-repletion of the air-vesicles,  and  a great
strain upon them; swellings of the bronchial glands,  by compressing the
bronchi, frequently give  rise to vesicular emphysema.   We have stated
that Laennec's view  of the manner in which  emphysema is produced, is
difficult of comprehension, because a plug that prevents the exit of the
air is likely to prevent its admission; and although a valve-like action
may, by a curious combination of circumstances, be  induced so as to  be
followed by such an  effect, the structure  of  the bronchial tree forbids
our assuming its frequent occurrence.  There are other still  more forcible
arguments against Laennec's theory, which  have  been put forward by
Dr.  Gairdner.1  He  remarks that the theory  of Laennec, which ascribes
emphysema to mucus in  the bronchi and accumulation of air behind the
obstruction, is vitiated by the ample proof which now exists, that ob-
struction of the bronchi  has precisely the opposite effect, giving rise  to
voiding of the air-cells and collapse of the lung; he rejects  the idea that
emphysema is dependent upon  forcible expirations as utterly untenable.
Dr.  Gairdner  has found  that emphysema never occurs unaccompanied
by pulmonary collapse, or by one or other form of pulmonary atrophy;
the  greater volume  of the  emphysematous  lung  depending, not upon
increase of tissue, but mere distension.  He denies that it is ever preceded
by any altered condition  or  diminished  resistance in the  walls of the
air-vesicles; he has  usually found the bronchi leading to affected parts
entirely unobstructed; and he concludes that emphysema is a lesion oc-
curring from mechanical causes, in those parts of atrophied and collapsed
lungs to which it has the most free access; in other words, it is produced
by atmospheric pressure in the comparatively sound portions  of such
lungs.  According to  Dr. Gairdner's theory, the increase  of volume of
the emphysematous lung is supplementary to the diminished volume of
those parts from which the air is excluded ;  but the real effect is, that
while the surface of the breathing membrane is extended, its physiological
capacity of aeration is much diminished, so that the individual comes to
labor under two  morbid conditions  instead  of one.   Another form  of
emphysema is that to  which  the name interlobular has been applied, and
which is analogous to  the emphysema occurring on the surface of the
body; like this, it consists in an effusion of air into the cellular, or rather,
as applied to the lung, into the interstitial tissue, and is due to a lacera-
tion of the bronchial  tubules or the air-vesicles.  It generally  induces
a puffy swelling under the pleura, and is commonly  associated with a
subcutaneous  extravasation  of air, affecting  the chest, neck, and head.
Emphysema, in its turn, like every disease which impairs the circulation

in expiration, thereby over-stretched and made unfit to express the air afterwards; so that
these bladders retaining more air than is usual, the substance of the lungs must appear
always inflated."
  1 British and Foreign Medico-Chirurgical Review, April, 1853, p. 452. 
ATELECTASIS PULMONUM.
397
through the lungs, is liable to induce dilatation of the right side of the
heart.
  We must be careful to distinguish  the two forms of emphysema just
alluded to from one  another, as well as from the post-mortem evolution
of gas, which may produce similar appearances.  In the latter instance,
there are general indications of decomposition to guide us; and we shall
find that the bladders of air that distend  the pleura  may  be  easily
removed by pressure, and the accumulation pushed aside more readily
than when we have to deal with a pathological product. Nothing, in fact,
is more difficult than to free an emphysematous  portion of lung from air ;
even in drying it slowly, the diseased cells, as Hasse observes, retain their
air, whilst the undilated cells dwindle down into a hard and almost solid
mass.   The determination as to the nature of the emphysema may be
of importance in forensic medicine, in determining the question as to the
employment of violence in causing the  death of  an individual.


                   ATELECTASIS  PULMONUM.

  Diametrically opposed to the condition which we have just considered,
is one which is peculiar to early life, and frequently has been confounded
with the results of pneumonia.  It consists in the permanence of the foetal
condition of the lungs; the vesicular structure either  not being properly
developed, or the infant  not possessing  sufficient force to expand the
thorax, and cause  the dilatation of the breathing  apparatus. It was first
observed, and  duly  described, by Professor Jorg,' under  the name  of
Atelectasis Pulmonum;2 who found that it occurred chiefly in full-grown
infants of very feeble powers, or in such as had been  born prematurely,
and were, therefore, not in a condition to dispense  with the placental
circulation. The inferior portions of the lungs are most liable to present
this state;  it occurs in patches, which offer a  darkened  color, do not
crepitate on compression, and offer a smooth surface on section.  The
affected part sinks in water.  The part or lobule that  has not undergone
the due expansion is below the level of the surrounding dilated lung
tissue;  hence, a lung  affected in this manner does not fill the cavity  of
the thorax as the  lung that has performed its functions; nor does  it, on
section, discharge a frothy sanguineous serum like the latter.  Atelec-
tasis is  not necessarily fatal;  it is probable that  in many instances it is
entirely overcome, as the child acquires vigor, or that,  while a few lobules
remain  in  a permanently contracted state, the  remainder of the lung
suffices for the purposes of aeration.  We frequently, in adults, meet with
puckerings of the surface of the lung, without any trace of inflammation,
which may perhaps be set down to this congenital state of the tissues;
or,  possibly, the small nodules of fibroid or calcareous matter, which we
often find equally without appreciable recent lesion to which they  could
be referred, may be  due to the same cause, as we know them  to  favor
parts  in which there is an arrest of  development. Dr. West  observes

  1  De Pulmonum Vitio Organico, &c, Lips. 1832, and Die Fotuslunge im GebornenKinde.
Grimma, 1835.
  2  Etymology—aTsXijf, imperfect; sxrartf, expansion. 
398
ATELECTASIS PULMONUM.
that if air be blown into a lung, some lobules of which are not duly ex-
panded, it will permeate the collapsed air-tubes ; the pulmonary vesicles
will, by degrees, become distended, and the solid lobules rise to a level
with the rest of the lung, acquiring the same color and consistence, and,
like other  parts of the organ, will  float  in water.   A single inflation,
however, is by no means sufficient to render this  change permanent; but,
the moment the tube is withdrawn,  the air will escape, and the lobules
recently distended will again collapse and sink below the rest of the lung;
their color, too, will become dark, though less so than before.   In con-
junction with imperfect expansion of the lung-tissue,  we invariably find
the foramen ovale and the ductus Botalli still open.   The pathology of
the affection, which we have attributed mainly to  a mechanical defect,
has been explained by French writers, who have termed it carnification,
as the result of pneumonia;  but, although pneumonia may supervene
in an atelectatic lung, the characters of the two  diseases are sufficiently
distinct to be discriminated on a careful examination.  We  meet with a
condition analogous to infantile atelectasis in advanced age;  we  find the
apices of  the lungs converted into a dense melanotic  mass,  in which we
are unable to trace tubercular deposit, while there  is  an obliteration of
the vesicular structure, and apparently also of  the bloodvessels.   The
tissues are converted into a viscid, tenacious mass, deprived of all air.
Under the microscope, we see an almost homogeneous membrane, through
which the carbonaceous deposit is scattered irregularly, with only here
and there a trace of the circular fibres of the lung. In the  cases which
have fallen under  our own observation, there was  a  thickened pleura,
forming a cap over the apex, which must, by its compression, have  con-
tributed much to the obliteration: whether any pneumonia had aided in
producing the result is doubtful; our impression  certainly is  against this
view,  the  excessive deposit of  carbonaceous matter associated with  the
large  pleuritic  exudation  in the  confined post-clavicular  region of  the
thorax appearing adequate in itself to account  for the effect produced.
Another question  is, whether fatty degeneration  affecting  any of  the
tissues was an element in  the process; possibly, the deposit of carbona-
ceous matter in excess may be viewed as the result of a  process allied
to fatty degeneration : we have not ourselves observed such an evolution
of oil as would justify the assumption that  the main  feature of  the dis-
ease belongs to this class.
   Another form of atelectasis, which Bailly and Legendre first  pointed
out, and which  has been well illustrated by Dr.  West,  is  that which
occurs after  respiration has once been fairly  established, and is  the
result of an interference with  the  mechanism of respiration.  It is this
form more particularly which  Valleix, and  Rilliet, and Barthez, under
the term  of  carnification, have attributed  to lobular pneumonia;  the
affection being limited to a single lobule or to a cluster, forming a hard,
compact mass,  surrounded by the  normal  tissue.  When the  affected
part is inflated  the vesicles distend, and thus show that there is no in-
flammatory effusion.  In  a  child, whose case is related  by Dr. West,
there  was no evidence of disease until the age of nine months, although
she had not thriven well, and  had become pigeon-breasted.   She then
lost flesh rapidly, and began to cough, without having had any previous 
(EDEMA PULMONUM.
399
catarrh.   Her case seemed to be one of bronchial phthisis.   Four days
before death she became suddenly oppressed, and the cough more severe;
the dyspnoea increased,  while the cough became less frequent.   A few
hours before death the lips were  quite livid;  she  breathed from eighty
to eighty-six times a minute; the abdominal muscles acting most vio-
lently, but the chest being scarcely at all  expanded.  No tubercle was
found in any organ  after  death,  but  large portions of both lungs pre-
sented the undilated condition, which disappeared entirely on inflation;
the bronchi were pale, and contained very little mucus; the right side
of the heart  was greatly distended  with coagulated  blood, which its
thin, pale, and flaccid substance,  had evidently been unequal to propel
with the requisite vigor.
   There are consecutive conditions of the lungs which may respectively
be mistaken for emphysema or atelectasis.   Thus,  after long-standing
disease of one lung, impairing its  functions and diminishing its capacity,
we find its fellow taking on a vicarious action, and expanding so much
as to  displace adjoining  viscera; a point of importance in forming
diagnoses of diseased states of the thoracic contents.   On opening this
side of the thorax the lung may  appear too large  for its cavity, and in-
duce the assumption  of  an emphysematous condition.   The history of
the case, the  examination of the lung, and the shrunken, contracted,
bound-down, and atrophied condition of its  fellow,  will determine  the
real nature of the case.   Whether in this instance there is  an actual
new formation of pulmonary vesicles, it is difficult to ascertain; Roki-
tansky is of opinion that such an hypertrophy of  the lungs is due to a
dilatation of the air-cells, .with a simultaneous augmentation of their
tissues;  that it does not consist in an increase in the number of the air-
cells,  but in their dilatation, the  increased thickness of their walls, the
enlarged caliber of their walls, and in the  development of their  vessels.
There can be no doubt that the changes that take place are intended to
increase  the powers of aeration of one  portion of the breathing appa-
ratus; an increased thickness in the walls of the air-vesicles can scarcely
facilitate oxygenation, unless  it is by a reduplication of the  basement
membrane into the breathing cavity, so as  to afford a larger surface for
the capillaries to  ramify upon.   The special circumstances under which
the secondary enlargement and contraction of the lungs take place, will
be a subject for further consideration at a subsequent page, when  we
come  to discuss the pathological states of  the pleura.
                       03DEMA PULMONUM.

  Before investigating  the inflammatory conditions of the lungs, we are
required to devote some consideration to a morbid state, which we fre-
quently meet with in the dead  body, and which, since the attention  of
the profession  was first especially directed to it  by the researches  of
Laennec,1 has been known by the term of (Edema Pulmonum.   It con-
sists, as its name implies, in a serous infiltration of the interstitial por-
1 De PAuscultation Mediate, vol. i. p. 349. 
400                PULMONARY  CONGESTION.

tion of the pulmonary parenchyma.  It causes a puffiness of the organ,
which pits more or less on pressure, has lost its natural crepitant sensa-
tion, and does not collapse when the thorax is opened.  The cedematoua
lung is characterized by pallor and anaemia, and when cut into discharges
an abundance of clear, limpid serum, in which the comparative absence
of air-bubbles is characteristic.  It occurs in  connection with, and as a
result of,  a great variety of debilitating diseases, and rarely presents an
idiopathic character, though it is sometimes observed in  this form, and
may then be  termed serous apoplexy of the lungs.   Pulmonary oedema
very commonly supervenes immediately before  death;  and has  been
attributed to the extinction of the nervous power of the vagi, in conse-
quence of the experiments of Miiller, which  have shown that the fatal
effect of  dividing these nerves in the neck, is mainly due to the infiltra-
tion of the lungs and air-passages with serum.  Both lungs are gene-
rally affected to the same extent, nor is the oedema necessarily confined
to the posterior portions, even where it is only partial.  A peculiar fact,
remarked by Hasse, is, that where, in general dropsy which proves fatal,
the one lung is found universally adherent to  the pleura, and the other
not, the former is oedematous, and the latter compressed by hydrothorax.
Laennec  states that pneumonia induces a great proclivity to the pro-
duction of pulmonary oedema during the period of convalescence;  this
may have been partly due to the excessive depletion formerly in vogue,
for pulmonary oedema appears to occur so frequently, and so much in
the ratio of the general anaemia  of the individual, that  we see no reason
for assuming a special tendency in  one disease to produce  it.   The lax
texture of the lungs, like that of the superficial cellular tissue, neces-
sarily favors  a serous effusion under such circumstances.
                   PULMONARY CONGESTION.

  This spongy texture  of  the  lungs, coupled with the fact that these
organs contain a larger quantity of blood, in  proportion to their size,
than any other organ of the body, renders them peculiarly liable to the
various forms of congestion—a tendency which is enhanced by the re-
lation existing between the pulmonary and systemic circulation.  Most
of the various causes of death, while inducing an arrest of the circula-
tion, give rise to an accumulation of blood in the organs of respiration.
Nysten's experiments have shown, that the  contractile power of the
right side of the heart continues long after the  irritability of the left
side is extinguished;  and the effect of maintaining artificial respiration
in cases in which death from a lesion of the  nervous  powers is to be
apprehended, further demonstrates the great share taken by the lungs
in the production of death.  The elasticity of the arteries also exercises
some influence in producing an engorgement of the lungs, at the moment
of,  and immediately after death, by propelling their contents  into the
venous system, and thus overcharging the right side of the heart.   Nor
must we forget that, in long-standing  debilitating  disease, whether a
specific fever or an adynamic condition, resulting from other disorganiz-
ing processes, respiration is carried  on  with little vigor, while the mus- 
PULMONARY  CONGESTION.
401
cular tone is reduced to ft low ebb, so that both causes conspire to retain
the blood in the pulmonary tissues.  Hence, in estimating the pathologi-
cal changes in the lungs  connected with  the actual disease, to which
death has been attributed,  we must be very careful in distinguishing be-
tween the effects of  the dying and death itself, the  secondary products
of debility and dissolution, from the changes  attributable to active dis-
ease.  Both, however, often  pass  imperceptibly into one another, with
gradations, which only confirm the view  that disease is, in itself, incipient
death.   And  though we may lay down  rigid classifications of  the modes
of dissolution, and we may occasionally  meet with types corresponding to
our scientific arrangement, still, as Dr. Williams observes, in his admirable
Principles of Medicine: "In the  slower dissolution by which diseases
generally prove fatal, all functions and structures are more or less in-
volved, and life in all is dwindled down  to so slight a thread, that, when
it breaks in one, others scarcely retain  it long enough to enable us to
say that death begins distinctly in any part."  Still, whether we  can
trace the death to asthenia or apncea, coma or paralysis, the  prevailing
effect is to induce those  symptoms to which we have above alluded in
the lesser circulation.
   It is not within our scope  to dwell upon the treatment of disease, but
we may be allowed to urge these facts as of the utmost  importance in
connection with that department of medicine, inasmuch  as they demon-
strate the necessity  of, under all circumstances, attending to the state
of the pulmonary circulation, and removing all avoidable sources of local
embarrassment, while we stimulate the general forces to carry the patient
through the valley of danger to the pleasant heights of recovery  and
health.  The congestion which belongs  chiefly to  the causes first alluded
to, is most liable to  affect  the posterior and inferior portions  of  lungs;
after death, as in the debility resulting from  disease, the blood follows
the physical  law of gravitation, and sinks to the  lowest  point it  can
gain.   If there be no concomitant inflammatory changes, the congested
portion presents a  dark red color, and, though firmer  than  the more
bloodless anterior part, still crepitates under the finger, and floats in
water.   The color is almost  uniform, and the line of definition between
the congested and the non-congested portion  is tolerably defined.  The
pleural surface of the engorged portion presents a corresponding violet
tint, which sometimes is more or  less  circumscribed at single points.
The depth of the color varies somewhat in different diseases; and in very
anaemic cases, especially in  those associated with general dropsy, there
is more or less serous effusion with the sanguineous congestion.   In a
medico-legal point of view, congestion  of the  lungs may become a ques-
tion of life and death; thus, in the recent trial of Mr. Kirwan,  in Dublin,
the conclusion that  his wife's death was due to violence,  which has since
been shown to be erroneous  by the highest authority in medical juris-
prudence in this country,  Dr. Taylor,1  was based mainly upon the  fact
of the lungs being congested posteriorly.   This was the main fact upon
which the medical witness, Dr.  Hatchett, relied, in proof of death hav-
ing been brought about  by drowning; we know that it may be the result

                    1 Dublin Quarterly Journal, Feb. 1853.
        26 
402
PULMONARY'APOPLEXY.
of post-mortem changes, and, as Dr. Taylor observes, "it is not of the
least value as medical evidence  of drowning, unless observed soon after
death,  and unless attended with  other  appearances, which, upon  the
assumption of death by drowning, or by some other form of asphyxia,
ought always to accompany it."
  But  recently, a lad was examined at St. Mary's Hospital,  who was
brought in asphyxiated by  drowning; he was, in fact, dead at  the time,
but still some efforts were made to restore him.   The  post-mortem ex-
amination  showed none  of the visible signs commonly attributed  to
drowning, and there was no congestion of any of the viscera.
  It is doubtful whether there  are any means of  determining whether
hypostatic congestion has occurred  after death or within a few days of
dissolution.  We  know that in  full vigor the blood is not disobedient to
the laws of gravitation, as we may easily ascertain by allowing our arm
to hang down and then raise it into a vertical position, or by  elevating
our feet above our head; therefore, it is not  surprising that, in  the re-
cumbent position, as the powers of  life fail, the  blood should  gravitate
to the  posterior portion of  the  lungs.  If the congestion is confined to
one lung,  or to the anterior parts of the lungs, we may safely attribute
it to morbid processes ; and if there are any other traces of inflammatory
action, to  which we shall advert  further on, we may equally  set down
the congestion to  a pathological cause.
  Hypostatic congestion is closely allied to the disease which has been
termed pneumonic des agonisans, by Laennec, and has been  fully de-
scribed by Mr. Erichsen1  as the congestive  pneumonia, to which  the
majority of deaths following capital operations are  due.
                    PULMONARY  APOPLEXY.

  The most formidable phenomenon to which congestion of  the  lungs
gives rise, is  the disease to which, from the earliest times, the term of
pulmonary apoplexy has been applied.  It is distinct from  the hemor-
rhage that occurs from  the bronchial mucous membranes, either owing
to an adynamic state of the blood or to active congestion, both in the
symptoms it produces during life, as well as in the post-mortem appear-
ances.   The seat of pulmonary apoplexy is the parenchyma of the lung,
and, most probably, with few exceptions, only the intervesicular tissue,
for  it is  rarely associated with haemoptysis, which we  should expect if
the effusion took place into the air-vesicles themselves.   The apoplectic
spot may be felt before the lung is cut into as a globular mass, of greater
density than the surrounding tissue,  and, if near the surface, its darker
color also attracts attention.   On section, we find a dark red, almost
black,  homogeneous, circumscribed  spot, varying in size  from a  pin's
head to an orange, of the appearance and consistency of damson cheese,
bounded  by tissue,  which is comparatively  healthy  both  in  color  and
consistency.  The only interruption to the uniform color that  is  met
with, is that  caused  by the dividend bronchules,  which are less  dark
1 Medico-Chirurgical Transact, vol. xxvi. p. 29. 
PULMONARY  APOPLEXY.
403
than the surrounding parts.  The more recent the hemorrhage, the more
defined the outline ;  while, if the patient has  survived the immediate
shock, the margin of the spot fades away, owing to incipient absorption.
Thus we have seen, as in the  patient from whom the  accompanying
drawing was taken, several spots, evidently varying in their date.  The
breathing capacity of the part is entirely destroyed; it contains no air,

                               Fig. 184.
 Pulmonary apoplexy, occurring in a man aged 53.  There were several apoplectic masses, exhibiting a deep
purple, almost black hue, and causiDg an homogeneous solid appearance of the part affected, as shown in the
section.

and when scraped,  only yields  a dark, thick, bloody fluid, in which  the
microscope detects  nothing but  blood-corpuscles and some pulmonary
debris.   If  the margins of the clot be scraped and examined, we may
find exudation  corpuscles, varying in size from sYcs 0I> an inch, showing
that some irritative action and organic change are going on.
   The base of the  lungs is the part most commonly affected,  and there
may be  one, two,  or  three isolated apoplectic spots.   Laennec, who
viewed  pulmonary  apoplexy and haemoptoic engorgement  as  modifica-
tions of the same disease,  considered haemoptysis as a symptom equally
of both, and was of opinion that the former not unfrequently terminated
in resolution and  recovery.  Without  disputing the  possibility of the
absorption of an apoplectic clot, it certainly appears that there is  an
essential distinction between bronchial and parenchymatous hemorrhage,
which we must explain by a preliminary alteration, as yet not sufficiently
understood, in the  proper  lung tissue.  This is  the more probable when
we consider that the hosmoptysis which  is  the harbinger and concomitant
of tubercular  disease, rarely, if  ever, presents  the lesion denominated
pulmonary apoplexy, and  that the latter  is frequently met with in the
dead body without  its presence having been manifested by hemorrhage
durin^ life.   Louis1 states that, during  the epidemic yellow fever, which
occurred in Gibraltar, in 1828, pulmonary apoplexy was very frequently
found  in  the victims to the disease, in none of whom haemoptysis  had
taken place; on the other  hand, he had never, in phthisical patients who
had died during, or shortly after, attacks of haemoptysis, met with ap-
1 Researches on Phthisis, Syd. Soc. Ed. p. 168. 
404
PULMONARY APOPLEXY.
pearances resembling those of pulmonary apoplexy.   We are, therefore,
in every way justified in looking upon the two affections as  essentially
distinct from one another.
  Pulmonary apoplexy occasionally gives  rise to hemorrhage into the
pleural sac, from a laceration occurring in the pleura ; this will probably
be owing  to  the same process  of  disintegration, which permitted  the
apoplectic effusion in the first instance.
  The interstitial form of pulmonary hemorrhage may be due to various
predisposing  causes, that affect  the constitution of the blood, or of the
tissues,  or both together; while the exciting cause is most commonly to
be found in a morbid condition of the heart and great vessels, and more
particularly in hypertrophy of the right ventricle.  About two-thirds of
the cases on  record have exhibited some  lesion of  this kind;  still, as
Hasse very justly remarks,  a preternatural condition of the  pulmonary
texture  appears  always to precede, while a chemical analysis of the blood
would probably  exhibit a scorbutic  diathesis or an hydraemic character.
It has been observed that drunkards are prone to be affected with pul-
monary apoplexy.
  The secondary processes  to which apoplectie  spots of the lungs  are
subject  are, a gradual absorption of the blood effused, suppuration and
abscess, or isolation by the formation of a cyst; none of these processes,
however, extend  far, and with  regard to the last, no satisfactory proof
is extant of  its  occurring at all, beyond  an  imperfect observation by
Bouillaud.1

              1 Archives Generates de  Me"decine, vol. xii. p. 399. 
CHAPTER  XXIX.
                          PNEUMONIA.

  Inflammation of the pulmonary tissue is commonly assumed to pre-
sent three stages, which we may trace in regular succession in the patient,
or which we find coexisting at various portions of the lungs in the same
dead subject.  The first stage, that of congestion, we have already con-
sidered ;  its situation, its effect upon the cohesion of the tissues, the co-
existence of other  inflammatory changes, and  the  history of the case
must assist us in determining its character, though it is often difficult to
be certain of its nature.   The general effect of -acute  inflammation, in
altering the cohesion of the tissues, is a point of considerable importance;
it particularly affects, as Sir Robert Carswell has pointed out, the uniting
cellular element, and may thus  demonstrate the previous existence of
inflammation, though the  redness and  vascularity have  disappeared, or
but faintly mark the degree of alteration which  the disease has effected
in the process of nutrition.  This general law is compatible with the
observation that the second stage  of  pneumonia,  or hepatization, is
accompanied by a state of solidification ; for, as the first-named author
remarks, though the tissues feel harder than natural when compressed,
the diminution of  cohesion which  has  taken place between  their ana-
tomical elements is rendered conspicuous by the facility with which they
are penetrated, broken down, or crushed.
   In  doubtful cases the  microscope would aid  us, by determining the
presence or absence, in the congested  portion, of exudation-corpuscles,
which we find where the naked eye fails in distinguishing the existence
of inflammation, and which, at all events, show that some organic meta-
morphosis of the  vital fluids is  taking place, not consistent with the
ordinary physiological changes.   The confines  of the first and  second
stages merge into one another, and are often difficult to  define.  In
the second, the stasis of the blood becomes more marked, the specific
gravity of the pulmonary tissue increases, the overcharged vessels relieve
themselves by fibrinous exudation into the interstitial tissue, and by slight
hemorrhage into the air-vessels, which, mingling with  the bronchial secre-
tions, gives rise to the pathognomonic rust-colored expectoration of pneu-
monia.  This stage has received the name of hepatization, owing to the
increased density of the parenchyma causing the affected portion of the
lungs to resemble a piece of liver.   M. Andral, who considers the soft-
ening process to predominate, prefers the term ramollissement rouge, as
applied to this condition.  It is well to  remember that both designations
are used indiscriminately for the same morbid condition. 
406
PNEUMONIA.
  The color of the affected part is of a dark red, which is more or less
venous  or dusky, in proportion to  the type  of  the inflammation; the
crepitant character of the tissue is fast disappearing;  the lung, on sec-
tion, has lost that light spongy appearance peculiar to it in health, and

                               Fig. 185.
  Lung in a state of red hepatization; the air-cells are filled with corpuscular fihrin or exudation-matter, and
are surrounded by enlarged and congested vessels.  Magnified twenty diameters. (Bayle's Granulations.)
From a man set. 66, who had double pneumonia.

but little frothy red fluid exudes from it.  On the pleural surface, instead
of the  slate-colored, marbly hue  of the normal state, we find  a more
uniform, dusky-red color, scarcely broken by the interlocular septa.  At
this period, as Gendrin first pointed out, repeated washing and continued
maceration fails to restore the natural color of the  tissues, which they
recover, under such a process, if the redness is due merely to congestion.
Before that exudation and  general  infiltration  have taken place, which
constitute the succeeding stage of pneumonia, we find that, on breaking
up a portion of hepatized lung, the surface is studded with small pinky
granulations,  which are  identical with  the pulmonary granulations  of
Bayle.   This author, and some of his successors, looked upon them  as
the first stage  of tubercular disease;  but,  as Andral has   satisfactorily
shown, they are a product of inflammation, and must be  considered as
an agglomeration of a few hyperaemic vesicles.
  Though the specific gravity of the hepatized lung is considerably in-
creased, the  dimensions of the organ are not necessarily augmented;
occasionally, however, the organ is shown  to be enlarged  by the inden-
tations left on its surface by the ribs.
  In the present state  of our knowledge of inflammatory processes
generally, and of the form which they assume  in the lungs especially,
it is impossible, with certainty,  to show the minute changes which take
place in this stage of pneumonia.  That the parietes of the pulmonary
vesicles should themselves thicken,  consisting  as  they do  of basement-
membrane only, is, at least, not proved, and, though given on  the  ex-
alted authority of Andral, he fails to state the actual grounds  for the
view which he takes.  That some change occurs in the solids  as well as
the fluids of the inflamed part,  that the chemical and physical  proper-
ties of both undergo an alteration, that their mutual affinities differ from
those of health, is  manifest from  the phenomena  of disease, but the
ultima ratio yet remains to  be discovered.  Andral's theory of the pul-
monary granulations being due to injection  and  tumefaction  of the 
PNEUMONIA.
407
parietes of  the air-vesicles, is not consonant either with theory or ob-
servation ; for it is not difficult to trace the deposit within a cavity, nor
is it intelligible, without actual demonstration, how swelling of a mem-
brane could produce such uniform nodules without any anatomical reason
to assign for such regularity.   We regard  the second stage  of  pneu-
monia,  that of  red hepatization, as  a perpetuation of the congestive
stage, with incipient exudation into  the parts surrounding the vessels of
the  albuminous constituents of the blood; the exudation  takes  place
both into the interstitial and into  the inter-vascular spaces, according
to the laws regulating the exosmosis of inflamed vessels; the microscope
exhibits a vast congeries of gorged vessels  permeating the pulmonary
structure and surrounding the air-vesicles; while the exuded fluid shows
a  granular blastema, blood-corpuscles, and exudation-cells, which are,
probably, of an oily or albuminous  character.
   These exudation-cells, here, as elsewhere,  are the product of organic
or bio-chemical changes, and not, as  Hasse1 would  seem to imply, the
mere effect of chemical agents applied on  the table of the microscope.
They can be traced in the various stages of formation from the granular
corpuscles to the agglomerate corpuscle and the perfect cell  immediately
on removal of the fluid from the body; and their character is essentially
the  same, as we have elsewhere shown, in  the most various situations.
   The  different degrees of congestion of the inflamed  portion produce
a mottling  of the surface;  the congestion itself may be circumscribed
with a  definite line, or it fades off  gradually into the healthy tissue.
As the  second stage  progresses, marbling of a different kind occurs,
which is due to the gradual disappearance of  the coloring particles of
the  blood, the absorption of the blood itself, and the substitution of a
fibrinous deposit,  or pus.  We now enter into the third stage  of pneu-
monia,  or  that  of gray hepatization.  The term  well  denotes the ap-
pearance of the affected portion ; it is entirely consolidated and deprived
of  all air;  it presents a grayish or grayish-yellow color, which is only
varied  by the almost linear  remains of the compressed bronchules, and
the  pigmentary matter scattered through the lung tissue.   The general
condensation of the tissues necessarily, also,
involves the  bloodvessels, and arrests and           FiS-186-
prevents the circulation; so  that  the fur-
ther changes must be mainly due to extra-
vascular metamorphoses.  The parenchyma
becomes  gradually softer,  and the  more
straw-colored and paler its hue, the more
fully the suppuration process is established,
and the more friable  the  tissue becomes.
A purulent fluid  nOW exudes  On pressure.   Microscopic characters of the contents
 .  * ,                   n ,i ■       ,1    ■    of an air-vesicle in gray hepatization,
At the  commencement of this stage the air-  cons.sting of granu]ar matter> pus.cor.
Vesicles may be  isolated  in the Shape  Of  puscles, exudatiou-cel!*, and cylindrical
gray granulations, of a globular form, con-  epithelium.
tainiug  an  opaque granular matter.   The
microscopic  characters of gray hepatization, at this period, have erro-
» Pathological Anatomy, Syd. Soc. Ed. p. 211. 
408
PNEUMONIA.
 neously been stated to be those of suppuration only; but true pus-cells
 are by no means the predominant forms seen under the microscope;  the
 corpuscles that we have found to prevail wTere  much  larger  than pus-
 cells, varying from ^^^ to -g^-^ of an  inch, presenting a sharp out-
 line, and  containing  one or more  glistening granules or globules, re-
 sembling oil.  These are seen surrounded by a  granular  stroma, which
 also contains  pus-corpuscles, free oil, cylindrical  epithelium,  and some
 forms  resembling fibroid cells.   The great rarity of actual abscess
 occurring in the  lungs, compared with the  frequency with which  pneu-
 monia reaches its third stage, would alone indicate, that this part of the
 process does not  consist simply in suppuration;  and we would explain it
 by the double exudation, which takes place into the vesicles and into the
 interstitial spaces, the one continuing somewhat, though remotely, under
 the  influence of the  atmosphere, the other  being entirely beyond its
 action.  The condensation that takes place in the tissues in pneumonia,
 and the form of  the deposit, is  of  a very different character from that
 occurring in tubercular disease,  and would alone serve to prove that the
 exudation takes place both within and external to the air-vesicles.  The
 consolidation of  pneumonia does not produce  any material  change in
 the form  of the vesicular structure, which continues to present its glo-
 bular form even in the third stage; now, if the  exudation  took place
 exclusively within the vesicles, their mutual compression would produce
^ polyhedral forms, while the exclusive effusion  external to them would
 not only obliterate  them, but entirely destroy all trace of them; as it
 is, we continue to trace their form, because the extra and intra-vesicu-
 lar effusions  being  tolerably uniform, the  pressure is  equable, and no
 material alteration in the form of the air-cells takes place.   This is not
 the case,  as we shall see, in tubercle, where the  effusion is limited to the
 intra-vesicular spaces.
    When the third stage of pneumonia advances to a fusion of the inter-
 vesicular septa, and an entire breaking down of the tissues, all trace of
  the normal structures disappears, and we only  find a confused mass of
  pulmonary debris, pus, and ichorous sanies.  We  then have to deal with
  genuine pulmonary  abscess.
    The parts most liable to idiopathic pneumonia are the inferior portions
  of the lungs, while  the upper lobes  and apices of the lungs are  rarely
  affected with pneumonia, except  in connection  with  tubercle.   Louis
  states that he has constantly found pneumonia affecting the  upper  and
  anterior part of  the lungs, without  a trace of the disease existing pos-
  teriorly,  to be tuberculous; and he lays  it down as a  rule that  this
  localization of pneumonia may lead to the diagnosis of tubercular disease
  previously undiscovered.  This is undoubtedly  correct in the main, but
  as Dr. Watson observes, it is probably exaggerated ;  and exceptions to
  the rule, regarding  pneumonia, are met with, as  well as in reference to
  the ordinary site of tubercle.   Indeed, the numbers given  by Andral
  would almost destroy the validity of the law altogether ; for though they
  yield the preponderance to the  lower lobes, they seem to show a much
  greater proclivity in  the  upper than they are commonly supposed to
  possess;  in eighty-eight cases of pneumonia, he found it limited  to the 
PNEUMONIA.                        409
lower lobes in forty-seven;  in thirty in the upper lobes, and in eleven
the entire organ was inflamed.
   The general tendency of pneumonia is to spread from below upwards;
and for this reason  we commonly meet with the several  stages in the
same lung; the base to a  greater or less extent presenting  the gray
hepatization—red hepatization affecting the adjoining portion next above
the former—while the upper lobe offers more or less pneumonic conges-
tion.   The smaller  bronchi of the affected part are not, as  has been
stated by several authors, invariably affected at the same time ;  we often
see them  meandering, as white rivulets, through the  inflammatory mass;
and they occasionally appear to possess a repellent  power, and to form
a line of demarcation between two parts that are unequally affected.   A
curious exception is  mentioned by Rokitansky, in which, owing tobygone
pleuritic effusion,  the base  of the right lung had not recovered its pris-
tine elasticity, and where the entire lung was in a state of red  hepatiza-
 tion, with the exception of the apex, the anterior margin,  and  the base,
 which latter is scarcely ever found exempt.  It is  equally exceptional
 to find pneumonia  limited  to the central portion of the lungs, though
 such cases undoubtedly occur;  hence, one  of the most ordinary compli-
 cations of the disease is with pleurisy; for which reason  some authors
 prefer the compound  term  pleuro-pneumonia, to  the separate names
 pleuritis  and pneumonia.                                    ,
    According to the unanimous testimony of all observers,  the right lung
 is more frequently affected than the left, while  double pneumonia is less
 often met with than either;  the analysis of two hundred and ten cases
 of pneumonia by Andral,1  yielded the following results:—
        The right lung alone was the seat in......^
        The left       do.       do.......|°
        Both together   do.       do.......zo
        The seat undetermined in........
                              Total......210

  The relation is somewhat,  though  not essentially, altered by the larger
  numbers collected-by Sir John Forbes; he finds that in  1131 cases—
         The right lung was affected in.......^
The left in
       And both together in........
  The pneumonia, as we  have described  it, is the form which has re-
ceived the name of lobar pneumonia, as affecting entire lobes, in contra-
distinction to the lobular form of pneumonia, in which it is limited to
individual lobules scattered through the healthy lung tissue.   It is, m
fact a partial pneumonia, which, from some unknown cause, does not
spread beyond the point  of primary lesion.  Small  spots with a scal-
loped outline, presenting the various stages  of congestion  of red and ot
era/ hepatization, are found on section  scattered indiscriminately
fhrouo-h  the  organ.   It is peculiar to infant life, and is  probably con-
nected with  the  same imperfect  development of the vesicular tissues,
which we have already found to constitute an important disease of early
1 Clinique Medicale, vol. iii. p. 470. 
410
PNEUMONIA.
 childhood.  In many instances there is no doubt that the two conditions
 have been confounded.   This cannot, however, be the case when we find
 the lining studded with small, yellow spots, satisfactorily indicating the
 third stage of pneumonia.   TJius, in a child of one year and a half old,
 which  was under our own observation, and from  his  ninth month had
 been subject to repeated  attacks of broncho-pneumonia, we  found the
 whole  of  both lungs studded with small  purulent  deposits; on the left
 side, where the softening process was furthest advanced, pus readily
 exuded on pressure; there were no cavities, nor  was any tubercle dis-
 covered.  The latter point, the absence of tubercle, is one of import-
 ance in determining that  these purulent accumulations are not vomicae,
 but due to a simple  inflammatory process, independently of other  cha-
 racters that mark tubercle.  The disease is stated by writers to result
 from phlebitis, accidents, and operations; but we shall have occasion
 to see  that secondary abscesses and  the form of pneumonia peculiar to
 individuals who have been operated upon, differ materially from lobular
 pneumonia.
   According  to  Rokitansky, the character  of ordinary pneumonia ia
 essentially allied to croup, on the ground that the exudation takes place
 into the air-cells, and not  into the interstitial tissue;  this  author  dis-
 tinguishes two forms of exudation in pneumonia, the one taking place
 into the cavity of the vesicles, the other interstitial.  This classification
 is not  borne out by what we see in the dead  subject;  and Ave are of
 opinion that the inflammatory effusion  takes place into both at the same
 time.  Our means  of  analysis are  scarcely sufficiently advanced at
 present to determine whether it predominates in one or the other occa-
 sionally.  Moreover, the character of croup is so peculiar, and the term
 generally understood to be applied to a form of inflammation of certain
 mucous membranes, so distinct from the inflammatory processes to which
 they are ordinarily exposed, that Ave are only likely to produce confusion
 by applying it to processes Avhich, theoretically,  we may consider allied
 to it.  In the present  instance there is  not, however, even any theo-
 retical presumption in favor of Rokitansky's view, for there is no rela-
 tion  betAveen the occurrence of pneumonia and angina membranacea; the
 latter is essentially a disease of childhood, the former is the property of
 all ages;  a peculiar habit tends to produce the one, certain seasons  and
 places  also create the proclivity to it;  while in the other, inflammation
 of lungs,  we do not  trace the agency of  the same  influences.   The de-
 scription of the minute changes recurring in pneumonic exudation, which
we have given, also tends to disprove the existence of an analogy, much
less an identity, between the two processes.
   The varieties of pneumonia which are spoken of by authors, as differ-
ing from ordinary acute pneumonia, are all characterized by presenting
 a more asthenic and  less acute type, than the ordinary form which we
have just discussed.  The  hypostatic pneumonia  of  Piorry,  typhoid
pneumonia,  congestive pneumonia, the bilious,  and the erysipelatous
form of Riverius, and older writers,  the senile pneumonia described by
Hourmann and Dechambre, are all forms of asthenic pneumonia, occur-
ring  in subjects debilitated by other diseases, in whom  the lungs  are
attacked  by a low, creeping, sneaking inflammation.   The  congestion 
PNEUMONIA.
411
is of  a more  venous character, causing a dusky brownish  violet tint;
the physical law of gravitation exerts a strong influence upon the blood
in the thorax, and the  posterior portions are predominantly affected;
 Pleural surface of a portion of eplenified lung, affected with typhoid pneumonia, from a female set. 25, who
died of typhoid fever. The lung closely resembled the spleen in consistency, was of a brownish red hue, in-
terspersed with deep purple spots of an apoplectic character.

the tissues are more friable and  lacerable even in the first stages, and
in the progress of the disease we  fail  to  find that  evidence of plastic
inflammation  which accompanies  ordinary sthenic  pneumonia.  Much
yet remains to be done with regard to determining  the  actual morbific
ao-ent in many of the forms of disease with which we have to deal; and
when we  shall  have  arrived at a  correct appreciation  of the erases,
which  induce the  palpable manifestations  of inflammatory action, we
may hope to reconcile theory and practice more fully than has yet been
done;  we may then also explain why such various modes of  treatment
are successful in combating symptoms, which, to our short-sighted vision,
indicate  the  same disease, though  in  reality they  are  due  to totally
different  causes.   Thus, pneumonia, occurring  in  a system in which
there is a predominance  of lactic or lithic acid, would  necessarily de-
mand different remedies from one in which an alkaline or septic principle
prevails.  But to return to our legitimate sphere: the hypostatic form ot
pneumonia occurs  in a variety of diseases, in which the  patient is con-
fined to the recumbent posture, and in which the system is much debili-
tated    Under  the name of congestive pneumonia, it has been described
bv Mr Erichsen as the most fertile source of the fatal issue of  capital
operations, after the patient has survived the first shock, and therefore
calls for  the special attention of the operating surgeon.
   In this form, the congestion is by far the most prominent  symptom;
and though enough of vitality remains to give rise to some active symp-
toms  yefthe debility of  the patient, and of the organs of respiration
is so ereat as to prevent a reaction of a vigorous character.   Mr. Erichsen
has analyzed sixty-two post mortems of individuals who  died after ope-
rations, and has set down as pneumonic only those cases in which either
one lung alone was affected,  or else, in which some other palpable sign
of inflammatory action was manifested in the cavity of the thorax, beyond
a merely congested or softened  condition of these organs, such as solidi-
i Medico-Chirurg. Transact, vol. xxvi. p. 29. 
412
ABSCESS.
fication of their tissue, whether hepatization or splenification of it, the
effusion of recent lymph  or serum into the pleural sacs, or  marked evi-
dences of inflammation of the bronchial mucous membrane.   The result
of his  analysis is as follows:  There  were tAventy-eight  in which there
were evident signs of pneumonia;  eleven in which the lungs  presented
the characters common to the first stage of pneumonia and passive con-
gestion ; nine where the  lungs were diseased, but neither inflamed nor
congested;  and  fourteen  in which these organs were healthy, though
many may have presented cadaveric congestion.   A fact connected with
this form of pneumonia, and pointed out by Mr. Erichsen, is, that while,
in ordinary sthenic pneumonia, the right lung is most frequently affected,
the left next, and lastly,  both organs conjointly, here, the two lungs are
most frequently affected together.   In the  twenty-eight cases in which
pneumonia Avas traced, the right lung alone was affected three times, the
left lung alone also three times;  and  ooth lungs  together, though not
to the  same degree, in tAventy-two  cases.
   In the pneumonia accompanying typhus, congestion is equally a pre-
dominant symptom, and requires the more to be carefully watched during
life, as the insensibility of the patient and the general torpor  of the
nervous system  allow it  to run  its  course  without producing (in many
cases)  any symptoms of inflammatory action beyond those obtained by
the stethoscope.  Cough, expectoration, and dyspnoea,  may be absent,
while we find extensive crepitation over a large  extent of surface.  In
addition to the post-mortem  appearances already  detailed, we find the
affected parts very  soft, and the  product  is of an  aplastic, jelly-like
character, while there is no definite limitation  to the disease.  In some
cases of atypic pneumonia, where we have reason to suspect an arrested
secretion of bile in the liver, we find a genuine jaundice of other viscera,
and then the frothy juice exuding from the cut surface of the pneumonic
lung may present a yellow tinge, which has probably  given rise to the
term of bilious  pneumonia.   Again, in senile  pneumonia,1 the  follow-
ing varieties are described as belonging to the second stage;  the lung,
on incision, appears perfectly smooth and homogeneous, discharging a
reddish, frothless serum, the inflammation occurring in patches, which are
elastic, or soft; or, if granulations are present, they are much larger than
in younger individuals.   In the third stage, a peculiarity has been occa-
sionally observed by Hourmann and  Dechambre, which Hasse confirms;
it consists in the purulent matter being sharply defined in spots of from
one to  two lines in diameter, which prove to be the irregularly dilated
air-cells, often met with at intervals throughout the lungs of aged persons.
                            ABSCESS.

  We have already seen  that the  formation  of abscesses, such as we
meet with in  other  organs and on  the surface of the body, is rarely
found in the  lungs, notwithstanding the frequency with which inflam-
mation attacks them.   Yet a suppurative destruction of the tissue occa-
1 See Hasse's Pathological Anatomy, p. 229. 
METASTATIC ABSCESSES.
413
sionally leads to this result, and we then find a cavity varying in size
from that of a marble to that of an entire lobe, and presenting ragged
parietes; it contains pulmonary debris and pus, which partially infiltrates
the adjoining tissues, as there is no lining membrane; or the abscess may
have discharged its contents, and we then only meet with the irregular
excavations with jagged walls.  Formerly, the frequency of pulmonary
abscess was considered to be much greater than we now know it to be,
because tubercular  cavities were confounded with this lesion.   Noav that
the nature of both affections is better understood, the error is less likely
to arise; when we are in doubt, the history of the case, the situation of
the abscess, the condition of  the  surrounding parts, the presence or
absence of tubercular deposits  in the lungs, are points that will aid us
in establishing a correct opinion.   Carswell  has very justly  remarked
that the mere presence of pus must be carefully distinguished from sup-
puration.   In the latter case, we have to deal with an  active process, in
which the tissues and bloodvessels of the part in which we find the pus
are primarily engaged, or with suppurative  inflammation;  the process
which John Hunter conclusively showed  to  be analogous to secretion.
In the former, the pus is a foreign  body in the blood, and may be con-
veyed to the seat of disease by the vascular channels from elsewhere,
or be developed from the constituents of the vascular current Avithin  the
vessels, and subsequently be discharged from them; a process more allied
to chemical decomposition than to secretion.
                    METASTATIC ABSCESSES.

   The mere presence of pus in the lungs, simulating abscesses, and, from
the cause to which they are attributed, termed metastatic abscesses, or
purulent  deposits, constitutes a pathological phenomenon, which occurs
more frequently in the lungs than  the  other  parenchymatous viscera.
This is quite in accordance with the known relation  existing between
phlebitis  and the formation of secondary deposits ;  the lungs, as  the
receptacles of the entire mass of the venous blood, might therefore be
expected  to exhibit a peculiar liability to any morbid affection connected
with this  portion of  the circulating system, a point of great importance
in reference to the subject immediately under our consideration, as well
as to other pulmonary diseases.  The appearances by which we recog-
nize these deposits are, spots of yellow pus, varying in size from a pin's
head to a walnut, generally situated near the surface of  the organ, and
surrounded by a defined  patch of deeply-congested tissue, which may
present a color approaching to black; beyond  this, the parenchyma is
in a healthy condition, or, at all events, in a state totally distinct from
the circumscribed disease.   We  generally find several of these abscesses
in various parts of the lungs.   The  pulmonary tissue of  the seat of the
abscess may have entirely disappeared, or we  may be yet able to squeeze
out the pus, so as to show the normal structure.
   Secondary abscesses in the lungs are almost invariably accompanied
by similar deposits in one or several other viscera, and more especially 
414
FIBRINOUS DEPOSITS.
in that one which, as a depurator of the venous blood, is second in im-
portance only to the lungs—the liver.
   The universal concomitant of these abscesses is now well ascertained
to be  the suppuration  of some distant part or  organ, Avhich induces
phlebitis at the seat of primary injury.  This may be the uterus  after
delivery, periostitis of the leg, fistula in ano, psoas  abscess, or any other
similar affection.  The system must be in an ataxic condition to permit
of the poisoning of the circulating current, and, though the introduction
of pus into the blood is  proved to  be necessarily fatal, it is  probable
that the local injury would not give rise to phlebitis, unless a  peculiar
predisposition to  it existed.   Another  question  is, whether, after the
occurrence of local phlebitis, the pus is necessarily conveyed from the
part to each point that afterwards shows a secondary abscess, or whether
a catalytic effect is produced on the blood,  in consequence of Avhat the
older authors called a purulent diathesis.   It certainly does not appear
that the secondary local effects are a necessary consequence of purulent
infection;  but that this  may prove fatal without producing  them.  M.
Lebert gives two instances in Avhich he noted the absence of metastatic
abscesses, notwithstanding manifest purulent infection.
                     FIBRINOUS DEPOSITS.

  We  occasionally meet with  deposits of a different character in  the
lungs,  which Rokitansky appears to regard as  identical with  the puru-
lent deposits just  considered;  but Avhich certainly  present  different
characters, and are connected with a different  state of the system, un-
less, indeed,  Ave adopt the view that pus  and fibrin are essentially the
same.   These deposits occur in a more or less  wedge-shaped form, with
the base towards  the  pleura, near the  surface of the lung.  They pre-
sent a light red or yelloAvish white color,  surrounded by somewhat con-
gested crepitant tissue, with a defined margin.   The lung tissue is in a
state of  disruption, and the microscope exhibits  the  pulmonary debris
in a granular stroma, in which granulated nuclei, varying much  in size
and shape, and some  highly refracting globules of oil, are seen.  The
color,  the  consistency, the appearance of the tissue immediately sur-
rounding these fibrinous deposits, as well  as their microscopic charac-
ters, establish so  many points of difference between them  and purulent
deposits, that we are  scarcely justified  in classing  them together, espe-
cially as we do not observe that the two morbid products occur together
in the same individual.  Nothing can be  more valuable than a simplifi-
cation of the elements of  disease, and the demonstration of the real
identity of apparently different  forms;  at the same time nothing  is
more liable to lead us from the path of legitimate induction than hasty
generalization.   With  regard  to the  origin  of these deposits, we are
inclined to regard them as an exudation from  the capillary circulation,
rather than as a  result of fibrin being detached at distant points of the
circulation, and carried by the  current into the pulmonary parenchyma. 
GANGRENE — CHRONIC PNEUMONIA.
415
                            GANGRENE.

   The most marked form which septic disease assumes  in the lungs is
 presented in cases of gangrene; it is, as Dr. Watson observes, very
 Beldom the result of acute inflammation, and is almost as uncommon as
 the formation of true abscess.  It appears to be due to  a  peculiar con-
 stitution  of the blood, or to a specific poison.   Dr. Stokes has published
 some cases in all of which the patients had been  habitual drunkards;
 the abuse of spirituous liquors does not, however, seem to exert  a uni-
 form influence in its production; for, in chronic alcoholism, as described
 by Dr. Huss,1 this lesion has not been met with.  It is also remarkable
 that ergotism, Avhich has a peculiar tendency to induce  superficial gan-
 grene,  is not accompanied by pulmonary sphacelus.   The  same applies
 to the analogous disease spedalskhed,2 or the Norwegian leprosy.   It
 presents  two forms, the diffuse and  the  circumscribed.   In the former,
 the lung  tissue  that is  inA'olved is broken  up into shreds, which hang
 into a  cavity filled with  a  fetid, purilaginous,  discolored sanies, and
 through which the bronchi and vessels may yet be traced  entire.  The
 gangrenous portion presents a variety of hues, in the different shades of
 green,  brown, and black.  The surrounding parenchyma  is infiltrated
 with ill-conditioned pus.   An entire lobe, or even  the greater  portion
 of one lung, is  found to be in this  condition; though  the upper lobe
 appears to be most prone to the affection.  In circumscribed gangrene,
 which is more frequent than the former, we find one or more  patches,
 varying in size and of irregular form,  scattered  through  the  lungs.
 There is much less tendency to involve the adjacent parts, and the course
 of the affection  is more chronic than the former.  Laennec describes the
 color of the mortified portion as black, with a greenish tinge—the texture
 as moister and more  compact  than that of the  lung, and its  aspect
 closely corresponding to an eschar, produced upon the cutaneous surface
 by nitrate of silver.   The neighboring pulmonary tissue is in a state of
 inflammatory congestion;  and, after the sphacelated spot has become
 detached, a false membrane, of  a grayish, dirty-yellow color is formed,
 which secretes an ill-conditioned pus.  At times, the membrane is formed
 even before the entire separation  has  been effected.   If the gangrene
 involves the pleura, rupture and discharge into the pleural sac may
 ensue, or  otherwise the bronchi may be the channels by which the  evacu-
 ation is effected.

                     CHRONIC PNEUMONIA.

   The  existence of chronic  pneumonia has been  disputed  by  some
 authors;  but both at the bedside, as well as in the dead-house, avc find
 cases to which no other name can be giATen, though, in the present state
 of our knowledge, it is often difficult to define the exact limits of the
acute and chronic forms.  Another difficulty which has yet to be re-
moved,  in regard to this subject is, to  determine whether chronic pneu-

  1 See Dr.  Huss's Work on the subject; Alcoholismus Chronicus, &c, Stockholm, 1849.
  2 Dr. Daniellsen and Boeck, Om Spedalskhed, &c.  Christiania, 1847. 
416
CHRONIC  PNEUMONIA.
monia is essentially different from the intercurrent pneumonia associated
with tubercular phthisis, and if so, whether there are any marked cha-
racters by which in the dead body, where we only have to consider it at
present, it can be recognized.   Andral, who looks upon it as a frequent
idiopathic affection of the upper lobes, and as that form of pneumonia
which, from this circumstance, has not  met with the proper  attention,
differs materially from the views promulgated by Hasse, and those who
look upon chronic inflammation of the lungs as essentially connected
with the tubercular cachexia.
   The chief feature in chronic pneumonia, which we find equally dwelt
upon by almost all  observers,  is the hypertrophy of the  intervesicular
tissues, owing, probably, to a deposit of an albuminous character in them.
Rokitansky, in contradistinction to his croupous form of pneumonia,
gives the name of interstitial pneumonia to a second form, which he re-
gards as identical with the chronic form of other pathologists, as, for
instance, Andral and Hasse;  the difference is rather one of names than
of reality, for Rokitansky also admits that the walls of the air-cells are
often implicated.  He describes the inflammation as commencing be-
tween the pulmonary lobules  and  the smaller groups of air-cells; the
tissue, unless much carbonaceous matter be present, becoming of a pale
red color, and being swollen  by albuminous  infiltration, while the air-
cells are either pale or more or less compressed, in proportion to the
swelling; or if they are  involved in the  inflammation, reddened,  and
sometimes finely granular.  In the progress of time, the interstitial in-
filtration becomes organized, coalesces with and obliterates the air-cells,
and finally converts them into a similar tissue.  In some cases this pro-
cess may terminate in suppuration;  in others it  extends from lobule to
lobule,  at the apices of the lungs, and  is frequently combined with cir-
cumscribed pleurisy.
   Dr. Williams describes  a chronic form of pneumonia,  in which the
hepatized portion, owing to the thickening of individual vesicles, assumes
an oolitic aspect.   He is  of opinion that consumption may originate in
this species of pneumonia without  the  pre-existence of any distinct
tuberculous disease.  It is not impossible  that some of the fibroid con-
tractions of the  pulmonary tissue, which we  meet with, particularly at
the apices of the lungs, may  be due to an arrest of chronic pneumonia
as well as to previous  pleuritic inflammation; Ave occasionally meet with
depressions  in  otherwise  healthy lungs,  which are unconnected with
emphysema, and for which no other  explanation can  be offered than  a
foregone inflammatory condition of the interstitial tissues of an aplastic
character, an opinion  in which we are  also borne out by the authority
of Dr. Williams.1
1 Principles of Medicine, p. 313.  London, 1843. 
CHAPTER  XXX.
          ADVENTITIOUS  PRODUCTS  IN THE  LUNGS.
                                             •
  We now arrive at  the  consideration of  a  subject which, both  in  its
scientific and in its practical  bearings, is one of the utmost importance
in connection with the  morbid anatomy of the lungs more than with
that of any other  organ, the  deposit of tubercular matter.  In the sec-
tion devoted to the general pathology, we have entered into the prevail-
ing views  entertained with regard to the nature of tubercle.  The affinity
between lymph and tubercle insisted upon by older writers, and recently
more fully urged by Dr. Alison, Dr. C. J.  B. Williams, and, under the
appellation of fibrinous  erases by Rokitansky, must not be lost sight of,
although  it only states  the  one fact, that tubercle is a secretion of a
morbid constituent of  the blood, in  different terms, without actually
defining  the character of the change.  It leaves the relation between
the salts of the circulating fluid  and  the  albuminous constituents un-
touched, nor does  it determine whether any chemical agent which the
exuded matter  may meet with, in any way alters its nature, and thus
converts what, in  the first instance, may have been  innocuous, into a
deleterious agent.   We are led to make these remarks by the interest-
ing experiments lately published by Dr. Parkes,1 on the  "Precipitation
of Albumen by Acids and Neutral Salts," which promise  to throw much
light on the ultimate constitution of tubercle, as well as  upon  many
points connected with its origin  and metamorphoses.  Our limits will
not allow us to detail  the processes employed, but the conclusions arrived
at are sufficiently  important to justify their introduction at this place ;
they are: 1. That  the albumen in the serum of the blood  is occasionally
in a condition in which  it is  not precipitated by an  acid and a neutral
salt.   2.  That if  that albumen be exposed for some time to a strong
alkaline solution it ceases to  be precipitable by acids and salt.  3. The
continued action of acetic acid on serum also  annuls the action of acid
and salt on albumen; hence  it is evident that the albumen, as it exists
in the serum, is usually in that condition in which it is most easily pre-
cipitated by acids  and chloride of sodium; but that it very readily passes
out of this condition under the continued influence of acids and alkalies,
and is then, in  all probability, incapable of reassuming it.   Dr. Parkes
also shows that, under certain circumstances, the albumen is found in a
corpuscular condition, viz: in the form of round globules and cells of
different sizes, sometimes inclosing each other, and  forming conglome-

               ' Medical Times, 1850, July 27, and 1852, July 3.
       27 
418        ADVENTITIOUS PRODUCTS IN THE LUNGS.

rates, and sometimes  completely resembling  the  eye-globules of  fat.
The former observations indicate  the nature of the bio-chemical changes,
which obtain, when an aplastic  deposit, such as  tubercle, is effected,
while the latter assist  in explaining the fact that Ave meet  with what is
called fat or oil, in varying quantities in all tubercular deposits, and also
aid in the intelligence  of that morbid state of nutrition known under the
term of fatty degeneration.
   The lungs  are the organs which, above all others, are liable to tuber-
cular deposit; a circumstance easily explained, if we admit that tubercle
is deriAred directly from the blood,  as the lungs are the chief organs of
haematosis, and anything tending to check  the purification and arrest
the circulation  of  the current would also induce  an  elimination of the
morbid  element.  Hence, too, the apices, from being inclosed in a  less
yielding case, mechanically favor the effusion more than the lower lobes.
We are unable  to  reconcile with this fact  the categorical  statement of
Rokitansky, that the main feature  of the tuberculous crasis or diathesis
consists in arteriality  or a predominant arterial  development of fibrin,
since, if this were the  case, we should certainly expect to find the tuber-
culous deposit more frequently in  the  brain and  kidneys  than in  the
lungs, and more commonly in  the  interstitial  tissue  of the latter, as a
secretion from the  bronchial arteries, than in the respiratory vesicles.
That the deposit is extravascular, is undoubted.   Messrs. Gulliver  and
Addison have shown that it is  effected on the surface of the air-cells, or
under the basement-membrane, though our own observations lead us to
believe  that the primary deposit  is  invariably at  the  point of smallest
resistance; and hence, in the first instance, always into the free cavities.
That, when these are  filled, the morbid plasma may be deposited in the
interstitial parenchyma, is certain ; Dr. Williams is even of opinion that
tuberculous matter may form within the bloodvessels themselves, as he
has repeatedly found something  presenting  all the external  characters
of yellow tubercle in the bloodvessels of tuberculous lungs.  "In fact,"
he continues, "wherever fibrin may coagulate, there its degraded form,
tubercle, may occur.   It is but in accordance with the general rules of
morbid formations, that the  deposit of tubercle should undergo modifi-
cations both  in  form and  chemical  constitution, according to the organ
in which it appears and the  habit of the individual;  hence, though its
characters are sufficiently uniform  to justify our treating it as a disease
sui generis, numerous  variations present themselves, owing to the influ-
ence to which we have  alluded, which have given rise to conflicting state-
ments.   The  microscope has  more especially appeared to complicate,
instead of solving the difficulties, owing  to the presence of epithelium-
corpuscles, nuclei,  and proper corpuscles (as in the glands), in most of
the parts where tubercular deposit occurs.   The greater or less conges-
tion, irritation, and inflammation coincident with tubercular deposit, has
no less  confused the doctrines relating to the subject; though, if we take
the whole complex of pneumonia, and  analyze  the  successive stages
which we meet with, we shall find that  the real obscurity is not so great
as it at first  sight appears.  A material difficulty in the examination of
diseased lungs is that, in all the early stages, the quantity of air contained
in the tissue is so great as to constitute  a  considerable impediment to the 
ADVENTITIOUS PRODUCTS IN THE  LUNGS.        419
minute investigation; and, though the examination of dried or seasoned
specimens may assist in elucidating some points of morbid anatomy, it
is manifest that the most important questions will remain unsettled, unless
we arrive at our conclusions from what we discover in the most  recent
examples.
   The primary  deposit of tubercle takes place, in a semifluid form, into
the vesicular cavity, which it distends  so  as to form a  round point, of
the size of  a small pin's head, visible  to  the naked eye.   It forms  a
Miliary tubercle, scattered throughout the pulmonary tissue, forming translucent, grayish, and circular
                          points, of the size of pins' heads.

translucent mass, which entirely blocks up the cavity, stopping abruptly
at the entrance of the ultimate bronchule, like a bullet that exactly fits
its mould.   The fine basement-membrane of the vesicle is more or less
obscured by the dark ring of exudation-corpuscles covering it, and which

                                 Fig. 189.
 Microscopic appearance of miliary tubercle.  The drawing to the left shows the site of the deposit and its
relation to the pulmonary tissues; the effusion has taken place into the air-vesicle, which is distended into a
globular ball. The drawing to the right exhibits a section of miliary tubercle without the bronchules, sur-
rounded by congested vessels.

we invariably find wherever there is any irritation accompanying the
deposit,  whether of a primary or a consecutive character.  The ultimate
divisions of the bronchi escape the power of unassisted vision, but,  in a
successful section, may be clearly seen with a power of twenty diameters. 
420        ADVENTITIOUS PRODUCTS IN  THE LUNGS.
This deposit scarcely encroaches upon the surrounding parenchyma; but
when, instead of solitary vesicles being the seat of the exudation, whole
clusters of breathing-cells are at once charged with tubercular matter,
the microscopic  appearances are rather those of a mould of grapes taken
in blanc-mange, and we no longer detect the interstitial  spaces, partly
from  the increased opacity of the deposit rendering  it impossible to
transmit light through a section of  any thickness, partly from the com-
pression exerted upon the interstitial tissue obliterating it.   The oblite-
ration of the pulmonary  tissues progressively increases; the rounded
form  of the  vesicular  structures is gradually destroyed; by  mutual
pressure they assume an hexagonal or polygonal shape, a  mere line indi-
cating the points  of separation ; the bronchules leading  to this  morbid
mass  are seen  to be  obliterated, dwindling down, near  the tubercular
aggregation, to a  point, and  ending, like a ligatured artery, in a  mere

             Fig. 190.                            Fig. 191.
 Microscopic appearance of a mass of miliary       Hexagonal appearance caused by the mutual
      tubercle, in close aggregation.          pressure of the air-cells, filled with yellow tubercu-
                                   lar matter, with obliteration  of the bronchules
                                   leading to the lobules.  Magnified 60 diameters.
                                                                       \
thread.   The  translucent  character  of the tubercle, by this  time, is
utterly lost; it has assumed,  partly owing to original constitution, but
more,  in  our opinion,  owing  to  secondary changes  which have  taken
place in it, an  opaque cheesy appearance, of a creamy or clayey color,
resembling fresh Stilton or pale Cheshire, both in hue and consistency.
  If the  tubercular matter be analyzed by the higher  powers of the
microscope in these various  stages, we find that it presents corresponding
differences in its ultimate elements.   In the  earliest and  most recent
form we see a fine molecular blastema of an almost homogeneous appear-
ance, in which  faintly, but  definitely, the outline of lighter particles of
an oval or circular shape, and from  0.0003" to 0.0002"  in diameter,
may be traced, themselves  less granular than the stroma in Avhich they
are imbedded.  The tubercle-corpuscle contains no nucleus, a point which,
as M. Lebert has shown, is  confirmed by the addition of acetic acid fail-
ing to bring it  out,  and which serves to  distinguish it from similar
formations.  The tubercular elements  are not, as has been asserted, a 
           ADVENTITIOUS PRODUCTS IN THE  LUNGS.        421

mere modification of epithelium; but though we frequently find epithelium
mixed up with, and possibly, at  times, closely resembling the more de-
veloped forms seen in tubercle, they possess a character and evolution
of their own.   The denser the deposit, the more uniform the conversion
of the blastema into definite oval, or somewhat angular corpuscles, with
a definite cell-wall and granular contents.   The corpuscle is not a mere
lamina, but appears to have an ovoid shape.  A neAv process of disinte-
gration now appears  to ensue, and we see the elimination  of  a large
number of highly refracting particles, hitherto considered as fat or oil,
but possibly, according to  the experiments of Dr. Parkes above alluded
to, peculiar modifications of albumen.   When the tubercular deposit has
arrived at this stage it appears that an arrest of the morbid process  may
take place, it may become  obsolete, and undergo  changes  that enable
the system to bear  its presence without serious  inconvenience, or the
morbid process advances with more or less activity, inducing a softening
of the deposit, and a destruction of the pulmonary tissue, all of which
we shall have occasion to investigate further on.
   We now turn to consider the morbid  phenomena and changes in the
pulmonary tissues associated with the  deposit of  tubercle.  These are
of a more  or less active  character, according to the exciting and predis-
posing  causes operating in  the  individual  case, and according to the
general  habit of  the  patient.  It has, therefore, become customary to
form two  groups of pulmonic tubercular diseases, the acute and the
chronic.   Other authors have preferred dividing the subject, according
to the characters presented  by  the tubercular deposit, into the  gray  or
yellow varieties, or, as Rokitansky more particularly has done, according
to the place of deposition, into the interstitial and infiltrated form; the
former term being applied  to tubercular matter  exuded into the inter-
vesicular textures, the latter to  its occurrence within the cavity of the
vesicles.   We have already seen that the density of tubercle varies with
the period of its deposit, 'and with the  amount of pressure it may  be
 accidentally exposed to.   No important characteristic seems to depend
 either upon its color, except that the most decidedly gray and translucent
 form is the more recent, and most  commonly connected  with a more
 actively inflammatory condition  of the  parts; the same influences which
 induce the change of form and consistency undoubtedly modify, together
 Avith the  molecular alterations  that coexist, the color of  the  deposit.
 Still, the  deposit may, from the first,  present an  opaque yellowish ap-
 pearance, and, as Carswell observes,  the  gray,  semi-transparent sub-
 stance does not necessarily precede the formation  of the pale yellow or
 opaque tuberculous matter.  After the tubercular matter has become
firm, it may, at some  future period, be converted into a pulpy grumous
fluid, presenting  various colors  of a greenish, red,  brownish, or other
hue, dependent upon the admixture of serum, blood, or pus, which pervade
the substance of the tubercular matter, loosening and detaching it.  From
 this it follows that there must be some error in the  commonly received
 doctrine  that the  softening ahvays commenced in the centre of the
 deposit.   We commonly find a depression  in the middle of an  accumu-
lation of tubercular matter.  This has been attributed by Laennec  to
 softening.   Carswell's  explanation  is  as follows: "When tuberculous 
422        ADVENTITIOUS  PRODUCTS IN  THE LUNGS.

matter is found in the lungs it is generally contained in the air-cells and
bronchi.  If,  therefore, this morbid product  is  confined to the surface
of either, or has accumulated to such a degree as to leave only a limited
central portion of their cavities unoccupied, it is obvious that when they
are divided transversely the  following  appearances  will be  observed.
1. A bronchial tube will resemble a tubercle having a central depression,
or soft central point, because of the  centre of the tube not being, nor
ever having been, occupied by tuberculous matter, and because of its
containing a small quantity of  mucus or other secreted fluids.   2.  The
air-cells will exhibit a number of similar appearances or rings of tuber-
cular matter,  grouped together, and containing in their centre a quantity
of similar fluids.  When the bronchi or air-cells are completely filled,
the tuberculous matter presents no such appearances as I have described,
and hence the reason why tubercle, in such  circumstances, has  been said
to be still in a state  of crudity, or that condition which precedes the
softening process.   Softening begins  most  frequently at the circumfer-
ence of the tuberculous matter, or where its presence as a foreign body
is most felt by the surrounding tissues. Hence, the reason why softening
is frequently  seen making its appearance in several points of an agglo-
merated mass of this substance, which has included within it portions of
the tissues in  which it was formed.   This is frequently  observed in the
lungs, and cellular tissue in other parts; whereas, in the brain, the sub-
Btance of which has, from the commencement, been separated and pushed
outwards by the tuberculous matter, the softening process begins, and
is always most marked on the circumference of this morbid product."
  As we have assumed that there is essentially but one form of tubercle
possessed of characters sufficiently definite to justify the classing under
one head varieties which owe their  differences to accidental or  trifling

            Fig. 192.                               Fig. 193.
 Microscopic appearance of minute vessels, sur-    A section of an air-vesicle filled with yellow tubercle,
rounding air-vesicles in tubercular pneumonia,        and surrounded by exudation-corpuscles.
and miliary tubercle.

circumstances, and as we believe that the diathesis of the blood and the
general constitution of the individual are essentially the same, in which
the deposit is effected, so  also  are the  symptoms and local  changes
 
           ADVENTITIOUS PRODUCTS IN  THE LUNGS.        423

accompanying the elimination of tubercle more or less the same in the
different cases.   They are  essentially those  of a low  type of inflam-
mation.   The primary deposit of tubercle is always  accompanied by an
increased afflux of blood to  the part; hence the great danger in scrofu-
lous subjects of the slightest catarrhal inflammation, because the diathesis
being present, nothing is required to  induce the deposit but a congested
state of  the parts generally liable to it.   The  further evidence of an
inflammatory process is given in the constant occurrence of exudation-
corpuscles in the immediate vicinity  of the air-cell into which the effu-
Bion is taking place, or has recently been effected.   These  corpuscles,
whether in the form of cells with a proper wall,  or of mere aggregation-
molecules, are  seen entirely coating  the air-vesicle if we obtain a view
d posteriori; or, if we succeed in making a transverse section, a dark ring
formed by these corpuscles, and probably external to the basement-
membrane, between  the vessels and vesicular  coat, is seen bounding the
tubercular matter.   This point the more deserves attention, because in
certain experiments made by Gluge  to  disprove  the views entertained
by Dr. Addison, that the morbid state of the lungs accompanying acute
miliary tubercle is of  an inflammatory character, stress has been  laid
upon these corpuscles being distinct from tubercular matter, and that
the  error had arisen from their being in the previous experiments mis-
taken for the cacoplastic exudation  itself.   Their characters  are  cer-
tainly well defined, and it is this  point that, in  our opinion, confirms
the views of the inflammatory nature of  the process, which, not only in
miliary, but in every form of tubercular deposit, accompanies its elimi-
nation.   In the words of Dr. Graves, the most important thing for the
student to impress on his mind, with  regard to all cases of phthisis, is,
that the pectoral symptoms, of whatsoever  nature  they  may  be, are
caused by scrofulous inflammation.   The haemoptysis which  is found to
precede  or accompany two-thirds of all  cases of pulmonary consump-
tion, and is so  constantly connected with tubercle,  that Louis has  laid
it down  as denoting with  infinite probability the  actual presence of
some tubercles  in the  lungs, at once furnishes a proof  of the manifest
congestion accompanying the lesion,  and of the peculiar aplastic condi-
tion of the blood, by which, under comparatively slight exciting causes,
it is forced through  the coats of the vessels.  This haemoptysis also con-
firms the view  we  have  advocated with  regard to  the intra-vesicular
character of tubercular effusion; Ave  never find any symptoms  of apo-
plectic hemorrhage, or hemorrhage within the  pulmonary parenchyma
accompanying  tubercular disease, but it  is  invariably an exhalation on
the free  surface of the respiratory membrane.   Now it is fair, to con-
clude that if the tubercular blastema Avere effused  interstitially in the
first instance, we should here also, in a  proportional number of cases,
find  the results  of hemorrhagic effusion, which is not  the case.
   With reference to the mode in which tubercle is distributed through
the luno-s, we find that it presents  three varieties, which are generally
tolerably defined in the lungs of one individual, though occasionally the
several forms of deposit occur together.   Hasse describes them in the
following terms: "First, they are  found single, isolated, and more or
less uniformly disseminated miliary tubercles; secondly, they are found 
424        ADVENTITIOUS PRODUCTS IN THE LUNGS.

in scattered groups, assuming  various forms, the tubercles  being now
loosely  collected together,  now closely  connected either  in  a regular
mulberry shape, or in  clusters  of indefinite form, aggregate  tubercles;
thirdly  and lastly, they are found densely crowded throughout  a por-
tion  if  not the  whole  of a lobe, so as to constitute seemingly but one
coherent mass, tuberculous  infiltration."  We  also  coincide  with the
observations which follow the preceding  extract:  " Their  mode  of dis-
tribution is naturally influenced by their mode of development.   Where
they form  rapidly they are the  more equally dispersed, where  slowly
they become in the same measure subject to the law which causes them
to accumulate in the summit of the lung, and from  thence downwards
gradually to decrease in compactness, with a proportionate tendency  to
run into groups.   The aspect of the individual tubercles is  also modified
by the manner of their distribution, the gray variety in particular be-
coming  whiter and losing its transparency, when densely congregated."
  A species of antithesis exists in  the  lungs  between the tendency  to
tubercular deposit in their apices and the liability of the lower lobes  to
idiopathic inflammation.  This may be accounted for by the  encourage-
ment to deposition from the blood offered in the apices of  the lungs, by
the lesser expansibility of these parts.   The movement  of the clavicle
and two upper ribs is very small compared with that of  the  lower ribs,
and  the intercostal muscles are more  rigid here than  below, circum-
stances  that are enhanced  by a sluggish habit, while they favor any
accidental  impediment to the  aeration of the blood.   This, in its turn,
diminishes the rapidity of the current as well as its quality;  hence the
morbid  deposition ensues, and, as the cavities of the air-vesicles are the
points of least resistance, the effusion is effected into them.   We have
already mentioned that the  more rapid the course of phthisis, the more
generally we find the deposit diffused through the lung.  In a case  of
acute miliary tubercle, from which one of our illustrations is taken, the
bases and the apices of both lungs were uniformly affected; both  organs
being studded throughout with the deposit, which had probably taken
place but a few  days previous to death, in a subject debilitated by rheu-
matic affection of  the heart and central  softening of the  brain.   Both
lungs, according to the laAV of  symmetry, present a proclivity to tuber-
cular disease; Laennec considered that  a greater tendency existed on
the left than on the right  side, OAving to his having met with five in-
stances  in  which it was limited to the left lung, while only two occurred
to him  in which the right  alone Avas the seat of disease.   Other ob-
servers  have failed to confirm Laennec's observation, and have asserted
either that the right lung Avas more frequently affected,  or that  no dif-
ference  was traceable.  If a difference exists in the early  stages of the
disease; and it is probable that, in its progress, the balance is restored;
our own experience decidedly tends to show  a  predominance on the
right side,  in the incipient period.
   The  questions which next suggest themselves for our  consideration
are the  ulterior  processes which the tubercular matter and  the  pulmo-
nary parenchyma undergo  after the deposit  has been  effected.   They
may be  of an opposite character;  either exhibiting  a progressive deve-
lopment, a tendency to destruction of the part and dissolution of life; 
           ADVENTITIOUS  PRODUCTS  IN THE  LUNGS.        425

or manifesting a retrograde movement, with evidence of the product of
the disease becoming obsolete, and the morbid germ being extinguished.
After  the  first deposit of tubercle is completed, the morbid diathesis
may, as  it were,  have exhausted  itself, and the process enters into a
state of  abeyance, all active  symptoms being arrested; or the inflam-
matory action is perpetuated  and  the course  is continuous to the fatal
termination.  In  the former case, every recurrence of bronchitic or
pneumonic  inflammation  finds a  nidus of tubercle around which fresh
matter is deposited, or which  becomes an additional source of irritation.
In both  cases  a  process  of fusion takes place,  serum and pus are se-
creted from the parts in which the morbid deposit has been effected, the
intervesicular septa are more  and more absorbed and broken down, the
softened matter finds its way into the larger bronchi and  is expectorated,
a mixture of pus, mucus, melanotic, oily, and granular matter, interspersed

                               Fig. 194.
 The apex of a lung affected with tubercular pneumonia; the limitation of the disease was defined by a
        sharp line bounding the inflamed tissue, which surrounded the tubercular.deposit.

with epithelium and the elastic  fibres of the lungs, and the result is a
cavity in the pulmonary tissue.  The walls of this cavity may be  more
or less rugged, and be  more or less lined with tubercular matter, or
present no traces of it, according  to the  date of its formation;  these
tubercular cavities were formerly often mistaken for genuine  abscesses
—Ave find them in all numbers ; there may be but one, or so many as to
give the entire lung a riddled or honeycomb appearance when cut into;
they vary equally in size, from a pea to  a man's fist  and more.  The
communication between the abscess and the bronchus passing  out of it,
resembles a fistulous opening,  the  peculiar relation of which to respira-
tion causes many of  the phenomena  of auscultation.  It is rare, as
Laennec observes, to find a  single cavity; the excavation  is commonly
surrounded by crude and miliary tubercles which  gradually soften, are
then discharged into the main  cavity, giving rise to the  anfractuosities
which we  commonly observe.   The excavations  are often  traversed by
bands of pulmonary tissue infiltrated with tubercular matter,  and com-
pared by Laennec to the  columnae carneae of  the  heart.    He also sug-
gests that the}- were mistaken  by Bayle for vessels  passing across the
cavities, for vessels  are  scarcely ever seen in this position.   The pro-
gress of the tubercular deposits causes the obliteration of  the vascular
channels as of the  other parts of  the  normal tissue, and we  only find
the vessels of a larger  caliber in the vicinity of the  cavities.  The 
426        ADVENTITIOUS PRODUCTS IN THE LUNGS.

bronchules,  and  successively the larger  air-tubes, are  subjected to the
same destructive agency, until the  power of  resistance caused by the

                                  Fig. 195.
  A lung, exhibiting extensive tubercular disorganization throughout its upper lobe, which i* almost con-
verted into one rugged cavity.  The pleura is very much thickened; intimate adhesion has taken place be-
tween the upper and lower lobe, and the tubercular deposit is seen'encroaching upon the latter.

stronger walls of the bronchi of  the first and second  order is too great
to be overcome by the morbid process.
   Instead of  a mere uneven rugged surface, as  if the lung  had been
mouse-eaten, the walls of the  abscess  often present  a uniform velvety
appearance, and are invested by  a  false  membrane, which  may assume
a considerable thickness of  one-third  or half a line.   At  the earlier

                                 Fig. 196.
The apex of a lung containing numerous cavities, with tubercular deposit intervening. The large cavity, and
             several of the smaller ones, are lined with an adventitious membrane.

periods of  disease, the  membrane  is of slight consistence and  easily
separable.   The membrane is described by  Hasse as being formed  out
of the hepatized crust that encircles the enlarging cavities, and which, 
           ADVENTITIOUS PRODUCTS IN THE LUNGS.        427

instead of becoming softened and liquefied through purulent formation,
merely becomes saturated with coagulable substances  more akin to the
organism;  "but," he continues, "no sooner is the tubercular diathesis
revived and aggravated by a catarrhal or inflammatory attack, than the
protecting  false  membrane liquefies,  and purulent secretion,  mingled
with tubercle, again sets in.   The cavity itself, which  under the above
circumstances  seemed to shrivel and  contract, gains  size, new  vomicae
form, the lung becomes more and more deeply involved, and the  mis-
chief terminates only in death."  The tissue beyond  the lining mem-
brane may be in a healthy condition, or present  tubercular deposit in
various degrees, but generally containing much melanotic carbonaceous
matter.  In the majority of instances both lungs are  found to  present
excavations.  Louis states  that in one-sixth only of  his total cases of
phthisis, they were limited to one or the other lung, and when  present
on both sides were of different size;  in somewhat less than one-tenth of
his cases, both  lungs were  the  seat of enormous excavations,  equally
large on both sides, and in another  tenth, where the cavities presented
but  small or moderate dimension, these dimensions were the same in
both organs.  Large cavities (of the size of a goose's egg or a clenched
fist) Louis found to occur in about one-half of the cases,  and with equal
frequency in each lung ; in the remainder of his subjects he found cavi-
ties of the size of an ordinary-sized  apple or walnut.
   The complications of  disease  occurring in the course of tubercular
phthisis and at different periods, are inflammations of the mucous mem-
branes of the  air-passages  of the pulmonary parenchyma  and of the
pleura.   Of the appearances presented by the first, and of  the  relative
frequency of occurrence in them of ulcerations in consumption, we have
already spoken.  There can be no doubt that the  acrid character of the
expectorated matters  very  much  favors the  ulcerative process.   The
frequency with which slight  attacks  of pneumonia supervene  in the
course of phthisis, is not surprising, if we look upon it merely as an
exacerbation of the process actually constituting the disease—it is rather
in each case the cause of an extension of the morbid  deposit, than the
result of the previous elimination of tubercle.  The pleurisy accompany-
ing tubercle, may supervene at various periods, and by the adhesions it
causes and the consequent increased immobility  of the lung, it necessa-
rily much favors the development of the tubercular process.  That the
tubercular deposit has a tendency to excite pleurisy, is evident from the
frequency with which the latter occurs at the apices of the lungs, often
forming a complete  cartilaginoid cap from which it is difficult or impos<-
sible to detach the lung entire.  When tubercular excavations approach
close to the pleural surface, and are not preceded by thickening of the
pleura, as generally occurs, a perforation may take place, inducing  effusion
of air and  liquid into the cavity and secondary inflammation ; we  then
have to deal with hydro-pneumothorax, upon which a rapidly fatal issue
is almost certain to follow.  Mere cellular adhesions, according to Roki-
tansky, cannot prevent this termination; they are, in part, mechanically
loosened by the effusion from the cavern, and being involved  in the pleu-
ritic process, they are in  part likewise destroyed in  the  exudation.
Rokitansky describes three  forms  in which the communication between 
428        ADVENTITIOUS PRODUCTS IN THE  LUNGS.

the tuberculous cavity and the sac of the pleura may be established ; the
pulmonary pleura may be  detached from the affected surface by the
mere  force of the air rushing in so  as  to form a  bulla, which after-
wards bursts; it  may be converted into a whitish eschar which tears or
becomes detached unbroken, or the pleura, together with  the infiltrated
parenchyma  surrounding the cavern,  may become gangrenous  and be
converted into a purilage.   The complication  of  pulmonary tubercle
with tubercular deposits in other  organs is of very common occurrence;
Louis1 found tuberculous ulceration in  the intestines in five-sixths of the
cases he examined, the lymphatic glands Avere affected in the following
order of frequency, the bronchial  most, next the mesenteric, the axillary,
mesocolic, lumbar, and cervical: the spleen and kidneys exhibited tuber-
culous deposit in about one-sixth  of the cases ; several times the prostate
was found more or less transformed into tuberculous matter, and tuber-
cular deposit was also  met Avith  in  the cerebral arachnoid, though the
frequency is not stated.  The prevailing  condition of the liver in pul-
monary phthisis  is one of  fatty degeneration.   Louis  found it fatty in
one-third of  his  cases.   With regard to the coexistence  of pulmonary
tubercle, with tubercular deposit in other organs, the general law has
been established, that wherever,  after  the age of fifteen,  tubercles pre-
sent themselves in any organ of  the body, we  are  certain also to meet
with them in the lungs.
   When the  tubercular deposit in the lungs does not advance and
undergo the progressive changes  which we have described, a process of
obsolescence occurs which appears to consist in certain chemical changes
in the tubercular matter, accompanied by an extinction of the peculiar
crasis which had given  rise to its elimination, and followed by certain
secondary  alterations  in the surrounding tissues  by  which they are
adapted to the requirements of the  case.   These we find  to exhibit two
distinct forms, which  probably depend upon  a  difference not yet pro-
perly appreciated or well defined, in the diathesis primarily giving rise
to the deposit.   They are  characterized by a fibrinous or a calcareous
metamorphosis.   In the former  case  we find the tubercle assuming a
more dense and leathery character,  of a semi-cartilaginous consistency,
drying  or shrivelling up as it were, accompanied by a contraction of the
superimposed tissue.   If Ave examine  the  yellowish deposit under the
microscope, we find mixed  up with the ordinary forms of  tubercle  a dis-
tinct fibrinous formation exhibiting a linear, striated appearance.  In
the latter, a conversion of the tubercular matter  seems  to be  effected
into a  chalky substance, at  first moist  and soft, gradually, owing to
absorption of the fluid constituents, becoming harder and drier, and, at
the same time, shrinking from its previous dimensions; thus, at times,
we find, to use Hasse's  words, "that a considerable portion of the lung,
as may be inferred from the size of the bronchial tubes leading thither,
becomes reduced to a hard shell, holding in its centre  a chalky tubercle
no bigger than  a pea."  The chemical  characters  of these formations
have  already been alluded  to; but it may be well to remind the reader
that,  although termed chalk, they do not consist of carbonate of lime,
1 Researches on Phthisis, Syd. Soc. Ed. p. 150. 
ADVENTITIOUS PRODUCTS IN THE LUNGS.        429
or of the elements of gouty chalkstones, urates of soda, but that they
are mainly composed of chloride of sodium and sulphate of soda, as de-
monstrated by the researches of M. Boudet.1  Lebert has also repeatedly
observed cholesterin in chalky tubercles.   The  black pigment, which
is at times met with to  a considerable amount in tuberculized lungs, and
still more in the bronchial glands, does not present any different features
from that commonly found in the pulmonary parenchyma.   It appears
to consist of pure carbon, and may present a mere amorphous granular
form, imbedded in and scattered irregularly through the tissue, or it is
found inclosed in an epithelial cell.  That  it bears  some relation to the
defective oxygenation of the blood, is manifest from the normal tendency
to the deposits being greater in proportion to the advance of  life; and
it has appeared to us to accumulate very rapidly in some cases of chronic
inflammation.   The presence of this black matter in the  expectoration
of phthisical patients in part gives rise to the grayish or dirty tinge we
frequently observe.
   Obsolete tubercle is surrounded by a  dense capsule resulting from
inflammatory induration.  It  is commonly found at the  apices of the
lungs, and may be easily felt on handling the part, and, if near  the sur-
face, their effect is  rendered visible by a drawing in and  puckering  of
the pleural surface.
   The metamorphosis  of tubercle into fibrinous or cretified masses must
be regarded  as evidence of  a curative  tendency.  Whether  we are
justified in  assuming, as it  appears Carswell2 does, that  an  entire  ab
sorption of tubercular  matter may take  place  without a metamorphosis
of this kind, or without the  formation  of a cavity, is a question which

                                Fig. 197.
       Cicatrix at the apex of a lung, resulting from the previous arrest of tubercular disease.

we are not prepared to  answer positively, though there is no certain
proof to the contrary.   That the healing process is  not limited to the
first stages of the disease, but is also seen after the formation of cavi-
ties, is established by the unanimous  testimony of the best  observers.
Andral remarks that  traces of cicatrization  are  found  in individuals
who, at  one period of  their life, have been subject to a severe affec-
tion of the respiratory organs, which was regarded as phthisis, or in
such as have been cured of a previous pulmonary attack, but have suc-

  1 Recherches sur la Gue"rison Naturelle ou Spontanea de la Phthisie  Pulmonaire.
Paris, 1843.
  2 Llemcntary Forms of Disease, Art. Tubercle. 
430        ADVENTITIOUS PRODUCTS IN THE LUNGS.
cumbed to a subsequent one of the same character; or, lastly, in persons
who from the first day of their  cough have continuously grown worse,
in whom, therefore, after the cicatrization of one cavity new ones  had
formed.  The cavities may disappear  altogether, leaving a dense Avhite
fibrous tissue, ramifying irregularly in the surrounding tissue; or the ob-
literation is incomplete, the cavity remains partially open, and  the cha-
racter of the lining membrane undergoes a change assimilating it to a
serous membrane, or, which is more commonly the case, converting  it
into a vascular villous covering, resembling a mucous membrane.  Roki-
tansky states that, in the latter case, aneurismal dilatation, or a gela-
tinous degeneration of  the vessels subjacent to  the membrane, is liable
to give rise to hemorrhage into the cavity, which either proves  fatal, or
else, by coagulating and plugging up the vessel,  becomes a further means
of  obliteration and ultimate cure.
   Before quitting the subject of pulmonary tubercle,  we have to  allude
to certain differences which exist between the manifestation of  the  dis-
ease in early life and later  years.  In  the former instance, the  lungs
are much less liable to  become the seat of the deposit than they are in
the latter;  it is more commonly simultaneously deposited in a greater
number  of organs ;  and while, according to the extensive researches of
Messrs.  Rilliet and Barthez, which are confirmed by those of Dr. West,
the yellow  form of tubercle largely predominates, there is a remarkable
immunity from tubercular cavities.  The cavities that do occur are much
smaller in  proportion, and, though occasionally very  numerous, do not
give  rise to the  same  amount of destruction  of the pulmonary tissue
that we  see in the adult.   The differences alluded to  may be accounted
for, partly by the greater  share  the  nutritive organs  take in all the
functions of early life, and partly by the proclivity existing in the lungs
to lobular inflammation.   The latter  circumstance renders  it  probable
that  a minute examination of tubercle  in the  infant, would  exhibit a
greater  production  of pus coincidently with the elimination  of  tuber-
cular matter, than is  found in the adult.  We extract the following
table from  Dr. West's classical work on the diseases of childhood,  as
the best illustration that can be offered of the  relation borne  by tuber-
cle to the different organs of the body in early and advanced life.
   Of 100  instances  in which tubercle was deposited  in some  of the
viscera, it  was present in
The lungs
Bronchial glands
Mesenteric do.
Small intestines
Spleen
Pleura
Peritoneum
Liver
Large intestines
Membranes of the brain
Kidneys
Brain
Stomach  .
Heart and pericardium
Children from	Adults from 20 years and		
1 to 15 years. According to Rilliet & Barthez.	Accordin Louii	upwards. g to According to Lombard.	
84	100		100
79	28		9
46	33		19
42	33		0
40	13		6
34	2		1
27	0		0
22	0		1
19	10		0
16	0		2
15	2		1
11	0.8		2
6	0		0
3	0		0
 
CANCER.
431
  The table, as Dr. West remarks, shows not only that  the liability of
certain organs to become the seat of tubercle, is different in childhood
from what it is in the adult; but, also, that tubercle is  simultaneously
deposited in a greater number of organs in the young than in the old.
                               CANCER.

  Malignant disease of the lungs is not a common disease.  Mr. Adams's
research has, however, shown that it occurs  more frequently, both as a
primary and as a secondary affection, than was supposed to be the case
by Bayle, who, in 900 subjects examined, only once met with cancerous
growths in these organs.   Both Laennec and Bayle only found the me-
dullary variety ;  other forms  have since been  met with, but the ence-
phaloid is that which vastly preponderates.    Hasse has seen an instance
of colloid cancer; in  the Reports of  the Pathological  Society of Lon-
don  for 1849-50, a  case of primary fungus haematodes of the lung is

                                 Fig. 198.
Fig. 199.
 Infiltrated cancer of the lung, with its microscopic elements. The lighter part is that containing the de-
posit • it was of a brownish-red tinge, and of greater density and hardness than the unaffected parts. It
occurred in the right lung of a young woman, aged 34, whose right bronchus was surrounded with a mass of
medullary cancer; the right kidney also contained a large growth of the same kind, and the 11th dorsal
vertebra, especially its right side, was extensively destroyed by the same disease.

detailed by Mr. Adams.  The only fact by which  it appears that we
may determine the  primary or secondary character of the  deposit, is
the circumstance of the lungs either being  the sole,  or, at any rate, the 
432
CANCER.
chief seat  of the disease.   It  is  stated by high authorities, that  the
former always assumes the infiltrated character, while the latter appears
exclusively in nodules or isolated tumors  scattered through the  lungs.
This  distinction cannot, however, be rigidly maintained.   The pulmo-
nary texture entirely vanishes in the  malignant growth, while the sur-
rounding tissue is compressed and  its functions interfered with.   The
neighboring lymphatic glands  are invariably involved in the degenera-
tive process.  With regard to the parts of the body from which cancer
spreads to the lungs, Hasse remarks " that the  bones and testicles  ap-
pear to furnish the  most frequent starting-point;  and numerous  exam-
ples  tend to show that surgical operations for the  removal of cancer in
those parts, are very speedily followed  by its transition to internal
organs.  Many instances are adduced in which  the skin and  the mam-
mary glands, the uterus, the liver, the membranes of the brain, were
first assailed.   I have seen a very remarkable  instance consecutive to
primary cancer of the submaxillary gland.  On the other hand, cancer,
in organs whose veins are tributary to the portal  system, does not  ap-
pear to spread  to the lungs, although it is known  to lead very often to
corresponding disease of the liver."  To this we would add that malig-
nant  disease, occurring in the  mediastina, as  it  frequently does, does
not appear to possess a great tendency to affect the lungs.   We  often
see large masses of  cancerous growth occupying these  parts, and, per-
haps, causing death, as well by  suffocation as by exhaustion,  without a
trace of malignant  disease in the lungs, although  there is  proximity of
tissues as well as an intimate relation by the bloodvessels.   The only
case of the  pancreatic variety,  to use Abernethy's apt designation,  that
has lately fallen under our observation, entirely filled the upper part of
the anterior mediastinum, and infiltrating the  pectoral muscles of  the
right side without affecting the lungs, otherwise than  by pressure.   A
good instance of reticular  carcinoma of the posterior mediastinum was
exhibited by Dr. Jenner, at the  Pathological Society of London,1 which,
however, slightly encroached upon the  root of the lung; we had an
opportunity of  examining  it, and could, therefore, confirm the fact of
the reticular character.   Neither of these  varieties  has been seen to
occupy the pulmonary texture.  Whether the peculiar  functions of  the
lung influence the nature of  the deposit, or whether this depends upon
some other cause, there is no evidence to show.
   A law universally adopted, and one that appears perfectly consistent
with the inherent tendency to endogenous multiplication in cancer, and
the absence of this character in tubercle, is, that the  cancer does  not
coexist  with tubercle.   We do not wish to  assert that  there are no ex-
ceptions from the rule; but they are  so rare, and in those instances on
record  the  diagnosis generally admits a reasonable doubt, so that the
law is in no way inA*alidated.
   In  connection with  cancer, we have to allude  again to an excessive
deposit of carbonaceous matter  in the lungs;  when this is the case, we
have to deal with what Carswell has termed melanoma.  The excessive
secretion from the blood of black pigment accompanies  the normal pro-
1 See Reports, 1851-52, p. 253. 
CYSTS.
433
cess of involution, tubercular disease and  cancer ; and, as we have
already had occasion  to observe, appears to be mainly due to the inter-
ference with  the oxygenation of the  blood.  Carswell himself admits
the complication of  true  melanosis with fibrous, carcinomatous,  and
erectile tissues, and  since it does not in itself offer any characteristic
features which would serve to establish its pathological identity as an
independent  formation, Ave are justified  in  regarding  it rather as an
accidental addition than as an essential constituent of a physiological or
pathological  tissue.

                              CYSTS.

   The formation of cysts  in the lungs is of rare occurrence and  per-
fectly latent, so that  they are not  discovered until after death, unless
they  excite  irritation;  they may then find their  way into the bronchi
and be  expectorated.  They occupy the lower lobes of the organs; they
consist  themselves of a double membrane of a clear pellucid appearance,
which, under the microscope,  present an  homogeneous, delicately lami-
nated structure.  The laminae form  parallel lines, so as to resemble the
pages of  an open book.   The pulmonary tissue  adjoining  the  cyst is
covered by a dense membrane, so that, although entirely surrounded by
the pulmonary parenchyma, there is not in reality any real intimate re-
lation with  it.  They generally contain a  limpid fluid, and present an
endogenous  development of hydatids of the same character as the parent
cyst.   They vary in  size, but an instance which  occurred to us of an
acephalocyst, sufficiently  capacious  to contain a hen's egg, must be
looked upon  as unusually large.  It  neither contained secondary hyda-
tids nor echinococci.  A unique case of  cysts in the  lungs, filled  with
air, is quoted by Hasse.1

                1  Pathological Anatomy, Syd. Soc. Ed. p. 337.
28 
CHAPTER  XXXI.
                           PLEURITIS.

  The serous sac inclosing the lungs and serving to facilitate the move-
ments of respiration, is more prone to  morbid affections than any other
serous membrane; of these, inflammation is the most frequent, and one
that arrests the physician's  attention very commonly both in the pa-
tient and in the dead subject.   Some  of the  products of inflammation
were formerly set  down to physiological causes, owing to their being
frequently met  with in individuals whose histories did not give evidence
of pleuritic  inflammation having  occurred in the course of their life.
But the inference is not just, because  even in severe pleurisies the
symptoms are not necessarily of a character to attract the patient's at-
tention, and most persons are familiar with the occurrence of occasional
pains, of a not  very enduring  character,  which may be accompanied by
some effusion, though  not  of  sufficient intensity to interfere with the
function of respiration.   The great frequency  of the concurrent inflam-
mation of the pulmonary tissue and its investing membrane, has given
rise to a frequent misapplication of the term, and to a variety of theories
in reference to  the cause of pleurisy.  So distinguished an author aa
Portal attempted to prove that pneumonia was not  essentially different
from pleuritis;  but since the more careful prosecution of morbid anatomy,
and the clearer distinction of  symptoms during life which we owe to
auscultation, no doubt exists that the tAvo, though often associated, differ
in their symptomatology as they do in their etiological and pathological
relations.
  The first stage of  inflammation of  the pleura is manifested by the
appearances of greater or less  congestion, causing a  multitude of ves-
sels, not visible in the perfectly healthy pleura to the naked eye, to be-
come filled with blood;  a marked distinction may sometimes be observed
between the venous and arterial channels, as exhibited in the different
colors of the two systems.   The vessels form  an irregular network, and
the more intense the inflammatory condition, the more uniform the red-
ness becomes.  At times, we find the character of the congestion to be
more punctiform, and to resemble, as Laennec has it, an attempt made
to dot over the pleural  surface with a  paint-brush, with small spots of
blood of an irregular  shape, and closely  approaching  one another; it is
probable that in many cases this appearance  is due, not  to  the peculi-
arity of the disease, but to a partial emptying of some vessels as a post-
mortem effect.   The membrane, at the parts  most  affected, soon loses
its  natural transparency and  gloss, in  consequence  of a secretion from 
                              PLEURITIS.                          435

the overcharged vessels investing its surface with a  coating of lymph
or fibrin, a straw-colored semi-gelatinous effusion which may be easily

                                 Fig. 200.
 Straw-colored lymph, coating the lower lobe of an inflamed lung, in recent pleurisy, before there was a
trace of adhesion to the costal pleura.  The outline represents one of two coils of new vessels, seen under
the microscope in the fringe of lymph at the lower end.

stripped off from the serous membrane.  The  microscopic appearances
of this fibrin are delicate linear fibriHee, of a generally parallel  direc-
tion,  enveloping and entangling the gran-
ular  and  corpuscular  forms  observed in
fibrinous exudation.  We very rarely meet
with cases of what Andral has termed dry
pleurisy, as the effusion is a rapid sequel
of the first  stages  of inflammation; but
we frequently have  an opportunity of  ob-
serving a limited plastic  exudation at one
point,  while  the  greater part  of the  re-
maining pleura or  its fellow  may exhibit
the first stage of  the disease.   In the re-
cent  cases of sthenic inflammation,  the
effusion presents the appearance of a thin
layer of thick cream, which,  at  the most
dependent parts, seems  to be  dropping
from the organ.   The older the  effusion,
the more  it assumes  a membranous cha-
racter, the friction and compression to which
it is  subject  giving  to  it an irregularly
honeycomb   or  cellular  appearance,  or
causing it early to put  on a filamentous
or  mossy form.   The plasticity of  the
effusion is in a ratio with the plastic cha-
racter of the blood; hence, it does not always present the characters ju*t
described, but varies much in cohesion, in color,  and  quantity, accord-
ing to the constitution of the individual attacked, and according to  the
Fig. 201.
 Portion of the lower lobe of the left lung
of a patient, compressed by turbid serum,
occupying the pleural cavity.  A thick
layer of lymph covered the hepatized por-
tion of lung; it was perfectly smooth from
the contact with the liquid, and there was
a free scalloped margin at  some parts, of
an inch in breadth. The exudation-mat-
ter consisted  of filamentous matter, en-
tangling corpuscular fibrin. 
436
PLEURITIS.
exciting cause; thus we may, even in the same subject, meet with differ-
ent products of inflammation at different parts of the same lung.  The
exudation may be of a more serous or of a purulent character, in which
case the sac will contain more or less of these fluids in which wre find
portions of lymph detached from the pulmonary surface floating about,
while their peculiar color, from an admixture of more or less  blood,
may present a proportionately reddish tinge.   The  more  asthenic the
type of the inflammation,  the more the effusion departs from the cha-
racter of a plastic exudation, the more inorganizable it becomes.   While
the discharge upon the inflamed surface of organizable material is emi-
nently the result of acute pleuritis, the effusion of aplastic or cacoplastic
matter  is  connected with the chronic forms.
   At one time, pus and puriform  secretions from serous surfaces were
considered organizable; a doctrine of which ViHerine*  and Dupuytren
were the  chief  exponents, but which  is  now  entirely exploded, the
general view being in the  main that advocated by Dr. Hodgkin:1 that
these matters are always more or less excrementitious, and that, where
an outlet  from the body is not afforded, they invariably retard the cure
by interfering with the progress  of  organization in those substances
which are formed in conjunction with them, and are susceptible of this
change.
   When the progress of sthenic pleuritis is uninterrupted, the change
that next ensues  after the effusion  of  coagulable  lymph on the surface
of the  membrane, is the  formation in the  former of new vessels, and
such further alterations  in the exudation itself as to induce an assimi-
                             lation to surrounding textures, and a re-
                             storation to a state of comparative, if not
                             absolute, health.  The adventitious mem-
                             branes  that  thus  become  permanently
                             formed  are of greater or less extent, and
                             may be limited to the one pleural surface,
                             or  connect the  pulmonary  and  costal
                             pleura;  thus giving rise to further im-
                             portant changes of structure, which may
                             seriously involve  the  entire  thorax, and
                             consecutively even affect the spinal co-
                             lumn.   The adhesions are of an opaque,
                             whitish hue, and become more  firm the
                             older they are.   The  great frequency
                             with which they are met with, has  given
                             rise to their being called ligaments of the
                             lung, as if they formed  a normal  con-
stituent of the organ.   The manner in which the new vessels, that we
at a very  early stage perceive in the exudation, are produced,  has been
the subject of much discussion, the arguments adduced being based upon
physiological experiments  or  direct observations, according to the in-
quirer's bias.  The course  of the new  vessels is generally less tortuous,
and presents more parallelism than the vascular channels of the pleura;
Fig. 202.
A
^lltl
 The lymph of pleuritis, with new vessels
already formed in it; a deposit of fat has
also taken place. Magn. 20 di.
1 Lectures on the Morbid Anatomy of the Serous Membranes, vol. i. p. 42. 
PLEURITIS.
437
they appear to be active agents in effecting the absorption of a portion
of the exudation matter, and after aAvhile a retrograde process ensues,
and they in part cease to exist.  The earliest trace of vessels which
we have ourselves discovered in a case of acute pleuritic effusion occu-
pying the base of one lung, where, as yet, no  adhesions had taken place,
and  the creamy effusion  was yet  eminently  fibrinous,  exhibited the
appearance of small coils, near the edge of the lymph, closely resembling
a renal Malpighian tuft, into which  two vessels could be  seen entering;
the sharp outlines of the formations, and a somewhat lighter tinge than
the surrounding fibrin, alone marked them  ; they contained  no blood
corpuscles, and it Avas, therefore, only by inference that  they were con-
cluded  to be young vascular channels.  Dr.  Hodgkin's view is that the
new vessels are formed by the minute bloodvessels of the inflamed part
becoming distended, and that their  delicate  parietes, and the structure
through which they ramify become softened, and, yielding to  the pres-
sure  of the blood in the distended vessels, give way at numerous minute
points; he considers that the very small quantity of blood thus escaping
from  its vessels does not diffuse itself, but is received into the soft sub-
stance  of  the false membrane,  which accordingly exhibits  numerous
bloody points on the surface when detached from the serous membrane.
That the vis a tergo of the general vascular current is an element in the
distribution of the blood to  the false membranes, cannot be  doubted;
but we must demur to the view that it  is diffused at random  into the
exudation  matter, and then, as it Avere, prepares its OAvn  channels. The
thickness  of the false  membrane varies  from a delicate film to many
lines; it may itself  become the seat of secondary inflammation,  but  in
most cases it exerts a repulsive influence upon fresh attacks, and assists
in protecting the adjacent parts from encroachment.  A marked instance
of this occurred under our observation lately, in an old man who had
suffered a fracture  of seven  ribs of the left  side, followed by inflam-
mation of the corresponding pleura.   The  two surfaces of the upper
half of the pleural sac had formed intimate adhesions, and the subjacent
pulmonary parenchyma had remained in a healthy condition;  the loAyer
half contained two and a half pints  of turbid serum; there was a thick
layer of false membrane on the corresponding half of the lung, and this
part  of the organ was rendered unfit for respiration by the inflammatory
process transmitted to it.
   The  amount of liquid effusion resulting from pleurisy varies from the
smallest appreciable quantity to  as  much  as twelve pints.   A case,  in
which  this amount was removed from a man aged 33, by paracentesis
thoracis, is given by Dr. Novarra, in the Medical Repository  for 1^20.
Dr. .'lod'gkin1 details an interesting  case of empyema, which partly dis-
charged itself through the  bronchi, and in which, after death, three large
basins were filled with the sero-purulent contents of one pleural sac.
   Liquid effusion necessarily induces not only compression of the lung
on the affected side, pushing it upwards, but also displaces the adjoining
viscera; the heart  is forced over to the right thorax when the effusion
is into  the left pleural cavity; if into the right, the liver impressed;
' Lectures on the Morbid Anatomy, &c. vol. i. p. 121. 
438
PLEURITIS.
in both cases the diaphragm is forced doAvn, and its movements interfered
with, while the intercostal spaces of the affected side exhibit a marked
prominence, and the ribs are maintained in an elevated position.  These
anatomical features of extensive pleuritic effusion can scarcely be too
strongly insisted upon in the bearing they have upon diagnosis.  How-
ever, we must bear in mind that exceptional cases occur, in which, owing
to a partial reabsorption of the fluid having been effected,  the symptoms
above detailed are not always so marked as to render the diagnosis easy.
Laennec observes that, at the epoch at which we ought to operate, the
affected side, though full of pus, is less than the  healthy  side, owing to
this circumstance and the consequent falling in of the parietes.
  The secondary changes resulting from firm adhesion being formed are
of a different character.   If they have been associated  with previous
extensive effusion, which has become absorbed, the degree to which the
compressed lung will regain its former functions depends upon the dura-
tion of its confinement, and upon the firmness of the adhesions.   The
immediate consequence of the absorption was first shown by Laennec to
be a falling in  of the affected side, owing to the expansion  of the lung
not taking  place in the  ratio  of the removal of the liquid;  and the
firmer  the adhesions are at given points, the more will this tendency be
promoted by their increasing density and contraction.  The depression
is generally most marked at the loAver  part of the  thorax, about the
seventh and eighth ribs;  and, owing to  the consequent atrophy of the
respiratory muscles of the affected side, the equilibrium  is destroyed,
and the spinal column is deprived of its symmetrical support; from this
a curvature of the spine results, the convex margin of which is  directed
towards the healthy side.  The  shoulder of the diseased side  sinks in
proportion.  A falling in of  the upper portion of  the thorax, or of the
infra-clavicular region, is commonly  noticed as an  accompaniment of
phthisis, consequent upon the formation of extensive cavities,  and the
coincident thickening and contraction of the pleura, to which we have
alluded when speaking of tubercular disease of the lungs.
  There is  no affection with which tubercular phthisis is so commonly
associated as adhesions betAveen the pleural  surfaces, and the  relation
the two bear to one another appears to be in the ratio of the extent of
the former.   Hence, the pleurisy has both a chronic and a more local
character, and must be set down to the secondary irritation arising after
the deposit has been effected.  The gradual thickening assumes a carti-
laginoid consistency, and the union becomes so intimate that considerable
force is often required to remove the lungs, and  it is scarcely effected
without laceration of their tissue.   The intercurrent pleurisy accom-
panying tubercular disease of the  lungs is the source of those flying
pains which, from time to time, attack phthisical subjects. The frequency
of its occurrence is best illustrated by the statement of Louis, that, in
one hundred and twelve phthisical subjects, he found but one whose lungs
were perfectly free in every point of their surface. In eight cases only,
he found the right pleura wholly unattacked, and in seven the  left; in
these cases there were either no cavities in the non-adherent lung, or they
were very small.   Irritation, proceeding from other parts, may equally
give rise to partial pleurisy; thus, we find it limited to  the diaphragmatic 
EMPYEMA.
439
Burface, in relation with a diseased liver, spleen, or peritoneum.   Irri-
tation of the mediastinal portion may be excited by morbid affections of
the heart or bronchial glands; a limited effusion is frequently observed
connecting the interlobular fissures, especially in connection with pneu-
monia and tubercular irritation.
   The proclivity to pleuritis is greatest about the middle period of life,
and diminishes in the ascending and descending scale of age.  Before
the fifth year, it  is not often met with.   Dr. West observes that  acute
idiopathic pleurisy, unconnected with pneumonia, or in which the inflam-
mation of the lung bears but a very small proportion to that of the pleura,
is certainly an uncommon  affection during the first years of childhood,
and as a cause of death its rarity is extreme;  and it certainly has ap-
peared to us that, in  cases of pneumonia, there is decidedly a less tend-
ency, in early life, to excite pleuritic inflammation than we should observe
in corresponding affections of a later period.  With regard to chronic
pleurisy, Dr. West remarks, "that, while it is a very rare occurrence as
a purely idiopathic affection  in early life, it is one of  the most common
complications of  the  dropsy  which often succeeds to scarlatina."
   We do  not generally find extensive pleurisy affecting both sides  at the
same  time, while there is a marked difference in regard to the tendency
of  either pleura to inflammatory attacks, the left side presenting  a
much greater proclivity than the right.   Hasse certainly states that the
two sides are equally prone, but  considers  the fatality to be  greater
when  the left side is  attacked, than when the  inflammation affects the
right.   The  thirty-five fatal cases which  he observed, were distributed
in the following manner: nine were  double  pleurisies, and in five out
of  the nine, the  affection  was trifling on  one side; in the  remain-
ing tAventy-six, the left side  was the seat sixteen, the right ten times.
He also quotes Mohr's experience, who found that  of  fifty-six  cases,
the left side was the seat thirty-seven times;  the right, nineteen times.
Drs. Hamilton Roe,  Hughes, and Copland,  are also of opinion that
the disease  exhibits  a much greater  frequency on  the left than on
the opposite side of the thorax.   It appears from the  observations of
Messrs. Rilliet and Barthez that the converse is the prevailing character
of infantile pleuritis, and  that in  children the right side is more  liable
to the idiopathic  affection than the left.
                            EMPYEMA.

   We have stated above that the more chronic the form  assumed by
inflammation of the pleura, the greater the tendency to liquid effusion.
Some authors assume that, in these cases, the plastic matter first thrown
out may be subsequently converted into pus, a point which has not been
determined by  direct observation, and certainly is  not  sufficient to  ac-
count for  the enormous accumulations that sometimes take  place.   The
chronic forms are frequently marked in such a Avay as to deserve the
term of latent pleurisy;  the symptoms, in the first instance, apparently
indicating disease in an  organ unconnected with the thoracic cavity.  It
is  here that, during  life, the value of the stethoscope is  particularly 
440
EMPYEMA.
manifested,  as  its  application will  at  once remove the difficulties of
diagnosis. It is to the chronic effusion of a serous or sero-puriform fluid
that the name of empyema is properly applicable, and the inorganizable
nature of the  pleural contents in these cases is dependent upon dimi-
nished tone  and vigor of the constitution.   The solid matter, according
to the views expressed by Dr. C. J. B. Williams, " is throAvn out in a
disintegrated state, utterly insusceptible  of organization, and diffused
through the fluid in flakes or particles,  forming a mixture more or less
resembling pus, although in many instances this is the result of a more
chronic form of pleurisy than that Avhich forms lymph, and,  oavcs its
increase and persistency to the want of  vitality in its solid matter.  Yet
we do meet  with cases of empyema which arise from very acute forms
of inflammation.   In these instances the fluid is more strictly purulent,
the solid  matter being in  the  form of  globules like  those of pus,  and
seems to be the result of what may be called a suppurating diathesis, in
consequence of which all the albuminous products of inflammation tend
to assume a purulent character."  A marked difference  exists  between
the pleura and peritoneum in regard to  this point, for, while the former
is peculiarly liable  to effusions resulting from a low form of inflamma-
tion, the fluid accumulations that we  meet with  in  the  latter are more
often of a mechanical origin; hence, the result of operative interference
is very much more favorable  in  cases  of empyema and inflammatory
hydrothorax than in ascites;  in the former, when the diseased condi-
tion giA'ing rise to  the effusion has subsided, there does not exist a tend-
ency to  repeated  accumulation as in the latter;  hence,  paracentesis
thoracis is more likely to prove  a curative  agent than  tapping of the
abdomen, where it rarely serves otherwise than as a means of palliating
urgent symptoms.  Dr. Hamilton Roe, who  has disproved Laennec's
statement, that paracentesis was  rarely  successful, obtained a recovery
in eight out of nine cases of empyema, and of nine  out of thirteen of
inflammatory hydrothorax; and in the same paper from which we derive
this information,1 we find  that Mr. B. Philips records a brief analysis of
122 cases of paracentesis, thirty-one of which were  performed for  em-
pyema, and  nine for hydrothorax ; of the former tAventy-six, of the latter
six were cured.
   It is, however, admitted on all hands, that it is essential to  the suc-
cess of paracentesis thoracis that it be  performed at an early period of
the disease.
   When  the fluid is not evacuated by an operation, it is occasionally dis-
charged spontaneously, either  by perforation of  the pulmonary tissue,
by the thoracic parietes, or by the diaphragm.  Dr. Williams considers
the second,  while Laennec and Hasse look upon the first as the more
frequent  occurrence.  The perforation  of the intercostal spaces takes
place, not as would be expected, at the  base  of the lung, but about the
middle lobe of  the lung;  the discharge externally generally being
effected by  sinuous openings  burrowing under the integuments.  The
prospect of  recovery is greater here, than when perforation of  the pul-
monary pleura leads  to an  effusion into  the lung; for, in the  latter
1 Medico-Chirurgical Transactions, vol. xxvii. 
PNEUMOTHORAX—HYDROTHORAX.
441
instance, in addition to the mechanical influence of the fluid filling the
bronchi, we have to deal with the contamination of the system likely to
result from the decomposition of the fluid produced by its contact with
the atmosphere.

                        PNEUMOTHORAX.

   This forms one of the modes by which pneumothorax, or the accumu-
lation of air in  the pleural cavity, is produced.   The most frequent
origin  of this condition, however, is perforation of the pulmonary pleura
by the  extension of a  tubercular cavity, before the opposing surfaces
have become agglutinated  by fibrin; the mere softening of one or two
tubercles  formed close to the pleura, and communicating with a minute
bronchus, is described by Dr. Copland as another, though rarer cause
of this  accident.   It has been found to result from rupture of emphyse-
matous vesicles;  and Rokitansky also  states  that it may be consequent
upon perforation of the diaphragm or  of the mediastinum, arising from
acute softening of the stomach or oesophagus.   That perforation of the
superficial  parts leading  to the pleural sac induces pneumothorax, will
be naturally inferred at once ;  but it is very improbable that it is ever
due  to the  evolution of gases from the fluids of hydrothorax by sponta-
neous decomposition, until after death.  The perforation  leading into
the pleural sac is generally a  small oval aperture, or a mere fissure, a
few lines in length, and situated in the vicinity of  the third and fourth
ribs  near the axilla.  The left side offers the greatest liability ;  Louis
found it affected  in seven out of eight  cases; Hasse has met with nine
in Avhich the left, and seven in which the right side was the seat of the
lesion ;  and of fifty collected by Reynaud, thirty-three were on the left
and  seventeen on the right side.  The immediate result of the perfora-
tion  is imminent, if not actual suffocation from collapse  of  the lung; if
death does not at once ensue, intense pleuritis is set up, and the patient
rarely  survives for many days.  We find  the lung compressed  to the
utmost, and the other viscera are much displaced, according to the side
in which the air has accumulated, the  epigastrium protruding from the
descent of the diaphragm,  and its action on the liver and stomach; the
other pathological conditions  are those indicating  inflammation of the
pleura; and we may observe  an  attempt  at repair in  the shape of a
false membrane investing the fissure.   The occurrence of pneumothorax
is only possible when the  pleura at the point of perforation has  not
previously  become adherent; but it sometimes happens  that the  ulcera-
tive process is continued after the pulmonary and parietal  pleura  have
been agglutinated, and passing through the uniting  medium attacks the
intercostal  muscles and integuments.   A fistulous opening  may thus be
established.

                         HYDROTHORAX.

   Hydrothorax, or dropsical accumulation of fluid in the pleural sac,
occurs in tAvo forms, as a primary and  as a consecutive lesion; the for-
mer is a disease  of much less frequent  occurrence than was at one time 
442               HEMOTHORAX — GANGRENE.

supposed.  Laennec states that one could  not establish  a higher ratio
for the occurrence of idiopathic hydrothorax as a cause of death, than
one in two thousand.  Let us hope that the days are past in Avhich such
errors of diagnosis, as he alludes to, can be committed; for he asserts
having found hypertrophy of the heart, aortic aneurism, phthisis  pul-
monalis of a somewhat irregular character, and even  scirrhus  of the
stomach or liver, without the least effusion into the pleura, mistaken for
hydrothorax.   The affection  consists in the effusion of a limpid serosity
into the pleura, to a  greater  or less amount, generally limited  to one
side, and unaccompanied by any appreciable  change of  structure in the
serous membrane;  the compression exerted  by the fluid upon the lung
and the  adjacent parts, is necessarily the same  in  this instance as in
those forms of fluid accumulation which have already been considered.
   The secondary  or symptomatic form  of hydrothorax is a  common
sequel of acute or  chronic diseases, heralding the fatal termination, and
giving evidence of that loss of tonicity that results from exhaustive
maladies.  The circulating system is more  frequently found to be at
fault  than any other; hypertrophy of the heart, valvular disease, peri-
carditis,  are  common causes ; it is also often associated with renal de-
generations,  tubercular and cancerous affections.   The  same cause  that
induces the effusion into the pleura, gives rise to dropsical accumulation
in other serous cavities, or in the  cellular tissue ; hence symptomatic
hydrothorax  is generally accompanied  by other affections of the same
kind.   As in the primary form, we find no definite lesion of the serous
surface associated with it; it is not in fact an affection of the membrane
at all, but exclusively of the vascular system, and we must look to the
blood and the capillaries for an  explanation.   According to Laennec, it
rarely occurs more than a few days before death ; and  though  it often
produces no  sensible effect upon the patient's feelings, it often  causes
suffocative attacks, which render his last moments painful amd  distress-
ing.   The liquid itself is commonly a clear straw-colored serum.
                         HEMOTHORAX.

  When the pleural  sac  is filled with blood, or Avith a  fluid of a de-
cidedly sanguineous character, we have to deal with haemothorax.  This
is  commonly due to some mechanical  lesion or to the rupture of an
aneurism;  but it has also been met with as the result of capillary ex-
halation—of the same  character as that to which  active  or  passive
spontaneous hemorrhages are  commonly attributable.  It is said to be
capable of  reabsorption  or  to  superinduce inflammatory  action ; or,
again, to be liable to  decomposition, and thus to  give rise to pneumo-
thorax.

                           GANGRENE.

  Before considering  the adventitious products met Avith in the pleura,
we must briefly advert to the occurrence of gangrene.  It is an unusual
lesion, and is commonly  connected with gangrene of the pulmonary 
ADVENTITIOUS  PRODUCTS.
443
tissue.   The  sloughs are to  be recognized by their greenish brown or
blackish hue, of a circular or irregular form, extending to some distance
beyond the  part  detached.  The fetid smell will also assist in deter-
mining the character of the lesion.
                   ADVENTITIOUS PRODUCTS.

  Among the homologous formations occurring in the serous membrane
of the lungs, authors enumerate cartilage, bone, and  fat.  A cartilagi-
noid thickening of the pleura, more especially at and about the apices,
is by no means  unusual;  but  the microscope invariably resolves this
deposit into  one  of a fibrous, or, as Lebert  terms it, chondroid, charac-
ter.   If the result-of gone-by inflammation of the pleura,  it affects the
free surfaces of the membrane with Avhich it intimately coalesces; when
due to subserous congestion, it is found in the subserous tissues,  and in
the membrane itself.    The lung exhibits fibroid formations, which, like
those found on the heart, the liver, or the spleen, are frequently but the
indications of a fibrinous blood crasis, independent of any actual inflam-
matory process;  they are smoothed, nodulated, very dense, and adherent
only by their exterior surface.  We meet with  the  formation of true
bone in the pleura as little as of genuine cartilage: the osteoid deposits
are mere amorphous  aggregations  of calcareous matter, occurring in
plates or irregular points;  they may  be encysted, and occasionally they
form pedunculated projections invested by the pleura.  To  this class we

                               Fig. 203.
 Old cartllaginold capsule of the apex of a lung, in a man aged 63; both lungs were similarly affected, and
like patches were also found on the spleen.  There was some appearance of obsolete tubercle, and much black
pigmentary matter. No definite structure was to be traced in the capsule by the microscope.

may probably refer  the case of ossification  of the lungs given by Dr.
Baillie,1 for, in  the delineation, the ossified  parts are  distinct polypoid
offsets from  the pulmonary tissue, though apparently invested by the
1 Morbid Anatomy, Second fascic. pi. vi. 
444
ADVENTITIOUS  PRODUCTS.
same membrane.  Rokitansky states that fibrous exudations invest the
costal as well as the pulmonary, but that they only ossify on the costal
pleura, the subserous products occurring chiefly in the intercostal spaces,
from which they may  be discharged into the cavity of the thorax in the
shape of round nodules.  That ossification of the  pleura is generally
preceded by some  inflammatory condition, may  be  inferred both from
the frequent occurrence of other inflammatory products in the pleura,
and  from  the analysis of a considerable number  of cases in a disserta-
tion  by Dr. Posselt;! he found that out of twenty-seven instances twelve
affected the right, and fifteen the left side, while the ratio of  the sexes
was  as thirty men to  four women.  The size of  the osteoid deposit  is
occasionally very extensive.  Dr. Hodgkin  removed from an old man
Avho died at Guy's Hospital, a plate of  bone subjacent to the parietal
pleura, which half  encircled  the chest and formed a considerable mass.
The fatty deposits which we find  connected with  the pleura are rarely
on the free surface, but seem to be  the result either of a transformation
of previous  inflammatory products, or  a fatty  growth  under  a false
membrane.   Recent  fibrinous exudation  occasionally closely resembles

                               Fig. 204.
Fig. 205.
 Naked-eye and microscopic view of cancer of the pleura. The growths were mainly in the interlobar
fissures, and occurred in a female who had malignant disease of the left mamma.  The liver also exhibited
cancer-nodes.
    i

adipose tissue both in color and form, though there can be no real diffi-
culty in determining its  nature.   Tubercular  deposit is not  often  met
with in the pleura; and  almost  exclusively occurs as a secondary form
1 De Pleurae Ossificatione, Heidelberg, 1839. 
                   ADVENTITIOUS PRODUCTS.     ,           445

of the disease.   The pleura, in this respect, differs in a marked manner
from the peritoneum and  the arachnoid, both of which  are  more prone
to primary tuberculosis than the former.  Tubercle forms either under
the pleura or in the sac—in the latter case, its seat is invariably in a
false membrane;  tubercles of this  description, Dr. Hodgkin remarks,
when thickly set, have been mistaken for thickening of the pleura itself.
Pleural tubercle, according to Rokitansky, not unfrequently softens and
gives rise to tuberculous abscesses in the different pseudo-membranous
structures in which it  is deposited;  these abscesses  may penetrate the
pleura, and even the thoracic Avails.
   Malignant growths never affect the pleura primarily, but involve the
membrane by  extension  from the mamma, the bronchial  glands, the
mediastina, or other neighboring tissues.   They appear on the pleura as
flattened  masses, rarely larger than an almond, surrounded by a halo of
bloodvessels.    While tubercle  occurs  in very numerous small spots,
spread all over the membrane, cancer  is only seen in  a few isolated
patches.  Both are liable to induce serous effusion  of a sanguinolent
character.  Medullary carcinoma and melanotic cancer are the forms of
malignant disease that most frequently attack the pleura.
   Hydatid cysts appear to occur in the pleura.  Cruveilhier1 details a
case in which  a large number  of acephalocysts were  discharged from
an artificial opening, apparently communicating with  the pleural cavity,
in a whitesmith, aged 29; the man entirely recovered, after the evacua-
tion of above five  hundred hydatids.  Dr. Hodgkin,2 in his fifth lecture,
speaks of a  specimen presented to Guy's Museum, in  Avhich a large cyst
containing acephalocyst hydatids is situated in part beneath the close
pericardium  about the base of the  heart, and  partly under the pleura
pulmonalis, at  the root and summit of the right lung.
1 Anatomie Pathologique, vol. i. p. 247.
2 Morbid Anatomy of the Serous Membranes, vol. i. p. 137. 
/■ 
THE PATHOLOGICAL ANATOMY OF THE
              ALIMENTARY  CANAL.
                 CHAPTER  XXXII.

              I. OF  THE  MOUTH AND  FAUCES.

  Congenital malformations  sometimes consist in an excess of  the
natural  number of parts, so that the jawbones, "the mouth, and  the
tongue, are double, and unite in one common gullet."  More often they
show themselves by defective formation of the mouth and fauces (astomia),
of the upper jaw (ateloprosopia), of the lower law (agnathia and atelog-
nathid), of the lips (achelia and atelochelia), of the tongue (ateloglossia).
Arrest of development shows  itself in the  common  single or double
harelip, the fissure existing at the union of the intermaxillary with  the
upper jawbones;  in fissures of the hard and soft palate; in fissures of
the tongue, the lower lip, and the lower jaw, which  are all very rare.
In some rare instances, the orifice of the mouth is wanting (atresia oris).
  The buccal mucous membrane shows but little tendency to be affected
by catarrhal inflammation; it is, however, often inflamed in one or more
spots  from some local irritation,  or  morbid action.  Thus,  a  carious
tooth, a piece of diseased bone, a crop of ulcerations, will excite inflam-
mation in their vicinity.  In adults, general inflammation of the mucous
membrane is sometimes produced by the abuse  or excessive  action of
mercury, and shows a marked tendency to pass into a state of ulceration
and sloughing.  Mr. Tomes mentions the occasional occurrence of spon-
taneous salivation, with considerable inflammation of the gums.  Chronic
inflammation  of the gums is  not  uncommon, and has appeared to us
sometimes to be of rheumatic origin.   It may extend over the whole
mouth, or be confined to the  vicinity of two or three teeth.   "The
surface of the gums,"  Mr. Tomes says, "becomes minutely nodulated;
and the secretion of epithelium increased; the papillae are increased in
prominence, while the substance of the gum is generally thickened, and
the  edges about the teeth become thick and round."
  In another form of so-called chronic inflammation, the gum rather
decreases in size,  and " assumes a very smooth and polished surface, and
mottled aspect;" the hard palate also  becomes implicated, and there is
acute intermittent pain.  Ulcerations  often  form on the gums, as well 
418
THE MOUTH AND FAUCES.
as on other parts of the mucous membrane of the buccal cavity;  they
are sometimes simple aphthae, sometimes small, round, slightly excavated,
and Avithout any surrounding inflammation.   In some cases, the ulcera-
tions are attended with much inflammation, and SAvelling of the mucous
membrane and subjacent  tissues, and, in others, they are rather  of a
sloughy nature, and form  upon a surface dark colored by asthenic con-
gestion.
  Epulis (sHi, ova-ov) is a fibrous  tumor, which originates in the fibrous
tissue of the gums, or in the periosteum,  and not only grows outward
toward the cavity of the mouth, but also penetrates  into the Haversian
canals and cancelli of the  bone.  Its surface is generally pretty smooth,
"like the gum," or it may be rough and more or less lobulated.  "Osseous
spiculae not  uncommonly shoot,"  according  to  Mr. Tomes, "from the
surface  of the jaw into the tumor, and, in some cases, isolated nodules of
bone (calcification?) are found in the substance."  Polypus of the gum
is a local hypertrophy of its tissue, occasioned by some mechanical irri-
tation.  It shows, " on section, an undulating fibro-cellular tissue, covered
by a thick layer of epithelium."  Vascular tumors, consisting essentially
of dilated vessels, sometimes appear on the gums.  Mr. Tomes describes
one of .a bright scarlet color, soft in texture, and easily compressed and
emptied of blood, and prone to bleed on slight irritation.   Cancer, almost
always in the form of scirrhus, occasionally attacks the gums.   Its size
varies usually from that of a pea to that of a nut.   It ulcerates after a
time, and may throw out fungous growths.
  The vesicles of herpes,  and  the  pustules of variola, occasionally are
developed upon the buccal mucous membrane.
  The croupy process (the diphtheritis of Bretonneau) appears in adults,
according to Rokitansky, in two forms.  In one, " after a previous vivid
or dark purple reddening of one or more papillae, and the vesicular
elevation of the epithelium at the point and the sides of the tongue, dots
or patches, of the  size of a lentil or pea,  appear on the inner surface of
the lips and cheeks, and, finally, on the mucous membrane of the fauces.
They present an exudation which has a frosted,  or flocculent, or villous
appearance, or is more of  a membranous character, and extends into the
cavities of the follicles;  it is of a grayish, or yelloAvish-white color, and
of a lardaceous,  or soft,  creamy, or  fluid consistency; if removed, a
shallow, excoriated depression, surrounded by an  inflamed  margin, re-
mains, on which the exudation is repeated, involving a further destruction
of the mucous tissue. In the second instance, livid spots, which rapidly
coalesce, and become invested with a dirty, gray, shaggy, pultaceous,
and sanious exudation, form upon  the softened,  bleeding gums, and the
mucous membrane of the cheeks, the fauces, and the tonsils.  The gums
themselves ultimately degenerate into a bad-looking, pulpy, sanious mass,
and  the mucous membrane of the cheeks and  fauces, underneath  the
exudations,  is equally found converted into  a  friable fetid pulp, or a
firm slough."  The epidemic adynamic character of the above described
process, is now well known.  Andral, writing more  than twenty years
ago, contended most justly that the  congestion of the part affected, though
first in order, was  but secondary in regard to casual agency ; and Roki-
tansky's investigations of  the different kinds of intra and extra-vascular 
THE MOUTH  AND FAUCES.
449
fibrin, which we have before noticed, have made it almost certain that
the essence of the disease consists in an alteration of the liquor sanguinis,
which gives rise to unhealthy exudation from the bloodvessels at various
parts.  Andral mentions that blistered and all denuded surfaces, during
the prevalence of such epidemics, become covered with false membranes
like those which form on mucous surfaces.   Wounds and ulcers at such
periods are found unusually inapt to heal, and all experience of the
juvantia and Isedentia, seems to  testify that the local morbid process is
extremely  different  from common  inflammation, and is  essentially de-
pendent upon a grave alteration of the  general system.   The color of
the exudation,  which is naturally whitish, is often rendered  darker  by
sanguineous effusion saturating  it; when this is the case, its aspect, and
the extreme fetor which it exhales, give to it a considerable resemblance
to a gangrenous slough.   This would  be still more increased if it were
situated, as it sometimes is, beneath, and not upon the layer of epithelium.
   The succeeding kinds  of  ulceration which we shall describe are, for
the most part,  seen in children.   Aphthse are small whity specks, some-
times so closely set together that they coalesce and form patches, which
may be very extensive.  They separate after a time, leaving the mucous
membrane beneath either simply excoriated, or superficially ulcerated.
After being detached they  are often produced again,  and this may
occur several times in succession.  It  is not yet quite decided of what
these specks really consist; analogy would  support  the olden opinion
of their being  simply a variety  of false  membrane, but some microsco-
pists  contend that they are solely clusters  of parasitic fungi.   We  in-
cline  with Dr.  West to the  belief that the  former opinion is the more
correct, not that we doubt the correctness of the observation of a growth
of fungi in the exudation, but that Ave think it much more probable that
these are developed  secondarily in  an unhealthy,  aplastic, animal mat-
ter, which is freely exposed to  the contact  of  air.  Dr. West  suggests
the idea that  the sporules of this fungous growth might, by lighting
upon the mucous membrane, and  exciting irritation there, cause the
production  of  the aphthous  specks.   This, we think, is very improba-
ble, as, were this the case, but few children could hope  to escape: the
diffused sporules which affect one child, might as well affect all who were
at all disposed.  It should be mentioned that the termmuguet is applied
by the French  to the more extensive deposits of this kind.  Bad health,
indigestion, or  abdominal disorder are the precursors and attendants on
aphthae.  The  whole of the buccal  mucous  membrane appears to be in
a state of asthenic  inflammation, and the  same  condition extends in
some  measure to the whole alimentary track.  The  disorder is, certainly,
a general  one,  manifesting itself by a  local  symptom, and not  confined
to that part.   Adults are sometimes affected by aphthae as the  result of
indigestions, or as indicative of  decaying vital powers.  A late eminent
physician  prognosticated his own approaching decease from the appear-
ance of aphthae on his tongue.   Dr. H.  Salter describes  small circular
ulcers which form  at the tip and along the edges of the tongue.   These
we have experienced ourselves, and can scarce think  they should  be
separated  from aphthae.   According to  him they  are produced by the
       29 
450
THE MOUTH AND FAUCES.
effusion of lymph into one of  the fungiform  papillae, which soon disap-
pears by sloughing or  ulceration, leaving an  ulcer which  continues to
spread for some time.
  Follicular stomatitis is described by Dr. West as sometimes idiopathic,
sometimes a  concomitant of measles.   In either case it is  rare, after
five years of age.  " The mouth is hot; its mucous membrane generally
of a livid red, while a coat of thin mucus covers the centre of the tongue.
On  the surface of the tongue, especially near its tip on the inside of the
lips, the  cheeks, near the angles of the mouth, and less often  in other
situations, also, may be seen several small, isolated, transparent vesicles
on the ulcers, which,  after bursting, they leave behind.   The ulcers are
small, of a rounded or oval form, not very deep, but having sharply cut
edges; and their surface  is covered by a yellowish white, firmly-adhe-
rent slough."   " When the ulcers are healing, no change in their aspect
is observable, and they continue to  the last covered by the same  yellow
slough, but, by degrees, they diminish in size;  and seldom or never is
any cicatrix observable in the  situation  which they occupied."   The
vesicles  form  in  crops, not generally  containing  many; the resulting
ulcers sometimes coalesce and form a  continuous patch.   The affection
is sometimes  complicated with herpes of the skin of the lips, and might
almost be considered  as a similar eruption of the mucous surface.
  In ulcerative stomatitis,  as  described  by the  same  observer, " the
gums are red, swollen, and spongy, and their edge is covered with a dirty
white or grayish pultaceous deposit; on removing which  their surface is
exposed, raw, and bleeding.   At first  only the front of the gum is  thus
affected; but as the disease advances,  it creeps round the teeth to their
posterior surface, and then destroying  the gum, both in front and behind
them, leaves  them denuded, and very loose in their sockets.  On those
parts of the lips and cheeks, however,  which are opposite to, and conse-
quently  in contact with, the ulcerated  gums,  irregular ulcerations form,
which are covered with a pultaceous pseudo-membranous  deposit, similar
to that which exists on the gums themselves.   Sometimes, too, deposits
of false  membrane take place  on other parts  of the inside of the mouth,
the  surface beneath  being red, spongy, and bleeding, though  not dis-
tinctly ulcerated.  .  .  .   When recovery has commenced, the disease
ceases to spread; the drivelling of fetid saliva diminishes; the white,
pultaceous deposit on the gums, or on the ulcerations of  the cheek or
lips, becomes  less  abundant;  the ulcers  themselves grow  less;  and,
finally, the gums become firm," and  slowly, and perhaps with  partial
relapses, regain their healthy condition.   The disease is common, rarely
fatal, rarely  associated with, or proceeding to gangrene.   It  is some-
times designated by the term  Noma.
   True gangrene of the mouth is a much less frequent, and  much more
fatal affection.  It is very seldom  idiopathic, almost always occurring
consecutively to  measles or some  other disease.  Messrs. Rilliet and
Barthez found, out of twenty-nine cases, nineteen aged from two to five
years, and ten aged from six to twelve.  We again quote Dr. West's de-
scription, which pictures very well the  only case which we have witnessed
ourselves. There is at first scarce any suffering, and some unusual  fetor 
THE MOUTH AND FAUCES.
451
 of the breath, some profuse secretion of offensive saliva, and swelling of
 the cheek, are the first circumstances which are observed.   The characters
 of the swelling of the cheek are almost pathognomonic.  It is not a mere
 puffiness, but is tense, red, and shining—looking " as if its surface had been
 besmeared with oil, and in the centre of the swollen part there is gene-
 rally a spot of a brighter  red than that around.  The cheek feels hard,
 and is often  so unyielding, that the mouth  cannot be opened wide enough
 to get a good view of its interior.  The disease is almost always limited
 to one side,  and generally to one cheek."  Occasionally, it begins in the
 lower lip, never in the upper, but it may extend to either.  " Whatever
 be the situation of the external swelling,  there will  generally be found
 within  the mouth, at a point corresponding  to the  bright red central
 spot, a deep excavated ulcer, with irregular jagged edges, and a surface
 covered by a dark, brown, shreddy slough.  The gums opposite to the
 ulcer are of a dark  color, covered with the putrilage from its surface,
 and in part  destroyed, leaving the teeth loose, and the alveolae denuded.
 Sometimes, especially if the disease be further  advanced, no single spot
 of ulceration is recognizable, but the whole inside of  the cheek is occu-
 pied by a dirty putrilage, in the midst of which large shreds  of  dead
 mucous membrane hang down.  As the disease extends within the cheek,
 a similar process of destruction goes on upon the gum, and the loosened
 teeth drop out one  by one.   The  saliva continues to be  secreted pro-
 fusely, but shows by the changes which take  place in its character the
 progress of  the disease.   At first, though remarkable for its fetor, it is
 otherwise unaltered, but afterwards loses its transparency, and  receives
 from, the putrefying tissues over Avhich it passes, a dirty, greenish, or
 broAvnish color, and at the same time acquires a still more repulsive odor.
 While the gangrene is thus going  on inside the mouth,  changes no less
 remarkable are taking place  on  the exterior of the face.  The redness
 and swelling of the cheek extend, and the deep red  central spot grows
 larger.   A black point appears in its midst;  at first, it is but a speck,
 but it increases rapidly, still retaining a  circular form—it attains the
 bigness of a  sixpence, a shilling, a half-crown, or even a  larger size.   A
 ring of intense redness now encircles it, the gangrene ceases to extend,
 and  the slough begins to separate.  Death often takes place before the
 detachment of the eschar is complete; and it  is fortunate when it does
 so, for sloughing usually commences in the  parts left behind.   The inte-
 rior  of the mouth  is now exposed, its  mucous  membrane and the  sub-
 stance of  the  cheek hang down in shreds from  amidst  a  blackening
 mass," which exhales a horrible fetor.  There is no acute pain through-
 out, the patient is generally rather drowsy,  and death takes place quietly
 in most cases.   No cause  has been assigned for the occurrence  of gan-
 grene in this  part;  all that can be said is that a true mortification or
 death of the textures seem to take place, which is itself the primary evil,
 and not the result of inflammation, disease of the vessels, or obstruction
 of their channels.   This is a good illustration of the doctrine we main-
 tained, Avhen  speaking of mortification, viz:  that  it essentially  con-
 sisted in  a loss of the vital  powers which maintain, in opposition to those
of inorganic chemistry, the complex constitution of the animal tissues. 
452
THE MOUTH AND  FAUCES.
  The tongue is liable to be affected by inflammation, or glossitis, as it
is termed.   This in some rare cases, said by Dr. Salter to occur most
often in scrofulous  persons, causes  the formation  of abscess.  On the
matter being evacuated, the tongue  speedily returns to a healthy  state.
Sometimes a partial inflammation of the tongue is met with, the morbid
process being confined to the portion of the base bounded in front by
the V-shaped line of circumvallate  papillae.   It occurs as an extension
of tonsillitis, which we  shall presently notice.   Deglutition  in  these
cases is seriously interfered with.  The inflammation of the.gums, which
is produced by mercury, sometimes involves  the tongue, and occasions,
in some cases, very great and rapid swelling.  It does not seem to have
even  produced suppuration.  One  variety  of  glossitis has  been dis-
tinguished by the term erectile, by Dr. Salter.  He describes " the mor-
bid condition of the tongue in this disease as consisting in an enormous
and rapid  distension of the organ  by blood, rendering  it very large,

                              Fig. 206.
Tongue, swollen hy Glossitis.
hard, and stiff.  The distension becomes so great that respiration through
the mouth is quite prevented, and even can with difficulty be performed
through the nostrils.   Though the congestion becomes so intense  that
the organ  is of a dark black  color, neither mortification  nor  abscess
appears to haAre eATer taken place.  Free incisions give exit to the blood,
and recovery ensues.  Sometimes one-half of the tongue only is affected.
In most cases it occurs in persons who are in  perfect health, and Avithout
any manifest exciting cause."
   Severe and deep ulcerations of the  tongue may arise  " from mere
disorder of the alimentary  canal," especially in debilitated persons.
Some of these, attended Avith  much induration, may bear  a very close'
resemblance to cancerous ulcers.  Constitutional syphilis produces small
superficial circular ulcers, which sometimes extend in depth, and some-
times in length only.  Rhagades or fissures result from the  same cause;
they often occupy the medium line in the front part of the organ ;  they
may be mere cracks, or extend three-quarters of an inch in depth,  with
irregular ulcerated edges.  Often, they are associated with tubercles of
the surface of the tongue.   These, which are admirably described by
Dr. H.  Salter, under the name of glossy tubercle, appear to be of the
same nature as the syphilitic  tubercles termed gummata.  Ricord speaks
of them as  deep-seated  tubercles of  the  subcutaneous areolar tissue, a 
THE MOUTH  AND FAUCES.
453
kind of chronic furuncles;  and refers to two cases of recurring syphilis,
in which the tongue was so full of them  that  it felt as if stuffed with
nuts.   According to the French  observer, they produce  horrible de-
structive ulcerations.  Dr. H. Salter describes  them  " to consist in an
effusion of lymph into the cellular tissue underlying  the mucous mem-
brane ;  this effusion is very dense, and raises and distends the  surface
of the tongue at the affected part above the surrounding portions; the
effect is that the papillae near it are opened out, and sometimes totally
obliterated.  Hence the surface of the tubercles is smooth,  and,  as they
become absorbed, the papillae reappear again.
   The tongue is liable to be the seat of cancerous growths of the scir-
rhous and epithelial species.  The former is described by  Mr. Travers
as at first  being an irregular rugged knob, generally situated in the
anterior third, and  midway between the raphd and  one edge.  Ulcer-
ation sometimes takes place very rapidly ;  the  surface at the same time
throwing out luxuriant  fungous growths: in  other  cases it " is very
uneven, clear and bright granulations appearing in parts, and in others
deep and sloughy hollows."  In a peculiarly interesting  case of epithe-
lial cancer, carefully watched by Dr. H. Bennett, the first appearance
of the  disease  was  a small ulcer  on the  margin of the  tongue.  This
extended, in spite of its  being shielded from  the pressure of the teeth,
and had hard, everted edges, undermined some way by ulceration.  These
became more ragged, and here and there  over  the surface  some degree
of suppuration  and sloughing  occurred.   Much improvement followed
the excision of the tumor—the wound healed favorably.  Not  long after,
however,  the glands under the  jaws enlarged, and Avere removed; and,
in about nine months after this, the disease returned  in the tongue and
proved fatal.   The  morbid growth which had been removed  presented,
on a transverse section, a tract of white, indurated, convoluted structure
immediately below  the ulcer, and  above the muscular substance of the
tongue.   This  indurated tract was half  an inch thick posteriorly, and
consisted of a fibroid structure inclosing debris of muscular fibre, and
some of the characteristic circular loculi of epithelial cancer. The surface
of the ulcer was covered with papillary elevations, which consisted chiefly
of enlarged, softened epithelial scales splitting into fibre, so as  to form
a kind  of fringe.  This history shoAvs, we  think, beyond any doubt, that
Avhat Dr. Bennett would distinguish  as cancroid, are in many, if not
most cases, as  true cancers as any of the  other  species.   The  circum-
stance mentioned by Dr. Bennett in his Appendix to his work is curious
and significant, viz : that the enlarged glands beneath the jaw contained
quantities of epithelial  scales similar to those found in  the  primary
growth.  This indicates a potentiality in the  blastema, absorbed from
the epithelial tumor, to cause a reproduction of like cell-structure.
   Fatty tumors and simple cysts are occasionally met with in the tongue,
and Dr. Salter mentions  the occurrence of pediculated polypoid growths,
which  seem to be of the nature of fibrous  tumors, or, perhaps, in some
cases of enchondroma.   The tongue is liable to be affected by an extra-
ordinary hypertrophic enlargement, in consequence of which it protrudes
from  the mouth, sometimes  as much as two and a  half inches.   The 
454
THE MOUTH AND FAUCES.
structure is altered, becoming  much more dense than  natural;  but  it
has not been  determined exactly in what the alteration consists.   In
one case, recorded by Mr. Liston, the enlargement of the organ  seems
to have been  occasioned by the development of naevus-like structure.
Atrophy of the tongue  only occurs as  the  consequence of paralysis,
from division of the hypoglossal nerve, or attacks of hemiplegia.  It is,
of course, confined to the affected side.   Dr.  Salter gives an interesting
account of  the morbid changes which the lingual papillae undergo.  The
circumvallate  papillae may be hypertrophied, and form  little tumors as
large as  peas.   The  epithelial caps of the  conical or  filiform papillae
may become extraordinarily elongated,  so as to be half an inch long;
they  are of a dark  color,  and look exactly like little  brown  hairs.
Minor degrees of this  condition  are, we think,  not uncommon.  The
papillae sometimes  become  atrophied.   " Mr. Lawrence  mentions  the
case of a person, in whom, from habitual drinking, the  tongue was, for
the greater part of its surface, destitute of papillae: it was white, smooth,
and opaque on the surface."   Blood and  lymph may be effused into the
substance of the fungiform  papillae.  The pus which so commonly col-
lects on the surface of the tongue in disease, consists of detached, and
more or less disintegrated epithelium, with varying proportions of amor-
phous matter.  We  can corroborate Dr. Salter's statement, that, in
some healthy persons, the tongue is habitually  furred.  In  very rare
cases the fraenum of  the tongue is so short that it is quite tied down to
the floor of  the buccal  cavity, and cannot  perform its proper  move-
ments.   Minor degrees of the same condition are not  infrequent, and
gradually  improve  of themselves.  In  the   opposite condition, " the
movements of the tongue are too free;  it can be inverted, and its apex
thrown back into the pharynx, which embraces it," and thus the  access
of air to the lungs through the glottis is  prevented.  The sides of the
tongue have been known to become closely adherent  to  the internal
surface of  the cheeks.
   The tonsils are a more common seat  of inflammation and its  conse-
quences.   In  an acute  attack  they become more  or  less, sometimes
enormously swollen, so as to  impede the respiration.  The pillars of
the fauces, and the soft palate, are also involved  in  the  inflammation.
Suppuration often occurs, and is, perhaps, the best result, next to com-
plete resolution; but more frequently, the imperfectly  subdued hyper-
aemia produces actual enlargement, and fresh attacks recurring, a chronic
hypertrophy of the gland is the result.   We have examined some en-
larged tonsils  which had been excised, and found their  structure to  be
quite identical with that of the healthy gland, so that the  alteration
constituted a true hypertrophy.   It seems worth  while  to notice briefly
the structure  of the tonsils, which we  think is not well understood, as
it explains in  some measure their great liability to hypertrophic enlarge-
ment.  They  are made up of  a number of duplicatures and involutions
of the mucous membrane, which, however, is  differently  constituted here
to what it  is in other parts in the vicinity.   A vertical section  shows
the  thin surface layer  of scaly  epithelium  with  a thick underlying
stratum, consisting of nuclear, or very slightly developed celloid parti- 
MORBID CONDITIONS OF THE TEETH.          455
cles.  This layer is traversed by vessels, which are of capacious size in
hypertrophied specimens, running up to the basement-membrane which
supports the layer of scaly epithelium.   When there is any habitual
hyperaemia, and consequent exudation, this low submucous celloid growth
readily assimilates the effused plasma into similar substance, and so the
enlargement continually  goes on.   The morbid  condition -which  most
resembles it is  enlargement of the Peyerian patches, which we  shall
presently describe.   Induration not unfrequently occurs as the result of
inflammation, and depends, beyond doubt, on a fibroid development of
the  exudation.   Rokitansky says: "In  scrofulous subjects the tonsils
are  often affected, in addition to hypertrophy and habitual hyperaemia,
with a peculiar blennorrhcea,  and the purulent secretion not unfre-
quently becomes inspissated, so as to form  tubercular cheesy plugs, or
even chalky concretions.  These, in  their turn,  keep  up a perpetual
state of irritation in the tonsils."   Cancerous disease  is very rare in
this situation, but common indurated enlargement  has often been spoken
 of as scirrhous.
          II. MORBID CONDITIONS OF THE  TEETH.

  The brief summary that we shall give  of these  conditions is taken
from the excellent work of Mr. Tomes on the subject, to which we must
refer for fuller information.  Malposition of the other teeth is scarce
more  than a  disfigurement, but when the wisdom  teeth take a wrong
direction the effects produced are  sometimes very mischievous.  Those
of the lower jaw cause more serious evil by their wanderings than those
of the upper.  Sometimes the tooth, though not deviating from its pro-
per position, is held down by indurated gum.  Esquirol mentions a case
in which mental derangement depended  on this cause.   The wisdom
tooth may take a false direction inward or outward, and cause by its pres-
sure, ulceration of the tongue or  the  cheeks.   It may grow  directly
forwards against the posterior surface of  the second molar,  which  has
proved the source  of severe pain, resisting all treatment but  that of ex-
tracting the offending tooth.   Lastly, the  tooth may advance against
the coronoid process, causing disease and necrosis  of the bone, and in-
flammation  and abscess in the surrounding  parts.  The teeth are very
liable to caries, which is  an affection very much of the same kind as that
occurring in bones.  Mr. Tomes believes that " the dentine, from abnor-
mal (nutritive) action, loses its vitality," and thereAvith becomes liable
to be decomposed by the fluids of the mouth.  It seems necessary that
both conditions should exist, that the tissue should be dead, and that the
oral fluids should  be in  an acid  state, capable  of  dissolving it.   Test
paper applied to carious teeth almost invariably  shows the presence of
free acid.  Healthy saliva is  alkaline, while that of dyspeptic persons
is prone to  be acid, and it is in such that caries  is most  apt to occur.
The enamel  is, of course, first  affected, but a very small perforation
throuo-h this tissue may exist with a considerable amount of disease in
the subjacent dentine.   It appears that when the acid solvent has once 
456          MORBID  CONDITIONS OF  THE TEETH.
penetrated to the surface of the dentine, it extends laterally under the
enamel, destroying, extensively perhaps,  the body of the tooth, and
undermining and eroding the enamel on its attached surface.   The de-
structive process does not go on nearly so fast in the fang, which seems
to possess a higher degree of vitality than the crown.  A most interest-
ing observation  of Mr.  Tomes demonstrates completely the vital nature
of the actions going on in the dentine  under the influence of disease.
He shows that when a portion of dentine has become dead, it is circum-
scribed by the consolidation of the adjacent  living tissue.   " The tubes
become filled up, they are  rendered solid,  and the  circulation is cut off
from the dead mass by the obliteration of the tubes."   It is remarkable
"that the consolidation does not go on gradually from  Avithout inwards,
keeping in advance of the decay, but occurs at intervals."   It is formed
also in successive lines, a second one being produced when the first be-
gins to be attacked, and afterwards a third, when the second gives way.
The consolidated  zones vary in width and  in  completeness,  probably
according to the vigor of the conservative action.    Another interesting
exhibition  of vital action is displayed  in  the production  of  secondary
dentine by the surface of the pulp, under the  excitement  of caries in
the contiguous  tissue.   This  vascular papilla,  originally the formative
organ  of the dentine, which had for years confined its action to nourish-
ing the perfected  structure, under the stimulus of disease renews  its
formative action, and throws out a barrier between  itself and the  ad-
vancing mischief.   How very analogous is this to  the  throwing out of
lymph on the  outer surface of a hollow viscus which is threatened with
ulcerative perforation!   The  structure of secondary dentine  is not so
perfect as the original,  and it is commonly vascular. Under the micro-
scope " a transverse section of carious dentine, rendered soft, like carti-
                lage, from  the loss of its lime, presents a cribriform ap-
    Fig. 207.      pearance.   The tubuli are much enlarged  and irregular
                in outline," differing entirely from  their normal shape.
                This indicates that the solvent enters the tubes, and  dis-
                solves,  first, their  walls, and afterwards the intertubular
                material.  In the  consolidated zones the deposit obliter-
                ating the tubes is first removed, and  afterwards their
                walls and the intervening tissue. A confervoid growth is
                very often seen on carious teeth, and on the tartar that
                may incrust them.  Imperfect formation of the enamel
                is a frequent cause of  caries.   It is mostly deficient on
  Drawing of a tooth   ^g surface presenting deep pits, with the intervening
attacked  by  caries               n-iit-
with barrier  of se^   structure well  developed; sometimes, however, small
condary dentine.     cavities exist in its substance, while the rest is perfect.
                Deep narrow fissures are often met with extending from
the free surface to within  the  Tu^th  of  an  inch of the dentine;  the
enamel forming the walls of these is in parts perfect, in parts imperfect.
Not only may the enamel  be deficient, but it may  be  also imperfectly
formed in various parts.  The columns of its pulp  consist of cells  and
granules, which, normally, become lost and fused  in the  homogeneous
fibre;  sometimes this fusion  does  not take place,  and  the granules  re-
 
MORBID  CONDITIONS OF THE TEETH.
457
main, giving the  enamel fibre a permanently granular aspect; or the
cells do not undergo their wonted arrangement and elongation, and thus, <
though they calcify, do not form fibres.   Sometimes the fibres of the
enamel are not  perfectly united at their margins; the resulting  inter-
space  may  either appear  as  a broad  line, or as  a series  of minute
cells.
   The teeth are  subject not  only to decay, but  to  death, to necrosis,
which  may be either complete or partial.   After this has occurred, cer-
tain physical changes  commence.   " The tooth  gradually assumes  a
darker hue  than  natural, which increases in  intensity till  it is almost
black.   The dental periosteum gradually detaches itself from the fang,
the tooth becomes loose, and unless held in by the crooked form of the
roots,  drops  out.   The surface of the  fangs is generally rough, and,

                                Fig. 208.
               Imperfect formation of enamel. From Mr. Tomes's work.
               a. Enamel.
               b. Dentine.
               c. A perforation in the enamel.
               d. A cribriform layer of tissue in the enamel.
               E. A large cell lying transverse to the enamel-fibres.
               f. Cells in the enamel about the apices of the coronal dentine.
               a. Lines of minute cells between the enamel-fibres.

near the neck, dotted over with nodules of hard green-colored  tartar,
while  the ends of  the roots often  look worm-eaten, as though  absorp-
tion had commenced."   Mr. Tomes compares the  process of necrosis
of a tooth  with that which  occasions the shedding  of  the  antlers of
a deer.  In both,  the minute  tubes or cavities through which nutrient
fluid is conveyed, become obliterated by calcareous deposition; the whole
tissue  being consolidated into an inorganic mass.   The dead  tooth acts
as a foreign body, causing inflammation  and suppuration of the  dental
periosteum, as well as absorption of the  latter, the alveolus, and gums.
More serious effects are occasionally produced, " the periosteum of the
alveoli becomes inflamed, together  with the neighboring parts;"  and, if
the case be  still neglected, the adjoining teeth are not unfrequently lost,
and necrosis  of a  considerable  part of the jaw may also result.  In
some instances, where the death  of the tooth has taken place gradually,
patches of newly-formed cementum, thrown out by the irritated dental 
458           MORBID CONDITIONS OF THE TEETH.
 periosteum, adhere closely to the latter, and thus the tooth is held in
,its place.  A single spot of  necrosis in the fangs may cause inflamma-
 tion, and abscess, and such severe pain that the tooth, though otherwise
 quite healthy, is obliged to be removed.  " Instances are not uncommon
 when the pulp of the  tooth  has died Avhile the external surface of the
 fang has preserved its vitality.  In these cases the dentine becomes dis-
 colored, and gives a general  dark appearance to the tooth.   One of the
 three fangs of a molar tooth  may alone be affected by necrosis, or the
 disease may be confined to one side of  a single fang, producing absorp-
 tion of the gum and alveolus on that side.
   The layer of osseous tissue, called cementum, which coats the  fangs
 of the teeth,  is liable to become  hypertrophied.   This may proceed to
 such an extent that the fang near its  extremity  may be twice the dia-
 meter of the  neck.  It results from irritation of the dental periosteum,
 which may itself be occasioned by caries, or necrosis of the tooth.   The
 enlarged fang necessarily compresses  and irritates the nerves which
 pass through the orifice at its extremity to the pulp; and this irritation
 may be the cause of epileptic seizures, or paroxysms of neuralgic pain.
 The fangs of the teeth are  occasionally absorbed to a greater or less
 extent, in some rare instances to the same extent  that those of the tem-
 porary teeth  are.   The dental pulp,  a  highly sensitive  and delicate
 structure, is very liable to be affected by severe pain from the irritation
 of caries in the tooth,  or even from  disease of the pulp of an adjacent
 tooth, or one situated on the opposite side or  even in the other jaw.
 This is an excellent example of the reflection of sensations.   Inflam-
 mation often  attacks the dental pulp, changing its natural pinkish-gray
 color to a bright scarlet, and terminating very commonly in its suppura-
 tion and death.  Sometimes when there exists  an opening formed per-
 haps by caries, into the pulp  cavity,  the  inflammation  affects  only a
 part of the pulp.   This is  intelligible from the  circumstance that the
 secreted matter has a  channel of exit, and  does  not diffuse itself over
 the rest of the pulp, and also because  the  irritation of the oral fluids,
 and of the carious dentine, is confined to the adjacent part of this struc-
 ture.  The inflammation, after having caused the  destruction  of the
 pulp, may extend to the dental  periosteum, and  occasion  the death of
 the fang;  it may even extend further to the periosteum of the jaw, and
 produce necrosis of the bone.   The dental  pulp may be  removed by
 absorption after the cavity of the tooth is laid open by caries, or it may
 ulcerate or perish from gangrene.  Or again, it may become the seat of
 a fungoid growth, not of cancerous nature, which is sometimes termed
 polypus.
   The dental periosteum may be inflamed acutely  or chronically.  When
 the former takes place, it causes the periosteum to separate, to a greater
 or less extent, from the surface of the fang, leaving a cavity which is
 occupied by pus.   The cavity becomes enlarged  at the expense of the
 alveolus, and this  chiefly at  the apex  of the  latter.   Sometimes the
 pus makes its way  into the mouth at the neck of the tooth, having de-
 tached the periosteum up to  that point; but more commonly the abscess
 advances through an opening in the alveolus into  the gum, from whence
 it ultimately makes its way to the surface.   In unhealthy states of 
                THE PHARYNX AND (ESOPHAGUS.            459

system, the disease may involve the bone adjacent, and  cause  necrosis
to a considerable extent;  or it may creep on and affect the
periosteum of contiguous teeth.   The inflammation rarely
arises spontaneously; most often it is the sequel of inflam-
mation of the pulp.  In the chronic form, there is no tendency
to the formation of abscess, but there may be a slight dis-
charge of pus from the. edge of the gum. " The tooth becomes
loose, the alveolus absorbed, and the edge of the gum in-
flamed.   The gum gradually  sinks with the  absorption of
the alveolus,  and the  tooth  drops out or  is  removed."  puruientcystat
Sometimes  partial chronic inflammation occurs, causing  the fang of a de-
"the  periosteum about the extremity of the tooth to be-  cayedtooth,often
come  thickened and nodulated."  The alveoli are liable to  *eRimf ovi?n
      .  „       .                                         of most serious
necrosis from various causes, as other bone is; they undergo  mischief.
absorption in old age naturally, and sometimes prematurely
in persons  who have been subjected  to long-continued  salivation,  or
whose gums have  been  rendered unnaturally vascular by  other causes;
and, lastly, they are  sometimes the seat of exostosis, Avhich, gradually
as it increases, extrudes the tooth.
    III.—ABNORMAL  CONDITIONS  OF  THE PHARYNX  AND
                          (ESOPHAGUS.

  This part of the alimentary canal may be congenitally absent, or may
terminate in a ccecal pouch, or  be  fused with the trachea, or be dilated
into a sac,  or, in rare instances, be traversed by separate fissures.  The
pharynx and  oesophagus  sometimes become dilated throughout, their
parietes, and especially  the muscular tunic, being hypertrophied. Roki-
tansky alludes  to one case in  which  the passage was large enough to
admit a man's arm.   In some instances, of  a less degree of dilatation,
the coats are relaxed and  attenuated.   Partial dilatation appears in the
pouches  which sometimes are  formed by  all the coats  of the canal,
sometimes  consist of the mucous membrane only.  In the latter case,
"the mucous membrane is protruded  between the muscular fibres, and
becomes dilated by the  food that enters; it is at last forced out in the
shape of a  cylindrical appendix, which lies between the vertebral column
and the oesophagus, in a line Avith the axis of the pharynx, so that all
ingesta pass into it, and death from starvation results."
  The oesophagus is liable to be constricted, either by the  compression
of external growths, or by cicatrices in its own walls,  the results of
former ulceration or sloughing, or  by  cancerous  formations in  its coats.
Acute inflammation occasionally attacks the pharynx, or  rather its mu-
cous lining, chiefly by extension of the disease  in cynanche tonsillaris,
or simultaneously with the fauces  in  scarlat. anginos.   Sometimes the
affection, though  then  generally less acute, is  independent,  and con-
stitutes cynanche pharyngea.   Chronic pharyngitis is very  common,
especially in  persons of an atonic habit, or who speak much  from the
throat.   The  mucous membrane appears  slightly swollen, and of  an
even surface, colored by an uniform redness, and denuded to  some ex- 
460
THE PHARYNX AND (ESOPHAGUS.
tent of its investing epithelium.  In  many cases, the redness is more
patchy, and seems to affect more the small veins and adjacent capillaries,
                          and is of a darker tint.  M. Chomel has de-
         Fig. 210.           scribed one form of this affection, in which
                          the mucous follicles are specially the seat of
                          morbid action.   He says  the  arch of  the
                          palate is seen to be covered by small  red
                          points, which are more thickly disseminated
                          on and near the uvula.   These become more
                          numerous and larger as the disease advances,
                          till at length they run into each other, form-
                          ing ridges and raised patches, between Avhich
                          only a small part of the mucous membrane
                          retains its  natural  appearance.  It occurs
                          much more frequently in males than females,
                          and chiefly between the fifth and seventeenth
                          years.   Croupy inflammation sometimes ex-
                          tends  to the pharynx and commencement of
                          the oesophagus, and, on the continent at least,
                          diphtheritic exudations are by no  means in-
                          frequent in this situation.   They are essen-
                          tially  similar to those which  form on  the
                          buccal mucous surface,  which  have  been
                          already described.   The pustules of variola
                          are  occasionally met with in the  pharynx,
    stricture of the oesophagus.      and those which are caused by large doses of
                          tartar-emetic in the lower third of the oesopha-
gus.  The same part of this canal is liable to  softening, which, usually
associated with softening of the stomach, attacks especially the left side,
which adjoins the left pleura, and occasions perforation and effusion of
the contents of the stomach into this serous  cavity.  Fibrous tumors
originating in  the submucous or deeper-seated  areolar tissues may grow
inward, and, obtaining an investment of mucous membrane, hang down
into the oesophagus in the form of a polypus.   Sometimes they remain
without thus protruding in the submucous tissue.   Tuberculous deposit
is very rarely found in the  pharynx or oesophagus.   Cancer is more
frequent  in the  oesophagus than in the pharynx,  in  the proportion
of thirteen to  four ; in the former, it mostly affects the upper part, just
below the larynx: in both parts,  it  almost ahvays assumes the form of
infiltrated scirrhus, from an ulcerated basis of which soft fungoid growths
may afterwards sprout.  In the  pharynx, according to Dr. Walshe, it
generally presents, at least in the early period, "a hard imperfectly cir-
cumscribed mass," which may form a tumor visible externally.  In the
oesophagus it mostly constitutes an annular layer, constricting  the canal
for a variable  distance,  and often, by extending  outward, producing
adhesion of the diseased mass to the spinal column.  We have observed
one instance in which encephaloid cancer in this situation had proceeded
to a considerable  extent without producing any symptoms.  In the oeso-
phagus of a man who died with peritonitis, there was  a thick mass of
encephaloid, ulcerated on the surface surrounding the lower part of the
 
        ABNORMAL CONDITIONS OF THE PERITONEUM.     461

canal, just above the  cardiac orifice of the stomach, for an inch and a
half.   It had evidently originated in  the submucous tissue, and groAvn
inward, not contaminating  the  other coats.   Higher up,  there were
several smaller submucous tumors.  Rokitansky mentions the formation
of ulcerated openings communicating with the trachea and the bronchi,
or even with the aorta and the right pulmonary artery.
    IV. —ABNORMAL  CONDITIONS OF THE  PERITONEUM.

   Congenital deficiencies in the peritoneum will, of course, exist when
any of the viscera which it invests are absent, or imperfect, or when the
walls of  the  abdominal cavity are in a like state.   It appears also that
the various folds may of themselves be imperfectly developed, e. g. the
omentum or mesentery may be unnaturally small or absent.   On the
other hand, these same folds may be  of unusual dimensions, as when a
mesentery of more than common length allows the intestines to float up
to the surface  of an abdomen distended  by ascites.   Certain  pouches
are also occasionally met with, chiefly, according to Rokitansky, in the
hypogastric,  iliac, and inguinal regions, Avhich somewhat resemble com-
mencing hernial sacs, and like them may inclose and incarcerate portions
of the intestine.  Most remarkable changes in the shape and size of the
peritoneum are produced by the dropsical distensions which it undergoes,
and the displacements to which it is subjected in various cases of large
and inveterate hernia.  The peritoneum is extremely liable to inflam-
mation, which may be of various degrees of acuteness, or may be chronic
ab initio.   The former is extremely common, and results not only from
all  causes of irritation applied to it, but also originates spontaneously;
or,  as Rokitansky avers, in consequence of the rheumatic poison.   The
inflammation varies much in extent; very often it is general, affecting
the whole membrane, but often also it is  partial, confining itself to a
certain region.  The simplest instance of partial peritonitis which we
can take is, perhaps, that which occurs when an ulcer is making its way
through the walls of the intestine, and threatening to perforate  them.
Opposite the threatened spot,  a patch of injected vessels appears on the
serous membrane, which pour  out a fibrinous  exudation forming a pro-
tecting investment, or an adherent  medium uniting it to adjacent parts.
Inflammation, however, when  set up at one part is very prone, as in all
serous membranes, to propagate itself to  the  surrounding, and thus it
very commonly happens that peritonitis, which commences in one locality
over an inflamed or irritated organ, diffuses itself OArer the whole mem-
brane till it becomes general.   In the early period, injected vessels are
very distinctly seen in the inflamed membrane, forming streaks or patches
of redness.  The  injection, however, is seldom very strongly marked,
Avhich is, perhaps, due in part to  the readiness  with which exudation
takes place.  This  is often seen as a delicate thin layer  of fibrinous
matter closely investing the inflamed surface;  sometimes it is so scanty
that it is scarcely discernible,  unless the surface is carefully scraped, or
adjacent  intestinal convolutions are separated from each other, when it
appears as minute filaments stretching across the interspace.  The exu- 
462     ABNORMAL CONDITIONS OF THE PERITONEUM.
dation sometimes collects in the furrows between  conArolutions of intes-
tines pressed together, and is more manifest there than elsewhere.   In
instances of sthenic inflammation the exudations are often very abund-
ant, and much puriform is  mingled with the fibrinous  matter.   Serous
fluid is also poured out often in considerable abundance, and is rendered
turbid by flakes and molecules of  fibrin  and pus-corpuscles diffused

                              Fig. 211.
          Portion of inflamed peritoneum, with numerous glomeruli between the fibres.

throughout it.  In peritonitis, attacking persons who are in an asthenic
Btate the serous and puriform effusions  generally predominate.  Adhe-
sions are very often found in the peritoneum, connecting  the visceral
and parietal layers together,  and are sometimes  of considerable length;
in many instances, no doubt, they are the result of partial inflammations
giving rise to  fibrinous exudation, which is afterwards transformed into
areolar tissue; in other cases we are inclined to  think the exudation
takes place with little or no preceding hyperaemia.  The inflamed mem-
brane becomes somewhat thickened by the effusion taking place in  its
own texture.   In  the specimen  from which  the  annexed  sketch was
taken, numerous small corpuscles somewhat resembling glomeruli were
seen everywhere among the  natural fibres.  Bands  of adhesion some-
times become  the cause of fatal incarceration of the intestine, an open-
ing being formed by these means into which a coil of intestines passes,
and after a time having become  distended, is strangulated by the  ab-
normal band.   A case of this kind is recorded in the Report of the
Pathological Society, 1851-52, in which seven  or eight inches of the
lowest part of the small intestine were strangulated by a ring formed
by a strong fibrous band  passing from the mesentery to  the anterior
surface of the  rectum.   The intestines are very commonly distended  by
gas in  acute peritonitis, which is probably secreted by the mucous mem-
brane under the influence of the irritation to which it is  subjected in
consequence of the adjoining inflammation.  At the same time there is
reason to believe that the action of the muscular fibres  is more or less
interfered with if they are not actually paralyzed, and hence the dis-
tension being  unopposed is greater than it otherwise would be.  Roki-
tansky  says that " hemorrhagic exudation is frequently seen on  the
peritoneum; it forms large,  saturated coagula, disposed in thick layers."
Suppuration, as has been  said, is not  unfrequently a  result  of acute
peritonitis, the purulent matter being, as it were, smeared  all  over  the
surface of the  membrane; sometimes, however, it takes place in a single
part, and forms a circumscribed abscess.   On opening the  abdomen of
a female who had been attacked with peritonitis after the  operation of
ovariotomy, and who survived several weeks after the inflammation had 
        ABNORMAL CONDITIONS OF  THE PERITONEUM.     463

been subdued, there was found not only traces of lymph on the surface
of the intestines, but a quantity of well-formed pus in the interior of a
cavity formed by adjacent convolutions.  Had life been prolonged, the
pus would have made its way by ulceration into the intestinal tube, and
thus been evacuated.  Rokitansky, in mentioning this occurrence, speaks
of the abscess  sometimes discharging itself through the  abdominal
parietes, or opening  this way as well  as into the  intestine, so  that a
fistulous communication with the bowel is the  result.  Chronic peri-
tonitis of a simple kind is not of common  occurrence; a case is, how-
ever, recorded by Andral,in which serum, turbid with albuminous flocculi,
was  found in the serous cavity after  death,  while  ascitic effusion had
existed for more than the last month  of life, unattended with pain  or
any  evident symptom of inflammatory action.  We think we have seen
a case somewhat similar.  There is, however, another form of what may,
perhaps, be termed chronic  peritonitis, though we doubt very much  its
essential dependence on any inflammatory process.   In this, the serous
surface is invested closely for a greater or less extent by a firm, whitish,
false membrane, which can be pretty easily detached from the subjacent
peritoneum, and appears,  when held up  to  the  light, of much thinner
texture in some spots than in others.   The situation in which  the false
membrane is most completely formed is upon the surface of the liver, to
which it forms sometimes a complete capsule, compressing and atrophy-
ing it, and  giving rise to ascites from interference with the free passage
of the blood through the structure of the  gland.   We incline to the
belief that these exudations, which we have seen on the surface of the
pleura, as well as on that of the peritoneum, are the results of an ab-
normal condition of the fibrinous constituent of the blood, in consequence
of Avhich it is prone to be effused either in  the  substance of tissues, as
in cirrhosis, and puckering of the cardiac valves, &c, or on the surface,
as in the case before us.  One of the best-marked varieties of chronic
peritonitis is that which is often justly called "tubercular," from its being
essentially dependent on the presence  of tubercles in the  peritoneum.
These appear sometimes  as semi-transparent gray granulations, some-
times are more opaque, though  still of miliary  dimensions.   They are
diffused everywhere throughout the subserous tissue, but are said by Dr.
West to be  most numerous on the surface of the diaphragm, or  on the
abdominal walls in the neighborhood of the spleen, while  the parietal
peritoneum  is not  so much  affected  as  other  parts.   The chief
tubercular  deposit is sometimes in  the  omentum,  and may  assume
the  form of crude tubercular masses.   Inflammatory irritation  is pro-
duced by the tubercles acting as foreign bodies; exudation of lymph
takes place, and adhesions  are  formed between  adjacent parts of the
serous surface, which are  often so close and dense that the intestines or
other viscera are torn in making an attempt to separate them from each
other.  We have seen the whole of the serous sac  in  this way entirely
obliterated.   There is usually some serum  in the peritoneal cavity, but
no puriform matter, unless, as occasionally happens, acute inflammation
has supervened upon the chronic, and proved fatal.   The tuberculous
deposit sometimes undergoes softening, as in other situations, and the
extension of this process  may cause perforation  of the walls of the in- 
 464     ABNORMAL CONDITIONS OF THE PERITONEUM.

 testines, and either establish unnatural communications between distant
 parts which have become adherent together, or lead to the effusion of
 the intestinal contents in the serous cavity.  The latter event, however,
 is more likely to be produced by the softening  of tubercle in the sub-
 mucous tissue, which is often present there at the same time  as well as
 in  the mesenteric glands.  There is no relation apparently between the
 amount of deposit  in the peritoneum,  and in these two other localities.
 The lungs and bronchial glands are often  tuberculous when the  perito-
 neum is affected, but often in a much  less degree, and they may some-
 times be exempt altogether.   Rokitansky describes the muscular tunic
 of  the intestines as being still more affected in this disease  than in acute
 peritonitis; it becomes pale, is  easily  lacerated and broken up.   This
 gives a further reason why laceration often occurs on attempting to
 separate the intestines which are matted together.
   The peritoneum  often appears somewhat thickened, of a dull, dense,
 whitish sodden aspect in cases of chronic  ascites.   We have examined
 the membrane  thus altered, but were unable to find any very  marked
 alteration in texture, only that the tissue  seemed more  granular and
 less purely fibrous than natural.   A local change  of somewhat the same
 kind is often seen in the peritoneal covering of the liver and the spleen.
 In  these it forms  dense  whity patches, which  shade off  gradually at
 their margins, and  are for the most part  quite free  from  bands of ad-
 hesion on  the surface.  The change  in the splenic  capsule is often so
 great that it has been termed "cartilaginification."   When  the  exuda-
 tion,  which in  all  these  cases  takes  place into  the subserous  tissue,
 contracts and draws the part together, it  produces "lobulated laminae,
 and projecting  granulations,"  of a firm, dense structure.   Calcareous
 matter is sometimes deposited in these fibrous formations, and gives rise
 to " compact, smooth, or uneven lobulated  plates of varying thickness."
 It appears from Rokitansky's account, that false membranes, the result
 of  inflammation, may be so disposed as  to form serous  cysts, which
 obtain an internal smooth lining, and are either pedunculated or sessile
 on  the peritoneum.
   Cancer  attacks the peritoneum in  some very-  rare cases primarily,
 but most often by an adjoining growth extending to it, " perforating it,
 and penetrating into  its cavity."  The  disease is  sometimes  of  the
 encephaloid variety, but more often of the colloid.  The latter, when
 the process of development is acute,  is  often  spread  over the entire
 serous surface,  in  the form  of small,  miliary  nodules, in some parts
 clustered together.  " Sometimes it occurs as a layer of areolar  cancer-
 ous tissue,  varying  in thickness, or as a circumscribed, round, lobulated
 aggregation.   The  omentum is very commonly  found to shrivel up and
 to degenerate into  a transverse band; or, in the opposite case, with an
 enormous increase of size into areolar cancer."   Cancerous growths not
 uncommonly originate in the post-peritoneal cellular tissue just in front
 of the spine.   In this part they are firmly adherent to the vertebrae;
 are of homogeneous (probably firm scirrhous) texture, and confounded
 with the crura of the diaphragm.   In  its peripheral parts the  growth
has a more loose  and lobulated structure.  Dr. Walshe,  tracing  the
progress of the mass from its point of origin, says, "it spreads upwards, 
           ABNORMAL CONDITIONS OF THE  STOMACH.       465

extends  to  the stomach, presses  under the liver,  penetrates between
the laminae of the transverse mesocolon, twists round the duodenum and
pancreas, and, pushing forward the stomach (with the small curvature
of  which it contracts adhesion), forms a  tumor  in the epigastrium.
Such tumors mould themselves upon  these various parts and organs in
so close a manner, that, after separation, the surface of the mass retains
the impressions of the adjoining viscera."  The course of these growths,
though rapid,  is often for a long period unattended with pain or dis-
turbance of the system.


       V. —ABNORMAL  CONDITIONS OF THE STOMACH.

   In very imperfect monstrosities, especially the acephalous, the stomach
is either wanting, or very  imperfectly developed.  It  is  also  absent
occasionally, according to Rokitansky, in individuals othenvise normally
built, and provided with a well-developed intestinal tube, or it may be
only  indicated by a small saccular  dilatation of the oesophagus.   The
shape of the stomach is sometimes found remarkably altered; its cavity
being partially divided into a cardiac and pyloric portion by an annular
contraction, or even still further subdivided into three or four sacculi,
so as to present some resemblance to the multiple stomachs of ruminants.
These peculiarities of shape may either result from congenital  malform-
ation, or at least, in their  minor degrees, from irregular contractions of
the muscular coat,  or from destruction of substance and  subsequent
cicatrization.   Sometimes  the stomach deviates  from its  usual  shape, in
the Aray of  assuming greater simplicity; it is destitute  of  its cardiac
cul-de-sac, and the  oesophageal opening is quite at its  left extremity.
The stomach is  liable to great variations of size;  these within certain
limits are physiological, and are manifestly contemplated in the peculiar
convoluted  disposition of its mucous lining.   A  healthy stomach, when
empty, naturally contracts upon itself, and this  to such an extent that
its cavity is wellnigh obliterated.   This is  purely the effect of the un-
opposed action of its muscular  coat, and is no evidence of disease in the
viscus.   It  may proceed from  starvation, or from stricture of the  oeso-
phagus.   Contraction of the cavity of the stomach in a less degree may
be  produced by l^pertrophy, and cancerous disease of the coats, or by
the cicatrization of extensive ulcers.   Dilatation of the  stomach, often
to a considerable  extent, is of very common occurrence, and  depends,
partly, on copious secretion of gas from its lining membrane, and partly
on loss of contractile power in  its  muscular fibres.  In its more extreme
degrees, it is generally the result of obstructive  disease at the pyloric
outlet, in consequence  of Avhich the  ingesta  accumulate within the
cavity.   The distension  in  such cases  is sometimes so  enormous  that
the stomach extends over the  entire abdominal cavity.  Rokitansky
says,  "that repeated repletion, in consequence of  a morbid  appetite,"
may become the  cause of as great distension as when  the  pylorus  is
obstructed ; or that this may also " occur as a result of  paralysis from
concussion,  traction,  or  dislocation, produced by large scrotal herniae,
and that it kills slowly with vomiting,  with or without gangrene of the
       30 
466       ABNORMAL CONDITIONS OF THE STOMACH.

mucous membrane, under symptoms of complete paralysis."  The coats
of the stomach may be abnormally thick, either in consequence of can-
cerous disease, or from simple hypertrophy of the muscular layer.  The
pyloric outlet is generally the part Avhere muscular hypertrophy sIioavs
itself, and here it seems to affect more  especially the  layer of annular
fibres.  Atrophy of the coats, speaking generally, is most  commonly
observed in cases attended with much emaciation ; it  occurs  also some-
times in consequence of extreme dilatation of the cavity,  sometimes
spontaneously.   The muscular layer is, in most cases, the one most pal-
pably  affected;  the  mucous  membrane  is, however,  not uncommonly
atrophied also,  as we shall more particularly describe when speaking of
textural changes.  The following list  of abnormal situations, Avhich the
stomach may occupy, is given by Rokitansky:  " It may lie  external to
the abdominal  cavity in eventration, and in umbilical hernia; in  the
left side of the thorax, the diaphragm being Avholly or partially absent
on that side;"  it may lie \rertically, as in the foetal  state ; or Avith the
fundus on the right ride, as in general lateral transposition.   The fore-
going are congenital malpositions ; the  following acquired.   The sto-
mach may protrude externally after extensive Avounds, or make its way
into the thorax, after injuries to, or ruptures of, the diaphragm; it may
be carried doAvn into large hernial sacs, especially umbilical and scrotal;
or be displaced by new growths  or enlargement of adjacent organs;  or
sink lower itself, in consequence of increase in size, as in the case of a
scirrhous  pylorus.
   Acute inflammation of the stomach but rarely, if ever, occurs, except
as the result of  irritants directly applied to it.  The cases  related  by
Andral give  proof, however, of  its existence as an  idiopathic affection,
or as the sequel of rheumatism,  or of epidemic cholera.  We quote  the
account he gives of the morbid  changes.  In Case 1, the stomach was
strongly contracted so as to be nearly the size  of the transverse colon:
" Its inner surface, over nearly its entire extent, was of a brownish red.
This color had its exclusive seat in the mucous membrane,  Avhich had
become in every part very thick, and  was at the same  time very friable.
On  its free  surface there was  discovered a multitude of small red or
blackish points, which seemed to have their principal seat in the villi;
however, beneath these the body of the mucous membrane was red, and,
as it were, penetrated with blood ; in no part could this membrane be de-
tached, it gave way under the forceps, and in several points it resembled
a pulp without any consistence."   Near the pylorus, the mucous mem-
brane resumed its normal consistence, and was of a grayish  color.   In
Case 2, also, the stomach was strongly contracted.   Its mucous mem-
brane was of a dark red color, over the entire surface of the great cul-
de-sac, and over all the posterior surface from  the cardia to the pylorus.
This redness penetrated  the entire substance of the  membrane, which
had lost its consistence in every part where it was red;  in some points
it Avas merely a sort of pulp.  ToAvards the anterior surface the mucous
membrane presented  a slate-colored tint, Avithout its consistence being
much changed;  near  the pylorus some mammillation was observed.
The surface  was covered by a viscid  thready mucus.   In another case,
also idiopathic,  the parietes  of  the stomach were  remarkably softened, 
           ABNORMAL  CONDITIONS OF THE STOMACH.      467

 " over all the left portion of this viscus, its tunics, from the peritoneal
 to the mucous, had no longer any consistence ; they gave way under the
 fingers as a sort of pulp.  Wherever this softening existed, the parietes
 of  the stomach Avere of a dark red color, and as it Avere ecchymosed.
 Near the pylorus the parietes of the stomach resumed their natural con-
 sistence,"  and of a grayish tint.   In persons dying of  gastritis, conse-
 cutive to a malignant cholera, Andral found, at an early period of the
 disease, the mucous membrane red and softened; at a later period it was
 sometimes in the same condition, sometimes brown or slate-colored, and
 its  tissue thickened and indurated.   Judging from our  examinations of
 other inflamed mucous membranes, Ave feel no doubt that the microscope
 would show, in such instances, more or less hyperaemia of  the vessels,
 Avith abundant granular exudation, stained by exuded haematin in the
 substance of the mucous tissue, as well as  loss of its investing epithe-
 lium, and wasting or breaking up of its glandular tubuli.   We feel the
 more  confidence in  Andral's description  above quoted, because he has
 so carefully distinguished inflammatory hyperaemia from mere passive
 or post-mortem congestion,  or  red  staining, and has contended so pru-
 dently against the extravagances  of over-zealous Broussaians.  We have
 recently examined  an excellent  instance of intense hyperaemia of the
 stomach.  The Avhole mucous surface  was of a deep red, almost black;
 the subjacent tissues were  much  less affected.  The cavity was  empty,
 and the organ was  much contracted.   The surface was uncovered  by
 mucus, only  a little alkaline fluid lay in the furrows between the  rugae.
 The capillaries were gorged with blood in every part of the membrane,
 they Avere seen running  parallel to the tubes in their whole length, but
 those which adjoined the free surface (which are ahvays the most con-
 gested), had given way in numerous spots, and saturated the tissue round
 them with  extravasated blood.   The tubes were healthy, and there was
 no  apparent  exudation  among them.  The patient died with cardiac
 hypertrophy and general dropsy.   The liver and spleen  were much con-
 gested, and it is  pretty certain that the hyperaemia of the stomach was
 passive rather than active.
  As Rokitansky observes,  we have rarely, if ever, the  opportunity of
 observing the first stage of acute catarrhal inflammation of the stomach,
 but we may reasonably infer that  it consists, as in  other parts, of a more
 or less considerable  hyperaemia, Avhich relieves itself by £ copious exu-
 dation of mucus upon the surface, instead of a fibrinous exudation in the
 substance of the tissue.  A chronic catarrhal state is by no means un-
 commonly  met with, the anatomical characters  of which Rokitansky
 enumerates " as a dark reddish-broAvn, or slate-gray, or even blackish-
 blue discoloration of the mucous membrane, copious secretion of a stone-
 colored, occasionally glassy pituita, thickening, increased condensation
 and induration, i. e. hypertrophy of the mucous membrane,  Avhich pre-
 sents  itself in various degrees :  (a.) In the loAvest degree, the mucous
membrane  shows simply an increase of thickness  and hardness in its
tissue ;  (p.) In a higher  degree it presents, in addition to its increased
thickness, an uneven, racemose, or Avarty surface, a surface mamellonde;
(y.) In a still more advanced degree, it  forms prolongations in the shape
of permanent firm folds or of polypus.  The submucous cellular tissue, 
468
ABNORMAL CONDITIONS
OF  THE STOMACH.
and the muscular coat, also participate in this hypertrophy in various
degrees—the entire  parietes of the stomach presenting unusual thick-
ness, firmness, and  hardness.   The pyloric portion is the chief seat of
chronic catarrh, and  it is there that hypertrophy of  the mucous and
other membranes is most prominent."   Andral remarks that, in chronic
gastritis, the mucous membrane may  appear after death to be in a per-
fectly natural state, or at  least to have undergone no alteration discerni-
ble by the eye.   The subjacent tissues, and particularly the submucous
areolar tissue, are,  however, in these  cases  more or less  affected.  In
the majority of  instances, however, the color,  the  consistence, and  the
substance of the membrane are variously changed.  A gray slate, broAvn,
and  more or less deep black tint  are often observed, as Avell as some-
times a dull white milky aspect.   In  regard  of consistence, the mucous
membrane may be indurated, or softened ; the latter is more frequent
than the former.   Induration may exist with all the different shades of
color just mentioned.  With respect to its substance the mucous  mem-
brane  may  be thickened or attenuated, or may remain unaltered.   A

                               Fig. 212.
Vertical section of mucous membrane of stomach, the tubes being completely wasted and replaced by fibroid
         tissue,  (a.) Kemaing of mucous membrane, (b ) 1 ibroid tissue,  (c.) Fat-veils.

state of thickening may coexist with induration or with softening; the
former combination is peculiar to chronic  gastritis, and affords a good
example of false hypertrophy.   Induration, like the thickening, may be
partial  or  general.   Attenuation of the  gastric  mucous  membrane is
most often met with towards the great cul-de-sac, in  the same situation
where softening is most frequent.  Andral says : "Sometimes, hoAvever,
I have found the mucous membrane towards the pylorus, so attenuated
that it resembled a sort of  transparent extremely fine web.  On attempt-
ing to raise it,  it was changed into a reddish-white pulp, as happens  in
certain  degrees of softening."  He admits, what we shall  presently
remark, that this attenuation may occur as a pure atrophy totally inde-
pendent of inflammation.
  We have lately examined carefully with the microscope more  than a
hundred stomachs taken indifferently, and have published,  in the Assoc.
Journal for Oct. 7th and Jan.  27th, 1854, the  details of  the following
varieties of change : (1.) One of the commonest, especially in its minor
degrees, consists in the infiltration of a  low fibroid  tissue loaded with 
           ABNORMAL  CONDITIONS  OF  THE STOMACH.        469

nuclei among the tubes, which  themsehres  undergo atrophy, so that at
last the mucous membrane totally loses its  tubular aspect, and becomes
a mere fibroid stratum, more or less densely set with nuclei throughout.
In this state the basement-membrane may still persist, and  the thick-

                                Fig. 213.
 Vertical section of mucous membrane of stomach, showing the lower parts of the tubes, and a nuclear
    mass extending among them upwards,  (a.) Tubes.  (6.) Nuclear mass, (c.) Submucous tissue.

ness of the tissue  be little diminished.   In some instances the nuclei
disappear, and the fibroid  stratum develops fibres more decidedly.   (2.)
There are formed masses of nuclear particles, most often at the bases of

                                Fig. 214.
  Cavity formed in the mucous membrane of stomach, by the disintegration of a nuclear mass. The sur-
rounding tissue is pervaded by nuclear deposit,  (a.) Basement-membrane of surface. (6.) Altered mucous
membrane,  (c.) Submucous tissue.

the tubes  encroaching upon them, often also in the substance of the
mucous membrane, and sometimes  at its  surface: these are sometimes
circumscribed, sometimes  diffused, and then  pass  into the preceding
forms by gradual  shades.    (3.)  The  nuclear deposits sometimes seem
to give rise to cystic cavities, or  these may form  from dilatations of the
tubes, or arise de novo, as  in other situations.   (4.)  The  mammillated
condition appears  to depend on  a process of local atrophy, at least in
most  cases, the tubes being wasted in the track of the  furrows, which 
   470       ABNORMAL CONDITIONS OF THE STOMACH.

   sometimes are so deep as  to fissure the membrane down  to its  corium.
   (5.) A fatty state is very commonly met Avith, and in two  forms, one
   in which the epithelium is bulky and the tissue healthy, or  nearly so;
   the other, where the epithelium is atrophied, in consequence, generally,
   of  pressure by new-formed  fibroid tissue  upon the  tubes.  (6.) The
   tubes  in the pyloric  region are  often found  changed in the following
   manner:  the continuous row of tubes is interrupted, and  there are seen
   at intervals instead groups of convolutions containing a fatty wasted
   epithelium, and not possessing any manifest outlet on  the surface.  We
   think  that inflammation  is  not the most essential  moment in  these
   changes.  The nuclear masses, when not  of large size, may be regarded
   as identical with the naturally existing solitary glands.
     Croupy inflammation resulting in fibrinous exudation,  which  forms a
   false  membrane, sometimes of regular areolar surface, is very rarely
   seen at least in England,  and is said  by Rokitansky to  be a " sequela
   or degeneration of exanthematic processes, as of variola, typhus, pyaemia,
   and particularly puerperal phlebitis.  Sometimes inflammation of a low
   erysipelatous kind attacks  the submucous cellular tissue of the stomach,
   and occasions suppuration.  The pus, after a time, escapes by numerous
   irregular cribriform openings  into the cavity of the viscus.
    We proceed  to notice the effects of caustic fluids, such as the  mineral
   acids, which have  been swalloAved.  The mucus in the mouth and fauces
   is coagulated into flocculent masses, the epithelium is detached here and
   there,  and "converted  into a thick grayish-white, rugose layer," and
   the subjacent mucous membrane is pale.  If the caustic fluid has pene-
   trated more deeply, " the superficial layers of the  mucous membrane of
   the fauces and oesophagus are  found  congested, of a  dirty,  whitish,
   leaden hue, and the capillary network blackened by its carbonized con-
   tents.   The lower strata of the mucous membrane, and the submucous
   cellular tissue,  present serous  infiltration.   In the  follicles  at  the root
   of the tongue,  the  mucous  secretion  is coagulated into dirty white
   masses.  In a still higher  degree of corrosive  action, the  entire  mucous
   membrane is destroyed, and converted into  a  dirty gray mass, which is
   traversed by black vessels; the submucous cellular tissue is infiltrated,
,  and partially ecchymosed; the muscular coat  of the oesophagus itself is
   shrivelled, pale, ashy.   In the highest degree, the  mucous membrane of
   the oesophagus, together with the submucous cellular tissue, is converted
   into a  soft, black mass, which is  distended by a sanguinolent fluid, and
   is easily detached from the muscular coat.  The latter is itself either
   destroyed in the  same manner, or  is  perfectly colorless, friable, and
   presents an ashy, gelatinous  appearance.  The mucous  membrane of
   the stomach," in consequence of being longer  in contact with the corro-
   sive substance,  " almost invariably suffers the changes of the last degree
   but one, though in varying extent and thickness.  It is either affected
   in single  folds, or streaks which  pass from the cardiac  orifice to the
   lesser curvature, and from  the large curvature to the pylorus;  or over
   a large extent; or we find the entire surface converted into a black car-
   bonaceous mass, of several lines in thickness, distended by sanguinolent
   fluid, and  consequently presenting a tumefied appearance."  The muscu-
   lar  coat is affected, and the parietes of the stomach are often perforated. 
          ABNORMAL CONDITIONS OF THE STOMACH.       471

" The acid affects the neighboring organs through the membranes, and
thus either coagulates or tans the contained fluids, fuses the tissues into
a gelatinous mass, or carbonifies  them; the discoloration produced is
ahvays very marked.   In many cases, not only the blood of the neigh-
boring bloodvessels, but also of the larger trunks, and even of the aorta,
is  changed  into pultaceous,  pitchy, greasy, black cylinders.  Beyond
the stomach, and especially in the duodenum, and at the commencement
of the jejunum, the effect of  the lowest degree is exhibited in coagula-
tion of the intestinal mucus, and of the chyle, in  corrugation and opa-
city of the epithelium, in the  tanned  state of the mucous membrane,
and the dark injection of its vessels."  The highest degrees of corrosive
action are rapidly fatal,  " the lowest degrees are followed by exudative
inflammation, the mortified epithelium  sloughs, and being replaced by a
new formation, as  soon as the  reaction has abated, recovery ensues."'
In all  the higher degrees, inflammation, passing into suppuration, pro-
duces the separation of the superficial  mortified layers.   The suppurat-
ing process  may be protracted, or may terminate  early with the forma-
tion of cicatrices.   " According to  the depth to which  the tissues  are
destroyed, the loss of substance is repaired under a formation of struc-
tures that vary in  size and  consistency."  When the mortification is
limited by the submucous cellular tissue the latter becomes condensed,
and "forms, at  some places, projecting ridges, or valvular, and even
annular, duplications tOAvards the oesophagus;"  in  this  way peculiar
membranous strictures are produced.   " If the ,muscular coat itself is
involved, it  is partially or entirely destroyed, and  the walls of the oeso-
phagus are converted into a  fibro-cellular  firm tissue, which contracts,
and thus produces the most  important and most resisting strictures."
Chronic suppuration sometimes occurs  as the result of profound injury,
leading to the formation of abscesses and sinuses  of the muscular coat,
and of the surrounding cellular sheath of  the oesophagus.  These may
produce perforation  of adjoining  passages, the trachea or bronchi, or
may heal, leaving considerable contractions of the  tissues and strictures.
Cicatrices and strictures are formed in the same way, though less fre-
quently, in  the membranes of the stomach.   The morbid changes pro-
duced by arsenic are as folloAvs: "At  one or more points  to which  the
powder happens to attach itself to  a larger amount, the mucous mem-
brane  appears plicated and tumefied, reddened, invested by a detached
epithelium,  and a  tawny exudation; its  tissue is  softened, pultaceous;
and at the  spot where the Avhite  grains of arsenic are attached, it is
converted into a yellowish or greenish-brown slough."  The tissue in-
tervening between these solitary foci is often quite healthy.
   Ulceration of the  coats of the stomach is much less frequent than
that of other portions of the intestinal canal.  It occurs sometimes  as
the result of chronic gastritis, or of  the  corrosive action of  poisons.
These  ulcers require no particular notice;  but there is one particular
kind which is rather peculiar to this organ, and which is of especial in-
terest, from its occurring in tissues which otherwise appear quite healthy,
and from the serious and rapidly fatal  effects to which it too often gives
rise.   Rokitansky terms this  the perforating  gastric ulcer, on account
of its having  a  decidedly marked tendency to perforate the parietes of 
472       ABNORMAL  CONDITIONS OF THE STOMACH.

the stomach.  He describes it as follows:  " In a well-defined case there
is, in the region of the pylorus, a  circular orifice of  from three to  six
lines in diameter, with a sharp peritoneal edge, as  if a  round piece of
the gastric parietes had  been punched out.  When  viewed from within,
the loss of substance on  the internal membranes  of the stomach, and

                               Fig. 215.
        Perforating ulcer of stomach; the mucous membrane ia puckered into folds round it.

especially of the mucous layer, appears  more considerable, so that the
edges of the hole  seem bevelled off  from within outwards."   In some
cases the  margins of the ulcer  are  quite  smooth  and thin, in others
thickened and indurated.   " The pyloric half of the  stomach," Roki-
tansky proceeds, "is the seat of the  ulcer:  it is most frequently found
in the middle zone of this  portion; it is oftener seen  at  the  posterior
than at the  anterior surface, almost always  near to/and frequently at,
the lesser curvature; and it occurs  in extremely rare cases only at  the
fundus."  A similar ulcer may form in the upper oblique portion of the
duodenum, but not, as far  as observation has yet  shown, in  any other
part of the  intestinal canal.  The size of these ulcers, Rokitansky tes-
tifies, may equal that of a cheese-plate;  we have never  seen them  ex-
ceeding that of a half-crown.   Their  form is commonly circular', at least
in the outset, though they often become  elliptical or quite irregular, as
they extend.   Sometimes the ulcer enlarges in its transverse diameters,
so as to obtain  a zonular form.  Sometimes two ulcers coalesce together
more or  less completely.   " In  the  majority of cases there is only a
single ulcer," (there is no mention of more  than  a single one  in three
cases Avhich are recorded consecutively in the Report of the Pathologi-
cal Society  for 1847-48,) "but frequently there are two  or three, occa-
sionally four or five, and these are then  commonly placed above or near
to one another at the posterior surface of the. stomach, or at the lesser
curvature."  When the ulcer is perfectly circular, the narroAving of its
area, as it extends in depth, is very marked, the muscular coat is less
extensively  destroyed than  the  mucous, and the peritoneum again less
extensively  than the muscular;  the perforation, in fact, taking place, as
Rokitansky  describes  it, in  the centre of the included circle.  The
exact nature of the process by which the ulceration commences, is not
at all ascertained, at least, has not yet been the subject of direct obscr- 
          ABNORMAL CONDITIONS OF THE STOMACH.       473

vation.   Rokitansky writes: " It is probable that it commences with an
acute, circumscribed,  red softening (hemorrhagic erosion);  or  with a
circumscribed sloughing of the mucous membrane; it is still more pro-
bable that the ulcer increases in this manner, the  tissues at the  base of
the ulcer  sloughing and  exfoliating, layer by layer."   He thinks that
" the process offers a  A'aluable analogy to sloughing of the lungs."   We
think the gastric  ulcer may be very properly compared to the simple
ulceration of the cornea, which it resembles closely in several respects.
Both, when the system has made no reparative effort, may have  smooth
level margins.   Both may heal by the deposition of fibrin at their base
and around their margins.   Both show, when they advance unchecked,
a decided tendency to perforate the tissue in which they exist.  In both
the ulceration is evidently not the result of violent inflammation, but of
a local loss of substance or  disintegration.  It seems as if the tissue
sloAvly liquefied, molecule by molecule, in a ghren part, in consequence
of defect  of assimilative power.   The process in the case of  the cornea
is evidently not  identical with  sloughing, such as occurs in purulent
ophthalmia, and there is reason to believe  that the same is  true also of
the analogous change in the gastric parietes.   Rokitansky states that
the ulceration " is invariably accompanied by chronic catarrh and blen-
norrhcea of the gastric mucous membrane."  This we  much doubt, for,
though pain and various dyspeptic symptoms are complained of in most
cases where ulcers of this kind are found, yet this is not constant, and
certainly  the amount  of the dyspepsia is no indication whatever of  the
existence of ulceration.  The point we wish especially to notice  is, that
the ulcerative action  is not in any way dependent  on irritation or in-
flammation, but on a loss of vital  assimilative poAver in the part affected.
The bearing of this part upon  the treatment is  most important.   Dr.
Copland  states, and  some of our own  observations are confirmatory,
" that this affection  is most frequent in needleAvomen,  or  female  ser-
vants.  The patients, in most instances, have been anaemic,  or suffering
from disordered menstruation, as well as  from pains in the stomach,  but
" have generally been able to pursue their avocations, and to take their
food, up even to the period of the fatal seizure."   The ulcer, especially
when seated near the smaller curvature,  is apt to involve some arterial
branch, from which blood is poured out in abundance.  The hemorrhage
may be so copious as to destroy life at once, but more frequently death
does not occur till  after repeated  attacks.   The  deeper the ulcer  has
extended, the larger in general  are the vessels it meets with, and  the
more serious,  in consequence, the loss of blood.   It has  happened, that
an  ulcer,  after perforating the coats of  the stomach, has lighted upon
the  pancreatic duct, and  produced a fistulous opening into it.   The
most dangerous situation for an ulcer to occupy is  the lower half or two-
thirds of  the anterior surface of  the stomach, as, in case of perforation,
there is no organ to Avhich it can easily become adherent.   On the  pos-
terior surface, adhesions form between the stomach and pancreas, or the
adjoining lymphatic glands, and  on  the  upper and  pyloric part of  the
anterior surface the escape of the  gastric contents  into the peritoneal
cavity is sometimes prevented  by the left lobe of the liver.  In a re-
markable case, recorded in  the Report of the Pathological  Society, 
474       ABNORMAL CONDITIONS  OF THE  STOMACH.

1847-48, p. 252, the barrier opposed to the extension of an  ulcer by
the left lobe of the liver proved insufficient,  as  the  destructive process
continued until it perforated the diaphragm,  and gave rise to hepatiza-
tion and a gangrenous cavity in the lower lobe of the left lung.   These
ulcers may heal at any period of their course;  it is not uncommon to
find the cicatrices, which are their  results, on the inner surface of the
stomach.  There can be no doubt that an effusion of plasma undergoing
development into fibroid tissue, is the means whereby the separation is
effected.  This takes place both in  the margins of the ulcer, producing
thickening and subsequent contraction, and  also at  the base, which it
lines with a thin smooth layer.   Cicatrices of  this kind present a de-
pression of the size of the ulcer, surrounded by thickened and elevated
margins, others, where more contraction has taken place, are of a linear
or corded shape.
  Hemorrhagic erosion of the gastric mucous  membrane is thus described
by Rokitansky: "There are round or roundish spots of the size of a
pin's  head or pea, or narrow elongated streaks, at  Avhich the  mucous
membrane appears dark  red, lax, soft, bleeding, and  presenting a de-
pression in consequence of loss of substance or slight erosion.  Sometimes
this loss of substance involves the entire thickness of the mucous mem-
brane and the submucous cellular tissue, and  produces an appearance of
small round, or striated ulcers.   This process is invariably accompanied
by hemorrhage," the effused blood being mixed in a more or less altered
state with gastric mucus, which is poured out by the membrane affected
with recent or inveterate catarrhal inflammation.  The erosions are often
very numerous, studding, perhaps, every part of the stomach, with the
exception of the fundus ; their chief seat is at the pyloric portion.  They
are not peculiar to  any form of disease.  Microscopic examination of
one of these ulcers showed the surface sunk in, the basement-membrane
gone, and the tubes quite atrophied and replaced by low fibroid substance,
infiltrated with diffused yelloAv pigment.
  Softening of the stomach requires  an especial notice, as an affection
of great importance, though as yet very imperfectly understood.  One
form of it, called by Cruveilhier gelatiniform softening, occurs, especially
in infants, between the age of four  and eighteen months.   The  process
commences Avith the mucous membrane of the fundus, and " extends to
the muscular coat and  the peritoneum, converting them and the inter-
vening cellular tissue into a  grayish  or grayish-red, transparent jelly,
with a yelloAvish  tinge, through which single  dark-brown streaks, the
broken-down bloodvessels, are obsenred to pass.   The softened portion
of the stomach tears at the slightest touch,''  and rents in it take place,
sometimes perhaps during life, but more frequently  after death.  The
softening process  sometimes extends to  the diaphragm, causing perfora-
tion of it, and effusion of the gastric contents Into the left pleura.^  Dr.
Copland expresses  his  opinion, that  "the softening often  exists to  a
considerable degree previously to  death;  but the  advanced stage of
disorganization, and more especially  erosion and perforation  are early
consequences of dissolution, which  the fluid  of the  stomach may have
been, more or less, concerned in producing."  The same authority states
that the disease  is almost endemic in  certain  places, and epidemic in 
          ABNORMAL CONDITIONS OF THE STOMACH.      475
          *
some  seasons.  " It may appear  in  the  course  of infantile remittent
fevers, of hydrocephalus, or of chronic bronchitis; or it may folloAv the
Gholera infantum, or scarlet fever, or diarrhoea, especially after weaning,
or when the infant ha3 not enjoyed the advantage of a healthy nurse, or
is brought up by hand."   " General anaemia," as Rokitansky testifies,
" which is particularly apparent throughout the intestinal canal, and
general collapse and wasting, Avhich are chiefly evident in the muscular
tissue, are constant accompaniments of this disease."   It has been much
debated whether the affection should be regarded as of an inflammatory
nature; but the entire absence of hyperaemia, or of the products of in-
flammation in the softened tissue, must be considered as almost decisive
of the question.   Rokitansky  observing  its frequent  supervention on
hydrocephalus, or some cerebral affection, suggests that " the proximate
cause may be looked for in diseased innervation of the  stomach, owing
to a morbid condition of the vagus, and to extreme acidification of the
gastric juice."   The gastric mucous membrane is not unfrequently found
softened in adults who have died from various diseases.   Andral notices
its occurrence in many chronic diseases, especially pulmonary; and also
as the first sign of failing power in old persons, Avhose health has been
generally good.   The morbid change betrays itself by anorexia, uneasi-
ness and weight at the epigastrium; emaciation and rapid loss of strength.
Death takes place in the way of asthenia,  without prominent affection of
any organ, and the autopsy only reveals gastric softening, with or Avithout
hyperaemic injection.  The color  of  the  softened tissue, according to
Andral (and we are quite disposed  to agree with him), is by no means
uniform ; it may be normal or paler than natural, or of a dead white, or
red or brown.  Rokitansky, on the other  hand, says " the parietes of
the stomach are converted into a more or less  saturated dark brown or
reddish pulp."   In our examinations, we  have very commonly, indeed,
found  the splenic region of the stomach  more or less  softened.  The
mucous membrane appears  thinned, more  translucent  than usual, and
dark stained; under the microscope, its tubes appear in various degrees
of disintegration.  The change is, we think, partly post mortem, partly
owing to failing nutrition ; its constant seat in the splenic region seems
to be  connected with  the  greater thinness of the walls, especially the
muscular, in that part, in consequence of which it is very often abnormally
distended.  In some  cases  the other coats are involved, as well as the
mucous membrane, and even the diaphragm may be thus  perforated.
" The  stomach is found to contain large quantities of a fluid resembling
coffee-grounds  or  ink, which is often  vomited during life."   The oeso-
phagus, as we have before mentioned, is sometimes contemporaneously
affected in its  lower  third, in  consequence of  which, perforations and
effusion into the left side of the thorax may result.   " The fundus is the
seat of all the  softening processes  of the  stomach," from whence they
extend to the larger curvature.  This applies not only to the softenings
which commence during life, but, at  least in the majority of cases, to that
which  occurs only after death.   It  is often  difficult,  as Rokitansky
alloAvs,  to distinguish  certainly between the mere  cadaveric  chemical
changes, and those which  take  place from  alterations in the vital nutri-
tive processes.   The  distinction, however,  may generally be made by 
476       ABNORMAL CONDITIONS OF THE STOMACH.
                                                         »
attending to the following circumstances, which he enumerates : (a) " the
absence of  all symptoms during life  which indicated softening, or the
morbid processes that give  rise to it;  (b) sudden death,  from natural or
other causes, during the digestiA'e act, while the stomach is filled with
chyme, without previous illness;  (c) limitation of the  softening to the
mucous membranes, and especially to the  projecting folds, so as to form
streaks;  (d) and at the  same  time, its extension  beyond the  ordinary
boundaries of morbid softening—its development being most remarkable
at those points at which there is a stagnation of  the greatest quantity
of the gastric contents;" this latter circumstance  determines the seat of
post-mortem softening to be  the part Avhich is most depending.   An
experiment performed by M. Cameron, illustrates  very well the influence
of impaired  vitality in promoting the softening of the gastric tissues.
A fluid obtained from  the stomachs of  two children,  who died from
gelatiniform softening, Avas introduced into the stomach of a living rabbit,
and  produced no injurious  effect; the viscus being found quite healthy
when the animal was killed.   Another rabbit was treated in  the same
way, having previously had its pneumogastric nerves divided, the mucous
membrane  of the  stomach was found in a state of softening.  If the
nerves only were  divided, no softening took place.  This  experiment
seems confirmative  of the opinion of Dr. Copland, noticed above.
   Fatty tumors, originating in the submucous tissue, and increasing in
size, may either press inwards towards the cavity of the stomach, or
outwards, toAvards the peritoneal sac.  In either  situation they may be
sessile or pedunculated.  Fibroid nodules  sometimes form in the areolar
submucous tissue,  " chiefly in the vicinity of the cardiac orifice, and the
lesser curvature."   Erectile tissue may be developed  at the free ex-
tremity of polypoid growths,  or may occupy a larger surface of a sessile
tumor.   Tubercle is very rarely seen in  the stomach, and  only occurs
in cases " where intestinal tuberculosis  has advanced to an extreme
degree."   Cancerous disease of  the  stomach is  frequently met  with;
this  organ ranks next to the uterus in  the list of mortality from this
cause.  Primary cancer exists in the majority of cases.  Dr. Walshe
speaks of secondary " as almost unknoAvn," except where it invades the
organ from  extension of adjacent growths.  It  is  not uncommon to find
a solitary growth in the stomach, no other part being implicated, as in
a case we have recently examined.  "The pylorus," says Rokitansky,
" indifferently at all parts of its circumference,  is  knoAvn to be the chief
seat of primary fibrous and areolar cancer of the stomach.  From  this
point the degeneration  extends chiefly along the lesser curvature over
the pyloric  half of the stomach; in many, though severe cases, it affects
the entire stomach, attacking the fundus last, which, however, generally
remains partially free.  The  parietes of the stomach may attain an inch
in thickness, being rigid and generally tuberculated on  their inner sur-
face ; the cavity of the stomach will at the same time be diminished in
size."  Dr. Walshe states  that cancer of  the orifices may extend to the
duodenum or the oesophagus.   Rokitansky affirms " that cancer of the
pylorus is  accurately bounded by the pyloric ring, and never extends
to the duodenum," whereas, cancer at the cardia invariably involves a
portion of the oesophagus.  We certainly think that scirrhous disease 
ABNORMAL CONDITIONS  OF THE  STOMACH.       477
of the pylorus does not extend much beyond its original  site, at least
along the intestine, although it may propagate itself to the head of the
pancreas, or the adjacent lymphatic glands.   Commonly, as Rokitansky
describes it, the  scirrhous pylorus is bound doAvn by the degeneration
of the tissues lying behind it; but, in other cases, it remains movable,
and may, be felt as a distinct tumor having descended more or less over
to the lower part of the abdomen.  The pylorus, the cardiac orifice, the
greater,  and,  lastly,  the  lesser curvature are liable, according to the
order in  which we have placed them, to be the seat of cancer.  Fibrous
cancer undoubtedly is  the most common, i.  e. scirrhus, or, as  Ave are
inclined  to think,  a  combination of scirrhus Avith colloid.   Medullary
cancer ranks next, according to Rokitansky,  and areolar or colloid last.

                               Fie. 216.
Scirrhus Pylori. At the diseased part, the walls of the stomach are extremely thickened, and of a whity color.

He notices the frequent primary combination, and the yet more frequent
secondary, of scirrhus with encephaloid, or of both with colloid.  The
following description was taken from an exceedingly well-marked speci-
men of scirrhus pylori, in Avhich the walls  of the passage were so thick-
ened as to be nearly an inch in  diameter.   The cut surface presented a
Avhity grayish  tissue, contrasting well with the  injected mucous mem-
brane, and exhibiting a  distinct  striation vertical to the axis of the
canal.   A section under  the microscope  showed grayish-white bands,
separated here and there by transparent gelatinous  matter.  The bands
consisted of  homogeneous, faintly-mottled substance,  occasionally divi-
sible into  fibres closely resembling those  of organic  muscle, and, like
them, exhibiting elongated nuclei when treated with acetic acid.  Towards
the mucous membrane this close stroma was replaced  by a loose fibroid
tissue, forming circular  loculi of various  sizes,  which were filled Avith
very various  forms  of cell-groAVth.   Among  them granule-cells  Avere
often apparent, but  the main mass consisted of nuclei and  low develop-
ments  of  them.  Some large mother-cells  Avere seen, containing several
Avell-formed nuclei and granulous  matter: in the  interspaces  between
the fibrous bands  these mother-cells had attained a gigantic size, and
appeared to constitute the loculi; one of them Avas  distinctly bifurcated
at its narroAV end, and the branches  were of some length.  Dr. Bennett,
v. p. 43  of his Avork, doubts  the cell character  of these  conglomerate 
473       ABNORMAL  CONDITIONS OF  THE STOMACH.

masses, chiefly from the  absence of a  cell-wall.  We  are, lioAveA'er,
inclined still to believe that the loculi, in  this instance, and in colloid
generally, resulted  from the development of an endogenous  growth
within parent cells.   In this case, Ave consider that there Avas a combi-
nation of colloid  Avith scirrhus, the former being constituted by  the cel-
loid  substance.   In Dr.  Bennett's  xxi.  Observation,  the  alteration
Avhich had taken place in " the Avails of the  stomach was wholly of a
fibrous character."   No cancer-cells Avere detected, only elongated and
fusiform nuclei;  but they Avere  numerous  in  the enlarged mesenteric
and lumbar  glands.  This latter circumstance is, we think, decisive of
the truly cancerous nature of the morbid change in the stomach.  Such
a case may  then  be  regarded as one of pure scirrhus,  upon which ence-
phaloid growths  are sometimes  secondarily  developed, appearing as
fungus  or cock's-comb-like bleeding excrescences.  Encephaloid, Iioav-
ever,  either in the form of knotted tumors, or degeneration of the sub-
mucous tissue, or infiltration of new-formed  erectile  tissue, sometimes
occurs primarily.
   Colloid cancer, affecting  the  stomach, behaves much as  it does else-
where ; it originates, as the other species generally do, in the submu-
cous tissue,  and,  as in  a  case excellently described by  Dr. Walshe, may
cause atrophy and destruction of the mucous membrane, over a more or
less considerable  space.   We agree with this observer, that colloid may
also be developed in the mucous  membrane itself; for we have seen, in
examining the mid-region of the stomach affected with scirrhus  pylori,
two large oval cysts, or cells, lined by a vesicular epithelium, and full of
a clear fluid in the substance of the mucous  tissue.  It  seems not impro-
bable that these would have developed into a colloid growth, especially
as the scirrhous  formation contained loculi, somewhat similar to those
described in the former observation.   The  mucous membrane, covering
the cancerous  growth, may undergo various changes.   " It sometimes
degenerates into an areolar cancerous  tissue, Avhich  discharges  large
quantities of  gelatinous mucous fluid; or it is converted into  erectile
tissue as a fungoid growth, which becomes the  seat of  encephaloid infil-
tration, suppurates,  and  partially exposes  the  submucous scirrhous cel-
lular  tissue; or,  lastly, it most frequently becomes the  seat of  a sloe-
black softening, with hemorrhage,"  -or  it  is  quite  destroyed, and the
sloughing process attacks even the denuded scirrhus itself.   In a speci-
men we recently examined of scirrhus pylori,  where the mass, limited
to the  pyloric region, was exposed  on its inner  surface, forming a
sloughy ulceration with  elevated, thickened margins, a fatty transfor-
mation had  very evidently commenced.   It was most apparent  in the
contents of the loculi, Avhich, in  some parts,  consisted  of well-formed
nuclei  and granulous matter, but, in many others, only of an amorpho-
granulous substance, imbedding ,much oily matter.   It  is conceivable
that the further progress of this change might  have effected a cure.  In
this case it Avas very  distinct; and it is worthy of remark, that, while the
muscular  coat had undergone very considerable hypertrophy, it Avas in
no degree affected by  the cancerous disease.   This, though encircling
the pyloric outlet, had not caused any actual obstruction to the passage,
nor was the stomach distended in any very considerable  degree.  The 
          ABNORMAL CONDITIONS OF THE STOMACH.       479

cause, therefore, of the hypertrophy of the muscular coat does not seem
sufficiently explained.
  A case is  recorded by Andral, in which  enormous  dilatation  of the
stomach had taken place, although the pyloric orifice was free, and even
larger than natural.  He accounts for this by the non-existence of mus-
cular fibres in this instance in  the  vicinity of the pylorus.   Admitting
this explanation, Ave  are inclined to think that the very alteration of the
natural condition of the outlet, its  being reduced to a passive and rigid
orifice, may necessitate a greater exertion of the muscular fibres,  which,
if it fails to take place, and thus induces a consenrative hypertrophy,
dilatation must  result.  Dr. Walshe, after  mentioning the more usual
occurrence of dilatation ensuing Avhen the pyloric opening is obstructed,
and contraction  Avhen the  cardiac is, the  size remaining unchanged when
the body of the  organ  alone is  affected, notices as "less intelligible" the
fact  to which we have just  referred.  He also remarks that, "as a gene-
ral truth, the mucous membrane exhibits a  notable power of resistance
to the  encroachment of the disease."  This, Ave think, is  true, at least
as far as naked-eye  investigation can ascertain; but in one case, where
the mucous membrane appeared tolerably healthy, we  found the tubular
secreting structure in process of disorganization, not, however, from the
extension of the cancerous disease.
   It is necessary to be on one's guard   against confounding scirrhous
cancer with simple induration  and  hypertrophy of  the coats of the sto-
mach.  Rokitansky enumerates  as distinguishing signs the preponderating
increase of  substance in the submucous cellular tissue, and its Avant  of
uniformity, the  accompanying cartilaginous hardness and closeness  of
texture, the fusion Avith the mucous and muscular coats, and particularly
the alteration in the muscular tissue itself.  We think the microscope, in
practised hands, would generally clear  up  all  doubt.   When loculi  of
cell-substance are mingled with  the fibrous tissue, there  can be little
hesitation in  regarding the  growth as  cancerous.   If the structure is
purely fibrous, attention must  be  directed to the limitation of the dis-
ease, and to  the existence of the infiltrating,  softening, and contami-
nating properties of cancer.  Ulceration, usually the result of secondary
gastric cancer,  may cause perforation of the stomach and fatal  perito-
nitis ;  it  more  frequently happens, hoAvever, that effusion  is  prevented
by the  formation of adhesions betAveen the  threatened part and  con-
tiguous viscera.  The liver and pancreas may thus become the  seat  of
further cancerous invasion and destruction, or the ulcer may eat  its way
into the  transverse colon, and thus cause an unnatural communication
between its cavity and that of the stomach.  A dark fluid, resembling
coffee-grounds,  is often found  in the cancerous  stomach after death,  as
Avell as  vomited during life.  In  one case, where we examined it, Ave
found it to consist of very numerous blood-globules, together with black
granules and grains (probably altered haematin), and a very large quan-
tity  of amorphous, with some oily matter.  It is to be remembered that
vomited matter  of this kind is not peculiar  to cancerous disease; the
same may be brought  up  Avhen there is simple exhalation of blood from
the  mucous  membrane, common ulceration, or follicular ulceration, or 
480   ABNORMAL  CONDITIONS  OF THE  INTESTINAL  CANAL.

even  softening.   The  only circumstances necessary for  its production
are hemorrhage and the acid secretion of the stomach.
  Besides blood, there may be several other  matters abnormally present
in the stomach.  Unhealthy mucus in large quantities, purulent and
other exudations, bile, biliary calculi, fecal matter, and lumbrici, are
more or less often met with.  Foreign bodies, of the most various kinds,
are also to be included in the list, as the sealing-wax, brick-dust, cinders,
&c. swallowed by hysterical females, or those who are subjects of the
morbid state termed pica, or  by actual lunatics.   A remarkable case of
this kind has been recorded by Mr. Pollock, in the Report of the Patho-
logical Society for 1851-52,  in Avhich  the stomach Avas  distended by a
large mass of  hair and string, while another occupied the lower portion
of the duodenum and commencement of the jejunum.
VI.—ABNORMAL  CONDITIONS  OF THE  INTESTINAL  CANAL.

   The intestine is not unfrequently defective in some part of its course ;
this most commonly is the case near its loAver  termination, and inArolves
an imperforate condition of  the anus (atresia ani).   Sometimes the in-
testine  is only unusually short and of uniform  caliber, or consists of
several  detached coecal  portions, or it  may  terminate at the umbilicus,
or in  a cloaca common  to it and  the  genitourinary organs.   Andral
refers to a case in which there Avas only a single straight canal, extend-
ing from the termination of the oesophagus to the commencement of the
rectum, to  another in Avhich  the duodenum was double, a third in which
there  were two colons, to a fourth  in which the  appendix vermiformis
was unusually large, and  at the same  time double.  All  these, except
the first, are instances  of  excessive development, though Rokitansky
refuses  to regard them as such, and considers them as " arrests of for-
mation."   Among  these, he especially includes the diverticula, which
are not  very unfrequent, and which deserve  a particular description.
Andral  compares them to the fingers of a  glove, and states that they
form coecal  appendages, one or  more  in  number, which  are  given off
from the intestine at various points, and  communicate  with its cavity.
They are most frequent at from 18  to 21 inches from the termination of
the ilium, according to Rokitansky, but have been seen in the jejunum,
the duodenum, and even in the rectum.  Their  length is various; some-
times  only a few lines, sometimes  several inches;  their cavity may bo
equal, greater or less than that of the intestine with which they commu-
nicate.   It is most usual to find  but one, but as many as six have been
met with, originating from the same portion of intestine at a  little dis-
tance  from each other.  In structure, they are  sometimes identical with
the intestine; sometimes their several coats appear to be hypertrophied;
sometimes, on the contrary,  more or less  imperfectly formed.   Meckel
has founded on this difference a distinction of these diverticula into true
and false.   The false might  be regarded as produced by a mere hernia
of the mucous membrane, such as occurs in  the bladder.  True diverti-
cula, Meckel considers to be formed by the non-closure of the vitelline
duct at the usual spot, so that a portion of the canal, of varying lengths, 
    ABNORMAL CONDITIONS OF THE  INTESTINAL  CANAL.   481

remains open  after  the  intestine is fully developed.   Rokitansky does
not quite assent to this view, but still believes that "it evidently has its
origin in the development of the intestine in the umbilical vesicle."  We
are inclined to join with Andral in doubting the correctness of Meckel's
theory.  It is not by any means  shown  that the  multiple diverticula
occasionally found are produced by a hernial protrusion of the mucous
membrane.   The  distal extremity of these  offsets is generally  free,
sometimes adherent  to the parietes of the abdomen, or to the mesentery,
or to a loop of intestine.   Occasionally, it is open;  Meckel met with an
instance in which a diverticulum terminated at the umbilicus, leaving an
orifice by which a probe could be introduced  into  the intestine.   The
omphalo-mesenteric  vessels  were persistent  also, accompanying the
diverticulum ; so  that in  this case, at any rate, Meckel's  view would
appear justified.   A case is recorded by Dr. Lionel  Beale, in the Report
of the Pathological Society for 1851-52, in which fatal peritonitis en-
sued from softening  and perforation of the lower part of a diverticulum,
which Avas twice as broad there as  in the upper part adjoining the intes-
tine.   It is  very conceivable  that these offsets, like  the appendix vermi-
formis, may become sources of danger by offering a favorable situation
for the lodgement of cherry-stones, or other indigestible matters.  Roki-
tansky gives the following description of the characters of "false diver-
ticula," which he regards as mere herniae  of the  mucous  membrane,
"resulting  from  the  separation of the  fibres of the muscular coat."
They consist solely of mucous membrane and  peritoneum.  They occur
at any part of the small and large intestines.   " They are found in con-
siderable numbers.   They occur from the  size  of a  pea to that of a
walnut, in the shape of round baggy pouches of the mucous membrane.
They form, more  especially in the colon, nipple-shaped appendages,
Avhich occasionally are grouped together in bunches; when occurring in
the small intestine,  they are commonly developed on  its  concave  side,
and are therefore  placed  between  the layers of the peritoneum; when
in the colon, the  feces are retained by  them, and dry up into stony
concretions."  Uniform dilatation of the intestine may take place either
from inaction of the muscular  coat, or from distension from accumula-
tion of its  contents  above a stricture.   Disease of  the nervous centres,
inflammation of the serous investments, or simple atony of its contractile
fibres, may be the  cause of paralytic inaction and consequent distension.
When  a stricture exists,  enormous dilatation  sometimes takes place.
Andral relates a case in which the large intestine was so distended that
it resembled that of a horse, and concealed almost  all the viscera.   In
such cases, the muscular  coat may be in full  and  painful activity, not
ceasing its  action, although unable to overcome the obstruction, but
reversing it so as to produce fecal vomiting.
   Contraction of  the intestine may occur either throughout a consider-
able extent, or  in a very small one.  The first is not a condition of
disease, though it has been mistaken  for such, and  results merely from
the canal at  that part being empty for some time; so that  the natural
contracting  efforts of the circular fibres are  unopposed, and the sides of
the tube are brought together.  We have seen  the descending colon in
this way so  shrunk as to  be  scarcely larger than the  little finger.  Of
       31 
482   ABNORMAL CONDITIONS OF THE INTESTINAL CANAL.

course this condition is most likely to occur in the part of the intestine
below a stricture.   The second kind of contraction of the  intestine is
almost always morbid, and may result either from external pressure, as
from a strangulating band, or compressing tumor, or from disease of the
tissue  in the  part affected.   The cicatrix of a simple or tuberculous
ulcer, which had  assumed an  annular  form, or a cancerous growth of
like shape, has, in  most instances, been the cause of stricture originating
in the  intestine itself.
   Changes in the position of the  intestine leading to morbid  effects,
require some particular notice.  The most common of these constitute
the several varieties of  hernia.  As these are fully described in all
surgical works, it  does  not seem necessary to  make  mention of them
here;  and we shall, therefore, confine  our attention, following Roki-
tansky, to  the morbid  changes of position which befall  the  intestine
within the abdominal cavity.  A portion of intestine may be twisted
upon its own axis, so as to obstruct the canal by the approximation and
contact of the walls.   This seems to have been  observed  only in the
ascending colon.   The  mesentery may be twisted  upon itself, forming
a kind of  cone, with more or less of the intestine attached  to its base,
which  becomes  strangulated by being  twisted  round the  mesentery.
" One  portion of  the  intestine, either  single or double—a coil—may
afford the axis round which another portion with its mesentery is thrown,
so as to be throughout in contact with the circumference of the axis,
and thus  to compress  it  like a ferule.   A  coil of small  intestine, the
sigmoid flexure, or the  ccecum, may form  the axis."   Abnormal length
of the mesentery  probably predisposes to these affections.   More fre-

                               Fig. 217.
 Strangulation of intestine by a portion of it slipping through an opening in the mesentery or omentum.

quent than the foregoing, are the instances in which a portion of intes-
tine, generally  the  small, becomes  strangulated  by consequence  of
having got into one of the following situations: (1) into the  fissure of
Winslow; (2) into an opening in  the mesentery; (3) into an opening
in the omentum;  (4)  into  spaces  included  by  corded bands  of  false
membrane, and various parts of the abdominal viscera; (5) into similar
spaces formed by  a long vermiform process, or intestinal diverticulum. 
    ABNORMAL  CONDITIONS  OF THE  INTESTINAL  CANAL.  483

The colon  and the  rectum have  been known  to  be compressed and
obstructed by a mass of loaded small intestine lying upon them; and
Andral refers to a curious case in Avhich the transverse colon, in a child
of six  months old, was compressed between the duodenum and the ver-
tebral  column.  These  varieties of incarceration occur at  every period
of life;  they are  more  common, Rokitansky avers, in the female sex
than in the male, because the sexual organs of the former not only offer
an additional point of attachment  for constricting bands, but  may also
themselves give  rise to constricting  growths.   The consequences of
strangulation taking  place in any of the  above ways are  distension of
the intestine above the compressed part, peritonitis and ileus: the incar-
cerated portion in the cases Avhere there is much pressure on the mesen-
teric A'essels, is peculiarly liable to congestion and gangrene.   Andral
well remarks that the mere existence of the bands of adhesion, forming
the orifices above described, by no means necessarily involves a strangu-
lation  of the intestine;  this, however, in such cases, may come on very
rapidly when the included portion of intestine becomes  distended from
any cause.   In  some cases symptoms are observed for several months
or years, indicating that some  impediment to  the free  passage of the
intestinal contents exists.   Dr. Peacock has  related, in the Report of
the Pathological  Society for 1848-49, two cases of so-called  mesocolic
hernia; the  small  intestines being contained in a  sac, formed by the
layers of the  mesocolon.   In  the  first  of these  cases, there was  no
strangulation, though the  ileum passed  out  of the  sac  over "a thin
crescentic edge;" in the second, the ileum was strangulated at the part
where it escaped.
   Invagination of the intestine implies the inA'ersion of a portion, and
its intrusion into another, an  upper portion  being generally intruded
into a lower, and the conArerse rarely occurring.   The following account
we abbreviate from the very full details given by Rokitansky.   Invagi-
nations not uncommonly form, during the last moments of life, especially
in  diseases which  give rise to irregular and disturbed innervation.
Thus,  they are often met with in the dead bodies of children  who have
died from hydrocephalus.  They are characterized by the absence of all
appearances  of reactions, such as we shall presently mention, and by the
parts  being  easily restored  to  their proper  situation.  Several often
occur in  the same case.   When they occur during  life as a primary
affection, or consecutive  only  to  diarrhoea,  they  speedily  bring  the
patient into a condition  of extreme danger.  Every  intussusception
must present at least three layers, as will be  readily comprehended on
vieAving  the  accompanying diagram : the outer, called tbe  sheath, is
formed by a portion of  intestine in  its natural  position ;  the middle is
formed by the portion of intestine immediately above, which is  averted;
so that its mucous  surface looks  outward, and is  in contact with the
mucous surface of the  sheath; the  inner is the portion of  intestine
next above, with  its serous surface opposed to that of the middle layer,
which  is simply intruded into the canal beyond it.  Five layers  will
exist if another portion  of intestine be forced down, and inverted into
the  original  intussusception,  which  then becomes  a  sheath  to  it.
"Between the middle and inner layers there  is a portion of  mesentery 
484
ABNORMAL CONDITIONS  OF THE  INTESTINAL CANAL.
Fig. 218.
  Diagram of intussusception.
fa) The sheath.
{b) The receding or inverted tube,
i c) The entering tube.
corresponding in size to that of the intestine displaced, and folded up so
as to represent a cone,  the apex of which lies at the free termination of
                       the volvulus, with its base in the sheath, and at
                       the entrance to the invagination.   This portion
                       of  mesentery is always in  a  state of tension,
                       which chiefly affects the part belonging to the
                       inverted  tube,  and has a  singular influence
                       upon the form of the volvulus.   It is the cause
                       of  the following circumstances:  Firstly,  that
                       the volvulus (the middle and inner layers)  does
                       not lie parallel to its sheath, but always offers a
                       greater curvature than the latter; the inverted
                       tube (the middle layer) being compressed in its
                        concavity into tense transverse folds.  Secondly,
                        that the orifice of the volvulus  does not lie in
                        the axis  or in the centre  of  the sheath, but
                        external  to it;  and that, following the traction
                        exerted upon  it by the mesenteric fold  that
                        belongs to the inverted intestine, it  is directed
                        towards the mesenteric wall of the sheath;  that
                       it is not circular, but represents a fissure.  Intus-
susceptions occur with  equal frequency in the colon, and small intestine;
but several cases occurring in  the former are remarkable on  account of
the  magnitude they attain.    In these, the  sheath contained a  very
long portion of the colon  and ileum; both may be inverted two or three
times, and the intussuscepted part advances to the vicinity of the anus."
Contraction of one part and distension of another, are probably the con-
ditions which give rise to invagination;  the  upper contracted portion,
whose muscular coat is for some distance upwards in a state  of activity,
being propelled onward into  the  dilated  part below.   Disordered  and
irregular innervation is  probably the  remote cause, in  this as well as
in the case  of intussusceptions taking place during the agony.  Increase
of the invagination always takes  place by more and more of the intes-
tine becoming  inverted, so that the upper border of  the middle layer is
continually shifted loAver  doAvn.   The consequence of invagination  is, as
may be expected, peritonitis and  its results.   Inflammatory congestion
is set up, not at first, in consequence of  annular constriction of the vol-
vulus, but from compression of the vessels; especially the A'eins of the
portion of  mesentery which is  dragged down by the advancing and in-
verted  layers.   This obstruction to the circulation,  Rokitansky  says,
gives  rise  to  violent inflammation with  " plastic effusion on the  con-
tiguous  serous surfaces of  the entering and receding (inverted)  tube,
and upon the mucous membrane of the latter.   The inverted portion is
invariably the one that suffers most;"  "and it is  characteristic,  that,
even when the inflammation of the volvulus runs high, its mucous mem-
brane remains pale."  The sheath  is not so much affected except in
large invaginations.  The tumefaction resulting from  the inflammatory
congestion may cause strangulation of the  Arolvulus, usually  at the
entrance, but sometimes at other  points.  If death does not  result  from
the  peritonitis, the ensuing  gangrene,  or the  strangulation, recovery 
    ABNORMAL CONDITIONS OF  THE INTESTINAL CANAL.  485

takes place with one of the three following terminations to the morbid
process: (a) Complete adhesion having been formed  between the two
opposed serous surfaces of the sheath, and the inverted tube at the point
of inversion, the whole contained  volvulus mortifies and is thrown off,
and becomes discharged per anum.   In a case referred to by Andral,
the portion of intestinal tube thus evacuated, measured eighteen inches;
and  He'vin  relates two cases, in one of which twenty-three inches of
the colon were thus parted  with, and in the other  twenty-eight  inches
of small intestine.   An annular swelling, more or  less interfering with
the canal of  the intestine, is found in the corpses  of persons in whom
this termination  has occurred, besides adhesions of the serous surfaces
in the vicinity,   (b) "In rare cases, in which the incarceration has been
developed at an unusual point, only a partial sloughing of the volvulus
takes  place;  and  the portion  which  lies  above  the  strangulation is
retained.   Under these circumstances, the latter forms a conical plug
with a narrow channel, and projects  into the cavity of its sheath,  sur-
rounded by a thick fringe  of mucous  membrane."   (c)  Occasionally,
after adhesion  has taken place, the inflammation  abates,  and  the  vol-
vulus is retained.   The first mode of termination  is the only one  that
produces a  permanent recovery; in the others, there ahvays  remains
a  degree  of chronic  hyperaemia, with  liability  to exacerbation.  No
age  is exempt from the  occurrence  of  invaginations.  Andral  quotes
from  Monro a case of a very considerable one, in a child four months old.
   Prolapsus ani is an affection very analogous to invagination,  differing
chiefly in not having a sheath, as  Rokitansky remarks, and also, as Ave
think, in the peritoneum being less involved.  In  trifling  cases,  only a

                              Fig. 219.
Prolapsus Ani.
fold of the mucous membrane comes down, but in the more serious, both
the mucous and muscular tunics descend.   The tumor thus formed is of
a sausage or pyriform shape, pediculated by the contraction it undergoes
at the anus, and having at its extremity, in the minor degrees, a round
central orifice, and in the greater, an eccentric fissure.   The results of
prolapsus ani  (more properly recti), are not, for  the most part, nearly
so serious as those of invagination.  In some cases, indeed, strangula-
tion takes place, the everted part  swells to tAvice or  thrice  its proper 
486   ABNORMAL  CONDITIONS OF  THE INTESTINAL CANAL.

size, assumes a red, purplish color, with an appearance of ecchymosis
and  of  impending  gangrene.  More often, even in inveterate cases,
there is only a discharge from the irritated or mucous  membrane  of a
thin  muco-sanguineous fluid, with, perhaps, some superficial ulceration.
In some cases the epithelium of the  mucous surface, from constant ex-

                              Fig. 220.
                             Prolapsus Ani.

posure, assumes a  cuticular character.  The affection is of common
occurrence in children, for which Sir B. Brodie assigns the following
reason: "The attachment of the rectum  to the surrounding part does
not extend so high in children, as in persons of mature  age;  while the
reflection of  the  peritoneum takes place loAver down;  and hence the
rectum is more liable to be pushed out."
   Wounds and lacerations of  the  intestines demand  a  brief notice.
When the bowel is  Avounded by the thrust of a cutting instrument, the
danger of escape of the intestinal contents,  and  of consequent perito-
nitis, is not so extreme as might be supposed.  The mucous membrane
being somewhat loosely attached and thrown into natural folds, protrudes
at the orifice so as to close it, if it be not very large;  at the same time
the constant  pressure of the parietes tends  to keep the  wounded point
applied against the opposing surface,  to which, moreover, it becomes
glued before  long by adhesive exudation.   If an  opening is made into
the intestine  by ulcerative perforation of its  Avail, the effusion of lymph
uniting it to  adjacent parts becomes  occasionally the  medium through
Avhich a fistulous communication is established, either Avith the exterior
of the body,  or with another hollow  viscus in the vicinity.  Sometimes
the ulceration, instead of penetrating further, causes simply the forma-
tion of abscess in the sub-peritoneal cellular tissue, fecal abscess, as it is
termed.   When the intestine is divided completely  across, the two ends
will occasionally unite, if brought together and maintained in apposition
by stitches; but no one has yet succeeded in repeating Ramdohr's experi- 
    ABNORMAL  CONDITIONS  OF THE INTESTINAL CANAL.  487

ment  (said to have been  successful), in which  a large  portion  of  an
intestine having mortified, was cut off, and the upper end inserted within
the lower, and kept in that position by a suture.   It  is very unlikely,
that a mucous and a serous membrane would unite by adhesions,  which
is said to have occurred in that case.
  The muscular coat of the intestines is very rarely, if ever, primarily
the seat of inflammation, though it very often is involved by extension
of the mischief from the serous or mucous tunics.   We have, therefore,
noAv to  consider chiefly the condition  of  the mucous membrane and  its
follicles when inflamed.  It must be premised that no  kind or amount
of vascular injection can be accepted  by  itself as a decisive proof of the
existence of  inflammation.   Obstruction to the  free return of blood by
the veins, according to the degree in  which it exists, will produce rami-
form, patchy, or general injection; and  the  same  cause will also give
rise to the punctiform, which has  been thought more  characteristic of
active hyperaemia.   Very marked injection also  results from mere gravi-
tation of the blood after  death to the most depending parts.   MM.
Trousseau and  Rigot found in  dogs, which  had been suspended  after
strangling in a vertical  position,  the  blood  collected in those parts of
the intestines which were the lowest, giving  the mucous membrane and
its villi a deep  red  tinge, and extravasating itself  on the surface  and in
the submucous tissue.   When the bodies were suspended in the reverse
position, the same effects took place in those that were then the lowest.
This  hypostatic congestion is especially liable to take place in fevers, in
severe cases  of Avhich, the blood is so commonly found fluid after death.
Redness, resulting  from mere staining of the tissues, is sometimes very
similar to that of active hyperaemia.   The injection which  takes  place
from engorgement  of the  veins may be distinguished from that  of in-
flammation,  by the circumstance  of its  being ahvays traceable  to dis-
tended veins, and,  further, we think,  by the redness being more general
 than that of inflammation commonly is.  In general, the smaller and
more isolated the patch of injection is, the more likely is it to be inflam-
matory; thus,  we find small separate patches of injection  around com-
mencing typhous deposits, Avhich contrast with the generally pale mucous
 membrane.
   Inflammation, affecting chiefly the  mucous lining of the intestines, was
 distinguished by Cullen as  enteritis erythematica.  It  corresponds to
the muco-enteritis  of others, especially the French pathologists.   Roki-
 tansky speaks of it as catarrhal inflammation, Avhich may be either acute
 or chronic, and either attack the raucous membrane uniformly or be de-
veloped mainly in  the villi and  the  follicles.   It  is  excited by various
 causes  of irritation, and especially by  certain  atmospheric influences.
 " The anatomical signs of the acute form  are, more or less intense red-
ness  and injection  of the mucous membrane, affecting its entire surface,
 or appearing as  punctiform reddening from  affection of the villi, or as a
vascular halo  surrounding the follicles;  relaxation  of  the tissue,  and
 intumescence of the mucous membrane,  equally affecting the entire sub-
 stance, or only the villi and follicles; opacity of the mucous membrane
 and its epithelium, from infiltration of the former and softening of the
 latter;  friability and softening  of  the mucous membrane.  The sub- 
488  ABNORMAL CONDITIONS OF THE  INTESTINAL  CANAL.

mucous cellular tissue is injected, relaxed, and infiltrated Avith a watery,
opaque fluid; the secretion is at first copious and serous; as the affection
increases in intensity, the former diminishes in amount, becomes opaque,
viscid, and puriform.
   Chronic inflammation is characterized, in addition to the above signs,
by a dark, rusty, livid discoloration, which, in severe cases,  appears to
pervade the entire mucous membrane;  by a tumid state of the mucous
membrane and  its follicles,  accompanied by increased density of the
tissue, copious secretion of an opaque grayish-white or yellow puriform
mucus.   The acute form may subside  completely, or several  relapses
occurring,  it may merge into the chronic, which  seldom "admits of a
complete  cure."   The following are the principal changes produced by
chronic intestinal catarrh: (1.) A more or less abundant deposit of black
pigment in the whole mucous membrane, or in its villi or follicles only.
(2.) A permanent tumefaction of the mucous membrane, depending pro-
bably on dilatation of its vessels and interstitial exudation, which causes
increased density of its tissue, and may give rise, "in higher  degrees,
to  elongation  of the  membrane, and formation  of folds  and  polypi."
(3.) Hypertrophy of the submucous cellular  tissue and of the muscular
coat.  (4.) Profuse secretion of a grayish-Avhite and milky, or  of a trans-
parent gelatinous and viscid  mucus. Suppuration and ulceration some-
times result from catarrhal inflammation, especially when an acute attack
supervenes upon the chronic form. "The mucous membrane is converted
into a dark-red, granulated, and friable tissue, on the surface of, and
within which, suppuration is established." The burrowing of  the ulcers,
so as  to pass through even the muscular  coat, gives rise to sinuses, in the
vicinity of which there is often a production of polypoid growths from
the mucous membrane.   Corrugation of, and pigmentary deposit in the
tissues, are constant accompaniments of this process.  Cicatrization of
the ulcers and sinuses  takes  place, with formation of the  usual fibroid
tissue, which, by its subsequent contraction, may  give rise to  puckering
or obstruction.   Rokitansky states that  the most usual scat of catarrhal
inflammation is in the coecum and rectum;  we doubt if this  is true, if
applied both to the acute and chronic forms, for  there can be no doubt
that, in the majority of instances of muco-enteritis, the small intestines
are affected even to a greater degree than the large.  He observes him-
self that "catarrhal irritation, and even  inflammation, undoubtedly often
affect the duodenal mucous membrane, and are frequently induced by an
anomalous condition of the  bile."   This condition, as Dr. Stokes  has
observed, "may extend to the biliary ducts  and give rise to jaundice, an
instance of which we have lately had under our care.  Besides the tume-
faction of the mucous membrane, the increased pouring out  of mucus,
and the enlargement of the glands of Brunner in  this  situation, we have
noticed an atrophy or destruction of the villi, Avhich had lost their sharp
exterior margin  of limitary  membrane, and  were shreddy and wasted.
The chronic form of catarrhal inflammation does  seem to be more fre-
quent in the large intestine, at least the slaty and black discoloration is
more often seen in the coecum than elseAvhere; but it may admit of some
doubt whether this discoloration is a certain sign  of previous  inflamma-
tion, whether a  deposit of pigment may not take  place here as in the 
    ABNORMAL CONDITIONS OF THE INTESTINAL CANAL.  489

areolar tissue of the lung, or in the skin, without any disease.  We have
certainly examined instances in which the microscope showed nothing
the least abnormal except the pigmentary deposit.
  It seems very doubtful whether there  is a  distinct affection such as
that which has been termed glandular or  follicular enteritis.   Dr.  Cop-
land speaks of it as occurring almost always consecutively to other dis-
eases, as fevers, continued or remittent, dysentery, and even tuberculosis.
Rokitansky does not seem to recognize its special character, but to con-
sider that the follicles may be more particularly affected in morbid pro-
cesses of different kinds.  In this opinion we entirely coincide, but wish
to notice  here an anatomical point which we think is  not generally
understood.  The solitary glands of the  intestine, which occur both in
small and large,  as well as their aggregations, constituting the patches
of Peyer, which do not extend beyond  the  ilio-ccecal valve, are quite
destitute of the follicular character, that is, are not involutions of the
general mucous surface, im'ested by a lining  of epithelium.   They are
simply  solid aggregated  masses of nuclear particles, with  very  little
 Vertical section of Peyerian patch, and solitary gland of large intestine.  The glands in both are rather
               enlarged,  (a) Peyerian patch from ileum,  (b) Solitary gland.

intervening granulous matter, which lie completely beneath the sheet of
basement-membrane that  covers the surface.   They are not contained
in a distinct capsule of homogeneous membrane, but lie partly in the
corium of the mucous tissue, partly in that layer of nuclei and granulous
matter Avhich  is spread under  the basement-membrane,  and forms the
chief substance of the villi, to which we gave, some years ago, the name
of "substratum."  It is apparent, from this structural arrangement, that
they cannot be  secreting  organs like the Lieberkiihn tubes all  round
them, for they have no outlet.   On the other hand, they are, from their
very structure, peculiarly liable to become enlarged and prominent, the
nuclei attracting to themselves plasma, and developing into cells.   There
seems no doubt that they are much more developed in some persons than
in  others, and Ave  are much inclined  to think that masses  of precisely
similar appearance may be formed in the mucous membrane, solely as
the result of irritation.  We have been led  to  this belief from having
found only  a  few  distant  and  widely scattered glands in the mucous 
490   ABNORMAL CONDITIONS OF  THE INTESTINAL CANAL.

membrane of some persons, even Avhen it was examined after immersion
in acetic acid, which makes them much more opaque and white, while in
other cases they Avere extremely numerous and close together.   There
really seems to be a good deal of resemblance betAveen them and small
pustules of the skin, like Avhich, Avhen the  inflammation  reaches a cer-
tain point, they are  extremely apt  to  suppurate and slough.  We shall
now subjoin Rokitansky's  account  of  "ulcerative inflammation  of  the
follicles of the colon, such as we find in lientery, brought on by tedious
diarrhoeas.  The follicles  are at first tumefied in various degrees, and
consequently project as smaller or larger round, conical nodules on the
internal surface of the intestine, being surrounded by a dark-red vascular
halo.  Ulceration noAv ensues in the interior  of the follicle, the small
abscess penetrates the mucous membrane within the vascular halo, and
a fringed ulcerated opening, of  the size of a millet-seed, appears, which
leads to a small follicular abscess with  red spongy Avails.  The ulceration
continues, and the follicle is eaten away," so that an ulcer of  the size
of a pea  or lentil is formed.  In its further progress, the mucous mem-
brane becomes  extensively destroyed, and that with great rapidity, the
muscular coat being frequently exposed.  The most extensive destruction
always  takes place in the sigmoid flexure and in the rectum.  The dis-
ease is always  confined to the  colon; but, when  it  runs a very rapid
course, it may be  accompanied by  catarrhal  irritation of  the  small
intestine.  We have notes of a case in wdiich there were a great number
of the so-called  solitary follicles in the lower  part of the small and in
the  large intestine, although no irritation had existed during life.  Their
development seems to depend on some other cause besides mere irritation,
though this, no  doubt, promotes it.   Like the Peyerian patches, they
are  sometimes very prominent  in cases of typhus, sometimes scarcely
discernible ; and the same is true of common catarrhal irritation and of
dysenteric.  It can scarcely be supposed that  the  Lieberkuhn follicles,
which are mere involuted  extensions of the mucous surface, should not
be affected Avherever the mucous membrane is; but the solitary glands,
which differ essentially in structure, seem to be by no means necessarily
involved.
   We proceed to the other form of enteritis, that termed by Cullen, E.
Phlegmonodea.   The effects  produced by this, which, indeed, are just
those of common inflammation, have already been several  times adverted
to;  but we think it well  to subjoin the  following excellent description
from the pen  of Dr. Copland: "The villous coat in acute  enteritis is not
only more vascular and  turgid, but  it is also softer, and  sometimes
thicker than  natural.  If the  inflammation has proceeded far, it pre-
sents a brick-red tinge, and is easily detached  from the subjacent coats,
the connecting  cellular tissue being soft,  turgid,  and inflamed.   When
this state exists in a considerable portion  of the tube, the coats  are ap-
parently thickened, arising from the extension of the inflammation to
the more external tissues, till the attached surface of the  intestinal peri-
toneum is  reached.   The substance or parietes of the bowels may be
 considered as affected in these cases, even although the external surface
may present no further lesion than red vessels shooting into it.   Occa-
sionally, in addition  to  this  state, the red capillaries in  the inflamed 
    ABNORMAL CONDITIONS OF THE  INTESTINAL CANAL.   491

peritoneal coat are connected with the effusion of coagulable lymph, par-
ticularly in the parts where they are most numerous, the lymph or albu-
minous exudation existing in specks, or in considerable spots or patches,
on  the serous  surface.   When, however, these latter appearances are
remarked, the interior of the inflamed intestine frequently presents more
serious changes than yet noticed.   The villous surface is then deeply
inflamed, and seems abraded or excoriated in parts.  It is sometimes, in
other  parts, covered by patches of lymph, or of an albumino-puriform,
or muco-puriform fluid, or by a sero-sanious matter; and it is often also
ecchymosed in numerous points or specks, or it presents still larger marks
of sanguineous  infiltration.  In  other  cases, portions of a dark,  slate-
colored,  or sphacelated  hue are  observed, with  or without  ulcerated
specks, or even large ulcers, which have nearly penetrated as far as the
external coat, in adjoining parts."   Sometimes  then ulcers actually
perforate the intestinal Avail, and gh^e rise to escape of the contents.
" In the forms of enteritis in which the substance of the intestine,  or its
peritoneal coat, is chiefly affected, either primarily or consecutively, the
whole  of the  coats are often very vascular,  red, or of a brick-red color,
and are readily torn."  Suppuration sometimes takes place between the
coats,  as in  an interesting case recorded in the Pathological Society's
Reports, 1851-52, by Dr. Hare.   General  peritonitis not unfrequently
occurs, in  which  the omentum  may  markedly  participate,  becoming
greatly thickened and red.
   The intestinal mucous surface  is sometimes the seat of a kind of in-
flammatory process, which is mostly subacute  or chronic, and  gives rise
to an exudation much resembling that  of croup.   It is remarkable that
the attacks often recur several  times, each presenting  a stage of irrita-
tion, Avhich ends in the formation and throAving off of the false membrane,
after Avhich there is a pause.   The quantity of the exudation varies  much
in different cases; sometimes it forms a layer  of some thickness, extend-
ing pretty uniformly over  the surface, or appearing in the stools as
tubular casts  of the  intestines ; sometimes it is as thin as a wafer, or
consists merely of tattered shreds.  In one  case, mentioned by Dr. Cop-
land, there were also shreds of dysmenorrhceal false membrane discharged
from  the uterus, but not at the same time as those  from the  bowels.
Rokitansky mentions the occurrence of less consistent fibrinous exuda-
tions, which probably approach more or less closely to those of diphthe-
ritis.   They are, as  he  observes, " the  expression of a  constitutional
affection," the results of an altered blood crasis.
   The changes which take place in the intestinal  mucous membrane in
continued fevers have been most diligently examined, and  minutely de-
scribed by Rokitansky;  but our limits forbid us  to follow him closely,
and we shall, therefore, only endeavor to give a short-and comprehensive
account of the A'arious phenomena belonging to what he calls the typhous
process.   The intestinal affection, as is well known, is no necessary part
of fever.  We have examined the intestines of persons dying of fever,
in which very little trace of Peyerian  patches or  solitary glands  could
be detected, certainly less than we have seen in  the bodies of persons
avIio have died from other diseases.  When, however, the malady spe-
cially affects this seat, we observe the folloAving series of changes:  Hy- 
492   ABNORMAL CONDITIONS OF TnE INTESTINAL  CANAL.
Fig;. 222.
peraemia, to a greater or less extent, is set up around the solitary follicles,
and in and  around Peyer's  patches.   Enlargement and distension of
these glandular structures proceed nearly pari passu with the hyperaDtnic
congestion.  After a certain time, the length of which varies in different
cases, the contents of the enlarged glandular masses soften, break down,
and are discharged.   The cavity which remains on the mucous surface,
constitutes the typhous ulcer, to which Rokitansky attributes the follow-
ing character: (1.) Its form is elliptical, round, or irregular, and sinuous,
according to the shape of  the part which has been  affected.   Thus, a
large patch,  when destroyed, gives rise to an elliptical ulcer; a smaller
or  a solitary gland to a  round one; partial destruction  of a patch Avill
produce an irregular ulcer.   (2.) The size of the ulcer varies from that
                          of a bemp-seed to that of a half-crown.  (3.)
                          Those of an elliptic shape are always situated
                          opposite to  the insertion  of the  mesentery,
                          and have their long axis  parallel to that of
                          the intestine. The typhous ulcer very rarely
                          indeed forms a zone.  (4.) " The margin of
                          the  ulcer is  invariably formed  by a well-de-
                          fined fringe of mucous membrane, which is a
                          line or more wide,  detached, freely moA'able,
                          of a bluish-red, and subsequently of a slaty
                          or blackish-blue color.   (5.) The base of the
                          ulcer is  formed by a  delicate  layer  of sub-
                          mucous tissue which covers the muscular coat;
                          like the marginal substance, it is quite void
                          of morbid growth.   (6.) The small intestine
                          is  the seat of the ulcerative process, and the
                          lower third is most liable to be involved—the
                          number and size of the ulcers increase as they
                          advance towards  the ilio-ccecal valve."   We
                          must add with respect to the last character,
                          that the ulcerative process is by no  means
                          confined to the small intestine; we have seen
                          the mucous membrane of the large intestine,
                          down to  the rectum, riddled with ulcers.
                          They were many of them of large size, and
                          had clean cut, non-thickened margins.  This
condition, indicating  the absence of reparative action, is not nearly so
frequent as  that  of  thickening and induration,  which generally takes
place to some extent in the side of the ulcer.   The bottom of the ulcer
is commonly  formed by the submucous  tissue, sometimes the muscular
fibres are completely exposed.   This, hoAvever, is generally the result
of secondary  advance, subsequent to the expulsion of the typhous deposit.
Rokitansky particularly insists on the point, and we think he is correct,
that when an ulcer increases  in depth so as  to perforate the intestine,
it advances not by continued deposition and softening of typhous matter,
but by simple extension of  the ulcerating action.  We feel inclined to
doubt Rokitansky's statement respecting the extreme rarity of a typhous
ulcer assuming a zonular form.  We think Ave have  seen some that in-
 Typhous ulcers in small intestine.
Death from hemorrhage. The outline
figures represent vertical sections. In
the upper figure the margins of the
ulcer are thickened; in the lower they
are clean cut, as if punched. 
    ABNORMAL  CONDITIONS  OF  THE  INTESTINAL CANAL.   493

volved a considerable part of the circumference of  the intestine, and
Andral mentions  a case  in which  there were a dozen ulcers encircling
the canal like rings.   It is  true, he  does not positively state that they

                                  Fig. 223.
  Inflamed mesenteric glands in Typhus and so-called typhous matter. At the lower and left part is repre-
sented a small ulcer in  the mucous membrane, in which ulceration is seen extending round the  central
typhous deposit, which is still in situ.


were the result of fever, though this seems almost implied.   The matter
which causes  the  tumefaction  of the  agminate  and  solitary glands  is


                                  Fig. 224.
  Typhous ulcers in various stages. The outline figures are vertical sections, which show the elevation of the
mucous membrane by submucous deposit, (a.) Mucous membrane. (6.) Submucous tissue, (c.) Muscular
coat,  (rf.) Peritoneal coat.


simply a kind of albuminous exudation, not differing we  believe essen-
tially  from  any other.   It either, which is most  frequent, forms a solid
mass imbedding the natural nuclei of the gland, or affords a plasma, out 
494   ABNORMAL  CONDITIONS  OF THE  INTESTINAL  CANAL.

of which  these nuclei develop celloid particles.  Black  granules and
grains of  pigmentary matter are often present in it, but they are by no
means peculiar to the typhoid  state.   They give  to the glands a  black
dotted appearance,  as seen by the naked eye, and this we have observed
more than once after death from other causes than fever.   The mesen-
teric glands become invariably enlarged  in  all  cases of intestinal  affec-
tion, just  in the same way as  an inguinal gland enlarges  when there is
a chancre on the glans  penis.  Their enlargement seems to be simply
the result of irritation ; we have found nothing in their substance besides
the normal nuclei but granular and amorphous matter, and some celloid
particles  or  cells.   The  vessels  of their  capsule are generally  much
congested, as Avell as those which penetrate their interior.   Rokitansky
states that " the mesenteric glands decrease in size, as soon as the de-
tachment  of the intestinal morbid growth has commenced."   Of course,
they must remain for some time more congested with blood, and larger
than  natural, eA'en  under the most favorable circumstances.  It by no
means necessarily follows that ulceration takes place after a patch or a
single gland  has been enlarged; the exudation may liquefy and  be again
absorbed  into the blood, and  the  part return to its normal condition.
Cicatrization of the ulcers  is not  unfrequent,  as  Dr. Watson  testifies.
He says :  "The ulcerated surface seems to clothe itself afresh, by degrees,
with a new mucous membrane, which is  thin, hoAvever, and  adherent to
the subjacent tissues, and does not slide over them when pressed between
the finger and thumb, as the healthy portions of the coats of the bowel
will do upon  each other.  And in the place of the cicatrix there is usu-
ally to be seen a manifest puckering, and a  number of little wrinkles or
lines, radiating from a common centre."
   Rokitansky speaks of the new-formed membrane as a serous lamina,
which becomes at its circumference as it were  dove-tailed  in  between
the muscular and mucous coats.  He confirms the observation of Sebas-
tian,  that small villi sometimes form upon  this  lamina, even before its
union with the mucous  membrane.  In most  instances,  hoAvever, the
absence of "villi forms one of the distinctive  features of a cicatrix.   We
feel much hesitation in accepting Rokitansky's  absolute assertion, that
the cicatrix of a typhus ulcer never in any way gives  rise to a diminu-
tion  of the caliber of the intestine.  Dr. Carswell speaks  positively of
the occurrence of fatal  ileus in persons  who had suffered some months
before from typhoid fever, the cicatrix  of  an ulcer being  found  after
death, which  had  destroyed the muscular coat around tbe whole circum-
ference of the tube.
   The morbid changes in Dysentery have their especial seat  in the  large
intestine,  the ileum being sometimes (Dr. Copland says very often) in-
volved, but always in  a  less degree.   Our observation  quite accords
with  Rokitansky's,  that " as a rule its intensity increases from the
coecal vah'e downwards," so that the sigmoid flexure and the rectum are
found most  severely affected.  It commonly runs, Rokitansky  says, an
acute course, "though it  is frequently chronic in the milder degrees;
this,  hoAvever,  does not  materially alter  its  character."  Dysentery
presents itself to the medical  observer  under  a very great variety of
forms, but it would  be impossible to range the post-mortem appearances 
    ABNORMAL  CONDITIONS  OF THE  INTESTINAL CANAL.  495

in corresponding  groups.   All that can be said in general, is that both
the symptoms  during life, and  the textural lesions, will coincide in in-
dicating whether  a given case is to be considered of sthenic or asthenic
character.   Looking, then, upon dysentery generally as  inflammation,
more or less acute, of the mucous  membrane of the large  intestine, and
premising that it is very prone to pass on into a lingering chronic state,
we shall folloAv Rokitansky's account of the changes produced by the
disease.   He considers them " as divisible into four natural degrees."
In the lowest, the mucous  membrane in its projecting folds is injected,
swollen, and softened, its  surface seems  excoriated, the  epithelium  is
detached  as a grayish-Avhite layer, or elevated  by effusion into small
vesicles containing serum,  as in  a  case Ave witnessed, or  it may be min-
gled with amorphous matter in an exudation of dirty gray and reddish
color covering  the surface.  Dr. Baly, Avho mentions the detachment  of
the epithelium and its mingling Avith amorphous matter, describes the
solitary glands in his first  stage  as being enlarged, forming round promi-
nences, which, in a chronic state, by sloughing and ulceration, assume
the form of open sacs.  The mucous and submucous coats  become thick-
ened.   " In the second degree,  the textural alterations are not limited"
to the projecting folds, " but extend over a larger surface, still, hoAvever,
presenting a greater development at one part than at  another."  The
mucous membrane is invested to the same extent, by a dirty, gray layer,
consisting of desquamated epithelium and a thick glutinous exudation ;
or this may already have been removed, and the subjacent mucous mem-
brane, in either case, appears converted  into a  soft, sanguineous, pale
red and yelloAvish gelatinous substance, which may be easily detached."
The submucous tissue becoming infiltrated, gives  rise to more or less nu-
merous protuberances, on  the internal  surface of the intestines;  these
 " correspond  to  those points of  the  mucous  membrane, at Avhich the
morbid affection  is most developed,"  while in  the  intervening portion,
there is not much change  beyond slight redness and SAvelling.   The  in-
 testinal cavity is dilated by the  pressure of exhaled gas upon  the semi-
 paralyzed muscular coat, and contains a mixture of effused lymph and
blood,  together  with mucous liquid and feces.  Dr. Baly marks  his
 second degree by the sloughing of the solitary glands, either principally
 or equally with  the  surrounding  mucous membrane.   In this way  are
 formed either clear circular ulcers of various depth, or large excavations.
 The prominent  rugae are chiefly affected.  Rokitansky  also  remarks,
 that the  affection of the follices may predominate, and states  that  the
 anatomical condition is the same as that already described in connection
 with catarrhal inflammation as  attendant upon lientery.  "In the third
 stage,  the  protuberances are   set more closely together, the mucous
 membrane investing them partly retains the same condition  as  in  the
 former, partly" is  converted into a  slough, which is here and there
 blended Avith the desquamated  epithelium "and the exudation,  and  is
 firmly attached to them;  it is of a dark-red, or blackish-broAvn, or gray-
 ish-green color."  In some cases, the infiltrated and thickened submu-
 cous tissue  is in  great part exposed, being covered here and  there  by
 the remnants of the  mucous membrane, "in the  shape of solitary, dark-
 red, flaccid, and bleeding Avascular  tufts, or  as  dilated follicles, which 
496   ABNORMAL CONDITIONS OF THE INTESTINAL CANAL.

are easily removed."   The  protuberances are  occasionally found  to
have coalesced, and the intestine then presents an uneven plicated sur-
face, accompanied by an equal degree of infiltration  and thickening of
its parietes;  the mucous membrane is  uniformly affected over  a large
extent, and there are no free interstices.   The contents of the intestine
are of a dirty brown or reddish, ichorous, fetid, flocculent, and grumous
character.
  In  the  fourth and highest degree, the mucous membrane  degenerates
into a black, friable, carbonified mass, which may often be subsequently
voided in the shape of tubular  laminae (so-called mortification of the
mucous membrane).  The submucous cellular tissue appears to  be pre-
A'iously infiltrated Avith carbonified blood,  or  a sero-sanguinolent fluid;
or it is pallid, and the blood contained in its vessels is com'erted  into a
black, solid,  or pulverulent mass; subsequently, it shows  purulent in-
filtration, in consequence of the reactive inflammation which is  induced
in the lower, healthy strata, for the purpose of eliminating the gan-
grenous portions.   Dr. Baly's third degree seems to correspond  to the
fourth of Rokitansky;  he describes the mucous membrane  as converted
into a gangrenous slough, glands and all alike, the blood being dark
and coagulated in the  submucous tissue.   The prominent rugae  are first
and most severely affected, the intervening portions  being  SAVollen and
red.  All the coats sometimes are much  softened, and the submucous
tissue becomes sloughy.   The changes just enumerated as  occurring in
the most  extreme  degree of the disease, are of much the same kind  as
those which  Dr. Copland describes to take place " in  the  most  malig-
nant  varieties, and in  the scorbutic complication.   The  internal surface
of the whole digestive tube is," in these  cases, " of a  livid  purple, or
dark  color,  with  patches  of ecchymoses, excoriation,  ulceration, and
sphacelation.  The villous coat, particularly in the seat of  ecchymoses,
may readily be rubbed off; and the ulcers have a foul and dark appear-
ance.   The  liver is sometimes large, soft, and spongy; at others, pale
and soft,  especially in  cases where the loss of blood has  been very large.
The spleen is sometimes so softened as to appear semi-fluid or sphace-
lated.  The heart is often partially softened or flaccid;  the pericardium
and pleural  cavities containing a bloody, dark, and  dirty serum.  The
lungs are often congested;  the bronchial lining  dark  or ecchymoscd;
and the blood, in  all the large vessels, is semi-fluid, black, and of  a very
loose texture."   "In prolonged  inflammatory cases,  thickening  and
almost cartilaginous induration of a  considerable part  of the colon are
not unfrequent, the thickened or indurated portion being also contracted
in caliber.   In such cases, the  parts above the  contraction are greatly
distended, the coats being thinned, ulcerated, and even lacerated;" so
as to give rise to  effusion and fatal peritonitis.   The darkly-congested
mucous membrane is often discernible through the peritoneal and other
coats, especially if, as is often the case, the intestine is distended.  In
the severer  cases, the serous  membrane  is dulled and  discolored, and
sometimes coArered with a brownish ichorous exudation.  The mesocolic
lymphatic glands  are swollen and  congested.  In the  dysentery which
occurs in this country, abscess of the liver is rare;  a  case, however, is
recorded  in  the Report of the Pathological Society, 1851-52.  Dr. Baly 
    ABNORMAL CONDITIONS OF  THE INTESTINAL CANAL.  497

has never met with it during his experience at the Millbank Penitentiary,
where the disease is very common ;  but in India, it is said  to  occur  in
nearly half the  cases.   We have recorded, in the Report of the Patho-
logical Society,  1847-48, an instance in which the  destruction of the
mucous membrane was confined to the interstices of numerous promi-
nences or ridges, these being themselves the sole remnants of the mucous
tissue.   This is  the converse of the  more usual condition, in which the
prominent parts are most affected.   After extensi\re  ulceration has oc-
curred, reparation may be effected in the usual way by organization  of
plastic exudation into a smooth fibroid layer which constitutes a cicatrix.
This probably may be covered after a time by an epithelial layer; but
it  has  not been shown yet that the follicles of Lieberkiihn are  repro-
duced.  When extensive  destruction of  substance has taken place, the
cicatrix tissue " is frequently condensed into fibrous bands, which form
corded projections into the intestinal cavity,  interlace with one another,
and not unfrequently encroach upon the caliber of the intestine in the
shape of valvular or annular folds, thus giving rise to a stricture in the
colon of a very peculiar  form."  Instead of reparation  taking  place,
the disease may continue in a chronic though altered form;  the remain-
ing mucous membrane being in a state of chronic catarrhal inflammation,
and the intervening part3 being the  seat of suppuration with formation
of sinuses and abscesses.
   Gelatiniform softening, analogous to that described as affecting the
stomach, occurs also in the intestines, but much less frequently.  "It
involves," Rokitansky says, "the external coats, converts them into an
homogeneous, grayish-red, transparent,  and deliquescent gelatin, and
leads to spontaneous perforation."   It is far more often met with in chil-
dren than adults, and seems to be occasioned by unsuitable  food, bring-
ing up by hand, and  generally by  causes which depress the organic
nervous power; diarrhoea, absence  of fever, and great and increasing
debility, are the prominent symptoms.  Dr.  Droste, quoted by Dr. Cop-
land, distinguishes three  stages of the softening process; in the first,
the villous surface retains its texture, but loses its consistence  more  or
less extensively; in the second, it is converted into a  thin, soft, gelatin-
ous and nearly transparent substance, capable  of being washed  away;
in the  third, "no trace of organization is left in any of the coats," which
are perforated, or on the  point of being so, in various places.  Fatty
tumors, sessile or pediculated, occur in the intestinal  canal; they origi-
nate in the submucous tissue, where fat-vesicles always exist, and grow
inwards.   Serous  audi fibro-serous cysts are met  with but very rarely
between the intestinal coats. Fibroid nodules, not exceeding the magni-
tude of a pea, are sometimes found in the submucous tissue.  Calcareous
concretions, formed by the deposition  of earthy matter  in  new-formed
fibroid tissue, in obsolete  tubercle, or desiccated pus, or fibrinous exuda-
tion, occur very rarely.   Rokitansky describes  erectile growths to exist
in the intestinal canal, either in the form  of sessile tumors, or pedicu-
lated  polypi.   We  are not sure whether  he would include  under this
head instances of fibrous polypi, such as two recorded  by Mr. P. HeAvett,
in the Report of the Pathological Society for 1846-47, Avhich, though
of marked fibrous structure, were livid in appearance, and pretty plenti-
       32 
498   ABNORMAL CONDITIONS OF  THE INTESTINAL CANAL.

fully  supplied with bloodvessels.   The  presence  of these  polypi may
give rise to invagination and  its consequences.   Tubercle  selects the
small and large intestines not unfrequently as its seat of deposit.   It is
met with more frequently in children than in adults, in the proportion
of sixty-one to forty-three, and is more than twice as frequent in the
small as in the large intestines.  In the majority of cases the affection
of the intestines  is secondary to that of the lungs, and usually takes
place after the tubercles in the latter have begun to suppurate, and the
cachexia has become fully developed.  The course of intestinal tubercu-
losis is  "frequently chronic, but much oftener acute."   The seat  of the
deposit is the submucous tissue, or the corium of the mucous membrane;
it is certainly subjacent to the basement-membrane, and not contained
in the follicles, as Dr. CarsAvell taught.  Rokitansky states that there
is, in the chronic form, "no perceptible inflammatory action, and the
disease appears in the shape of the gray transparent granulation,  which
softens at its  centre,  and is  gradually conArerted from within outwards,
into the yelloAv  cheesy tubercle.   It seems blended with  the mucous
membrane,  and  projects into  the  intestinal cavity in  the shape of a
sessile, hard nodule.   Considerable inflammatory action attends  upon
acute tuberculosis.  The exudation affects first Peyer's patches, then
the solitary glands, and, lastly, every other part of the mucous tissue;"
it appears in large masses, and in the  shape of yellow cheesy matter,
which speedily undergoes a purulent transformation.   The surrounding
tissue is extensively  congested, reddened, and  turgid, offering a good
illustration  of the influence of hyperaemia in promoting tuberculous
exudation.  In the great majority  of  cases, as the tubercle softens, the
mucous membrane over it gives way, and the suppurating mass escapes.
In very rare cases this does not take place, but there  is formed a small
abscess in the submucous cellular tissue. The margin of the tubercular
ulcer is firmly attached, rounded, and indurated; its base, usually formed
by condensed areolar  tissue, may contain or not tuberculous matter.
The  enlargement of the ulcer in depth and in extent is effected by a
process of essentially the same kind as is observed in cavities  of the
lung.   The margin and the base become infiltrated with tuberculous
exudation which  softens and suppurates, and so the destructive process
continually advances.   Perforation  of the intestinal  wall sometimes
occurs, the  ulcer retaining throughout  its  original character, in which
respect it differs  from the typhous.   The fatal event is often prevented
by timely exudation of fibrin on the serous surface, which either thickens
the wall or else unites it to an opposing surface.  Mr. Ancell contests
the statement that the tuberculous ulcer always retains its original cha-
racter; he does not believe that ulcerations, the result of  tuberculosis,
are always  produced  by the deposit  of tubercle.  He A'iews them as
the  result of "the ulcerous  diathesis  of the  disease."  Before this
opinion can be accepted, microscopic evidence must be adduced to show
that  the base and marginsv are not the seat  of tubercular infiltration,
which  Rokitansky affirms is the case.   The mesenteric glands are  en-
larged by the special deposit, and often  to  considerable size.   This,
however, it may be stated, is not the  essential circumstance in the dis-
ease  formerly called  tabes  mesenterica.  Tuberculous ulcers heal by  a 
    ABNORMAL  CONDITIONS OF THE  INTESTINAL  CANAL.   499

cessation of the morbid deposit taking place, and subsequent effusion of
plastic fluid, which becomes organized into the cicatrix tissue before de-
scribed.   The contraction of this, if the ulcer has been of a large size,
or extended round the intestine, may  cause more or less contraction of
its canal.   Tuberculous disease generally, but not  ahvays, selects the
lower part of  the ileum as the  seat of its chief ravages; it oftener de-
scends, we think, to the coecum and colon than extends  in the upward
direction.
   Cancer not uncommonly attacks the intestinal canal; it is far more
frequent in the large than in the small intestines; out of three hundred
and seventy-eight fatal cases from this cause, in two hundred and twenty-
one the disease was located in  the rectum.  All the three species occur
in this situation,  and colloid more frequently than in most others.   Dr.
Walshe seems to consider  the small intestines  to be more  frequently
affected than Rokitansky does; the latter  says that "the  colon is almost
exclusively the seat of cancerous  degeneration," while " the small intes-
tine is scarcely ever the primary seat of cancer, except in the case of
acute  and extensive encephaloid disease.   In the Report of the Patho-
logical Society for 1847-48, there is recorded one case of cancer (colloid)
of  the small intestines and mesentery, and four  of the coecum, colon,
and rectum.   The duodenum and upper part of the jejunum are the parts
of  the small intestine most  frequently affected, the rectum and sigmoid
flexure those of the large  Avhich most frequently suffer.  Rokitansky
describes primary cancer of the intestines as occurring (1) as encephaloid
infiltration of the submucous tissue and patches of Peyer; (2) as carci-
nomatous infiltration of erectile tissue ;  (3) "more  frequently in the
submucous cellular tissue, as round nodulated  accumulations; (4) most
commonly as an annular deposit of the cancerous tissue in the submucous
layer."  Mr.  Curling has met  with an instance of epithelial  cancer in
the coats  of the intestine.   When the disease has its seat in the rectum,
it most usually occurs at  from  two  to  three inches above the  anus,
according  to  Dr. Walshe,  and tends to  spread  upwards rather than
downwards.   When the groAvth assumes an annular form, encircling the
intestine, it produces gradually increasing constriction,  which may ad-
vance to such an extent that the canal is reduced to the diameter of a
goose  or even a crowquill.   A tuberiform growth, occupying only one
side of the intestine, also  gives rise to  considerable constriction; but
this is not so  great  generally  as in the  former  case.   The narrowing
of the passage, it is manifest, will be greatest while the growth remains
in its original (crude) state ; but if, as not unfrequently happens, slough-
ing and ulceration take place in the morbid mass, the obstructed passage
will be again more or less reopened.  In  many cases, however,  the ob-
struction to the passage of  the contents is such that the portion of the
canal above the structure becomes immensely dilated, Avith its muscular
tunic much hypertrophied, and its  mucous, on the contrary, sometimes
thinned, while that below contracts upon  itself and becomes very small.
Death often takes place in cases  of intestinal cancer from the superven-
tion of ileus and inflammation.  The ileus (or anti-peristaltic action) is
set up not only in consequence of the stricture  preventing the passage
of  the contents of the bowel, for it may  ensue  when the canal is still 
500   ABNORMAL  CONDITIONS OF  THE INTESTINAL CANAL.

tolerably pervious;  but from the paralyzed condition of the Avails of the
intestine in the dilated and distended part, and from the masses of fecal
matter which accumulate there.  Inflammation  attacks first the dilated
part of intestine, " and is there most intense.   This portion is discolored,
of a dark blue or  reddish  aspect, its coats are infiltrated with blood;
the serous lining covered with exudation is easily detached, the muscular
coat is discolored and friable ;  the mucous membrane, owing to its dis-
tension, is devoid of plicae, villi, or follicles; dark red, distended at some
parts  with coagula, and sloughy."  Sometimes  perforation and its con-
sequences take place.
  We  shall lastly notice some morbid conditions of particular parts of
the large intestine.  The frequent occurrence of catarrhal inflammation
in the coecum has been  already mentioned ; but  Rokitansky directs
attention  to  a particular form Avhich he terms  Typhlitis  stercoralis,
indicating thereby its  production by accumulation  of indigestible and
fecal  matters in  this situation.  Sedentary habits  and rheumatism of
the muscular coat of the bowels are also stated to be causes of the dis-
ease.   We believe the proximate  cause  to be atony of the contractile
fibres.  "Removal of the  accumulated  pus,  and  avoidance of  fresh
accumulations, generally suffice  to establish  a cure.  If this is not
effected, ulcerative  destruction of the mucous membrane,  and continued
sinuous suppuration of the muscular coat, result.  In this manner, rapid
perforation  of the  intestinal  parietes, and especially of  the posterior
side,  may follow, either inducing extensive inflammation, ichorous de-
struction of the cellular tissue in the iliac and lumbar regions, and death;
or giving rise to general peritonitis," from transmission of the inflamma-
tion to the serous membrane.   Inflammation sometimes attacks  the lax
cellular tissue which lies between the posterior surface of the coecum and
the iliac fascia, and is apt to pass into suppuration.   In many instances
it is  doubtless set up by pre-existing,  perhaps chronic,  inflammatory
disease of the bowels;  but in others it occurs  idiopathically, or meta-
statically, as Rokitansky states.  A calculus descending along the ureter
has given rise to abscess in this  situation.   The purulent matter dif-
fuses itself often for some considerable distance  beneath the  serous
membrane; it has been known to make its way up as high as the kidney,
and as low as the interspace beneath the rectum  and  bladder.  The
abscess often opens into the  coecum,  and also externally.   When the
catarrhal affection  of the ccecum  exists in a chronic form, it may cause
the condensation of the  surrounding  cellular tissue, and  shrivelling  of
the intestine itself, so that it  " is found  converted  into a slate-colored
capsule, with dense parietes, the size of a walnut or of a  pigeon's egg."
The cavity of the vermif. appendix often affords lodgement to indurated
pellets of fecal matter, cherry-stones,  or other such bodies, which cause
irritation and inflammation,  thickening of its coats, and subsequent
ulceration.   If the irritating substance can be got rid of, and the ulcer-
ation ceases, the  appendix shrivels up entirely, or in part, according to
the extent of the mischief, assuming a lead or slate color.  In two very
interesting  cases  recorded  together in  the  Report of the Pathological
Society for 1847-48, the vermiform  appendix protruded as a hernia,
and had undergone ulceration  in  this situation.  In the first, after an 
    ABNORMAL CONDITIONS OF THE  INTESTINAL  CANAL.  501

abscess and sinus had been laid open, a small piece of bone, of triangu-
lar  shape,  and with sharp angles, was discharged, and recovery very
quickly took place.  Death occurring from a  different  cause not long
after, it was found that the appendix vermif. was lying  in the inguinal
canal; it was enlarged to three times its usual  size, its coats much thick-
ened, and  its apex opaque, contracted, and adherent to the bottom of
the canal.   In  the  second case, there was a swelling  of the scrotum
caused by the hernial protrusion of omentum enveloping  the  appendix
vermif.  Abscesses and sinuses formed in the part, healthy pus was at
first discharged, afterwards sanious and offensive matter; the quantity
of discharge was profuse, but varied in quantity, and was frequently of
a pale orange color.   Death occurred from exhaustion, and it was found
that the  appendix, healthy in  structure all the way down  to near  its
blind extremity, was ulcerated  at  about half an inch from this  point,
and that a communication existed  between its interior and  the sinuses
of  the scrotum.   More often  inflammation, excited in  the  vermiform
appendix by the presence of hard bodies, extends to the peritoneum,
and either  at once induces general peritonitis, or gives rise to adhesions,
which  even if gangrene of the part and perforation occur, may prevent
the fatal  result for some time.  Rokitansky mentions, a curious accident
of a different kind which  sometimes befalls the appendix.   Its canal
gets blocked up at a certain part by a foreign body Avithout ulceration
taking place.   In consequence of this, the mucous secretion accumulates
in the closed receptacle, which  it distends into a kind of dropsical pouch
lined by  a  thin, serous-like membrane.      •
  The defective state of development of  the rectum already alluded to
as atresia ani is of various degrees, consisting either in simple closure
of  the anus by the integument being continued across it, or in the rec-
tum terminating in a blind pouch  at a  greater or less distance from the
anus.  Sometimes the canal extends for  an inch or two upwards from
the anus, and then terminates.  It is  important to remark that when
the deficiency in the rectum is considerable, the pelvis is  also imperfectly
developed, especially in its antero-posterior diameter.
  Lacerations of the rectum and  anus  occasionally take place, all the
coats sometimes being torn through, as after  a  seA'ere  labor Avhen the
perineum has quite given way, or  only the mucous lining being injured,
as  sometimes happens after the passage of concretions, or hardened
feces.  The rectum may be excessively  distended by  fecal accumula-
tions, especially in persons of lax fibre and low nervous power, or when
paraplegia  exists.   Sometimes its channel is much narrowed by the
pressure  of surrounding organs, when  displaced or diseased; a retro-
verted uterus, an enlarged prostate, a vesical calculus, or a pessary in
the vagina, may all  have  this  effect.   Rokitansky  asserts that hyper-
trophy of the sphincter ani may give rise  to obstinate constipation, and
even to ileus, and that it frequently induces excoriation of the mucous
membrane, the so-called fissure of the  rectum.   We think the converse
is generally, if not always, the case, that  excoriation or cracking of tbe
mucous membrane, by the irritation which it excites, becomes the cause
of excessive action and consequent hypertrophy of the sphincter.  This
is the opinion also of Sir B. Brodie, who  says that  " the  contraction of 
502   ABNORMAL  CONDITIONS  OF THE  INTESTINAL CANAL.

the sphincter  appears at first merely spasmodic; but in proportion as
this  muscle is  called into  action  it increases  in  bulk;  and after the
affection has continued for some time, it becomes  considerably larger."
Fissures may be situated at various points, as described by Dupuytren;
some, which are below the sphincter, and scarcely involve any texture
but the skin, occasion only  pruritus.  Those which  are above the sphinc-
ter give to the finger the sensation of a knotty hard cord, and during
the act of defecation  give  rise  to indescribable  tenesmus.   They are
commonly produced by the ulceration of internal  piles, and  mark their
situation on the cylinder of feces by a  streak of puriform,  sometimes
bloody mucus.  Fissures situated  on a level with the sphincter are the
worst,  being attended with  such  agonizing pain during  defecation, that
patients have been  known  nearly  to starve  themselves to avoid the re-
currence of the action as much as possible.  The appearance of  these
ulcers is that of a narrow fissure, " the bottom  of  which is red, and the
margin somewhat swollen and callous."    "Catarrh  and blennorrhcea,"
says Rokitansky, " accompanied  by hypertrophy of the coats, which
frequently gives rise to plicated and polypous excrescences of the mucous
membrane, are very frequent  affections of the  rectum."  Dr.  Copland
describes rectal polypi as varying from the size of a pea to that of an egg,
having a broad or a very narrow pedicle, situated high up or low down,
presenting generally a mucous aspect, a pale-reddish hue, and a smooth
or lobulated surface.   A small growth of this  kind, which we had the
opportunity of  examining through the kindness  of  Mr.  I. B.  Brown,
had a short pedicle, was of the size of  a  pea, rather  highly vascular, of
lobulated aspect.   It consisted entirely  of Lieberkiihn follicles, and of
     Piles, after excision, showing the dilated veins, of which they are in a great measure composed.

low folds or ridges covered with well-marked columnar epithelium, and
mingled with only a small quantity of fibroid tissue.  Hemorrhoids de-
pend essentially on a dilated condition of the veins of the rectal mucous
membrane, and  are quite analogous to  the varices of the legs, which
are so common.  They are named internal, or external,  according as
they are situated above or below the sphincter.   Although  all take
their origin in dilatation of the haemorrhoidal veins, yet in their subse-
quent progress  they come to  present  different appearances, which we
proceed to notice.  The first  variety, sometimes  termed  mariscse, are
described by Dr. Copland as " fleshy tubercles, of a brownish  or pale-
red color,  situate within the anus, or  descending from  the  rectum.
They have  a somewhat solid or spongy feel; and when divided they pre-
sent a compact, or porous and bloody surface.   As the blood oozes from
the cut surfaces, they become pale and flaccid."  Whether internal or ex-
ternal, they often contain a central cavity filled  with fluid, or  coagu-
lated blood, of a dark color.   " More frequently, there is no  regular 
    ABNORMAL CONDITIONS OF THE INTESTINAL CANAL.   503

cavity, the substance of the  tumor being  as  if infiltrated with blood,
which becomes coagulated and dark;  but this appearance is not owing
to extravasation, but rather to a dilatation  of a number of small vessels
which traverse the tissue in the direction of the axis of the rectum;  as,
upon dividing the part  longitudinally, numerous dark  streaks are seen
in its substance, while  a section  made  transversely shows only small
roundish specks."   These tumors elongate, assuming a conical  form
with bases  larger than  their  necks.   Sometimes blood is exhaled from
their  surface, sometimes only a serous fluid, and sometimes,  when they
are external,  they are quite dry.   At first, they generally disappear in
two, three, or four days; but return again at an uncertain, or at a regu-
lar period, and increase in size, becoming firmer in texture.  " After
some  blood is evacuated  from them,  or  after  the determination of
blood to the  parts  has  ceased, they  collapse, leaving  small pendulous
flaps  of skin, which  ultimately  disappear if the  tumors  have  been
small;  but if they have been large,  these flaps continue  conspicuous,
and give a projecting and irregular margin to  the  anus."   Having
been strangulated by the sphincter, or repeatedly engorged with blood,
or chronically inflamed, these  tumors become more permanent and solid.
" The permanent state of the tumors is owing partly to the development
of capillary vessels, and partly to the effused blood and lymph becoming
organized; this latter circumstance especially giving rise to the excres-
cences, or irregular mass of tumors found around the anus in those sub-
ject to haemorrhoids."   The  second  variety  of  haemorrhoidal tumors
includes such  as are  formed  by a pure  dilatation, or varicose  state
of  the  veins  of  the part.  Dr. Copland,  from whom we continue to
quote,  describes  them " as not so disposed  to  enlarge  at particular
periods, and  as  more permanent, and less painful, than" the  first
variety.   " They are commonly of  a  dark or bluish color,  and soft
and elastic to the touch."   They are  easily  emptied  by compression,
but quickly fill  again.    " They  are round  and  broad at the  base,
and often  distributed in  irregular or  ill-defined  clusters," which ex-
tend  often for some way up  the  rectum, sometimes eAren as far as the
colon.  " M.  Begin observes that, in most cases, the dilated, superficial,
submucous, or subcutaneous  veins are  only the  smaller  part  of  those

                               Fig. 226.
 A slightly lobulated tumor divided in its middle, and the cut surfaces exposed.  It was passed per anum.
It seems to have been formed by exudation taking place around varicose dilatations of the veins. The cavi-
ties seem to have resulted from the dilatation of mucous follicles.

surrounding the rectum.   Sometimes the lower  part  of  this intestine
appears as if plunged in the middle of a network of dilated and engorged
veins, forming a thick vascular  ring, the incision or puncture of  which
may give rise to  dangerous hemorrhages."   If,  in  consequence of  in- 
504  ABNORMAL CONDITIONS OF THE  INTESTINAL  CANAL.

flammation  on the congestion of the varicose vessels, exudations of
plastic matter take place around or in  the substance of these tumors,
they become more solid, and  more or less similar to those of the first
variety.   Sometimes the products of inflammation are deposited within
the dilated vessel, which induces its obliteration, and the atrophy of the
tumor.   Perhaps in some cases the reverse  takes place, a vein within
an originally solid tumor may become considerably dilated.   In short,
the varieties met with seem chiefly to  depend on the  predominance of
vascular  dilatation, or surrounding plastic  exudation.   A third variety
of haemorrhoidal tumors are described as of an erectile character.  They
are soft and spongy, and of a purplish color, and give rise to considera-
ble losses of blood.  Dr. Colles found in one case " bloodvessels of the
size  of crowquills, running for  some way  down the intestine,  then
dividing  each into numerous ramifications, and each forming, by the in-
terlacing of its  numerous branches, one of  these erectile or vascular
tumors.   The trunks and branches of these vessels wTere  covered only
by the lining membrane of the intestine."  Some haemorrhoidal tumors
appear to result from the effusion and coagulation of blood in the sur-
rounding tissue.  The reality  of this occurrence is denied  by Rokitan-
sky, but  we  quite acquiesce in  the remarks of Mr. H. Lee,1 that it is by
no means easy to determine wThether the delicate, smooth,  and shining
membrane lining the cavities  in which the coagula are contained, is the
lining membrane  of the venous system, or one of new formation derived
from the  blood itself.  He also notices the effect of haemorrhoidal tumors
on the mucous membrane around them, which is raised and  forced down
along with them when they are protruded beyond the sphincter, so that
at last it becomes permanently relaxed and "baggy.''   The female sex,
sedentary occupations, and constipation, are enumerated as the chief
cause of  haemorrhoids, to which wre should add  a plethoric  habit, and a
lax condition of fibre.   It does not appear at all proved that cirrhosis
of the liver, or obstructive disease of the heart, has  any marked influ-
ence in the production of piles, as  one  would  naturally expect.   The
mucous membrane thinned  over an haemorrhoidal tumor  is  prone  to
ulcerate, and the resulting sore, according to Rokitansky, is character-
ized by its seat in the vicinity  of the sphincters, its irregular shape, its
indented  and  sinuous flabby  margin of mucous membrane, and  the
ridges of similar  tissue  that surround or  pass over it.  These ulcers
may continue  to  burrow into  the surrounding  areolar tissue, and gh'e
rise there to abscess, and ultimately to fistula in ano.  This, however,
more  often results from inflammation being  set up in the deeper-seated
tissues, the  areolar and adipose, but still in  the vicinity of the bowel,
which advances to suppuration, and in  most cases makes  its way first
outwardly through the integument surrounding the anus, and afterwards
establishes a communication with the cavity  of the rectum by a small
aperture situated very constantly at the distance of an inch, or an inch
and a quarter, from the anus.   It does  not  clearly appear why fistula
in ano should occur so often as it does in persons prone to pulmonary
tuberculosis, and still less why its existence should  be preservative, at
1 Medical Gazette, August, 1848. 
ABNORMAL CONDITIONS OF  THE INTESTINAL CONTENTS.   505

least  in  not a few  cases, against the  invasion of the dread malady.
Cancerous disease attacks the rectum in most of the forms mentioned as
affecting the whole intestine; the only one which it seems desirable
especially to notice, is' that which gives rise to the annular structure.
This occurs  almost exclusively at the upper portion of the rectum,  espe-
cially at the junction of the sigmoid  flexure; the strictured  part  is
sometimes unattached, more often firmly agglutinated to the promontory
of the sacrum, but is, nevertheless, pushed  doAvn  by the feculent  accu-
mulations above, so as to be within reach of examination by the finger.
    VII.  ABNORMAL CONDITIONS OF THE  INTESTINAL
                           CONTENTS.

  The secretion of an excessive quantity of gas from the lining mem-
brane  of the intestinal  canal  constitutes  the  most ordinary form of
Tympanitis.  It often occurs in  inflammatory  affections of the canal,
which induce more or less paralysis of the coats, in consequence of Avhich
the gas is  not  expelled, but goes on  accumulating.   The  gas  in the
stomach of an executed criminal was found by Magendie and Chevreul
to consist of atmospheric air with a  part of its oxygen replaced by car-
bonic acid, and  some hydrogen.  In cancerous strictures of the pylorus,
and in chronic catarrhal states,  the gas contains but little oxygen, much
carbonic acid, probably also hydrogen, and carburetted hydrogen, and
constantly  also sulphuretted hydrogen.   In  the  small  intestines of
criminals, Magendie and Chevreul found an abundance of hydrogen and
carbonic  acid, no oxygen,  and  a varying  quantity of nitrogen.   Mar-
chand found in the gaseous contents of the large intestines carbonic
acid, nitrogen,  hydrogen, carburetted hydrogen, and a small proportion
in one case of sulphuretted hydrogen.   That these gases are secreted
by the mucous  lining, and  do  not proceed  from decomposition of the
ingesta, is considered improbable by Lehmann.  We cannot, however,
coincide in his  opinion, at least to the exclusion of the first-mentioned
way of production, if for no other reasons, on  account of  the  experi-
ment performed by Frerichs, which  he himself details, that a portion of
intestine emptied of its contents, and isolated from the rest of the canal
by two ligatures, always became full of gas after being left some  time.
Mucus in any appreciable  quantity can scarcely be said to exist in per-
fectly healthy intestines; but it is secreted abundantly, as we have seen,
under catarrhal  irritation.   Rokitansky  applies  to  it the following
epithets in  various cases; it is either milky white, yellowish, and puru-
lent, or glutinous, transparent,  vitreous, spawny.  He also states "that
there can be no doubt  that a peculiar gelatinous constitution of the
mucus is the nidus of intestinal  entozoa, and the cause of helminthiasis."
Under irritation of an  acute character  small  membranous patches of
mucus are often passed; we have seen these in a case of dysentery con-
stituting the whole of the scanty evacuation.   Between these  and the
fibrinous tubular formation before  noticed, there is no very essential
difference, and both are to  be  distinguished from certain membranous
substances which occasionally appear in the evacuations, and may cause 
506   ABNORMAL  CONDITIONS  OF THE  INTESTINAL CONTENTS.

some perplexity to  the  patient and physician, unless their  nature be
understood.   These are simply the undigested remains of some tendin-
ous expansions,  which contain a great deal of yellow elastic  fibre, on
which the gastric juice seems to act with much less energy than on the
white.   Rokitansky says that "the occurrence of an excessive elimina-
tion of feces from the intestinal  secretions is  an established fact.  It
takes place  as  a critical discharge in various  diseases," but may also
occur as  an  idiopathic affection, "which may, by the excessive drain  it
causes, give  rise to atrophy of the intestinal coats, and to general emaci-
ation.
   Concretions are occasionally met with in the intestinal canal, and in
rare instances of very large size.   Dr. Monro  (Primus)  observed  some
varying from five to eight inches in circumference, and Monro (Secundus)
removed one from  the  colon which weighed four  pounds.   Sometimes
several, as many as thirty, exist together, but commonly there  are not
more than two.   The color of the smaller resembles that of iron ochre,
the larger are more of a coffee color, and occasionally whitish.   "They
are generally found in concentric  layers, and are often radiated, some-
times very obscurely from nuclei.  They are more or less porous, either
spheroidal or oblong,  and vary from the size of a pea to that of a  hen's
egg, or  still larger."   The nuclei of concretions may  be gall-stones,
fragments of bones, fruit, seed, &c, round which saline  and animal or
undigested matters  collect and become condensed.  In Scotland, where
oatmeal  is much used as an article of food, the fibres of the husk of the
oats have been found to constitute a large part, or nearly the whole of
the concretion;  and in a similar manner, chewed paper, the several por-
tions being  matted  together by mucus with fecal and earthy matter, has
been known to cause  their formation.  Such concretions often exhibit
no distinct nucleus.   Concretions, which may be mistaken for gall-stones,
but which are of a fatty nature, are  sometimes voided  by persons Avho
suffer from a torpid state of the bowels, and deficient digestive function.
Dr. Copland describes them as of a globular form, varying from the size
of a pea to  that of a large grape, of a cream color, slightly translucent,
and of the  consistence of soft wax.   It is probable  that these concre-
tions, as well as the evacuations of a more fluid fat which occasionally
take place,  are connected in some  measure with disease of the pancreas.
Observation of  disease has in several" instances shown  the coincidence
of the two phenomena;  and Bernard has offered a physiological explana-
tion, viz: that the  use  of the pancreatic secretion is to make the fat
contained in the food capable of being absorbed.   His results, however,
are  denied  by  Frerichs, Bidder, and Schmidt.  Blood is  sometimes
effused in greater or smaller quantities into the intestinal canal.   This
may result from active or  passive hyperaemia, ulcerations, purpura, scor-
butic dysentery, and  we have once seen it in a case of death from a
severe fall. 
CHAPTER  XXXIII.
          ABNORMAL CONDITIONS  OF  THE LIVER.

  Congenital malformations are rare; absence of the liver is only ob-
served in extreme cases.   Sometimes the left lobe  retains, in a greater
or less degree, its foetal proportion  to the right.
  Congestion.  The vascular  apparatus  of the liver is  very large, its
capillaries are more capacious than those of most other parts, and the
caliber of the portal, and especially of the hepatic veins is extremely
ample.  It is, therefore, capable  of containing a very large quantity of
blood.   Though its  surface is closely invested by its capsule, yet this
membrane allows of a good deal  of distension, and this  is also attested
by the tortuosities of the arterioles  of the surface, which probably exist
for the purpose of allowing the vessels to be  elongated without injury
to their texture.  Congestion of the liver may  be general or partial.
The latter is far the more common  condition, and, indeed,  in its lower
degrees is not morbid.  The central parts of the  lobules, in  perfectly
healthy livers, are often seen to be  marked by a spot of redness which
occupies about the middle tAvo-fourths  of the  whole diameter.  This is
produced by the blood,  as the circulation gradually failed, having stag-
nated in the hepatic veins, in  their  radicles, the intra-lobular veins, and
the surrounding capillaries.  Mr. Kiernan named this, "Hepatic Venous
Congestion of the first degree."  When the congestion extends further
in the direction backwards,  there are seen no longer mere spots of red-
ness,  but  patches of very  irregular shape surrounding, more or less
completely, portions that are not congested.  These portions are situated
at the interlobular spaces, where three or more lobules adjoin.  Such a
condition was named by Mr. Kiernan, " Hepatic Venous Congestion of
the second degree."   This may coexist with a perfectly healthy condition
of the cells  which occupy  the "meshes of the capillary  plexus, but not
unfrequently these are variously altered, and  thus  give rise to some
modification  of the appearance.
  The "nutmeg" condition may  be here referred to; it consists, in its
best-marked  instances,  of deep  red congestion, forming  patches and
streaks, occupying the central parts of the lobules, and surrounded by
patches of a grayish, or dirty white color.  The congested portions are
most definitely limited, and the contrast between them and the pale parts
is extremely striking.   This probably depends on the circumstance that
the portions thus devoid of  blood are  affected with fatty degeneration,
a change which, by causing the cells to increase in bulk, occasions com-
pression of  the interwoven capillaries.   That this is the true cause of 
508         ABNORMAL  CONDITIONS OF THE LIVER.

the limitation of the congestion is proved by its  exactly ceasing at the
inner margin of the zone of fatty degeneration.   Many of the  cells in
the congested part are seen filled with dark yellow matter; very many,

                                 Fig. 227.
Section of liver, showing the nutmeg appearance; the dark parts are the deep red congested central parts of
                                 the lobules.

also, are atrophied,  probably in consequence of the pressure exerted by
the distended capillaries.   The nutmeg appearance may be exhibited in
some degree, by livers which are quite free from fatty degeneration, but
it is never so marked as  in the condition just described.
  When the congestion extends still further and becomes general, occu-
pying every  part of the  liver,  the organ presents  a  deep red color
Fig. 228.
 (a) Section showing lobules of the liver, bounded by marginal zones In a state of fatty degeneration.  The
interior of the lobules is deeply congested, and contains much dark yellow pigment in masses.
 (b) Cells loaded with pigment, atrophied cells and granular matter from the interior of the lobules.

throughout, though, even in this case, the centres of the lobules present
the darkest tint;  it is also enlarged  often  to a  greatly increased size, 
            ABNORMAL CONDITIONS OF THE LIVER.         509

and becomes more firm and prominent, so as to be  readily perceptible
to the touch, below the margin of the ribs, on the right side.   The result
of injecting a  liver which is nearly drained  of its blood, as one taken
from a slaughtered sheep, is very instructive as to  the  amount of en-
largement that may be produced by congestion.   The organ  swells up
as the fluid is thrown in, and when fully injected, is of nearly double its
former size, greatly more dense  and solid, with its thin anterior margin
prominent and  hard.   Such a state may well produce a sense  of weight
and fulness in the right hypochondrium.
   The most frequent cause of congestion to  any degree that can be con-
sidered morbid is organic disease of the heart, especially such as produces
great obstruction to the circulation, and throws the blood back upon the
right side of the heart, and the  venous system  in  general.  All causes
of apnoea produce the same effect, and act in the same way.  Congestion
thus induced is passive; active  congestion takes place in inflammation
of the liver, or, as we  have observed, when  large  doses  of  calomel are
administered.   The congestion  which occurs in the cold stage of ague
and other fevers, seems to depend simply on the recession of  the blood
from the surface, and  is, therefore, more of the nature of passive than
of active.
   Portal venous congestion is a rare variety of partial; the centres of
the lobules are  pale, and are surrounded by  continuous red zones.  It is
said to occur in children only.
   Congestion of the liver, although extreme, does not seem to occasion
any structural change, if it  is only temporary; but if, as in the case of
obstructive cardiac disease, it results from  a permanent  cause, and is,
consequently, itself permanent,  it produces the following effects: The
distended capillaries of the portal-hepatic plexus, press on the  intervening
cells; these become, in  part, atrophied or stunted, in extreme cases almost
destroyed: in part, they are gorged with yellow matter to such a degree
that they appear as opaque masses.  The quantity of yellow matter thus
formed is far greater than any that exists in  healthy states of the organ,
and, as some of it  is doubtless absorbed and carried into the blood, we
find in this circumstance some explanation of the icteric hue which is so
often observed  in such  patients.   The connection which certainly exists
between the congestion and the yellow engorgement of the cells, as cause
and effect, gives additional support to  the opinion that the  yellow bile-
pigment is  a modification of, and derived from, the coloring matter of
the blood.   Whether  long-continued congestion produces still further
changes, is not yet made out clearly.  We have often thought that the
lobular parenchyma was infiltrated by a  dense, homogeneous, solidified
blastema, distinct from the debris  of the atrophied  cells, but this may
have resulted from  a different cause.
  Hemorrhagic effusion may take place  as  the result of extreme con-
gestion, but this is rare; the blood may be  poured  out  either on the
surface, detaching the  capsule for  some extent, or deeper in the sub-
stance of the organ. The former occurrence, Rokitansky states, is most
common in infants, and may even proceed to such an extent as to rupture
the serous investment,  and allow the escape of blood  into the peritoneal
cavity.  The deep-seated extravasations occur more frequently in adults 
510         ABNORMAL CONDITIONS OF  THE LIVER.

than the superficial, and constitute apoplectic  spots of various forms and
size.  After their partial absorption, a  cellulo-fibrous cicatrix remains.
  Inflammation of the liver must be considered as affecting either the
substance of the organ, chiefly, or its capsule.  The former is, in tem-
perate climates, a  rather rare affection, the  latter  extremely common.
Acute inflammation of  the parenchyma of the liver produces general
congestion and more  or less softening.   "These effects," Rokitansky
says,  "are confined to one or more patches; the congestion, though
general, is not universal.   The viscus is swollen in proportion to the
number and size of the inflammatory patches, and this tumefaction is
particularly perceptible when a section is made, the turgid tissue  rising
above the edges of the incision and the peritoneal sheath."  The paren-
chyma "is loosened and lacerable;"  this depends in great part on the
cells losing their natural cohesion together, so that  they no longer form
radiating series.   In the latter stages of inflammation, the red color of
active congestion fades, and is replaced by a brownish or grayish-red
tint in some parts, with yellowish-red or pale-yellow in others. Abscess
is a frequent result of acute inflammation of the liver: it is sometimes
preceded by a short stage of  diffuse suppuration,  when the form of the
lobules can still be recognized, though their substance is  very soft and
of a yellowish color.  The commencing abscesses are at first very  small,
like spots of purulent matter dispersed here  and there through the in-
flamed and softened  tissue;  they gradually enlarge,  several coalesce
together, and thus form cavities of irregular shape and size.  The pa-
rietes of the abscess are uneven, presenting the remains of former par-
titions ;  they are covered by a kind of pyogenic membrane, which consists,
in great part, of pus-globules; external to this, the wall  is  formed by
hepatic  tissue, infiltrated with exudation-matter, which serves to  bound
and limit the abscess, as in the case of a common phlegmon.   In very
small abscesses, and  those of very recent formation,  as  also in cases
where the vital powers are  greatly depressed, this limitation of the
abscess  by exudation-substance does not take place; on the other hand,
in old abscesses, and those of very large size, occurring in tolerably
healthy systems, a  strong enveloping cyst may be found, consisting of
fibroid tissue, and amounting sometimes to three  or four lines in  thick-
ness.   If the  abscess  be deep-seated and encysted, it may  continue,
especially if of small size,  for a long time, without increasing much, or
producing serious disturbance of the health; but, if it be near the sur-
face, it  excites inflammation of the serous investment, and effusion of
lymph, which soon unites its wall with the part with which it is in contact.
This may be the wall of the abdomen,  or  some of its  contained hollow
viscera, or the diaphragm which roofs it in above;  and by any of these
various  routes the abscess may  extend, and at length discharge its con-
tents.   By extension, also, in the parenchyma of the liver, the abscess
may reach a branch of  the portal vein or of  the hepatic,  excite inflam-
mation of its coats, and consequent obstruction  of its canal by exuded
fibrin.  When the enlarging abscess reaches an hepatic duct-branch, it
affects it in a different Avay; it does not set up inflammation in its walls,
and cause its obstruction (though  this may no doubt occur in some of
the smaller), but it ulcerates through its tunic, and establishes a commu- 
ABNORMAL CONDITIONS OF  THE LIVER.         511
nication between the efferent channel and its own cavity.   Hence, it
occurs that the pus contained in large abscesses is always mingled with
a considerable quantity of bile, while that of the smaller and recent
abscess is almost pure.  An  abscess of the liver  may sometimes heal
either after  the evacuation of its contents,  or after  they have been
absorbed; the latter occurrence is, we should conceive, exceedingly rare.
In either case, the walls of the abscess approach each other, and at last
collapse together, including sometimes a quantity of solidified purulent
matter, which at  a later  period  forms a cheesy or cretaceous  mass,
attesting,  by its presence in the midst of the cicatrix, the nature of the
changes which had previously taken place.
   Several  different causes have  been assigned for the formation  of
abscess in the liver, but none are probably nearly so  effective as that
to which Dr. Budd has especially  drawn attention.   Dysenteric ulcera-
tion,  or any accident producing inflammation of the veins that originate
the V. Portae, charges  the current of blood proceeding to that organ
with puriform matter, which, in its passage through the  capillaries of
the lobules  sets up secondary inflammation, attended  with albuminous
exudation, and terminating quickly in the formation of matter.  It is
not clearly made out in what way injuries  of the brain  act in  producing
abscess of the liver; but it is probably in the  same way, though by a
less direct channel than that just  described ; so, also, many regard  the
occurrence of the so-called secondary depots in the liver, subsequent to
amputations, and  other great  operations,  as the result of  phlebitis at-
tacking the veins of the injured  part.  The only other causes which
can be named  with any certainty as producing abscess  are, external
violence inflicted on the region of the liver, and violent  acute inflam-
mation of the organ, such  as  occurs in tropical climates.  It is worthy
of remark, that typhoid and tuberculous ulcerations of the intestines,
as Avell as those consequent on burns, do not, at least, have not yet been
observed to, produce abscess of the liver.
   The capsule of the liver is very often indeed attacked with  inflamma-
tion,  or presents,  on post-mortem  examination, such changes as  are
usually ascribed to this process.   Bands of adhesion of various length,
and  attaching different parts of  its  surface to contiguous organs, are
very  often  found:  these  are pretty certain evidences  of  an acute  or
subacute by-past hepatitis ; they are  often traversed by newly-formed
vessels which  establish  a communication between the capsular arterioles
and the contiguous vessels of the general system.  In a specimen which
we injected, the vessels of a patch of false membrane, on the surface
of  the capsule,  are seen to be of  much greater caliber than the vessels
in the adjacent  healthy part.   Adhesions commonly  form, as said, over
superficial abscesses of the liver:  it is rare that  this  fails to take place,
and that an abscess bursts into the peritoneum.  Over hydatid tumors
and cancerous masses they are less frequently formed.  Dr. Budd par-
ticularly notices their absence, and considers that their production is the
exception and not  the rule.  This may,  perhaps, be  in some measure
accounted for by another  circumstance relative to cancerous  tumors in
this organ, mentioned by the same observer, viz : that they seem capable
of  tainting Avith their  own peculiar  morbid action,  opposed parts with 
512         ABNORMAL  CONDITIONS OF THE LIVER.

which they come in contact;  such tainting of a part may be conceived
to be quite inconsistent with the effusion of comparatively healthy lymph.
The capsule of the liver is  very frequently found thickened,  appearing
whiter,  more  opaque, and  dense; this thickening generally occurs in
patches of various size, which sometimes coexist together with the bands
of adhesion just noticed, but quite as often are independent of them, or
coincident with similar thickenings of other serous membranes.  It seems
doubtful whether these changes should not be more properly classed as
degenerations than as inflammations.
   Gangrene of the liver is very rare;  Rokitansky well  observes  that
" it is developed in parts affected with inflammation and suppuration,
not  so much as a result of  intense inflammation as of  certain peculiar
conditions which cause a tendency to gangrenous  degeneration."  These
peculiar conditions may be probably either low, unhealthy states of the
general system, or, as in the interesting case recorded by Dr. Budd, the
septic influence of a previously healthy part which had been affected by
gangrene.
   Phlebitis  of the portal  or hepatic vein-branches  has  already been
alluded to as resulting occasionally from  abscess of the  liver, but it may
be produced by other causes.   A fish-bone has been known to perforate
the wall of  the stomach and the head of  the pancreas, and  wound  the
superior mesenteric vein, exciting thus inflammation of the coats of the
vessel which extended to the divisions of the portal  vein.   The effects
of phlebitis are the same in these as in other veins; it may simply occa-
sion the effusion of lymph and blocking up of the channel with fibrinous
coagula, or  it may also proceed in some portions of the vein to the form-
ation of pus.1  In the former case, when  the inflammation has subsided,
the obstructed vessel gradually shrinks, and is reduced to  a fibrous cord,
while the surrounding tissue to which it was distributed, being deprived
of its supply of blood, atrophies and falls in, so that the course of the
vein is indicated by a deep linear fissure.  If suppuration occurs, a string
of small abscesses is  produced in the tract of the obliterated vein, the
abscesses being connected together by a dense fibroid cord.   The con-
sequence of such attacks must be  the diminution, to a greater  or  less
extent, of efficient hepatic parenchyma, and as the importance  of  this
structure to the due performance of nutritive absorption is very manifest
(were it attested only by the intimate relation in  which it is placed with
the portal blood), it seems very probable  that the abiding  emaciated and
enfeebled condition of many  persons who  have  suffered inflammatory
attacks of the liver,  really depends on their having-been thus deprived
of a greater or less part of this important organ.
   Cirrhosis.—A liver which  is affected by this change  in  an extreme
 degree is remarkably altered.  It  is  much smaller than  natural, much

   1 In a case  occurring at St. Mary's Hospital, all the portal veins throughout the liver,
up to those of a very small size, were converted into channels with ragged walls filled with
 a  tenacious pus.  Here and there the vein-channel was enlarged into an irregular pouch,
but there were no distinct abscesses.  _ The cause of the phlebitis appeared to have been
 a  patch of ragged ulceration at the origin of the portal vein. The parenchyma was not
 atrophied. The hepatic ducts were not inflamed, but the gall-bladder and duodenum ap-
peared so. 
            ABNORMAL  CONDITIONS OF  THE LIVER.         513

paler, and  instead of presenting  a smooth  surface, is contracted and
puckered so as to resemble, according to a former observer, " a conge-

                               Fig. 229.
     Section of liver in a fatty state, with abundant new-formed fibrous tissue between the lobules.

ries of little firm  globules like the vitellarium of a laying hen."  These
globular portions are of various sizes, and evidently  consist of  paren-
chymatous substance; they are surrounded, and  as it were capsulated
by firm fibroid tissue which extends  throughout the whole liver, and
gives it a remarkable degree of density and firmness.   This fibroid tissue
is evidently a new formation, and as such tissue frequently does, it con-
tracts and  shrinks together, and so draws in the surface at various parts
as to produce the irregular  nodulated, or " hobnail"  condition, as it is
familiarly termed.   The same  shrinking also  affects  the vessels which
supply the liver; they are surrounded and ensheathed by fibrous tissue
in the healthy state, and when this is morbidly thickened and condensed,
the pressure exerted upon them  narrows their channels and materially
diminishes the quantity of blood which they are able to convey.  Hence
the portal  current is checked at its very origin, and the congested capil-
laries  are  obliged to relieve themselves by effusion of  serum into the
peritoneal cavity.   The capsule of a cirrhotic liver is sometimes smooth,
sometimes thickened or attached  by adhesions to adjacent parts; these
adhesions  are often traversed by neAvly-formed vessels, which  form a
kind of collateral circulation between the portal vein and the general
system.
   Such is a brief description of a liver affected with ordinary  cirrhosis ;
but there are other conditions of the organ, essentially similar, in which
the  external appearances are very different.   The organ is  firm and
dense  evidently  from the presence of an increased quantity  of fibroid
tissue; but  its  surface  is not puckered, or but slightly, nor  its edges
rounded ;  instead of being pale, it may be highly congested with blood,
usually of the hepatic  venous second  degree, this often  depending on
obstructive cardiac  disease.  Microscopic examination  shows that the
quantity of fibroid tissue forming the Glissonian sheaths is considerably
increased, sometimes to such a degree as  to encroach on the  lobules to
        33 
514         ABNORMAL CONDITIONS  OF THE  LIVER.
a great extent, and produce atrophy of their substance.   It is possible
that some livers which present these appearances may be  in an early
stage of cirrhosis,  and would subsequently become contracted and nodu-
lated ; but we  strongly incline to the  belief that this  is not the case

                               Fig. 230.
  Fibres originating from nuclei from fibrous tissue of a cirrhotic liver.  Some cells are figured of the natural
                       size, others are very much atrophied.

with the majority, and that the morbid alteration is somewhat different.
The difference  probably consists in the  more  general and  extensive
formation of fibroid tissue throughout the liver, in its being less confined
to the portal canals.   It is rather remarkable that the  hepatic cells in
extremely contracted cirrhotic livers present a tolerably healthy aspect;
their nuclei are distinct, and though, perhaps, containing less oil than
usual,  they  are by no  means destroyed or seriously altered.   They  are
far more affected in the dense, firm, uncontracted livers, partly as  the
result  of congestion with impletion of yelloAV  matter, partly by atrophy
from the encroaching fibroid tissue.  The minute ducts which run  in
the smaller  portal canals and betAveen the lobules are  often atrophied
by the pressure of  the condensed fibrous tissues, so  that they can  no
longer be detected;  in this way the biliary secretion may be materially
interfered with.
   It seems to be proved by the observations of Dr. Bright  and Dr.
Budd  that  in  the  early stage  of cirrhosis the liver is enlarged ; this
would  seem  to depend on the effusion  of lymph  and serum  within  its
texture during the  existence of inflammatory action.   In  many cases
there can be little  doubt that  this is the case,  and that the  cirrhotic
change results from a  subacute inflammatory  action being set up in  the
Glissonian sheaths.   But in many cases we are  disposed  to think  the
process is different; that, both in the finally contracted and uncontracted
livers,  the fibrous tissue is hypertrophied and  condensed  rather  by a
degenerative action than by one which  can  be  termed inflammatory.
The change seems to be of a similar kind to that which produces carti-
laginoid induration of  the capsule of the spleen, stiffening of the valves
of the heart and contraction of its  orifices, which can scarcely be  re-
garded as of inflammatory origin.  We  are  confirmed in this view by
having often observed  various minor degrees of condensation and thick-
ening of the Glissonian sheaths  in cases  where  there was no  trace of
inflammatory action, as well  as by a  circumstance which  hitherto has
been quite unexplained.  This is, that the spleen, albeit exposed to  the 
            ABNORMAL  CONDITIONS OF THE LIVER.         515

backAvard pressure of  the  blood retarded  in  the  splenicvein, does  not
become distended in the way that one would expect, but is often, on the
contrary, small and soft.   In such spleens, we have often observed very
many of the nuclei throwing  out fibres,  which  is certainly not their
natural metamorphosis; and hence it seems not improbable that in this
way, OAving to the increase of  fibrous tissue in its substance, the paren-
chyma of the spleen is less distensible than usual, and has  a contrary
tendency to shrink and collapse.
   The remote cause of cirrhosis, in  many cases, is certainly the habit
of spirit-drinking:  the alcohol  absorbed into the portal blood  first passes
through the liver, and very  probably exerts some action  on its tissue.
This suggests the idea of  the spirit acting as a  local irritant, and with
this Dr. Percy's  observation of the  greater affinity of alcohol  for  the
liver than for other organs in  animals  poisoned by it seems  to harmon-
ize.  But it is most probable that the crasis of the blood is also changed,
and that this fluid comes  to be in that condition which Rokitansky de-
nominates the fibrinous crasis.   This would also account for  the similar
changes which are often found in other parts coexisting with cirrhosis.
Obstructive cardiac disease  is  probably not a direct cause of cirrhosis
in any of its forms or degrees, but certainly must be a predisposing one.
Congestion favors the occurrence both of inflammation and of degenera-
tion.   Both the heart disease (e. g. constriction of the mitral orifice),
and the cirrhotic change  in the liver, are often, no doubt, common re-
sults of the same condition of the blood, viz:  that to which we have
above alluded.   There are,  no doubt, other  exciting causes  besides the
ingestion of alcohol,  but  they can  scarcely be  particularized;  we be-
lieve them to be in general  such as increase the  quantity and alter the
 quality  of the fibrin of the blood.                           _
   The next condition of  the  liver which we shall describe is that ot
fatty degeneration.  A liver  thus affected is usually much enlarged,

                                Fig.  231.
m of liver in an advanced state of fatty degeneration. The cells are much broken up ani fused
                          together.

 than natural, and, in most  cases, softer: sometimes, however, it
 feelino- of  great solidity.  The capsule, in cases of uncomplicated 
516         ABNORMAL CONDITIONS OF THE  LIVER.
fatty degeneration, is not thickened, nor attached by adhesions to adja-
cent parts.   The thin edge of the organ is somewhat rounded, and the
thickness generally increased.  On microscopic  examination, it is at
once seen that the hepatic cells are engorged with oil: instead of con-
taining a few minute drops  imbedded  in  a mass of granulous matter,
they are filled to the  extent of one-half or  two-thirds, or  even their
Avhole cavity, with colorless fluid oil.  Sometimes a  quantity of  yellow
matter is also seen in the cell-cavity,  together with  the oil,  but  this is
often absent.  The nucleus disappears, as is generally the case in cells
that have fulfilled their work of secretion, but the envelop persists, and
is sometimes  a little thickened and striated.  In very advanced cases
the cells are not found merely gorged with oil, but,  to a great  extent,
broken up and lost; in their place there are  seen only granular debris,
entangling multitudes of  oil-drops  of  different sizes.  There seems to
be less tendency to the development and growth of young cells than in
the healthy state; those that are forming appear stunted, and many be-
come very early  the seat of oily  engorgement.   The  fatty change is
very often confined  to the margins of the  lobules, and is  always, we
think, most adA'anced there; sometimes, however, it may commence in
the centres  of the lobules.   The pale condition of the liver  depends on
the enlarged size  of the  cells, Avhich  are  pressed closer together, and
thus constrict the capacious capillaries  and allow less blood  to be con-
tained within them.   There is, however, no obstruction to  the  Aoav of
                              blood, such as we have seen in cirrhosis;
                              the soft  state of the oil-laden parenchy-
                              ma sufficiently accounts for  this.  We
                              think it  most probable that fatty degene-
                              ration  does not consist merely  in  the
                              impletion of the  cells with  oil, in their
                              containing  a  greater  quantity of  this
                              matter  than  they naturally  would,  but
                              that  there  is  an  actual impairment  of
                              their development and nutrition, of their
                              active power of formation and secretion,
                              so that the tissue really undergoes  a kind
                              of decay.   In  support  of this view, Ave
                              may  mention that Ave  have  scarcely ever
                              found sugar present  in  the parenchyma
                              of a  thoroughly fatty liver, Avhile  it can
almost always be detected in livers that are not so affected;   this  is cer-
tainly a remarkable  fact,  and  seems to show that one very important
function  of the liver  in  such cases is, at least, very imperfectly dis-
charged.   It is an interesting fact,  that the  bile in these cases under-
goes no constant or necessary alteration ; it is sometimes unusually pale,
but often has the dark green tint of ordinary bile.  The minute ducts
are tolerably natural, and doubtless  continue  to  discharge their part of
the bile-secreting process.  A fatty condition may coexist with  a con-
siderable degree of cirrhosis.   The  appearance of a section under  the
microscope is then very remarkable; the lobules appear as opaque islets
 (a) Empty envelop of an hepatic cell
from which the oil lias efcaped.
 (b) (c) (d) (e)  Hepatic cells  containing
much oil. 
            ABNORMAL CONDITIONS OF THE LIVER.         517

separated more  or less Avidely  from each  other, by more  transparent
spaces of fibroid tissue.
  There is a variety of the fatty liver which is termed the waxy.  It is
described by Rokitansky as having a color resembling that  of beeswax,
and being more consistent  or firm, dry, and  brittle than the ordinary
fatty  liver; the  color  probably  depends on the presence  of yellow bile-
pigment in the cells, and the increased firmness and brittleness on  the
oil being replaced by some of the more  solid kinds of fat.
  The proximate cause of  the production  of fatty liver  is, we  believe,
the existence of an  undue quantity of  oily matter in the blood, in pro-
portion to the assimilative power.   In  cases  of disease, it  is also very
probable that the vital power of the  hepatic cells is much lowered.   It
may,  therefore, occur:  (1.) When an animal is largely fed on food con-
taining much fat.   (2.) When, in  the course  of an exhausting  disease,
rapid emaciation takes  place, and causes the blood to become loaded with
oil from the waste of the adipose tissue.  (3.) When the type of  respira-
tion is low, and  the blood necessarily, therefore, contains much hydro-
carbonous matter.   In the first and third class there may be simply
accumulation of a large quantity of oil  in the tissue of  the liver; in  the
second there is generally, also, more or less degeneration of the hepatic
structure.   AVe  have verified this by  positive observation, as respects
the first and second class.   Animals fed for  some time with fatty food
have  their livers loaded with oil, but the cells are not at  all destroyed;
they  contain much oil, and  much  also is deposited between them.   We
have  found the liver, in persons dying,  in a condition of extreme emaci-
ation from other diseases besides pulmonary phthisis, in a  complete state
of fatty degeneration, and  this has  occurred so often, that we should
expect to find it in most cases of great  general wasting.   It is certainly
the emaciation of consumptive disease that produces fatty transformation
of the liver, and not the mere destruction of the oxygenating apparatus.
This  statement is strongly confirmed by the analysis of about a hundred
cases, in which we examined, microscopically, the condition of the liver.
Among them, there were  eighteen  in  whom the liver was thoroughly
fatty, or nearly so; of them, only one died of pulmonary phthisis, four
others of scrofulous affections, the remainder  of diseases having no con-
nection with any form of phthisis; ten cases of phthisis occurring in  the
same list, presented either no fatty degeneration, or an  imperfect  and
partial change only.  A fatty state of  the liver is sometimes coincident
with  a similar condition of the kidneys,  but not by any means invariably.
   Another form of degeneration of the liver, is that which Rokitansky
has termed the lardaceous, or bacony.   This  term simply expresses  the
idea which the appearance of the morbid tissue conveys, and is, perhaps,
preferable to that of scrofulous enlargement, which  has  been given to
this form of disease by others, inasmuch as evidence is certainly wanting
of the new deposit being identical  or  similar to any known  kind of
scrofulous matter.  Rokitansky thus enumerates the characteristic  fea-
tures of this condition: "considerable increase of size and weight, with
remarkable lateral development and flattening of the organ; smoothness
and tenseness of the peritoneal  investment; a certain degree of doughy
consistency, combined with hardness andelasticity; anaemia; pale, watery, 
518         ABNORMAL CONDITIONS OF THE LIVER.
portal blood; gray, grayish-white, or grayish-red color, tinged with yel-
low or brown; the surface of a section being smooth and homogeneous,
resembling bacon." In thin sections it is well seen, under the microscope,
how the normal tissue is infiltrated with, and  partly replaced  by a_ho-
mogeneous, refracting substance; this forms  small masses of various
size, which lie heaped together between the hepatic cells, and so com-
press  and atrophy them, that  they form in many parts a kind of wide-
meshed plexus, the intervals of the plexiform bands being occupied by
the glistening bacony matter.   AVhen liq. potassae is added, this matter
loses much of its  refracting power, and is reduced to mere delicate films;
it  shoAvs no  trace  of organization, and  seems  to  be  deposited rather
between than  in  the  cells themselves.   The  cells, in  such cases, often
contain  oily matter, or yellow pigment; the oil  remains  very apparent
after  the action of liq.  potassae, and is very  distinct  indeed from the
bacony matter.   Deposits of similar matter  are not uncommon in the
spleen, and we have seen  it also in the  capillaries of the Malpighian
tufts of the kidney and in the gastric mucous  membrane.  The exact
nature of the substance thus deposited is unknown, but it is probably a
variety of  deteriorated albuminous matter.  Neither does it seem to be
special to any particular form of disease, but to occur  generally in per-
sons whose constitutions are gravely impaired.   Rokitansky states it to
concur with scrofulous and rickety disease, with syphilitic and mercurial
cachexiae, and occasionally to  appear as  a sequel of remittent fever in
cachectic persons.  We have  seen it produced in the spleen, as well as
Bright's disease of the  kidneys, apparently from the injurious drain on
the system occasioned  by an  empyema, discharging externally. The
presence of the abnormal matter in the tissue of the lobules causes ob-
struction to the current of the portal  blood;  it  is thrown  back on the
capillaries of the  intestines, and ascites or sometimes diarrhoea results.
   The next morbid condition of the liver which we shall consider is that
which exists in the various affections in which jaundice forms a  promi-
nent symptom.   There is little doubt  that  in  most cases a jaundiced
condition of  the  liver precedes and occasions a  similar condition of the
whole body.   General jaundice is commonly supposed to depend upon
the absorption into the blood  of bile that should have passed  out into
the intestine,  and this is,  doubtless, the cause of it in  many cases.  In
these, the bile locked up in the substance of  the liver causes  it to be
tinged yellow, a result which we have produced  artificially by placing a
ligature on the duct. com. choled. in animals.   But in many cases more
than this  occurs.   Dilatation of the heart, or obstructive valvular dis-
ease,  throwing back the blood on  the venous  system,  occasions  perma-
nent congestion of the liver, and often produces the  condition  termed
"nutmeg" in its  most marked form.  In this, as before  described, the
congestion is  exactly coextensive with extreme  yellow engorgement of
the cells; a much larger quantity of yellow matter is  contained in the
liver; there is hepatic jaundice, and together  with  this,  and, no doubt,
in  consequence  of it,  general jaundice frequently occurs.   In these
cases, we think the evacuations continue of their natural color; a certain
quantity at least  of bile flows into the intestine.  In most  healthy ani-
mals the cells of  the  liver have only a very faint, if any, yellow tinge, 
ABNORMAL CONDITIONS OF THE LIVER.        519
but, by repeated doses of calomel, we have caused the production of a
large  quantity of yellow matter in the cells; there is evidence  also to
show  that the same has occurred in the human subject.   In the acute
yellow atrophy, as Rokitansky names  that condition of the  liver which
is found in cases of jaundice occurring often in several  members of a
family, one  after another, attended with  symptoms of toxaemia,  and
proving fatal by coma, there must certainly be a greatly increased pro-
duction of yellow pigment.  The flow of bile Jnto the intestine  is  not
so completely stopped as it is  in  other  instances of jaundice, and  the
yellow coloration of the liver  is  deeper than it is almost ever seen.
Icterus neonatorum appears also to  be an instance of the excessive pro-
duction of bile or of  bile pigment:  there is evidently no disease of the
liver, or any obstruction in the biliary ducts, but  owing to the organ at
birth  being highly congested  with  blood, and  the  system  not  having
adapted itself to its new condition,^ greater quantity of yellow pigment
is formed out of the  coloring matter of the blood than  can be  readily
carried off by the bile; this again returns into the blood  and  produces
jaundice.   This  explanation seems preferable to that which assigns a
kind  of hyperaemic, or half-bruised state of the skin, as the cause of the
yellow stain; were this so, how could the conjunctiva come to be affected?
AVhen jaundice occurs in the course of fevers or in pyaemia, it then depends,
in all probability, on an alteration taking place directly in the haematin
of the blood, which, as  in the case of an extravasation, is changed from
a red to a yellowish tint;  in  this  case, there  would be  no preceding
jaundice of the liver.  It  is evident that, in all  instances of jaundice,
the unnatural tint results from the presence of a yelloAV (usually identi-
cal with bile) pigment in  the  blood ;  this is  easily demonstrable in the
urine and other secretions, by the stain imparted to  linen, or by the play
of colours which it  gives with nitric acid; but there is little or no evi-
dence to  show that real  biliary  matter is present in the blood or the
secretions.   From jaundiced livers  plenty of yellow pigment can be ex-
tracted, reacting with the  nitric  acid  test, but no  cholic acid,  or  any
substance that gives  the reaction of Pettenkofer's test.   The  blood, in
cases of jaundice, is  more often  found to  contain bile-pigment without
cholic acid, than the reverse.  The same  is the case with the  urine;  it
often gives  a  characteristic  reaction  with nitric  acid  when  none  is
afforded by the test of  sugar and sulphuric acid.   From these data, we
must conclude that jaundice depends on the presence of bile-pigment, or
some similar modification  of haematin  in the blood; but that it is by no
means certain that bile, as such, is  actually present.   It may be that,
in the graver cases of jaundice,  attended with toxaemia,  cholic acid, or
some modification of it, is present in the circulation in large quantity,
as Avell as yellow pigment.  The color of  the liver  in jaundice  is of a
more or less marked yellow, in some cases passing to a green or broAvn-
ish tint;  this will be, of course, modified, and more  or less concealed by
the blood contained in  the vessels.  There is no other particular change
to be noticed except in the acute yellow  atrophy.   Here, the color  of
the oro-an is an intense yellow; its  texture is flabby, a section shows
 nothing of the natural lobular  arrangement;  its size is greatly dimi-
nished, and  it seems almost or quite bloodless.   The blood in the large 
520         ABNORMAL CONDITIONS OF  THE LIVER.

vessels, is said  by Rokitansky to be reduced in consistence, and of a
dirty reddish-brown color, and the coats of the V. Porta? to be tinged
with bile.  Under the microscope, it is seen that the cells are completely
destroyed, and  even their nuclei have  perished; the parenchyma is a
mere mass of broken-up granular matter, tinged deeply yelloAV and con-
taining some largish yellow masses, together with diffused  oily matter.
In one instance which Ave examined, no  sugar could be  extracted from
the liver, though  it is usually abundant in  healthy organs; this  may,
however, have depended on the non-ingestion of food for some time  be-
fore death.  The  minute ducts we have  found gravely altered; they had
lost their natural structure, and  were filled with subgranular matter and
opaque whitish globules.  These globules, probably a kind of  concrete
oily matter, were very abundant in the  lymphatics, and  rendered  their
course remarkably distinct.
   The following may be enumerated as adventitious growths in the liver :
(1.)  Lipomatous tumors.  (2.) Cavernous tissue.   (3.) Tubercle.   (4.)
Hydatids.   (5.)  Cancer.  The  lipomatous  tumor  is very rare, and,
according to Rokitansky, seldom larger than a pea.   Cavernous tissue
is said by this celebrated pathologist to be of frequent occurrence;  we
doubt, however, whether  this is the case in England.  Its size varies
from that of a hempseed to that of a hen's egg, or  still larger; it is of
dark color, from  the  quantity of blood  occupying its cells,  and is thus
seen through  the peritoneum of the surface more or less prominent,
according to the degree of distension.   If its cells are empty, it is found
collapsed and  shrunk.   These  growths may be single or numerous.
 Tubercle is a deposit  not very unfrequent in the liver, at  least to a small
amount, but it is very rare  that  it forms large masses, or that  it under-
goes softening or other changes.   It  most  frequently appears in  the
shape  of semi-transparent, grayish, miliary  granulations,  or  of yelloAV
crude  tubercle; the masses are  of a small size, seldom  larger than, or
even so large  as, a pea; they are  generally few in number and widely
scattered.   We think Ave have often seen nodules of  fibrin deposited in
the substance of the liver, which might easily have been confounded with
the miliary granulations ; their microscopic characters would sufficiently
distinguish  them.  Rokitansky mentions a state of acute tuberculosis as
occasionally affecting the liver;  it is found  then "in a peculiar state of
turgescence, the  tissue relaxed,  friable, pale, and gorged with a serous
or sero-sanguineous fluid."   Such  an occurrence indicates a high degree
of tuberculous dyscrasia, "a tendency to universal tubercular deposition,
and especially in the abdominal viscera."   The tubercle  thus tumult-
ously  deposited occasionally softens and breaks down, but not exactly in
the way of suppuration that it  does in the lungs, and thus an hepatic
vomica may be formed, "which  offers no peculiar characters beyond the
biliary discoloration of its  contents."   It appears that such  a vomica
 may be occasionally confounded with  a  condition  to be  subsequently
 described, in which a cystic dilatation of the minute  biliary ducts takes
 place, the cavities of the cysts becoming  filled with a whitish  cheesy
 matter.
   Hydatid cysts are  of frequent occurrence in the liver, more  so in  this
 than in any other organ.   Sometimes they are single, sometimes there 
ABNORMAL CONDITIONS OF THE LIVER.        521
are several separate cysts.  They often attain a considerable size.   Ro-
kitansky mentions  one  in the Vienna Museum of  a foot in  diameter,
and we have very recently examined  one of  an oval  form, whose long
diameter measured six  inches.   Their usual site  is the right  lobe, and
the largest are  generally found here, but  the one  just mentioned was
situated at the extremity of the left, and had grown in, and far beyond,
the left lateral ligament.  As their size increases, they rise to the sur-
face of the liver, and sometimes excite inflammation of the serous mem-
brane, by which adhesions are formed connecting them with  the parts
adjacent.   The  prominent part is, of course, that  where least resistance
is offered  to the pressure of the  fluid within, and its wall may hence
atrophy and give way, or be destroyed in the  course of suppurative in-
flammation, and  the contents thus be effused into some neighboring
cavity.  The cysts  have been known to burst into the peritoneal  sac,
into that of  the right pleura, or into  the bronchi of  the corresponding
lung, into the duodenum or transverse colon, and in some rare instances,
into a large bloodvessel  or  branch  of  the  hepatic  duct.  When the
tumor, in its progress, causes ulceration of  one  of the smaller  ducts,
which is  not uncommon, bile makes  its way into the cavity, mingles
with and tinges its contents, and  very often excites suppurative inflam-
mation of the walls of the sac.  This seems to be the reason that hydatid
tumors in the liver suppurate much more frequently than those in other
parts.1  Other circumstances, however, may certainly cause these cysts
to inflame and suppurate.  The detailed description of the structure of
hydatid cysts will be found under the  head of Parasites, p. 218 ; it  will,
therefore, be sufficient  to mention here that  they possess an outer Avail
or envelop, formed of condensed areolar tissue and that of the  surround-
ing structure; within which, and  rather loosely  adhering to  it, is the
proper membrane.   This is white and laminated, and is itself lined in-
ternally by a softish layer in which the echinococci are developed.  The
cavity of the primary cyst is occupied in some instances  by a transpa-
rent limpid  fluid only;  in others, and  the majority, it also contains a
numerous  progeny of secondary cysts, which may themselves contain
another  generation.  Dr. Budd mentions  the interesting  fact, that  in
cases where suppuration has occurred in the cavity of the primary cyst,
the secondary hydatids, though floating  in purulent matter themselves,
contain a perfectly limpid fluid.   He  also points out characters Avhereby
to distinguish between an abscess and a suppurated hydatid cyst, in the
differences which the cystic membranes in the two cases present.   That
of an  abscess consists of dense fibroid  tissue, is not laminated,  and never
contains calcareous matter.   The hydatid membrane does not adhere so
firmly to the surrounding tissue, is markedly laminated, and in old cases
contains very often plates or grains  of  calcareous matter in its coats.
When an hydatid tumor has evacuated its  contents  as above  described,

   1 Some doubt may exist whether the  purulent-looking fluid contained in the cyst is
always true pus. In a case occurring at St. Mary's Hospital, the matter from the inte-
rior of a laro-e cyst, which had to the naked  eye all the appearance of pus, was  found
under the microscope  to consist of much granular  and oily matter, with some choles-
terin, and numerous utterly irregular granular masses. There  were no true pus-glo-
bules. 
522         ABNORMAL CONDITIONS OF  THE LIVER.
it  may collapse and a cure be effected; but if its Avails  are very thick
and firm, and  the cavity large, its obliteration in  this way may be im-
possible, and thence there is too much reason  to fear that, owing to the
entrance of air or other matters, suppuratiA'e inflammation of the sac
will be excited, and the  drain exhaust the strength of the patient.   But
an hydatid cyst may come to a spontaneous cure in a different way; its
proper membrane, instead  of secreting a watery  fluid may produce a
putty-like matter, consisting of phosphate  and some carbonate of lime,
with cholesterin  and albuminoid matter.  This  accumulates within the
sac, or sometimes around it, imbeds the secondary hydatids, and  causes
them to shrivel up and  perish.   Such a change reminds one forcibly of
the cretification of tubercle, which is often observed in cases where the
tubercular dyscrasia has ceased, and the deposited  matter  has been par-
tially absorbed.   Hydatids in the liver are not  unfrequently associated
with hydatids  in other parts, in the lower lobes of the lungs, or in the
spleen, or in the mesentery ; in such cases, Dr. Budd is inclined to regard
the hepatic cyst as the  parent, and  the others as originated  from  germs
conveyed  from it.   The  arguments Avhich support this view  are, the
greater apparent age of the hepatic  cyst, and  the circumstance that the
one " in  the liver is  associated only with cysts in the lung or in the
mesentery;" this seems to indicate  rather that the one is derived from
the other, than that  both are of independent origin.   It  is also  to be
remarked that an hydatid cyst often occurs in the liver alone, but rarely,
if ever, alone  in the  spleen or mesentery.  These arguments are, cer-
tainly, of weight, but seem hardly sufficient to counterbalance the objec-
tions, that it is difficult to conceive how a germ from the hepatic cyst
should make its way backwards against the stream of blood to the  spleen
or the mesentery,  and that it cannot  be considered improbable that a
second  hydatid  should originate  in a different locality, in a system
which  has already shown  itself favorable to the  production of  a pri-
mary one.
   Cancerous  disease is very frequent in the  liver : it stands fourth in
the list of organs thus affected, according to  the Parisian registers;
these show that it occurs about once in every sixteen cases of cancer :
Rokitansky estimates its occurrence in the liver to be much more fre-
quent ; he states " its numerical relation  to carcinoma of other organs,
as 1 :  5."  The  above statements do not, of course,  refer  to  primary
cancer  of the liver  only,  but include  secondary  cancer  also.   Three
varieties of cancer have been observed in  the  liver; colloid is extremely
rare, neither  Dr.  Budd nor Dr. Walsh has  met  with it;  Rokitansky
seems only to have seen a single case, and he does not state whether it
was primary or secondary.   Scirrhus is not very unfrequent, or a tran-
sition variety  between it and encephaloid:  it constitutes roundish tumors,
 about the size of a large nut, whitish, fibrous, and tolerably firm.  En-
 cephaloid is far the  most common, and,  as  in other  parts, attains far
 the largest size.   AAre have seen almost the whole organ converted into
 a mass of this kind.  It sometimes forms  separate tumors, sometimes
 infiltrates the parenchyma.   Rokitansky's description of the  separate
 tumors seems to us  to  apply equally to the  scirrhous and  encephaloid
 varieties, as he himself appears to allow.   He says: " Their general 
            ABNORMAL CONDITIONS OF  THE LIVER.        523

form is spherical, though their surface not unfrequently is slightly race-
mose or lobulated.  Those which have been developed in the peripheral
portion of the organ, and are, therefore, in contact with the peritoneum,
present a flattened or even an indented surface, and the indentation may
extend to the very nucleus  of  the morbid  growth.   The  peritoneal
lamina in the  indentation is opaque and thickened," probably from
having become involved in the  cancerous degeneration ; it seems to be
retracted and drawn in much the same way  as  the  skin is in subcuta-
neous cancer.  The number of the cancerous tumors varies in different
cases ; they may be solitary or  very numerous;  primary cancers are
usually few, secondary may amount to some hundreds. Dr. Walsh thinks
they are most numerous when they occur consecutively  to cancer of the

                               Fig. 233.
Encephaloid growth, occupying a large extent of the liver.
stomach.  The scirrhous tumors have scarce any investments of cellular
tissue, and adhere closely to the surrounding hepatic parenchyma; the
encephaloid  have a delicate cyst-like investment, though this does not
seem to be constant, and they can be detached more  readily.  " Infil-
trated encephaloid," according to Rokitansky, "always contains oblite-
rated and obsolete bloodvessels, and ducts which are gradually absorbed.
The infiltration attacks larger or smaller segments of the viscus; it does
not present  distinct boundaries, but insensibly passes into the normal
parenchyma.  It rarely occurs Avithout nodulated cancer."   The sepa-
rate  tumors often inclose strata of remaining hepatic structure, a fact
which seems to mark a connection between the twro forms; some degree
of infiltration taking place in each; but in one, the growth simply pushes
the parenchyma  aside,  in  the other  it spreads its germs everywhere
among its elements.  The structure of cancerous tumors presents no-
thing different from that of cancerous tumors in other parts,  and is de-
scribed  under the general  head of cancer (p. 187).  Their  degree of
vascularity varies:  some tumors  shoAV very little trace of bloodvessels,
others are richly supplied,  and are the seat also of  interstitial effusions 
524         ABNORMAL  CONDITIONS  OF THE  LIVER.

of blood; to such, the term haematoid or fungus  haematodes is  appro-
priate.  Black pigment often is scattered through  the substance of the
growths, and may be so abundant as to make them appear entirely black.
These claim, of course, the appellation melanotic.
  Cancerous tumors in most cases produce  considerable enlargement of
the liver, the  atrophy of  the proper  tissue which  they occasion being
more than compensated by the amount of  their own enlargement;  in
some rare cases, however, this does not take place, and the liver,  though
containing many cancerous tumors, is smaller than natural.  Masses of
cancer which appear on the  surface of the liver,  sometimes excite adhe-
sive inflammation of the investing serous membrane, and  thus become
united by false membrane  to adjacent  parts.  Instead of this, they have
been known to infect with their tainted fluids the parts in  contact with
them, and to cause secondary formations of cancer in them, or to  extend
into them, by the ordinary way of infiltration.  Ascites, to some  extent,
is not unfrequently produced by the presence of  cancerous masses  in
the liver: this probably depends on the  obstruction of the portal vein-
branches, either by the tumors themselves, or by cancerous matter de-
veloping in them, or  by fibrinous effusion coagulated within their chan-
nel.   Jaundice is often observed in cancerous disease of the liver ; its
production, doubtless, takes  place in the same way  as that just noticed;
the gall-ducts being  obstructed, and  the escape  of bile  from  various
parts  of the organ prevented.  AVhen the  masses  are so situated as to
press  on the common duct leaving the others  free,  enormous distension
of the gall-bladder may take place—it has been  seen as large  as the
foetal  head; such  a  result,  however, is more likely to be  produced by
cancerous disease of  the head of the pancreas, than by growths in the
substance of the liver.  Primary cancer of the liver is stated  by Dr.
Budd, seldom, if ever, to  occur before the age of  35: from this to 55
is the  epoch at which it  most frequently manifests itself.   Secondary
cancers of the liver may occur at any  age:  they  seem, according to Dr.
AValsh,  to affect  a preference for the superficial  parts of the  organ.
They  are believed to be produced by the  transportation of germs in the
blood, or by the medium of the lymphatics;  this, doubtless, is often true,
but we certainly are  of opinion that fluid cancerous blastema is quite as
adequate to  their production as any solid particle,  and this cannot but
be absorbed by blood passing through  a malignant  tumor.   There seems
eA'idence to  show that when the part primarily affected returns its blood
to the liver directly,  as in the case of cancer of  the stomach, the infec-
tious matter is all  detained there, and tumors are  not formed in other
parts; but when  hepatic cancer is consecutive to cancer of the  breast,
its development must  then  depend on the absorbed matter finding a
suitable nidus in  that organ.  A  sort of spontaneous  cure of hepatic
carcinoma has been occasionally observed, the morbid growth becoming
converted into a fatty mass, doubtless by a change of the nature of
fatty  degeneration. 
ABNORMAL CONDITIONS OF THE BILIARY PASSAGES.  525
   ABNORMAL  CONDITIONS  OF  THE BILIARY PASSAGES.

  Malformations.—The gall-bladder is sometimes wanting—in animals
it  has  been found  double;  its shape may be variously deformed;  its
duct, as well as the common duct, may probably be imperforate.  The
cystic  and hepatic duct may remain separate, and communicate either
both with the duodenum, or one with the  duodenum and the other with
the stomach.  The mucous lining of the gall-bladder  and ducts is often
attacked with inflammation, which may extend from the duodenum, and
spread upwards along the ducts.   It is often of the catarrhal kind, and
is  essentially similar to the affection of the gastro-intestinal mucous
surface; like it,  subsiding  after a time,  and leaving no traces of its
existence behind.   The effects it produces will be those of vascular in-
jection, some degree of tumefaction, shedding to a greater or less extent
of the epithelium,  and casting off of mucous corpuscles and  various
forms  of immature  epithelia, together with exudation  of liquor muci, of
various degrees of  viscidity and tenacity.   The gall-bladder alone may
be the seat of acute idiopathic inflammation, or this may be  excited by
unhealthy bile, or,  perhaps, by the irritation of a calculus.   The result
of such inflammation may be  closure of the cystic duct, and conversion
of the gall-bladder into an abscess.  If  the catarrhal inflammation, or
that set  up in any other way, attain a  certain  degree of intensity, it
causes the effusion of muco-purulent or purulent matter,  and at  the
same time it seems to induce paralysis  of the contractile  coat of  the
biliary ducts; these tubes, thus weakened, yield to the distending force
 within of the accumulating secretion, and become dilated at intervals
 into cyst-like pouches, filled with muco-pus tinged yellow or green by
 bile.   The dilatation will, of  course, be promoted, if the common duct,
 or the hepatic, is obstructed by a calculus, or in any other way.  After
 such pouches have existed a  certain time, they become entirely cut off
 from the duct in which they originated, the tube becoming  obliterated
 by adhesion, and their contents then undergoing certain changes. Thus,
 the muco-purulent matter  may be converted into a clear glairy fluid,
 more  or less tinged with bile; we have recently  observed a case of  this
 kind,  and though we were some time in  doubt as to the nature of the
 cyst,' which was  found in a healthy liver, we were soon convinced by
 detecting particles of columnar epithelium in the matter lining its  sur-
 face •  besides the  fluid in this case, there were several small whitish
 masses attached to the inner  surface, consisting of a  semi-homogeneous,
 semi-granulous,  soft substance, containing imperfect celloid forms.   It
 seems probable that, had the person survived longer, these whitish masses
 would have increased considerably, so much as to fill the cyst, and that
 in this way one of those peculiar tumors would have been produced which
 Dr. Budd has called "knotty tumors of the liver," and which he believes
 to be  formed within the ramifications of the hepatic ducts. He describes
 them  as  firm, white nodules, surrounded by a distinct cyst, and contain-
 ing a cheese-like  substance,  in the centre  of which  is  a small mass of
 concrete  biliary matter;  they are evidently situated m portal canals,
 and have often been mistaken for cancerous tumors.  We think it is too 
526  ABNORMAL CONDITIONS OF THE  BILIARY  PASSAGES.

much to assume that all such tumors as  contain a glairy fluid have origi-
nated in catarrhal inflammation ; probably the morbid, cyst-producing
action is in many cases of a more chronic  kind, and the fluid is glairy
from the first.  In  a  boy who died with pneumonia supervening on  a
tuberculized state of the lungs, we found the  liver, with the exception
of marginal oily  accumulation in the lobules, and a somewhat atrophied
condition of the cells, apparently healthy, except  that here and there
throughout its substance there were seen green-colored spots of the size
of a pin's head.  These  seemed to exist about  the termination of  the
minuter portal canals, and Were, doubtless,  connected with the terminal
ducts;  they consisted  of yellow and orange  or reddish pigment coloring-
matter, heaped up  together and forming a mass which encroached on
the parenchyma; in  one  of them, columnar  epithelial particles Avere
seen, proving that a duct was involved in  it.   The cells  contained no
yellow matter, so that it was evident that these  green masses  had been
produced by a morbid action set up in  the  minute ducts.  Ulceration of
the gall-bladder is  not unfrequent; it may occur as a  consequence of
suppurative inflammation,  or be set up  in an organ  which has been the
seat of chronic disease, or occur in the course of remittent or  typhoid
fever, or be produced by the irritation  of calculi, and probably also by
that  of unhealthy and acrid bile.  The ulcers  are sometimes small and
numerous, sometimes  there  is but one large one;  they are sometimes
attended with sloughing of the coats, and sometimes go on to perforate
the wall completely.   When this happens,  the bile, if the gall-bladder
contain  any, escapes into the  cavity  of the  peritoneum, and rapidly
excites fatal inflammation. If, from long closure of the cystic duct, the
gall-bladder contains no bile, but only a mucous or serous fluid, this does
not escape so rapidly, and the inflammation is more limited to the neigh-
borhood of the liver.  When ulceration is excited  by the presence of
gall-stones, it usually happens  that the bladder becomes adherent  to
some adjacent part, commonly the colon or duodenum; and, as the pro-
cess  advances, a communication  is established  between the two viscera,
by means of which the calculus escapes into the  bowel, and may be dis-
charged.  AVe have, however, seen a case  in which fatal obstruction of
the intestines was occasioned by a gall-stone, which had probably escaped
by a fistulous opening from  the gall-bladder.  AVe do not know much of
ulceration of the ducts ;  the smaller branches  are  so  rarely examined,
that its existence may have been overlooked. Dr. Budd records one very
interesting case, in  which  an ulcer of  the  common duct made its way
into  the superior mesenteric vein, close to its termination in the portal;
the result was phlebitis of the vessel, and purulent formations in various
parts of the liver and the  lungs, as well as in the skin and subcutaneous
tissue of the head and face,  and in some other parts also.  If inflamma-
tion, attended, probably,  with some amount  of ulceration,  attack  the
cystic duct, obliteration of its channel  may be the  result; or  the same
may be occasioned by a gall-stone lodging there. The gall-bladder now
has become a closed sac; the bile Avhich it contained is gradually absorbed
and replaced by  a mucous  or glairy fluid ; this  is at first so abundant as
to convert the bladder into a dense capsule,  resembling, according to
Rokitansky, the sound of fishes; but aftenvards this fluid is reabsorbed, 
ABNORMAL STATES OF THE BILE.
527
and the gall-bladder contracts and shrivels.  Cholesterin is often present
in great abundance in the fluid contents  of such gall-bladders; this is
especially the case Avhen the coats are diseased and thickened.  The loss
of the biliary reservoir seems to have no injurious effect on the health.
The  duct. com. choled. may be closed by concretions, cancerous growths,
or croupy exudation:  the outflow of the bile being thus prevented, it
collects within the  ducts, and  causes general  dilatation of them.  In
such cases, Rokitansky says, the liver is in a condition resembling that
of yellow atrophy, the  parenchyma of a dark-yellow or green  color,
turgid, though pulpy and friable.   Dr. Budd, in the  case he records,
describes it  as of  a  deep olive, finely mottled with yellow; the  tissue
flabby, but not easily broken down; the lobules undistinguishable. The  >
cells in this and in  another case were destroyed, and only granular and
oily  debris,  mingled, in Dr. Budd's case,  with yellow matter,  remained.
In tAVO cases which we have obserAred, the  cells were not destroyed; they
had  a yellow or  greenish tint, and Avere  rather stunted, but not at all
broken up.   AVe  injected in one  a large  dilated duct, and obtained the
important result  that the terminal  ducts  were  not dilated, and were of
about  the same size  as  in healthy livers.   Rokitansky says that "this
affection inArariably proves fatal  with symptoms of biliary infection of
the blood and consequent cerebral disease, which is often combined Avith
exudation on the arachnoid, Avith  intense icterus, and extreme pain  in
the  liver."   In Dr. Budd's case, there were no symptoms of cerebral
poisoning, and the  mind remained clear to the last.
   Croupy inflammation occasionally, but very  rarely, attacks the gall-
ducts.   " It gives  rise  to tubular  exudations, in which the  bile forms
branched concretions, which block up the passages, and thus cause dila-
tation of the capillary gall-ducts."   The coats of  the gall-bladder may
become oedematous in dropsy, or the subserous tissue infiltrated, as in
peritonitis;   increased deposit of fat  may also  take place in  the  latter
situation, and, perhaps,  induce  (coincide with ?) fatty degeneration of
the  muscular layer.   Rokitansky also notices the formation of osseous
plates in the thickened  parietes of gall-bladders which have been the
seat of inflammation, an and increased production of fibroid tissue, which
may be so firm and white as  to  give a cartilaginoid appearance.  The
biliary ducts very rarely contain tubercle.  Cancer sometimes extends
to, the gall-bladder from the liver; or,  it  is said, may occur in it prima-
rily  • it forms nodules in the submucous tissue, or infiltrates the mucous
membrane;  more  commonly, its wall  is  perforated by growths in the
liver, which push their way into its cavity.
              ABNORMAL STATES  OF  THE BILE.

  A brief account of the various unhealthy states of  the biliary secre-
tion  will properly follow here.  It must be premised, however, that our
knowledge of these states  is extremely imperfect, from the bile being,
unlike the urine, almost inaccessible in the living subject  to our ob-
servation, and from the changes which it spontaneously and rapidly
undergoes.   It  may be  secreted  in too great  quantity, as commonly 
528
ABNORMAL STATES  OF THE BILE.
happens to Europeans on first arriving in India, and occasions a bilious
diarrhoea.  The same  thing  often happens in our own country in au-
tumn, and from the same cause, probably, viz: increased excitement of
the liver.   The converse of  this sometimes  occurs, bile  is secreted in
too small quantities, or for a  time ceases to flow altogether.   This  pro-
duces pain and uneasiness in the bowels, which are  relieved when the
bile flow returns.   It seems that bile is  the natural and healthy stimu-
lus to the intestines, and that, if it is absent,  the  other contents, acid,
and, perhaps, in other ways  irritating, tease  and distress the  sensitive
mucous membrane.  AA'e cannot judge correctly  of  the  bile  that has
been poured out of the liver  by  that which we find in the gall-bladder,
for the latter may be unnaturally dark and viscid, or othenvise altered,
simply in  consequence of its continued  sojourn there.   Still, in many
cases, we have no  other source  of information,  and from this we must
form the  best judgment we can.  In cirrhosis, Dr. Budd says, the bile
is  often thin or serous, and of an  apricot or  orange color;  in other
similar cases it has its natural appearance.   Sometimes it is black and
thick.  In yellow atrophy, the gall-bladder generally contains  but little
bile, often only some mucous fluid, tinged yellow or green :  the hepatic
ducts have been found  quite  devoid of any biliary tinge.  In cases  of
fatty liver the bile is sometimes  unusually pale.   AAre have seen it, how-
ever, of a deep greenish color ; and this is also  the  case  in fishes  in
which the fatty condition is natural.  In the lardaceous or bacony  con-
dition, Lehmann speaks  of the  bile as  light-colored  and watery.   In
tuberculosis, the bile is often found  poorer in solid contents, but some-
times also more  rich  in them.  Extensive  inflammations, especially
pneumonia and diabetes, are  said to  render the bile more  watery.  This
occurs also in some  cases of typhus and disease attended with dropsy.
The solid contents, according to Lehmann, of the bile are increased in
diseases of the heart, and those abdominal  (others also ?) affections  in
Avhich the motion of the blood in the larger veins is delayed.   The bile
in malignant cholera is very thick and tenacious, and is  like  the blood
manifestly drained of its Avater.  In this disease, and in Morbus Brightii,
urea has  also  been  found  in the bile.   Albumen seems  to have been
found occasionally in bile;  Lehmann says  that  it has been  observed in
cases of  fatty liver, of Bright's disease, and in the  embryonic state.
The quantity of mucus is  often relatively increased Avhen  the bile is
Arery dilute; this has been  noticed  in typhus  fever.  Free  oil is occa-
sionally seen in bile, and probably always might be during decomposi-
tion of this fluid.   The bile is very rarely acid ; this has been  observed
in cancer and typhus;  it probably depends on some of the acids being
detached from their bases.   The foregoing statements are very unsatis-
factory ;  and, perhaps, the only definite conclusion that can  be drawn
from them is, that there is no constant  relation between the  condition
of the parenchyma and that of the secreted bile, nor between  the latter
and  the  greater number of  the various diseases  to which  the body is
liable.  Obviously, they tell  us  nothing as to the varying condition of
the resinoid biliary acids, the essential  constituents of the bile.   Two
conditions, however, of the bile in the gall-bladder deserve  our close
attention, on account of the important consequences which  often result 
ABNORMAL STATES OF  THE BILE.
529
from them.   One is, the bile being so loaded with coloring matter from
concentration, or  other  causes, that  a deposit  of this substance takes
place; the other is, the bile containing a large  quantity of cholesterin.
From these two substances all biliary calculi almost are formed.  They
are far most common  in the gall-bladder, but  also occur in the ducts,
both within  and without the  liver.   " Their1  form and surface vary
much.   Single calculi are commonly round, oval, or cylindrical; when
very large so as  to occupy" the entire cavity of the gall-bladder, they
are frequently slightly curved ; " if many exist together they mutually
prevent their enlargement, and, in consequence  of the friction and pres-
sure they exert  upon one  another, they assume  cubical, tetrahedric,
prismatic, or irregularly polyhedric shapes, with convex or concave sur-
faces.   The calculi found in the ducts  are  generally cylindrical, occa-
sionally branched, or entirely amorphous.   The texture of the calculi
may be uniform  or varied, in proportion as they consist of one substance
or of several layers.   Many show no distinct arrangement;  some have
an  earthy pulverulent fracture, or a fibrous, striated,  laminated, mica-
ceous texture, as  is particularly observed in calculi consisting of cho-
lesterin."    Gall-stones  are  not  of  any great
degree of consistence; they may sometimes be         Fig. 234.
compressed  easily between  the fingers:  they            jgg
are  rather  light,  but not  so  much  so as  to
float in water.   Their color varies from a milky-
white  to  various  shades of green,  yellow,  or     Sj nff "JBL<^
brown : internally, they often  present an alter-    ^P ^Lw  ^&
nation of different-colored laminae.   They may     $&  J&, ^&
be  said  to  consist generally  of cholesterin,          ^^
mingled  with a combination  of pigment  and  small,irregulargaii-stones, com-
v   ■      •           ,•__  t „„„„ „„11 „*„„„„   posed of inspissated and altered
lime in various proportions.  Large gall-stones, ^ ^^ by mucu,_Froa
with the exception of their nuclei, consist almost Dr. Budd's work.
entirely  of cholesterin, and  are,  therefore,
whitish and crystalline; their sectional surface presenting a number of
striae radiating from the centre.  Small gall-stones, resembling grains
of  black  pepper, of an  irregular, tuberculated  form, and almost black
color,  are occasionally found:  they consist  almost  entirely of pigment
and earthy matter, the carbonate and  phosphate of lime.   Cholesterin
generally forms the principal mass of biliary calculi; it often alternates
with layers of pigment, and almost always itself surrounds a nucleus of
the same matter.
   The secretion of a  large quantity of cholesterin does not  seem to be
the essential and adequate circumstance for the  formation of gall-stones;
the gall-bladder sometimes contains mucus loaded with sparkling tablets
of this substance, Avithout any trace of calculi.   It  seems most probable
that pigment-granules cemented together by  mucus  first constitute  a
nucleus   round   which  cholesterin  afterwards  is  deposited   in layers.
Other matters,  however, may  serve  as a nucleus;  blood, a portion of a
distoma  or a lumbricus, or even a pin, are said to have been found in
this situation.
34
1 RokitaDsky, vol. ii. p. 162. 
530
ABNORMAL STATES OF THE  BILE.
Fig. 235.
 From a gall-bladder, which
was shrunken, a calculus
being impacted in the cystic
duct.
 (a) Cholesterin tablets.
 (b) Glomeruli.
Fig. 236.
 Gall-bladder  and  cystic
duct,  containing  calculi,
which have a crust of pure
cholesterin.  The two upper
are  divided. — From  Dr.
Budd'a work.
  Gall-stones  are  not  peculiar  to,  or especially
associated  with,  any condition of the  liver—they
are said to be most frequent with  cancer, but very
often occur in other states;  they are  more often
found in females than males, in the proportion  of 4
or 5: 1—rarely before,  but often  after the middle
period of life.   A sedentary life, and obese condition
of body,  are  favorable  to the formation of gall-
stones; they are not, however, unfrequently present
in lean and temperate  persons.  As cholesterin is
a variety of fatty matter, this might seem surpris-
ing, did we not remember  that its formation may
be referred to a kind of fatty degeneration, as well
as to the presence of an increased quantity of oil
in  the system.  Cholesterin is certainly secreted
often in large quantity  by the thickened  coats of
the gall-bladder, and by additions from this source
the large solitary calculi  are probably formed ; there
is no doubt, hoAvever, that  in other  cases  it is  de-
posited from the bile, owing to the  decomposition
of the taurocholic  acid  or its salts, by which it is
naturally held m solution.  Calculi are often loose
and free in the cavity of the gall-bladder;  some-
times they are  attached to its surface by exudation,
or included in compartments formed by organized
lymph.  Small ones are sometimes, also, contained
in saccular dilatations  of  the mucous  membrane,
and may appear to lie external to the cavity of the
gall-bladder.   The following effects are produced
by  biliary calculi: They  become  impacted in the
cystic duct, and occasion its obliteration, the gall-
bladder undergoing the changes  that  have been
described.   The  same thing occurs, but  much more
rarely, in the common duct, which is straighter and
wider; great distension of the gall-bladder and ducts,
and occasionally rupture of the former, then  take
place.  If, on account of the angular shape of the
stone, the duct is only partially obstructed, the same
effects are  produced, but in a less degree.  "While
lodged in the gall-bladder,  calculi  may  excite irri-
tation, thickening,  inflammation, and suppuration
of its  coats, andv sometimes ulceration.   Of these
we have lately  spoken.
  Acephalocysts, and the, distoma hepaticum,  oc-
cur in the gall-bladder.  For a description of them,
vide art. Parasites, p. 199. 
CHAPTER XXXIV.
  ABNORMAL CONDITIONS OF THE PANCREAS,  AND  THE
                  OTHER SALIVARY GLANDS.

  These  are not very numerous.  Congenital deficiency  is observed
only in Arery imperfect monstrosities, and excess of development is very
rare.   Hypertrophic  enlargement, Rokitansky states, is altogether un-
usual, and Avhen it does occur, affects chiefly the cellular tissue, which
is interwoven with the glandular tissue.  We have, however, examined
one specimen in Avhich the ultimate vesicles were stuffed with epithelium
to such a degree, that  their investing fibroid envelops appeared stretched
and distended,  and the Avhole gland was of a very  remarkable  density.
AVe think minor degrees of this condition are not uncommon.
  Atrophy of the pancreas takes place in some instances spontaneously,
chiefly in advanced age; or it may result from chronic inflammation, or
fatty  degeneration.   The  organ may  be soft  and lax, or  of leathery
consistence.
  Inflammation, at least  in  the  acute form,  but rarely  attacks the
pancreas; it is, however,  not infrequent in the other salivary glands,
where it constitutes the disease  termed mumps.  AA7e have seen inflam-
mation and  suppuration of the parotid gland occur as the result of fever.
The phenomena of inflammation are the same here as in other similar
parts.   The gland swells considerably, partly from the congestion of its
vessels with blood, partly  from  exudation  into the areolar tissue which
envelops it.   In the ordinary case  of mumps, suppuration rarely takes
place, and simple resolution occurs; but when  the result is less favorable,
the glandular structure becomes, in a measure, fused with the interstitial
exudation, and probably penetrated by it also, and the whole mass softens
and breaks down into purulent matter.   This had occurred in the case
of fever above alluded to.   The suppuration may affect the whole gland,
or be limited to distinct spots, and form an abscess.   " Chronic inflam-
mation induces condensation, induration of the cellular tissue, obliteration
of the acini, and either permanent enlargement, or subsequent atrophy
of the gland."   A specimen of this kind which we examined, was in the
following condition:  There was a very  large  quantity  of coarse fibrous
tissue surrounding and enveloping the  lobes  and lobules of the gland.
In this  there was much irregular fatty deposit, appearing more like
masses of concrete, fatty matter, than true adipose tissue.   The gland-
tissue was more or less atrophied, not nearly so apparent as  natural, the
ultimate vesicles were not well seen.   The  epithelium looked coarse-
grained, and contained  much  oil.   The fatty deposit seemed  to  have 
532    ABNORMAL CONDITIONS OF  THE PANCREAS, ETC.
taken place in a secondary manner as the result of the shrinking of the
gland.
  Fatty  degeneration  of the  pancreas is  described by Rokitansky as
frequent  in drunkards, associated with fatty liver.  It is not, however,
a degeneration  of the same kind, but rather, from this  account, seems
to take place by intrusion  of the surrounding adipose  tissue  on  the
wasting  organ.   Serous cysts occur occasionally in the  pancreas, and
the other saliArary glands.
  Cancer does  not select these glands as one of its ordinary sites.  It
does,  however,  affect them not unfrequently both primarily and second-
arily.  Scirrhus and encephaloid are the  only two forms which  occur.
It is probable that,  in several of the cases reported  as cancer  of  the
parotid, the disease was really seated in  some  of  the  adjacent  or  im-
bedded absorbent glands.   The head of the pancreas, where it is em-
braced by  the  duodenum, appears  to  be the  part of the organ most
frequently affected.   As a result of the growth of the tumor, the ductus
choled. sometimes is obstructed, and jaundice is produced.   The disease
may extend much further than this,  according to Dr. Walshe, implicat-
ing "the duodenum, the omentum, mesentery, liver, and even the  supra-
renal capsules  and kidneys."  Rokitansky says, "that the secondary
affections of  the  salivary glands, by an  extension of the disease from
adjoining organs, and in the case of the  pancreas  especially, by an  ex-
tension from  the scirrhous pylorus, is very common.
  Salivary fistulse  are usually caused by the  progress  of ulceration.
Thus, a perforating ulcer of the  stomach may make  its way into the
pancreatic duct, and the same with regard  to the duct  of Steno,  which
is oftenest perforated.
  Dilatations of the ducts are produced  in consequence of  obstruction
of their outlets, Avhile the secretion accumulates and distends the canal.
                     The obstruction may depend on an external tumor,
      Fig. 237.        or a mucous plug, or on a calcareous  concretion.
                     Sometimes the dilatation occurs at several separate
                     points; sometimes it forms fusiform "or closely-
                     set  expansions, partially  separated from one an-
                     other by valvular folds formed by the coats  of the
                     duct."   The  salivary concretions, or  calculi, are
  saihary calculus of consi-   described by Rokitansky as " white, friable, and
derable size;  removed by ope-    ..        iii      i- i •  1      ,    \  .
ration.                 either round, oblong, cylindrical, or obovoid; m
                     size varying from that of a millet-seed or pea, to
even  that of a hazel-nut.   They  are either solitary, or, if small, fre-
quently very numerous (twenty and  more); and they are composed of
phosphate and carbonate of lime, held together by animal matter." The
saliva from which they are formed by deposition, must be, as  Dr. Walshe
remarks, in an  unhealthy state ; for while the concretions consist chiefly
of phosphate of lime, sometimes  containing 94  per cent., there  exists
very little of  this salt in the normal secretion.   " It becomes, therefore,
extremely probable that the excess of  phosphate is generated through
the influence  of irritation of mucous membrane."
 
ABNORMAL CONDITIONS OF  THE DUCTLESS  GLANDS.  533
   ABNORMAL CONDITIONS OF  THE DUCTLESS GLANDS.

  Of the Spleen.—This organ is generally absent in acephalous  mon-
sters ; sometimes it is wanting, together Avith the stomach, or the fundus
of the stomach, in subjects otherwise well developed; or it may be  itself
alone in a rudimentary state.  Small supernumerary spleens, which are
often met with in the vicinity of the organ, are  not to  be  regarded as
instances  of its multiplication, but of its subdivision.   The  spleen  is
liable to very great variations in size, probably more  than  any other
organ of the body.  This depends chiefly on the very large size of its
vascular system, and on the great quantity of yellow, elastic fibre con-
tained in its structure, Avhich allows  it to  be  distended to a prodigious
extent.   Most,  if not all, hypertrophies  of the spleen,  hoAvever, are
produced not only by engorgement of the vessels, but  by an  alteration
and increase of the red, pulpy parenchyma Avhich they traverse.  This
parenchyma consists of nuclei, with granulous matter in small  quantity,
and some  slight traces of cell-development.   It evidently is not a very
highly organized substance, like a muscular fibre, and  will easily admit
of increase or diminution.   AVe  shall here only mention the degrees of
change  in size which  the spleen  may undergo.   Rokitansky states that
"the spleen not unfrequently measures sixteen inches in its long, seven
inches in its short  diameter, and four inches in thickness; its weight may
amount to 13^ lbs.,"  or even, as others affirm, to 20 lbs. and  upwards.
The  opposite change of atrophy may reduce the spleen to the size of a
hen's egg, or a Avalnut. The form of the spleen is rather various.  It may
be tongue or platter-shaped, or cylindrical or globular.    One of the most
important circumstances to note  under this head, is the great frequency
of notches in its anterior border, which may be felt through the abdominal
parietes when  the organ is  enlarged.   The  spleen is  liable to various
displacements, some of Avhich are congenital, others the result of disease.
Haller found it lying by the side of the bladder in a child one  year old,
Desault in the right  side of the  thorax in a new-born  infant.  It has
been found in  the  left thoracic cavity when the  diaphragm was absent,
and external to the abdomen in  large umbilical hernias, or where the
abdominal parietes Avere fissured.  Displacement may ensue  from the
enlargement or distension of adjacent parts, or from its own increase in
size.   Sometimes in the latter case it descends  to, and slides off, the
ilium, " so as to occupy a diagonal position  in  the hypogastrium, and
extend over  the right ilium."
  Wounds and Ruptures of the spleen occasionally happen from  inju-
ries or accidents.  The only point of interest respecting these is, that
there appears, from the observations of Mr. Athol Johnson, ground to
believe that, under careful  management, they do not  necessarily prove
fatal.   Spontaneous ruptures of the spleen  have also occurred in con-
ditions of intense  congestion, and when the  texture of the organ was
probably Aveakened; as in typhus, cholera, and  the cold stage of ague.
These always  prove fatal.
  AVith regard  to  the textural  changes  in  the spleen, Rokitansky re-
marks " that  they almost  ahvays arise from certain  anomalies of the 
534  ABNORMAL CONDITIONS OF THE DUCTLESS GLANDS.

blood, which, though little known, bear a remarkable and positive rela-
tion to the spleen.  The spleen may, in fact, be considered as the most
sensitive test for a variety of dyscrasic states of the fluids."  In this
Ave doubt not that there is  much truth, and  think  the view that a cer-
tain  anomalous condition of blood  is necessary for the  production of
great enlargement of the spleen is much supported  by the circumstance
that the organ is scarce ever materially enlarged in cases of cirrhosis of
the liver, when the current through the splenic vein must be so greatly
impeded.
  Hyperemia of the spleen occurs  both from mechanical causes, and
from that just noticed.   Rokitansky remarks that,  though it occurs in
organic diseases of the  heart  and in hepatic obstructions, it does not
amount to the extent, nor take place so frequently as might be expected,
and he accounts for this by the deranged circulating fluid having no
affinity for the tissue of the spleen.  In the bodies  of drowned persons
the spleen is found  gorged  and distended with blood.  This blood, no
doubt, might all be washed out by injecting the vessels with water, and
the organ would return to  its normal  size;  but when congestion  comes
to be permanent, the exudation which takes place in  the red parenchyma
becomes organized into similar celloid substance, and the spleen is then
truly hypertrophied.
  An anemic state of the spleen is  observed in the highest degree when
the parenchyma is infiltrated with  bacony matter,  to  be  presently no-
ticed; but it also exists  in many atrophied conditions, which very often
depend on, or coincide with, a development of the nuclei into fibres.
  "Primary inflammation of the spleen," Rokitansky says, "is as rare
as spontaneous primary phlebitis; secondary,  as frequent  as  secondary
phlebitis."   Primary inflammation of the spleen, unless ending in reso-
lution, gives rise to an  exudation of laudable pus or fibrin.   The pus
may be contained in a circumscribed abscess,  and thence  become obso-
lete,  or the cavity may go on enlarging until the abscess makes its way
into the left thoracic cavity, the stomach, the transverse  colon, or the
peritoneum.  When the  latter event happens, circumscribed  peritonitis
often forms  a sac for the pus  with the aid of the  surrounding  parts.
Secondary splenitis seems to be  identical with pyaemic deposits, and is
stated  by Rokitansky to consist  in nothing  more  than the (purulent)
" metamorphosis of an infected coagulum within the channels of  a vas-
cular ganglion."  The deposits are well defined, always situated  at the
periphery, usually of  a cuneiform  shape, the apex  directed inwards;
their color is considerably darker than  the surrounding tissue, and their
consistence  firmer.   A  ring of reactive inflammation is  often set up
around them.   The process  may terminate either in the case of  a be-
nignant fibrinous  exudation  in conversion of  this into a cellulo-fibrous
callus, which contracts and causes a cicatrix on the surface; or  in the
case  of a less healthy exudation in  the conversion of this  " into a puri-
form, creamy mass, or into a sanious, greenish, greenish-brown, or cho-
colate-colored pulp."  Rokitansky notices the frequent occurrence of
the above affection in "inflammation of the internal vascular coat, and
particularly" in endocarditis.   As  he  makes  no special mention else-
where  of the fibrinous block so common in the splenic parenchyma, we 
     ABNORMAL CONDITIONS OF THE DUCTLESS GLANDS. 535

conclude that he comprises it among the phenomena of secondary sple-
nitis; but we cannot help doubting whether  this is correct.   To  us  it
seems much more  probably to be  a simple exudation of fibrin, which
takes place in consequence of the blood being surcharged with this pro-
duct; and we should regard the simultaneous deposition of fibrin on the
endocardium of the valves of the  heart as a mere coincidence, and not
in any degree  as  a cause.  M. Simon is inclined  to  consider that, in
many cases, disease of the artery leading to the part is the cause of the
deposit.   The appearance of these deposits is that of a circumscribed
yellowish mass, with a surrounding  margin of darker  or lighter red
congestion, of increased consistence, so  as  to be  readily detected  on
handling the part, and exhibiting under the microscope a confused mass
of granular Avith more  or less oily matter, infiltrated among the remains
of the parenchyma.   They very commonly undergo fatty degeneration,
and this  appears to be the way in which they are removed.
   Among the various enlargements of the spleen more or less connected
with hyperaemia, that occurring in typhus deserves  to be noticed.  The
parenchyma, in very marked cases, is exceedingly soft, almost breaks
up under the hands; its  color is a dirty red, varying  from different
shades of depth to a light chocolate; its  size is greatly increased; but
it shows, under the microscope, no  very noticeable alteration of its struc-
tural elements.  There may be some increase in the quantity  of diffused
granulous matters ; but the nuclei appear quite natural.  The change is
one better judged of on a large than on a small scale.  We have ex-
amined,  at  different  times, numerous  specimens  of greatly enlarged
spleen, but we have found little that could be regarded as characteristic
of the several alterations.  This is not surprising;  it could not be ex-
pected that specific differences in the blood  should  mark themselves  by
corresponding varieties of form in the cell-growths  of  their exudations,
any more than that the syphilitic virus should be detected by some spe-
cial modification of the pus of a chancre.
   In a case of Leucocythemia, recorded by Dr. Chambers in the Report
of the Pathological  Society for 1846-47, it is stated that the spleen,
which measured  14 inches by 4 or 5, was extremely dense, "exhibiting
on a section a beautiful mottled  appearance; but under the microscope
presenting no obvious deviation from the normal character.  In a similar
case we noted that the nuclei of the parenchyma were more granular
than usual, and were often in process of cell-development, but the  same
change often occurs in other diseases.  In a man dying with ulcerations
of the colon, producing excessive diarrhoea, and who  had formerly passed
large quantities of lithic acid, the  greatly enlarged spleen presented a
perfectly uniform smooth surface, of a rather light  red color, and  exhi-
bited under  the  microscope no  peculiarity of  structure, except  that,
together Avith the normal elements, there were mingled numerous largish
crystals, probably those of  triple  phosphate.  In  a female dying with
cancerous growths in   the fauces  and in the lungs, the spleen was  so
enlarged as to weigh four pounds twelve ounces.   Its cut surface exhi-
bited an  irregularly raised appearance, being formed of elevations of a
dull whitish color, with intervening red streaks.  The whitish elevations
consisted of pale, colorless, nuclear corpuscles,  closely resembling the 
536  ABNORMAL CONDITIONS OF THE DUCTLESS  GLANDS.

normal corpuscles of the Malpighian bodies.  The red parenchyma had
almost disappeared, there Avere only a few vessels seen running between
the hypertrophied Malpighian masses.  There was a considerable amount
of black pigment deposited in the course of the vessels, and some crys-
tals, like those seen in the former case, were also present.  The exami-
nation of  these two specimens seem  to warrant  the conclusion that, in
the former, the red parenchyma was the  seat of the hypertrophy, the
Malpighian corpuscles in the latter.   The two following instances seem
to be examples of the infiltration of the splenic parenchyma Avith fibrinous
matter, rather than of a true hypertrophy of it like  the preceding.   It
is especially to be observed that they were general, and not confined to
one part of the viscus.   Dr. Ogle has recorded, in  the  Report of the
Pathological  Society for 1851-52, the case of a man who  died with
pleurisy in connection with granular  degeneration of  the kidneys.  The
spleen Aveighed seventeen ounces, and was of firm, solid texture through-
out.   " In its substance were three or four large patches of a  yellowish-
colored deposit, having a slightly pink hue towards their central  parts.
These existed at the peripheral  portions of the viscus, and  penetrated
to some extent into the interior.  Moreover, the whole viscus Avas of a
mottled color, owing  to an extensive infiltration of a lightish-colored
material, which gave to it its firm, unyielding character.  Examined  by
the microscope, the deposits proved to consist of amorphous and granu-
lar matter, larger fatty granules, with great numbers  of small, oval, and
elongated cells, having a nuclear appearance,  along  with an  admixture
of Avhat seemed to be the natural cells of the organ.  No indications of
ulterior development or organization existed in the deposit.  The invest-
ing fibrous capsule of the spleen Avas thickened  and rendered opaque,
having several tough bands of false membrane attaching it to contiguous
parts ;" and the lining of the splenic artery contained atheromic deposit.
In the following case, a similar deposit had taken place both in the liver
and spleen, giving to both organs a great increase of firmness and tough-
ness.   The cells of the liver were almost entirely destroyed, and replaced
by a fibroid tissue containing in its substance numerous nuclear and cel-
loid particles.  The spleen weighed three  pounds six ounces, and mea-
sured fifteen inches by ten and a half; it Avas very bloodless,  but  its
arteries appeared healthy, though the aorta was  highly atheromatous.
The cut surface of the organ had a peculiar gray, uniform aspect, with
some small red specks and dots scattered over it.   Under the microscope
it showed a  granular, homogeneous  basis, having a  slight  tendency to
fibrillate,  with numerous nuclear corpuscles and much oily matter'dis-
persed through it.   The nuclear corpuscles resembled  exactly those of
the healthy organ.  In a third form of chronic enlargement of the spleen
the character of the alteration is distinctly marked  by the presence of
a peculiar form of deposit which is described  by the terms lardaceous
and bacony.   It often exists at the  same time  in the liver and kidneys,
and always appears in connection with a lowered condition of the organic
power.  It appears, under  the  microscope, as irregular fragmentary
masses,homogeneous, translucent, and sub-refracting,  mingled commonly
with more or less of the structural elements of the  part in  Avhich it  is
deposited.  It has appeared to us sometimes to be deposited in the situa- 
ABNORMAL CONDITIONS OF THE DUCTLESS  GLANDS. 537
tion of  the Corpora Malpig., so that  there  are seen spots or circular
spaces Avhich  are separated from each other by the remains of the  paren-
chyma.   The organ is often much enlarged, is remarkably bloodless
when extensively invaded by the deposit, and at  the same time is brittle,
and gives a peculiar resinoid fracture.   AVe  may recapitulate the fore-
going account of chronic enlargements of the  spleen, by enumerating
them  as resulting from (a) true hypertrophy, (b) infiltration with fibrin-
ous deposit, (c) a condition compounded of hypertrophy and infiltration,
and (d)  deposition of lardaceous matter.  Rokitansky states that many
cases of splenic enlargement " depend  upon the formation of certain
corpuscles, in addition  to the existing hyperaemia."  He denies  that
these corpuscles are identical Avith the Malpighian,  but his own descrip-
tion of  them shows  that  they are very similar; and as Ave know, from
our own examinations, that these do  occasionally exist, Ave are much
inclined to believe that those to Avhich Rokitansky refers are no other.
   The  fibrous capsule of the  spleen  is very  frequently  the  seat  of
chronic fibroid thickening,  which sometimes proceeds to a very great
extent.   The thickened  membrane has much  the
aspect of cartilage, but none of its real characters.        FiS-238-
Usually, the thickening  extends pretty uniformly
over the surface, leaving, however, here and there,
spots less affected; sometimes  it  forms nodular
masses  grouped  together.    In one  case  we  ex-
amined carefully, it Avas very  apparent that  the
thickening had taken place on the inner surface of
the capsule, at the expense of the parenchyma,  and    ™roid «**«»-*°'«»p-
      I  .   '        1 •  i    •          11   i_          sule,  encroaching on  the
we are  inclined to think this is generally the case,   dark parenchyma, vertkai
Certainly, the process is distinct from the formation   se«iou.
of bands of adhesion  to adjacent  parts.   Fibroid
tumors  of the parenchyma are rare.   Ossification  of  the thickened
fibroid layers takes place rarely, except in very old persons.  Fibrinous
deposits in the parenchyma may, together with other alterations, cretify.
Phlebolithes may form  in the venous channels.
   Tuberculous matter is, for the most part, deposited in the spleen only
in acute universal  tuberculosis; it  occurs more frequently in children
than  in adults, in the  proportion of 40 : 13.   It appears  both  in the
form of gray granulations, miliary crude tubercles, or yellowish cheesy
masses, of the size of a pea and above.   In acute tuberculosis, the spleen
is described by Rokitansky as becoming swollen and  softened, much as
in the typhous state.  The organ was  much enlarged in the last case we
Avitnessed, but it Avas distinctly  observable that  there was no congestion
around the tubercles. Their substance consisted  of an amorpho-granulous
matter  imbedding oily molecules and freely-fbrmed nuclei.   Rokitansky
notices the formation of  a pseudo-cyst round tubercles, and the not un-
frequent presence of a small central cavity in their interior.
   We have occasionally  observed small cysts in the spleen, or, perhaps,
to speak more accurately, in  its capsule; in a female of mid age dying
with  fever, there were  several small, firm, nodular prominences  on the
anterior border; they were of conical shape and lightish red color, ap-
pearino- like so many groAVths on the surface; under the microscope, they 
538                 OF THE THYROID  GLAND.

                               Fig. 239.
Masses of crude tubercle in spleen.
were found to be small cyst-like cavities of varying size (one measured
g'g inch diameter), oval or spherical, containing numerous large granule-
cells floating in a transparent liquid.

                               Fig. 240.
            Cyst in the capsule of the spleen, containing a clear fluid and glomeruli.

  Hydatid cysts are  sometimes found in the spleen alone, or concur-
rently "with one in the liver; it rarely attains the size it reaches in the
latter organ."   Dr. Coley exhibited to the Pathological Society a speci-
men of the magnitude of a cocoa-nut.
  Cancer is rare in the spleen, the only form which it  assumes is en-
cephaloid, and this is very rarely, if ever, solitary; it occurs associated
with similar disease of the liver, stomach, and omentum.


                   OF THE THYROID GLAND.

  We are not acquainted with any instance of excessive congenital de-
velopment of this gland, unless the rare occurrence of simple hypertrophy
should be regarded as such.  Mr. Curling has recorded in the Medico-
Chirurgical Transactions, two instances of its  absence in idiots.  The
most complete account of its morbid alterations is that given by Professor 
OF  THE THYROID GLAND.
539
Hasse, from  which we shall  extract the greater part of the following
summary:  " Inflammation of the  thyroid  is rare.  It may attack the
organ, either when healthy or when enlarged by  previous disease.  Its
course is more  frequently chronic than acute.   Within a very  brief
interval the  gland often swells  considerably—becomes very bloodshot,
tense, and  painful—its texture softened and  friable, assuming first a
brown-red, and  ultimately a dingy-gray color."   When  suppuration
occurs, there may be several foci, or one large one involving the whole
gland.  The abscess may open externally, or into the  oesophagus, or
into the trachea.   After this  has occurred, the gland on the side affected
shrivels "into a hard, cellular,  filamentous  knot, which adheres firmly
to the skin and  the surrounding parts.  Sometimes  the shrivelling of
the one gradually brings on wasting of the  other  lobe."  Andral states
that acute tumefaction of the thyroid may come on after violent exertion.
Simple enlargement  of the  thyroid is  frequent, says Hasse,  and for
the most part inconsiderable; but  it implicates  the  entire gland, and
thus may  cause greater  disturbance  than  a more extensive tumor of
another kind.   " Both lobes of the gland, and even the middle one, swell
so as to encroach equally on each side, against the trachea and vessels
of the neck."   The affection is almost wholly confined to youth, and is
frequent about the age of  puberty in both  sexes—more so,  however, in
the  female, in whom enlargement  is especially  apt  to  prevail at the
approach of the menstrual period.   The essence of simple hypertrophy

                                                Fig. 242.
    Bronchocele from the King's College col-       Section of a bronchocele, showing calcareous de-
   lection.  The oesophagus is seen to be     posits.—From the Middlesex Uospital Museum.
   pushed to the right side by the tumor.

seems to be the derangement of the equilibrium naturally existing between
the processes of secretion and absorption, that  continually go  on in
the gland.   AVhen the former predominates, the vesicles, and of course
the whole organ, become distended.   M. Coindet relates that a regiment
of young recruits were almost all attacked  by considerable enlargement
of the thyroid, shortly after their arriA'al at  Geneva.  On changing their
Fig. 241.
 
540
OF  THE THYROID GLAND.
habitation, and the water which they used for drink, they all quickly
recovered.   In this instance, and in a multitude of similar ones, it seems
beyond doubt that some constituent of the Avater being absorbed into the
blood, acted as a stimulus to excessive  secretion into the thyroideal
cavities.  The effect  produced would be quite analogous  to that of a
diuretic salt.  In the chronic and permanent enlargements of the thyroid,
a more considerable amount of change takes place.   The vesicles of the
gland are not only distended by excess of their  natural secretion, but,
besides being greatly enlarged, are filled with calcareous, atheromatous,
and other matters.   It is probable  that some new vesicles are formed,
as well as old ones enlarged.  Hasse makes  two separate  varieties of
melicerous degeneration and cystic formation ; but Ave think they run so
much into one another that they may be classed together.   In the pure
melicerous degeneration, the secretion which  distends the vesicles, and
some of them much more than others, is a tenacious, viscous, jelly-like
substance, of the color of honey.  The vessels seem  to be usually com-
pressed, so that the gland appears bloodless.   The change is sometimes
limited to certain portions,  an interesting  instance of the power which
the vitality of each individual  elementary part has in determining the
character of its actions.  In the more common cases of enlarged thyroid,
the vesicles  contain,  besides colloid  matter, more or less inspissated or
fluid, varying quantities of calcareous, often  ossiform substance.  AVe
have  seen crystals approaching the octohedral form in the  contents of
the cavities, as well as tablets of cholesterin ; and fatty matter seems to
be not unfrequently present, probably as the result of fatty degeneration.
An instance related by Dr. Haen, shoAvs the great variety of appearance
which  the contents of the cysts may  present.   He says that, in a  fright-
fully enlarged thyroid, he found almost eA'ery variety of tumor existing
together.   "Here was a steatoma, there an atheroma; in another place
a purulent tumor; in  another, an hydatid; in one, there was coagulated,
in another, fluid blood; on this side was a loculus full of glutinous matter;
on that, was one filled  with calcareous  matter, mingled with tallow."
One of the cystic cavities sometimes enlarges prodigiously at the expense
of the others;  Andral relates having  found a thyroid transformed into
a cyst with bony walls, filled with a honey-like matter.   Another kind
of enlargement of the thyroid, consists in the dilatation of its vessels,
constituting what is called vascular or aneurismatic bronchocele.  The
veins in particular, writes  Hasse,  form  very dense, capacious, often
knotted plexuses, and the whole texture consists, apparently, of a dense
coil of A'essels.   The substance of the gland has almost entirely  lost its
granular character—it is flabby and dark-red.  After death, the tumor
collapses considerably.  The walls of the arteries and veins are attenu-
ated; the dilated  membranes of the A'essels contain  considerable clots,
and  capacious  cavities  are  found, filled  with  black  coagulated   blood.
In a remarkable specimen, which seemed in part  to belong to the above
class, we found the greatly dilated vessels completely coated  with oily
matter, so as in some  parts to appear like white cylinders by direct light.
At the same time, the glandular vesicles Avere destroyed, and only some
traces  of their  epithelium  could  be discovered.    This,  which  would
certainly be the most important feature of the alteration, is not directly 
SUPRA-RENAL CAPSULES.
541
stated by Hasse to take place in the above description, though it seems
inferable from the statement, that the granular (vesicular) character of
the gland is almost entirely lost.   AVe have  observed  in a second case,
the same destruction of the glandular structure, and dilatation and oily
incrustation of the vessels, but there was a more considerable deposit of
earthy matter.   Tuberculous deposit is  rarely if ever found in the
thyroid.   Cancerous  disease is  also  very rare, but has been observed
both in the forms  of  scirrhus and  encephaloid.  "When primary, the
disease is usually of the infiltrated form; when  secondary, of the tube-
rous."   Encephaloid  growths sometimes attain such a degree  of vascu-
larity, that they resemble fungus haematodes.
   Of the thymus.—Absence of  the thymus has only been observed in
cases of acephalism.  Inflammation is an exceedingly rare occurrence;
but Hasse refers to two cases, in one of which an abscess is said to have
opened into the trachea.  In cases of tuberculosis the thymus is  occa-
sionally involved; it becomes considerably enlarged, "firmly united with
surrounding parts, and either converted by tubercular infiltration  into a
hardened mass, or else  partially destroyed by softening."   Mr. Simon
mentions a case in Avhich suffocation was occasioned  by the  pressure of
a tumor  apparently of  sarcomato-cystic character, in  the situation of
the  thymus; and  Sir Astley Cooper met with a case of encephaloid
growth in this part.   The  thymus is not unfrequently found greatly
enlarged; but the nature of the  hypertrophy, as it is called, has not
been exactly determined by microscopic  observation.   It  is  tolerably
certain that this enlargement is  not, as has been supposed, the cause of
attacks  of sudden and sometimes fatal dyspnoea occurring in  children.
For it has been shoAvn that "thymic asthma," as it is termed may occur
Avith an unnaturally small thymus; and that the gland may be greatly
increased in size without producing any symptoms of dyspnoea.
   Of the supra-renal capsules.—AVe take the following brief account
in part from Rokitansky.   The  supra-renal  capsules  may be  deficient,
especially where there is a deficiency in other  organs  also.   Their ab-
sence, however, does not coincide with that of any other organ in parti-
cular, and they may be  present wrhen  one  kidney is absent, so that their
name must not be taken to imply any correlation of function. Accessory
supra-renal  capsules are of  frequent  occurrence.  They are  sometimes
found hypertrophied, but the nature of the enlargement does not appear.
Their normal condition is one of at least  relative atrophy, that is, they
do not grow and increase in size  together with  the other parts of the
bodv.   Their most usual condition, according to numerous examinations
that we have made, is the following:  On making a transverse section,
there is seen a cortical  layer of a whity-gray or yelloAvish color,  often
markedly striated, and  consisting  of  cells, more or less laden with oily
matter, and arranged in very perfect rows.   AVithin  the cortical, and
usually not occupying more than one-third of the whole diameter, is the
medullary, traversed  by the central vein or its branches.   This is of a
pale opaline, often dark-red color, and consists of large nuclei set in a
granulous basis, containing very little oil.  There is often much yellow-
ish pigment in the cells of the cortex where it adjoins the  medullary
portion; these cells resemble very much those of the  liver when laden 
542
SUPRA-RENAL CAPSULES.
with yellow matter.  The principal indications  of  atrophy are mani-
fested, we think, by the shrinking and diminution of the medullary sub-
stance, and the breaking up of the cortical cells into oily masses.  It is
interesting to compare the condition of the degenerating  capsule with
that of an hepatic lobule.  In one instance, where a careful search was
made, at our request, for the supra-renal capsules in  the body of a child
six years old, who had died from a burn, no trace of them could be found;
but a small quantity of lax, dirty-looking, reddish, infiltrated, areolar
tissue, which presented  under  the microscope only a mixture of altered
granulous nuclei, large granulous or oil-holding cells, and  a very large
quantity of  diffused granulous matter imbedding some oil-drops.  This
was a case of unusually early atrophy.   Another indication of atrophy
is  afforded by the formation of a central cavity, which exists  in  some
cases quite distinct from that of the vein.   It is formed, we believe, by
the wasting of  the  medullary  substance, and the production  thereby of
a space which is traversed by bloodvessels, and occupied only by serum,
and a little stromal fibre.  In this way a lax spongy tissue is first formed,
which often is stained of a dark maroon or bistre color, by exuding and
altered haematin.  This tissue is afterwards absorbed, and a cavity with
more or less smooth walls  is thus produced.   Rokitansky says: " Hemor-
rhage not unfrequently  occurs in them, on  account of the vascularity of
their medullary substance.  The capsule is found distended in propor-
tion to the amount of extraArasation caused by the rupture  of a vein;
and according to the period which has  elapsed since the occurrence of
hemorrhage, we find the blood more or less discolored and  changed in
constitution, inclosed within the cortical substance, which  has become
pale and atrophied, and is finally converted into a fibroid layer.   Sup-
puration and induration are occasionally met with as results of inflam-
mation of these glands.   They have been found converted into  purulent
pouches in the  new-born child, and in the foetus.  " Tubercle commonly
appears in the  supra-renal  capsules in large  masses, and  either fuses
into pus, inclosed in a callous  sac, or is converted into a chalky concre-
tion invested by a fibroid tissue."   Cancer in  the form of encephaloid
occasionally attacks the supra-renal capsule,  according to Dr. Walshe
and M. Roger, only as  secondary to disease of the kidney, or (on  the
right side) of the liver.   It causes considerable enlargement, and when
hemorrhage takes place the mass may be broken down into a chocolate-
colored pulp. 
MORBID  ANATOMY  OF  THE  URINARY
                    APPARATUS.
                  CHAPTER  XXXV.

   Congenital Anomalies.—The kidneys are very rarely absent entirely;
but it  is not uncommon  to  find one  only.  In this case, Rokitansky
makes a distinction between the unsymmetrical and the solitary kidney.
The former has its usual position and shape, and is  only larger  than
natural.  The solitary kidney is produced by the more or less complete
fusion of the two organs together; in its  lowest degree it constitutes
the horseshoe kidney, the low7er parts of each being connected by a band
of renal substance passing across the vertebral column.  In the highest
degree, there is only a single disk-like kidney, lying in the median line,
and situated much lower down, at the promontory, or  in the concavity
of the sacrum.
   Hyperemia.—This condition of the kidney is  of frequent occurrence,
but is almost always the result of some prior  general  affection, as of
obstructive disease of the heart, the  scarlatinal poison, or the arrest of
the cutaneous  transpiration.  We shall  describe an  extreme case, to
convey an idea of the state of congestion  that may often  be inferred on
good ground to exist, and shall hereafter  refer to it as the commence-
ment of other affections.  The kidney  is enlarged,  its weight  often
doubled;  it  is  of dark-red color, and drips with blood  when cut into.
The cortical substance, the medullary cones, the mucous lining of the
calyces and  pelvis, are all much congested.  The former is somewhat
softened, of a dark-red color, and presents in many cases small  dark-
red spots, Avhich  are the result of hemorrhage into  and between  the
tubes.  The Malpighian tufts are also distinctly seen as minute, reddish,
subtransparent grains, prominent on the cut surface.   In the medullary
cones, the congested vessels form long dark-red streaks.   A somewhat
turbid sanguineous fluid is  contained in the injected calyces and pelvis.
The capsule, if the hyperaemia  has befallen  a  healthy kidney, can be
peeled off readily.  Microscopy  shoAvs the Malpighian and other  capil-
laries loaded with blood, extravasation sometimes into the capsule of the
former, and often into the channel of the tubes.  In a typical case, no
other alteration would be visible; but it is scarcely conceivable that the
hyperaemia should proceed to any great  degree Avithout exudation of
fibrinous fluid taking place, which is then  seen, having coagulated in the 
544                       HYPEREMIA.
tubes, forming casts of their interior, and consisting  of a  granular or
homogeneous material entangling blood-globules, and often  some de-
tached particles of epithelium.  In one case, where we  observed the rise
of hyperaemia almost from  its commencement, and which was  further

               Fig. 243.                            Fig. 244.
   Hemorrhage into Malpighian capsules compressing       Tube containing some yellow granules,
                the tufts.                     the remains of extravasated blood.

peculiar, in that there  was no  manifest exciting  cause, the fibrinous
exudation appeared as extremely pale-reddish, granular films, entangling
some  renal epithelium ; subsequently, casts were observed, and blood-
globules.   The gradual  nature of the  commencing effusion was probably
the cause that the fibrin did not coagulate at once  in the cavity of the
tubes.   Congestion, then, often reaching an extreme degree, early giving
rise to fibrinous exudation,  and in many more advanced cases to hemor-
rhage, and an otherwise sound state  of the renal tissue, are the  prin-
cipal features of hyperaemia.
  AAre  may here notice somewhat  further  the  circumstance of  renal
hemorrhage.  It may occur as an endemic,  and, to judge from  the ab-
sence of bad  effects, scarcely serious phenomenon.   Dr. Prout remarked
its prevalence during the period first  subsequent to  that in  which the
cholera prevailed;  it was  uninfluenced  by remedies, and after  some
weeks ceased of its own accord, and without leaving any unfavorable
result.   Turpentine and cantharides have not unfrequently caused  renal
hemorrhage; they act as irritants upon  the organ, and produce a state
of congestion.   Malignant fevers, purpura, and scurvy, are not uncom-
monly attended with hematuria, and there is  good  reason  to  believe
that in most  cases the blood comes from the kidney.  In some of  these
affections, characterized by a  fluid  condition of the blood, the casts of
the tubes would probably be absent, or very imperfectly formed.  Blows
on the loins are another cause of renal hemorrhage.  In an interesting
case recorded by Dr. Johnson, the bleeding recurred several times, the
blood coagulating in the tubes, and forming casts which appeared in the
urine.   A calculus lodged in the calyces  or pelvis of the kidney is  often
the cause of  hemorrhage, which, though  taking place from the  kidney,
and perhaps being very abundant, is distinguishable from the preceding
forms, as well  shown by Dr. Johnson, by the circumstance  that  there
are no casts of the tubes.   These cannot be formed; as the blood, not
being effused from  the  renal  tissue,  but from the mucous membrane,
 
NEPHRITIS.
545
does not traverse their channels.1   Cancerous disease of the kidney is
sometimes attended with bleeding, but this can scarcely be distinguished
from that which  is the  result of  the irritation  of a calculus.  Blood
globules, when retained  in the tubes, sometimes undergo  change into
small yellow corpuscles,  very much like those which  are often found in
the spleen.  It is necessary to be aware of this circumstance, as other-
wise the observer might  suppose that biliary matter was present.
  Anemia.—General anaemia does not  seem to affect particularly the
condition of the kidney, at least, we have notes of one case of extreme
anaemia, the result of menorrhagia, and which at last terminated fatally,
in which, although the kidneys were small, the epithelium of the tubes
was very perfectly formed.   Mr. Simon notices, however, a condition
of atrophy of  the epithelium,  resulting from the obstruction of an arte-
rial branch by atheromatous and fibrinous matter, which would of course
produce a local anaemia.   In  that which  is regarded by several as  the
second stage of renal degeneration, the kidney, though much enlarged,
is often remarkably pale.  This anaemia,  however, is not attended with
atrophy, and is itself, probably, in part the result of pressure exercised
on the intertubular plexus.
  Nephritis, analogous to common inflammation of other parts, and like
it often passing  into suppuration, is not  a very common disease.  It is
most frequently seen  as  the result of the irritation of calculi in the kid-
ney, or  of inflammation of the bladder, which has either spread up along
the ureters, or directly attacked the kidney.  Blows on the loins are
also mentioned by Drs. Prout and Johnson, as causes of nephritis.  The
latter also believes that a morbid state of the blood, such as gives rise
to carbuncles, may act  in this way.  Rokitansky speaks of nephritis
following acute or chronic diseases, and presenting a type corresponding
to the general dyscrasia.  Whatever  be the cause, the general characters
of the inflammatory action will not differ  materially, provided it is true
nephritis that we are dealing with, and that it passes on to  the stage of
suppuration.   Nephritis, unattended Avith  the formation  of pus, would
probably be undistinguishable from  the condition of hyperaemia above
described.   In a man,  who died  in St.  Mary's  with  an enormously-
thickened bladder and inflamed kidneys, the bladder being  the original
seat of disease, and the kidneys secondarily involved, Ave found the latter
organs  in the following condition.   They were very greatly enlarged,
and in some parts very  much injected;  in others, the  red  surface had
numerous whitish spots, or patches, appearing through it;  these were
seen in  sections  to be the ends of long striae, which commenced at the
base of the medullary cones, and extended to the surface of the organ.
Between them were interposed streaks of congestion.  There was nothing
remarkable in the medullary cones, except that they had a coarse aspect.
Microscopy showed that the  cortical tubes wTere  quite  infarcted with
their epithelium; in the whitish portions this was especially accumulated,
and altered  so that it resembled a mass of nuclear particles; the tubes
also were not clearly seen; they were doubtless so distended and crowded

  1 In a case of chylous urine, now under Dr. Chambers in St. Mary's Hospital, a large
Quantity of blood as well as fibrin comes away in the urine, but there are no casts.
     *  35 
546
NEPHRITIS.
together that their outlines were lost.  In  some parts the basement-
membrane of the tubes was gone,  and the contents appeared as a naked
strand of nuclei and granular  matter, part of Avhich became dispersed
between the tubes, and  made  the mass quite uniform. ^  This mass of
altered renal structure was evidently on the  point of fusing down into
fluid  pus.   The  Malpighian tufts appeared healthy.   The medullary
tubes were also  infarcted, some  of them very  much, and were opaque, as
if containing finely-divided oily  matter.  There seemed to have occurred
also an extra-tubular effusion of plasma, solidifying into a granular stuff.
Dr. Johnson, in narrating a case of  suppurative  nephritis, says, " that
the appearances in the kidneys  showed the transition from  epithelial
cells to pus-corpuscles;  some tubes being filled with desquamated epi-
thelium, others  with pus, while  in other parts the pus-cells  had accumu-
lated so much as to destroy all  trace of tubular structure."  The urine
in these cases is found to contain cylindrical  masses  of  pus-celh, which
have evidently been formed in the renal tubes; this  sign, while it lasts,
serves to distinguish suppuration in  the kidney from that  taking  place
in the bladder, as in the latter case the pus-corpuscles form only shape-
less masses.   When the suppurating renal tissue is quite broken down,
the pus will no longer form casts, the tubes being destroyed.   Rokitan-
sky remarks, that enlarging renal abscesses  are bordered  by a red in-
jected halo, Avhich gives rise to a fusible product, leading to  an extension
of  the abscess.   They are  always more numerous in  the  cortical sub-
stance, and generally of a roundish shape, while in the tubular substance
they are more  elongated, like  striae.  The  mucous membrane of the
calices and pelvis, especially when a calculus  is  lodged in these cavities,
is softened and inflamed, and secretes a purulent fluid.   The extension
of  renal abscesses may go on until the whole organ  is  converted into a
mere pouch of pus; in this case,  or  even before the organ is quite de-
stroyed, the abscess may make  its way by the  usual process of absorp-
tion, penetrating through surrounding indurated tissue, and evacuate its
contents in either of the following situations: (1) Externally into the
lumbar region;  (2) into  the cavity of the peritoneum ;  (3) into the as-
cending or descending colon, or  into the duodenum; (4) into the bronchi
after perforation of the diaphragm.  Acute inflammation of the kidney
may become chronic, or the inflammation may have a chronic character
from the outset; its results may be suppuration or induration, and con-
secuthTe atrophy of  the organ.  Dr.  Watson  thinks that nephritis,  con-
fined to the parenchymatous substance, may  arise and pass through all
its  stages without announcing itself by marked local signs, such as pain,
&c.   This would give the process, though truly acute, an appearance of
being chronic.   It seems desirable to notice  the possible simulation of
an  abscess by a  mass of softened fibrinous exudation, which may be bor-
dered by a red halo as in abscess; the microscope would sufficiently dis-
tinguish the one from the other.1

  1  We have recently witnessed a very interesting case  of fibrinous deposit in the kid-
neys ; in which cavities were formed,  closely resembling abscesses.  A youth, set. 20,
suffered with symptoms of fever with pus, mucus, and blood in his urine for nine days, at
the  end of which time he died.  The bladder was empty and contracted, and only pre-
sented some ecchymosed spots;  the left kidney contained several  small spots of softening 
           DEGENERATIVE DISEASE  OF THE KIDNEY.        547

  Degenerative disease of the kidney.  Morbus Brightii.  Desquamative
and non-desquamative nephritis.  Subacute  inflammation  of the  kid-
ney.—These names refer to an extremely common and important disease

                                Fig. 245.
Fibrinous deposits in a granular kidney. The situation of the patch is marked by the irregular outline)
                            which was a deep red.

of the kidney, whose main features  were discovered by Dr. Bright, but
whose real nature is still a matter of doubt.  In calling it a degenerative
disease, wre have expressed our own opinion respecting it, which coincides
very closely with  that held by the late Dr. Prout.   Our brief limits for-
bid any detailed discussion, and we shall  therefore simply endeavor, first,
to describe the morbid  alterations which seem to belong to  this disease,
and then to give some account of its pathology and nature.   A kidney
in the state of hyperaemia, which we have  above described, or somewhat
approaching to  it, with fibrinous exudation  in the  tubes, is considered
by Frerichs as in the first stage of Bright's disease: we  greatly doubt
if this  is  generally the case, and cannot look upon hyperaemia as a
necessary element in the morbid process.   Dr. Johnson considers the
same condition as the  result of  acute desquamative nephritis, and be-
lieves that complete recovery may not unfrequently take place.  In this
we quite agree with him, and so, we  think, would most observers.  He
differs, therefore, from  Frerichs, in  not  considering the hyperaemic con-
dition as constituting  the first stage of Bright's  disease.    The urine
produced by  kidneys in this  state  is  very characteristic  ;  it is  of a
rather deep, smoky-red color, with a copious dark-reddish deposit, con-
sisting of blood-corpuscles, renal epithelium, and fibrinous casts entang-
ling more or less of the latter.   Sometimes corpuscles are present which
resemble  those of pus,  and like them have compound  nuclei.    The

fibrin, the right many large  ones, several of which had broken down, and  given rise to
cavities with ragged  and sloughy walls.  There  was no manifest trace of  inflammation
of the other parts of the kidney; the microscope  showed the tubes in a tolerably healthy
state.   This seems to have been a case of fibrinous deposit confined to the kidneys; it
was remarkable that  though  the kidneys themselves were uninflamed, inflammation had
been excited in the peritoneum by the disorganizing processes taking place in the right. 
548        DEGENERATIVE DISEASE OF THE KIDNEY.

appearance of this  deposit will be best understood by reference to  the
accompanying figure.  The haematin of the blood-globules exudes from
them, and gives the peculiar red color to the urine, which is at the same
time scanty and loaded with  albumen.  It will be manifest that an  op-
portunity rarely occurs of examining kidneys during the existence of the
intensity of the  hyperaemia, as this  has  generally subsided, or been
removed, before the disease proves fatal;  the  observer, therefore, must

                               Fig. 246.
Drawing of red deposit from urine in intense renal hyperemia.
not be surprised  at  finding kidneys, which he  supposed to  have been
recently in a state of great congestion, without much appearance of it:
the hyperaemia will,  of course, decline, in proportion as it is relieved by
the hemorrhagic  effusion, or by treatment, and the  urine, at the same
time, Avill begin to increase  in  quantity, to  lose  its red color, and to
contain a less amount of albumen.   The effusion of serum, with a certain
quantity of fibrinous matter, continues for some time after the hemor-
rhage has ceased, so that casts of the tubes, which become, however,
more delicate and pale, traces of renal epithelium  and albumen are still
discoverable in the urine, until recovery is complete.   Crystals of uric
acid,  in  considerable quantity,  are also often present during conva-
lescence, and we have also seen oxalate of  lime.   These may be viewed
as indications that the organ is recovering  its  lost  power.
   AVe have thus noticed the hyperaemic or acute inflammatory disease of
the kidney, because, though not believing  it ourselves to belong to the
truly degenerative processes,  it produces  symptoms in some measure
similar, and is regarded by one of the best authorities as always taking
the initiative in a more or less marked manner.   It may, of course,
give rise to a true degeneration, and apparently pass into it; but there
is  not more  connection, we believe, betAveen the tAvo, than between an
attack of bronchitis  and succeeding pulmonary phthisis.  In the  first
form of renal disease which appears to us truly degenerative,  the kidney
is  considerably enlarged, even more sometimes  than in acute hyperaemia;
it is generally pale, sometimes of an opaque grayish-white, with mottling 
           DEGENERATIVE DISEASE OF THE KIDNEY.       549

spots or streaks of red; its capsule  peels  off readily;  the  surface is
smooth and tolerably uniform, or  presents opaque spots, indicating the
site of future granulations;  or these, again, may be just beginning to

                               Fig. 247.
 (a) Tube containing an homogeneous cast, which projects from its broken end. (b) Malpighian body; the
                        capsule is filled with oily matter.

become prominent.   The surface of a section shows the thickness of the
cortical substance much increased, and the medullary cones also some-
what  enlarged  and  markedly  striated, so as to resemble  a  plume of
feathers ;  they  are usually more congested than the  cortex.   The renal
tissue in the latter part appears to be obscured or confused, as if some
coagulating fluid had been effused throughout it; it is commonly marked
also by similar  indications of  commencing granulations to  those which
are seen on the capsular surface.   The mucous membrane of the calices
and pelvis is somewhat SAvollen and reddened.   The consistence of the
kidney is  rather diminished;  it is  rather  flabby and soft.  The above
description applies to many instances of an early degenerative condition;
but there  are many others also, in an early stage, which differ in several
respects.  The size of the organ may not be materially increased, though
its structure  is evidently altered;  its consistence may be  dense, firm,
and brittle, instead  of soft and flabby; its  capsule may be firmly ad-
herent, and its color more approaching  the natural.   Cysts are some-
times observable on  the surface of the organ, but this is no necessary
part  of the morbid change.   When thin sections are  examined micro-
scopically, the  following circumstances are  observed:  The epithelium
lining the cortical  tubuli  is  greatly  increased  in bulk;  sometimes
its particles  are  more  completely  formed  than  usual,  and  appear
more  distinct and separate ; sometimes their size is greatly exaggerated,
so that  a  few  particles cohering together form a  large bulky mass;
sometimes the  tube is filled  with  a melange of  stunted or  withered-
looking  nuclei, granular matter, and ill-formed celloid particles.   The
central channel of the tube, which should, normally, be about one-third
or one-fourth the whole diameter, is much  encroached on and  even
obstructed by this accumulation of  epithelium; from  the  same cause, 
DEGENERATIVE  DISEASE OF THE  KIDNEY.
the tube becomes dilated, and hence the bulk of the  organ  is  increased.
Coagula of fibrin also  are  present  in  some of  the  tubes, but  not in the
great majority, and doubtless aid in  increasing the obstruction.   The
Fig. 248.
  (2) Cortical tube, infarcted with epithelium, and bulged in  a  good part  of its extent.  (3) Cortical tube
containing a dumb-bell crystal of large size.  (4) Cortical tube, infarcted by epithelium at (a) below it; some
of the separate particles are shown more highly magnified.  (5) Bulky epithelium from cortical tube; the
group at (a) are remarkably enlarged, those below them are more or less fatty.  (6) Medullary tube much
infarcted; the contents are seen escaping from the upper end.
Fig. 249.
  (a) Cortical tubes, containing a very fatty epithelium,  (b) A short homogeneous cast, containing two
corpuscles,  (c) Portion of a medullary tube, containing three casts, looking much like cysts and oily matter.
  The four preceding figures are intended to illustrate the changes observed in the enlarged form of degene-
rated kidney. 
           DEGENERATIVE  DISEASE OF THE  KIDNEY.       551

basement-membrane of the tube, in  some  cases, is  natural, in some is
decidedly atrophied, and scarcely can be detected.  A condition of the
epithelium is sometimes  observed which is  extremely significant, we

                               Fig. 250.
 Microscopic view of epithelium-cells and fibrinous shreds from the tubuli uriniferi of a kidney affected with
Bright's disease.   (1) Epithelium-cells  from the tubuli uriniferi, loaded with oil-globules, magnified 400
diameters.  (2) Fibrinous shreds from their interior, having blood- corpuscles and oil-globules entangled in
them, magnified 200 diameters. (3) One of the tubuli from a kidney affected with Bright's disease. Oil-
globules are seen through its walls.

think, of the nature of the morbid process; it is noticed by Dr. Johnson
as peculiar to that form of disease which he denominates non-desqua-
mative nephritis.  The epithelium in  this does not accumulate  and block
up the tubes, but appears as a coarsely granular opaque stratum, of the
natural width, resting on the basement-membrane.
  The Malpighian tufts are  more opaque than  natural, the capillaries
being obscured by a film of coagulated fibrin; in some cases this is so
abundant,  and  so  mixed with  oily  matter,  that the  capsule becomes
notably dilated; in others, the pressure of  the refluent fluid from the
obstructed tube  compresses the tuft into a small space at the  bottom of
the capsule.   Oily matter, in the form of minute dark molecules, and
various-sized drops, is often present  in  small, sometimes in considerable
quantity; when very abundant, it imparts to the kidney a dead milky
or yellowish-Avhite  aspect.   In such cases, the epithelial particles often
become so filled with oily molecules as to resemble very closely granule-
cells. In many cases, however, there is no trace of it, and it is certain that
it is not of the essence of the disease.   In the more advanced instances
of degeneration—before, however, atrophy of the kidney has  become
decidedly apparent,  the cortical  tubuli  exhibit unequivocal  traces of
breaking  up.   Their basement-membrane is lost;  their epithelium,
though  still preserving  the  tubular  form, is  tending to become a mere
detritus, and  the  commencing  appearance  of granulations shoAvs  that
atrophy is taking place  in  some parts, while others remain prominent
and distended by  their included cell-growth.   Microscopic  cysts  are
sometimes imbedded in  the cortical tissue, and may tend, in some mea-
sure  to increase the  size of the kidney; but they are not so numerous
as in the  more atrophied condition.   The  medullary tubuli are less
affected than the cortical;  those near the base of the cones, especially,
often are filled by accumulated epithelium, while those nearer the mam- 
552        DEGENERATIVE  DISEASE  OF THE  KIDNEY.

mellae are more free, and contain  either some oily matter,  or  fibrinous
casts, or yellow  corpuscles,  the result of hemorrhagic effusion.   The
matrix-tissue is little altered in itself, but is often infiltrated with  a
granulous exudation-matter, containing a few  nuclear corpuscles;  these
are sometimes  elongated and developing fibres.  The urine  produced by
kidneys in the foregoing condition is  generally paler than natural, of
somewhat altered smell, and deposits a whitish  sediment, consisting of
fibrinous casts, renal epithelium, and vesical scaly particles.  Its acidity
is less than that of the natural secretion, and its specific gravity, which,
in the earlier stages, may be above, tends to  fall  more and more beloAV
the standard of health.  While the fibrinous casts contain epithelial par-
ticles, it may be inferred that their cell-growth  is  still produced in the
interior of the tubes; but Avhen the urine deposits large cylindrical casts,
with very little trace of epithelium imbedded in them, it betokens that
the basement-membrane is denuded, and that  the condition  is becoming
more unfavorable.  AVhen oil-drops appear  in the epithelium  or in the
casts, it is, of course, a sign that oil is deposited  in the kidney; but it
is  by no means certain that this particular change is of any moment.
Blood-globules are not generally present, unless  as the result of  some
recent congestion. Albumen is constantly present, except in a few rare
cases, where  it disappears for a short time; its  quantity  varies  con-
siderably, being,  apparently,  much more influenced by  other circum-
stances than by the period of the disease.  Frerichs states that the daily
drain from the blood varies from 54 to 360  grains.  The quantity of all
the solids of the urine diminishes as the degeneration adArances, the urea,
the lithates, the alkaline, and earthy salts are all diminished; in one
case, mentioned by Dr. Christison, the total amount of solids  excreted
from the kidneys, in twenty-four  hours, amounted only to  J.jth of the
normal average.  Dr. Rees has lately shown that an increased quantity
of extractive matter is  often poured out in cases of renal degeneration,
which constitutes a further drain, in  addition to that of the albumen.
  The next condition  of kidney which we  shall  describe  is often re-
garded as a  further stage of  the  preceding;  this is, we  believe, some-
times the case, but not by any means necessarily or universally.   The
organ is greatly atrophied, and  evidently contracted;  its surface is
covered with  irregular  prominences,  the  so-called granulations.   Its
consistence  is  considerably  increased, so  that the structure has,  as
Frerichs says,  a kind  of leathery toughness; this is more marked in
proportion to the atrophy.  The color is decidedly less pale than in the
former variety; it often seems  to depend  very much on  a moderate
amount  of passive hyperaemia.  The  capsule  is always  very adherent,
but it is worth noticing that, sometimes, when it is thickened, a layer of
it may be peeled off, leaving behind an apparently  smooth surface.   The
cortical part is most affected by the atrophy, being reduced, in extreme
cases, to a layer  two or three lines in  thickness;  the medullary cones
suffer in a less degree.   The  external form is  often  remarkably lobu-
lated, reminding one of that of  the foetal kidney.   Microscopically ex-
amined, the renal tissue is found to have perished extensively, and this
generally  in proportion to the shrinking  of their size.   In extreme
cases, one may scarce find in  a  section anything  except mere granular 
DEGENERATIVE DISEASE OF THE KIDNEY.       553
debris;  some of these, perhaps, still preserving the contour of the  ori-
ginal tube, but the  greater  part constituting an  indefinite shapeless
Drawing of atrophied kidney.
mass.  In other less advanced cases, and in some parts, indeed, of  all,
the  tubes are  still  discernible:  they are  irregularly distended, and
opaque with granular contents, wrhich have wellnigh, or perhaps corn-
Fig. 252.
 Cortical part of a very granular kidney, containing very numerous microscopic cysts.  The tubes are very
            much degenerated and broken up.  Two Malpighian bodies are shown.

pletely blocked up their canals.  Oily molecules, sometimes accumulated
in considerable quantity, lie here  and there amid the granular matter,
and increase the opacity greatly.  The granulations are made up of the
infarcted convolutions of tubes, and are the parts in  which most traces
of the natural structure still persist; they remain prominent, because
the intervening parts  have  perished  and  shrunk in.  The basement-
membrane of the tubes, in most instances,  is lost; occasionally a trace
of it may be seen, giving a  sharp definition to a mass  of epithelium;
but as a rule, it seems to disappear with advancing  degeneration, and
Ave cannot confirm the observation of Frerichs and others, that it is still
existent  among the atrophied tissue. 
554        DEGENERATIVE DISEASE OF THE  KIDNEY.

  In specimens where its presence is very manifest in infarcted but not
atrophied tubes, Ave have observed sometimes a single tube with its ho-
mogeneous membrane denuded  by separation  of  the  epithelium,  as

                               Fig. 253.
The upper figure is from the medullary, the lower from the cortical portion ; they are intended to represent
       a thickened condition of the matrix.  Drawn from actual observation by Dr. Sieveking.

noticed by Dr. Johnson.   AATe have also seen Avhat we think has not yet
been described, a kind of thickening, or hypertrophy of this membrane,
which has seemed to us  to  result from the atrophy of the epithelium,
and its fusion into an  homogeneous layer on  the inner  surface of  the
tube.   The Malpighian tufts, in  consequence of the general  collapse,
appear closer together ;  a feAv of  them remain tolerably healthy, others
are compressed and  shrunken;  often the capsule  is filled, to a greater
or less extent, with  an  oily-looking matter, or  the  capillaries are  ob-
scured by fibrinous  exudation.   AVhen  that peculiar  condition  of  the
blood exists, not very uncommon, which leads to the deposit of  "bacony
matter"  in  the liver and  in  the  spleen, this  is  often  observed also in
the interior of the Malpighian capillaries, and we have not detected it
in any other part of the organ.  The  membrane of the capillaries  has
rather appeared to us thinned than thickened,  as  Dr. Johnson describes
it, and to this thinned and probably otherwise  altered condition of their
tunic,  we should  ascribe  the constant draining of serum that  takes
place.   A very important and  significant alteration has been  observed
in the condition of  the  small arteries  by Dr. Johnson;  he finds their
coats  considerably thickened, both the inner of longitudinal  and  the
outer  of circular fibres, and  he regards  this  thickening as an instance
of true hypertrophy induced by  the increased pressure  exerted upon
their  parietes by the  retardance  of the circulation through the  inter-
tubular venous plexus.   No particular change  is observable in  the last-
mentioned  capillaries,  or in the  veins, except that the  latter often con-
tain firm coagula of blood, Avhich are more or less closely adherent to
their walls. 
DEGENERATIVE DISEASE OF THE KIDNEY.
555
  AVe proceed to  the consideration of the cystic growth which  often
takes place  so abundantly in  diseased  kidneys.   These formations ap-
pear as vesicles of very various  size, varying from microscopic objects
of TT5iTJTJ inch diameter to the  magnitude of a cocoa-nut.   They contain
usually a  clear, colorless fluid, which is slightly albuminous, and  holds
                                  Fig. 254.
V_J
                           Renal cysts, and cyst-like* casts.
 g^^S^Ccontaining granulous matter and nuclei; in V, the celloid contents are disposed so
as to form an epithelium round a central space; in b", the nuclei are elongated.
 (c, c) Cysts containing granulous and oUy matter.
 Id, d, d) Small transparent vesicles.
 (e) Young cyst diameter, l-2000th of an inch in the remains of a tube.
 ^Tto^^^SX^w.^dWInet envelop, consisting of granulous and a little oily
matter.
 (6) An oval fibrinous cast advanced in fatty degeneration.
 (c) Pale, homogeneous, fibrinous casts.

in solution the ordinary salts  of  the serum.   Sometimes  it is of a dark-
yellowish color, and more  or less viscid, indicating, perhaps,  the pre-
sence of colloid matter.   We found,  in one  instance  a  large  quantity
of yellowish-granular corpuscles diffused through the fluid, and frag-
ments of an Epithelial pavement, consisting of closely opposed  nuc ei.
So urinary principles are found  in them, at least as a general rule, but
oily matter I  not unfrequent, and cholesterin is occasionally present. 
556        DEGENERATIVE DISEASE OF THE KIDNEY.

As they extend and attain a largish size, they seem to cause  absorption
of the cortical rather than of the medullary substance, so that on laying
open a  cyst, a medullary cone may be seen at the bottom  of it, and
forming perhaps a ridge in its interior.  Respecting the origin of cysts,
opinions  are divided; Drs. Johnson  and Frerichs maintain that they
are produced by obstruction of the  tubes, and  subsequent dilatation
from secretion taking place within  them.   Mr. Simon first proposed the
idea that they originate as new formations or growths  within the tubes,
each cyst having its origin in a germ  or nucleus particle, such as under
healthy conditions might have produced an epithelial cell.  Rokitansky
and Paget have also adopted this view, and we have ourselves been long
convinced of its accuracy.  It applies especially to those cases where
the cyst-formation is extremely abundant, but we are  more inclined to
believe that the few and rather large cysts which occur in kidneys not
seriously diseased, are produced in the former manner.  When the tuft
in the interior of a Malpighian capsule is compressed  and spoiled, we
believe that a cyst may be developed from the capsule  in the same way
as from a portion of a tube.  The smaller cysts  contain usually either
a clear fluid, or granulous, or an admixture of granulous  and oily mat-
ter.   The  larger ones sometimes  contain an endogenous cell-growth.
The envelop in all is well marked, formed of a  distinct homogeneous
membrane;  it occasionally presents concentric laminae.   Oval and round-
ish  fibrinous casts, when impacted  in the medullary  tubes, may simulate
very nearly the aspect of cysts, especially when some  epithelium is im-
bedded in them.  The more or less altered remains of hemorrhagic effu-
sions, in the form of black or yellow  matter, are  not unfrequently met
with in the  cortical substance; in some very rare cases small  collections
of pus have been found,  though it  is possible these may have proceeded
only from disintegrating fibrin;  urinary deposits, such as uric  acid, urate
of soda, and oxalate of lime, have sometimes been observed in  the tubes;
and lastly, tuberculosis of the kidney has been noticed, when their organs
were at the same time affected with Bright's disease.   There is nothing
very characteristic of the urine passed from small atrophied kidneys;
it is generally, however, more abundant, of lower specific gravity, of
paler color, less albuminous, and deposits a  less quantity of epithelial
sediment  than that from the  enlarged  organ.  Fibrinous  casts  will
rarely be  entirely absent, though  their quantity, and  the presence or
absence of blood-globules, will  depend very much on the degree of con-
gestion  which may be induced by  various circumstances.  With regard
to the causes of renal degeneration, it appears that taking first the pre-
disposing,  no age is exempt, but that, as Frerich's Table  shows, the
greater number of cases  occur between twenty and forty.   If, however,
Ave exclude  the acute hyperaemic  attack, as we  are inclined  to do, the
number occurring in the early years of life will be much reduced.   The
large mottled kidney is often observed in early adolescence, the con-
tracted belongs more to a later period.  The male sex seems  to be more
affected than the  female, but we doubt if this would apply to the true
degenerations.   Whether  the  scrofulous diathesis  occasions  special
liability to the disease is not quite ascertained; we are inclined to think 
           DEGENERATIVE DISEASE OF THE KIDNEY.        557

that it1 does; a female suffering from very marked renal degeneration
lately told us, that  she had lost three brothers and two  sisters " by a
decay of nature."   Occupations attended with  much hardship and pri-
vation are those in which most cases of Bright's disease occurs. A damp
cold climate is most favorable to the production of renal disease, but it
is common in tropical regions also. The exciting causes may be referred
to two classes, the one tending to induce acute  hyperaemia of the  kid-
neys, and to  giATe rise to that  form of Morbus Brightii, which  is not
essentially degenerative;  the other by impoverishing the blood, and de-
pressing the  general powers, acting as direct promoters of renal degene-
ration.   In the first class we  comprise stimulating diuretics, blows on
the loins, arrests  of perspiration, the congestive influence of  the exan-
themata, and of cholera.   In the  second,  excess in  spirituous liquors,
bad nutrition, inveterate syphilis, mercurial cachexia, and exhausting
suppurations, as Avell as the deteriorating  effect of continued fever on
the general system.  AVe do not think that obstructive diseases of the
heart have much to do with the production of renal degeneration, at the
most they only act as predisponents.  The same may be said of preg-
nancy;  as, though it is, unquestionably, in some instances, the efficient
cause of renal congestion, and consequent convulsions from uraemia, yet
Frerichs acknowledges that even among such cases traces of real dege-
neration are  rarely discoverable.   AVe regard, therefore, albuminuria in
pregnancy and in obstructive heart disease only as  an indication that
the kidney is the seat of a passive  hyperaemia, which we do not think is
often followed by  actual degeneration.   It is possible that the increase
of fibrin in the  blood, which takes place in the latter months of preg-
nancy, may,  where a predisposition exists, induce true M. Brightii, but
this at least  is rare.   The effects of renal degeneration manifest them-
sehres primarily and  principally in the blood, and as we  have already
spoken of uraemia as a disease  of the blood, we shall merely enumerate
here the changes which it undergoes.  The blood-globules  are destroyed
to a very great extent, especially in the advanced stages of the disease,
the specific gravity and albumen of the serum are diminished,  the fibrin
remains at the normal figure, the extractive matters are slightly increased,
the quantity  of oil and of salts  is scarcely altered; urea has often been
detected in considerable quantity, and becomes most abundant when the
secretion of urine is very scanty.  As this unhealthy blood circulates
through the system, it occasions disorder and disease of different organs.
The serous membranes are often inflamed, and pour out copious effusions;
the luno-s are apt to become congested and infiltrated with fluid, or bron-
chial catarrh is  set up, and becomes habitual;  the  brain  and medulla
suffer, and coma, or convulsions, prove fatal; dyspepsia, vomiting,  and
diarrhoea may announce disorder of the stomach and intestines; chronic
rheumatism  is a  frequent  complication ;  atheromatous disease  of  the
great bloodvessels, and dilatation  of  the heart, are also with justice
artributable in some cases  to the poisoned state of the nutrient fluid.
The liver is often  found affected with more or less of cirrhotic change,

  1 The fir*t form of degeneration in which the kidney is enlarged and  pale, or fatty,  is
often met with in patients dying with tubercles and cavities in their lungs. 
558        DEGENERATIVE DISEASE OF THE KIDNEY.

but we believe  this to be rather a coincident effect of the state of the
blood which produces  renal  degeneration, than  a secondary result of
that degeneration.
   AVe come now to the consideration of the nature of Bright's disease,
excluding the acute hyperaemic attack as of a different kind.  Frerichs
makes it entirely consist in a preceding hyperaemia, occasioning exuda-
tion of fibrin into the tubes;  this filling of the tubes accounts for the
increase of size, and the pallor of the kidney ;  and the detachment of
the epithelium he believes is only occasioned by the fibrinous casts adhe-
ring to it, and  carrying  it along with themselves when they are swept
out by the current from the Malpighian tufts.   As the coagula and the
epithelium  are  carried forth, the  tubes collapse, and the kidney thus
passes into a state of atrophy.   The causes of  the  effusion are, accord-
ing to Frerichs, either mechanical hinderances to the Aoav of blood in
the renal veins, or a  supposed  paralytic dilatation of the capillaries,
which may be  directly  brought  about by irritants, or  an unnatural
state  of the blood, as in scarlatina, or by a reflex action from the skin.
We remark upon this theory that it is far too mechanical; that it takes
no account of  the great number of recoveries which take place after
acute hyperaemic attacks, and does not accord with the frequently latent
origin of hopeless degenerations ; that it does not explain sufficiently the
important changes which take place  in the epithelium, and in the base-
ment-membrane, nor why there should be so marked a difference between
simple Nephritis  and M. Brightii.   Dr. Johnson's  theory, we think,  is
far more tenable; it is expressed  by him as follows: "All changes of
structure commence in the secreting cells of the gland, and are the re-
sult of an effort made by the cells to eliminate  from the blood some ab-
normal products, some materials which do not naturally enter into the
composition of  the renal secretion."   AVith the first part of this state-
ment we quite  agree, the second we think, is much more doubtful.  That
a  diseased  state of the blood  is the essential cause of renal degeneration,
we have little doubt, but we conceive that this consists in an unnatural
state of some  of the normal  constituents of the blood, probably the
fibrin or albumen, and that this  induces an unhealthy nutrition  of the
renal tissues.   As we are ignorant of  the way  in which the  epithelium
subserves the secretory process, how it eliminates the urea, uric acid, &c,
from the blood in which they are formed, we cannot understand in what
Avay a diseased state of the epithelium disables  it from fulfiling its func-
tion.   Comparing, however, generally, the healthy with the  morbid
structure, it may be said that the former conveys the idea of a delicate,
quickly forming,  and quickly changing material, similar to the gray mat-
ter of the hemispheres, while the latter appearing coarser, more granular,
and having often more shaped and more consistent  particles, seem cer-
tainly much less  apt to undergo rapid  change.   The hypertrophy of the
epithelial particles, and  their accumulation  in  the  cavity of the tubes,
may  be only the result of  their not  disintegrating in the formation  of
the secretion as they normally should.  Some time ago we examined an
enlarged thyroid, in which most of the vesicles were filled and distended
by collected secretion, but some were filled Avith epithelium only.  In
the same Avay,  sebaceous follicles distended into cysts sometimes contain 
DEGENERATIVE DISEASE OF  THE KIDNEY.       559
considerable quantities of epithelium, sometimes  oily matter prepon-
derates.   The  accumulation, therefore, of epithelium within the tube,
is no sign that the cells are striving more actively to  eliminate morbid
matters, but only that, being unhealthily nourished, they do not disinte-
grate in the secreting act as  they normally should.  The  deposition of
oil in the  cells  seems to us also an  indication that  their vitality is at a
low ebb, that the plasma out of which they  are formed does not  main-
tain its normal composition.   So  also, the  perishing  of the basement-
membrane seems strongly to indicate unhealthy nutrition.   The  expla-
nation given by Dr. Johnson, of the mode in which  hyperaemia of  the
kidney and consequent exudation is produced, seems to us most  conso-
nant with sound pathology.  He starts from the important experiment
of Dr. Reid, Avhich shows so well  the effect of arrested nutrition in ob-
structing  the passage of blood through the capillaries  of a  part.  When
the air-cells of the lung  contain  a normal  proportion of oxygen,  the
blood traverses freely the pulmonic capillaries;  when they become sur-
charged with carbonic acid, the current of the blood is obstructed in  the
same capillaries.   The increase of  pressure in a haema-dynamometer in
an artery, and the decrease in a corresponding vein, show that  the  un-
aerated blood cannot traverse freely the  systemic  capillaries.   As  the
cells lose  their power of  eliminating the urinary constituents, the blood
passing through the tubular venous plexus is retarded in its  course, and a
continually increasing congestion is set up.   This affects necessarily the
Malpighian tufts, and occasions the draining  off of liquor sanguinis from
them, and often hemorrhage also.   The  thickening of the walls of  the
small arteries before mentioned is another result of this backward pres-
sure.   We think the term " chronic desquamative nephritis" unsuitable,
as the hyperaemia which it induces is only of a  passive kind, resulting
from  obstruction, and herein  probably essentially differing from  the
active  condition of the acute hyperaemic attack.   Deposition of oil in
the degenerating epithelium Ave hold to be accidental, and not  in any
way essentially modifying the morbid state.  As it is most common and
abundant  in the renal cells of dogs and cats, in England and Germany,
without any disease, so its presence in the condition we are considering
cannot be of much  moment.   With regard to the two  forms of diseased
kidney which we have described, we feel some degree of doubt as to  the
exact relationship they bear to each  other;  some  regard the atrophied
kidney as the more" advanced condition of the enlarged one, others con-
sider the two as  distinct varieties.   AVe  strongly incline to  the latter
opinion, and to the belief that the enlarged degenerated kidney possesses
pathological affinities with phthisis  and the class of scrofulous maladies,
while the  contracted eminently granular kidney is allied to such changes
as those seen in cirrhosis of the liver, and contraction and thickening
of the cardiac valves.   Between the two  forms, of  which we  have tried
to rr'we a typical  description, of course there are very numerous inter-
mediate ones which the student must expect to find.  In some of them,
it is scarcely possible to determine  by the naked eye whether the organ
be diseased or not; but a careful microscopic examination of the cortical
tubes, the Malpighian bodies, and  the medullary tubes, together Avith a
reference  to the "state of the urine during life, will  usually clear  up  all 
560        DEGENERATIVE DISEASE OF THE KIDNEY.

doubt.   The adhesion of the capsule to the  surface, if decidedly un-
natural, is a valuable morbid sign.
   Tubercular disease of the kidney.—Tubercle is not of frequent occur-
rence in the kidneys.  These organs stand only in the  eighth  place of
the scale given by Rokitansky.   It is  found sometimes in  the miliary
form, sometimes in larger masses, which preserve the shape  of  the part
in which their substance seems  to be infiltrated; sometimes it extends
to the kidneys, from  the mucous membrane of  the calices, and proceed-
ing up along the sides of the cones, gradually advances inwards into the
secreting structure.  The miliary granulation is sometimes (when a high
degree of tubercular dyscrasia exists)  associated with a considerable
amount of  hyperaemia of the organ; when the deposit takes place in a
chronic manner, the,surrounding tissue is quite pale.  The large masses
that extend throughout the diameter of the kidney, from the surface to
the hilus, are remarkably bloodless.   This is well shown in some injected
specimens in the museum of St.  George's  Hospital.  When the tuber-
cular deposit extends to the renal tissue, from  the mucous membrane of
the calices  and pelvis, these cavities become remarkably enlarged; they
extend up  on  the sides  of the cones, into the  cortical substance, and
approach more or  less near to the surface.  At the same time, the whole
organ is enlarged, and appears rather pale.   The  epithelial lining of
the tubes is more or  less  opaque and granular, or of oily aspect.  As in
other situations, the  tuberculous matter tends to soften and break down,
and  thus cavities are formed sometimes  of rather large size.   These may
contain a mixture  of tuberculous  detritus and pus.   Fibrinous moulds
in great numbers are  sometimes present in the tubes.   The middle period
of life is that at which the disease is most liable to occur.   In most cases
there is a deposit of tubercle in other organs, especially  in the lungs,
and  often in various  parts of the genito-urinary apparatus.
   Cancer.—AA"e have not exact data for determining the frequency of
renal cancer, but it is certainly not rare.   Secondary seems to be more
frequent than primary cancer.   Scirrhus is rarely if ever found ; and
the same may be said of colloid.   Encephaloid growths, especially, we
think, in children, attain in the kidney an enormous size.   A  case has
been mentioned to us by Dr. T. K. Chambers, in which the weight of
the tumor was  three-fourths that  of the  whole body.   No trace of the
kidney Avas discoverable in this case, on the side of the tumor, and the
ureter was lost in  it  above.   The liver  contained some smaller tumors
of similar  kind.  These facts seem sufficiently to prove the  renal origin
of the tumor.  In a specimen in  the museum of St. George's Hospital,
there are several small cystic cavities in a carcinomatous  renal growth.
The statement of  M. Rayer, that cancer of the liver and right kidney
frequently coexist, as well as cancer of the adjacent parts of the stomach,
or descending colon  and left kidney, is confirmed by Dr.  AValshe.  Roki-
tansky notices that  cancer of the  kidney often  coexists with cancer of
the testis on the same side; the renal disease, we think, is most commonly
deA'eloped  after that of the testis.  "In thirty-five cases of renal cancer,
the  disease," Dr.  A\Talshe says, "affected both organs sixteen times, the
right alone thirteen  times,  the left alone six."   The table given by this
author, shows that the period from fifty to seventy is that  which is far 
  ANOMALOUS CONDITIONS OF THE URINARY PASSAGES.  561

most liable to cancer of the kidney.  Ten cases only occurred in the
previous years of life, while nineteen were noted in the succeeding twenty.
  The urine  excreted by cancerous kidneys, may long retain its natural
characters.   In a case recorded in the Transactions of the Pathological
Society, 1846-47, nothing remarkable seems to have been observed in
it, although both kidneys were converted entirely into encephaloid masses.
AVhen, however, the growth softens and breaks down, blood, puriform
matter, or cancerous detritus, may appear in the urine.
  Entozoa occurring in the kidney, are the acephalocyst, the cysticercus,
and the strongylus gigas.   The so-called hydatids from the first of these
have, in rare cases,' been passed with the urine.
  The adipose tissue, in which  the kidney lies  imbedded, may increase
to such a degree as to penetrate by the hilus into the substance of the
organ, impede its nutrition,  and induce a kind of atrophy.  Rokitansky
states that, in the highest degree of this  change, the kidney presents the
appearance of a mere mass  of fat,  without the  slightest traces of renal
organization ; the urinary passages at the same time being atrophied and
obliterated.
  The capsule of the kidney may be inflamed, in consequence of which
fibroid thickening may take place, and more or less of induration,  atro-
phy, and obliteration of the organ.  The cortical substance is especially
apt to be involved, and the surface is sometimes overspread with purulent
matter, Avhile the tissue itself becomes sloughy or gangrenous, or is only
congested and softened.
  ANOMALOUS  CONDITIONS  OF  THE URINARY  PASSAGES.

  Under these we comprise the ureters, and their upper termination, as
the pelvis and calices of the kidney.   The ureters may terminate from
congenital defect, in a cul-de-sac, either in the vicinity of the kidney or
of the bladder.   Sometimes they are double or triple, usually from fissure
of the pelvis of the kidneys, but they generally unite again before their
vesical termination.   It is not uncommon  to find them considerably
dilated, when the opening  into the bladder has been  greatly narrowed
or obliterated.   The calices expand  at the expense of the renal tissue,
and extend outwards  towards  the surface, till at length there remains
only a thin layer of  the  cortical  substance compressed  against  the in-
vesting capsule,  and the kidney is converted into a number of pouches,
separated by membranous loculi, which contain the remains of the me-
dullary cones.   The surface of the kidney becomes lobulated in a marked
manner from the pouches, pressing outward  between the  interlobular
septa.   The ureters are at the same  time distended, sometimes  to that
extent that they resemble a portion of small intestine; at the same time,
their walls are somewhat thickened,  so that they do  not appear to be
much thinner than natural; they only attain, however, a considerable
thickness when there is concurrent inflammation.  The  ureters become
also increased in length, and therefore do not lie straight, but are thrown
into coils or flexures.  Their mucous lining does not appear to be  so
often inflamed or ulcerated as that of the  calices and pelvis.   The
       36 
562  ANOMALOUS CONDITIONS  OF THE URINARY PASSAGES.

pouches formed by the dilatations of these, are often filled Avith puriform
fluid, or with a mixture of pus and urine, or even with clear serum only.
To  the latter condition, the term hydrops  renalis has  been given.  It
seems to take place  when the obstruction  to the flow of urine into the
bladder is complete, and Avhen, in consequence, after extreme distension

                               Fig. 255.
Kidney converted into cysts.
Fig. 256.
      Pyelitis; there was a concretion in the ureter, consisting of phosphates and animal matter.

and atrophy  of  the renal tissue, the secretion of true urine ceases, and
is replaced by a mere serous fluid.   After a  time, such  tumors may di-
minish, and  almost disappear, from the  absorption of their  contents.
The  ureters  in  such cases also contract, and become obliterated.   It
frequently happens that the  renal  tissue not only atrophies, but also
becomes inflamed, and infiltrated with pus, so that it is still further in-
capacitated from carrying on  its function, and  death  ensues  from the
effects of urea being retained in the  blood.
  Inflammation of the urinary passages often coexist Avith the state  of
dilatation ; it may also occur, though  much  more rarely, as a  primary
disease.  It is not unfrequently produced by the irritation of calculi,  or 
ANOMALOUS CONDITIONS OF THE URINARY PASSAGES.  563
results from the extension of vesical disease, or from metastasis of this,
according to Rokitansky.  Stricture of the urethra is a  common cause
of disease of the mucous membrane of the bladder, as well as of dilata-
tion of the ureters.   The  inflammation set up  there  is  very prone to
creep backward, and affect the urinary passages, which are predisposed
to it  by their unnatural distension, and the prolonged  contact of un-
healthy urine.  The mucous membrane is found in various degrees tume-
fied, injected,  or of a saturated red color, of villous aspect, and covered
with a muco-purulent fluid.  Perforation of the ureters may take place
in consequence of sloughing, the urine infiltrating into the adjacent tis-
sues,  and producing  either extensive sloughing,  or  circumscribed ab-
scesses.  The  inflamed mucous membrane, in many cases, either secretes
phosphates, or a mixture  of these and carbonates;  or  these may be
deposited from the  urine.   AVhen atrophy of the kidney takes  place,
these saline deposits, cemented together by mucus, form a "yellowish-
white, greasy, and chalky  pulp, which fills the calices," and is inclosed
by the wasted organ as by a  cyst.  In other  cases,  a  renal calculus,
such  as is described by Dr. Prout as the Phosphatic,  may be produced
in this way, and become itself a further cause of irritation and disor-
ganization to  the kidney.
   Rokitansky mentions the  occurrence of inflammation, which he dis-
 tinguishes by the name Exudative, from the above catarrhal form, as a
 secondary affection in cases of  serious blood disease.   It is observed in
 typhus, in the exanthemata, in diphtheritis, and acute tuberculosis, and
 also  in  pyaemia, and occasions the formation of unhealthy  fibrinous
 effusions upon the mucous surface, associated  in cases of necraemia with
 hemorrhage.
    Cysts, containing a glutinous or hard (colloid ?) matter, about the size
 of millet-seeds or peas, are occasionally found developed under the mu-
 cous membrane of the urinary passages.
    Tubercle.— Rokitansky states that  this "is always a symptom of
 tubercular disease, that has spread from the male genitals to the urinary
 organs."  We think  some  cases recorded in  the Transactions of the
 Pathological  Society, and some that we have seen ourselves, show that
 this  is by no means  necessarily the  case.   It is most frequent in the
 ureters when  the kidneys are  involved at the same  time, but we  have
 seen it in them when the  kidneys were healthy.   Usually, there exists
 at the same time tuberculosis of some  important organ, as of the lungs
 or the hip-joint.  The deposit takes place in the submucous tissue, and
 forms, when  its progress is chronic, gray granulations, which become
 yelloAV  soften, "and give  rise to small  circular ulcers."  AVhen the
 disease is  more acute, larger  patches  of deposit are formed, or " the
 mucous membrane  becomes  infiltrated throughout with the tubercular
 product of inflammation,  which is at once detached as a cheesy, puru-
 lent mass."                                            .   ,
    Cancer but  rarely attacks the urinary passages, and  only when it is
 elsewhere in  process of development.   The disease may extend to them
 from the kidney, from the  lumbar glands, or from  the bladder, either
 when it is  itself primarily affected, or involved in uterine cancer. 
564       ANOMALOUS CONDITIONS  OF THE  BLADDER.
        ANOMALOUS  CONDITIONS OF THE BLADDER.

  This  receptacle is subject to various congenital malformations,  of
which we shall only  mention two.  The first is  termed inversion of the      ,
bladder, and results from a  defect in the  loAver part of the abdominal
parietes.  There appears in the hypogastrium  " a red, mucous, dilated

                               Fig. 257.
  Extrophy of the bladder, a. Everted bladder.  6, 6. Orifices of the ureters, c. Penis without urethra.
d, d. Pubic symphysis,  e. Scrotum and testis. /. Congenital inguinal hernia.—From Gross on the Urinary
Organs.

spot, the edges of which join with the common integument; in the male
sex it passes downwards, so as to terminate in the fissure of the urethra;
in the  female it is surrounded by two diverging tumors, which represent
the  labia, and  it terminates in the lamina  of the general integument
which  invests the rima vulvae."   The opening of the ureters are seen at
the lower and lateral parts of this mucous surface, which is, of course,
the  posterior Avail  of the  bladder.   In a case which we saw recently,
the penis Avas very short, and the  canal of the urethra open above in its
Avhole  length.   The second malformation is attended Avith fissure of the
opposite  side of the bladder,  and of the adjacent cavities, so that a kind
of cloaca is formed, similar to that which exists in the lower animals.  In
some rare  cases the urachus remains pervious, so that Avhen urine is
passed it escapes at the umbilicus.  In  others, again,  the  bladder has
no external opening, the communication with the urethra is not formed.
  Dilatation of the bladder is no uncommon occurrence, and  may be
occasioned  either by paralysis of the muscular tunic, or by some obstacle
to the  outflow of the urine, as stricture of the urethra.   We think that
the amount of dilatation is  greatest when the muscular coat is paralyzed, 
          ANOMALOUS CONDITIONS OF THE  BLADDER.       565

and that in the other class of cases, where some  obstruction exists, the
great hypertrophy of the muscular fibres which is induced prevents the
distension becoming  so great.  Rokitansky, however, seems to consider
obstruction  as the most powerful cause of dilatation of the bladder.  The
effect of the stronger contractile coat of the bladder in preventing dila-
tation, is  shown in some cases recorded in the Transactions of the Pa-
thological Society, in which it is  mentioned that the ureters were much
distended, while the  bladder  was  contracted, or not dilated.   The blad-
der may be so dilated as to rise  above the  umbilicus considerably, and
to contain twenty pints of urine.   The paralytic dilatation depends, we
belieAre, in  some  cases,  on fatty degeneration of  the  muscular  coat.
Diverticula, or partial dilatations  of  the  bladder,  are  not infrequent.
They are always found in cases in which the  muscular tunic is  hyper-
trophied,  and  seem to be produced by protrusions of the mucous mem-
brane taking place between the fasciculi, which are subsequently pushed
outwards  more and  more by the  pressure  of the  urine.   The  lateral

                                Fig. 258.
 Sacculation or partial dilatations of the bladder; section of the bladder and prostate,  a. Mucous surface of
the bladder, b, b. Lateral lobes of the prostate, c. Middle lobe. d. Large cyst or pouch, partially laid open,
and communicating with the bladder by a small orifice.—From Gross on the Urinary Organs.

portions, the posterior surface, or the neighborhood of the fundus, are
the situations in which diverticuli usually form.  They have no muscular
tunic,  except, occasionally, a  few scattered fibres,  which  Rokitansky
suggests may be some evidence of their being congenital.  Calculi get
into these pouches sometimes, and become so lodged and concealed as to
escape detection by the sound.
   Contraction of  the bladder most often is rather apparent than real,
and depends on  irritation of the mucous  lining, Avith hypertrophy of
the muscular coat.    Sometimes  it is partial, or may cause a kind  of
hour-glass constriction of the cavity.   When a calculus is present, the 
566       ANOMALOUS CONDITIONS OF  THE BLADDER.

walls are sometimes found closely embracing it; and a case is mentioned
by Morgagni, in which the bladder was so closely contracted around a
needle, that there was scarce room for  anything more in its  cavity.
  Hypertrophy of the muscular coat  is observed in cases where  that
tissue is unusually exercised, and is often of a manifestly beneficial tend-
ency.  AVhen the mucous lining is irritated  by the contact of unhealthy
urine, perhaps in some degree inflamed or ulcerated, the reflected stimu-
lus from the spinal cord becomes more intense, and  the contractions of
the muscular fibres  more  energetic.  Again, when in consequence of
stricture, the difficulty of expelling  the  urine becomes  great, the  con-
tractile force is increased to meet it, and this increase is occasioned by
the greater exertions which are necessary.   The appearance of the inner
surface of  a bladder whose muscular coat is  hypertrophied, is peculiar,
and  is  well compared by Rokitansky to that of the right ventricle of the
heart.  The muscular fasciculi become  unusually prominent, and by their
diArisions and interlacements produce a kind of irregular network into

                              Fig. 259.
Hypertrophy of the muscular coat of the bladder.—From Gross on the Urinary Organs.
the meshes of which the mucous membrane dips, and through which  it
may be forced in sacculi. The technical term for this condition is colum-
nated, or in the French original, vessie a colonnes.   Dr. AAralshe has
seen polypoid growths from the inner surface of the bladder, consisting
of prolongations of the mucous and submucous tissue, in a state of simple
hypertrophy.   If Ave except these, and the diverticula before mentioned,
it does not appear that there is any true hypertrophy of the mucous
lining.  Rokitansky  has, in rare cases,  seen the mucous  membrane
atrophied, " reduced to a very  delicate, shining membrane, resembling
the arachnoid," while the muscular coat almost entirely disappears.
   The bladder  is liable to various displacements.   It may form the con-
tents  of inguinal,  vaginal, and perineal  hernia, it may be  introverted
and forced into the urethra, and even in females project from the meatus 
          ANOMALOUS CONDITIONS OF THE BLADDER.       567

urinarius externally.1   When hernia of the bladder occurs, it is either
in part, or, more rarely, completely  destitute  of  peritoneal  covering.
This depends  on the anterior part of the viscus, which has no serous
covering, being  the first to prolapse; but, as  the  organ descends, the
posterior part which is lined, carries with it  the peritoneum,  and thus
forms a sac, into which intestine or omentum is often protruded.
   Hyperemia of the  bladder of a passive kind, occurs when there  is
some obstruction to the  free passage of blood through the pelvic veins
and  the V. cava; it is, therefore, associated generally with a  similar
condition of the adjacent viscera.   It produces increased secretion of
mucus, sometimes spots of  extravasation, and occasionally such dilata-
tions of the veins as have  been termed vesical haemorrhoids.   These,
however, do not  appear like the  common little tumors of the rectum, but
rather as prominent and distended vessels.
   Inflammation of the bladder is much more often seen in a  chronic
than in an  acute form;  this depends  partly on the acute stage of the
disease in  recent cases having  generally subsided before death occurs,
partly on the greater frequency of  cystitis, which  is chronic  from the
commencement.  The appearances in acute cystitis are strong vascular
injection of the mucous lining, with brownish patches in the vicinity of
the neck and  fundus; more or  less thickening of  the membrane, with
exudation of fibrin  or pus on the surface, or foci of the latter in  its sub-
stance.  The mucous tissue may be ulcerated at several points, softened,
or affected by commencing  gangrene.   Abscesses may form in the sub-
stance of the parietes, and open either into the cavity of the bladder,
or upon its external surface.   Sometimes the mucous membrane is almost
completely destroyed, a few shreds or filaments being  the  only traces
remaining, while the muscular tunic is left as if cleanly dissected.  This
is probably the  result of phagedenic ulceration.
   Chronic cystitis may be the  condition resulting  from one or more
attacks of the acute form, or may be produced  by the extension of ure-
thral inflammation, or by the irritation of unhealthy urine, or of calculi.
Its  characters are various  degrees of  vascular injection, mingled with
dark-reddish, slaty or bluish-black discoloration, more or less tumefac-
tion of the mucous membrane, with secretion  of mucus, or muco-pus,
often in considerable quantity.   Sometimes, from the irritation excited,
the  muscular coat becomes hypertrophied and columnated; but the more
ordinary condition in chronic cystitis, is the thickening and more or less
uniform induration of the  parietes, which assume an homogeneous, lar-
daceous  appearance,  doubtless  from  their  infiltration  with exudation
matter.   It not unfrequently happens that an  acute attack, or  exacer-
bation, supervenes  upon a state  of chronic inflammation.   The  following
abridged account of the appearances which then present themselves,  is
taken from Rokitansky: " The bladder is found dilated, and filled with
decomposed, intensely alkaline  urine, mixed up with blood of a brown
color,  viscid mucus and pus, sanies, lymph, and detached  portions of

   1 In the Report of the Path. Soc. 18r)2-53, there is an instance recorded by Mr. Pilcher,
in which about two-thirds of the bladder were extruded from the abdomen through the
inguinal canal, and lodged in the scrotum.  The hernial portion was large enough to con-
tain 50 oz. of fluid. 
568       ANOMALOUS  CONDITIONS OF THE BLADDER.

mucous tissue, in the shape of discolored flocculi, or larger patches."
The  mucous membrane, incrusted by a deposit of amorphous and crys-
talline phosphates, is sometimes " of a dark-red color, appears spongy,
softened, and pultaceous, is easily detached and bleeds ; when chocolate-
colored or greenish, it is found purulent, infiltrated with  sanious matter,
or con Averted into a friable flocculent tissue, which  is traversed by the
urinary sediment."   In some cases, the submucous and muscular tunics
are exposed, and are in various stages of softening, suppuration, and
disintegration.  As the morbid action advances outwards, the peritoneum
at last  becomes involved, and general inflammation of  this membrane
may be set  up.   Ulceration, attended or not with suppuration, some-
times extends deeply and gradually,  and at  last perforates  the walls,
when extravasation  of urine takes place,  if not prevented by inflamma-
tory exudation, and adhesion of adjacent parts.  The further progress
of ulceration sometimes forms a communication with the cavities of  tbe
adherent viscera; in this way the walls  of the rectum, the colon, and
the ilium, have been perforated, and their contents have made their way
into  the cavity of the bladder.  We lately examined a portion of a blad-
der which had long  been the seat of calculous  irritation, and had been
further inflamed by the operation for lithotrity, the man dying of pyaemia.
The  true mucous membrane was in great  measure destroyed ;  there was
no trace of basement-membrane or epithelium; the tissue was thickened
by indurating exudation and granular matter, and incrusted with amor-
phous granular particles and prisms  of triple phosphate; or scraping off
this layer, the surface beneath appeared  red and  bleeding.  No trace
could be found of the muscular coat, it was replaced by a thick layer of
fat, consisting of large, well-formed vesicles.   Chronic or subacute in-
flammation of the bladder is very commonly an attendant upon  para-
plegia, and proves the immediate cause of death.  The inflammation is
set up, we conceive, in the same way as that of the eye is when the fifth
pair  of  nerves has been divided, and  results from  loss of the nutrient
power of the tissues, and consequent stagnation of blood in toneless
vessels.  At the same time, the urine rendered  alkaline  by the decom-
posing influence of  the vesical mucus upon the urea, reacts, no doubt,
upon the inflamed membrane as a further  cause of irritation.   The urine
is turbid with quantities of muco-pus and detached epithelium, contains
often albumen, sometimes blood, and always prisms of the triple  phos-
phate.  The coats of the bladder undergo  similar changes to those above
mentioned, but of a  marked asthenic character.   The mucous membrane
is congested, and thickened and altered by fibrinous exudation, or puru-
lent, or sanious ;  it is  incrusted by a phosphatic deposit, and in  parts
may be gangrenous.  The muscular coat is also more or less affected,
and the submucous tissue.  Rokitansky describes exudative processes of
a croupy kind, as not very unfrequent in  the bladder; they occur in  the
course of exanthematic diseases, in pyaemia and typhus.    The exudation
does not affect generally a large surface,  but is limited " to round spots
or striae."  The mucous  membrane  beneath the exudation is more or
less injected, tumefied, and indurated, or in processes of lower character
is softened and converted into a pulpy, gelatinous,  sanious, or purulent
mass, or even becomes gangrenous.   Rokitansky has not seen variolous 
          ANOMALOUS CONDITIONS OF  THE BLADDER.      569

pustules upon the vesical mucous membrane, as others state they have,
but he mentions, what we have once observed ourselves, an eruption of
minute miliary vesicles, containing a clear  serosity upon the surface;
they accompany, he says, catarrhal inflammation and slight exudative
processes, as well as Asiatic cholera.   Acute and  chronic inflammation
of the muscular coat of the bladder are both spoken and written of, but
the former appears to take place only  as a part of general cystitis, and
the latter, if it intend more than hypertrophy of the muscular fasciculi,
is only that general infiltration of the  parietes,  with induration-matter,
which we  have before noticed.
   Pericystitis, however, seems to be a more distinct affection;  it con-
sists in the spontaneous inflammation of the cellular tissue surrounding
the bladder, arising either as a primary or a secondary process.  It is to
be regarded, Rokitansky says, as a localization of pyaemia.   From its
original seat, it is  apt to spread to the areolar tissue round the rectum,
to the anus, and into the scrotum;  it may involve also the coats of the
bladder, and cause perforation of them. It is  sometimes of a  chronic
form, and then gives  rise to induration, rigidity, and  callosity of the
bladder.
   Softening of the mucous membrane, not  resulting from inflammation,
was observed by M. Louis only twice out of fiAre hundred autopsies; in
these, the tissue was converted into a kind of pale mucilage. Rokitansky
has seen it only once, in a case of typhus.
   Tubercle  is infrequent in the bladder, and is  sometimes absent when
the kidneys are extensively affected by its deposit.   It is only met with
in the form of separate granulations, which are surrounded by more or
less hyperaemia, according  to the  rapidity of their production; these
soften and give rise to circular ulcers of the mucous membrane covering
them.   The cervix and fundus are the parts chiefly affected.
   Cancer is much more often seen in the bladder as the extension of
disease from contiguous parts than as  the  primary phenomenon.  This
at least seems to  be the more general opinion; but Dr. Walshe affirms
that primary vesical cancer is far  from being so uncommon as is gene-
rally supposed, and we are quite inclined to agree with him.  Scirrhus
is very rare in the vesical parietes.  Mr. Coulson has neA'er seen it, nor
has Sir B. Brodie, except  where it constituted part only of  a  morbid
growth.   Rokitansky mentions having seen it extending over large sur-
faces of  the  sides of the bladder.   Encephaloid,  forming nodulated
prominences or cauliflower-like excrescences, is the form which vesical
cancer commonly  assumes.   These may be  of very various consistence,
and often very vascular, easily bleeding, and  situated especially at the
trigone the neck, the  fundus, and the vicinity  of the urethral orifices.
They are developed  in the submucous tissue; but, as they grow, the
mucous membrane is  destroyed, and either an ulcer is produced, or a
soft luxuriant, fungous mass.   They produce irritation of the bladder,
more or less difficulty in micturition, and, in the latter stages, hemorrhage,
which may  be  considerable and difficult to  arrest.   The urine contains
mucus sometimes  blood, cancerous detritus, and portions of encephaloid
matter  at various times, when they happen to become detached. 
570         MORBID CONDITIONS OF THE URETHRA.
          MORBID CONDITIONS OF THE  URETHRA.

  AVe notice the following malformations:  fissure on the upper surface
(epispadia), or on the lower (hypospadia);  the former, when extending
the whole length, occurs as  a complication of eversion of the bladder;
the latter accompanies fissures of the scrotum, and occasions  a  resem-
blance to the female conformation. The urethra may terminate at various
points of its normal course, in the perineum, the root of the  scrotum, or
anywhere between this and  the glans ;  the opening in these unnatural
situations is very  small, and sometimes is completely closed (atresia
urethre).   A  kind of cloacal formation may also be  produced by the
urethra terminating in the rectum, or in the female in the vagina.  The
diameter of the canal may be congenitally narrowed at the extremity, or
at other parts.
   Contraction, however, is much more commonly the result of inflamma-
tory disease, under which head we shall describe it.
  Dilatation of the urethra  is often produced by some obstruction to the
flow of urine; it occurs, for the most part, in the membranous portion,
Avhich is expanded into a pouch, sometimes as large as a small orange.
The mucous lining of these  pouches is usually "injected and thickened,
presenting fungous vegetations, and occasionally coated with lymph."
The urethra is frequently distorted from its normal direction, either by
the dragging of large scrotal herniae or hydroceles, or by the pressure
of tumors.  Enlargement of the lateral lobes of the prostate pushes it
to one side, of the middle lobe divides it into tAvo passages.  The length
of the canal, in such cases,  is increased.
   Lacerations  of  the urethra may be produced by mechanical injuries,
by the. passage of fragments of calculi, or by  ulcerative  destruction.
They often give rise to urinary fistulae.
   Inflammation of the  urethra, of the catarrhal kind, is  exceedingly
common,  and constitutes the misnamed gonorrhoea.   It  commences at
the anterior extremity, and gradually proceeds backwards, in  very severe
cases extending even to the bladder. The mucous lining becomes swollen,
injected, and covered with mucous or muco-purulent secretion.  Its fol-
licles and lacunae  are attacked, especially the  lacuna  magna;  in the
chronic state they are enlarged and relaxed, and pour out, as well as the
general surface, a thin mucous, so-called gleety, discharge.   During the
acute stage, when the inflammation extends deeper to the fibrous structure
of  the corpus spongiosum, exudation of fibrin sometimes takes place in
the venous cells, which  renders them incapable  of distension, and thus
occasions, during erection, a bending of the penis towards  the affected
part which is termed chordee.  Abscess  may form also in the same situ-
ation, from suppuration of the exuded fibrin, or, perhaps, also  from severe
inflammation of the lacunae.  The inflammation may spread along the
continuous mucous lining to  other adjacent parts, to Cowper's gland, the
prostate, the vesiculae seminales, and  the  testicles.   This extension of
the morbid action to other parts is commonly attended by a subsidence
of  it in its original seat, so  that it is often questionable whether actual
metastasis has not occurred. The gonorrhoeal discharge passes through 
MORBID CONDITIONS OF THE URETHRA.
571
the same stages as that from other inflamed mucous surfaces; it is at first
a thin mucous fluid, then more tenacious and muco-purulent or purulent,
and, as the inflammation subsides, it becomes again thin and pale.  When
a chancre coexists with gonorrhoea,  "the discharge has usually a grayish
or reddish tint, or sanious aspect."  The mucous follicles in the vicinity
of the meatus are liable to be  specially affected both in the male and
female.  Dr.  Oldham appears to refer to this condition under the name
of follicular inflammation of the vulva;  and  Kleeberg,  as quoted by
Dr. Adams, thus speaks of their condition in the male:  "The orifices ot
the lacunae become closed by inflammation, and in the course of  two or
three days pustules are formed in their places, which break and discharge
a yellow pus.  The orifices of the large mucous follicles are now seen
dilated and surrounded by a swollen dark-red border,  and  they discharge
 a muco-purulent fluid into the urethra."  The disease  sometimes assumes
 a chronic form.  The contact of unhealthy vaginal secretion is the most
 common cause  of urethritis, and it is important to  be aware that this
 effect may be produced by the fluids of females who are perfectly chaste.
 Stimulating injections, the irritation of calculous fragments, the presence
 of stimulating  diuretics  in the blood, the materies morbi ot gout ot
 influenza, and the  suppression of cutaneous eruptions, are mentioned as
 causes of this inflammation.  Abrasions and excoriations  ot the urethral
 mucous limn* are  occasionally found Avhen it is inflamed, but ulcerations
  are (probably)  always the effect of other causes.   The syphilitic poison
  producing urethral chancre, the presence of foreign  bodies, calculi, &c,
  the irritation caused by a stricture in the part behind, softening tubercle,
  are so many causes of more or less extensive ulceration.  It is said by
  Mr. Adams  to occur in rare cases spontaneously.
    A very frequent result of inflammation is stricture.   This consists in
  a narrowing of the canal from some organic change in  the structure
Fig. 260.
Fig. 261.

6trictured urethra.
Strietured urethra.
 t tho mrt itself, or in that of those around.  It may affect any part,
W I most f equent in the anterior  part of the membranous  portion.
Out of one huXd and eighty-nine cases  examined by Mr. Phillips, 
572         MORBID CONDITIONS OF THE URETHRA.

the seat of the stricture was  in one hundred and  thirty-eight from
four to six and a half inches distant  from the  meatus.  Contusions
and wounds occasion stricture of the urethra, which,  in severe cases  of
the latter is  extremely intractable.  The simplest form of stricture is
when the canal is  partially occluded  by a fold of membrane  passing
across it; this may be of such a shape that a crescentic, or, sometimes,
an annular opening is left.  Several of these strictures may coexist  in
the same urethra; as many as eight are said to have been observed by

       Fig. 262.                              Fig. 263.
       Strictured urethra.                      Strictured urethra.

Calot.   They are probably produced by the organization of fibrin effused
on the  mucous surface; others believe that they may result from the
healing of an ulcer, or the raising up of a fold of the lining membrane.
In the more common kind of stricture the urethra is narrowed in a much
greater extent of its course, and sometimes in an extreme degree.  Half
an inch or  an inch is not uncommonly the length  of the contracted
part, and sometimes the whole extent of the spongy portion is affected.
The  stricture occupies sometimes one side, at  others it completely en-
circles the canal.  It is not difficult to understand the mode of its pro-
duction, which is very illustrative of the general contractile tendency of
exudation-matter.   Fibrin is effused during inflammation in the mucous
tissue  itself, or  in the submucous,  as well as sometimes in the  corpus
spongiosum; if  this be not  absorbed, it passes into the state  of  fibroid
or induration-matter, and continually tends to shrink up and contract
into  a  narrower space.   In proportion as this takes place,  the canal
must be contracted.   The mucous membrane lining the indurated part,
is often ulcerated and destroyed, commonly from the mechanical effect
of catheters pushed against it;  but it may also take place  spontane-
ously,  and it has happened that the indurated  part being destroyed by
the extending ulceration, the stricture has thereby been cured. A more
common and less favorable result of deep ulcerations is the perforation
of the canal and the formation of  a fistulous opening.   AVhen the ob-
struction occasioned by a stricture  is very great, and  it  may be such
that the passage will hardly admit a bristle, the urethra behind  is dilated,
often inflamed, and  sometimes ulcerated,  so as to give rise to urinary
 
            MORBID  CONDITIONS OF THE  URETHRA.         573

fistula, or effusion of urine.  The bladder and ureters are affected as we
have before described.   Of course the hypertrophy of the bladder, by
propelling the  urine more forcibly against the  stricture, must tend  to
increase the dilatation of the canal behind.   The urethra is sometimes
obstructed by warty  growths, which  are situated generally near the
meatus, and are remarkably vascular; they are developed as the result
of gonorrhoea,  and polypous growth is occasionally found, but is much
more rare.  Chronic  diseases of the lacunae sometimes converts  them
into small indurated tumors, Avhich become imbedded in the corpus spon-
giosum ;  of this kind, perhaps, is an instance mentioned by Rokitansky,
in Avhich numerous cartilaginous protuberances, from the size of a millet
seed to that of a pea, were scattered over the surface as far back as the
bulb, not, however, obstructing the passage.  It may be well to remind
the student that the  common expression  of " old cartilaginous stric-
tures" intend simply the density and firmness of the induration-matter,
and not at all that it contains  any true cartilage.   Stricture is  rare
before puberty, but has been found at the age of ten years; it is well
to be aware that it may at this age, possibly, be the result of the habit
of masturbation.   Mr. Adams enters his caveat against the  "indiscri-
minate use of stimulating injections" as an occasional cause of stricture.
Fibrinous exudation in very rare cases occurs primarily on the urethral
mucous  lining,  and chiefly in children.  It is probable that it  takes
place also here as a secondary process in the same diseases  in which it
is found in the bladder and ureters.  Variolous pustules are not unfre-
quent in the urethra.    Tubercle is of rare occurrence in the urethra ; it
is only present  when  the entire urinary apparatus is  likewise affected.
It has been found in the miliary as well as in the more massive form.
Cancer affects  the  urethra, either  in the male  or female, for the most
part, as an extension  of adjacent disease; but cases are recorded where
the groAvth in this  part was either primary or isolated.  Dr.  AValshe is
inclined  to think that the vascular excrescence of the meatus, in the
female may  " acquire  a  basis of scirrhus, or  become  infiltrated  Avith
encephaloid."
   We notice separately the  morbid  conditions of the female urethra.
Displacements of the uterus, especially retroversion, cause compression
of the passage, as also does the pressure of the child's head during labor.
Such compression not unfrequently produces sloughing of the parietes
and vesico-vaginal  fistula.  Dilatation of the urethra  is  in  rare cases
congenital; it is sometimes effected purposely for the sake of removing
calculi from the bladder, and may be safely carried  to the extent of per-
mitting a stone  one inch and a half in diameter to be extracted.  Para-
lysis, hoAvever has sometimes  resulted, and consequent incontinence  of
urine from excessive  dilatation.  Prolapsus  of the bladder  alters the
direction  of the canal of the urethra so that  it passes upwards  and
forwards.  There  is  no essential difference between  catarrhal inflam-
mation of the female and of the male urethra;  it is generally consecu-
tiA'e to  a  similar  condition  of the vagina.  The lips of  the meatus
are seen to be  swollen, and on  pressure upwards  muco-pus flows from
the orifice.   Stricture is very rarely, indeed, the result of inflammation,
which appears to be oAving chiefly to the circumstance that  the disease 
574           MORBID CONDITIONS OF THE  URINE.

in the female is not of long duration.  Mr.  Curling met with a case in
which a stricture, attended with complete retention  of  urine, was pro-
duced by contusion experienced during a severe labor.  The vascular
tumor of the meatus is thus described by Sir Charles Clarke: "Its text-
ure is seldom firm; it  is of a florid  scarlet  color, resembling arterial
blood; and if violence is offered to it, blood of the same color is effused.
It is exquisitely tender to the touch;  and if an accurate examination of
it be made, it appears to shoot from the inside of the urethra.  Its
attachment is so slight that it appears like a detached body lying  upon
the parts."  Sometimes the growths extend  partially along the urethra,
or may even be situated at the neck  of the bladder.  The tissues of the
urethra occasionally undergo a kind of  chronic  hypertrophy, so as to
form "a bulbous tumor."   The veins are enlarged and varicose, and the
areolar tissue increased in quantity,  while the mucous membrane may
be either thick, or, on the contrary,  thin and  shining.  A mucous dis-
charge takes place from the canal and from the  vagina.  AVe are much
inclined to consider this  state as more truly deserving the name of
chronic urethritis than that which Dr. Ashwell has so denominated, but
which seems more of the nature of severe pruritus.
             MORBID CONDITIONS OF THE  URINE.

  A brief resume of these, including urinary concretions, seems pro-
perly to follow here.  Urine is a fluid of amber color, of acid reaction,
rather aromatic odor, quite clear and limpid, but depositing, after stand-
ing some time, a delicate  cloudy sediment, varying in specific gravity
from 1015 to 1022, and amounting in the twenty-four hours to from 30
to 40 ounces.  Its quantity and its sp. gr., for  the most  part very in
versely, so that in summer it is less abundant and heavier, in the Avinter
more  copious and lighter.   The quantity of fluid taken of course influ-
ences the  quantity  of the secretion;  if fresh spring-water be drank
early in the morning, upon an empty stomach, it will  pass off with ex-
traordinary rapidity by the kidneys, so that the quantity of urine passed
will be treble or quadruple the normal.   Opium, in some persons, a few
other substances, and certain emotions, have the effect of  producing an
unusually aqueous  urine, as well as the unknown cause of the disease
now called polydipsia.
  The acidity of the urine varies very remarkably,  according to the
time which has elapsed  since food was taken;  it is less  acid, or  even
alkaline, during digestion, especially  of vegetable food,  and becomes
most acid when digestion has been finished for some hours.  The urine
is often alkaline from the presence of fixed alkali in healthy persons; it
is important not to confound  this condition, which will probably be re-
placed by acidity some hours after, with alkalescence  from carbonate of
ammonia, which is always indicative of disease.  The permanence oT
the blue color of reddened test-paper, which  has been dipped in the
urine, will distinguish the former condition from the latter.
  The limpidity of the  urine is disturbed by a great variety of precipi-
tates, which we shall presently notice.  If the sp. gr. becomes very high, 
              MORBID  CONDITIONS OF  THE URINE.           0(0

the secretion at the same time not being diminished in quantity, it be-
comes  an indication  of disease, probably  of diabetes.   Diminution of
the sp. gr., on  the other hand,  the quantity  not  being temporarily
rendered excessive by any of the causes mentioned, is also  a  sign of
disease; it may be of M. Brightii, or polydipsia.
   The presence of sugar constantly in the  urine constitutes the malady
called  diabetes,  with  whose true pathology  we are as yet unacquainted;
it  seems, indeed, certain that <£ health the  sugar in the blood is oxidized
and converted into carbonic acid, while in diabetes the oxidizing process
fails;  but it does not appear  that the proportion of  carbonic  acid ex-
pired  is diminished  in  this disease, which certainly,  according to the
theory, should be  the case.  Sugar is detected with great readiness by
the test called Trommer's, which consists  in the  reduction of  the hy-
drated oxide  of copper to the reddish-yellow sub-oxide, by the  deox-
idizing agency of  the sugar.   Oxide of silver may be used as a test in
the same Avay,. and will  be  reduced  to  the metallic  state if  sugar be
present.  It must be  remembered that uric acid  and  albumen  will act
somewhat in the same way as sugar, and probably other substances have
a  similar effect, but this is not  so rapid  or decided as  that produced by
sugar.1
   Albumen is often present in the urine'in its soluble form,  and is best
detected by the addition of a  few drops of nitric  acid, which render it
insoluble, or coagulate it, so that it falls down as a whitish precipitate.
It is necessary to  remember, that the addition  of acid may cause a pre-
cipitate of lithates, Avhich is scarce distinguishable  from that of albumen,
except by being redissolved by heat; it is, therefore, always  desirable
to boil the fluid after it  has  given a  precipitate with acid.   Rare  cases
may occur in which the  albumen, though present  in considerable  quan-
tity, is so modified that it does not  yield  the  ordinary reactions.   Dr.
Bence Jones has described a substance of  this  kind, which did  not pre-
cipitate immediately  by nitric acid, and  when heated did not coagulate,
nor was precipitated  Avhen nitric acid was added to the boiling  urine.
   Chylous matter (so called) is occasionally present in the urine,  but it
appears that the essence of the disease does not consist in the flowing-
off of chyle (from which the name is derived) constantly by the kidneys,
but that, even during fasting, liquor sanguinis, with occasionally  some
trace  of blood, escapes  from the Malpighian tufts, and forms in the
urine jelly-like  coagula.  In Dr. B.  Jones's case,  the influence of exer-
cise in promoting and of perfect repose in preventing this unnatural
drain  from the  blood was very marked, and showed clearly  that  it re-
sulted from some  peculiar defect in the organization of the Malpighian
capillaries which rendered them unable  to  bear the increased stress of
the somewhat excited circulation, without allowing more transudation to
take place than was  natural.   The white color is due to the presence of
oil in  a finely-divided state, and is  most  abundant after food.  Urine
passed at this time forms sometimes  a solid coagulum like blanc-mange,
assuming the shape of the vessel in which  it is contained.

   ' The onlv difference between ordinary diabetes (D. Mellitus, as it is termed), and the
disease called D insipidus, consists in the circumstance that  the sugar, which is abund-
antly present in the urine, is  tasteless.  In composition, it is identical with sweet sugar. 
576           MORBID CONDITIONS  OF THE URINE.
   The coloring matter of the urine is often of a much deeper tint than
 natural; this is chiefly the case in febrile disorders.  In cachectic and
 exhausting diseases it often appears deficient, the urine appearing pale
 and wheyish.  Urine of high  color is often strongly acid, in moderate
 or diminished quantity, and tends to deposit uric acid crystals; it indi-
 cates, in some measure, a sthenic state of" system.  Urine, which is pale,
 is often alkaline or  neutral, copious, more or less clouded by mucus or
 detached epithelium, and tends to  deposj^ prismatic crystals of triple
 phosphate.   This state is a faithful sign of asthenia.  The color of the
 urine may be altered  by haematin diffused through  it; nitric acid  and
 the microscope will then generally demonstrate the presence of albumen
 and blood-globules.   Biliary pigment gives a remarkably deep  tint to
 the urine, so that it is sometimes justly said to be like porter.   This
 occurs, not only when there is  actual jaundice, but  generally when the
 liver is congested, and is a  useful  sign of this state.  Its  presence is
 demonstrated by the play of colors which  takes  place when  nitric acid
 is added, the original tint  passing through green,  blue, violet, purple,
 to a pale red.
  Urine is occasionally met with of a blue  color, and this, from the pre-
 sence of one of three different pigments, viz: cyanourine,  indigo, and
 Prussian blue.   It appears that these substances may be actually gene-
 rated in  the economy, though the latter two, of course, may be derived
from without.  Their pathological relations are quite unknown, and we
must refer for an  account of their chemical habitudes to Dr. G. Bird's
work.   Nearly the same may be said of melanourine and melanic acid,
which are black pigments, giving the urine an inky  aspect.   They  are,
 probably, peculiar modifications of haematin.

                               Fig. 264.
                             Urinary deposits.
                (a) Various forms of uric acid.
                (b) Urates, pointed, globular, and molecular (common).
                (c) Triple phosphate, prismatic, and steUar forms.
                (d) Oxalate of lime, octohedra, and dumb bells.
                (e) Cystine.

  A great many vegetable coloring  matters  affect  the urine,  and  it
should always be considered whether an abnormal tint of this fluid may 
MORBID CONDITIONS OF THE URINE.          577
not depend  on the presence of one of them.  Logwood, beetroot, and
rhubarb are, probably, the most likely to be met with.
  The quantity of urea excreted varies according  to the nature of the
food taken and the amount of exercise.  Lehmann, when living on an
animal diet (thirty-two hen's eggs daily), found that his urine, in twenty-
four hours, contained 819.2  grs.; when a mixed  diet was taken, the
quantity was 500.5 grs.;  when it  was  purely vegetable, the  quantity
was 346.5 grs.; and when non-nitrogenous, it was only 237.1 grs.  The
quantity of uric acid varied similarly, though  not in so great a degree.
Exercise was found by Lehmann to increase the discharge of urea, lac-
tic  acid, phosphates, and sulphates; it diminished, however, that of uric
acid, phosphates,  and sulphates.   Dr.  Prout has  noticed two morbid
conditions,  which  are  often  termed  azoturia and anazoturia, distin-
guished by an excess and deficiency of urea respectively.  They are,
probably, not so much essential maladies in themselves as symptomatic
of  certain disordered states of assimilation.   Azoturia is detected by a
formation of nitrate  of urea taking  place when nitric acid is added  to
the unconcentrated urine; it is not unfrequent in the oxalic  acid di-
athesis.   The quantity of urea in diabetes is considerably increased; in
M. Brightii it is, as we have seen,  greatly diminished.
   Deposits  of uric acid in crystals, or of its combinations with ammonia
or  soda,  are exceedingly common.  Now, with regard to these, it is first
to be mentioned, that there  are no  certain evidences  of an increased
Fig. 265.
Fig. 266.

Fig. 267.
©
o
o
0
Fig. 268.
Fig. 269.
Fig. 270.
4
    0
>  A
Uric acid crystals.
exertion takinc place.   Dr. Bence Jones  has shown that urine, which
appears thick from a deposit of urates, may contain actually less  uric
acid than urine which remains clear, in the proportion of 0.52 to 0.87.
The appearance of uric acid crystals  depends on  increased acidity of
the urine, though we do not certainly know what is the  cause  of this;
       37 
578          MORBID  CONDITIONS OF THE URINE.
probably, however, the acid phosphate of soda.   Three  circumstances
may occasion a deposit of lithates: (1.) An increased formation of them;
(2.)  Increased  acidity of the urine; (3.) A low temperature.   The pri-
mary form of uric  or lithic acid is  the  rhombic prism;  but  there  are
innumerable modifications of it, chiefly depending on an  elongation  of
Fig. 271.              Fig. 272.                 Fig. 273.
Fig- 274.                   Fig. 275.               Fig. 276.
                             Uric acid orystals.

its long, and diminution of its short diameter, with rounding off of its
angles, or on an approach to the rectangular form.   The crystals often
cohere in a radiated form.  Their color is commonly a reddish yellow,
derived from the urinary pigment, but they are, when pure, colorless.
The common, so-called lateritious sediment", is in like  manner colored
by the pigment of the  urine, and occurs sometimes nearly white.   It
consists of urate of  soda, with small proportions of  urate of ammonia
and  lime.  This is positively stated  by Lehmann, and we have satisfied
ourselves of his being correct.   Under the microscope, the deposit is
seen to consist  of minute granules, which cohere together in somewhat
branching lines or shapeless masses.   Occasionally, large opaque glo-
bules are seen,  and separate, needle-like crystals; or the latter are ob-
served radiating from a centre, which may be constituted by one of the
large globules.   These forms, however, we have scarcely observed, ex-
cept in -urates of potash, soda,  or  lime, artificially prepared.   Their
ready solubility by heat, and the  deposition  of uric acid crystals on the
addition of acid, are sufficient tests for all urates.  The  appearance of a
sediment of lithates can, in many cases, scarcely be considered morbid;
it results from  some diminution  in  the cutaneous  transpiration, some 
MORBID CONDITIONS OF THE URINE.           579
slight dyspepsia, &c.   In febrile diseases, it is of very common  occur-
rence, especially in gout and rheumatism.  It is, however, particularly
to be observed, that, in acute gout, before the  paroxysm, and in chronic
gout, the quantity of uric acid in the urine is  diminished, while it accu-
mulates in the blood.  (Lehmann and Garrod.)  In various diseases of
the heart and lungs which interfere with respiration, in cirrhosis  of the
liver, at the close of paroxysms of ague, the urine  deposits a sediment
of lithates abundantly.
   Phosphoric acid exists in the urine, combined with soda, ammonia,
lime, and magnesia.   The insoluble,  earthy phosphates are held in solu-
tion by the acid phosphate of soda.   When the urine becomes alkaline
from the presence of ammonia, a deposit takes place, which, if the alka-
lescence be slight, consists of the monobasic phosphate of ammonia and
magnesia  (HO, NH40, MgO)-|-P205;  if considerable,  of  the bibasic
(NH40, 2MgO) + P205.  The former is in the shape  of separate pris-
matic crystals,  the latter of  dentated laminae, radiating from  a  centre
something like  a star-fish.   Simple  star-like  and  penniform shapes of
the  monobasic  salt are also described by Dr.  G. Bird.  Deposits of
Fig. 277.
Fig. 278.
IP     -7f>    /x
Fig. 279.
Fig. 280.
                            Earthy phosphates.

phosphate  of lime are  occasionally met with  as  opaque, amorphous,
granular sediments.   The presence  of any of the  phosphatic deposits
generally indicates a feeble and depressed state of system, with nervous
irritation.  The quantity of earthy and alkaline phosphates in the urine
may be  greatly increased, without the appearance of any deposit, or
any tendency to alkalescence.  Dr. Bence Jones states that the alkaline
condition, with its frequent accompaniments of triple phosphate crystals,
" has no relation of any sort or kind"  to an increase in the total amount
of phosphates.   The disease in which these are most abundant is acute 
580          MORBID CONDITIONS  OF THE URINE.
inflammation of the brain; in delirium tremens they are remarkably de-
ficient, if no food is taken.
   Oxalate of lime is not unfrequently found in the urine as a sediment
which appears to the eye like a delicate mucous cloud, but is seen under
the microscope to consist of multitudes of octohedral crystals, mingled
in rare instances with dumb-bell forms.   The pathological importance
of a deposit of oxalates has been considered doubtful, and it is certain
that it may easily be over-estimated.  The conclusions which Mr. Coul-
son adopts (p. 79,  of his work  on Diseases of the Bladder) we believe
to be correct.   These are, that the occasional presence of a few crystals
is no indication of disease; that the ingestion of aliments containing oxa-

                        Fig. 282.        Fig. 283.           Fig. 284.

                       m   fm         O         O    O
o
    D
*    xx
                             Oxalate of lime.

lates may occasion  a deposit of  this kind ; that the same effect  may be
produced by sparkling wines or ales; that such crystals are often observed
in the urine of those suffering from acute rheumatism, and in  that of
persons with emphysematous lungs, or who are short-breathed from other

                                             Fig. 286.

                            Dumb-bell crystals.

causes;  that it is of very frequent occurrence at the commencement of
convalescence  from acute disease;  but that its constant presence in the
urine of persons who are not to be included in any of the above classes,
is a valuable symptom of a peculiar dyspepsia, generally attended with
a remarkable  train of nervous symptoms.
  Cystine, or  cystic oxide, is of rather rare occurrence ;  it is said to be
of scrofulous and decidedly hereditary character.   A patient of our own,
whose urine contained an abundance of it for some time, was very eccen-
tric, and had a sister affected with mania. It  forms a whitish sediment,
consisting of hexagonal tablets of various size, mixed in  our  case Avith
much fatty matter.  The tablets are  often serrated at  the edges, and
contain  some oily matter in their centres. 
MORBID  CONDITIONS OF THE URINE.
581
Fig. 287.
0
 o
o
o
 Fig. 288.
a   ®
(i
Vii^.,
£>
Fig. 289.
    a
Fig. 290.
O
o
Cystine.
  Carbonate of lime often occurs in the urine, in the form of  an amor-
phous powder,  when  it deposits  phosphates; it is produced by the de-
composition of phosphate of lime by carbonate of ammonia, derived from
the urea.
  Calculi are concrete masses, made up of one or more of the various
substances we have mentioned, the several particles of which, if crystal-
line, are held together by mutual attraction ; if amorphous, are united
Fig. 291.
Fig. 292.
Lithic calculus.
Section of a lithic calculus, showing the internal
          concentric layers.
together by some animal matter.   Thus Dr. Walshe states the case, and
no doubt  correctly;  but we have recently examined  a small calculus,
which consisted of octohedra  of  oxalate of lime, united together by a 
5S2          MORBID CONDITIONS OF THE URINE.

considerable  quantity of  mucus, in which  they were  imbedded.   The
following description of the several varieties of calculi is an abbreviation
of Dr. Prout's:  (1)  The lithic acid calculus is generally of a broAvnish-
red, or fawn color, sometimes approaching that of mahogany.   Its outer
surface is commonly smooth, the sectional displays numerous concentric
laminae.   Its shape  is generally ovoid ;  its size very various; it is the
commonest species ;  dissolves completely in liquor potassae, and in  nitric
acid with heat, the dry residuum presenting a beautiful pink color.  (2)
Lithate of ammonia calculus is of  a clay color, composed of concentric
layers; its outer surface  smooth, or slightly  tuberculated; its sectional

             Fig. 293.                             Fig. 294.
       Oxalic or mulberry calculus.                 Internal structure of the same.

marked  by concentric  layers.   It  chiefly  occurs  in children under
puberty, and hence is  generally small, and rather  rare.  It behaves  in
several respects like the  preceding, but is more soluble  in water, and
gives off ammonia when heated with caustic potash.  (3) The oxalate of
lime calculus  is  generally of a dark-brown  color, from adhering and

               Fig. 295.                         Fig. 296.
            Cystic calculus.                    Internal structure of the same.

altered blood, but may be pure white.   Its surface is rough and tuber-
culated (mulberry), its texture is hard and  laminated.   When heated it
is decomposed, the acid being destroyed, and  an alkaline ash (lime) re-
maining.   Heated in a tube with sulphuric acid, carbonic acid and car-
bonic oxide gases are given off, and may be  recognized by the former
being absorbed by liquor potassae,  and the latter  burning with a blue
flame.   (4) The cystic oxide calculus is of a yellowish-white ; its surface
is smooth, and of a crystalline aspect.   It is not laminated, but appeara
 
MORBID  CONDITIONS OF THE URINE.           583
to be made up of a multitude of irregularly aggregated crystals, and has
internally  "the color and shining look of beeswax."  It is soluble both
in acid and alkalies, and crystallizes in hexagonal tablets from  its am-
moniacal solution.   (5) The phosphate of lime calculus is of a pale-brown
color, and  smooth porcelaneous surface.  It is regularly laminated, and
the laminae are vertically  striated.   It is  not common, and does not
Fig. 297.
Fig. 298.
Phosphatic calculus.
Ammonia magnesian calculus.
attain  a large size;  is soluble in hydrochloric acid, and  precipitated
from its solution by liquor ammoniae as a white powder.  (6) Phosphate
of ammonia and magnesia calculus is nearly white, its surface is uneven;
it is friable, and not  laminated, except in some rare instances, when it
Fig. 299.
Fig. 300.
Fusible calculus.
Internal structure of the same.
is  hard, crystalline, and more or less transparent and laminated.  It
yields  ammonia when heated, fuses with  difficulty, is  soluble in dilute
hydrochloric acid, and is precipitated from this solution by ammonia as
prisms or stellae.  (7) The fusible calculus, a mixture of the two preced-
ing, is whiter and more  friable than any other, often of very  large size,
and occurs frequently.   It melts readily, is soluble in dilute hydrochloric
acid, and its  ammoniacal precipitate consists  of amorphous particles 
584          MORBID  CONDITIONS  OF THE  URINE.
and stellar crystals.   (8) The alternating calculus is made up of two or
more layers of different urinary deposits, as seen in the following exam-
ples ; a nucleus of uric acid may exist with a covering of urates, oxalate
of lime, or phosphates—the nucleus may be oxalate of lime with a cover-
ing of uric acid, urates, or phosphates; a nucleus of uric acid may be
covered by oxalate of lime, and this by  mixed phosphates, or the latter
may be replaced by uric acid; again, a nucleus of oxalate of lime  may
be covered by uric acid, oxalate  of lime, and phosphate of lime in suc-
cession.  More than half the whole number of calculi are alternating,
and it is especially to be observed, that, in a very great proportion of
instances, the outer crust consists of phosphates; so that Dr. Prout has
stated it as a law, that a decided deposition of the mixed phosphates is
not followed by any other.   (9)  The  carbonate of lime calculus is  very
uncommon; it is perfectly white, and  very friable.   We think it is occa-
sionally found as a coating to renal calculi, being  thrown out from  the
irritated mucous  membrane.   In one such case  it appeared under the
microscope as grains and round  globules, about the size of those of the
blood; it  effervesces strongly Avith acid, and the lime after neutraliza-
tion with  ammonia can be precipitated by oxalate of ammonia.   (10)
 Uric or xanthic oxide calculi are very rare; they are of a light-brown
color externally, "and of a brownish flesh-color in  their interior;" their
surface is smooth and polished ; they consist of concentric layers, and
assume a waxy lustre on being rubbed.  For its chemical characters we
refer to Mr. Coulson's work, p. 282.   (11) The fibrinous calculus  is of
small size, of  amber color, and waxy consistence,  and is  probably  only
indurated fibrin, or mucus, therefore not a true urinary concretion. 
CHAPTER  XXXVI.
   ABNORMAL CONDITIONS  OF  THE MALE  GENERATIVE
                             ORGANS.

   Testicles and vasa deferentia.—There is no sufficient evidence to show
that more than two testicles ever exist.   They are absent when the en-
tire sexual apparatus is wanting, and in  some rare cases they are im-
perfectly formed, or one only may exist.  An apparent absence of one
or both glands at birth is not very unfrequent, the descent of the organ
being arrested or delayed, so that it lies in the groin, the inguinal canal,
or the lower part  of the abdomen.   Of one hundred and three  male
infants examined  by Wrisberg at the time of birth, seventy-three had
both testicles in the scrotum; while in twenty-one, one or both were in
the groin, and the  remainder  had one  or both  in  the abdomen.   He
found the imperfection more frequently on the left than on the right side,
in the proportion of seven to six.  Mr.  Curling believes that if the de-
scent does not take place within twelve  months after birth, it is seldom
fully and perfectly completed afterwards without  being accompanied by
hernia.   The reason of this is sufficiently apparent, the pressure of the
muscular walls of  the abdomen must tend to  cause  the descent of the
intestine through the open inguinal canal.  When the testicle  is still in
the abdomen at birth, it  may descend, and usually does, within  a few
weeks (it did so in ten out of the twelve cases mentioned by Wrisberg),
or it may not descend till some time before puberty,  or it may not appear
at all.  The cause of the testis remaining in  the abdomen is considered
by Mr. Curling, with much probability,  to be owing either to  paralysis
and defective development of the cremaster muscle, or to the contraction
of adhesions between the gland and some adjacent viscus.   The disco-
very of the continuation  of muscular fibres from the fixed attachment
of the cremaster up along the  gubernaculum to the testis in its primitive
situation by the side of the vertebral column, inclines  us strongly to be-
lieve  that these fibres must be the agents in causing the descent of the
gland into its appointed place.  Contraction  of the external abdominal
ring is also mentioned as one of the causes impeding the descent of the
testis.  In rare instances, the testis wanders  into other situations; one
has been found in the perineum, the other being  normally placed; and
in two instances a testicle has  preferred to make its exit by the crural
instead of the inguinal canal.   Sometimes it happens that the gland is
turned round in the scrotum, so that its anterior face becomes posterior.
It is quite ascertained that the abnormal situation of  the testes in the
abdomen is 'by no means inconsistent with  the full discharge of  their 
586
ABNORMAL CONDITIONS OF  THE
function.   Cases are occasionally met with in which the glands remain-
ing in the abdomen have been small and undeveloped;  but this  imper-
fection could not be dependent on the unnatural position, as the analogy
of animals  and positive observation in men shows.
   The vas  deferens may be absent in a greater or less extent, and even
the epididymis  has been found in great  part deficient.  What is very
remarkable is, that in several of these cases the testicle was fully formed,
and though incapable of fulfilling its function, was scarcely less than the
other.   Experiments on animals have also shown that obliteration  of
their  excretory ducts  does not cause necessarily atrophy of the  testes,
nor efface in the individual the characteristic marks of the male sex.
The most usual and least degree of this imperfection is  that the vas de-
ferens terminates in a blind extremity before reaching the vesicula semi-
nalis.  There is no such condition  known as true hypertrophy  of the
testes; the gland may become  greatly  enlarged when attacked with
inflammation, or when it is the seat of morbid growths ; but while in the
fullest activity of its function it does not exceed  the normal size.  This,
no doubt, depends on its secretions, which of course may be formed  in
very varying quantities, rapidly passing of by the excretory duct.  An
increased production of semen by the testis would correspond to apparent
hypertrophy of the thyroid by dilatation of its cavities.
   Atrophy of the testis, either congenital from  defective development,
or acquired, is not unfrequent.  Several instances are mentioned by
Mr.  Curling, in which  the penis and testicles of persons arrived  at the
age of puberty, or of adults, did  not exceed the size of those  of child-
ren ; two of these were of weak mind, but this condition is by no  means
the frequent  accompaniment of cretinism or idiocy.  A case recorded by
Mr. Wilson shows the influence of aroused  mental emotions in producing
the due  development  of the generative organs, which  had not  taken
place at  the  twenty-sixth year of age.   The atrophy  of the testis  in
old age comes on very gradually, the organ becomes flabby, and  its tis-
sues discolored, but is often little diminished in size.
   Mr. Curling states that the ordinary weight of a sound  testicle, in a
healthy adult, is  about six drachms, great  individual differences, how-
ever, being often met with, as well as differences between  the two glands;
the left was heavier than the right in five cases out of six.  If the weight
fall below three drachms, the organ may be  certainly  said to be in a
state  of atrophy.  " A testicle  in  an advanced state  of wasting, not
arising from  disease of the gland,  usually preserves its  shape, but feels
soft, having  lost its  elasticity and  firmness.  Its texture is pale, and
exhibits  few bloodvessels;  the lobuli and  septa  dividing the lobes are
indistinct, and the former cannot be so  readily drawn out into  shreds
as before.   The epididymis does not usually waste so soon, nor  in the
same degree, as the body of the testicle.   It sometimes, however, loses
its characteristic appearance; and I have even found it reduced  to a few
fibrous threads.   The fluid pressed out of the wasted testicle and  epi-
didymis  is entirely destitute of spermatic granules, and spermatozoa.
In many instances, adipose tissue is deposited behind the tunica vaginalis,
and encroaches on the  epididymis and the posterior part of the testicle.
Fatty matter is also found in the glandular substance of atrophied tes- 
MALE GENERATIVE ORGANS.
587
Fig. 301.
tides.   The structures composing the spermatic cord undergo a corre-
sponding diminution, the cremaster muscle disappears, the nerves shrink,
and  the vessels are reduced in size  and number.  The vas  deferens,
though small, can generally be injected with mercury as far as the com-
mencement of the epididymis.  The testis of  a  man, aged thirty-four,
dying of scrofulous disease of the lungs and kidneys, weighed little more
than two drachms.   The vas deferens  and epididymis appeared healthy.
The wall of the tubes had a fibroid aspect, and there were numerous fibre-
forming nuclei on their surface.  Their epithelial lining was everywhere
in a state of fatty degeneration; it was reduced to atrophied, sometimes
fattily degenerated,  nuclei, and small  corpuscles made up of oily mole-
cules.   The aspect of the gland tissue was dirty yellow; it was soft and
flaccid.  A testicle atrophied from disease is not only of diminished size
and weight, but is altered in shape,  being uneven and irregular, and
sometimes of an elongated  form.   The surfaces
of the tunica vaginalis are adherent, and its ca-
vity is partly or entirely obliterated.   There is
no, or very little, trace of the  proper glandular
structure,  the organ being converted into fibrous
tissue  of a firm  texture.   It loses its peculiar
sensibility to pressure, but is sometimes the seat
of morbid sensibility."   The  causes  of atrophy
of the testis are very  various: deprivation of  its
supply of  blood from  obliteration of the sperma-
tic artery, injuries of  the spinal cord, producing
paraplegia,  and probably therewith  the  loss of
the  nervous  influence necessary for  the gland,
inflammation of its tissue, over-excitement of the
organ, the long-continued use of iodine, which is
said to affect the female breast similarly, tuber-
cular  elephantiasis, injuries to the back of the
head  and  nape  of the  neck, the  pressure  of
effusions,  and of large  herniae,  neuralgia—all
appear, on good  evidence, to be  real causes of
atrophy of the part  in question. ^ The most com-
mon cause is inflammation;  and it is  easy to un-
derstand  how the effusion  of fibrin within the
unyielding capsule  of the  gland  should compress  and  obliterate  the
bloodvessels, as well  as the tubuli seminiferi themselves. ^
   The serous covering of the testis, the tunica vaginalis, is liable to be
attacked by acute inflammation, and  then suffers as ^ other serous mem-
branes do.  The membrane becomes  thickened and injected with blood,
and is coated with a more or less  considerable quantity of fibrinous
exudation.  Serum is at the same time  effused into the cavity, and is
rendered  turbid by flakes of fibrin floating in it.  The exudation may
take the form  of pus, but this rarely occurs.  The unabsorbed fibrin
very commonly forms adhesions between  the  opposing  surfaces, which,
in time become very  firm and dense,  and may obliterate the cavity.  It
is by  no means  rare  to  find  adhesions, to some extent, in the tunica
vaginalis;  Mr. Curling  observed such in nine  out  of twenty-four in-
 Inflammation of tunica Ta-
ginalis,  after application of
caustic; the aperture made by
this is shown at*. There are
flocculi of lymph on the serous
surface  of the testis.—From
Mr. Curling's article. 
588
ABNORMAL CONDITIONS OF THE
Fisr. 302.
stances.   The epididymis is prone to partake in the inflammation of the
tunica vaginalis, and vice versd.
   Hydrocele is  a dropsy of the serous covering of the  testis, and does
not differ essentially from  dropsies  of other  serous sacs.  The fluid is
usually clear, and of a straw color, sometimes turbid, with albuminous
flocculi, and not unfrequently contains a considerable quantity of shining
particles  of  cholesterin.   Its quantity is sometimes very considerable;
six quarts are said to have been withdrawn in the case of Gibbon.  The
serous membrane in old hydroceles  may be more or less thickened, and
even the seat of calcareous deposit.  Adhesions formed between  the two
layers of the tunica vaginalis may, according  to their length and extent,
alter  the usual position of  the testicle, so  that  it appears  in front,
instead of lying at the posterior and lower part of the distended sac; or
they may subdivide the  cavity, and produce  thus a multilocular hydro-
cele.   The  natural  cul-de-sac which exists between the epididymis and
                      the body of  the testicle, on the outer  side, is
                      sometimes much distended, so as to form a pouch,
                      which projects  on the  inner side of the gland.
                      The  morbid  action in hydrocele  is confined to
                      the  serous membrane ; the testis  either remains
                      natural, or is somewhat flattened, and, in some
                      cases, partially atrophied by the pressure of the
                      fluid.   When, however, the original seat of  dis-
                      ease is in the gland itself, the serous covering is
                      often secondarily involved, so that serous effusion
                      in the  sae  very often  is associated with chronic
                      orchitis, or other diseases of the testicle.  This
                      combination is termed a hydro-sarcocele.  There
                      is contradictory evidence on the question, whether
                      hydrocele is  more  common  on  the right, or on
                      the  left.   Mr. Curling's observations  show that
                      the  right side is most often  affected.
                        In  congenital hydrocele the  dropsical tunica
                      vaginalis retains its  foetal  communication with
                      the  peritoneal cavity.
                        Encysted  hydrocele, as it is called, proceeds
                      from the development of new cysts beneath the
serous membrane.   These are exactly similar  to  the  simple cysts  we
have described,  p. 183, having a wall of thin fibrous tissue, and a lining
of tessellated epithelium, with usually limpid, fluid  contents. They may
be situated: (1) " beneath the visceral portion of  the tunica vaginalis,
investing the epididymis;  (2)  between the  testicular  portion  of  the
tunica vaginalis and the tunica albuginea,  which  are  thus separated
from each other; (3) between the layers of the loose or reflected portion
of the tunica vaginalis."  In the two last-mentioned  situations they
rarely occur.  When formed  on the epididymis, they sometimes carry
the serous membrane outwards as  they enlarge, so that they become
pedunculated, just as the small serous cysts in the  neighborhood of the
ovary  often  do  with  the peritoneum.  Mr. Curling states that these
pedunculated cysts do not acquire a large size, seldom  exceeding that
 Drawing of large hydrocele,
combined with scrotal hernia.
—Curling's Art. on Testis, Cy-
clop* Anat. and Phys. 
MALE GENERATIVE ORGANS.
589
of a currant.   Several cysts may coexist in the same gland, and, when
opened, produce the  appearance of a  sacculated arrangement.  The
walls of the cysts are liable to inflammation, which causes their contents
to be mingled with various exudations  of serum, fibrin, or even blood.
Spermatozoa are very frequently present in the fluid of encysted hydro-
celes, to which they impart a milky or  opaline opacity.   They subside
to the bottom of the vessel,  where the fluid is left at rest, leaving the
upper portion more transparent, but containing some albumen, which is
not  found in  the  limpid contents of ordinary cysts  of this kind.  It
is extremely  probable that they make their way  into  the cysts in
consequence of rupture of some seminal  canal  lying in contact with
them, just as  a biliary duct sometimes opens into the sac of an hydatid.
This opinion  is confirmed by the circumstance that  patients generally

                               Fig. 303.
  Encysted hydrocele of tunica vaginalis.-From Mr. Curling's article. The cyst is between the tunica
                   albuginea and the tunica vaginalis of the testis.

report the swelling to have commenced after some injury to the testicle.
Spermatozoa are rarely, if ever, present in  the fluid of common  hydro-
cele.  In one  case, a  few seemed to have escaped *nto  the general
cavity, from the rupture of a small cyst.
  Diffused hydrocele of the spermatic cord is a rare affection.   It con-
sists in the enlargement of the cells of the areolar tissue, and  their dis-
tension  with a white or yellowish serous fluid.   The  inclosing  fascial
sheath is condensed and thickened, and at the lower part of the swelling,
which is always the largest, separates it  completely from the tunica
vaginalis   The nature of the disease does not  seem to be sufficiently
ascertained.   Mr.  Curling classes it  with simple oedema ; we  should be
more inclined to regard it as a chronic inflammation. 
590
ABNORMAL CONDITIONS OF THE
  Encysted hydrocele of the spermatic cord  forms a tumor,  of oval
shape, and  seldom attaining  the size  of  a hen's egg.  It  is loosely
attached to  the vessels of the cord which pass behind it.   Instead of
there being  only one cyst, there may be several, forming a  series  along
the cord.  This circumstance  indicates  their origin, from the partially
obliterated process of peritoneum, which is carried down with the  tes-
ticle in the  formation of the  tunica A*aginalis.  According to  another
view, they are simple  cysts, of new production,  analogous to those  which
constitute encysted hydrocele  of  the testis.   It may be mentioned that
simple hydrocele occurs not  unfrequently  together with some of  the
other varieties, and also with inguinal hernia.
  Hematocele is the term applied to a tumor  formed by an effusion of
blood from the vessels of the testis,  or of the spermatic cord.  Its most

                              Fig. 304.
   Hematocele: tunica vaginalii greatly thickened; testis pretty healthy.—From Mr. Curling's article.

common seat is in the tunica vaginalis, which may be so greatly distended
as to exceed the size of the adult head.  The blood undergoes various
changes, coagula being formed, sometimes in separate masses, sometimes
in firm layers, as in the walls of an aneurism.  The fluid part, in old cases,
is more or less thick and grumous, sometimes resembling coffee-grounds.
The presence of the blood occasionally excites inflammation, leading to
fibrinous and serous effusion, and, it may be, to suppuration.  The effused
blood sometimes putrefies, offensive gases are produced, and, unless free
exit be given to the decomposed matter, fatal gangrene takes place.  The
tissues surrounding the tunica vaginalis are apt to become involved in the
inflammation, though  they are affected in a  more chronic manner, and 
MALE GENERATIVE ORGANS.
591
thus the walls of the serous cavity are considerably thickened, perhaps
so as to be  half an inch in  diameter.   The testicle  usually remains
unaffected, except that in old  cases it is atrophied from pressure.   An
encysted hydrocele of the testicle or epididymis may be converted into
Fig. 305.
                 Bruise of the scrotum, a form of haematocele.—Listen.

an haematocele, by the effusion of blood  into its cavity.   So, also, may
the encysted hydrocele of  the  cord.  Both  these, however, are rare
affections.
  Diffused  hematocele of the cord  results  from the rupture of some
vessels of the cord, which  are, probably,  in some way diseased (e. g.
varicose), in consequence of which blood is  effused, in greater or less
quantity, Avithin the spermatic fascia;  and, if the bleeding continues, or
recurs after an arrest of varying length  of time, a tumor of enormous
size  may be formed, reaching  down  even to the knees, as in  a case
recorded by Mr. Bowman, in the Medico-Chirurgical Transactions, vol.
xxxiii.   The cause of the rupture is generally some straining effort.
   Orchitis (op**«, a testicle), may be either acute or chronic.  The acute
disease is sometimes primary, as when the testis has  suffered from ex-
ternal violence; more often it  is consecutive, extending along the vas
deferens, to the epididymis and testis.   In the latter  case, the disease
has been called epididymitis, from this part being chiefly and most con-
stantly affected.  Opportunities rarely  occur  of  examining the gland
when acutely inflamed,but the following appearances have been observed:
The testis itself is not  much enlarged, owing to  the unyielding  nature
of the tunica albuginea;  its vessels are congested, so that it has a  darker
tint than natural.  The epididymis is enlarged, especially at the lower
part, to twice or three times its  natural size,  "and feels thick, firm, and
indurated."  This enlargement depends on the presence  of  exudation-
matter.  "The coats of the vas deferens are thickened, and the adja-
cent vessels injected.   The tunica vaginalis  is inflamed, and its  cavity
contains  the usual effusions.   Suppuration rarely occurs in the body of
the testis in consecutive orchitis, it is  more frequent in  primary; indeed,
in the former, it is not uncommon for the gland itself to escape entirely.
When pus has been formed in the testis, it does not easily make its way 
592
ABNORMAL CONDITIONS OF THE
out, and consequently burrows in different directions, disorganizing the
tissue of the gland.  Sometimes, when all active inflammation has sub-
sided, the fluid part of the pus becomes  absorbed, and the remainder
passes into the state of a concrete, whitish mass, much resembling crude
tubercular matter.  It may, however, be distinguished from this, by being
contained in a cyst, and by the condition of the adjacent glandular tissue,
which is more altered from its healthy state than it is in the neighbor-
hood of tuberculous deposit.  The color of the yellow exudation in chronic

                              Fig. 806.
Acute orchitis, attendant on gonorrhoea.
orchitis, and its relation to the tubuli, serve to distinguish it also from
concrete pus.   Another result  of inflammation of the  testis is wasting
of the gland, occasioned by the interstitial fibrinous exudation passing
into fibroid tissue,  and compressing the bloodvessels and tubuli.   The
enlargement of the epididymis not unfrequently subsides  very incom-
pletely, leaving an indurated,  knotty  swelling, situated usually at its
lower part.  The fibrinous matter which imbeds the duct and the areolar
tissue in this part, does not cause the obliteration of its canal, which is
even sometimes considerably dilated, as Mr. Curling has observed, so as
to be four  or five times its usual dimensions.   "In old cases, the epi-
didymis acquires the density and consistence of cartilage, and sometimes
even of bone."  "The coats of  the vas  deferens are also found, for some
extent, thickened and indurated."
   Chronic orchitis is characterized by the effusion of a yellowish, homo-
geneous looking matter, in the substance of the testicle.   This matter,
when first formed, is soft,  but  afterwards becomes firm and  solid, and
intimately blended  with the glandular tissue.   It may occur as a single
deposit, or as seAreral coexisting in the same gland.  These enlarge and
coalesce, until they occupy the  whole organ, giving it a uniform yellow-
ish white  appearance.  In some cases, the epididymis is attacked by
the same deposit, but, in the majority, it escapes.  The seat of the yel-
low matter seems to be the interior of the tubuli.  Mr. Curling, describ- 
MALE GENERATIVE ORGANS.
593
ing the condition of a specimen which he examined after injection of the
bloodvessels, says, that at the anterior part of the  testicle the deposit
appeared  as round, isolated bodies; " about the  centre it assumed a
beaded arrangement, and towards the mediastinum formed  a number of
closely-set yellow lines,  or processes,  radiating towards the  posterior
part of the testicle,  where they  were amalgamated  into  one uniform

                               Fig. 307.
         Chronic orchitis, with fungous protrusion of testis.—From Mr. Curling's article.

mass."   The deposit is usually considered, and we believe with justice,
as of scrofulous nature, but Mr. Curling speaks confidently of its being
coagulable lymph.
  As the yellow deposit increases, it  often causes adhesion of  the two
layers of the tunica vaginalis, as well as of these to the skin, and at the
same time  occasions ulcerative absorption of  these layers, and of the
tunica albuginea, so that, at last, a  fungous protrusion of  the  affected
tissue takes place. This projecting growth presents an ash or yellowish-
white appearance, varied  by irregular patches of a pale red hue, and
sometimes  of black.   It  is closely  girt by the scrotum, the ulcerated
edges of which are often thickened and everted.  The fungous protrusion
is not peculiar to chronic orchitis alone, a  similar one may take place
whenever inflammation of the gland has produced ulceration of the tunica
albuginea, the softened and tumefied tissue within  escaping at the open-
ing, much as the brain does when hernia cerebri occurs  from giving way
of the dura mater.  The result of chronic orchitis may be different to the
above, but equally destructive  of  the  efficiency of the  gland.   The in-
flammation, after it has given rise to a considerable amount of deposit,
may subside, and the gland remain for a long time somewhat enlarged
and  indurated,  but  not painful.   The deposit at last  contracts  and
shrinks,  inducing gradual atrophy of the testis, which  may be reduced
to a  mere nodule, chiefly consisting of dense fibroid tissue, scarce larger
than  a  nut.   In these cases the epididymis  often remains tolerably
healthy, but is sometimes  rendered "nodose, irregular, and hard."
  Purulent deposits have  been found in the testicle, apparently, as the
result of pyaemia, in connection with synovitis  of the shoulder-joint and
lobular pneumonia.  A preparation of this kind is in the Museum of St.
George's Hospital.                                           #>
   Tubercle is not very infrequent in the testis; situated sometimes  in
       38 
594
ABNORMAL CONDITIONS OF THE
the body of the gland, but more often  in  the  epididymis.   In the for-
mer site, it appears as a  single or as several masses of opaque yellow
matter, which may increase, so as to occupy almost the entire gland—
a thin layer of glandular tissue  alone remaining around  the morbid
mass;  on the  tubercle softening  and breaking down, a cavity may be
formed, which ulcerates and discharges its contents externally through
the scrotum.  In the Museum of St. George's, there  is  a  preparation
which shows extremely well the cavity of a large scrofulous abscess of
this kind, with a  thick layer of  tuberculous matter forming its wall.
This is exactly analogous  to a tuberculous cavity in  the lungs.   Mr.
Curling gives a drawing of a specimen  in which the epididymis was oc-
cupied by tubercular deposit in its whole extent, while  the body of the
testis remained perfectly sound.   Cretaceous  matter  is occasionally
found in the testis, which  is doubtless the  residuum of tuberculous de-
posit, which has softened  and undergone calcareous change.   It resem-
bles exactly that which is  found in the lungs and in the bronchial glands.
Some uncertainty prevails respecting the actual site of tubercle in the
testicle.  Dr.  Carswell regards it in this part, as elsewhere, to be formed
on the free surface of mucous canals, or their continuations.  Mr.  Curl-
ing's conclusion Ave believe to be the more correct, that  it may  be depo-
sited both interstitially, as well as Avithin the tubuli.  The tunica vagi-
nalis is frequently inflamed when there is tuberculous deposit in the
testicle.  Pulmonary  tubercle, or general  tuberculosis,  is  present in
many cases  of similar disease of the testis.
   Cancer is common in this part, and is most frequently primary.   The
scirrhous variety is occasionally met Avith, but  is very rare;  "it is cha-
racterized by its slow progress, as  by its great induration."  Encepha-
loid is  the  ordinary form of orchitic  cancer;  it commences as one or
two masses among the tubuli, which  it gradually destroys, as it accumu-
lates.  Whether it advances  by infiltrating the tissue, as  well  as by
pushing it aside, does not  seem  quite  determined;  the  latter, however,
seems to be the more common occurrence.  As it increases in  size it
causes absorption of the tunica albuginea,  which gives way, and allows
the growth to  sprout out,  and  to vegetate freely in the scrotum, which
it distends sometimes to the dimensions of  a  foetal head.  The scrotum
does not soon  become involved in the disease, and ulcerated, probably
in consequence of its distensile nature  and loose  connection with the
testis.   " The epididymis  remains  for  some time unaffected."   In one
case, mentioned by Mr. Curling, its tubes Avere found filled with  can-
cerous matter.   Great enlargement of the vessels takes place; the sper-
matic artery has been observed as large as the radial.   The spermatic
cord becomes  invaded by the  disease, and sooner or later  the lumbar
glands, and perhaps the inguinal, become affected, while secondary can-
cers spring  up in various parts.  Encephaloid has been known to attack
the testis in the first year of life, but is most common about the middle
period.  Its duration is  very variable, from  a few months to several
years.   Colloid cancer and melanotic have very rarely been observed in
the testis.   The tunica vaginalis is said to have been affected with fun-
goid (cancerous) disease, the testis remaining healthy.
   Cyst-production sometimes takes place in the substance of the  testis 
MALE GENERATIVE ORGANS.
595
in a  very marked manner.   The cysts may be only two  or  three  in
number, or excessively  numerous,  causing considerable enlargement.
They vary in size, from the most minute to  the dimensions of a pigeon's
Fig. 308.
Section of cystic sarcoma of the testis.—After Mr. Curling.
egg.  Their  contents  are, in the younger  cysts, a transparent, light-
colored fluid—in the older, a more thick, viscid, and  very albuminous.
The cysts are sometimes imbedded in  solid stroma, probably of fibroid
tissue;  sometimes small masses of enchondroma are developed between
them.   A lobulated growth sometimes arises from the wall of the cyst,
and occupies its cavity more or less completely.  In  one specimen we
have examined,  the contents of the cysts were not  identical;  in some,
which appeared as opaque white spots, they consisted of layers of scaly
epithelial particles,  more  or less flattened  and pressed together; in
others, the contents were a pulpy  mass of swollen scales, with very
abundant amorphous and  oily matter, and small, delicate vesicular glo-
bules;  others again contained  a  clear fluid, and a soft, whitish pulp,
consisting almost entirely of small  oil-laden, granulous vesicles.   The
stroma inclosing the cyst  cavities consisted of a dense fibroid substance.
Hemorrhage  may take place into a number of the cysts  at different
places, as is  well seen in  a beautiful specimen of the disease in  St.
George's Museum.   In this case, the  testis was  inclosed in  a common
covering—probably  the tunica albuginea—along with the tumor, and
lay at one side of it; in other cases, the glandular structure is expanded 
596
ABNORMAL CONDITIONS  OF THE
over the growth.  There was no contamination of the glands, nor, as
far as known, any return of the disease in the patient from whom  the
tumor just mentioned was removed; but in other cases of  cystic disease

                               Fig. 309.
                 Contents of various cysts in the case referred to in the text.
In the lowest figure, the epithelial scales are flat and opposed to each other; in the middle, the epithelial
          scales are much swollen, and mingled with granular matter and corpuscles.

the removal of the part has been  followed by development of cancer in
other localities.   These latter are probably instances  of the combina-
tion of  cyst-production with cancer.
  Loose bodies are occasionally found in  the tunica vaginalis, similar to
those occurring in joints.   They are, in all probability,  masses of exuded
fibrin, and have, at least in the majority of cases, no claim to the epithet
cartilaginous, which is often given to them on account of their external
appearance.  Calcareous  matter  is sometimes deposited in them; and
Mr. Curling has observed  the presence of laminae similar to those of
bone.   The remains of a foetus have been found in  the scrotum, in con-
nection with the testicle.   This seems to have resulted from the inclusion
of a second  atrophied embryo in the abdomen of the first, from which it
passed out with the testicle into the scrotum.
   Morbid dilatation of the spermatic veins constitutes varicocele.  In
an  advanced stage of the  disease, the coats of the  veins are thickened,
so that they do not collapse when cut across.   " The enlarged veins hang
down below the testicle, and reach upwards into the inguinal canal; and,
when very voluminous, conceal the gland, encroach on the septum, and
extend  to the other side of the scrotum."   The veins  in the interior of
the testis itself, and those  on  the surface  beneath the serous membrane,
also become enlarged.  The left veins are oftener affected than the right
—partly  in consequence of accumulation of  harder fecal matter in the
descending  colon than in  the ascending, partly on account of the left
spermatic vein opening at right angles into  the renal, and partly, per-
haps, from the lower position of the left  testis.  When the varicocele is
slight, it  does not impair the  nutrition of the testis; but, when  large, it 
MALE GENERATIVE ORGANS.
597
occasions  very marked atrophy—doubtless, in  consequence of the in-
creased venosity of the retarded blood.
  Fatty tumors are occasionally developed in  the spermatic cord.
  It may  be well to notice here the morbid conditions of the scrotum,
as a portion of integument which  has somewhat peculiar relations.  It
Fig. 310.
               Hypertrophy, or elephantiasis of the scrotum, in a Hindoo.

is one of the most frequent situations of elephantiasis—a disease which
M.  Cazenave regards as essentially connected with inflammation of the
lymphatics of the part.   This produces the most enormous enlargement
of the part—such that  the mass has been known to weigh 200 pounds
more than the weight of the rest of the body.   The epidermis, the corium,
and the subcutaneous areolar tissue, are all, especially the latter, greatly
hypertrophied.   The areolar  tissue  is  converted into  a large  mass of
fibrous material, infiltrated with an albuminous and fibrinous fluid.   Its
areolae are much enlarged in some parts;  the testes remain sound; the
spermatic cords are elongated several inches, owing to the testicles being
dragged  down,  but  are  not otherwise  diseased.   Hydrocele sometimes
occurs.   When the disease is confined  to the  scrotum, and the enlarge-
ment becomes very great, "the penis becomes drawn in, and ultimately
disappears, while the elongated prepuce  is  continuous at a navel-like
opening in the  skin of the surface  of the tumor."
  Common hypertrophy of  the integument  of the scrotum sometimes
occurs; in this, there is no alteration of the subcutaneous tissue. 
598  ABNORMAL CONDITIONS  OF MALE  GENERATIVE ORGANS.

  Epithelial cancer is  the common form in which it  appears in  the
scrotum, constituting what is commonly called  chimney-sweeper's can-
cer, on account of its being apparently produced by the contact of soot.
It is very remarkable that the disease may not appear  for many years

              Fig. 811.                           Fig. 312.
                                       Corpuscles from chimney-sweep's cancer.


after  the person has  ceased entirely to be in any way exposed  to the
influence  of soot.  Mr. Curling mentions a case in which a man, after
having been a sweep, went to sea, and led a  sailor's life for nineteen
Fig. 313.                            Fig. 314.
Enlarged prostate.                       Hypertrophy of prostate.
years before the disease made its appearance.  It is, of course, possible
that, in these  and similar cases, the  cancerous development  and the
sooty employment were mere coincidences.  Cancer of this kind does not
show much  tendency to contaminate the lymphatic glands or distant
parts.   Even the glands in the  groin are not always affected, and those
An aggravated example of chimney-sweeper's can-
   cer ; much superficial texture destroyed. 
     ABNORMAL CONDITIONS OF THE PROSTATE  GLAND.    599

in the interior of the abdomen very rarely.  The disease advances by
invading the adjacent tissues, and thus produces fearful ulceration, ex-
tending even to the groin and thigh, and destroying life by perforating
the coats of some of the large vessels.
   A case of melanotic cancer of the scrotum has been observed by Mr.
Curling.
   Fibrous tumors are sometimes developed in this part, and may form
a large  mass when several are grouped together.
 ABNORMAL  CONDITIONS  OF  THE VESICUL.E SEMINALES.

  They participate in the defective development of the testes, being ab-
sent or imperfect when their related glands are so.   Chronic catarrhal
inflammation not uncommonly attacks the vesiculae, causing tumefaction
of their mucous membrane, secretion of unhealthy mucus, dilatation of
the cavity, and thickening of its parietes.  Ulcerative destruction of the
mucous membrane occasionally takes place, the result of which may be
thickening and cartilaginification of the parietes (the morbid action hav-
ing subsided),  or perforation, with formation  of abscess in the adjacent
parts.
  Tubercular deposit occasionally affects  the vesiculae, chiefly in cases
of extensive tuberculosis : it appears as " a thick yellow, cheesy, larda-
ceous, fissured, purulent layer," which  replaces the mucous membrane,
and causes thickening of the superficial layer of their coats.  It never
occurs before puberty.  Scarce anything is known respecting cancer of
these parts except that they only suffer secondarily from extension of
adjacent disease.
    ABNORMAL  CONDITIONS  OF THE PROSTATE  GLAND.

  The prostate is  imperfectly developed when the organs  of generation
are so.   Its size is diminished in some  cases, when the testes are atro-
phied ; it is then rather  consolidated in texture.   In other cases it un-
dergoes what has  been termed  eccentric atrophy; by which is meant
the dilatation of its cavities, with  thinning of its walls, in consequence
" of the increase in size of calculous concretions in its follicles."  " Cases
sometimes  occur, in which the whole of one  lobe, or even  the  entire
organ, is converted into a thin fibrous capsule, the proper substance of
the gland being almost Avasted."
  Hypertrophy of the prostate  is extremely common, and to some ex-
tent may be regarded as  an occurrence natural in old age.   It comes on
quite imperceptibly, as one of those changes whose existence is unknown
till  their secondary effects begin to be produced. The enlargement may
take place in all the dimensions of the  gland, so that it  expands later-
ally, downwards, and upwards.  Most often, one lateral lobe is enlarged
more than the other, which occasions a deviation  of the urethra to the
other side.  It  said that the left is the one  most commonly affected,
and that it also frequently projects more than the  right towards the 
600              ABNORMAL CONDITIONS  OF THE

cavity of the bladder.   This, however, is by no means an invariable rule.
The  middle  lobe is  commonly enlarged  more or less when  the lateral
lobes are so, but may attain a great size without any corresponding by-

                               Fig. 315.
Lobulated hypertrophy of prostate.
pertrophy of the lateral.  It forms a kind of pyramidal elevation, pro-
jecting into the cavity of the bladder, and causing the urethral orifice to

               Fig. 316.                         Fig. 317.
Hypertrophy of middle lobe.
be raised, and in some measure blocked up.   The enlarged middle lobe
has been found of the size of a small orange; more often, it does not ex- 
PROSTATE GLAND.
601
ceed that of  a walnut; its  surface may be smooth or nodulated.  The
hypertrophy of this part, when considerable, has the effect of throwing
the neck of the bladder forward, and increasing the depth of its lower
region so that calculi may  lodge behind and below the prostate in  its
cavity.   The canal of the urethra becomes lengthened in its prostatic
Fig. 318.
Irregular hypertrophy of third lobe.
portion;  sometimes divided into two channels by the  projection of the
middle lobe; or is tortuous from being curved to one side;  or, in con-
sequence of its vesical orifice being raised, describes a curve whose con-
vexity is doAvnward.   Its  pressure on  the rectum causes flattening  of
that channel, and  more  or less uneasiness in  it,  and may, perhaps,
occasion haemorrhoids, or  prolapsus ani;  in the same way it irritates
the vesiculae seminales, and induces thickening of their walls; pains felt
in the parts to which the  sacral nerves are distributed may be dependent
on direct  contact of these nerves with the enlarged gland, or on a re-
flected stimulus conveyed to their place of origin along the compressed
vesical  and haemorrhoidal filaments;  the most  important result, how-
ever, of the enlargement, is the obstacle which it  causes to the complete
evacuation of the bladder.   This depends partly on the narrowing of the
urethra, and partly on the circumstance that a  certain quantity of urine
is always contained in the lower part of the bladder, below the elevated
orifice of the urethra.  In some cases the urethra, instead of being nar-
rowed by compression, so as to appear like a slit on a transverse section,
is considerably dilated, so that the  prostatic sinus may contain two or
three ounces of urine. An enlarged prostate is often indurated, so that
by older writers it has been called scirrhous.  The retained urine  de-
composing, causes irritation and inflammation of the bladder, with all
its results, such as  we  have already  described.   Moreover, as Mr. 
602
ABNORMAL CONDITIONS OF  THE
Coulson  describes it, the enlarged middle lobe becoming broader, and
raising up a transverse fold of mucous membrane,  which passes off on
each side to the lateral lobes, constitutes a kind of valve, which is pushed
before the urine in every attempt that is made to void it, " and closes up
the opening till the cavity of the bladder is very much distended; then
the anterior part of the bladder being pushed forward, and the tumor
being drawn back in consequence of the membrane of the posterior part
of the bladder  being  put on the  stretch, the valve is  open, so that a
certain  quantity of water is allowed to  escape, but the bladder is not
completely emptied."
   Acute inflammation may attack the prostate, commonly as the result
of suppressed gonorrhceal discharge; it may go  on to suppuration, or
cause chronic  enlargement,  or an irritable condition of the  gland, with
increase  of its secretion.   When  abscess occurs, there may be one or

                              Fig. 319.
Abscess of prostate.
several;  a single one, large enough to contain half a pint of matter, or
small and numerous foci, so that  the  gland appears riddled with holes.
The abscess may open into the bladder, into the prostatic sinus of the
urethra, into the rectum, or, externally, into the perineum.
   Ulceration of the prostate scarcely occurs, except in  some cases of
chronic hypertrophy.   It occasions severe  suffering, and the admixture
of blood with the urine.
   Tubercle is not of frequent occurrence in the prostate; it is generally
coexistent with tuberculosis of other  parts of the  generative apparatus
and of the lungs.  It may form a single large mass, or numerous small
separate  ones.   As the tubercles  soften and disintegrate, they give rise
to abscesses, which pursue  the same course as those of inflammatory
origin.
   Cancer is rare in the prostate; five cases of it only were met with by
M. Tanchou among 8,289.  The scirrhous species is scarce ever observed.
Encephaloid, either primary or extending from the bladder, is almost the
only form that occurs.  It causes considerable enlargement of the gland,
and may also perforate the mucous membrane of the bladder, and vege-
tate in its cavity, filling it up so completely as to give rise to the idea of
the viscus being distended with urine.  The disease occurred in a patient
of Mr. Stafford's, at the  age of five years, and in one of Mr. Solly's,
at three.
   Fibrous tumors, as Rokitansky and Mr. Adams testify, are frequently 
PROSTATE GLAND.
603
A cyst of the prostate gland.
found in the prostate.  They vary in size from that of a pea to that of
a nut ;  cause distinct  hypertrophy  of  the
gland,  to whose tissue, however, they are, at
least in some cases, but loosely attached.
  Cysts  are, in extremely rare cases,  formed
in the prostate, as Mr. Adams thinks,  by clo-
sure of the outlets and dilatation of the cavi-
ties of follicles. The fold of mucous membrane
constituting the uvula vesicle is sometimes so
raised  up  by the increase of  the subjacent
tissue,  or  by that of the third lobe  of  the
prostate, that it  obstructs  the free  exit of
urine;  this is not to be confounded with simple
enlargement of the middle lobe.
  Concretions, in  greater or less number,  are
of almost constant  occurrence  in the  pros-
tatic cavities; they  often may be seen, on
making  a section of the  gland,  as reddish,
yellow grains.  The larger, fully formed ones
have a beautiful laminated structure, and resemble a good deal a section
of a lithic acid calculus.  Their form  varies very much ; in the smaller
it approaches the  oval or circular, in the larger it is more polygonal or
triangular.  They are not unfrequently pale or colorless.   They origi-
nate in large oval vesicles, formed of a well-marked  homogeneous en-
velop.    These appear to increase in  size, while  concentric laminae are
formed in their interior, whose interspaces are  occupied  by a finely-
mottled  deep-yellow or red matter.  A  central cavity is almost always
left within the last-formed laminae.  Deposition of organic matter may
take place, in some cases, exterior to  the original envelop, but in most
it appears to be within.   Concretions  of older
date seem to lose the beautiful definiteness of
their structure, and tend to  disintegrate.  The
contents of these semi-organized formations
appear to be earthy matter (phosphate,  with a
little carbonate of lime), tinged by the ordinary
yellow pigment which is so often derived from
the blood.  We do  not  think they are  deve-
loped  from  the  ordinary epithelial particles
of the  gland, but  that the original vesicles are
cells of a particular kind, which are produced
from organic exudation  upon the mucous  sur-
face, and fill themselves, as  their growth pro-
ceeds,  with  successive deposits of materials,
which  are probably  poured out when the  gland is  the seat of  vascular
excitement.  It is most probable that, in ordinarily healthy states, these
concretions undergo solution at an early period of their existence, yield-
ing up their contents to form part of  the  secretion of the gland.  But,
if this does not occur, and they go on increasing in  size,  they become
the nuclei of, or  are developed into, prostatic calculi.  These  are not
unfrequently very numerous ;  as many as fifty or  sixty have been found
Fig. 321.
Prostatic calculi. 
604         ABNORMAL CONDITIONS OF THE PENIS.

in an atrophied dilated prostate, which has, in consequence, when ex-
amined per rectum, given the sensation of a bag of marbles.  The calculi
sometimes cohere together, and form a large mass, projecting into  the
membranous portion of the urethra, which becomes in consequence much
dilated.  A remarkable case of this kind has been recorded  by Dr.

                              Fig. 322.
Prostatic concretions.
Herbert Barker,1 in which 29 calculi, weighing  together 1,681  grains,
were cemented together so as to form  a single  concretion, which was
nearly fiAre inches long, and of an elongated pyriform shape.  The sur-
faces of these calculi  are  faceted from  mutual pressure; they are of a
whitish or reddish color,  of  porcellaneous lustre and hardness, with a
radiated, laminated, or compact  structure.  Lassaigne's analysis gives
the following as their composition :  basic-phosphate of lime 84.5, car-
bonate of lime 0.5, animal matter 15.  The smaller calculi often escape
into the  bladder through the dilated  prostatic ducts; if they remain
there, they excite irritation of the mucous membrane and deposition of
phosphates upon their own surface.  A  coating of lithic acid has some-
times been formed on  a large  calculus remaining in the prostatic portion
of the urethra.
          ABNORMAL CONDITIONS OF THE  PENIS.

  The penis is  very imperfectly  developed in  some cases of  normal
condition of the  other sexual organs, as well as when they are themselves
imperfect.   We  have seen it extremely  short  and fissured in its whole
upper surface, in a case of eversio vesice.  When it is very small, fissured
below, and destitute of  prepuce, and when at  the same time the testes
remain in the abdomen, and the scrotum  is cleft,  there results a con-
siderable resemblance to the female conformation; or if the penis is less
atrophied, a pseudo-hermaphroditism.  Atrophy of the penis,  accompa-

          1 Transact, of Prov. Med. and Surg. Association, vol. iii. 1840. 
ABNORMAL CONDITIONS OF THE PENIS.         605
nied by obliteration of the cavernous  textures, occurs, according  to
Rokitansky, together with atrophy of the testicles.
  Hyperemia of the penis, being in the exercise of its function a natural
occurrence, scarcely ever  seems to become  morbid.  It has, however,
occasionally happened, during coition, that the erectile texture has given
way in  some part—probably from the rupture of some of the trabeculae
containing the small arteries.  The consequence of this is, that the organ
appears broke, and cannot assume  the  erect  condition beyond the part
injured.   Contusions,  which occasion bleeding from the urethra, indi-
cating that laceration  has occurred, are  sometimes the cause of severe
strictures; in some of  these cases, inflammation may have been set up,
resulting in the effusion of coagulable  lymph; in others, the deposited
fibrin of effused blood has furnished the induration-matter.   " Inflam-
mation of the  cutaneous investment of the  glans (balanitis), which is
generally complicated with inflammation  of  the  internal lamina of  the
foreskin, gives rise to  excoriation, exudation  of coagulable lymph, adhe-
sion of the prepuce to the glans,  suppuration,  and  ulceration; when
chronic, it induces exuberant formation of epidermis; and if the deeper
parts of the parenchyma of the  glans are involved, obliteration, cartila-
ginous induration, and atrophy, follow."
   The vesicles of  herpes sometimes form on  the prepuce, on its mucous
or cutaneous laminae.   These are not to be confounded with the specific
ulcerations, termed chancres, Avhich may form on the internal surface of
the prepuce, the fraenum, and near the meatus  Avithin the  urethra, as
well as upon the glans, which is their usual site.   We give Mr. Druitt's
terse description of the appearance of the various forms of chancre, pre-
mising that he has selected the  principal types:—
   The Hunterian chancre is nearly circular, deep and excavated ;  the
base and edges are hard as cartilage, but the  hardness is circumscribed;
there  is little  pain or inflammation; its  color  is
livid or tawny.  It may occur  upon the  common       Fig- 323-
integument,  the glans  or  body of the penis; in
the  latter  situation it is never  so  hard and  exca-
vated  as it is on the glans.
   " The non-indurated chancre is more frequently
found on the inner surface of  the prepuce."  It
appears as a  foul  yellowish or  tawny  sore, at-
tended with  slight   redness,   and swelling and
spreading  circularly.   It  subsequently throws out
indolent fungous granulations, unless it be situated
on the glans, where they do not form.                a vertical sore on a com-
   Phaqedenic  chancres are of irregular shape,  mon/ufle- Jhe ;*araTfrs
   -*■ " i7                       .   .  *3  .     r     are chiefly those of the Hun-
their edges ragged or  undermined, their surface  terianchancre_AfterActon.
yelloAV  and  dotted with  red  streaks;  their dis-
charge is thin, profuse, and sanious.  The surrounding margin of skin
usually looks puffy and oedematous; but sometimes it is firm, and of a
vivid red.  The cicatrices left by chancres which have healed, are whitish,
more or less hard, striated, and depressed.
   Psoriasis of the prepuce produces a red, thickened, and fissured condi-
 
606         ABNORMAL CONDITIONS OF  THE PENIS.
tion of the part, which bleeds, Avhenever an attempt is made to draw it
back ;  and in consequence phymosis is apt to occur.

             Fig. 324.
Phymosis.
Paraphymosis.
  Paraphymosis is  the opposite condition, in  which a tight prepuce
having been drawn back, constricts the neck of the glans, from having
itself become thickened, and thus occasions a distended state of the glans,
and even  mortification, unless the stricture  be  removed.  Phymosis is
apt to  give rise to attacks of balanitis, from the accumulation of the
secretions of the coronal follicles.
   Warty  vegetations  belonging  to the  class of  epithelial tumors some-
times form on the glans, or  on the inside of  the prepuce; they are
                       commonly the result of  repeated inflammatory
                       excitement, and are  capable of being cured ef-
                       fectually by  removal.
                         Cancer may affect any part of the penis, but
                       is  most  frequent on the glans and prepuce.
                       Rokitansky  says, that  it  chiefly assumes the
                       encephaloid form; but we  think the epithelial
                       is  more often  met  with,  at least in the site
                       which has been mentioned as its favorite.   Dr.
                       Walshe  speaks  of scirrhus  as the species which
                       usually affects the penis, though it  may subse-
                       quently  give rise  to encephaloid vegetations.
                       He states that the disease may originate as a
                       warty excrescence, or as  a pimple, which dis-
                       charges  an excoriating fluid, scabs, and breaks
                       out afresh, while induration, followed by ulcera-
tion, advances at its base; or it may infiltrate the glans, so as  to con-
vert that  part into an indurated mass;  or venereal ulcers may take on
cancerous action, and fungate as primary cancer.  Secondary cancers,
except in the adjacent glands, are not of common occurrence.  Phymosis,
and the irritation attending  upon it, seem  to act  as  exciting causes ;
advanced  age as a predisposing.
Warts on Penis. 
THE  PATHOLOGICAL  ANATOMY  OF  THE
   FEMALE  ORGANS OE  GENERATION.
                 CHAPTER  XXXVII.

          THE EXTERNAL ORGANS OF GENERATION.

  The various tissues entering into the  composition of the external
organs of generation of the female are liable to numerous affections, dif-
fering according to the immediate seat of  the lesion.   In the pudenda,
which we shall notice first, we have to deal with the cutaneous covering,
the mucous lining, the loose, intervening  cellular tissue, and the  seba-
ceous and  mucous  follicles.  The  relation of the parts as the organs of
copulation, is one, that, in addition to the  pathological questions they
give  rise to, often has a most important bearing upon medico-legal points
of vital interest, which it is necessary for the medical man to understand
well, as numerous cases  are on record of  a misappreciation of the cir-
cumstances having led to very mischievous results.  In the labia, sugil-
lations are frequently met Avith as a result of external violence, or after
parturition; the effusion  from  a violent  injury may  give  rise to very
considerable tumefaction, which must not  be confounded with varicose
swellings.  When the consequence of childbirth, it  generally affects the
left labium,1 and occurs more frequently in primiparae than multiparae.
The  swelling in either case has been known to attain the size of a fist,
or a  child's head.   It presents  a tense, smooth surface, with a livid color.
Varicose veins of  the labia  may also acquire a very  considerable size;
but the slow increase of  the tumor, and the vermicular character of its
contents, will determine  the diagnosis.  Varicose  swellings,  too,  occur
during the course  of pregnancy, and, though sometimes very  considera-
ble, do not generally cause  any impediment to parturition, as they are
external to the vulva.   Cases, however, are recorded of their sudden
laceration during parturition, and of a consequent fatal issue.   The he-
morrhagic tumor disappears spontaneously, or  in consequence of treat-
ment, but exceptionally the swelling persists, probably becoming encysted,
and may then be  borne for  an indefinite  period.   A case is related by
Mauriceau,2 in Avhich a tumor, originating in this way, existed for tAventy-

  1 Kilian, die Geburtslehre, &c, vol.  ii. p. 517.  1840.   Frankfurt.
  2 Observations sur la Grossesse et 1'Accouchement des Femmes.  Paris, 1695. Obs. 29. 
608        THE EXTERNAL ORGANS OF  GENERATION.

five years.   Inflammatory affections of the labia may arise from internal
and external causes, and exhibit the various forms of inflammation met
with in other superficial textures.  Eczematous and aphthous inflamma-
tion, as  a result of derangement of the digestiA'e organs, of pregnancy,
of a want  of cleanliness, or of  sexual over-indulgence, are common.
Eczema is characterized by the appearance of a vesicular eruption scat-
tered over  the inner or outer surface of the labia.   The vesicles break
and  scab, and  they are  the source of much of the pruritus to which
females  are subject.
  The loose cellular tissue, occupying the interval betAveen the external
and  internal lamina, especially favors oedematous  swelling, and, when
the  inflammation  bears a phlegmonous  character, extensive sloughs
form."  Instances of this in early life are recorded by Mr. Kinderwood,1
who  witnessed an epidemic at Manchester, marked by great fatality.
  The mucous crypts, especially the aggregation lying on each side of
the vestibulum, and termed by Bartholinus the female prostate, are liable
to inflammation from catarrhal, herpetic, syphilitic, or other causes, re-
sulting in chronic ulceration or tedious discharges.   Even  young child-
ren  are  frequently  liable to simple  or benignant inflammatory affec-
tions of these parts, giving rise to  much  irritation and muco-purulent
secretion—a circumstance with which it is necessary to  be acquainted,
as popular prejudice is only too prone to attribute it to contagion.
  The syphilitic taint gives rise to  warty excrescences of the dermoid
tissues, which may affect the labia and the introitus vaginae.  They con-
sist of groups of small pedunculated tumors, aggregated together in such
a manner as to produce  a sort  of mushroom appearance.   These warts
are not  identical with, though  they resemble, the tubercule muceux of
French  writers on syphilis.  Mr. Safford Lee  describes these as round,
flattened tubercles, raised above the  surrounding tissues, sometimes be-
coming  elongated, of a reddish-blue  color, and frequently ulcerated on
their surface, producing  a moisture of the parts.2
  Encysted  tumors of slow growth affect the labia, and  are probably
due to an obstruction in  the first instance, and subsequent distension of
one or more of the follicular structures.  They consist of a membranous
envelop, containing a transparent, glairy fluid; and only prove a source
of inconA-enience after they have attained a large size.   Other tumors
are described as occurring in the pudenda, independently of the hyper-
trophy resulting from chronic inflammation.   Sir Charles Clarke has
described a \Tariety  under the  designation of  the oozing tumor of the
labium,  Avhich is  chiefly characterized by a profuse watery discharge,
corresponding in appearance with that from the cauliflower excrescence.
It is but slightly elevated above the skin, and has an irregularly nodu-
lated surface.  It  occurs in  persons advanced  in life, endowed with
general  obesity, and in  whom  the  labia are  enlarged.   Erectile and
scirrhoid tumors are  also met  with in  this part of the  system.   A re-
markable specimen of the latter is preserved in  the Royal College of
Surgeons of England (No. 2715), which  was successfully removed by

        1 Medico-Chirurg. Trans, vol. vii. p. 84.
        2 SafiFord Lee on Tumors of  the Uterus, &c. p. 254.  London, 1847. 
           THE EXTERNAL ORGANS OF GENERATION.        609

operation.  It weighed upwards of eleven pounds, and is six inches in
diameter.  It is covered with healthy skin, and consists of a pale  and
compact,  but soft and elastic, tissue, traversed in some parts by irregu-
lar, shining fibres, and in others having several small oval cavities in it.
The patient was thirty years of age, and the tumor had been  growing
for many years.  Under the head of hypertrophy, we must also allude
to the liability of the labia being affected by elephantiasis.  The nymphas
or labia minora are often abnormally enlarged, and frequently the seat
of chronic inflammation, and consequent induration.  In new-born infants
they normally project beyond the labia majora, and, in some wild tribes,
the custom exists of inducing their elongation by artificial means;  this
is said to be  the case among  the  Bushmen and the Kamschatdales.
Among the Arabs  and Copts  circumcision of  females  prevails, which
consists in removing a  portion of the elongated nymphae.   The  enlarge-
ment of  the nymphae  has been set down to an abuse of sexual indulg-
ence ; but this is, probably, as incorrect as the same statement has been
shown to  be with regard to hypertrophy of the clitoris.  This rudiment-
ary penis excites no attention,  unless enlarged much beyond its  normal
proportions.   It is  capable  of assuming the  most  extravagant size.
Some of the cases of hermaphrodism that are on record may be explained
by a reference to congenital  hypertrophy of the  clitoris.   The largest
specimen  that we have  met with is preserved in the Museum of the Uni-
versity of Bonn.  It is fourteen inches  in circumference, and weighs
eight pounds.   Mr. Safford Lee  quotes several  instances of  similar
hypertrophic enlargement. Parent DucMtelet met with enlarged clitoris
in only three cases  of  6,000  registered prostitutes in  Paris.  Dr. Ash-
well, in his remarks on the subject, expresses his concurrence with  the
last observer as to there being no necessary connection  between  an
habitual  sexual indulgence and the permanent increase of the clitoris.
He adds,  that he has often been struck with the integrity of the external
genitals in prostitutes, while the uterus  and ovaries have been bound in
all directions by bands of false membrane.  The warty growths, already
spoken of, also affect  the clitoris,  and  it  is occasionally the seat of
malignant degeneration, where the  parts  of generation are generally
involved.
   In the  Pathological  Society's Report for 1817-48, Mr. Brooke  has
recorded a case of  malignant disease of  the clitoris, which caused  an
excrescence of the size of  a nut,  attached  by a pedicle, and which,
having ulcerated and  involved one  of  the nymphae, was  successfully
removed  by an operation.  In this  case  it does not appear that  the
system at large was at all affected.
 " We allude to the urethra at present, only to speak of certain affec-
tions of the orifice which opens beneath the clitoris, into the vestibular
portion  of the vagina.    The very large crypts and  sebaceous  follicles
surrounding this sensitive point, are the frequent seat of blennorrhaic
and other forms of inflammatory action.   The mucous membrane of the
part is liable to an  hypertrophic development, giving rise to small Avas-
cular, generally pediculated tumors.  They are  exquisitely  sensitive
during life, and the  surface being  easily abraded by contact, they fre-
quently exude small quantities of blood,  or they are the cause of painful
      39 
610        THE EXTERNAL ORGANS OF  GENERATION.

micturition and protracted  leucorrhoea.   The  mucous  membrane  sur-
rounding the orifice of the urethra is very apt to become hypertrophied ;
the affection is  described,  by Sir C.  M.  Clarke,  as consisting  of an
inflammatory hardening and thickening of the cellular structure, with
an increase in the erectile tissue of the part.
  The valvular fold of membrane which  protects the virginal vagina,
the hymen, which is commonly ruptured when coition is  first completely
effected, has been a subject of much discussion by medical jurists, as its
absence has been regarded as an unequivocal sign of defloration,  or its
presence as a proof of the unimpaired virginity of the individual.  Neither
position is absolutely correct; for the best authorities are agreed, that,
on the one hand, it may be destroyed by ulcerative  absorption ;  or, on
the other, that it may persist, not only after coition, but even after  par-
turition.  The latter fact is corroborated by the testimony of Merriman,
Nagele', Ramsbotham, and  others.  Other deviations from  the normal
state of the hymen are, the cribriform perforations that it exhibits; or
it surrounds the entire  introitus vaginae, leaving a  central circular ori-
fice,  or it  entirely excludes  the  passage.  The latter  circumstance is
not likely to be discovered, as other atresiae of the  external orifices are
early in life.   WTith the approach of puberty it will induce much  incon-
venience from  the mechanical retention of the menstrual discharge, and,
unless  discovered and rectified, will be the source of serious disturbance.
The hymen is sometimes found much  indurated, and of a cartilaginous
consistency, and  even osseous deposits have been met with in it.   The
hymen, after it has been ruptured, is partially, if not entirely, absorbed.
The  carunculae myrtiformes, Avhich  have been  generally looked upon as
the remains of  the hymen, are now  regarded by many authorities as
normal formations that  are not associated Avith lesion of the hymen.
                          THE VAGINA.

  The vagina presents very considerable varieties of conformation and
size within the normal limits of health, differences depending upon the
age of the individual and  the  effects  of cohabitation or childbirth, or
the absence of these influences.  A congenital closure of the passage
may, independently of an imperforate hymen, or  adhesion of  the labia,
convert the vagina into a cul-de-sac, a lesion which can  scarcely be
attributed to anything but  intra-uterine inflammation, if the uterus be
present.   A remarkable instance, which appears to have been an arrest
of development, is  detailed by Dr. Boyd,1 where, in a female, aet. 72,
who had  been  married,  though necessarily without issue,  the vagina
terminated  in a cul-de-sac  about half an inch deep, beneath the  orifice
of the urethra.   There was  no vestige of a uterus, nor any Fallopian
tubes; the  right ovary was  natural, and attached by a loose ligament
to the bladder; the left ovary was abnormal, but  similarly connected
with the  bladder.  A multiplication  of  parts is, perhaps, more fre-
quently met with, and is produced by the formation of a septum, which
1 Medico-Chir. Trans., vol. xxiv. p. 187. 
           THE EXTERNAL ORGANS  OF GENERATION.        611

is  more or less complete;  it may extend through the  entire length of
the vagina, or only partially divide it.   A remarkable specimen of this
malformation was  exhibited by Mr. Birkett before the Pathological So-
ciety ;'  the vagina of a married woman, who had never borne children,
and had died of pneumonia and pericarditis, was completely divided in
the mesian line by a strong, dense, fibrous septum, extending from the
external opening to  the uterus; thus  two vaginae existed;  each vagina
led to a distinct  os uteri, both of which were  small;  the  neck of the
uterus was rather  longer than usual, the body smaller;  the  uterus itself
Avas nearly divided into two cavities by a septum in the  mesian  line.
   Occlusion, or stricture of the vagina, sometimes occurs as a result of
external injury, or of cicatrization of ulcers.   The rigidity or laxness
of the Avails varies much in different  subjects, according to the  general
habit and the  amount of  secretion from the glandular apparatus  sur-
rounding the vagina.  The great capability of the vagina for extension
is  best shown  in  parturition;  hence,  it is not  to be Avondered at  that
prolonged uterine  or vesical disease  should  induce a very lax  state of
the mucous membrane of the vagina, Avhich,  as  it often  does, becomes a
source of extreme  distress  and inconvenience to the party affected.   In
old women, we often meet with this relaxed condition, which may amount
to a complete prolapsus.   The anterior wall is  particularly prone to be
thus affected.  Dr.  Golding Bird has recently2  pointed out that  this
lesion gives rise to a fetid, phosphatic, and mucous state of the  urine in
elderly females, owing to an accumulation of the urine in the prolapsed
bladder lying in a pouch of the anterior vaginal Avail.   He shows  that
it  may be the source of great irritability of the bladder and incontinence
of the urine, which is best relieved by frequent catheterism, so as en-
tirely to empty the bladder.  Dr. G.  Bird compares the condition with
that resulting in  men  from enlarged prostate.  In  prolapsus of the
uterus, the mucous membrane of the vagina is necessarily dragged down
with the descent of that organ.
   The vagina and the external organs are exposed to mechanical  inju-
ries of  various kinds, and, in certain medico-legal questions,  it  requires
care to determine their exact  nature, as Avell as  to avoid  confounding
the menstrual discharge with hemorrhage resulting from injury.   Par-
turition frequently  gives  rise to laceration and severe contusions of
these parts.   The inferior portion of the  canal, either from  unusual
rigidity, or from want of proper care on the part of the attendant, is
apt to give way when the labor-pains  are at their climax; and the lesion
may vary from a  mere laceration of the fourchette  to  a rupture of the
entire perineum, from the vagina to  the anus.   It necessarily happens
that the perineum is perforated before the  infant reaches the natural
outlet,  and that  it passes through  the adventitious  opening  without
establishing a communication with the former.   Laceration  of the upper
portions of the vagina also occur to a varying  extent, in conjunction
Avith, or independently of,  rupture of the uterus.  A small  laceration is
not necessarily fatal. Ross3 reports the case of a woman who was tAvice

  1 Report, &c, 1847-48, p. 295.    2 Medical Times and Gazette, January 1, 1853.
  1 Dr. Francis H. Ramsbotham gives this and other illustrative instances in his Prin-
ciples and Practice of  Ob?tetric Medicine and Surgery.  London, 1841, p. 603. 
612        THE EXTERNAL  ORGANS OF GENERATION.

the subject of an accident of the kind, and each time recovered.  This
result is out of the question,  when, as  occasionally happens, the child
escapes into the peritoneal cavity.
  The mucous membrane of the vagina is  very frequently the seat of
inflammation; the commonest form is the catarrhal.   In the  first stage,
the passage is reddened, heated, and dry;  this is followed by the secre-
tion of  a white, creamy mucus;  or, if there be anything of a specific
character, the discharge is more purulent or flaky.   Whether simple or
complicated, it often assumes a chronic character, and is then converted
into a blennorrhoea, which, by the mere loss of fluid entailed upon  the
patient, often exerts a most  debilitating effect.  The secretion of  the
vagina in leucorrhoea has been recently shown by Dr. Tyler Smith,1 to
consist  mainly of squamous epithelium and epithelial debris, though its
essential characteristic, by which it  is distinguished from the discharge
derived from the cervix uteri, consists in its acid reaction, the interior
of the cervix yielding an alkaline fluid.   "It is to this  alkali  that the
secretion within the  cervix owes its viscidity and transparency, while
the curdled appearance of the vaginal mucus is owing to the presence of
the vaginal acid."  As the acid of the vagina is sufficient to neutralize
the alkaline secretion of the uterus, the fact of the latter being frequent
and copious is masked;  hence the discrepancy of the  opinions of various
authors on the subject of the source of leucorrhoea.  The external  sur-
face of the os uteri, according to Dr. Tyler Smith, yields a secretion of
the same character as the vagina  itself.   In  both  eczematous vesicles
are frequently met with, which the  same  author regards as identical
with the ovula Nabothi,  which, by some have  been  interpreted as  ob-
structed follicles, but Dr. Tyler Smith asserts that they  are often found
in situations where mucous follicles cannot be detected.
   Rokitansky describes  exudation, or croupy processes occurring in the
vaginal mucous membrane  primarily, but more frequently in conjunction
Avith a  similar disease of the uterus, in  the shape of puerperal disease.
"Exudative processes," he observes, "with various products,  occur more
frequently in patches, or throughout the vagina, as secondary diseases,
both as a result of puerperal affection of the uterus, as well as in conse-
quence of  an infection of the blood proceeding from other causes, or
from a degeneration of the typhous and various exanthematic processes.
They correspond to the condition of the  blood and its products,  and
accordingly produce a solution of the mucous membrane and  the  sub-
mucous layer, varying in  shape and depth, and not unfrequently re-
sembling gangrenous destruction.  A loss of substance  may ensue,  and
to this cause undoubtedly mUny cicatrices  found in these parts are to be
attributed."  The  secondary form of typhus  occurring in  the vagina,
Rokitansky states, does not exhibit itself  in the vagina  in its genuine
form,  but is often found degenerated into  croup and gangrene; an  ex-
isting  blennorrhoea,  especially if of gonorrhoeal or syphilitic origin,
exerting a powerful attraction upon it.
   A chronic thickening of the vaginal mucous membrane is occasionally
 met with;  the follicular,  the syphilitic, and  the carcinomatous ulcer,
Medico-Chirurgical Trans., vol. xxxv. p. 377. 
           THE EXTERNAL ORGANS  OF GENERATION.       613

also affect this  part.  Gangrene sometimes  results from  the  effect  of
parturition, or the contusion caused by rough manipulation.  The cica-
trix that results from the healing of a slough is occasionally an impedi-
ment at subsequent deliveries;  a puckering  of the vaginal membrane,
and consequent diminution of the passage, having taken place.
  The vagina is not often the seat  of morbid growths.   Polypi and en-
cysted tumors are the varieties that most frequently affect this situation.
The posterior part of the vagina is stated to be the  ordinary seat  of
polypoid growths.
  An instance  given by Mr. Curling, in the Reports of the Pathological
Society,' forms an exception to the rule.  Here the solid tumor which
was removed from a woman, aged forty-five,  grew from the upper  part
of the vagina, to which  it was attached by a broad peduncle, which
commenced just behind the meatus of the urethra, and extended back-
wards towards the uterus about two inches and a half.  The structure
of the polypi varies in character; they may be, as stated by Mr. S.  Lee,
fibrous-vesicular and  cellulo-vascular—the fibrous being the least fre-
quent.  They vary equally in size, from a trifling projection to growths
several pounds in weight.  The encysted tumors of the vagina originate
in an obstruction of the follicles with  which  the region abounds; they
contain a glairy, transparent, greenish, or dirty-brown, albuminous fluid;
and, though the source of irritation and inconvenience, are not produc-
tive of any danger: their correct diagnosis  affords*a speedy means  of
relief; but they have been  repeatedly mistaken  for  totally  different
affections, such as prolapsus of the womb or the bladder, or for hernia.
   Specimens of carcinoma affecting the vagina  are preserved in most
museums of pathological anatomy ; they show that this part is commonly
secondarily involved by  an extension  of the  disease from  the cervix
uteri;  "however,  it may exist," to employ the Avords of Rokitansky,
"though the  latter is in a very undeveloped state, and even without it, in
the shape of primary carcinoma of the  vagina."  The form in which it
occurs is of the fibrous or encephaloid kind; malignant epithelial growths
do not appear  to  affect the female organs of generation in the same
manner as they occur in  the male penis—a circumstance which may ap-
pear remarkable, as both possess a great analogy in regard to  the com-
ponent structures  and  the secretions  they give rise to.   The smegma
praeputii consists as essentially of epithelium as the vaginal discharges;
and the perverted nutrition giving  rise* to epithelial cancer, may fairly
be assumed to affect the secretory organs of the penis, and be regarded
as an extravagant expression  of the normal process.   The fact, how-
ever, is, that the mucous membrane of  the vagina has not  been shoAvn
to be obnoxious to this form of cancer.
1 Vol. i. p. 301, 1847-48. 
CHAPTER  XXXVIII.
          THE INTERNAL  ORGANS OF GENERATION.


                          THE UTERUS.

  The uterus, unlike most other organs combining  to form the human
body, has a  double existence;  one of  long-continued comparative qui-
escence, and  one of extreme, though brief, activity and  development.
The diseased processes affecting it are  mainly associated with, and the
result of the changes that take place in it, during and immediately after
pregnancy; hence, its pathological relations scarcely come to the cogni-
zance of the  medical man until its proper functions have been called
into action.   Before considering its acquired abnormities, however, we
must  turn our attention  to certain congenital  anomalies  presented by
the organ, which have a bearing upon the future  health of the adult
individual.  In  a morphological  and natural  historical point of view,
some  of these malformations  possess considerable  interest; though we
can only in so far advert to them  as they regard the practitioner.
  We have already given an  instance (page 610,) of an entire  absence
of the uterus—a malformation which need  not affect the  health of the
individual.  Rokitansky states  that the  occurrence is extremely  rare,
and that most of the cases  in  which the uterus appears  to be absent
may be  resolved into a partial arrest of development only, and that, by
careful examination, we may find behind the bladder one  or two  rudi-
mentary bodies  in the proper fold of the  peritoneum which represent
the uterus.  An actual multiplication of  the organ is equally rare; but
it is not an uncommon thing to  find a more or less complete attempt at
the formation of a double cavity, which  is  manifestly the result of an
arrest of  development.   The bilocular and horned uterus are the mal-
formations alluded  to;  in the  former, a more or  less  perfect septum
extends through the uterus in the mesian line; in the latter, the organ
presents the character of the uterus exhibited  by certain mammalia, as
the sheep, and is divided into  two lateral  compartments by a fissure,
extending vertically downwards from  the  fundus.  This  may be ex-
plained  upon the assumption of an imperfect union of the two rudiment-
ary bodies from which the normal uterus  is developed.  Only one  of
these may arrive at maturity, and we then  have to deal with  a uterus
consisting only of a single horn, or of one-half; there will then neces-
sarily only be a single  Fallopian tube.  The  uterus unicornis,  as well
as the uterus bilocularis and bicornis, are capable of becoming  impreg- 
           THE INTERNAL ORGANS OF GENERATION.        615

nated; Rokitansky1 details the particulars of an example of pregnancy
in a rudimentary uterine horn, which terminated fatally by rupture and
sanguineous  effusion into  the peritoneal  cavity, in the  third month.
When the two halves coalesce, the division which constitutes the mal-
formation may vary considerably in  amount; only  a  slight depression
may be visible at the fundus in one case, so that the organ scarcely de-
viates from its normal condition; in another, the fissure  extends  so far
down as to justify the appellation of  double uterus,  ordinarily bestowed
upon  the anomaly.  An excellent instance of this  is  preserved in  the
Museum  of St. George's Hospital (No. 104 of Dr. Lee's  preparations).
This preparation also  illustrates Avhat takes place after  impregnation;
while the ovum is  received into one horn, which becomes duly developed
with the  growth of the foetus, the other only sympathizes with it  so far
as to  form a deciduous membrane, and thus to prevent the occurrence
of superfcetation,  but otherwise undergoes but trifling  alteration  or in-
crease.   Though impregnation and parturition are not necessarily fatal,
these malformations seriously endanger the life of the patient—owing,
as Rokitansky observes, partly to the want of the necessary dimensions
of the part that undertakes the functions  of the entire organ, partly to
the obstacle  opposed to the uniform deA'elopment  of the impregnated
uterine half, by the unimpregnated  half.   These circumstances favor
laceration of the uterine parietes.  Rokitansky also shows that the di-
vergence  of the cornua from the axis of the body causes an impediment
in the act of parturition, while the  expulsive  power  of  the  uterus is
much reduced by  the  absence, in the case of the uterus  bicornis, of  a
true fundus.
   Hypertrophy and  atrophy of the  uterus are, in part, normal  at the
periods of puberty and involution; much tact is necessary to distinguish
some of the morbid from the  healthy conditions of  the organ.  The
weight and dimensions of the adult uterus fluctuate in  health considerably.
Kilian2gives the following, as the result of his measurements: the entire
length varies from twenty-four to twenty-six lines; the greatest breadth
is eighteen  lines; the thickness, nine lines;  the  cervix is from ten to
twelve lines long; its breadth, from six to eight; its thickness, from  five
to six lines ; the length of the uterine cavity is twelve lines ; its breadth,
nine  lines ;  the greatest thickness of the fundus, five lines ; of the sides,
four lines ; and of the cervix, three lines.   After one or more births, all
these measurements increase from  one-fifth to one quarter.  The weight
of the uterus varies from eight to twelve drachms, and may, after several
pregnancies, amount to two ounces.  With the aid of this  table we shall
be better able to  determine  whether we  have to deal with a morbidly
enlarged or diminished uterus.   Either affection may involve the entire
organ, or be manifested in a part only.   An atrophic  condition is pro-
bably a frequent source of sterility; the organ, and especially the cervix,
is small and anaemic, its tissue dense, and the OAraries present an equally
undeveloped condition.  After  the climacteric period,  the cervix often
disappears  entirely, and nothing but an indurated  ring  remains  at the
sumit of the vagina.

      1 Pathological Anatomy, vol. ii. p. 277. Syd. Soc. Ed.
      2 Die Geburtslehre, &c, von Dr. H.  F. Kilian, Frankfurt, 1839, vol. i. p. 92. 
 616       THE  INTERNAL  ORGANS OF  GENERATION.

   Hypertrophy is more  commonly met with  as  a morbid state, than
 atrophy ; partly, as an exagerated expression  of  the normal condition,
 at certain periods of life—partly, as the result of irritation,  set up by
 other morbid processes.   These may consist in tumors, occupying the
 substance, or filling the cavity of the  uterus; giving rise, eventually,
 to actual expulsive efforts, resembling labor-pains, or  to  blennorrhaic
 affections of the mucous surfaces.   Mere consensual irritation, proceed-
 ing from other organs, may suffice to induce it.   Thus, the Museum of
 St. George's  Hospital  contains  a preparation of the  internal female
 organs  of  generation (x.  7), in which  the  ovaries are  seen to contain
 cysts, while the uterus, which otherwise is perfectly healthy, exhibits
 very marked hypertrophy.  The cervix is liable to be hypertrophied by
 itself; the labia may form a single tumefied ring, or present two tumors,
 lying parallel to one another, and separated by a transverse fissure.  The
 first form is more likely to occur in women who have not borne  children,
 and the second in those who  haA'e.  The  anterior is more frequently
 enlarged than the posterior lip.
   The cavity of the uterus may be morbidly diminished in consequence
 of inflammatory affections of the surrounding textures, or by malposition
 or curvation, and  may amount to  complete obliteration.   An instance
 of obliteration of the cavity of the uterus is preserved in the St.  George's
 Hospital Museum (Dr. Lee's Preparations, No.  161), in which the cervix
 remained patulous.  An instance of complete obliteration of the os uteri
 is  recorded by Dr. A. T. Thomson, in the thirteenth volume of the
 Medico-Chirurgical Transactions, where, owing to this cause, in a female
 aged sixty-five, the uterus was found distended by eight quarts of broAvn
 fluid, slightly coagulated by heat.  The patient had borne two children.
 We shall have occasion to see  that the  os and  the cavity of the uterus
 are frequently plugged up by secretions, but this must not be confounded
 with actual adhesion of the parietes.  Strictures are commonly  met with
 at the external and internal orifices  of the cervix; they  appear to be
 mainly due to inflammation of the mucous and  submucous tissues of the
 parts.

               MALPOSITIONS OF THE UTERUS.

   No organ of the body is liable to so frequent, and so varied and ex-
 tensive changes of position, as the uterus;  all of which  very materially
 affect the  health  of the individual  and  her  prospects of maternity.
 There are two great classes of  malpositions;  those in which the uterus
 maintains its site  but alters its axis—deflections from the normal posi-
 tion—and those in which  it quits its nidus, and becomes altogether dis-
 placed, so that its relation to  all the pelvic viscera is perverted.   The
 deflections  are known by the terms anteversion  and  retroversion, in
 Avhich respectively the fundus  uteri is tilted forwards, or pushed back-
 Avards out of the  ordinary axis.   In either case, the abnormal position
 of the organ considerably interferes by its pressure with  the  functions
 of the adjoining organs, and especially the bladder and rectum, propor-
tional to the amount of deviation.   The term obliquity is applied to the
lateral deviation  from the axis which sometimes  occurs, either as the 
           THE  INTERNAL  ORGANS OF GENERATION.        617

effect of pregnancy, or of diseased conditions affecting one side only,
and thus disturbing the balance necessary to the integrity of the viscus.
Much  difference  of opinion  has existed  in reference  to the  question
whether anteversion (or,  as it is called by some, pronation) is a more
frequent occurrence, or retroversion.   Lisfranc asserts  that anteversion
is by far more common than  retroversion;  Rokitansky  positively states
the latter to be the more  ordinary occurrence.   In these three forms of
dislocation the different parts  of the  uterus  maintain their proper mu-
tual relations, but another variety exists in which  the cervix and body
form an angle (more or less acute) with one another.   The deflection is
almost invariably forwards; and may be congenital, as  it  is  met with at
early periods; and it is probably an  impediment, though not a bar, to
conception.   Disordered menstruation accompanies most  of the morbid
conditions we haAre adverted to, but whether as  a cause or as a compli-
cation  has not been determined.
  The second class of malpositions consists  in  a descent of the womb
into the vagina, or in its extrusion beyond the labia; the term prolapsus
has been, somewhat arbitrarily, applied to the lower degree, procidentia
to the  extreme form.  In either case the axis of the womb  must be
altered, as Avell as its  relations to the surrounding viscera.   The pre-
disposing cause is  a lax state of the tissues generally,  and more parti-
cularly of the ligaments of the uterus and of the vagina,  which may be
the symptom of debilitated constitution, as in lymphatic individuals, or
the result of repeated pregnancies.   The immediate  cause  is very fre-
quently an unusual bodily effort.  The secondary effect upon  the  pro-
lapsed organ is, that it is  irritated, and that its surface ulcerates, or that
it becomes the seat of congestion and hypertrophy, and  that its exposed
surface becomes  indurated and horny.  Prolapsus is  most frequently
met with after  the middle period of life; instances  of its occurrence
before puberty are recorded  by Dr. Ashwell,1 and other authors.  Dr.
Ashwell's work also contains the history of three cases in which, during
the whole period of pregnancy, the womb had lain  partly or entirely
external to the pudenda.   In two of  these the child was born while the
entire  uterus was beyond  the vulva;  in one, it had occupied that posi-
tion for several months, in the other for eight years previous to concep-
tion.
  A very serious malposition, which comes on  after  parturition, spon-
taneously, or as  the result of undue manual interference in  removing
the after-birth, in an unusually distended or relaxed womb, is that known
as inversion of the uterus.  It consists in  a  greater or less descent of
the fundus uteri into the  cavity of the organ, and  it  may amount to a
complete turning inside out.   It is generally accompanied by very dan-
gerous hemorrhage: if the organ is  not at once replaced in its proper
position, and the patient  survives  the immediate  shock, as sometimes
happens, the uterus becomes reduced  in  size,  and  the  inconvenience
sustained may be comparatively trifling.  Burns details a case  in which
an inverted uterus was borne for twenty years, menstruation continuing
during the whole  period.

  1 A Practical Treatise on the Diseases Peculiar to Women, p. 541.  London, 1845. 
618        THE INTERNAL ORGANS OF  GENERATION.

  Inversion is not, hoAvever, exclusively a sequel of parturition; it also
occurs as a result of the influence of fibrous  polypi, growing from  the
inner surface of the fundus.   An  unimpregnated inverted uterus is
preserved in the Museum of the Royal College of Surgeons of England
(No. 2,654), showing the Fallopian tubes obliquely in the upper part of
the vagina—the effect of a polypus growing from the fundus.   Velpeau
removed a  polypus from a woman,  who died soon after of peritonitis,
and the uterus was found to have been completely inverted.   The pre-
sence of fibrous tumors in the  substance of  the  uterus, or inclosed in
the cavity, when complicating pregnancy, favors  the occurrence of in-
version, by disturbing the normal balance of the expulsive contractions.
Some authors are  inclined to attribute it  to extreme shortness of the
umbilical cord.   Instances are  recorded  in which the  entire inverted
uterus has been removed  by ligature,  or by the  knife; in some cases
inadvertently, OAving to the tumor having been  mistaken for a polypus,
and of the patient's having entirely recovered.  One of  the latest cases
is that given by Dr. J.  Cooke.1
  We have  already had occasion to allude to  the occurrence of rupture
of the uterus, as a concomitant  of pregnancy in the horned or bilocular
malformation of the organ.  The accident is also met with in the normal
uterus.   A trifling laceration at the os tincae  occurs at every birth, and
is, therefore, of no consequence;  and it appears that until the solution
of continuity extends beyond the circular fibres of the cervix, no danger
is to be apprehended.   Above this point the  rupture may prostrate the
entire -thickness of the  parietes, so as to  allow an escape of the foetus
into the abdominal cavity; or one layer only, either on the inner or outer
surface, may give  way.   It has been shown  by several  observers that
the peritoneal investment of the uterus may, during parturition, alone
be lacerated, leaving the uterine substance entire.   The direction of the
rent is stated differently by authors.  Rokitansky affirms that it is gene-
rally vertical;  Burns asserts it  to be transverse, and  Kilian  maintains
that it is  commonly diagonal.   It very rarely affects  the fundus, but
most frequently the posterior and inferior surface, which corresponds to
the promontory, against which, in the act of parturition, the  expulsive
efforts propel the  child  with peculiar force.
   Rupture of the uterus occasionally takes place before parturition, as
a result of external injury; it  is said not to be necessarily fatal, nor as
dangerous as might be  supposed.  Its occurrence during parturition  is
unfortunately not a  mere pathological curiosity.   According to the
statistics of the Dublin  accoucheurs,  Drs. Cullen and Clarke, the a Average
frequency is about one  in five or six hundred births.   The former  met
with 34 cases in 16,414 births, the latter had 4 cases in 2,484 parturient
females.
   A remarkable  circumstance is, that of  the thirty-four cases that
occurred in Dr. Collins's2 practice twenty-three were male children, and
he accounts for the fact by the circumstance that  their  heads  are  uni-

  1 On the Removal of the Uterus in Cases of Prolapsus and Inversion.  London, 1836.
  8 Practical Treatise on Midwifery, &c. p. 244. 
MORBID GROWTHS.
619
formly larger than those of female infants.  The operation of turning
is stated to give rise to the accident, and it also appears that primiparae
offer a greater liability than multiparae.
                       MORBID GROWTHS.

  In order to avoid unnecessary repetition, we shall postpone the con-
sideration of the textural diseases of the  uterus until after we have
reviewed the morbid growths in the organ,  in order that we may more
conveniently connect the morbid  states of the unimpregnated  uterus
with the diseased conditions occurring after parturition.
  The abnormal formations that most frequently present themselves in
the uterus, are fibroid tumors; they occur imbedded  in the texture of
the organ, or protruding from its minor surface into the cavity, or from
some part of the external surface.  When projecting into  the cavity of

                              Fig. 327.
    *    Fibrous tumor projecting into the cavity of the uterus.—St. George's Museum, 128.

the uterus they receive the name of fibrous polypi.   While imbedded in
the uterine tissue they form  globular,  white, glistening, dense tumors;
there  may be only one,  or they may be numerous.   In  preparation No.
2,674, in the Royal College of Surgeons, we  see  a uterus, with from
eight  to nine large fibrous tumors in its walls, varying from one to four
inches in diameter.   In size they differ even more than in number; they
are seen in every gradation, from that of a pin's head to that of a melon.
The preparation spoken  of further on  is an instance of the great deve-
lopment they attain.  Dr. Lee mentions one weighing fifty-four pounds,
which contained several  cysts filled with fluid.  The fibrous  tumor is
surounded by a membrane which separates it from the uterine tissue, so
that there is no very intimate union between the two structures.  " The
most usual position for these tumors,"  according to  Mr. Lee's analysis
of seventy-four cases, "is the submucous, viz:  those projecting into the
cavity of the womb, and the pedicles of these are generally situated 
620
MORBID  GROWTHS.
just beloAV  the openings of  the  Fallopian tubes.   The next position in
which they are most abundant is, the posterior wall and  fundus  of the
uterus; they are very rarely situated in the anterior wall, and still more
rarely in the  cervix uteri."   Of the general truthfulness of these re-
marks, every  one may convince himself, by glancing through one of the
metropolitan museums  of pathological anatomy.   It  appears that  the

                                Fig. 328.
  A uterus, the upper half of which, is enlarged hy the growth of numerous fibrous tumors in its walls. One
tumor, larger than the rest, project? into the dilated upper part of the cavity of the uterus, and completely
fills it.  Five others are shown by the section imbedded in the anterior wall, and many others project on the
external surface of the uterus. The lower half of the uterus is healthy, but elongated. The walls of the
portion occupied by the tumors are thick and laminated, like the walls of the uterus in pregnancy.—St. Bar-
tholomew's Museum, xxxii. 16.

nearer the original deposit  takes place to the  mucous surface of the
uterus, the more a  gradual extension of the entire growth into its cavity
is likely to ensue.   In this way we account for the  gradual elongation
of the pedicle, which after a time  is  the only connection between the
tumor and its matrix ; it may then be  removed with comparative facility
by operative procedure.   The pedicle is not, however, a necessary con-
sequence of the arrival of the  fibrous tumor at the  external surfaces.
In one of the largest specimens which  has come under our  notice, which
is also remarkable  as affecting  the cervix (Royal  College  of Surgeons,
No. 2,672) exclusively, the remainder  of the uterus  continuing normal,
we find no attempt at the formation  of a pedicle; the tumor has evi-
dently formed in the substance of the posterior part? of the cervix, and
in its growth has separated the uterine tissue, which is  still spread out
over the upper part of  the  tumor, as  if embracing it.   The  tumor, in
this case, is tAvelve inches long, by five  inches thick, and  presents the
ordinary structure  of fibrous tumors.   The fibrous tumors  found almost
free in the abdominal cavity, or, at least, only attached to the uterus by
cellular adhesions, probably have the same origin as the  growths we
have just considered; having been developed  in the first instance under
the peritoneal investment of the uterus, they have subsequently become 
MORBID GROWTHS.                     621
detached.   This does not preclude the possibility of their being formed
primarily, at the points where they are found.
  The intimate structure of fibroid tumors  varies in some respects;  to
the naked eye it exhibits, at  times, a  concentric disposition of fibres ;
but more commonly, an irregular wavy appearance, without  any uni-
formity of arrangement, presents itself; and it is more particularly in this
case that cavities containing blood, a dark-colored gelatinous fluid, or a
clear serum, are formed, which give the tumor, on section, a resemblance
to the  sero-cystic disease of  the testis or mamma.  Occasionally, the
fibrous tumor presents a lobulated conformation.   The  microscopic ap-
pearances of the fibroid tumors of the uterus are not in accordance with
what we should expect to find in a true fibrous structure.   The micro-
scope,  in fact, demonstrates that  they  belong to an altogether different
class of  growths; the fibrous appearance is scarcely perceptible under
the microscope, which displays elongated nuclei, imbedded in an amor-
phous stroma.   It appears  to us, that,  from  the analogy they present to
the genuine uterine  tissue, in  the unimpregnated state, we should rather
class them with  homologous  than heterologous productions;  that they
should be regarded rather in a relation  to the Avomb analogous to that of
exostosis to the matrix  it springs from,  than  of a character totally  at
variance with  that of their  nidus.1
  The amount of blood supplied to fibrous tumors, varies.  The majority
are but scantily provided with vessels.   Some, when injected, only ex-
hibit one or two larger vessels traversing  the substance of the mass;
others exhibit considerable and  uniform capillary injection.   The he-
morrhage to which fibroid growths of the uterus may give rise, is not owing
to a laceration of these vessels, but to the irritation and congestion they
induce in the superincumbent mucous membrane, which, from the same
cause,  may  ulcerate and slough.  When complicating pregnancy, they
induce hemorrhage,  by preventing the normal development of the organ;
hence, they are very apt to give rise to miscarriages.   Fortunately for
the individuals, they are often a cause of barrenness.
  Not only the continued growth of these tumors, but also the occasional
tendency to secondary  changes occurring in  them, manifest  a greater
vitality than some authors have ascribed to them. Thus, we find abscesses
in the  very centre  of fibroid growths;  or  they may contain  encysted
melanotic tumors, as in the case of two preparations (Nos. 181 and 122)
in the  Museum of St. George's Hospital.   A species of ossification  or
calcification occurs  in  these  growths, analogous to the process of the
same kind met with  in other  morbid products; the production of true
cartilage, and the subsequent  conversion into ossific matter, is at least
doubtful, and not to be credited  until  we receive positive microscopic
evidence to that effect.   The calcification sometimes commences super-

  1 Since the above was written, a corroboration of the view expressed has been published
in the Report of the Pathological  Society for 1853, p. 219. Dr. Bristowe, in an elaborate
paper on the subject of fibrous tumors of the uterus, concludes, from his examinations of
them in the impregnated and unimpregnated conditions, that all so-called fibrous tumors
of the uterus, at least in their earlier stages, before degeneration has taken place in them,
are essentially muscular  tumors; not simply fibrous tumors with a greater or less quantity
of muscular fibre mixed up with them, but developments of true and undoubted muscular
tissue. 
622
POLYPI AND POLYPOID GROAVTHS.
ficially, at others, in the centre; the process seems to promote the spon-
taneous expulsion of the tumors from the uterus.  When  this occurs,
the proper texture of the latter takes on similar action, as if a foetus were
contained in its cavity, and it becomes hypertrophied.^  This is not the
case as long as the tumors occupy the tissue of the uterine parietes ; here
the pressure of the tumor rather inclines to produce atrophy; a remark-
able example of this is spoken of by Dr. Lee,1 in Avhich, at least, in
connection with a fibrous tumor at  the  fundus, the uterus had become
so much atrophied as to resemble a mere bladder.  Complete ossification
may, however, take place, and the tumor be  borne  for an indefinite
period, as in the case of the  old  lady mentioned by Mr. Arnott,8  who,
having died  at the  age of seventy-two, from the effects of a fall, was
found to have  a tumor weighing five pounds, and as hard as marble, in
the uterine parietes, Avhich had become converted into a mere membrane.
The tumor had been diagnosed as scirrhus, when  she  Avas at the age of
forty.  It was found, on analysis, to contain  nearly two-thirds of phos-
phate of lime.
  Fibrous tumors have not  been observed before  puberty.   Dr. Lee
agrees with the statement made by Bayle, that they are most frequent
in virgins, and that they exist in twenty out  of a hundred middle-aged
women.

              POLYPI AND POLYPOID GROWTHS.

  The growths which we shall next  consider, though  often confounded
with fibroid formations under the name of polypi, are essentially distinct
from them.  These  formations are soft and succulent, and  project into
the cavity of the  uterus, or depend into the vagina; they are attached
by a pedicle of greater  or  less width  to  the surface  from which  they
spring, while they are invested by the mucous membrane  of the part.
They are essentially a morbid condition of the surface structures, the
mucous membrane, the follicles, or sebaceous crypts of the different parts
of the uterus.  According to their predominant  character,  they  have
been termed by different authors—vesicular, mucous, cellulo-vascular,
or channelled polypi, or polypi of the Nabothian glands.  The last have
nothing in common  with an ordinary polypus; and, as Dr. Tyler Smith
has shown, can only be regarded as  a form of vesicular disease, affecting
the cervix uteri.   They are transparent cysts,  one or more in number,
and varying in size from a pin's head to a walnut, seated upon the cervix.
They are generally  sessile, but may become elongated, and thus acquire
a pedicle.   The mucous polypus is a pyriform projection from the  inte-
rior  of the uterine  surface, identical in structure with the villi of the
uterus, and hence, to be regarded as hypertrophy of this tissue.   The
cellulo-vascular polypus is described as a small red tumor, lying between
the os  uteri, and very much resembling the excrescences of  the orifice
of the urethra.  These growths are very liable to give rise to hemorrhage,
and especially at  the menstrual period put on the character of erectile
tumors ; hence, they vary much in size, according to the quantity of blood
they contain.

  1 Medico-Chirurgical Transactions, vol. xix. p. 94.      2 Ibid., vol. xxxiii. p. 199. 
CYSTS—TUBERCLE.
623
  The vesicular polypus is  stated by Dr. Lee always to be situated at
the fundus, under the lining membrane, Avhich is very thin and vascular;
he describes it as made up of a number of little round vesicles or cells,
which contain a thin, transparent fluid ; the whole is supported by a thin
fibrous tissue ; they are  of a dirty Avhite color, and sometimes present a
slightly yellow tinge.   The channelled polypus of the cervix is a rare
form of the disease ; Dr. Oldham describes it as made up of several large
channels, with  occasional  communications between them, and opening
by large orifices on the free  surface of  the growth; it does not appear
as a compound  of  pendent enlarged cysts, clustering together, but as a
solid single polypus, with  numerous orifices  on its surface.
  None of these soft growths can offer any impediment, as we see in the
case of the fibroid tumors or polypi, to the  act of parturition.   When
dormant, as they often are for a long period, they excite no symptoms;
but they become dangerous when  the  seat  of vascular  excitement, by
the hemorrhage-to which they give rise.   It is satisfactory to know, that
the operation by ligature or  excision, if  properly performed, is a  sure
means of arresting it; a spontaneous cure has sometimes been effected
by the constriction exerted upon the polypus, after it has passed the os
uteri, by the circular  fibres of the part.


                              CYSTS.

  Cystic growths  are extremely rare  in the uterus.  An  instance of
sero-cystic disease occurring here, is recorded in the first volume of the
Pathological  Society's  Reports (p. 108).   The  tumor  occupied  the
parietes of the organ, and presented a lobulated appearance; and some
lobes  seemed composed of separate bodies of various  form, contained in
and connected with the parietes of cysts.  A portion of a uterus is pre-
served at the Museum of the Royal College of Surgeons  of England
(No. 2,657), in which, according to the catalogue, a very large encysted
tumor had formed; the patient had been twice  tapped and the  cyst
emptied; it was supposed during life to be ovarian dropsy.   The occur-
rence of hydrometra, or a dropsical accumulation  in the cavity of the
uterus, is regarded by some  authors as  the  result of a  large hydatid
forming in the latter; but it is probable that it is rather owing to the
perverted action of the  lining membrane pouring out fluid,  which accu-
mulates, in consequence of the occlusion of the os tincae, and thus gradu-
ally distends the womb.   Dr. Ash well  describes, under the same head,1
the secretion and discharge of large quantities of limpid fluid, as a symp-
tom of  catarrh  of the  uterus; but  it  appears, from one of the cases
appended  to the chapter, that it may also  accompany fungoid disease
of the organ.

                            TUBERCLE.

  Tubercular deposit in the uterus, affects  primarily the lining  mem-
brane, where it is deposited in the miliary form, or  accumulated in
1 On the Diseases of Women, p. 506. 
621
CANCER.
masses, aggregated into  nodules, or forming  a cheesy layer OA'er the
entire surface;  the uterine tissue becomes secondarily affected, and  is
then liable to become infiltrated with the morbid product.   When the
affection has been accompanied by a  discharge,  Dr. Reynaud  has
shown  that the  vagina presents spots of ulceration, exhibiting a relation
analogous to that of the trachea in pulmonary phthisis.  The Fallopian
tubes are generally affected coincidently  with  the uterus.
  The  rarity of the affection may be inferred from the fact that, among
above two hundred phthisical females, Louis  only met with three Avho
furnished  examples of tuberculous disease of the uterus.   Considering
how frequently the functions of the organ are changed, or arrested, during
pulmonary phthisis, this is not  the  conclusion to which we should have
been led by a priori reasoning.


                             CANCER.

  Carcinoma of the uterus is  a  disease  of frequent occurrence.   Dr.
Lever1  has shown that the proportion of carcinoma to other uterine affec-
tions, is as one  to seven,  or about thirteen per cent.   The period of life
most obnoxious  to it, is that between the fortieth and fiftieth years ; and
though numerous examples are met with  earlier in life, the  statement  of
Boivin  and Duges, that in four hundred and nine cases they found twelve
under tAventy years of age, can scarcely  be credited, unless, as we are
assured by Dr.  Walshe, uterine cancer is more prevalent in the French
than in our OAvn capital.   The  analysis of  their cases yields  the folloAV-
ing table:—
       Under 20  years of age   .......  12 coses.
       Between 20 and 30........83   "
             30 " 40........102   "
          "  40 " 50........201   "
             50 " 71........11   •'

They attribute  a great share in the causation to sexual abuse, in which
view they are perhaps strengthened by the comparatively large number
of youthful victims.   Messrs. Bayle and  Cayol, however, emphatically
deny that their researches lead them  to  a  conclusion of a similar  kind,
but that they have found  the disease  occur with equal virulence in the
lowest  prostitutes, in  married women, and in chaste  girls.  Dr. Walshe
asserts that there is no shadow of proof that it ever  owes its production
to  disproportionate  or intemperate  intercourse.   Celibacy does not
appear  to  favor its deA'elopment;  the ratio,  according to Dr. Lever's
analysis, is:  single women, 5.83 per cent.; widows,  7.5 per  cent.; and
married females, 86.6 per cent.  This is found to be identical with the
relative frequency of other uterine  affections in their respective classes.
As  a rule, the cervix  is the part first  affected;  a  feature which broadly
distinguishes  this  disease  from fibroid growths.  A  very remarkable
exception is presented in a specimen  of cancer of the body  and fundus
uteri in St. George's Hospital Museum, in which the  cervix is entirely

           ,       ' Medico-Chirurg.  Trans, vol. xxii. p. 207. 
CANCER.
625
free from disease (No. 134).   The most eminent obstetric physicians are
of opinion that many instances of so-called cancer are perfectly curable
by proper remedial agents, from being  nothing more than irregular
thickening,  and induration of the cervix, consequent upon chronic in-
flammatory  action.  It is, therefore, necessary to be careful  in pronounc-
ing an opinion in the earlier stages of the malady, and not to assume a
patient to be  affected with malignant disease, because of a more hard-
ened and puckered condition of the os uteri.   We possess no means of
determining the nature of the affection during its first stage with cer-
tainty; nor  is it frequently brought under the notice of the morbid ana-
tomist.  The advance of the deposit, however, and the concomitant sub-
jective  symptoms,  the  fusion  and  ulceration,  the  implication  of  the
surrounding parts in the process, the fixation of the womb, and the rigid
nodulated degeneration of the vaginal mucous  membrane, soon enable
us to form a positive opinion if the  disease be malignant.   Rokitansky
has  rarely  found fibrous  cancer affecting the uterus;  this variety con-
sists of dense, whitish, reticulated fibres, containing  in their meshes a
pale-yellowish, translucent substance ; its limits are not sharply defined,
but are lost in the uterine tissue.   Rokitansky describes medullary car-
cinoma as the prevailing form of uterine cancer; appearing as an infil-
tration of a white lardaceo-cartilaginous, or loose encephaloid matter, in
which the uterine tissue is lost,  and,  like the former, giving rise to the
nodulated surface of the conical portion of the qrgan generally regarded
as characteristic of the disease.  Colloid cancer, as Dr. Walshe observes,
is probably never seen  in the uterus.
   The degeneration spreads more or less rapidly to the adjoining parts,
to the vagina, the rectum, the other pelvic viscera and its osseous frame;
and, in extreme cases,  the whole contents of the abdomen are matted
together, and present a frightful spectacle  of disorganization and can-
cerous destruction.  The ulceration that leads to  this result, while it
gives rise to fetid vaginal discharges, causes very extensive loss of sub-
stance of the parts first involved; the vaginal portion of the uterus, and
the vagina  itself, are the first to be eroded, and gradually communications
 are established between the various  abdominal organs; the destructive
 character of the affection nowhere  manifesting itself with the virulence
 that it here exhibits.   Lebert,  while admitting the dangerous character
 of the affection when attacking the cervix uteri, denies that it is genuine
 cancer;  he views it as cancroid, and therefore argues strongly in  favor
 of local  cauterization as  a means of cure.   He bases this opinion upon
 the frequent absence in cervical cancer of the  genuine cancer-cell, and
 upon the rarity of the extension of the disease to the body of the womb.
 We have elsewhere developed  our  views with  regard to  the nature of
 cancerous  disease generally; and, as we are unable to admit the exist-
 ence of a  specific and uniform cell-growth,  characteristic of malignant
 affections, we must decline the  inference of Lebert.   He regards cancer
 of the fundus  as  undoubtedly deserving the  name  applied  to it, both
 because the microscope detects the cancer-globule, and because the tissue
 of the or^an is throughout degenerated.  It is in the nodulated cancerous
 deposits, in this part of the organ, that he has often met with small puru-
 lent deposits.
        40 
626
THE VIRGIN UTERUS.
  Uterine cancer is ordinarily a primary affection ; carcinoma of other
organs may be developed simultaneously or consecutively ;  but, except
as a result  of  the fusion of the former,  and its consequent introduction
into the system, it is  not often the case.  The average duration of the
disease is stated by Dr. Lever to be twenty and a quarter months.  The
forms of uterine cancer, which Ave haA'e spoken of, are  not commonly
liable to induce hemorrhage; in this  respect, it differs materially from
cauliflower excrescence of the cervix, a disease to which Dr. John Clarke1
first drew attention.   He describes it as an irregular  projection, with a
base as broad as any other part of it, attached to some part of the os
uteri.  The surface  has  a granulated feel, and is not tender; at this
period the remainder of the cervix  exhibits no sensible alteration, but by
degrees the whole becomes involved.  On removal from the body, it col-
lapses, OAving  to its  vesicular character.   The rapidity of  the growth
varies; several observers differ from Clarke, in regarding it  as of a ma-
lignant character; a view which is corroborated both  by the revelations
of the microscope and its power of reproduction after having been removed
by the knife.  Mr. S. Lee describes it as consisting of cells covered  by
an epithelial membrane;  and, though he mentions the presence of com-
pound cells, certainly concludes, from the absence  of caudate cells, that
it is a simple  non-malignant structure.   Both Rokitansky and Renaud
regard it as a modification of encephaloid growth,  accompanied by a
remarkable developmentxof capillary loops, closely resembling, as shown
in the tfraAving accompanying Dr. Renaud's paper, the vascular arrange-
ment of the foetal  placenta.
  We may not conclude this subject Avithout alluding to a fortunate acci-
dent in connection with "scirrhous groAVths" of the uterus, two instances
of which are recorded by Dr. Ashwell, occurring in females respectively
twenty-eight and twenty-one years  of age. In both, large tumors broke up
spontaneously, and were discharged per vaginam.  Dr. AstiAvell is clearly
of opinion  that they were cancerous; as such, they must have differed
from the ordinary  infiltrated  character of uterine carcinoma, a circum-
stance that only adds to their peculiarity, the more so,  as in each case
the uterus appeared to have recovered its healthy condition.


                     THE  VIRGIN UTERUS.

  The textural diseases to which the  virgin uterus is  subject, are not of
a character to occupy much attention on the part of  the morbid anato-
mist.  It is chiefly during the  temporary physiological congestion, to
which the organ is subject after maturity at the menstrual  period, that
morbid influences manifest themselves;  and we then frequently haA'e to
deal Avith catarrhal and other slight forms of inflammation of the organ.
Still, they often become of great  importance  to the  individual, not so
much from  the intensity of the morbid process set  up, as from the pecu-
liar relation which the mucous lining of the womb, as a safety-valve to
the entire organism, bears to the constitution of the female.   The enact-
  1 Transactions of a Society for the Improvement of Medical and Surgical
vol. iii. p. 321. 
THE VIRGIN UTERUS.
627
ments of the Mosaic ritual, and the  prevailing customs of all civilized
nations at the present day, equally acknowledge the necessity of attend-
ing to these indications.  The extensive secretory apparatus,  in the
interior of the cervix, is chiefly liable to suffer, and to put on a chronic
form  of catarrh or blennorrhoea, marked by a  viscid,  straw-colored,
transparent secretion, or by a more or less  purulent and sanguinolent
discharge.   The rugae, and  deep  intervening fossae of the cervix, are
apt to accumulate the secreted fluids, and the more adhesive they are
the more a complete  plugging up of the os uteri  is likely to ensue;  it
is  thus  that  catarrh  may induce  sterility; its  extension to the lining
mucous membrane of the uterine cavity further adds to this peculiarity,
by impairing its functions, and rendering it  incapable  to  prepare the
proper nidus for the  embryo.  The  same applies to catarrhal inflam-
mation  passing  up the Fallopian tubes.  It has been stated that the
secretion of the  cervix uteri is distinguished from  that of the vagina, by
the former being alkaline, while the  latter is acid.   It  certainly is not
so invariably, for in two cases, which we recently examined, the straw-
colored mucus actually within the passage of the cervix was found  to be
strongly acid, while the microscope proved it to be made up exclusively
of mucus-corpuscles arranged  in strings.  The effect of continued leu-
corrhoea of  the  cervix is  to  remove  the  epithelium  covering the  part,
and to cause abrasion and ulceration.  In the latter case,  the villi are
themselves destroyed;  and  this, as  Dr.  Tyler  Smith has  Avell shown,
gives an eaten, corroded appearance to the mucous surface.   Dr. Smith
states that ulcers of the os uteri may be the primary  result of inflam-
matory action,  or arise from  eruptive disorders  of the mucous mem-
brane, similar to herpes or  eczema  of  the  skin.   But they more fre-
quently result from the  chronic  irritation  produced by the discharge
from the cervix.  This is confirmed by the fact, that, except in eruptive
disease, the os  uteri is rarely found abraded, unless  there  is coexistent
disease of the glandular portion of the cenTix.   This  circumstance,  as
well as the character of the majority of ulcers occurring  at the  part,
have an important bearing upon  our therapeutic  proceedings.  Taken
in conjunction with the statistical records given by Dr. Lee,1 they go a
long  way to disprove  the necessity of the  routine  treatment  of local
cauterization, which has recently been insisted upon as an almost essen-
tial element in female therapeutics.  The  scrofulous diathesis favors
both the profluvia of the cervix and deeper-seated destruction of its tis-
sues ;  it gives rise to more profound ragged erosion on the surface and
sides of the os, which, hoAvever, is not accompanied by  that knotted
induration which is generally characteristic of the carcinomatous ulcer.
Nor is it marked 03'  the same tendency to spread and involve adjoining
parts in its destruction.
   One  of the effects of continued irritation of the uterine mucous  mem-
brane is  hypertrophy,  which induces a species  of prolapsus,  or the
formation  of polypoid groAVths  at  different  points  of  the cavity, and
occasionally stricture  and occlusion, and consequent  accumulation  of
fluid in the uterus.

   1 Medico-Chirurg. Trans., vol. xxxiii. p. 261.  See also the admirable  Lectures by Dr.
West, very recently published, on Ulceration of the Os Uteri. 
628
THE VIRGIN UTERUS.
   In addition to the forms of ulceration  already spoken of, the uterus
is subject  to the specific  ulcers  of  primary and  secondary  syphilis.
Under the name of corroding ulcer,  Dr.  John Clarke has described a
A-ariety of  malignant destruction which differs from genuine  carcinoma
only in not being accompanied by an indurated  deposit.  No account
of the microscopic appearances  of the part so affected is on record ; a
link is, therefore, wanting to enable us to pronounce positively as to the
nature of the disease.   It is of  very  rare occurrence;  Dr. Ashwell, in
the course of an extensive practice of  tAventy years, has only twice met
with it.
   Of the textural affections of the  parenchyma of the uterus  in the vir-
gin state little need be said; a congestion of the  organ appears to be a
frequent  source of malaise to the individual, and is recognized by the
tumid, oedematous feel of the organ, and the injected  purplish color of
the parts when seen by the speculum; like other mere congestive affec-
tions, it rarely comes under the observation of the morbid anatomist. 
                  CHAPTER  XXXIX.

     MORBID  CONDITIONS  FOLLOWING AND PRECEDING
                         PARTURITION.

  It is immediately after parturition that the uterus, which during preg-
nancy has become, as it were, the focus of the entire system, and, having
completed the great cycle of its duties, is required to  lapse into its pre-
vious dormant state—it is while the organ is yet the seat of increased
vascular action, and its proper functions may be said to have ceased, that
morbid influences are received with facility, and produce destructive and
often rapidly fatal consequences.  A large denuded surface is  exposed
to atmospheric  contact; the process of absorption is  rapidly going on,
and  any morbific matter, ponderable  or  imponderable, finds a  ready
recipient in parts in which normally the balance between health  and
disease is very even;  add to this any depressing cause, acting on the
susceptible mind or constitution of the female, and the balance is rapidly
turned in favor of the latter. There are two states which are more par-
ticularly liable to supervene immediately  after parturition, which are
each of them a source of  danger, by the hemorrhage they give rise to.
The one is, atony or defective contraction;  the other, spasm or irregular
contraction of the uterus.  In the one case, we find the uterus maintaining
its dilated condition, its walls are flabby and soft; in  the other, various
irregular forms, to which the term hourglass contraction has been applied,
present themselves.   Both  may become the subject of post-mortem ex-
amination, and instances are preserved in the museums of pathological
anatomy.  They are both allied to that influence which the vital powers
sometimes sustain after parturition, from the severity of the shock to the
system, and which, in  its extreme form, may give rise to a  fatal issue
Avithout producing any other symptoms but those of mere prostration.
The various forms of inversion  of the organ, which are in part due to a
combination of these conditions, we have already alluded to.
                PUERPERAL INFLAMMATIONS.

  While the subject of fevers generally, and their proximate causes, are
still under discussion, the nature of puerperal fever has been established
with certainty to consist in inflammation of the uterus and its appendages;
the various forms assumed by the febrile affections that follow parturition
depend, in a great manner,  as Dr. Lee observes, upon the serous, mus-
cular, or venous tissues of the organ having become affected.  Of forty 
630              PUERPERAL INFLAMMATIONS.
cases  of puerperal fever, that had come  under the notice of  Dr. Lee,
when he published the result of his researches, the peritoneum and uterine
appendages  were found inflamed in twenty-six; in fourteen, there Avas
uterine phlebitis; in eight, inflammation and softening of the  muscular
tissue of the organ, and in four the absorbents  were distended with pus.
Almost  the only exception among the classical writers on the subject is
Dr. Copland, who asserts the occasional occurrence of a rapidly fatal
form of puerperal fever in lying-in hospitals, in which there is no local
lesion, but where there is a remarkable alteration of the blood, general
lacerability of the tissues or loss of their vital cohesion soon after death,
with a dirty, muddy, offensive, and sometimes serous  effusion into the
serous cavities.   According  to the predominant symptoms, nosologists
have  divided puerperal fevers into the inflammatory  and typhoid, as
Gooch and Boivin, and Duges; into the  inflammatory,  the ataxic, and
adynamic, as Tonnelle has done; or into the inflammatory, the synochoid,
and adynamic or malignant, as proposed by Dr. Copland.   Those who
study the histories of the various epidemics of this fearful malady, will
observe  that, while  there is  a general resemblance between  the local
lesions, Avhich more immediately concern us, the morbid symptoms during
life vary according to the genius epidemicus, which is influenced by the
predisposing as well as the exciting causes that are at work in each case.
Here, however,  there is also a general resemblance, which has been satis-
factorily shown  to present the same character as that of the erysipelatous
constitution.  That this consists in some poisonous agent capable of being
communicated from one person to another, and  analogous if not identical
with the effluvia of putrefying animal matter, is rendered probable by
the difficulty of arresting the spread of  the disease when it  has once
appeared in  a lying-in hospital;  the  strong evidence we possess of the
communication  of the infection from one person affected to another par-
turient female at a distance, through the intervention of the medical man,
and by the direct effect of preventive means adopted with a view to de-
stroy noxious effluvia and prevent contagion.   Dr. Gordon, in his essay
on puerperal fever, gives his adhesion to the  view that erysipelas and
puerperal fever possess strong analogies,  and that  they are concomitant
epidemics. He observed the two together in Aberdeen, where they com-
menced together, kept pace together, arrived at their acme and ceased
at the same  time.   Our limits forbid our accumulating evidence on this
point; we may, however, add the testimony of one more observer in the
Irish  capital, Dr. Beatty, Avho, speaking of two epidemics that he wit-
nessed, states that both attacks took place in January, and at each time
erysipelas was raging as an epidemic in the surgical wards of the hos-
pitals, and diseases  of a typhoid type were very prevalent in the city.
The strongest proof of the septic character of the disease has recently
been afforded by the observations of  Dr.  Semelweiss, that, in the fatal
puerperal fever which has long more than decimated the obstetric patients
of the Vienna hospstal,1 the poison was the  cadaveric matter communi-
cated by the students, who had previously been engaged in post-mortem

  1 See Dr. Routh's paper on the "Endemic Puerperal Fever of Vienna," Medico-Chir.
Trans, vol. xxxii. p. 27. 
PUERPERAL  INFLAMMATIONS.
631
examinations,  to the females.   The adoption of the proper precautions
suggested by Dr. Semehveiss, as we have  already shown in the chapter
on phlebitis, at once reduced the mortality.   Hence, it is manifest that
one source of danger may be easily guarded against, and accoucheurs
certainly cannot be too careful  to  cleanse themselves thoroughly after
making post-mortem examinations, and handling  putrid matter.  Nor
does it appear that this  is enough, but that the medical man should, in
these cases, be particularly on his guard to  avoid every other  possible
source of contagion; "in the hour of the  mother's peril," to use  Dr.
Holmes's eloquent words, "God forbid that any member of the profession
to whom she trusts her life, doubly precious at that eventful period, should
hazard it negligently, unadvisedly, or selfishly."
  When the uterus has  itself been the main seat of the puerperal in-
flammation, we find that a» exudative process has given rise to  the
formation of a yellowish, or greenish, more or less gelatinoid lining on
its internal surface, inducing a ragged, patchy appearance.  This exu-
dation may be easily detached from the subjacent mucous membrane,
which according to the intensity of the disease is more or less reddened,
tumefied, and  softened.   This  condition may penetrate  to  the deeper
tissues, and involve the  entire thickness of the uterus, which will then,
also, be more or less softened and discolored, infiltrated with a  low
sanious product, and even converted into a  mere  pulp.   But we must
guard  against mistaking the dirty-colored, broAvnish, flocculent matter
that is found investing the inner surface of the uterus soon after deli-
very, and which is merely the residue of the decidua, for the product of
disease.   This has been done by Boer  and others, Avho have considered
it as a proof of what has been  termed putrescence of the organ.  The
rugged appearance of the part  to which the placenta was attached also
simulates  this appearance.   Dr. John Clarke  states  that  this is only
the remains of the maternal portion of the placenta, and of the coagula
of blood left after its separation, which may be easily scraped off, show-
ing the healthy surface underneath.   He also  testifies  that he  never
met with mortification in any part of  the uterus except in one instance,
where it was manifestly attributable to the  employment  of instruments
during labor.   Rokitansky describes putrescence as the lowest form of
uterine inflammation, and states that it differs from ordinary sphacelus;
in this case, the internal layer of the organ  is covered with a thin,
opaque, or more dense product, varying  in color from pale green to
dark  brown, beneath Avhich the tissue, to  a greater or less depth, is
converted into a similar pulp.   Small abscesses are sometimes found in
the muscular tissue, without any perceptible change in the surrounding
parts; generally, however,  the structure  of the muscular fibre is  en-
tirely destroyed.   Tonnelle', who has analyzed two hundred and twenty-
two  cases  of  puerperal fever, in which  he  performed  post-mortem
examinations,  found the womb  affected Avith simple metritis in  seventy-
nine ; in twenty-nine there was superficial, in twenty deep softening.
  The more the  inflammation  presents a sthenic  character, the more
the products will  resemble  those of healthy inflammatory action; and,
conversely, the more ataxic  or  adynamic  the disease, the further they
will be removed from that  type.   Rokitansky  considers  metritis to be 
632
METROPHLEBITIS.
essentially of a croupy character, the peculiar nature of which, he says,
is fixed by the form of the product,  the condition of the subjacent tis-
sues, and  especially by the state of fusion exhibited by them.
                       METROPHLEBITIS.

  Of the tissues entering into  the  constitution of the  uterus  in preg-
nancy, and immediately after  parturition,  none appear to possess a
greater proclivity  to  be attacked Avith inflammation than  the venous
channels and the lymphatics; both  may be  primarily and coincidently
affected, AA-hich is generally the case, or they may be attacked separately
and  secondarily.   According to the  observations  of Tonnelle,  Avho
found  that, of two hundred  and tAventy-two fatal cases of puerperal
fever, one hundred and  thirty-two presented inflammation of the veins
and lymphatics of  the uterus, phlebitis  alternates with  inflammation of
the muscular tissue;  during  the  great  epidemic  which this author fol-
loAved  in 1829, the latter  occurred very frequently at the commence-
ment of the year, and disappeared in July and August, and recurred in
the months of September and October.   The intervening summer months
were characterized by the frequency of  phlebitis.
  Uterine phlebitis is generally set  up within the first twenty-four hours
after delivery, and though it cannot be  invariably traced to the orifices
of the veins, where the  placenta  adhered, it is probable that the intro-
duction by them, of foul exhalations or secretions  into the vessels, is the
main cause, both of the  local  and the general effect.  In the more favor-
able cases, adhesive inflammation prevents the spread of the malady; the
danger is increased if pus forms, and the most virulent symptoms result
if the product is of a sanious or septic character.  Dr. Lee is of opinion
that it not unfrequently occurs  Avithout proving fatal, and he bases his
supposition upon the fact of calcareous concretions and disorganizations
of various  kinds being  frequently met with  in the spermatic and hypo-
gastric veins of aged  females, which he attributes to previous phlebitis.
  In uterine phlebitis we find the organ studded with small abscesses,
which  may be traced to the vessels ; these  present the various appear-
ances  described under phlebitis, modified  according  to the character or
duration of the disease in  the  individual case.   When the lymphatics
are  affected, they, like  the veins, become varicose, and thickened and
distended with the purulent or  sanious products of inflammation.
   Uterine phlebitis is very commonly followed by metastatic abscesses;
it is to the  occurrence of the secondary purulent  deposits, and the coin-
cident infection of the entire system, that the main source of danger may
be  attributed.  The more  adynamic the type of the disease, the more
probable it is that pus will  be absorbed, and the local circumscription of
the disease prevented. 
\
PUERPERAL PERITONITIS.                633
                     PHLEGMASIA DOLENS.

  As a disease immediately secondary to uterine phlebitis, we must noAv
turn to the consideration of Phlegmasia alba dolens;  Dr. Davis deserves
the credit of having first shown it to consist in inflammation of the crural
vein ; Dr. Lee first succeeded in tracing the uterine  origin of this affec-
tion anatomically; he demonstrated the  inflammation commencing in
the branches of the hypogastric vein, and subsequently extending from
them to the iliac and femoral trunks of the affected side.  The cellular
tissue surrounding the vein participates in the inflammation, and that,
as well as the impeded  return of the venous  blood  to the heart, gives
rise to much oedema of the limb, and condensation of all the tissues.
This  may be followed by suppuration, or  sloughing; it  may terminate
in a complete  cure, by  resolution; or, in a partial  recovery, with ob-
literation of a portion of the vein, and permanent induration of some of
the soft parts.   In a case examined twenty-one months after the attack,
Dr. Lee found the external  iliac vein, with  its subdivisions,  and the
upper part of the femoral, converted into a ligamentous cord, so that it
could only be  distinguished  from the surrounding  cellular tissue  by
careful dissection.  No  traces of the entrance of the common iliac into
the cava could be made out.  The left side has a greater tendency to
become affected than the right.  The pathology of phlegmasia dolens is
considered, by Dr.  Copland,1 of a more  complete nature than we have
described it; while he does not deny that it most frequently consists in
inflammation of the femoral and  iliac veins, he thinks  it occasionally
commences in the nerves, and sometimes in the lymphatics and  glands,
the veins then  being secondarily affected.  Nor does Dr. Copland admit
that it is always referable, for its origin, to the uterus ; he attributes
the lesions in the veins, in some instances, to the  consequences of pro-
longed pressure, or to this cause, and the sudden removal of that pres-
sure, the disease originating in the  iliac and femoral  veins ; again, he
is of opinion that it may originate in lesion of any of the pelvic viscera,
or of the parietes of the pelvis, or that it may be unconnected with any
affection of this character, and owe  its  origin to  rheumatic influences
directly acting upon the lower extremity.


                   PUERPERAL PERITONITIS.

   The serous membrane of the abdomen is very frequently attacked by
inflammation  in  the puerperal state.  Peritonitis occurs primarily or
secondarily, but  the form in which it presents itself, as well  as its ex-
istence, depend much upon the character of  the epidemic;  thus, Avhile
M. Tonnelie found evidence  of peritoneal inflammation in 197 out of
222 cases Dr. Bartsch, in Vienna, under whom 109  fatal cases of puer-
peral fever  occurred in the fourteen months preceding December 31st,
1834, found that it seldom exhibited the form of  peritonitis, but gene-

               1 A Dictionary of Practical Medicine, vol. iii. p. 254. 
634
PUERPERAL  PERITONITIS.
 rally appeared as metrophlebitis.  If we examine the table of puerperal
 epidemics, collated  by Dr. Churchill,1 we find that, while of forty-three,
 in" which the predominant post-mortem appearances are given, only four
 were characterized by uterine phlebitis, twenty-nine  are stated as peri-
 tonitis.  It is then, undoubtedly, the lesion most commonly  associated
 with puerperal fever.   It may be limited to the surface of the  organ,
 and more particularly to  the part surrounding the neck, or it may in-
 volve more or less of the  entire sac.  In two epidemics, it appears that
 the  omentum was the seat of election.
   Dr. Joseph Clarke states that the  surface of the stomach, the liver,
 the spleen, omentum, great and small intestines, uterus, and the internal
 peritoneal lining of the muscles of the abdomen, will, in their turns, or
 altogether, be found to partake of the disease; but, as far as his experi-
 ence goes, no part more than another.
   The membrane never exhibits much vascularity, and in the low typhoid
 forms there is a remarkable absence of congestion and redness.   In the
 more sthenic forms, which approach to the  character of ordinary peri-
 tonitis, the greater vascular action is  accompanied by the production of
 lymph and pus of a healthy appearance, adhering  to the surfaces  and
 matting them together.  The ordinary character of the exudation, how-
 ever, is a copious effusion  of an  aplastic  character;  the abdomen then
 contains from a few ounces to several quarts of serum of a dirty-yellow,
 greenish, or  brownish hue,  in which  flocculent particles of lymph are
 floating, while but small patches of a thin  non-coherent exudation are
 observed on the  peritoneal sac.   A remark  of Dr. Hodgkin,2 in refer-
 ence to the small quantity  of tender false  membranes often  met with
 accompanying serous  effusion into the peritoneum applies here;  it is to
 the effect that, though unquestionably of inflammatory origin, they are,
 in many cases, to be regarded as the result of a secondary action which
 the presence of  the fluid has exerted in the  peritoneum.
   The smell  of the  fluid is also  distinctive; it will be recognized when
 once noticed, as  it differs from anything met with in  the human body,
 in health or disease.  The fluid is described by the older authors as of
 a creamy character; hence, the  long  prevailing fallacy that it was con-
nected with an actual metastasis of milk, which was in  a measure sup-
 ported by the failing supply of the mammary secretion  observed as one
 of the first symptoms of the disease.   The serum contains a  compara-
 tively small  portion of albumen, offers an acid reaction, and is said to
possess a very salt taste.  Beyond an analysis by Dr. Pearson, which
 is not equal to the requirements  of modern chemistry, we have not met
with a minute determination of its constituents.   The ovaries  and Fal-
lopian tubes are  very  frequently found inflamed in puerperal  inflamma-
tions; neither, however, are ever primarily affected, but  coincidently
with, or consecutively to, the diseased conditions just  considered.

  ' Essays on the  Puerperal Fever, &c, by Fleetwood Churchill, M. D.  (Sydenham
Society), p. 31.                                                v
  2 Lectures on the Serous Membranes, &c, p. 150. 
DISEASES OF  PREGNANCY.
635
          COMPLICATIONS  OF  PUERPERAL FEVER.

  We conclude this subject by a brief glance at the morbid processes
accompanying puerperal fever in other organs, in which we shall closely
adhere to Rokitansky.   The  entire track  of  the intestinal mucous
membrane is slightly reddened  and invested by a secretion  of a thin
serous  or viscid gelatinous  or  more  or less purulent character;  the
mucous membrane fuses, and the submucous tissues are infiltrated.  To
this  circumstance we  attribute  the diarrhoeas accompanying puerperal
fever.  The mucous membrane of the colon occasionally presents  a
dysenteric exudation, resembling that found on the internal surface of
the uterus.  Similar processes are also met with on  other  mucous sur-
faces, as  of the respiratory, urinary, or oesophageal tracts.  Dr. Clarke,
in alluding to the occurrence of aphthae in the  mouth  and fauces, as  a
frequent  symptom in puerperal  fever, and to their also being found at
the anus, denies the correctness of the  statement that the aphthae go
through  the whole intestinal canal, as it is not borne out by dissection.
The serous and  synovial membranes  of the  whole system sympathize
Avith the  morbid processes of puerperal fever;  the  pleura are  almost
constantly found to contain exudations similar to those met with in the
peritoneum; the pericardium contains them less frequently; the articu-
lations very commonly exhibit exudations  of  a fibrinous or  purulent
character.   The dura  mater often presents  a slight reddening, with  a
thin, soft exudation.   To  the secondary abscesses, resulting from capil-
lary phlebitis by the extension  of the inflammation of the uterine veins,
or by the absorption of pus, we have already alluded.   Rokitansky de-
scribes a black softening of  the mucous lining of the fundus ventriculi,
or of the oesophagus, indicated  during life by black vomit, as a frequent
occurrence.   The stomach may become ruptured, and the black matter
be thus effused into the abdominal cavity.
   The blood exhibits various changes;  its fibrinous  coagula  present  a
viscid, greenish-white appearance, or the coagula are scanty, gelatinous,
and soft. The blood  is of a dirty brown red, or chocolate color, and
glutinous, or it is much attenuated  and transudes all the tissues.  The
fibrin may form vegetations on  the valves from mere  mechanical deposi-
tion. The jaundice often affecting women during the  puerperal state,
is not dependent  upon an  appreciable  lesion of the liver,  but upon
pyaemia.

                   DISEASES OF PREGNANCY.

   The consideration of the morbid processes  complicating parturition is
appropriately  followed by an account of the diseased conditions met
with in the placenta and in the ovum; we shall, at the  same time, touch
upon extra-uterine pregnancy. 
636
THE PLACENTA.
                          THE PLACENTA.

   The placenta  varies  much in  size within the  limits of health.   Its
position  differs also considerably without  inducing  any detriment  to
mother or child;  but when placed near  or over the  os  uteri, the fre-
quent hemorrhages that occur endanger the lives of both.  The umbilical
cord, instead of being attached to the centre of the placenta, is  some-
times inserted at the edge;  this gives rise to what has been  termed the
battledore placenta, a  deviation  which,  though not  in itself perilous,
may become so by rough manipulation after the birth of the child. The
same applies to those cases in Avhich the vessels of the cord are divided
before they reach the  placenta,  or  are  inserted into  the membranes.
Other irregularities of the cord consist in its being excessively short, or
extravagantly long, and in its being tied  into knots.   The extremes  of
length on record are two inches and fifty-seven inches.
   Concussion,  or  other external violence, is a frequent cause of partial
separation of the placenta, inducing extravasation into the tissue, and fre-
quently giving rise to abortion.   That the placenta is the seat of nume-
rous morbid processes, may be inferred from the  close  relation it bears
to the nutrition of  the  foetus, the frequency of foetal disease, and the
necessary transition through the  placenta of any morbific agent, which
induces the latter.  It is only, however, very recently that the attention
of pathologists has  been directed  to the  diseased conditions of this
organ;  our knowledge of the morbid  changes  to which it is liable  is,
therefore, as yet,  very limited.
   Professor Simpson1 describes congestion of the placenta as affecting

                               Fig. 329.
 Sectional view of atrophied placenta.  The atrophy and fatty degeneration of the maternal and foetal por-
tions were caused by a fibrinous layer on the uterine surface,  a. Fibrinous deposit. 6. Maternal portion of
placenta, c. Foetal portion.

the maternal or foetal portion, causing the external surface of the organ
to assume a more or less deep violet, and, sometimes, almost livid color,
1 Edinburgh Medical and Surgical Journal, vol. xv. p. 265. 
THE PLACENTA.
637
the internal structure  presenting a  deep-purple  hue, from the vessels
being overcharged with blood, while the substance is heavier and more
solid  than natural.  One of the sequelae of congestion  is hemorrhage
into the body, or on the surface of the placenta, varying much in extent.
The effused blood undergoes the changes usually traced in coagula, and,
when there are several fibrinous remains,  they  cause  a  tuberculated
appearance.
  Inflammation of the  placenta begins from  the  uterine surface, or in
the substance of the organ, and presents the various stages seen in other
parts, producing local or general hepatization, effusion, irregular adhe-
sions, and secondary degenerations.
  Inflammation may attack the whole, or a portion of the  placenta,
causing a deposit of fibrin.  The effusion  and compression of the tissues
will vary according to the extent of  the inflammation, causing more or
less obliteration of the bloodvessels.   In an extreme case, we find a cap-
sule of dense lymph encasing the maternal  surface, the whole  is  con-
siderably reduced  below the normal  size, and the  soft, spongy texture,
is converted into a compact, splenified mass.  If  confined to individual
lobules, the alteration will be limited  in a corresponding degree.  Those
instances of adherent placenta which are  the source of so much anxiety
to the accoucheur, are probably referable to a prior inflammatory attack,
gluing the  afterbirth  to the uterus.  Professor  Simpson  admits  the
occurrence of total absorption of a placenta as one of the consequences
which may result from the agglutination of the afterbirth to the uterus.
A third stage of inflammation is occasionally met with in the  shape of
abscesses or of purulent infiltration;  it is also stated to give rise to the
effusion of  pus between the two surfaces of the  uterus  and placenta.
Rokitansky describes suppuration occurring here in the form of circum-
scribed abscesses,  or of diffused infiltration and fusion.   Fatty degene-
ration of the  placenta, to which Professor Kilian and Dr. Barnes have
recently drawn attention, is probably to be explained as  the molecular
disintegration resulting from the deposit of fibrin in the cells surround-
ing the' villi of the chorion; and not as a primary deposit of oil within
the placental capillaries, a view more fully developed by  Dr. Handfield
Jones,1  in  a paper on  fatty degeneration.   If portions of a placenta,
thus degenerated,  be thrown into water,  " the first thing which strikes
the observer," to employ the words of Dr. Barnes,2 is, "that the tufts
of villi  do not expand  or float  out  in  the  same way as in the healthy
placenta, and, on endeavoring to separate the fragments  into its com-
ponent villi with needles, the extreme brittleness of the whole structure
becomes apparent."  Examined by a high power, " we observe : (1) that
the villi are thickly studded with innumerable, minute spherules of oil; (2;
the chorion is much altered; it is thickened and destitute of nuclei;  (3)
the Avails of the vessels no longer contain nuclei, these having, in all pro-
bability, become degenerated into spherules of oil; (4) the spherules of
oil are contained, some  in the chorion, some  in the walls of the blood-
vessels,  and many in the  intervals  or spaces between these; (5)  the
1 Medico-Chirurgical Review, April, 1853.
2 Medico-Chirurg. Trans., vol. xxxiv. 
638
THE FCETUS.
cavities of  the vessels are almost invariably free from fatty deposition;
(6) the vessels are destitute of blood.
  The placenta is  liable to other  morbid processes, of a  degenerative
character;  the  vessels may undergo cretification, and  osseous deposits,
of a nodulated form, are met with imbedded in the tissue; the villi of
the chorion are not unfrequently found to  have become converted into
oval, pedunculated, serous vesicles, or  hydatids, clustered  together like
a bunch of grapes; the cysts vary in size, from a pin's head to a filbert,
and more, and they may amount to several hundred.  This pathological
condition has received the name of the vesicular mole; it is  to the expul-
sion of a mass of this kind, that the fabulous accounts of women having
given birth to several hundred children are attributable; the cysts having
been regarded  as  ova, and  these having been magnified  into infants.
Two beautiful specimens of the disease  are  preserved in  St. George's
Hospital Museum.
  It is the opinion of several distinguished accoucheurs, that the vesicular
mole may occur in the  virgin  state; in that case, the explanation we
have offered is necessarily incorrect,  and we must  seek  for it in some
derangement of the uterine tissues.
  Rokitansky denies the occurrence of tubercle in the placenta.   The
only instance on record that we have  met with, is one described by M.
Hardy,1 as having been found in a phthisical  female, aged thirty-five,
who died suddenly, in the seventh month of pregnancy.   The Caesarean
operation was performed immediately after  her decease, and the foetus
was dead.   Besides  the ordinary  appearances of pulmonary phthisis,
the external surface of the uterus exhibited numerous small projections,
which proved to be crude tubercles;  there Avere none in the tissue, or on
the internal surface; in the placenta, there were from eight to ten large
tubercles,  some as  large as a  pea, tAvo  nearly the size of a nut,  of  a
whitish  color, and dense; the foetal surface of the placenta presented to
the finger the sensation of a large  number of miliary tubercles.   The
organs of the foetus were normal.


                           THE FOETUS.

  The foetus is liable to become the  seat of morbid processes at every
stage of its development, and in every tissue and degree; giving rise, at
the earlier period of its existence, to an entire destruction  of the forma-
tive nisus,  or to partial arrests of development in individual parts, some
of which Ave have had occasion to allude to  in speaking of the malforma-
tions of different organs—inducing, in its later intra-uterine existence,
phenomena of  disease resembling those met with in the  human being
after birth. It remains for future inquirers to determine more accurately,
not only the exact pathological character  of the different lesions, but
also the primary or secondary  relation borne between the  morbid states
of the placenta and the foetus.  Many of  the masses that have passed
under the  name of moles, have originated in a blight of the ovum ;  "the
1 Archives Generales de Me"decine, 1834, vol. v. p. 244. 
THE F(ETUS.
639
embryo," as Dr. Ash well describes it, "having died early, the ovum has
increased in size and solidity, not  by a process of growth, as in natural
pregnancy, but by the effusion of  coagulable lymph, from inflammation
of the lining membrane.   This forms successive layers over the surface
of the dead ovum, giving it, eventually, a great degree of consolidation.
Some of these masses exhibit no cavity, but the chorion and amnion are
demonstrable, although the enveloping lymph may be  one or two inches
in thickness."   Dr. Ashwell describes  another  form of moles, which
does not owe its existence  to conception, and  may be  attributable to an
accumulation of fibrinous exudation within the caArity of the uterus, in-
duced by croupy inflammation of the lining membrane.   Tavo specimens
of this may be seen in St. George's Hospital Museum (Nos. 58 and 142).
   Every organ and  tissue of the fcetal body may become  the seat  of
atrophy  or hypertrophy; the latter may be characterized as actual ex-
cess of one or more organs, as we often meet with in  the  phalanges.
Numerous distortions, curvatures,  even fractures, and  other solutions of
continuity,1 demand the  attention  of the medical  man immediately after
the child's birth.  Atrophic  conditions are, generally, referable  to dis-
eased states of the placenta, Avhich interfere  with the nutrition of  the
child, and cause it to perish, or merely prevent its normal development.
Cases are recorded in which such  atrophic foetuses have  been borne  the
full  period, though their death had taken place early in  pregnancy;
these, as Dr. Montgomery2 remarks, illustrate the necessity of carefully
examining into the state of  the fcetal appendages as  to their healthy
condition or othenvise, before  we venture to pronounce an opinion on
the time that  has elapsed since  conception, merely from the  size and
general appearance of an  ovum or foetus shown  us.   In an accident of
this kind, an error in judgment might seriously,  though  unjustly, affect
the reputation of a female whose husband had died or  left home shortly
after conception.
   The curvatures that the foetus is most commonly subject to are, those
of the lower extremities—these, as well as the dislocations of the astra-
galus, the elbow, and other parts that frequently come under the notice
of a surgeon, are attributed to violent contractions of the uterus, or to
convulsions affecting the foetus.   Of the herniae, to which, as congenital
affections, we  must  allude, umbilical is  a frequent, and diaphragmatic
the rarer form;  both  are the result of imperfect development of  the
parietes, which  in each  case respectively ought  to completely close in
the abdominal viscera.   In the former,  the intestines, to a  greater  or
less extent, pass through the  umbilical  opening, and occupy a pouch
formed by the cutaneous coverings of the  abdomen;  in  the latter, they
enter the thoracic cavity, where they displace the lungs and the heart;
they commonly, though  not  necessarily, cause the death of the foetus.
The brain occasionally protrudes  through the cranium, giving rise  to
hernia cerebri; this, however, must not be  confounded with  a  tumor,
which often forms on the head of  the infant, simply  owing  to the me-
chanical  pressure exerted upon it during parturition,  and the conse-

   i See a remarkable case that was brought before  the  Medico-Chirurgical  Society, by
Mr. T. D.  Jones.  Alclico-Chirurg. Trans, vol. xxxii. p. 59.
   2 Art. Foetus, in Dr. Todd's Cyclopaedia of Anatomy and Physiology. 
640
THE FCETUS.
 quent extravasation,  and knoAvn as cephalhsematoma.   Encephalocele
 is described by Dr. Montgomery as, at first, a rather tense, smooth, and
 semitransparent tumor, giving generally a more or less distinct sense of
 fluctuation; in  shape, the tumor is globular or oval,  and  frequently
 tapers to a neck, where it issues from the head, at which point a circu-
 lar aperture can be detected in the bone, the  edges of which are, in
 general, smoothly rounded off.   The defect in the cranial bones, giving
 rise to this malformation, is analogous to that upon which spina bifida
 depends; here, there is a deficiency in the arches of one or more verte-
 brae,  allowing a protrusion of the dura matral sheath of the  canal, and
 the arachnoid  lining, in which an accumulation of the spinal  fluid takes
 place.  The arachnoid often forms  at  the most projecting parts of the
 tumor the  only investment, both the skin and  the dura mater being
 thinned  down gradually, and at last  entirely lost.  The fluid, in its
 turn,  presses upon the cord, and more or less displaces it.   When it
 occurs in the lumbar region, its ordinary site, the divided cauda equina
 may be seen, as Dr. Bright  has  shown,1 adherent to the sac, and  in-
 duces the erroneous opinion that  the  appearance is  due to  the nerves
 distributed OArer the  sac being turned backwards  from  their natural
 direction.  When there are seAreral  deficiences in  the osseous canal, the
 fluid  communicates between  the different  tumors; the  entire column
 may be deprived of its spinous processes and their  arches, so that the
 tumor occupies the whole region.   Spina bifida is often associated with
 hydrocephalus.
   One of the most remarkable occurrences in intra-uterine life, is the
 phenomenon of  spontaneous amputation of a limb; this is  sometimes
 < omplete—the severed extremity being entirely detached, and leaving
 a stump, in which the healing process is perfected;—at others only par-
 tial, the stricturing band not having cut through  all the tissues.   It is
 generally the left  lower extremity  that  suffers;  and Dr. Montgomery
 has demonstrated the fact of its being due  to  the umbilical cord being
 twisted round it, and not, as has been suggested by others, to  gangrene,
 or the accidental formation of  ligamentous bands.   He expresses his
 conviction  that many of the cases  of apparent  arrest of development
 may be set down to this cause, the amputated  member not having been
 found, either from its being atrophied or buried  in  coagula, and from
 the separation having been effected  at the early stages of pregnancy.
   Numerous observations are recorded  by authors, evidencing the oc-
 currence of the inflammatory process in the fcetal viscera.  Peritonitis,
 with its  various sequelae;  gastro-enteritis, followed  by ulceration;  in-
 flammatory lesions of  the liver, pneumonia, and pleurisy; abscesses in
 the> lungs,  the thymus, thyroid glands, and supra-renal capsules,  and
 pericarditis; have  each  been proved to occur in the foetus,  by Desor-
 meaux, Billard, Simpson, Cruveilhier, Montgomery, and  other patholo-
 gists,  to whose works we must refer for further particulars.   The same
 applies to the various  cutaneous affections of a syphilitic, variolous  or
 •ther  character.   Tubercular deposits and cancerous growths  have been
seen, but they  are  both  extremely rare.  Nor is it compatible with our
1 Reports of Medical Cases, vol. ii. p. 640. 
EXTRA-UTERINE PREGNANCY.
641
limits to do more than allude  to  the  endless varieties of monstrosities
which, from the causes mentioned, or from reasons to which pathology
offers no clue, affect the unborn child.
                EXTRA-UTERINE PREGNANCY.

  Five varieties of  extra-uterine  pregnancy are assumed  to  occur;  in
the Fallopian tubes, in  the walls  of the uterus, in the ovaries, in the
peritoneal cavity, and in  the vagina.   We have not  met with a well-
authenticated instance of the last form, and the occurrence of ovarian
pregnancy has also  been denied by authorities like Velpeau and Kilian.
The danger to mother  and child is almost  equal  in each variety;  in
fact, there is only one case on record in which both have survived; this
was one of peritoneal or abdominal pregnancy, which occurred to Dr.
P. L. Heim, and in which the Caesarean section was successfully per-
formed.1   The accident most frequently met with is the Fallopian tube
pregnancy.  In this case  the  ovum  is arrested  in its descent into the
uterus, and the process of growth and development  progresses as if it
had reached its  proper  nidus  up  to  the period  of  its discharge.  The
tube is distended, and its  walls become hypertrophied; the changes  in
the maternal system, though sometimes accompanied by certain anoma-
lous symptoms, are those  met in  ordinary pregnancy;  there  is general
turgescence of  the  mammae and  the uterus, and in  the latter organ it
has long been  taught that a decidua is formed, as if it contained the
foetus.  Denman, Baillie, William Hunter, and Elliotson, have met with
instances  in which  the decidua  was present; other cases have been
recorded by Mr. Langstaff and Dr. Lee, in which it had not formed. We
have ourselves examined a preparation in St. George's Hospital Museum
(No. 2,718), in which the  decidua is wanting ; nor does it seem difficult
to understand that  in one  instance the sympathetic irritation should  be
set up by which this membrane is produced,  and that  it should fail  in
others.   The development of the Fallopian  tube  does not keep pace
with that of the ovum,  and in the second or third month rupture gene-
rally takes place, the foetus escapes into the abdominal cavity, and the
mother sinks from the shock, the hemorrhage, or the peritoneal inflam-
mation that ensues.   In the majority of instances the  right tube is the
one affected.  Rupture  does not appear to be  the invariable issue.   In
the Royal College of Surgeons (preparation No. 2,719), we find a foetus
almost completely developed, but compressed and dried, which is stated
to  have  been removed  by operation from the Fallopian tube fourteen
years after gestation ; the patient recovered, and lived for a long time
after at Hamburg,  where the operation was performed.   This specimen
is a good instance of what has been termed a lithopaedia, a stone-child;
the parts intervening between the extremities  are ossified, and nutrition
appears to have been thoroughly  arrested.  These lithopaedia are some-
times retained within the uterus, as the remarkable preparation in the

           1 Rust's Magazin fiir die gesammte Heilkunde, vol. iii. 1817.
       41 
642
THE FALLOPIAN  TUBES.
same museum (No. 2,720) proves, of which Dr. Cheston1 has given  a
detailed account.  The mother, at the age of twenty-seven, carried her
fourth child to the full period, had labor-pains, but no child was born.
She recovered, and  died  paralytic at the age  of eighty.  The uterus
was found to contain an osseous sac adherent to the  surrounding part,
and resembling a middle-sized human cranium.  The  cyst seemed  to
have absorbed all the parts in contact with it, and contained a foetus  in
the same position as that in utero.   The brain, lungs, and  liver, pre-
served almost their natural appearance; but there was no trace of blood,
nor  any remains of membranes, placenta, or umbilicus.   The  osseous
sac, with the foetus, weighed three pounds, one ounce, four drachms.  A
similar instance  of thirty-two years' duration is described  by Prael.2
   The terminations of Fallopian tube gestations alluded to are not the
only issue which we meet with.  Adhesions form with different parts  of
the  parietes, and the  foetus  having been broken up by ulcerative dis-
junction, the parts may be discharged piecemeal, whereupon the cyst  in
which  they were contained contracts,  and the mother survives.   In this
way the foetus has been eliminated by the rectum and  the  umbilicus.
The above remarks also apply in the main to abdominal gestation; here
the ovum, probably owing to a want of that erectile tone in the fim-
briated extremity of the tube by which in ordinary pregnancy it is made
to embrace  the  ovary when conception is  effected, falls  into the peri-
toneal cavity, the development proceeds up  to a certain point, and death
ensues from peritonitis, or hemorrhage, or  else the foetus  is eliminated
in the manner above described.
   Pregnancy in  the parietes of the uterus probably consists in an arrest
of the  ovum at the point at which the tube is inserted into the uterus; the
sac, therefore, consists chiefly of the uterine tissue; but, owing to the irre-
gular development of the organ, the process cannot run its course to the
full  period in the normal  manner, the thinner portion gives way early
in pregnancy, and death ensues, as in  the other cases, from rupture and
hemorrhage.

                    THE FALLOPIAN TUBES.

   The Fallopian tubes are liable to various forms of inflammatory action.
Catarrh and exudative inflammation not unfrequently cause a temporary
or permanent closure of their channel, which prevents conception, and
may lead to dropsical accumulations and other morbid conditions.   Thus,
the fimbriated extremities may become agglutinated  to the ovaries, the
broad ligament, or the uterus itself; or obliteration may occur at one or
more points within the  passage;  unless the  mucous membrane of the
part still patent be deprived  of its functions, the  continued secretion
will cause distension, simulating a cyst-formation; we have seen a case
of dropsy of the Fallopian tube, in which the distension  amounted to
about five inches in diameter.   At other times, according to Rokitansky,
several saccular dilatations form between the separate angles and pro-

       1 Medico-Chirurgical Transactions, vol. v.
       2 De Foetu, duo de triginta Annos in Utero detento.  Goettingen, 1821. 
THE FALLOPIAN TUBES.
643
jecting  duplicatures of the tubal parietes, and give rise to an imper-
fectly loculated pouch, which, as in the former case, may contain mucous
matter of a more or less purulent character, or fluid of an heterogeneous
constitution.   These morbid  contents  are sometimes poured  into the
uterus, probably in consequence of the occlusion only having been ef-
fected by inspissated mucus; a less favorable issue, is rupture of the sac,
and effusion of its contents into the abdominal cavity.
   Cysts often affect the  fimbriated extremities  of the tubes;  they are
pediculated, and do not attain a large  size.  The. Fallopian tubes  may
also be the seat of fibroid growths, carcinoma, and tubercle.  Both the
latter are commonly secondary to uterine disease of the same character.
Dr. Lee states that carcinoma may originate in this situation ; and  with
regard  to  tubercle, Rokitansky  affirms that  it sometimes occurs inde-
pendently of uterine deposits, or in a condition of higher development.
He describes it  as being presented to us in the form of tubercular infil-
tration, and complete disorganization of the  mucous membrane, which
is converted  into a soft  purulent layer of cheesy, friable matter,  that
chokes up the passage, and causes the  tube to be more or  less swollen
and tortuous, and hard to the touch. 
CHAPTER  XL.
                         THE  OVARIES.

  The pathology of the ovaries, important as are the questions involved
in it, is still very imperfect,  owing to their site,  and  to the absence of
any secretion, the analysis of which may indicate their  condition;  their
examination by the means at our command being often neglected  from
motives of delicacy, their  morbid conditions are frequently not detected
until an advanced stage.  Many of the diseases in which the functional
derangements of the  system are referred to  a  local condition of the
generative organs, are exclusively attributed to  lesions of the  uterus,
from a definite physical examination being more practicable, and the
primary derangement of the ovaries is overlooked.  The stimulus which
puberty gives to the development of these organs  and their proper  func-
tions, is also the  starting-point for their morbid conditions; before this
time they are in a dormant state, and, except in connection with general
diseased processes affecting the abdominal viscera, or the  system at large,
they rarely  present any palpable lesions.   It  is, however, necessary to
bear in  mind that the ovaries may,  and often are,  sympathetically
affected during the  peritonitis of childhood, a disease of frequent occur-
rence.   Boivin and- Duges1 consider these inflammations a cause of
obliteration of the Graafian  vesicles, and a consequent source of sterility,
which they may also  induce by changing the position, or altering the
relation, of  the ovary and its Fallopian tube.  Even after the period of
puberty, the ovaries are exempt from many of those sources of irritation
to which the uterus, from its exposure to direct  injury, to contact with
morbid secretion, and from  the  entire revolution in its functions Avhich
it suffers during and after pregnancy, would appear to  be exposed; yet
it has been  shown  by Parent Duchatelet  and others,  that these  local
influences are  not  as powerful as would  be  assumed  d priori;  since
ovarian disease has been  found  peculiarly prevalent among prostitutes,
and frequently unaccompanied by any lesion  of  the external organs of
generation.  Of the frequent physiological congestion of the ovaries,  a
doubt can scarcely be entertained  by any one who  has watched the
relation these organs bear to menstruation, independently of the  direct
observation of Dr.  Letheby, Dr. Lee, and  others, of the presence of an
ovum in the Fallopian tube, and of the rupture of a Graafian vesicle in
females  who happened to die suddenly during  the menstrual period.
The almost uniform effect of a  morbid arrest of the catamenia, by ca-
tarrhal or similar influences, in producing symptoms of  an inflammatory

           1 Traite" Pratique  des Maladies de 1'Uterus, &c. vol. ii.  p. 509. 
                        OVARIAN DROPSY.                     645

process in the ovaries, further corroborates this view.  In the dead bodies,
ovarian inflammation is rarely met with in  an isolated form, but associ-
ated with affections of the uterus, or its appendages.  It does, however,
occur as an idiopathic disease.  In the  congestive  stage, the organ is
more or less gorged with  blood, even  amounting  to  extravasation or
apoplexy, enlarged and softened.  It is to the partial absorption of such
extravasations, and the  accompanying changes, that we must attribute
the so-called false corpora lutea.  These  differ  from the true corpus
luteum  in  the  yellow matter, from which  the name is derived, being
inclosed within  the Graafian vesicle, while  in the latter, the deposit is
effected  externally to the  vesicle, which in  the  recent state retains a
cavity, that only shrinks, and  is  obliterated  after  the  lapse of several
months.
   It is in the  corpora  lutea of various animals that Zwicky first dis-
covered and described certain varieties of organic  crystals, since termed,
by Virchow, haematoidin crystals, and shown, by him and other observers,1
to be produced in the blood of all animals and of man, in extravasations
occurring within the  body, or when treated in a certain manner after
its removal.   Inflammation of the ovaries may, independently of the
puerperal  state, lead to suppuration.   An observation  of Dr. Ashwell2
to this effect corroborates the statement of Rokitansky that, in this case,
it is always limited to the follicular structures.  The latter describes the
coats of the  follicles  reddened and softened,  and the  cavity filled  with
an opaque, flocculent, sanguineous, or puriform material, which neces-
sarily destroys the germ.
                        OVARIAN DROPSY.

  It is to the sequelae of acute inflammation, or to the effects of a chronic
phlogistic process, that we must attribute a large number of those morbid
states of the ovaries, which  form so considerable an item  in the list of
female diseases. Both the general pathology of the organ and the etiology
of the individual cases justify this remark.   We  particularly allude to
that class of affections known under the generic term of ovarian dropsy;
a disease that is characterized by the formation of  cysts, which in  this
organ exhibit a peculiar tendency to extravagant development, a circum-
stance that may be attributed to the reproductive powers of the part, to
the proportionally copious supply of blood, and to the  entire  exemption
from all pressure or restraint which might limit their growth.3  It is a
disease  which affects married women in a much higher  ratio than single
females.  Mr. Safford Lee has collected and analyzed 136 cases, with
a view to determining this point statistically, and  finds that only thirty-
seven were single, while ninety-nine were  married women or widoAvs.
This fact seems to prove  that the ovary undergoes a different excitement

  1 See an article in the British and Foreign Review, October, 1853,  on Albuminous Crys-
tallization, by E. H. Sieveking.
  2 On the Diseases of AVonien, p. 625.
  3 See  Dr. Hodgkin's Lectures on the Morbid Anatomy of Serous and Mucous Mem-
branes, vol. i. p. 242. 
646
OVARIAN  DROPSY.
in the discharge of  an ovum resulting from  impregnation, than when
this  takes place simply as a concomitant of the catamenia.   Another
point established by the same author has reference to the age at which
women are most liable to the affection.  He shows that it is erroneous
to assume dropsy of the ovary to prevail  during the decline of  life.
One  hundred and forty cases are distributed in the following manner:—
From 15 to 20.	20 to 30.	30 to 40.	40 to 50.	50 to 60.	60 to 70.	70 to 80.	Age not specified.
3	37	45	26	19	3	2	6
        This, as well as the preceding  numbers, satisfactorily proves that
     there is an intimate connection  between the morbid impetus inducing
     the disease and the reproductive process.   In the second table, we also
     find a feature which distinguishes  the former from  the cancerous dia-
     thesis, for while the climax of ovarian dropsy is between the thirtieth
     and fortieth,  that of carcinoma is  demonstrated to be between the for-
     tieth and fiftieth years.  Dr. Hodgkin is of opinion that  there  is an
     hereditary predisposition in some females to the production of ovarian
     cysts, but that we rarely find a simultaneous affection of the same kind
     in other parts of the body.   It  is  not often that we see both ovaries
     affected; the  right, according to  the statistics of Mr. Lee, being the
     more frequent seat of the malady; of ninety-three  cases, collected  by
     him, fifty occurred on the right, thirty-five on the left  side, and eight
     on both sides.
        Ovarian dropsy presents various forms characterized by features well
v    known to the practitioner,  and equally distinct in  their pathological
     relations.  The cyst-growths which constitute the disease are simple or
     unilocular, compound or multilocular, and complicated or cancerous.
        Simple cysts are globular sacs, containing fluid, formed of an envelop
     with a single undivided  cavity, and inclosed in the ovary or external to
     it.   They are solitary or numerous, and we occasionally find an  ovary
     scarcely exceeding the normal size, in which the stroma has disappeared,
     and is replaced by small cysts of this description, varying in size from
     a pin's head to a pea.   In  this case they are, probably,  always the re-
     sult of a distension  of  the  Graafian  vesicles by a morbid  increase of
     their contents, which, at the same time, necessarily  undergo a change
     in their constitution.  The  number of the Graafian follicles is stated
     to amount to about fifteen; where the number of  cysts considerably
     exceed this proportion,  we may perhaps be justified in attributing  them
     to an independent germinative power, though it suggests itself, that  if
     the view be correct that  an ovum is discharged at each menstrual period,
     either anatomists err in  their statement, or another view is requisite to
     account for their successive  formation; upon this theory,  there would be
     no unfair assumption  of an identity between the processes.  Another
     argument in  favor of the doctrine that the simple cysts  result from  an
     hypertrophy  of the  Graafian vesicles may be  derived from the  well-
     known fact  that they are  often found  to contain evidences of morbid
     germination,  in the shape  of hair,  teeth,  and  bones, not referable to
     impregnation.  They may attain a very considerable size, so as to hold 
OVARIAN DROPSY.
647
several gallons of fluid; the envelop  then presents a  leathery appear-
ance, varying in thickness from a quarter of a line to several inches,
and their fluctuation becomes a very manifest diagnostic sign.   A speci-
men of this kind is  the preparation  marked  X 16, in the  Museum  of
St. George's Hospital, which Avas  connected with  the right ovary, and
in the parietes of which several well-developed teeth  are  inserted,1  as
into the alveoli of the jaws, their crowns projecting freely into the cavity.
They more commonly, hoAvever, do not reach this magnitude, are of very

                                Fig. 330.
Incipient cyst-formation. The ovary is represented of the normal size.
 slow growth, and resist medicinal agents.   The fluid they contain varies
 as much in color and constitution as in quantity;  it is a clear, limpid,
 straw-colored, highly albuminous fluid; or it  presents  a viscid, glairy,
 more or less opaque character; or we find it of a coffee color, or greenish,
 with a large quantity of oily matter floating on  the  surface.   In the
 latter cases, the microscope demonstrates the  presence of blood-corpus-
 cles and cholesterin plates.   During life, paracentesis often is followed
 by discharges of several kinds of fluid  at  different periods of the opera-
 tion ;  this can only occur in  consequence of our  having to deal with a
 case  in which there are several cysts, Avhich are penetrated by the trocar
 or give way spontaneously.
   Simple  cysts, that form on  the surface, like  those produced in the
 Adcinity, may be altogether a new formation, though it is to be  remem-
 bered that  in the  advanced stage of development  the  relation  of the
 cyst to the ovary is considerably altered from what it presents at earlier
 periods.  Pedunculated cysts are always small  in size, possess thin coats,
 and their contents are transparent.   They evidently possess a character
 distinct from those previously spoken of.
   Multilocular cysts are growths possessed of a power of self-multiplica-
 tion  which is as surprising  in its features as it is characteristic of the
 heterologous source of their development.   They also form more or less
 circular tumors,  occasionally nodulated on the surface from the projec-
 tion of some of the  contained secondary cysts.   The  opportunity is

  1 AVe do not deny the occasional anomalous formation of bone, teeth, and hair, in cysts
contained in other situations besides the ovary, but the prevalence of this phenomenon in
the latter indicates a peculiar tendency. 
648
OVARIAN DROPSY.
rarely afforded of examining  the disease in its early stages, as it  does
not prove fatal until it has attained an enormous size; still, the various
appearances it presents are reducible to three classes, which Dr. Hodg-
kin was the first satisfactorily to demonstrate.   In the first variety, we
find that incision into the enlarged ovary, instead of  exposing a single
cavity, displays numerous  chambers,  each filled  with  smaller cysts,
which, in their interior, commonly exhibit a tertiary formation  of the
same kind.  The septa are probably the result  of rupture from over-
distension of cysts in the  earlier  stages.   The  cysts are  permanently
attached  to their  respective matrix,  bloodvessels ramify freely  over
them,  and there is a continuous  and  uniform  epithelial  investment.
Their contents are commonly of a viscid, glairy, albuminous character,
varying much  in color, yellow, green, blue, red, and grumous,  or trans-
parent, probably owing to accidental local irritation and the admixture
of the inflammatory products.  The microscopic appearances  of the

                               Fig. 331.
 A multilocular ovarian cyst, removed from a female, set. 29, during life, by Mr. .T. B. Brown. Septa form
larger compartments, in which there is a secondary and tertiary growth of cysts.  The tumour weighed 11
lbs. 3oz.

contents will vary accordingly;  but Ave have found what may be con-
sidered the genuine cyst-products to consist of granular cells of circular
form with  well-defined outlines, conveying  the impression  that the fluid
itself was  a germinating nidus.  The celloid particles vary in size from
to<jo"o- to tuouc °f an inch;  they float in a fluid blastema, are colorless,
and contain one or more granular nuclei;  there are also corpuscles that
are identical with blood-corpuscles, though  not contained in vascular
channels.  The  walls of the cyst  consist  of  delicate  fibroid tissue,
covered by a layer of cells,  and delicate cells may be seen imbedded in
the tissue.
   The second variety of compound cysts is  characterized by the develop-
ment of clusters of  pedunculated  cysts from the inner surface of the
primary sac.   " It sometimes happens that the number of cysts forming
the cluster is so great in proportion to the space they occupy, that, like
trees too thickly planted, they interfere with each other's growth ; their 
FIBROUS GROWTHS.
649
development is more or less limited to an increase of dimension in length,
yet, as their free extremities are allowed  to diverge, we sometimes find
the slender  peduncle gradually dilating into a pyriform cyst, at other
times the dilatation does not take place till near  the extremity of the
peduncle, and it thus produces a cyst more nearly resembling a grape
or currant."1  The pedunculated cysts may grow directly from the matrix
and form  a common footstalk; sometimes they  are  very vascular, at
others but feebly organized, and may become entirely deprived of vitality,
in which case  they prove a frequent source of irritation to the contain-
ing cyst. This induces inflammatory secretions of an inorganizable kind,
of a thick, yellow, grumous  appearance.
  In  the third variety, Dr. Hodgkin describes the secondary cysts as
distinguished by the  breadth of their basis and by a flattened form; they
are collected in clusters upon  the external cyst, and produce  a circum-
scribed and  more or  less considerable thickening of the parietes.   The
tertiary cysts  found within them present the same broad sessile character,
and both contain, " sometimes a mucous, at others a serous," secretion.
We should be inclined to class the first and third forms together as mere
accidental variations of the  same type.    This remark  almost applies to
the three varieties, since  the  fact of their being frequently  combined
in the same  ovary indicates the same fundamental  morbid tendency and
impulse.
   Rokitansky describes a form of compound ovarian  cysts,  which he
regards as identical with alveolar cancer,  though  peculiar to the ovary.
He states it  to be an accumulation of fibrous sacs, containing a glutinous
matter, which diminish from the circumference towards the  interior, and
especially towards the base of the morbid growth, so that  this presents
a condensed alveolar mass, of  a distinctly malignant character.
   The complicated form of ovarian dropsy is that in which  the cyst for-
mation is, as it were, engrafted upon, or associated with, other diseased
states of the organ, such as hypertrophy, fibrous  tumors, or carcinoma-
tous growths; this is a feature which becomes of  practical importance
in reference to the influence of curative means, and the question of ex-
tirpation.   The latter is also closely affected by those secondary inflam-
matory processes which the enlarging ovary is apt to induce; peritonitis
very commonly results, by which adhesions of the ovary to the  surround-
ing tissues are effected; and while the pressure of the enlarging tumor
materially interferes with the functions of the surrounding viscera, the
bladder,  the intestines,  the kidneys, the diaphragm,  and respiratory
organs, it also exerts a dynamical effect in producing ulceration and
perforation  of the colon  or bladder.   In the  earlier stages, ovarian
tumors prove  serious impediments to parturition.


                      FIBROUS GROWTHS.

   These affect the ovaries as primary formations evolved in  the  sub-
stance of the organ and closely resembling  those which  we have de-
scribed  as  occurring in  the  uterus; or, as  a secondary  development,
1 Hodgkin, 1. c. p. 233. 
650
THE MAMMJS.
accompanying  the  evolution of o\rarian cysts.  The fibrous  tumor is
developed  in  the tissue of the ovary, presents a  globular form, and
though of slow growth may attain  an'enormous size.  The largest one
on record occurred  in  the  practice of Dr. Simpson, and weighed fifty-
six pounds.   The outline of the tumor  is well defined;  it is commonly
supposed to be very scantily provided with bloodvessels, against which
the appearance of some injected specimens, contained in the  Museum
of St. George's Hospital, appears  to militate;  one (No. 145), that oc-
cupies the greater  part of the organ,  actually exhibits greater  vas-
cularity than the surrounding normal texture.   Like the tumors of the
same class in the uterus, they are  here  also found  to give rise to small
cysts in their interior.   Fibrous tumors of the ovary occasionally exhi-
bit a tendency to so-called  ossification, which consists in the conversion
of a portion of its  tissue into calcareous matter.
   Tubercle occurs so rarely in  the  ovaries that the  majority of morbid
anatomists are either  silent on the subject, or even, as, for instance,
Rokitansky, deny its deA'elopment in this  locality altogether.   Louis,
however, established the fact of these organs not  being exempt, as he
has observed a small quantity of tuberculous matter in two instances.
   Malignant disease assumes several forms  in the ovary, and though
its frequency has been exaggerated by Boivin and  Duges,1 who state
that it is more common than carcinoma of the female breast, and only
less so than that  of the uterus,  all  modern pathologists are agreed as to
its being by no means  a rare affection.  It appears as  scirrhus, ence-
phaloid, haematoid,  melanotic, and alveolar cancer,  either as an isolated
growth, or in the  infiltrated form.  " Cancerous  matter,'' to use Dr.
Walshe's  words,  "  especially the encephaloid, is  more  commonly dis-
covered in the ovary as an addition to some other morbid formation
than as the sole disease of  the organ; multilocular cystoid  productions
are those to Avhich it is most frequently superadded; in much more rare
instances a multilocular cyst pre-exists.   Under such circumstances, the
cancerous deposition goes on in connection with the walls of the cysts,
and exhibits all the varieties of pedunculated and sessile forms.  When
thus formed in the  walls of cysts,  encephaloid frequently coexists with
fibrous, cartilaginiform, calcareous, or ossiform infiltration of those walls."
   Ovarian cancer runs  a rapid course;  it is generally limited  to the
ovary of one side, and, as it extends, is liable to induce inflammation of
the surrounding parts, causing adhesions, which will fix the tumor  in
the pelvis, or attach it to the Ariscera, occupying a  higher level accord-
ing to the period  at which  they form.   Cancer occurs more frequently
at an earlier period of life in this organ than in the uterus; Dr. Walshe
has found forty-one  years  the  average  age at death; but it has been
met with even before puberty.


                          THE MAMM^l.

  Diseases of the mammae are essentially diseases of the  adult female—
Ave must not, however, overlook those cases which occur in the male sex
and in infant life.
1 Traite Pratique, &c. vol. ii. p. 554. 
THE MAJIMJ:.
651
  At birth, the breasts of infants of either sex  are  very commonly
swollen and somewhat indurated;  they contain a whitish serum, which
induces nurses to  employ friction for the purpose, as  it is termed, of
rubbing the milk away.  The result of this proceeding is frequently to
induce inflammation and abscess in the part; which, however, may also
occur spontaneously, and even become chronic.  At the period of  pu-
berty, the gradual development of the glands in the female serves to
mark their ultimate  function, and  to  define the character of the sex.
It is now that irregular evolution is exhibited as an atrophic, or an  hy-
pertrophic condition of the whole gland, or  of the nipple  only.   The
proper tissue of the  gland, as well as  the surrounding  fat,  and cellular
and cutaneous textures, may be separately or coincidentally involved in
each  case.  The hypertrophy sometimes attains  a  very considerable
size in unmarried females,  and appears to be an indication of a  gene-
rally  precocious tendency.   Commonly, both breasts are affected;  but
occasionally, one is inordinately developed.   A temporary enlargement
of the gland  very commonly accompanies menstruation; it may  occur
periodically, even  long after the cessation of this function,  as in an  old
lady of eighty-five, who  was under our care, and  who was subject to
this phenomenon regularly every month.  A permanently hypertrophic
state  is induced by lactation; the period which directly or indirectly
gives rise to many of those morbid  conditions  to  which the  gland is
liable.  Inflammation is  one that in the acute form is almost limited to
this period.   It produces congestion in one or more parts, accompanied
by swelling, interstitial effusion,  condensation, and finally, if the disease
be not  arrested,  suppuration and abscesses.   The  glandular texture
itself, or more frequently, the intercellular tissue, is the primary seat of
lesion; the lacteal secretion frequently continuing during the inflamma-
tory process, and even after  a chronic state  of induration and enlarge-
ment has been established, which  has  led to the removal of the organ.
When the inflammation is confined to the true gland structure, the  re-
sulting tumefaction is  irregular  and  lobulated, and deeper seated than
Avhen the  interstitial or  cutaneous  tissues are mainly involved.  When
suppuration is established, it  may be  limited to one spot  by adhesive
inflammation,  and the abscess be evacuated by pointing, as it usually
does,  near the nipple; or burrowing sinuses form, which may extend to
a considerable distance.  During lactation, large accumulations of milk
frequently distend the entire  system of ducts, or  a  single portion;  in
the latter case, a fluctuating tumor may result, which will scarcely dis-
appear without surgical  interference.    It is stated,  that as much  as  ten
pints  of milk have been  evacuated from a swelling of  this  description.
It appears to  be generally OAving  to an atonic state of the mammary
ducts, similar  to the condition of the  efferent channels in  the nipple,
causing a non-retention of the secretion.   The lactiferous tubes are oc-
casionally found to  contain sebaceous-looking  matter,  phosphatic con-
cretions, and other products, which have been  attributed to the  effects
of chronic inflammation  (College of Surgeons, Nos.  2,743, 2,744, 2,747,
2,748); but unless there is  a coincident change  in  the coats of  the
ducts, it is probable  that these matters  are the residue of an effusion of 
652
THE MAMMAE.
milk, which has been long retained, end  in which a partial absorption
has taken place.
  Adventitious growths are very frequently met with in the mammary
glands, presenting the characters of benignant and malignant formations,
and deserving careful attention on account of the pathological as well as
the practical interest that attaches to them.  Much difficulty is often pre-
sented in determining the diagnosis during life, and it is only since the
microscope has  been brought to bear upon an analysis of these mammary
affections that a clear light has been shed upon them, which has already
borne fruits in  practice.
  Encysted tumors present two  great classes,  those dependent upon an
expansion of the ducts, and those resulting from  a new growth in the
fibro-cellular or adipose tissue;  a state of things closely analogous to
what we  meet  with in  the kidney.   To the  former we  have  already
alluded.   The latter occurs as an isolated globular  or oval and more or
less movable cyst, or there are numerous growths of this kind,  varying
in size from a pin's head to a hen's egg.   The inner surface is smooth,

                               Fig. 332.
  or it presents a broad-based lobulated cauliflower-like growth or warty
  excrescences, and the substance of the surrounding  gland is indurated
  and atrophied.  These cysts may also occasion a retraction of the nipple,
* a point of practical importance, as this is often looked upon as pathogno-
  monic of cancer.   The transverse section exhibits a double sheath, one
  proper to the cyst,  the other the result of condensation of the adjoining
  textures.   The contents of the cyst may be fluid  or solid ; the former
  presenting either a limpid and  opalescent, non-albuminous character, or
  a grumous, brownish, more or less sanguineous appearance, in which case
  it is highly albuminous; the latter approaching the  character of fibroid
  deposits, being composed of a pale, firm, compact substance, traversed by
  undulating fibrous lines, which imperfectly divide it into lobes of various
  sizes or shapes.   These cysts have been termed cysto-sarcoma, or sero-
  cystic growths, by  Sir Astley Cooper, and Sir Benjamin  Brodie.   Mr.
  Birkett1 has found that they contain imperfect gland-tissue, and that the

      • The Diseases of the Breast, and their Treatment.  London, 1850, p. 04, seqq. 
THE MAMMiE.
653
intra-cystic growth is  invested by a reflection of epithelium from the
cyst-wall.   His views on  the subject may be  thus  expressed: Certain
collections of a plastic fluid take place in the areolar tissue of the gland,
a closed cavity is formed, lined with tessellated epithelium, and the intra-
cystic  growths,  being within the  sphere of nutrition  of the mammary
gland, present more or less resemblance to the latter;  hence, they may
be regarded as imperfectly-developed gland-tissue, which offers no analogy
to carcinoma, either in its local appearance or in its effect upon the sys-

                Fig. 333.                             Fig. 334.
  Example of cysto-sarcoma, from the breast. At a, the    Cysto-sarcoma simplex, from the neigh-
 cysts many; distinctly lined by a secreting membrane, and  borhood of the mamma. One large cyst,
 filled with a glairy fluid. At 6, a section made on another  a. 6. The solid part of the tumor; a sim-
 plane; cysts less numerous.                      pie stroma.

tem.  While we would not altogether deny the conclusions at which Mr.
Birkett has arrived on this point, we should be disposed to question the
secondary formation of gland-tissue in  a previously-existing cyst, and,
where we meet with an encysted growth of this kind, include it under
what he has appropriately termed lobular imperfect hypertrophy (1.  c.
p. 124); for although the tumors  of  this description ordinarily remain
in connection with the proper gland-tissue, they sometimes appear to be
altogether isolated, and a capsule of condensed  cell-tissue easily simu-
lates a genuine cyst.
  In a  small tumor  of this description, removed from the breast by ope-
ration, on the supposition of its scirrhoid nature and of its being uncon-
nected with the gland, which we had an opportunity of examining, the
microscope revealed well-marked ducts and lobules, in no essential feature
differing  from ordinary  mammary tissue.   We  have since repeatedly
examined the  structure  of mammary tumors, which were regarded as
malignant, and found them to consist of  follicular structure filled with
epithelial growth. Mr. Birkett describes this form of tumor as presenting
to the naked eye a granular appearance  of a white, rosy, or red color,
dependent in a measure upon the time it has been exposed to the air; it
is lobulated, divisible into the most minute lobules, attached by a pro-
longation to the breast, and invested by a fibro-cellular envelop continu-
ous with the proper fascia of the gland.   The lobules are connected by
common areolar tissue, and the growths vary in size from that of a marble
to that  of a child's  head. 
0.34
THE MAMMJ,
   The genuine hydatid cyst, containing the echinococcus, occurs in the
female breast, and may be recognized by its well-known features.   The
tumor itself grows imperceptibly,  causes  no annoyance to the patient,

                                   Fig. 335.
     Lobular hypertrophy of mamma. A. Section, showing the entrance of duct.  b. Cross section,
                              resembling cystic disease.

is firm to the touch, and contains clear  fluid, in which the microscope
detects the  tentacula  of the echinococcus, the  animalcule  itself  being
attached to the internal wall of the cavity.
   Many so-called fibrous tumors of  the  breast are  to be considered as

        Fig. 336.                Fig. 337.                   Fig. 338.
  This series of diagrams represents microscopic sections of a simple tumor removed by operation from the
female breast; consisting mainly of hypertrophy of the fibrous structure of the gland, with enlargement of
the included ducts and their epithelial linings, c. Section of the epithelium from one of the tubes.  6. Group
of epithelial cells from the same.  a. The same after the addition of acetic acid.__Bennett. 
THE MAMM.
655
Mr. Birkett has demonstrated, as belonging to the same class as that
just considered ; and though he does not deny the existence of an hyper-
trophied condition of  the  fibrous tissue, he has  found  the elementary
gland tissue to preponderate in all the cases called fibrous which he has
examined.   This accords with the  observations of other pathologists,
who  either  deny the occurrence of fibrous, cartilaginous, and osseous
tissues in the mamma, or  adduce only doubtful or  solitary  instances.
Sir Astley Cooper removed a  tumor from a young woman, aged thirty-
two, the larger portion of which had  the appearance of the cartilage
supplying the place of bone in the young subject; the remainder being
ossified.  Professor Miiller states that he met with a case of enchondroma
in the organ.
   Tubercle has not been met  with in the mamma.   Cancer affects the
mamma more  frequently than  any organ of the body ; it obeys the same
laws as to the  period of life in  which it most flourishes as we have traced
when speaking of uterine  cancer.  The  analysis of one  hundred  and
forty-seven cases1  exhibits  a marked preponderance  in the fifth decen-
nium of life, as the folloAving table, given by Mr. Birkett, shows :—■
From 1 to 10 years	1 case.	From 50 to 60 years	. 29 cases
" 10 " 20 "	3 cases.	" 60 " 70 "	. 10 "
" 20 " 30 "	. 11 "	" 70 " 80 "	. 2 "
« 30 " 40 "	. 32 "	" 80 " 90 "	. 7 "
" 40 " 50 "	. 51 "	" 90 "100 "	. 1 "
Of one hundred and sixteen cases, seventy-nine were married women,
and  thirty-seven single;  of fifty-five married women, forty-seven were
prolific, many of them having  borne several children, and  only eight
were sterile.   Sir A. Cooper knew a woman with this disease who was
pregnant seventeen times.  These numbers must not, however, be taken
as absolute indications, but only approximatively; it is to be remembered
that  the proclivity to cancer being greatest between forty and fifty, the
correct ratio of married and unmarried females could only be calculated
by knowing the total numbers of these two classes.   Dr. Walshe shows
that  the left  side is  more frequently  affected than  the right;  of one
hundred and  two cases, fifty-nine were  limited to the left, thirty-nine to
the right breast, and in four only were both implicated.
  All the varieties of carcinoma have been met with in the breast;  scir-
rhus is, however,  by far the most frequent form  in which it  occurs
primarily; the encephaloid variety may be primary, but is  more com-
monly engrafted upon the former; the colloid form is the most rare.  When
associated with other cancers, that of the mamma is stated by Dr. Walshe
to be invariably primary,  except in  those rare instances when the disease
spreads from the lymphatic glands or superjacent skin.
  Scirrhus occurs in the  form of a hard, lobulated tumor, imbedded in
the adipose tissue of the gland, causing adhesion to the skin, and retrac-
tion of the nipple; at first, somewhat movable, but soon becoming firmly
adherent to the subjacent parts, and involving more or less of the  gland-
tissue, the thoracic muscles, and the adjoining glands. Instead, hoAvever,
of occurring as an isolated  tumor in the first instance, it may, from the
1 Birkett, 1. c. p. 218. 
656
THE MAMMiE.
commencement, appear as an infiltration of the various structures of the
part;  it will then  be ill-defined, sending out branches into the adjacent
tissues, and in  that case  involving  in its mass the lacteal tubes and
Fig. 339.                                Fig. 340.
   Carcinoma of the breast, bisected. The figure of    Carcinoma, secondary.  An example of the nu-
 the tumor, with its effect on the gland and nipple   merous nodulated tumors, which often form in the
 shown.                                cicatrix of the former growth. One is ulcerated in the
                                      site of the mammilla.

lymphatics.  These become contracted and flattened into many bands,
which give a peculiar appearance to this form of mammary cancer.  Dr.
Walshe has repeatedly seen similar structures when cut across, exhibiting
an  obvious bore, and he has succeeded in detecting the character in  some
Fig. 341.
  Section of a large, hard, cancerous tumor, from a woman set. 60, imbedded in the breast, exhibiting a pale
dull-grayish basis, shaded with light pink, and intersected in every direction by short wavy lines, like bundles
of white fibres, which mingle together in a close irregular network.  This fibrous structure is most distinct
about the centre of the mass, its exterior appears more homogeneous.  *. The retracted nipple.—St. Barthol.
Museum, xxxiv. 14.


seen lengthwise;  but he has never  noticed these forms except in mam-
mary cancer.    Scirrhus is not  at first accompanied by pain; hence  its
existence is often accidentally  discovered when it  has already reached
the size of a  marble  or a pigeon's egg.   Ulceration of the skin, in the 
THE MALE MAMMA.
657
vicinity of the nipple,  supervenes;  the' edges of the sore are raised,
everted, and  puckered; a  purulent, ichorous fluid is * secreted, from a
bluish-red, eroded surface, offering a faint and fetid odor; bleeding often
ensues, and the  patient sinks from  exhaustion.   The amount of pain
suffered appears to depend upon the nervous  constitution of the indi-
vidual, since  it does not present any uniform  proportion to the extent
of the primary  affection, or of the secondary ulceration; one of the
largest scirrhous tumors that has fallen under our observation, followed
by extensive  ulceration and frequent hemorrhage, gave rise to  no bodily
pain from first to  last;  while it  is a matter of  daily observation that
intense lacerating pains in  the breast and arm of the affected side accom-
pany tumors  whose extent  does not warrant the  supposition  that any
direct irritation of the nerves can take place. Scirrhus generally attains
the size of an orange or a  man's fist, and more;  it passes  through its
various stages with more or less  rapidity,  averaging about  three years
altogether;  the ulcerative  stage once  commenced,  the powers of the
system are soon broken. Sir A. Cooper states that the period of growth
lasts from two to three years, and that, after it has attained its full de-
velopment, the time in  Avhich it proves fatal varies from six months to
tAvo  years. The older the individual at the  time at which it first appears,
the slower its subsequent growth; hence, the practical rule followed by
Sir A. Cooper, that,  in advanced life,  surgical interference is neither
humane  nor  scientific.   The  axillary lymphatic glands are commonly
swollen,  hard, and infiltrated with the  same carcinomatous product as
the mamma;  their affection appears to be coincident Avith the implication
of the skin  at the primary seat  of injury.  The pectoral muscles, the
ribs and costal cartilages, are also found secondarily involved to a greater
or less extent; a secondary affection of the pleura  and the lung is not
unfrequent.  Towards the termination of the disease, from direct inter-
ference with the  venous  circulation, oedema of  the extremity of the
affected side  is liable  to supervene.
   The encephaloid form of the disease  occurs  earlier  in life, and gene-
rally runs a more  rapid course than the one just considered.  It is much
less frequent, and, though sometimes primary, is commonly met with as
a complication of  scirrhus.  Moreover, it  presents  a less defined mar-
gin ; according  to Sir  Astley Cooper, it  is difficult to say where the
diseased  structure terminates, and where the healthy structure com-
mences ;  the base of the tumor is, therefore, diffused among the healthy
cellular membrane, or other parts, where it shall happen to be  situated;
another  diagnostic sign, as pointed  out by Sir A. Cooper, is  that the
disease may advance eAren to suppuration and  ulceration without  the
glands of the axilla becoming at  all affected.
                      THE  MALE MAMMA.

  The male breast is occasionally the seat of non-malignant and malig-
lant growths.  We have ourselves met with an instance, in a gentleman
iged twenty-one, of the former, which, to the touch, closely resembled
me of hypertrophy of the mammary gland ;  it was of the size of a shil-
      42 
658
THE MALE MAMMA.
ling; felt semi-cartilaginous, as if composed of lacteal ducts, and Avas
adherent to the skin of the nipple.  The individual had perceived it six
Aveeks  before applying  for advice; it gave no pain, and four months
later we were informed that it  had  almost disappeared without  any
active  treatment being  pursued.   This is in accordance with the struc-
ture of the male  mamma, which  Sir A.  Cooper has shown to resemble
the female gland, though in a rudimentary state.   Nor could we  other-
wise account for  the well-authenticated  cases of the secretion of milk
by men.  Mr. Birkett  gives  delineations,  shoAving the male  gland to
have all the  essential  elements requisite  for the  performance of the
function.  Mr. Stanley1 relates the case  of a man, aged forty-five,  who
was  affected with cancer of the right humerus, secondary to cancer of
the right breast.   Cruveilhier states that three cases have come under
his observation, one of which  is delineated in his atlas.2  In the College
of Surgeons (prep. 2,791), there  is the  section of the breast  of a  man
with a very vascular ulcer, five inches in  diameter, probably originating
in a lens-shaped, hard, cancerous tumor, or a degeneration of the  skin
and mammary gland.  The monographs  on diseases of the mamma also
contain records of simple cysts, compound cysts, and encysted tumors,
occurring in the male breast; but they belong to the mere curiosities of
medical experience.

  1 A Treatise on the Diseases of the Bones, by Edward Stanley, F. R.S., 1849, p. 255.
  2 Anatomie Pathol. Livr. xxiv. 
THE  PATHOLOGICAL ANATOMY  OP  THE
                         JOINTS.
                    CHAPTER  XL I.

                 DISEASES  OF  THE JOINTS.

  Malformations.—In cases of defective development, some joints may
be quite absent, the bones may  be united by congenital anchylosis ; or,
in a less degree of imperfection, they may be incompletely formed, the
ligaments  sometimes  being partly or altogether wanting even when the
rudimentary extremity of the bone is covered with cartilage.  On the
other hand, supernumerary joints exist, both when the number of bones
is natural and when it is excessive.
  Inflammation of the  Synovial Membrane.—This may arise as a pri-
mary disease spontaneously, from cold, from injuries, from localization
of the  rheumatic poison, or from that of syphilis, or gonorrhoea.  It
also occurs as a secondary affection, excited by disease of the cartilage,
or of the subjacent osseous tissue.   It may be acute in various degrees,
or chronic.  It is rare  in young children, less so about the age of pu-
berty,  and very frequent in adults.  Before we describe the morbid
changes, we must advert to two points in the anatomical arrangement
of this  membrane, which are of much importance.  The synovial are
commonly, and no doubt justly, classed with the serous membranes, and
are described  to form  shut sacs, just as  these  are.  Dissection, how-
ever, fails  to trace the membrane over the free surface of the cartilages,
and microscopic examination confirms its  absence, except in the foetus.
In these unused joints the cartilaginous surface is found quite smooth
and even,  and covered by a layer of delicate epithelial scales, such as
line the surface of the  synovial membrane when it passes over the liga-
ments.  In the articulations, however, of adults, not only is the epithelial
layer absent, but the surface of the cartilage is slightly irregular, as if
somewhat worn.  Our own examinations have convinced us of the general
correctness of these  statements, given by Dr. Todd and Mr. Bowman,
but we must also mention that  another high authority, Mr. Toynbee, is
of a different opinion, and believes that he can demonstrate the existence
of the  synovial membrane in  the  adult, by detaching an exceedingly
delicate layer from the cartilage, which, he states, does not contain any
of the cartilage-cells.  This, we think, is a film of the cartilage itself, 
660     INFLAMMATION  OF THE  SYNOVIAL  MEMBRANE.

only so thin that it cannot include the cells.   The  other point we wish
to notice is the existence  of a  set  of remarkable vascular processes,
coA-ered by a delicate  epithelium, upon the free projecting margin  of
those synovial  folds which advance  into the  cavities  of joints.   Mr.
Rainey, by  his discovery of these,  has confirmed the anticipation  of
Clopton  Havers, that  those synovial folds fulfil, in  some measure, the
function  of glands, being particularly concerned in the formation of the
synovia.   It is, we are  com-inced, from these vascular processes that
bloodvessels first enter the  false  membrane formed by exuded lymph.
  The results of acute synovitis are the following : More or less injec-
tion of the vessels, which in one instance, related by Sir B. Brodie, were
so distended with blood that, " throughout the whole of its internal  sur-
face, except where it covered the cartilages, the synovial membrane was
of a dark red color," like the conjunctiva in acute ophthalmia.  Effusion
of serous fluid, which may be so great as to lead one to suppose that the
sac is filled with solid matter. Effusion of lymph, forming flakes all over
the synovial surface, and not upon the cartilages.  In severe cases sup-
puration  may occur.  If the disease advance  unchecked, ulceration  of
the  cartilages is  very prone to  occur; the exuded lymph then forms
villous or fringed  processes, which  are in contact with the ulcerating
part  of the  cartilage, and  probably both  promote the  destructive pro-
cess, and aid in removing, by absorption, the disintegrating  tissue.  We
shall return to this point again under the head of ulceration of cartilage.
Under judicious treatment,  the whole of the fluid will be reabsorbed, and
the joint return to a  perfectly healthy state.   If, however, much solid
exudation is present,  its absorption will be  more  difficult, and some
amount of swelling and stiffness  of the part will still remain.
  "Chronic synovitis," Sir B. Brodie says, "causes an  increased secre-
tion of fluid,  but does not in general terminate in the effusion of coagu-
lable  lymph, or in  thickening of the inflamed membrane."  Fibrinous
matter is, however, if the disease continue long,  or often  recur, effused
either on the inside or outside of the  synovial  membrane, and becoming
gradually organized into a fibroid  tissue, thickens its substance  and
renders it sometimes firm and gristly.  A preparation in the Museum
of St. George's Hospital, shows the synovial membrane of the knee-joint
so altered in  this way as to be nearly an inch thick.  It may be difficult,
if not impossible, to detect the presence of fluid in the  cavity of a joint
which is  in this state.   Serous effusion, to a considerable amount, some-
times takes place in the synovial sac, without any manifest inflamma-
tion.   The affection is analogous to  hydrocele, and belongs to the class
of passive dropsies.   Its causes  are  generally obscure.   When  abscess
occurs in a joint,  the pus is commonly mixed with more or less of syno-
vial fluid, and flakes of lymph, and  is  sometimes quite of  a sea-green
color.   There  is, also, sometimes,  suppuration  outside the joint, the
color of the muscles is  altered, the periosteum and the osseous structure
in the vicinity are injected and inflamed.  A rapid effusion of pus into
the synovial cavities of joints, not unfrequently occurs in phlebitis, puer-
peral fever, erysipelas, and in cases of contamination of  the blood by
ssome  morbid matter.   In one instance of this kind occurring after a
thecal abscess in a finger, we found the synovial membrane  forming the 
         INFLAMMATION OF THE  SYNOVIAL  MEMBRANE.     661

margin of one of the ligamenta  alaria of the knee-joint manifestly in-
jected, and fringed with  a number of various-sized villous  projections.
These consisted of a fibro-homogeneous, granulous substance, imbedding
numerous glomeruli.  A  layer of similar matter was spread over the
whole of the synovial surface, which  was not injected with blood.  The
cartilage was  ulcerated in some part of its extent, its surface rendered

                                 Fig. 342.
   From a case of secondary depot in knee-joint, the same as described in the text, in the next page.
   (c) A cartilage-cell, immensely hypertrophied, lying in fibrous stuff.
   (6) A villous process springing from the synovial membrane.
   (a) A strip of fibrous tissue containing three enlarged cartilage-cells—one is also figured separately.

irregular by superficial erosions, and its texture altered to a lax fibroid
stuff.    The cartilage-cells in these parts were most remarkably changed,
containing sometimes 20-25 celloid masses in their interior, instead of
the two or three which they might  contain in their normal state.   The
inter-cell substance was  entirely deprived  of  its natural consistence ; it
broke  down under slight pressure.  The following description of the
condition of a joint which had been long in a state of suppuration  is so 
662     INFLAMMATION OF  THE SYNOVIAL MKMBRANE.

faithful and life-like that we cannot forbear transcribing it.   Rokitansky
says: "The quantity of purulent fluid effused into the cavity of the joint
is generally considerable, and  the capsule is, consequently,  much  en-
larged ; the synovial membrane is lined with  a firm, shreddy layer of
lymph, which  is dissolving  into pus, and  a  soft, purulent  precipitate,
which  can be easily  removed,  adheres to  the cartilages."    The terra
precipitate, which  is  here  employed, is worth  noticing, as  Rokitansky
states  most strongly, in a previous paragraph, " that no exudation is
deposited  on that  portion of the synovial  membrane which covers  the
cartilage;"  if any is found there,  it is to be  regarded as a  "secondary
precipitate" from the general exudation.  This circumstance strongly
confirms our view of  the disposition of  the  synovial  membrane.  The
layer of fibrin, lining the synovial membrane,  " is  opaque  and lustre-
less, its surface is rough, and  serum is  infiltrated, and blood in small
spots extravasated through its  tissue, as well as through that of  the
fibrous  capsule of the joint, and neighboring  cellular structures.   As
the disease advances, the infiltration and thickening of the neighboring
structures  increase, they become  filled  with a gelatinous, lardacebus,
white product, in the  midst of which fibrous tissues, capsules, ligaments,
or aponeuroses, can no longer be  recognized.   Here  and there, in  the
mass, there are  cavities of different dimensions, the  lining  of which is
vascular,  spongy,  and  granulating, and the contents purulent.  The
muscles near the joint  are  pale and flabby, infiltered  and  attenuated.
At length the infiltration reaches the subcutaneous  cellular and adipose
tissues, and the integuments become fixed to the disorganized structures
beneath.  The diseased joint then presents  the following external  ap-
pearance :  it is swollen, and always more  or less bent; it feels every-
where  soft  and flabby,  or in some  spots flabby, in  others firm, elastic,
doughy, and at the same time tuberculated  ; the integuments over it
are tense and pallid, leuco-phlegmatic, or they are traversed by varicose
veins.
   At length ulceration  commences, and advances in various directions.
"Externally, the capsule ulcerates in one or  more spots, and  then the
soft parts  adjoining it.  In some instances  large openings form in  the
capsule, and connect the joint  with ulcerated cavities in the soft parts;
in others,  mere sinuses are formed; but in  either case they  open exter-
nally through the skin,  and occasion and maintain  a  discharge of  the
contents of the joint.   Internally, the inter-articular cartilages and  the
ligaments  ulcerate, the  cartilage covering the bones, when brought into
contact with the matter, is  destroyed in the way that has been  men-
tioned,  and the ulcerative inflammation attacks even the bones, if they
have not been involved  already.   The cavity of the joint appears like a
cloaca,  surrounded with a gelatino-lardaceous mass; the  integuments
covering it are  of a dark red hue, and are  especially discolored at  the
orifices of the sinuses.  The joint contains pus or sanies of an offensive
odor, and  variously discolored; the  repeated hemorrhages  which take
place when there is acute caries of the bones, very frequently giving it
a red or brown tinge; the ligaments ulcerate, and the  cartilages sepa-
rate partly, or entirely, from the bones; the osseous surfaces are laid
bare, their compact wall is destroyed, and the spongy tissue is exposed 
        INFLAMMATION OF  THE SYNOVIAL MEMBRANE.     663

infiltrated with pus, and ulcerating, and surrounded on all sides by osteo-
phytes of various shapes;  remains of the fibrous structures of the joint,
pieces of loosened cartilage, and of necrosed bone, are  mixed with the
matter discharged from the joint.   The soft parts, and the entire bones
belonging to the diseased joint, are Avasted, most of the fat is absorbed,
the muscles are remarkably blanched  and thin, and the  bones, being
generally in a state  of eccentric atrophy, are  soft and  fragile.   More
or less quickly after the disease has reached this stage, spontaneous dis-
locations, as they are called, ensue."  The exudative product of inflam-
mation, in some instances, is, according to Rokitansky,  converted into
tubercle.  This occurs when there is a great amount  of general tuber-
cular disease.  The articular extremities of bones are sometimes affected
by tuberculosis simultaneously with the synovial membrane, sometimes
before it.
   Inflammation may attack the cellular  tissue around  joints, causing
effusion of coagulating fluid and consequent swelling, with  subsequent
formation of  pus.  One or more spots only may be  affected, so that
small, local  deposits  of pus are produced;  or the whole may be involved,
and the joint become enveloped in a large abscess.  In its later  stages,
the disease extends to the synovial membrane and the cartilages, or re-
covery may take place, the joint remaining sound.
   Pulpy degeneration of the synovial membrane is a very curious  and
peculiar disease, with the exact nature of which we are  yet scarcely
acquainted.    It was first described by Sir B. Brodie,  as  a morbid alter-
ation of structure peculiar to the  articular lining  membranes, nothing
analogous having been  obserAred in  the serous  sacs.   He says: "The
disease seems to commence in  the reflected portions of  the synovial
membrane, converting them into a light brown, pulpy substance, vary-
ing from a quarter to a half, or even a Avhole inch in thickness, inter-
sected with white membranous lines  and red  spots, formed by small
vessels  injected with their  own blood.   It then attacks  the synovial
membrane of  'the cartilages,'  beginning  at  their  edge  and extending
gradually over them, ulceration  in those cartilages going on correspond-
ently,  till the carious or ulcerating  surfaces of the bone  are exposed.
The cavity of the joint sometimes contains pale-yellow fluid in the floating
flakes of lymph, or pus, which is  discharged externally by  ulceration;
but sometimes neither.   Or abscesses may exist in the altered synovial
membrane itself, without communication in the joint."  We have given,
in the Pathological Report for 1848-49, a detailed account  of the dis-
position and structure of the synovial membrane thus peculiarly altered,
from which we extract the following summary: The new growth formed
prominent fringes of a soft, grayish structure,  which overlapped and
encroached  considerably on the surface of the articular cartilage.   The
marginal zone of the cartilage, for a varying extent, was converted into
a kind  of fibrous  tissue,  and blended with the altered  synovial mem-
brane.   More internally the cartilage was grooved on the  surface, pro-
bably so as to correspond with the overlying fringe.  The  fibrous tissue
into Avhich the cartilage was transformed was of an imperfect kind, not
dividedi into distinct fibres, and not containing  any of the natural cells,
but streAved over with numerous oil drops and yellowish molecules.  The 
664    INFLAMMATION OF THE SYNOVIAL  MEMBRANE.
change in the cartilage was effected by extraordinary enlargement of its
cells, which were crowded with an  endogenous growth  of young cells
containing each  a small oil drop and much clear fluid.   At the  margin
of the cartilage, which was obliquely truncated, the change was most

                                Fig. 343.
 (a) Vertical section of cartilage in process of absorption towards the left, and overlapped by the vascular-
ized pulpy synovial fringe.  The edge of the cartilage where it is obliquely truncated is continuous with the
fibrous tissue on the left hand.
 (b) Healthy cartilage-cells from the right-hand side, more magnified.
 (c) Greatly enlarged cartilage-cell, containing young cells.
 (d) Loculus, from thickened synovial membrane, filled and surrounded with nuclei.

advanced; in the interior the structure was quite natural.  The pulpy
synovial tissue consisted principally of well-formed nuclei and granular
matter,  with which were  mingled a few  fusiform  and  circular  cells.
These elements were contained in an enveloping membrane, very thin,
of  whitish aspect, and nearly homogeneous texture.   There  existed
scarce any trace of stromal fibres, but  a  good  many large vesicles, or
loculi, formed  of  almost homogeneous  walls, and  filled with material
similar to that which surrounded them.  Delicate-walled  bloodvessels
ramified through the mass,  but not in great  numbers.   It  seems very
probable that the altered synovial tissue promotes and is concerned in
the absorption of  the cartilage.   The disease  almost always occurs  be-
fore the middle period of life.   " In general, it can be traced  to ho  evi-
dent  cause;  but occasionally, it is the consequence of repeated  attacks 
INFLAMMATION  OF THE  SYNOVIAL  MEMBRANE.    665
of inflammation."  It rarely occurs elsewhere than in the knee, but has
been seen in  the ankle, and in  a joint of the fingers.   Sir B. Brodie
classes it with malignant disease, but from this it is differenced by well-
marked characters.
   Another very curious alteration, which  is sometimes  observed in the
synovial membrane, consists in its free internal surface being covered
by a growth  of  large villous processes, quite  perceptible to the naked
eye, which hang into  the cavity  of the joint, and present a shaggy ap-
pearance.  They are not developed on the surface
of the cartilages.   They have sometimes the form       Fis- 344-
of simple threads, or flattened shreds, or their free
extremities are split into filaments, like a  tassel, or
they have a club shape, or resemble melon-seeds,
hanging singly or in clusters from each stalk.   In
structure, they  consist of a fibroid material, con-
taining, we believe, in many instances, more or less
fat, and approaching herein  to  that  peculiar form
of fatty tumor which is called Lipoma arborescens.
The healthy texture of  the articulation is not ma-
terially interfered with,  at  least  in  many  cases.
They seem to be the  result of a slow exudation of  tJ^fjt^nais
plasmatic matter, which  may  pass into alow form  the only part unoccupied.
of organization.
   Inflammation of the  ligaments, both  acute  and  chronic, is  said to
occur; but Wickham states that, according to his experience, ilihe liga-
ments are the last of all the different parts diseased, and that it is very
common to find the ligaments perfect, even when every other texture is
either altered or destroyed."   From Mr. Key's account, it  seems that
inflamed  ligaments become thickened and  more pulpy than  natural.
The areolar  tissue which penetrates  among their fibres becomes highly
vascular,  and is probably concerned in producing the softening and ul-
ceration of their substance, which sometimes takes place.
   Relaxation of  the  ligaments may be the result of long-continued
chronic inflammation, or of simple disuse of the limb.  In the  latter
case, it has been known  to proceed to such an  extent as to allow the
head of the femur to slip out of the acetabulum.  Frequent and heavy
strains may produce a similar effect;  Mr. Wickham mentions a case in
which the leg was so much bent outward at the knee as to be at nearly
right angles with the thigh.                              #
   Loose cartilages (so called) are not unfrequent in the cavities of joints.
They are usually from the size of a millet-seed to that of a pea, but have
been met with as  large as a walnut.   In  shape, they are more or less
oval and  flattened.  Their surface is  smooth, as if invested by a serous
covering, which they sometimes evidently possess, when they are attached
to the synovial  membrane by a  pedicle of varying length.   Formations
of this kind  commence in the subserous tissue, and  as they  enlarge
gradually, make their way inward towards the cavity of the joint, in
which at last they become free by the  dissolution of the pedicle.  Others.
are formed  by a  condensation  of fibrinous  coagula;  "they are dis-
tinguished," Rokitansky says, " by their  uniform smoothness through- 
006           MORBID  CONDITIONS OF CARTILAGE.
out, by a delicate  albuminous  investing membrane, and frequently by
their manifest arrangement in concentric laminae."   They never contain
any of the characteristic cells of cartilage, and appear to consist solely
of compressed fibrillating exudation.   Occasionally, they are lodged in
Fig. 345.
       Trochlea of humerus; showing formation and connection of loose cartilaginous bodies.

ulcerated cavities of the normal cartilage, which might give rise to the
idea that they were truly fragments of this tissue, cut out, as it were, by
the process of ulceration.  We do not believe,  however, that this ever
happens.   Calcareous matter is sometimes deposited in the substance of
these false cartilages, and Mr. Rainey describes true bone lacunae, similar
to those seen in the  thin  plates  of  the ethmoid, as existing in their
interior.1
             MORBID CONDITIONS  OF  CARTILAGE.

  It is somewhat doubtful whether a true hypertrophy of cartilage ever
takes place;  but an apparent hypertrophy is not unfrequently observed.
The thickness may be increased to treble of that which is normal;  at
the same time, the tissue becomes  very soft and  yielding, and shows a
decided tendency to break up into fibres,  which are arranged vertically
to the surface.   There is some  evidence to show that, at a later period,
cartilages, so altered, would waste and disappear.  In  advanced age,
articular cartilages become considerably thinned—at least this  is the
case in the hip, and, probably, more or less in all joints that are exposed
to pressure.  Sometimes the cartilage is simply atrophied; in other  cases,
it is  replaced  by a semi-translucent, and in others  again, by  a  white
fibroid tissue.   Sometimes the cartilage seems itself to ossify,  being
converted into  what is called the ivory  or porcellaneous deposit.   This
is a peculiarly  dense kind of bone; its Haversian canals being filled up
by  the earthy salts.  Besides occurring as a gradual, almost unperceived
change in the aged, it is also  met with very constantly in  the disease
termed chronic rheumatic arthritis, of which we shall presently speak.

  1 A specimen  removed from a knee-joint by Mr. Lane, exhibited, on section,  a  central
cavity containing some fatty matter;  round this was a zone  of hard calcareous deposit
so arranged at its inner part as to include cancelli.  Lacunae  existed in this zone. The
outer zone consisted of a fibroid layer, imbedding very numerous oval and elongated nu-
clear particles.  This specimen was more than usually organized. 
MORBID CONDITIONS OF CARTILAGE.           667
  The free surface of cartilages is sometimes covered with a thin layer
of lithate of soda; and the same matter may also exist in the substance
of the cartilage, in the cancelli of the invested bone, and in the  subsy-
novial tissue.  It is deposited as the result of gout.  It is not uncommon,
on opening joints  which are not apparently diseased, to find the carti-
lages more or less deficient at  one or more points, and this especially
in the parts where they have had to  bear the greatest pressure.   The
cartilage is eroded more or less deeply, so that in the seat of the lesion
the bone may be exposed, and  this with scarce any traces of inflamma-
tion in the synovial membrane.   Sir B. Brodie " has many times observed
a portion of cartilage of a joint Avanting,  and in its place, a thin layer
of hard, semi-transparent substance, of a  gray color,  and presenting an
irregular granulated substance."  This indicates a partial atrophy, and
destruction of the  cartilage, with imperfect replacement of it by a fibrin-
ous exudation.   We have  lately examined the knee-joint of  a female,
set. 47, who  died  of pleuro-pneumonia, in which the  cartilage  of the
femoral condyles, and of the patella, was manifestly in a state of chronic
atrophy, or " usure," as it has  been termed by Cruveilhier.  There was
a slight injection of  one of the natural synovial fringes, but no trace of
inflammatory action; the joint, externally, appeared  quite healthy, and
no complaint had been  made respecting  it during life.  The cartilage
of the patella  was most affected ; it  presented, at its external part, an
unequal, irregular surface, about the size  of a  fourpenny piece, which
was softened in texture, and roughened by small grayish prominences.
The surrounding cartilage was  in a commencing state of similar change.
In a vertical section of the part most affected, it was  seen that the  cells
near the free margin were enlarged and multiplied, while the matrix at
the margin broke  up into fibres of various size, quite  separate from  each
other, the larger still imbedding some of  the cells.  The  accompanying
cut illustrates this degeneration of cartilage.
   Ulceration of cartilage, occurring as an acute or  subacute affection,
has been much inquired into, and our knowledge respecting it  has be-
come tolerably definite and exact.  It was formerly much  disputed,
whether the change  was effected by the action of the  vessels of the car-
tilage itself, or those of the synovial membrane, on the incrusted bone.
Now, however,  we  know  certainly,  that  human articular  cartilage is
entirely devoid of vessels; and we have good reason to believe  that
those of the surrounding textures are  not the effective  agents  in the
ulcerative process.  Mr. Key, who contends  most for  the influence  of
the  vascular fringes, allows that ulceration may  occur  as a  primary
affection, independent of the other textures of the joint.  If we refer,
as we may fairly do, to the instance of the cornea, as a very analogous
tissue  we can scarcely hesitate to admit  that ulceration is essentially
an alteration of the  nutrition of the affected texture,  and that the influ-
ence of the adjoining vessels upon it is only secondary.  The perforat-
ing ulcer of the stomach is also a striking instance of the truth  of this
position.   It being  then admitted that ulceration of cartilage is  pro-
duced by a special disorder of its own  nutrition, we  proceed to inquire
what has been  ascertained respecting the nature and the stages  of this
diseased action.  These were admirably set forth by Mr. Goodsir, in 
668             MORBID  CONDITIONS OF  CARTILAGE.

his well-known paper on the process  of ulceration in articular cartilage,
an extract from which we subjoin: " If a thin section, at right angles, be
Fig. 346.                                         Fig. 347.
  Vertical section of cartilage of patella, in       Diseased articular cartilage magnified 240 diameters,
state of usure.  The free margin presents     showing the enlargement of the corpuscles, the more
a number of fibres.  The left-hand  figure     superficial of which are throwing out their contents into
represents one of these fibres, more magni-     the softened inter-corpuscular substance.—Redfern.
fied, and containing some  groups of cor-
puscles.
made through the  articular  cartilage  of a  joint, at  any part where it is
covered by gelatinous membrane in scrofulous disease,  or by false mem-
                                      Fig. 348.
  Microscopic view of a perpendicular section of articular cartilage, showing its surface occupied by fibrous
bands formed by the splitting of the hyaline substance.  These bands rendered it velvety in appearance to
the naked eye.—Redfern. 
MORBID CONDITIONS OF  CARTILAGE.           669
brane, in simple inflammatory condition of the joint, and if this section
be examined, it will be found to present  the following appearances:  on
one edge of the section is the cartilage unaltered, with its corpuscles
natural in position and size.   On the opposite edge is the gelatinous or
false membrane, both consisting essentially of nucleated particles, inter-

                                 Fig. 349.
Fibrous tissue with included cells and nuclei; formed, as above described, on the surface of the cartilage of
                             the patella.—Redfern.

mixed, especially in the latter, with fibres and bloodvessels; and, in the
former, with tubercular granular matter.   In the  immediate vicinity,
and  on  both sides of  the  irregular edge  of the section of  cartilage,
where it is connected to the membrane, certain remarkable appearances
are seen.  These consist, on the side of the cartilage, of a change in
the shape and size of the cartilage-corpuscles.   Instead of being of their

                                Fig. 350.
 A'ertical section of cartilage in a diseased knee-joint, showing the cells enlarged, granular, and bursting.
On the right, and above, their contents are seen mingling with a fibrous and granular mass which occupies
the surface.—Redfern.

usual form, they are larger, rounded, or oviform;  and instead of two or
three nucleated  cells  in their interior,  contain a mass of them.   At the
very edge of the ulcerated cartilage, the cellular contents of the  en-
larged cartilage-corpuscles  communicate with the  diseased membrane by
openings  more or  less extended.   Some of the  ovoidal masses in  the
enlarged  corpuscles may be seen half released from their cavities by the 
670          MORBID CONDITIONS OF CARTILAGE.

removal of the cartilage;  and others of them may be observed  in the
substance of the  false membrane, close  to  the cartilage, where  they
have been left  by the entire removal of the  cartilage which originally
surrounded  them.   If a  portion of the false membrane be gradually
torn off the cartilage, the latter will  appear  rough  and honeycombed.
Into each depression on its surface, a nipple-like projection of  the false
membrane penetrates.  The cavities of the  enlarged corpuscles of the
cartilage open on  the ulcerated surface by orifices of a size proportional
to the extent of absorption of the Avails  of the  corpuscles, and  of the
free surface of the cartilage.  The texture  of the cartilage  does  not
exhibit, during the progress of the ulceration, any trace of vascularity.
The false membrane is vascular, and loops of capillary vessels dip into
Fig. 352.
                                             Drawing of ulceration of cartilage.
                                             (n) Vertical section of ulcerating carti-
                                           lage, magnified.
                                             (6) Naked-eye view, showing two ulcer-
                                           ated depressions.

the substance of the nipple-like projections, which fill  the depressions
on the ulcerated surface of the cartilage; but, with the exception of the
enlargement of the corpuscles, and  the  peculiar  development of their
contents, no change has occurred in it.  A layer of nucleated particles
always exists between the loops of capillaries  and the ulcerated surface.
The cartilage, where  it  is not covered  by the false membrane, is un-
changed in  structure.   The  membrane  generally adheres  Avith some
firmness to the ulcerating surface;  in other instances, it is  loosely ap-
plied to  it; but in all, the latter is accurately moulded to the former.
In scrofulous disease of the cancellated  texture of the heads of bones,
or in cases where the joint only is affected, but to  the extent of  total
destruction of the cartilage, over part or the whole of its  extent, the
latter is, during the progress of the  ulceration,  attacked from  its  at-
tached surface.  Nipple-shaped processes of vascular cellular texture
pass from the bone into the attached surface of the cartilage, the latter
undergoing the change already described.   The  processes from the two
Fig. 351.
Deposition of opaque calcareous matter, commencing in the
    walls of the cartilage-corpuscles.—Redfern. 
              MORBID CONDITIONS OF CARTILAGE.          671

surfaces may thus meet half-way in the  substance  of  the  cartilage, or
they may press from the attached, and project through a sound portion
of the surface of the cartilage, like little vascular nipples or granula-
tions.  The cartilage may be thus riddled, or it may be broken up into
scales  of  varying size and thickness, or it may be undermined for a
greater or less extent, or be thrown  into  the fluid of the  cavity of the
joint in small detached portions,  or it may entirely disappear."  Mr.
Goodsir believes  the cells of new formation, the nucleated particles of
the false membrane, to be the immediate agents  in the  absorption of the
cartilage.  We have had  several opportunities  of  verifying the above
account, and have already mentioned two instances in which we observed
a similar change in ulcerating or wasting cartilage.   We subjoin a short
account of another observation, because  it seems to show pretty clearly
the non-essentiality of the vascular false membrane, or at  least of its
apposition to the affected part, to the process of ulceration.   A child,
set. 4, died with  a  vast abscess surrounding the right femur;  the hip-
joint was sound,  but inflammation had extended to the knee, the syno-
vial membrane of which Avas inflamed, and contained some pus.   There
was an irregular  ulcerated surface, of about the size  of a  shilling, de-
nuding the bone on the  trochlear surface of the  femur.   One  of  the
synovial folds was much injected; its tissue was  thickened by interstitial
deposit, and adhering to its margin were some masses of exudation, con-
sisting chiefly of amorpho-granular matter, imbedding  numerous non-
nucleated pus-like corpuscles.   The injection of the  synovial fold was
very marked; its capillaries were distended, and it presented a strong
contrast  to other parts of the  membrane, which were, however, thick-
ened by and covered with exudation.  The layer of exudation adhering
to the edge of this fold was partially vascularized;  but it did not appear
that the vessels were continuations of those of  the synovial membrane.
 There was no adhesion  between  the ulcerated  portion of the  cartilage
and the vascularized false membrane, nor did the two seem to have been
in apposition.  Near the part where the bone was exposed, there was a
small spot of ulceration of the cartilage in progress; it  showed to  the
naked eye two  well-marked shallow depressions, and an intervening
 elevation, with a thin  investing  gelatinous  layer, v.  b.  Fig. 353.   In
 the deeper and healthy parts of the cartilage, as seen in a vertical sec-
 tion, the cells were small and elongated, containing  one or more  oil-
 molecules, with faint granulous matter  and a clear fluid.  Nearer the
 surface  they were  a  little  larger, and had  the same contents.  The
 matrix in both  these parts was  natural, and moderately opaque.  At
 some distance from the free surface, the  matrix became  suddenly much
 more  transparent, of  a pale,  homogeneous  aspect.   The cells  in  this
 part were swollen, and of a round shape, appearing to be distended by
 a clear fluid, in which floated some oil-molecules.  They were not much
 more numerous,  except on the ulcerating border, which was pretty even,
 and covered with escaped cells.   There was a  good deal  of oil, in the
 form of large and small drops, scattered about; but  this did  not seem
 to proceed from the cells or the  matrix of the cartilage, in neither  of
 which was there much oil  visible; the latter, in particular, appeared
 simply to liquefy.   The  investing gelatinous  layer consisted  of coarse 
672          SCROFULOUS  DISEASE  OF THE  JOINTS.

granular matter, imbedding  escaped cartilage-cells and corpuscles like
those of pus.   The bone subjacent to  the cartilage was of a  reddish
color, was  somewhat  softened, and its cancelli  contained, besides fat-
cells, multitudes of granular cells and nuclei.  Dr. Redfern has arrived
at the following conclusions from his  able  inquiries  into the subject of
ulceration of cartilage:  " Ulceration  in articular cartilage  differs from
that in  other tissues, in neither  being  accompanied by exudation, nor
attended with pain;  differences which depend on the absence of vessels
and  nerves.  Ulcers  in articular cartilages  heal by transformation of
the surrounding cartilage-tissue into fibre ;  but those occurring in other
textures are cured by the formation of  a cicatrix out of newly-exuded
blood-plasma."
           SCROFULOUS DISEASE OF  THE JOINTS.

  No doubt can exist of the propriety of the distinctive name given to
this affection, although its course does not seem to be exactly similar to
that of scrofulous disease of other parts.   The articular  extremities of
the bones are the primary seat of mischief; they become preternaturally
vascular  and  much softened, so that they are easily cut with a knife,
while  " a transparent and  afterwards a yellow cheesy substance is de-
posited in their cancelli."  From the observation aboA*e mentioned, we
are inclined to think that granular cells, formed in the primary exuda-
tion within the cancelli, play some  part in the absorption and removal
of the earthy salts of the bone.   As the disease of the bone advances,
ulceration of the  cartilage commences on its attached  surface in  the
manner described in the extract we have given from Mr. Goodsir's paper.
Before, hoAvever, this can take place to any great extent  the articular
lamina, so well investigated  by Mr. Birkett,  must be removed.  This
consists of a thin lamina of dense bone containing large lacunae with
scarce any canaliculi, Avhich bounds and  closes in the cancelli on  the
surface incrusted by the cartilage.   Until  this  is remoA'ed, no vessels
can shoot into the nipple-shaped processes of  false membrane which dip
into the cartilage.  The osseous tissue gradually wastes and is absorbed,
it undergoes a true caries ; sometimes also a part dies and may exfoliate.
In the fifty-first case related by Sir B. Brodie there was a small portion
of dead bone thrown off  into the cavity of the  left elbow, while in the
right knee, though it presented no manifest indications of disease, and
admitted of perfect motion, the bones were  unnaturally vascular and
softened; and an irregular cavity, occupied by little more than medulla
and a reddish fluid, had been formed in the mid-part of the lower extre-
mity of the femur.  In cases of this kind, it is not at all unfrequent to
find several joints affected with the same morbid change in various stages.
As the whole of the articulating surface is generally invoked in the dis-
ease, the attachment of the cartilage becomes loosened at all  points, and
it  is therefore, even at an early  period, much more easily detached from
the bone than is natural.   Sometimes, as Sir B. Brodie mentions, in the
adA-anced steps of the disease, nearly the whole  of the cartilage is found
forming  an exfoliation instead  of being  ulcerated.   "As  the caries of 
DISEASE OF THE SPINAL COLUMN.
673
the bones advances, inflammation takes place of the cellular membrane
external to the joint.  Serum and afterwards coagulated lymph is effused;
and hence arises a pulpy and elastic swelling in the
early, and an oedematous swelling in the advanced,
stage of the disease.  Abscess having formed in
the joints, it makes its way by ulceration through
the ligaments and the synovial membrane,  and
afterwards  bursts externally, having  caused the
formation of numerous and circuitous  sinuses in
the neighboring soft parts."  This disease of the
joint  especially affects children; it is  the essence
of the morbus coxarius which is so very common
among  the  offspring of  the  poorer classes.  It
rarely  occurs after the  age  of thirty.   Sir  B.
Brodie  cautions us  against supposing  that all in-
stances of increased vascularity and  softening of
bone  are  of the  same nature as the disease just
described.  Simple  caries, resulting from inflam-
mation, may produce the same effect, and it is only
the deposition of yellow cheesy matter Avithin the
cancelli which can be regarded as truly distinctive.
The youth of the patient, the simultaneous affection
of several joints, and the existence of scrofulous
disease in other parts, are also circumstances which
will aid us much in forming a correct  judgment.
denies that the yellow cheesy matter is anything more than concrete pus;
he has  rarely found any tuberculous matter in bone undergoing  caries
or necrosis,  even in  cases of disease  of the vertebrae with tuberculosis
of several organs.   We doubt whether in this M. Lebert has not been
led into error, by attaching too much importance to his so-called tubercle
corpuscles.   Scrofulous matter  may contain corpuscles, much more de-
veloped than  those  of  tubercle, and  yet there will be little difference
in the nature  and behavior of the  two products.   Rokitansky and Mr.
Paget  recognize both circumscribed and  infiltrating deposits of tuber-
culous matter in bone.
 Destruction of cartilage in the
    knee joint.—Lis ton.


M. Lebert, however,
DISEASE  OF  THE SPINAL COLUMN.
   The joints of the vertebra? are very liable to be affected in nearly the
same way as other articulations of more perfect development,  so that a
brief account  of  their morbid states will properly follow here.   The
cancellous tissue may be the seat of the scrofulous disease just described,
occasioning caries and deposition of cheesy matter in the cavities.   "In
these cases ulceration may begin on any part of the surface, or even in
the centre of the bone; but in general the first effects of it are  percepti-
ble where the intervertebral cartilage is connected with it, and in  the
intervertebral cartilage itself.   In other cases the vertebrae retain their
natural texture  and hardness, and the first indication of the disease is
ulceration of one  or  more of the intervertebral cartilages, and of  the
       43 
674            DISEASE  OF  THE SPINAL COLUMN.

surfaces of bone with which they are connected."   These cases may be
considered analogous to those of primary ulceration of the cartilages of
diarthrodial joints.   "There is still another order of eases, but these
are of more rare  occurrence, in which the  bodies  of the vertebrae are
affected with chronic inflammation, of which ulceration of the interver-
tebral cartilages is  the consequence."  To this we have not  any ana-
logue among the more  ordinary diseases  of joints.   "In whichever of
these ways the disease begins, if not checked in its progress, it proceeds
to the destruction of the bodies of  the vertebrae and intervertebral car-
tilages, leaving the posterior parts of the vertebrae unaffected by it; the
necessary consequence of which is  an incurvation of the spine forward,
and  a projection of the spinous processes  posteriorly."  The chronic
inflammation of the  bones  sometimes extends to the membranes of the

           Fig. 354.                             Fig. 355.
 Remarkable example of angular curvature  Angular curvature from caries. From a preparation in
and anchylosis.  From a preparation in my             my museum.__Pirrie.
museum.—Pirrie.
spinal cord, and when the cun'ature is very great the cord may be  so
compressed that it cannot properly discharge its functions.   " Suppura-
tion sometimes takes place at a very early period;  at other  times not
until the disease has made considerable progress.  The soft parts in the
neighborhood of the abscess become thickened and consolidated, forming
a thick capsule, in which the  abscess is sometimes retained for  several
successive  years;  but from which it ultimately makes its  way to the
surface, presenting itself in one or another situation, according to cir-
cumstances.   In the advanced stages of  the disease, new bone  is often
deposited in irregular masses  on the surface of the bodies of the neigh-
boring vertebrae: and where  recovery takes place, the  carious  surface
of the vertebrae above coming  in contact with that of the vertebrae below,
they become united with each  other, at  first by soft  substance, after-
wards  by  bony anchylosis.   This disposition to anchylosis is  not the
same under all circumstances; it is much less Avhere the bones  are  af-
fected by  scrofula than where  they retain their  natural texture and
hardness;  and this  explains wherefore, in  the  former  class of  cases a 
ANCHYLOSIS.
675
cure is  effected with more difficulty than  in the latter.   Occasionally,
portions of the ulcerated or carious bone lose their vitality, and having
become  detached are found lying loose in  the cavity of  the abscess."
When a large abscess has formed, the  pressure of the matter on the sur-
faces of the contiguous vertebrae may cause an extensive caries far beyond
the limits of the original disease.
ANCHYLOSIS.
  The term is derived from the Greek ayxt*.*?, which signifies a curve of
a joint, and was applied to such cases of stiff joint as remained fixed in
a curved, not a straight  position, which was distinguished by the term
Op6oxo>%ov.   The process which produces anchylosis  is  very similar to
that which unites the two  ends  of a fractured bone,  and the  union in
both cases may be effected either  by soft  fibroid tissue or by actual
bone.   For the production of anchylosis it is essential that the cartilage
encrusting the articular bony surfaces should be wholly,  or in great
part, removed.  When this is effected, and the conditions of the inflamed
parts  are  such  as  do not  tend to the  production of  pus, but of plastic
exudation, the  capillaries, which  have entered the  processes  of false
membrane from the bony surfaces, meet and  anastomose together; so
that the vascular systems of the two bones  are in free  communication,
while  the  intervening fibrinous exudation gradually undergoes  change
into a dense fibroid tissue,  mingled, as Rokitansky says, with an abund-
ance of fat.  If the  process stop  at this point,  soft or fibrous anchy-
losis is the result.  More commonly, hoAvever, under favorable conditions^
of perfect rest, proper food, and attention to  the health, the exudation
undergoes change  into osseous substance, so that the two bones become,
as it were, accurately welded together.  Mr. South quotes the following
interesting instance from Mayo, illustrating what we have  described as
the early  stage of  the  ankylosing process:  "A  young  man had a
lacerated  wound of the ankle, erysipelas came on, and matter formed
around, and made its way  into the joint, the cartilage of which became
rapidly absorbed.  The limb was removed two months after the accident.
Upon  a vertical section being made of the ankle, one  common change
was found to have taken place in both the  joints, which the upper and
under surfaces of the astragalus contributed to form.   In each of these
ioints  the cartilage had entirely disappeared;  and the  denuded ends of
the bones were joined together by a layer  of semi-transparent  and
organized lymph, from a  sixth to a  quarter of an  inch in thickness.
This union by  lymph was a step  towards union by bone.  One circum-
stance appeared to me of peculiar  interest.   The interior of the bones
was perfectly healthy; but  the surfaces to Avhich  the  ymph adhered
were   for the depth of one or two lines, extremely vascular.    lhere is
a kind of anchvlosis which is denominated the spurious or Jalse, most
common after  Synovitis, and which depends on the  presence of masses
of  exudation witiiin the synovial capsule, with thickening of this mem-
brane and of  the  ligaments.  The condition of the  muscles also seems
to promote the fixed state of the articulation, the extensors being para- 
676
CHRONIC RHEUMATIC ARTHRITIS.
lyzed and wasted, and the flexors, which exert in most instances a supe-
rior power, being contracted, shortened, and atrophied.   Anchylosis of
the bodies of the vertebras has  already been alluded to  as  the  mode in
which a cure takes  place after caries of their structure and ulceration
of the intervertebral  ligaments.  It is clear from this  that when the
destruction of these parts has been at all extensive, the avoidance of the
deformity of angular  curvature  is impossible.   Anchylosis of  some of
the less  important  joints occurs almost naturally in old age.  Some
rare instances are recorded  in which all the joints of the body became
spontaneously anchylosed.
              CHRONIC RHEUMATIC  ARTHRITIS.

  The chronic inflammatory nature of this affection is extremely well
marked, but the essential dependence of  it upon rheumatism is not so
well demonstrated.   It  occurs not  only after an attack  of  acute rheu-
matism, but after injuries and bruises, and sometimes without apparent
cause.   It  is very frequent in the hip, the shoulder, the knee, and the
articulations of the hand.  When it is fully established in the hip-joint,
it  is said, by Mr. R. Adams, rarely or never to extend itself to the
other articulations.   Sometimes both hips  only are attacked.  When
the knee is the seat  of the disease, or the shoulder, other joints will,
generally, be found more or  less implicated.  In the case of the knee,
Mr. R. Adams recognizes a first stage, " marked by evidences of sub-
acute inflammation, such as pain, heat, considerable SAvelling.  This is
followed by a  second period, in which the heat  and swelling diminish,
but the pain continues."  The disease in the hip and shoulder is described
by the same author as of a more chronic character from the commence-
ment, not being attended with  any sensation  of increased heat, or ap-
pearance of distension.   A very marked diagnostic sign of this affection
is, that pressing  the articular  surfaces together, and moving them, so
as  to  produce crepitus,  does  not cause  any uneasiness.    A  similar
attempt in  ulceration of the cartilages,  or in articular caries, would
cause severe pain.  We quote, from Mr. W. Adams's communication to
the Pathological Society, the following account of the appearances ordi-
narily observed in the advanced stages of chronic rheumatic arthritis:—
   " In the hip-joint.—1st. Great enlargement and irregularity of shape
of the head of the femur, which assumes a mushroom-like form, in con-
sequence of real or apparent flattening of its upper part, and nodulated
masses and flattened  ring-like layers of new bone, surrounding the edge
of its articular cartilage, and extending to a variable distance over its
articular surface.  To this mushroom-like  form, the apparent shortening
of the neck, in consequence  of  its  upper part being concealed by the
overhanging margin of new bone at the edge of the articular cartilage,
also contributes.  2dly. Absence of articular cartilage  to  a greater or
less extent, and the eburnation of  the bony surface.  3dly.  Nodulated
masses of  new bone, from the size of  a hemp-seed to that of a walnut,
attached by thin peduncles to the synovial membrane  on  the neck of
the bone, or to that  of the  capsular ligament—more or less spherical 
CHRONIC RHEUMATIC ARTHRITIS.
677
when small, but flattened and irregular when of large size.  In the os
innominatum.—1st. Increased  capacity  of acetabulum.   2dly. Ossi-
fication of the fibro-cartilaginous rim, or cotyloid ligament.  3dly. Ab-
sence of  articular  cartilage to a greater or less extent, and eburnation
of the exposed bony surface.   4thly.  Irregular osseous growths (stalac-
titic osteophytes)  on  the surface of the bones external to, and imme-
diately surrounding the joint.   In the knee-joint, the appearances were
essentially similar to those in the hip ; new osseous growths, of irregular
form, surrounded the  margins of the articular cartilages of the femur
and tibia; and pedunculated osseous growths, in considerable numbers,
and of all sizes, were  attached to the synovial membrane, both in the
notch and lining the  capsule.   In addition, however, the  articular car-
tilages on the condyles of the femur presented a thickened, nodulated
appearance, in their  central parts."  Mr.  R. Adams, describing  the
condition of the shoulder-joint, says: " The  capsular ligament is occa-
sionally increased in thickness, and its fibres  are hypertrophied; and it
is generally more capacious than natural, showing  that effusion of syno-
via to  a  considerable  amount had existed, although the external signs
of this phenomenon are not  usually evident.  When the interior of the
synovial  sac is examined, it will be found to present evidences of having
been  the seat  of  chronic inflammation.  Bunches  of long organized
fringes hang  into the interior of the synovial sac; and many of these
vascular  fimbriae,  which  in  the recent  state are  of an  extremely red
color, surround the corona of the head of the humerus.   We also notice
rounded  cartilaginous productions, appended by means of membranous
threads attached to the interior of the various structures which compose
the joint."   The size and shape  of  these bodies is various.  The  long
tendon of the biceps muscle is very commonly adherent to the superior
extremity of  the  bicipital groove, while  that portion of  it which nor-
mally passes  upwards, and takes its  attachment to the upper margin of
the glenoid cavity, is  destroyed.  The articular surface of the humerus
is very much enlarged, and  extends itself over the  greater and lesser
tuberosities,  and even over the  highest  part of  the bicipital groove.
The head appears to be  in a line with the shaft of the bone, instead of
being  directed upwards, inwards,  and backwards.   The cartilage is
more or less completely removed, the bone in some  parts eburnated, in
others porous.  Nodules of bone, vegetations, as Mr. R.  Adams terms
them, are thrown out around the  margin of the head.   The glenoid
cavity of the  scapula becomes much enlarged, and, losing its oval shape,
assumes  a  more  circular form.   This, however, depends  much  on the
position which the head of the humerus  occupies.  The depth of the
articular cavity is increased by osseous productions thrown out around
its marcrins;  its  encrusting cartilage is  remoA'ed, and the surface in
part is covered by porcellaneous deposit, in part remains  porous.  The
enlarged head of the  humerus comes into immediate contact, in many
cases,  with the under surface of the coraco-acromial vault, causing ab-
sorption and wasting  of  the tendons of the  supra-spinatus and biceps,
and the upper  part of the capsular  ligament.  The acromion  process,
the outer extremity of the  clavicle, and the coracoid process, in  most
cases become enlarged, though their under surfaces  are worn and ebur- 
673
CHRONIC RHEUMATIC ARTHRITIS.
nated by the friction and pressure of the head of the humerus.  Occa-
sionally, however, they are found atrophied, or altogether removed.  It
is a remarkable circumstance, particularly noticed by Mr. R. Adams
from whose article, in the Cyclop, of Anat. and Phys., we have taken
the foregoing account—that, in many cases, the  acromion process is
traversed in the line of junction of its epiphysis,  "by a complete inter-
ruption of its continuity, as if fractured."  This has  been  considered
by several  observers, as  well as the destruction of the  long tendon of
the biceps,  to be the  result of accidental violence.  Cruveilhier is quoted
by Mr.  R.  Adams as describing the bones  of  the carpus, in a case of
chronic rheumatic arthritis  of the wrist-joint,  to be  so  confounded
together into an irregular mass that it Avas difficult to say  which  part
each took in the construction of the carpal region.   The radius and the
ulna undergo like changes to those which have been described above;
the lower surface of the latter, confronting the cuneiform bone, becomes
smooth  and polished, the inter-articular fibro-cartilage having been re-
moved.   The nature of  the changes  taking place in this  disease have
been admirably investigated by Mr. J. Adams, from whose communica-
tion to the Pathological Society, 1850-51, p. 156, we extract the following
account.  Rokitansky regards the morbid process as an inflammatory
rarefaction, attended with swelling and softening of the bone.   " After
furnishing an osseous exudation within the texture of the bone, and all
around, an exudation Avhich  may be distinguished by its form  and
chemical composition,  it terminates in consecutive induration."   Mr.
Adams, from his examinations, arrives at a  different  conclusion.   He
believes the process  to consist: " 1st, in hypertrophy  of the  articular
cartilage, generally occurring  at the circumferential margin, but occa-
sionally taking place towards the central parts of the articular surfaces.
The  new growth of  cartilage  takes  place principally,  if not  entirely,
near to the articular  surface."  It is  very similar, though  not quite
identical with the original cartilage, a fibrillated character of the matrix,
and the scattered, solitary, or imperfectly grouped arrangement of  the
nuclei being the principal points of difference."  2dly,  "in the develop-
ment of true osseous tissue  in the hypertrophied  cartilage, ossification
commencing either in the newly-formed cartilage  or at the junction of
the new with the old cartilage.  Ossification proceeds more  rapidly in
the newly-formed and forming cartilage, for  its  groAvth is probably
simultaneous with the advancing ossification than in the old articular
cartilage ; so that considerable masses of new bone are formed, altering
the configuration of the articular extremities, whilst a layer of articular
cartilage remains in its normal position.  More  slowly, but as perfectly,
ossification takes  place in this  imbedded layer of articular  cartilage.
The  process resembles the normal process of ossification in  temporary
cartilage in the  intercellular  matrix being the  primary seat of earthy
impregnation,  and in the enlargement of the cells in the  immediate
vicinity of the bone."
   Effects of Dislocations.—The most common  cause  of dislocations is
a violent strain or injury to  the part; but they may also come to pass
spontaneously,  either from abnormal relaxation of the ligaments   or
from destruction of them in consequence of disease and muscular inac- 
/
                MORBID  CONDITIONS  OF BURS.E.             679

tion.   Dislocation, it is  affirmed, may also occur  congenitally.   What
we wish to notice here is,  the  changes which take place in the articu-
lating surfaces when a dislocation has taken place and remained a long
time unreduced.   Rokitansky describes these as follows:  "The capsule
becomes enlarged, and the place of its insertion altered;  the articular
cavities of the bones increase  in size, and undergo various  changes in
form; and corresponding alterations are produced in the articular heads
or prominences.  In other cases, in which the dislocation is complete,
the capsule wastes, and the bony cavities diminish in size, or are filled
with masses of new  osseous substance; the displaced head of the bone
loses its character, and a  new joint is formed.   The cellular structures
which  surround the dislocated head inflame, and  frame a new capsule
around it, which, for the most part, fits closely, is of fibroid structure,
and has a serous lining; whilst the pressure of the head,  in  its new po-
sition, occasions a shallow, articular excavation beneath  it.  In  other
cases, instead of an excavation beneath the head, a mass of callus springs
up  around it, and forms either a hollow to receive it or a level surface,
which  the head  may be flattened in  order to  fit;  or, lastly, the callus
may project, and that which Avas  the  articular head be  excavated to
receive it.  Sometimes the quantity of new bone deposited around a dis-
located head  is  very abundant, and retains it  firmly in its  place.   In
dislocations of long standing, the pressure upon the vessels  and nerves
interferes with the nutrition of the  luxated bone, and, like  the soft parts,
it is found in a state of atrophy."
   Morbid  Conditions of Burse.—These  small synovial sacs are liable
to be affected much  in the same way as larger.  They may be attacked
by inflammation, more or less acute, or  quite chronic, resulting from
rheumatism, the abuse of mercury, or some other constitutional affection,
or  excited by violence or  long-continued  pressure.  The  effusion which
takes  place  may, in cases of a  chronic  kind, be a simple  synovial or
serous fluid; but, when the inflammation is more acute, it  is either a
turbid serum, with flakes of fibrinous matter floating in it, or actual pus.
Suppuration sometimes is produqed artificially, for the purpose of causing
the obliteration  of the cavity of the bursa.  The matter sometimes makes
its way directly to the surface of the skin, and  is discharged;  but it
often, also,  escapes into  the  surrounding cellular  tissue,  and  diffuses
itself over a considerable extent.   Sir B. Brodie describes this as being
of  common occurrence after inflammation of the bursa patellae, so that
an abscess is formed between the  skin  and the  fascia," covering the
whole of the anterior part of the knee, and liable to be confounded Avith
inflammation of the synovial membrane of the joint.  When severe in-
flammation supervenes,  after the  puncture of a  large bursa, so  much
constitutional disturbance  is sometimes occasioned that the patient dies.
This is more likely to occur  in persons who are in a state of bad health.
The walls  of an inflamed bursa sometimes become prodigiously thickened
by the organization of layers of fibrinous effusion.  There is a specimen
in  the Museum  of St.  George's, in  which  the walls of an enlarged bursa
patellce are more than half an inch  thick,  while the cavity, which is  com-
paratively small, is  traversed by reticulating laminae of false membrane.
"When the inflammation has been of long standing," Sir B. Brodie says, 
6S0
MORBID CONDITIONS OF BURS^E.
Fig. 356.
"it is not unusual to find, floating in the fluid of the bursa, a number of
loose bodies, of a flattened oval form, of a light-brown color, with smooth
surfaces, resembling small melon-seeds in appearance.  There seems to
                       be no doubt that these loose bodies  have their
                       origin in the coagulated lymph which was effused
                       in the early stage of the disease; and I have had
                       opportunities, by the  examination  of several
                       cases, to trace the steps of their gradual forma-
                       tion.   At first, the coagulated lymph forms ir-
                       regular masses,  of no determined shape, which
                       afterwards, by the motion and pressure of the
                       contiguous parts, are broken down into smaller
                       portions. These, by degrees, become of a regular
                       form, and assume a firmer consistence, and at
                       last they terminate in the flat oval bodies which
                       have been just described."  The synovial sheaths
                       surrounding the flexor tendons of the fingers, as
                       they pass under the  annular ligament, are not
                       unfrequently the seat of increased secretion of
                       fluid, and of the formation of small bodies, com-
                       pared by Mr. R. Adams to grains of boiled rice.
                       "They are found in vast numbers in the same
                       cyst, mixed with a more  or less considerable
                       quantity of glairy synovial liquid." They occa-
                       sion, as they move to and fro, a distinct sensation
                      quite identical with those  described by Sir B.
 Enlarged bursa over the patella,
the result of pressure.  House-
maid's knee.
of frottement, and  are
Brodie.
   What  are called ganglions, are small  collections of fluids in bursal
cavities of new formation.   They  are most frequent on the back of the
wrist and forearm.   They do not seem to arise from inflammation, but
rather to be of the nature of simple  cysts.  They are slightly movable,
indolent, and painless, and appear  to be situated "in the reticular tissue,
which immediately covers the sheath of the extensor tendons."  To the
latter they are connected firmly, to the skin but loosely.  The consistence
of their contents varies from that  of limpidity to that of thick jelly-like
matter.1   According  to Velpeau, these cysts  occasionally communicate
with the articular synovial cavity.
  1 Some fluid of this kind, which we examined, was coagulated, in great measure at
least by nitric acid; it contained a few nucleated granulous corpuscles. 
THE PATHOLOGICAL  ANATOMY  OF  THE
                OSSEOUS  SYSTEM.
                   CHAPTER  XLII.

                  PRELIMINARY REMARKS.

  The peculiar rigidity of the bones, and the  large amount of  earthy
matter entering into their composition, as well as a certain difficulty of
making such close and frequent examinations of them as of other tissues,
rendered their pathology a terra incognita, until John Hunter demon-
strated the close  analogy which  exists between morbid  changes in the
hard and soft textures of the body.   While we detect with comparative
ease variations in  the consistency,  vascularity, and structure  of  the
latter, the determination of these points in bone is scarcely ever at-
tempted, unless we have to deal with very manifest lesions, owing to the
greater physical  difficulty which presents itself; hence our knowledge
of the early stages of disease, and of the accompanying changes, is less
satisfactory than it might be.  Fine sections for microscopic examina-
tion necessarily alter the relation of,  or destroy, the soft parts that enter
into the constitution of bone, and therefore deprive us of one important
element in the diagnosis of  morbid change.  Still, much  remains to be
done in regard to investigating and describing alterations perceptible to
the naked eye, and establishing the  links connecting certain bone dis-
eases Avith certain lesions of the system at large, with  which  we are
already well  acquainted.  The labor  necessary  to gain this point is pro-
bably greater than will be performed in the dead-house of an ordinary
hospital; and we must not expect a full solution of such recondite ques-
tions of morbid anatomy until we have established endowed professor-
ships, which may enable the incumbents to devote their  energies  and
time solely to scientific purposes.
  We have passed over the consideration of monstrosities  in other parts
of the frame, or  of their diseases during the foetal period.   In our re-
marks on the deformities occurring  in after-life, we shall  have occasion
to allude  to some congenital malformations which are  persistent; it
would, therefore, be inconsistent to review in detail  the intra-uterine
anomalies affecting the bone.  After birth, the  functions of the bones
may be said to remain almost dormant for some months;  but a  process
of  hardening and consolidation is preparing them for the  greater tax 
682
PERIOSTEUM.
that is to be made upon them when the infant learns  to shift for itself.
It is at this period that our attention is occasionally called to the state
Of the bones, from their development  not  taking place in a ratio with
the general evolution of the frame.  Instances are recorded of a preco-
cious ossification of parts  that normally are only membranous  or carti-
laginous in infant life;  but they are unusual.  Thus, the fontanelles may
close prematurely, or  the epiphyses and shafts  of the long  bones be
united by bone.   Derangements are much more  frequent in the oppo-
site direction ; an arrest of  osseous growth being caused  by a general
defect of nutrition more immediately acting upon  the process of ossifica-
tion, or inducing  morbid states which indirectly affect the  bones.
                          PERIOSTEUM.

  The intimate anatomical and physiological relation of the periosteum
to the subjacent bone renders it advisable first to consider the affections
to Avhich it is liable.   In many instances, the  pathologist would proba-
bly find  it impossible to determine whether disease  has commenced in
one structure or the other ; the more so, as periosteal  morbid action may
be followed by similar products as we see arising from primary disease
of the bone.  Incipient  inflammation of the membrane is characterized
by a red blush, a humid  succulent appearance, and more or less of a
serous effusion,  causing  a slight separation from  the bone.  The perios-
teum may, as Lobstein1 observes, be seen to present this condition in the
vicinity of chronic ulcers or of.  old  cicatrices.   As the inflammation
advances, the connection between the membrane and the bone  becomes
more lax, and the effusion exhibits a purulent  character; or the separa-
tion may have  been so sudden  and extensive,  especially in adynamic
individuals, that, as Dr. Copland shows, before suppuration has time to
supervene, gangrene of  the periosteum and necrosis  of the bone result.
An inflammatory process in the periosteum is also essential to the repro-
duction of bone after fractures, or other lesions of continuity calling for
repair.   The membrane is peculiarly obnoxious  to syphilis and rheuma-
tism—diseases Avhich are prone to fasten upon the fibrous investment of
the bones, and induce various secondary disturbances of a more or less
serious character.  Both chiefly  affect the more superficial parts; the
periosteum of the skull, the sternum, and  the  tibia, being  the points
most  commonly attacked.   Syphilitic inflammation, or  at  least that
which occurs in the course of syphilis, whether  as a result of the virus
or of the  mercurial treatment, is apt  to occur in  numerous detached
spots,  at which tumefaction,  induration, the  formation of new  osseous
matter, and necrosis, present themselves.   Mr. Stanley2 remarks, that
the hardness of a syphilitic node does not in itself indicate its composi-
tion, as he has  found supposed osseous nodes  to prove mere indurated
periosteum.  He also states that the pericranium differs from the fibrous
investment of other bones in never becoming ossified.  Rheumatic perios-
1 Anatomie Pathologique, vol. ii. p. 83.
2 On Diseases of the Bones, p. 346. 
PERIOSTEUM.
683
titis, like the former, presents chiefly the chronic type ; it is more liable
to occur in the vicinity of the joints, placed here to induce a peculiar
form of bony deposit, to which Ave shall again refer.   Another  form of
periostitis is that frequently met with in cachectic and scrofulous sub-
jects; it is of a sluggish character, causing  greater  thickening of the
membrane and closer adhesion to the bone, followed by suppuration in
the tissue, and underneath or upon it.  The  small amount of pain and
constitutional irritation resulting from a lesion, Avhich, under  other cir-
cumstances, or in  other constitutions, would give rise to violent symp-
toms, is remarkable; while, in a therapeutic point of view, the curability
of even very extensive lesions of this type affords a better ground  for a
favorable prognosis  than we should expect a  priori.   This applies also
to the cases in which scrofulous periostitis is followed by exfoliations of
the subjacent bone ;  in these cases, there appears to be generally a coinci-
dent  formation  of new bone, sufficient  to  prevent not only a  loss of
strength, but even a deformity.   In a practical point of view, we should
look upon these local manifestations of the scrofulous cachexia rather as
a tendency to concentrate diseased action at a distance  from vital organs;
they ought  not, therefore, to be hastily interfered with, but should  be
regarded rather as a safety-valve to the system, which may be allowed,
and even encouraged to act, until the system itself is sufficiently invigor-
ated to elaborate all morbid action.   The rapid evolution  of scrofulous
affections of internal organs, after the cure of the disease just  spoken
of, as Avell as the arrest of the former by a local and superficial eruption
of the disease, is of  too  frequent occurrence to permit a doubt of the
influence exerted upon the system by scrofulous periostitis.  One of the
forms of scrofulous periostitis not unfrequently met with, is that giving
rise to  the severer forms of panaritium or Avhitlow; the periosteum of
the phalanges being the seat of inflammatory action.  The longer the
duration of periosteal inflammation in any part of the body, the  more
likely it is that  the  subjacent bone will become more or less affected by
the process—a circumstance easily explicable by the physiological rela-
tion existing betAveen the two.   It is probable that a large number of
the osteophytic, and other osseous growths which form upon the bones
under various circumstances,  are more immediately the result of perios-
titis.   The large share which this membrane takes in the regeneration
of fractured bones, and  in the  repair of loss of substance  from  other
causes, as shown by surgical observation and  physiological experiments,
tends to confirm this view.  An examination of the preparations of bones
sawn through, contained in  pathological  museums, further establishes
the point.   Thus we see in St. George's Museum (prep. A. c.  10, H.),
a femur considerably enlarged from inflammation; it is in  fact a case of
eccentric hypertrophy; but the section exhibits  the shaft of the  bone,
though more compact and denser than normally of the ordinary dimen-
sions, traceable through the deposit which has  been derived from the
periosteum.   This deposit, in its turn, exhibits a  cancellous texture ad-
joining the original surface of the femur, bounded by a compact lamella
in contact with the periosteum.   Here we could scarcely assume the new
osseous  matter  to have been directly formed by  the  old bone, because
in that case we  should expect to see either a more entire fusion  between 
681
BONE.
the old and the new formations, or the latter presenting a more complete
identity with the former.
   Females are liable  to  a peculiar form of periostitis, especially after
parturition; Mr. Stanley, who has drawn attention to this point, states
that it is remarkable on  account  of  the  severity of its effects, and on
account of its liability to cause an error of diagnosis;  it effects the
pelvis, and mostly its posterior part; and when  it occurs  near the hip-
joint, its symptoms so much resemble those of disease of the joint, that
the two are apt to be confounded.  A correct diagnosis is material, as
the affection is very amenable to  treatment.
   Mr. Stanley describes a malignant disease of the periosteum, which
he has met with on the bones of the hip, and which he attributes to long-
continued and repeated attacks of inflammation, altering its structure,
and giving rise to the growth of a fungous excrescence upon the mem-
brane.  This is sometimes soft and flocculent on its surface, Avith a firm,
grayish, gelatinous base; at others it consists throughout of a firm gela-
tinous substance; it is both sensitive and vascular, and appears to possess
a considerable tendency to involve the adjacent bone and soft parts;
after removal by operation, the disease is apt to recur in the adjoining
tissues; it does  not, howeA^er, appear,  from the cases recorded  by Mr.
Stanley, that secondary formations of a similar character occur in  other
parts of the body; and he himself mentions one case in which, twenty
years after the removal of a leg affected with this disease, the individual
continued in  perfect health.

                              BONE.

   Authors commonly commence the consideration of  the  pathology of
bone  by an investigation of hypertrophy and atrophy—two  conditions
which are associated with, or are  consecutive  upon, various  primary
lesions; they are rather an element, or a symptom of diseased action,
than  the disease itself.   The terms  may be  objected  to, when Ave find
them indiscriminately applied to  morbid  conditions essentially  distinct;
thus, hypertrophy is  used to designate the increase of osseous  matter,
resulting from the physiological demands made upon the shaft of a long
bone, after it has become curved  by  rickets, as well as to the numerous
forms of bony growths, of a compact or cancellated structure, which we
meet with upon the surface of the skeleton.   Again, authors use atrophy
as a generic term, under which they class  diseases so remote  in  their
character from one another, as absorption  from pressure of  a tumor,
and mollities ossium.   Under such circumstances, language is rendered
rather a source of confusion than a  means of intelligence; and it be-
comes a question whether it would not be  advisable  to  eliminate from
special pathology terms  which  indicate a single element in  morbid
changes, or rather the result  of  morbid processes, than the nature  of
the process.   With this disclaimer, we shall first describe inflammatory
conditions of bone, and incidentally devote a few  remarks to hypertrophy
and atrophy, but confine  their application  solely to  an increase  or  a
diminution in the normal size and constituents of the bones.
   Occasions are  sometimes presented of viewing the various  stages of 
BONE.
685
inflammation in bone;  and it is manifest that the osseous textures are
subject to an increase in their vascular contents as are  other  organic
tissues.   The greater vascularity affects chiefly the lining membrane of
the medullary and  cancellous portions; the ordinary symptoms of in-
flammatory action may be noted in  their incipient stages in surgical
practice, but are scarcely seen in the dead-house, except  in conjunction
with more  advanced disease in  adjoining portions  of the  same  bone.
The first appreciable inflammatory changes in bone, to use Mr. Goodsir's
words, "occur within the Haversian canals; these  passages dilate, or
become opened up, as may be seen on the surface of an inflamed bone,
or better, in  a section.   The  result of  this enlargement of the canal is
the conversion of the contiguous canals into one cavity, and the conse-
quent removal  or  absorption of all the osseous texture  of the part."
Some softening  is  obseryed to follow inflammation  in  its early stages,
and this will be accompanied by tumefaction, at  first of  a more succu-
lent, subsequently of a more indurated character.   Acute inflammation
rarely takes  place, except associated with mechanical injury; the dense
structure,  and the necessarily slower process of effecting a change here
than in  the  soft tissues, are the reason why disease of the bone  com-
monly presents  itself in the chronic form.  The results  of progressive
inflammation are  congestion, exudation,  suppuration, caries, necrosis,
with the coincident, and in many instances, as  it were,  accidental, in-
crease of bone in adjoining parts.   An enlargement of the affected por-
tion is almost invariably met with, and may arise either from the changes
which take place in its interior, or by a deposit  on  its surface, or from
both.   The specific character of the disease in which the inflammation
 arises determines whether the compact or spongy parts, the  shafts or
 the epiphyses,  of bones are effected,  while the part of the  skeleton
 attacked is likewise in  a measure dependent upon certain uniform ten-
 dencies  exhibited by various diseases.   The
 spongy  and medullary portions  have  the
 greater  proclivity to  take on  inflammatory
 action, and of the hard bones,  those that lie
 nearest  the surface are the most liable to be-
 come inflamed.  Unless resolution  of the first
 or congestive stage takes place, an exudation
 of a rose-colored lymph, of a gelatinous ap-
 pearance,  is effected,  which as we  may ob-
 serve in the  same preparation, passes through
 a variety  of shades, light-red, yellow,  green-
 ish, or  white, filling up the cancelli,  or ex-
 panding the Haversian canals.   This exuda-
 tion,  in its turn,  is   absorbed, or  becomes
 organized and  converted into  new bone, or,
 yielding to  the continued  morbid action, a
 destructive process ensues.  In the case  of
 its absorption,  or of an arrest of the process,
 the parts  may  return to their normal  condition, or the  bone retains a
 permanently disorganized  condition, which may present either an in-
 creased condensation and induration, or an abnormal  rarefaction of the
Fiar. 357.
Microscopic drawing of inflamed and
      softened bone. 
686
BONE.
bone.   Of the former, we have a good instance in the minute structure
of gouty bone, where, as we are informed by Mr. Ure,1  the  Haversian
canals are enlarged, and choked up with cretaceous  matter, which also
lines the medullary canal; the osseous corpuscles are also found to  be
larger than  usual, rather irregularly scattered, and less distinct, and
their canaliculi loaded with chalk, which is shoAvn by analysis to be true
carbonate  of lime,2 and not like the tophi of adjoining articulations,
phosphate of'soda; Mr. Ure  states that he has found similar  appear-
ances in a femur of a person laboring under rheumatic arthritis.   The
latter, the rarefied state  of bone, is that to which  the  term of osteo-
porosis was given by  Lobstein.   This is a condition3  commonly met with
in rickety individuals, though  it is  also found in advanced life, in sub-
jects who do not  appear to be otherwise liable to rachitis.   The  affected
bone presents an increase  of size, and a diminution of  density, owing
to the  tissue being expanded;  the surface of the bone is irregular, and
very porous.  The periosteum, however, is  not altered, nor do the sur-
rounding textures exhibit any pathological changes.   The medulla may
be healthy, or changed in color and consistency.   The canals of Havers,
and the cells, will be  found enlarged according to the seat of the injury,
the gradual expansion inducing a thinning  of  the surrounding  osseous
layers,  and  eventually a communication betAveen  adjoining  cavities.
The condition may affect  the  compact  or  cancellous  tissues alone  or
together.   When the cortical layers are the seat of the change, the ap-
pearances may induce the resemblance of caries.   Lobstein  describes
the surface in this case as being covered with a multitude of longitudinal
fibres,  resembling those  of a foetal  skull.  He attributes them to the
development and the  action of the periosteal vessels, Avhich hollow out
for themselves channels in the osseous substance.   When this variety of
cortical rarefaction is raised  above the surrounding  tissue, it resembles
one form  of osteophyte, and  many of the  preparations  of caries pre-
served in museums are referable to the same head.   The rarefaction  of
the osseous tissue which constitutes  osteoporosis, though often inducing
a considerable increase of  bulk,  is essentially distinct  from the  process
giving rise to the formation of exostosis, in which the generation of new
osseous matter is the characteristic feature;  the former being essen-
tially an atrophic, the latter an hypertrophic, condition.  The term spina
ventosa, though one which has nothing but the prestige of antiquity  to
recommend it, is  applied, among others, to affections belonging to the
class just considered.   We will not seek to  perpetuate it  by defining its
characters, as it is an arbitrary designation, without any acknowledged
and established meaning.   Osteoporosis gives  rise  to fragility of the
bones affected with it, and undoubtedly takes its  origin in many of the
dyscrasise which impair nutrition; though we meet with it occasionally
in old age, as a mere effect of  mal-nutrition, without  any well-marked
symptoms  of a constitutional  crasis, or of inflammatory action.  An

  1 Lancet,  1847.
  2 In preparing sections of bone it is not unusual to employ putty powder; if some of
this insinuates itself  in the Haversian canals, we should necessarily find some carbonate
of lime, which might mislead the observer.
  3 See Lobstein, Anatomie Pathologique, vol. ii. p. 116. 
BONE.
687
analogy undoubtedly exists betAveen the forms of disease just adverted
to and mollifies ossium, but the latter presents so peculiar  a type, and
Fig. 358.
Fig. 359.
Suppuration in bone.
Abscess in bone.
is so evidently remoA'ed from anything like a local affection, or from in-
flammatory causes, that we reserve its consideration for the sequel, and
Fig. 360.
Fig. 361.
^ljccos? in bone.
Abscess in bone. 
688
CARIES.
Fig. 362.
now turn to examine the phenomena of suppuration, and the formation
of abscess in bone.   This may be diffused, or circumscribed, as in soft
parts.   It is secreted by the medullary membrane, and  in its  turn  ex-
cites more or less reaction  in  the surrounding textures.  The diffused
form is the most dangerous, and may arise both from severe mechanical
injury, and from constitutional causes.  It is commonly associated with
phlebitis.   The  pus occasionally penetrates the  bone,  and an  escape
                  having  been  thus effected,  a  cure  may be brought
                  about without loss of limb, though  the partial death
                  of the bone will necessarily result.   In circumscribed
                  abscess  we find a cavity, generally in or near the epi-
                  physes,  lined with a vascular membrane.  A process
                  of condensation or ossification is seen to take place
                  in the vicinity of the abscess,  while there is thicken-
                  ing of the adjoining periosteum, and  the surround-
                  ing cellular tissue.   It is probable, as Mr. Stanley
                  remarks, that circumscribed abscess is in some cases
                  attributable to the softening  of tubercular matter,
                  analogous to  a pulmonary vomica, and that the con-
                  tents may be discharged, leaving a cavity resembling
                  a tuberculous cavity of the lungs. The circumscribed
                  abscess, to use the words  of the same author, usually
                  remains of small size,  but in  some  cases it has  en-
                  larged much  beyond the natural limits of the bone.
                  Such an enlargement of the abscess is not the effect
                  of simple expansion of the walls of the bone;  for in
                  some of these cases  the  osseous wall of the abscess
has increased in  thickness with the  enlargement  of the cavity.  The
process consists of the combined action of absorption  on the  inside of
the abscess, and of osseous deposit on  its outside, whereby its osseous
walls may acquire any degree of thickness,  according to the  predomi-
nance of absorption in the one direction,  or  of deposit in the other.
 Limited  internal ab-
scess in lower part of tibia.
Sfction of bone.—Prepared
in Royal College of Sur-
geons' Museum.
CARIES.
  Chronic suppuration accompanies ulceration of bone, or, as it is com-
monly called, caries, a slow absorptive  process, which may occur in all
bones, and every part of their structure, but is most liable to attack the
cancellous tissue.  The bone presents a more or less  eroded and cribri-
form appearance, and while absorption  removes the tissue at one point,
the surrounding parts are more vascular and tumefied than in the normal
state, and the adjoining bone is commonly the seat of new osseous deposit;
or the softening process extends to  a distance, and the bone is converted
into a soft, pliable mass.  The more the earthy matter has been absorbed,
the fewer the number of osseous corpuscles  that remain; until they dis-
appear altogether, and in their place we see only a granular substratum,
with faint traces  of the lamellar structure.   The secretion is of  a sani-
ous, acrid,  and fetid character, owing to the decomposition which takes
place, and  which is of diagnostic value during life, in determining tbe 
CARIES.
689
Fig. 363.
existence or non-existence of disease of the bone.  The discharge also
contains minute portions  of bony matter, showing the disintegration
that is proceeding; and it is very frequently mixed up
with a grumous, flaky matter, resembling tubercle, evi-
dencing  the scrofulous character  of the  disease.   The
discharge is apt to discolor the exposed bone, and itself
become of a dirty brown, after exposure to air, as well
as to blacken the tissues and probes brought into con-
tact with it.  Caries may commence in the interior of
a bone,  as well as on the surface.   In the former case,
it commonly makes its way outwards.   When the caries
is superficial, the Haversian canals are  enlarged, and,
to use Rokitansky's description, the tissues within them
form, in part, a disorganized, soft, and  shreddy mass,
infiltrated with ichor,  or spongy granulations, which
easily bleed,  grow from them luxuriantly, and advance
outwards, over the rough surface of  the bone,  whilst,
internally, they partially or completely fill the enlarged
Haversian canals.   In both cases,  the  bone appears
porous  or cancellous, but its  color differs  in  the two.
In the  former, it is discolored by the contents  of the
Haversian canals;  in  the  latter,  it obtains  various
tints of red, from the color of the granulations.  When
 caries affects cancellous tissue, the bone acquires a livid
red  color, especially if  the  granulations be  at  all
 abundant; it becomes soft, resembles a mass of flesh, traversed by a
 delicate and brittle bony skeleton, and is  easily  cut  with a knife, or
 yields to light  pressure with a finger;  lastly, it  becomes swollen.   Ihe
 analogy of caries to ulceration of soft parts,  is manifested in the mode
 in which a cure is established,  as  well as in its destructive stages.  A
 healthy stimulus being set up,  the absorption  is converted into a repro-

                                          Fig. 365.
Caries.
 Caries of the elbow; mainly
affecting the condyle of the
humerus. The vegetative ef-
fort around the carious sur-
face well exemplified.
     44
 Necrosis and caries combined; in phalanges of the toes. In the
upper, the carious cavity is represented as still containing its se-
questrum. In the lower, the cavity and sequestrum are separate. 
690
NECROSIS.
  Example of caries in the metatarsal bone of the great toe. Two carious ulcers ; each surrounded by
               interstitial absorption as well as by attempts at reparative effort.

ductive process; the granulations  restore the  lost  parts, if the chasm
does not offer too great a tax upon the system,  or the cicatrix is formed
Avith more or less loss of the original substance.


                               NECROSIS.

  Though  caries often  accompanies necrosis,  the  latter is  as distinct
from the former, as mortification differs from the ulceration of soft parts.
Necrosis consists in the death of a portion, or an entire  bone,  resulting
from  various internal  or  external  causes, which  destroy  its  vitality.
The necrosed part presents  a dead white or  waxy hue, or  a greater

                                  Fig. 367.
  Necrosis of the head of the femur, acetabulum, and shaft, subsequent to amputation.  A. Necrosed aceta-
bulum and head, completely anchylosed and broken off at e from the neck. /, Remains of the articular sur-
faces, closely united,  b. Neck, and upper part of the shaft,  a, New bone; 6, new bone undergoing necrosis;
c. bone still containing bloodvessels, and in various stages of inflammation; d, a membranous septum, marking
the boundary of the dead and living bone.

intensity of discoloration passing through various shades of green, brown,
and black; changes attributed to the influence of the atmosphere, or of
the decomposing pus, though not necessarily due to either.    The limits
of  the necrosed portion are not always  easily defined, and,  at all times,
its outline is  extremely irregular.   It attacks chiefly the compact tissue,
and is, therefore, most frequently met with in the shafts of long bones, 
NECROSIS.
691
from which it rarely extends into the epiphyses, though instances of its
doing so are on record, as in the case of the tibia;  in the instance from
which Fig.  367 is taken,  the process is seen to extend through the neck
of the femur into the head of the bone, and even  to affect the innomi-
natum.   The relative frequency of its  occurrence in different bones, is
stated to be in the  following order:  the tibia, the  femur, the humerus,
the cranial  bones,  the  lower jaw, the  last  phalanx of the finger, the
clavicle, ulna,  radius, fibula, scapula,  upper jaw, pelvic bones, sternum,
and ribs.   Though a reparative process is commonly set up in the vicinity
of the dead bone, which consists partly, in an attempt at separation and
elimination; partly, in  the  reproduction of new osseous matter around
the necrosed portion, the  effort  of nature rarely suffices for this purpose,
Fig. 368.
  Fig. 368. Necrosis of the femur, after amputation. At a, the sequestrum in process of separation. At 6,
the parent bone enlarged, and undergoing inflammatory change, necessary for detachment and repair —
Lis ton.
  Fig. 369. The sequestrum detached; at its lower part, a, including the whole thickness of the bone.  Gra-
dually shelving upwards, as such sequestra usually do.—Liston.
  Fig. 370. Sequestrum; seen laterally; the external portions smooth, the internal rough and irregular.—
Li-iton.

and it is necessary  that  surgical interference should aid in the  removal;
othenvise, the powers of the individual will  probably be exhausted by
the continued  drain upon the system.   A  remarkable  instance of the
capabilities of an unaided constitution occurred to us, while investigating
the effects  of  the powers  of phosphorus in  producing  necrosis of the
maxilla.  A man came under our notice, in whom the destructiAre process
had caused death of the body and rami of the lower jaw to such an ex-
tent,  that the  entire bone, with the exception of the condyloid processes,
came to lie loose in the  cavity of the mouth ;  a new jaw having, in the
Fig 369.
Fig. 370.

 
692
NECROSIS.
interval, formed underneath, and not, as is usually the case, as a capsule
to the necrosed part.  The patient's mouth  not being of sufficient size
for the extraction of the bone, he sawed it across with  his own hand,
and then extracted it with ease.   It is, however, rare for the sequestrum
to be so completely separated from the living tissue by the inflammation
and suppuration set up in its vicinity, and we even have much difficulty
in determining sometimes, in the dead  body, the  limits of necrosis,  as

          Fig. 371.
 Fig. 371. Acute necrosis of the tibia. The bone extensively perished at o; the cortical formation has begun
to form.  Fibula, as usual, unaffected.—Liston.
 Fig. 372. Necrosis of tibia, more advanced. Cortical formation investing the greater part of the old bone.—
Liston.
 Fig. 373. Necrosis of tibia, in the chronic stage. Cortical, or substitute bone complete, and consolidated.
At several points cloacae seen, leading down to the sequestra.—Liston.

its boundaries are  imperceptibly lost in the healthy parts.   Rokitansky
describes the process of separation in the following words:  " All round
the necrosed portion, that  is to say, at its margins and  at the part
where its surface is exposed to that of the  healthy bone, the latter un-
dergoes  a gradual expansion, or rarefaction of its  tissue, by the en-
largement of its Haversian canals, assumes a  rosy color, and becomes
succulent.  It gradually acquires an areolar structure, and is thus more
rarefied; at length  it disappears altogether, and a red, soft, spongy
substance, a layer of granulations,  occupies its place.   This  change is
produced by  an inflammatory  process, which gives rise to suppuration
and granulation; the bony tissue, beginning with the Haversian canals,
is dissolved by  the matter secreted  within them, while the granulations
Avhich shoot forth  at the same time, fill up the enlarged canals.   The
immediate result of this process, is  the formation of a furrow of demar-
Fig. 373.
 
NECROSIS.
693
Fi». 374.
 Necrosis of tibia. At a,
the dead bone exposed. At
& b, the papillae repre-
sented,   communicating
through cloacae with the
sequestrum.
cation, which encircles the margin of the dead bone, and is filled up with
granulations, and, so far as the process is completed
on that surface, also of the living bone, which faces
the dead, so far is the sequestrum separated."  This
process further establishes the analogy existing be-
tween necrosis of bone, and the mortification of soft
parts, while the description just quoted corroborates
John Hunter's opinion, and the investigations of Mr.
Goodsir.   At the same time, the irregularity of the
necrosed portion, and the luxuriant growth of granu-
lations  from the healthy part, often cause so close a
dovetailing of the two, that it resembles actual or-
ganic union, which has misled some observers in their
conclusions respecting the nature  of the  process.
Mr. Gulliver has shown, by his experiments, that
dead bone may be mechanically introduced  into the
shafts of a healthy animal, and that a firm  adhesion
may be established between  the  two ;  hence, it is a
just inference that, after the  morbid  process is ar-
rested, and  a  physiological  healing  act set up, the
sequestrum may be retained  as an innocuous foreign
body.   The experiments of Mr. Gulliver were  also
 undertaken  with a  view to  determining a question
 long agitated, whether or  not bone,  once  dead, is
 liable to be  reduced by  absorption; and his results
 give a  decided negative to  this doctrine, which had
 probably arisen from the circumstance that an exfoliated portion of bone
 is  always  smaller than the  cavity from which it is removed, owing to
 the softening  and suppuration in the healthy bone, which has allowed
 of the  removal of the former.
    The process of reparation varies according to the seat of the necrosis
 and the parts implicated.
    Necrosis in the outer lamellae of a bone, when accompanied by de-
 struction  of its coverings, including the periosteum, is described by Mr.
 Stanley as giving rise to the following changes: thickening and consoli-
 dation of the inner lamellae of the bone;  inflammation of the surrounding
 periosteum, occasioning  osseous deposit beneath the membrane and in
 its tissue, and  in this way the  dead bone  becomes circumscribed by a
 thick projecting border  of new osseous substance.   By this means  the
 loss of substance is made to appear even larger than it really is.   When
 the necrosis commences within the bone, a large deposit of osseous matter
 generally takes  place under  the periosteum, and in  this manner  the
 sequestrum comes to be inclosed in a capsule,  which is perforated with
 openings  termed cloacae; these are not filled up until the dead bone has
 been removed.  After  this has  taken place, granulations spring from
 the inner surface of the shell, and  the cavity is  gradually filled with
 bony matter; so that, instead of a hollow shaft, we find a solid cylinder.
 A remarkable fact in connection with cloacse has been pointed out by
 Mr Goodsir  viz: that they are almost invariably opposite a smooth or
 unaltered portion of the surface of the dead shaft, and that they result 
691
NECROSIS.
from the pus thrown off  from the granulating internal surface of the
new shaft  making its way  to  the exterior, by  those  parts  not yet
               closed, in consequence of having been opposite to por-
    Fig. 375.     tions of  the old  shaft, which had not afforded separate
               osseous centres.   For those not familiar with Mr. Good-
               sir's researches, we may add that this fact is one upon
               which he bases  his doctrine, that  the  reproduction of
               new bone depends not so much upon the periosteum as
               upon the spicule of bone which remain attached to it,
               and which act as centres of ossification.   "When the
               entire shaft  of  a bone," he  says,  "is  attacked  with
               violent inflammation, there is generally time, before
               death  of the bone takes place,  for the separation of
               more or  less numerous portions of its surface.  When
               the entire periosteum has separated from the  shaft, it
               carries with  it  the minute portions of the surface of
               the bone.  Each of these is covered on its external sur-
               face by the periosteum; on its  internal, by a  layer of
               granulations, the result of the organized matter which
               originally filled  the Haversian canals;  the  gradual en-
               largement and subsequent blending of which ultimately
               allowed  their contained vascular  contents  to  combine
               with the layer  of  granulations just described, and to
               form the separating  medium between  the dead shaft
               and its  minute  living remnants.   These  minute sepa-
               rated  portions,  after  having advanced somewhat in de-
               velopment, appear, when carelessly examined, particu-
     cioacae.      larly in dried specimens, to be situated in the substance
               of the periosteum, and have been adduced by the advo-
cates of the agency of that membrane in forming new bones as evidences
of  the truth of their opinions."
   Mr. Stanley's views differ from those of the just-named author, inas-
much as he attributes the main ossifying power to the periosteum itself,
though he  does not deny that a capability for restoring lost bone resides
also in the portions of original bone, detached from its surface and re-
maining attached to the periosteum, in the articular ends of the original
bone and the soft  tissues around the periosteum, or  around the bone, if
the periosteum has been  destroyed.
   The surface of  the  new bone  is  at first very irregular  and rugged;
and, if a section be made, the central cylinder and the external capsule
exhibit a well-marked boundary.  The more time has elapsed for the
curative process to have been established, the more the normal appear-
ance of the surface is restored,  and the more completely the separation
is  obliterated.   The period in which the necrosis  and the subsequent
reproduction take place varies much, both according to the cause of the
lesion and the constitution of the individual.  The more rapid and com-
plete the death of a portion of  bone, the more  speedily, on the whole,
the reparative process is found to take place; while a sluggish and pro-
tracted dying of the osseous tissue, especially when resulting from causes
connected  with a  cachectic state of the  blood, or other  constitutional
maladies, will be followed by a slow process of regeneration.
 
RACHITIS.
695
                             RACHITIS.

  The most important and prevalent disease of mal-nutrition—to employ
the most general term that suggests itself—which we have to consider in
the osseous system, and which modifies the characters of other maladies
that supervene, as it tends to affect the entire bodily frame, is that known
as rachitis, or rickets.   While frequently associated with inflammatory
conditions, it is  not essentially an inflammation;  and,  while one of its
symptoms is  a diminution of the consistency of the osseous  texture,  it
neither exclusively  consists in rarefaction of the bone, nor does it mani-
fest those organic  and chemical changes which constitute the peculiar
disease known as mollities ossium.  Owing to one feature having been
regarded by different observers as characteristic of the disease, analogies
have been repeatedly set down as proofs of identity.   While a general
debility is the chief constitutional feature of the disease, a  deficiency
in the earthy matter of the bones is the chief local phenomenon ; yet, as
Fig. 376.
Fig. 377.
Section of a rachitic tibia, from the King's
         College Museum.
  Section of the femur of a rickety child cut with a knife.
The shaft consists throughout of cartilaginous and gelatinous
substances, intermixed and disposed in cells;  it is observable
that a greater quantity of cartilage exists in the middle of the
shaft, and towards the interior curve, than at any other part.
—St. Bartholomew's Museum, i. 34.
Mr.  Stanley correctly suggests, the rickety bone is  not simply a  soft
bone, but it undergoes, during the development and subsidence of the dis-
ease 'a series of curious and somewhat complex changes.   The affection
is especially one of early childhood; the first symptoms being commonly
manifested at the period when we expect the child to leave its mother s
arms and  to assert its independence.  Guenn found  that, of 346 cases,
209  were  affected between the first and  third  years; only three were 
696
RACHITIS.
congenital;  and 34 occurred between the ages of four and twelve ; 148
were males, and 198 females.  We commonly first perceive a change in
the conformation of  the lower extremities, which is commonly referred

            Fig. 378.          Fig. 379.                 Fig. 380.
Rickets affecting the femur.                Rickets affecting the tibia.
to premature  attempts at walking,  and  the mechanical effect of  the
pressure of the trunk upon the undeveloped limbs.  That physical in-
fluences, in some measure, determine the curvature, may not be denied;
but that they are but a trifling cause may be inferred from the  often
surprising rapidity with which, during a continuance  of the physical
influences,  but under improved  regimen and medical  treatment,  the
curvatures  are rectified.  A contortion of the bones of the pelvis, of the
spine, the thorax, the upper extremities, and malformations of the  skull,
may follow upon those of the legs.  That the disease does not consist in
a simple absence  of the due proportion of phosphate of lime, is shown
by the coincident  tumefaction of the epiphysis, the swelled joints, which
but too  often add to the deformity just spoken of.  The swelling depends
upon the exudation of a  reddish  serum into the enlarged cancelli and
canals, the  osseous corpuscles, at the same time, exhibiting a deficiency
or an entire absence of earthy contents;  so  that, in cutting a bone thus
affected, the knife meets  with  no resistance.  The  periosteum, at  the
same time, is  pulpy and thickened, and more than usually adherent to
the bone.  The chemical  constitution of the bone appears to undergo a
change  beyond the mere absence of the lime-salts;  the  character of the
cartilaginous framework being  itself altered in constitution.1  There is
  1 In deference to the high authority of Mr. Stanley, and on account of the weight which
his statements necessarily carry with them, we deem it our duty to advert  to°an error 
RACHITIS.
697
a diminution of the salts, varying according to the intensity of the dis-
ease; they may be reduced as low as eighteen per cent., while there is
Fig. 381.
Fig. 382.
                         Rickets affecting the humerus.

a uniform increase of fatty matter to about six per cent.; it also appears
that the fluoride of calcium, of which there is always  an appreciable
amount in healthy bone, is absent in rickets.
  In the  analysis of rickety bones, it is  important to  select the bone
before the  reparative  process is set  up.   When  this  is effected, the
swellings subside, and the distortions may, by the mere improvement of
the general health, be much diminished, and even altogether removed;
or  if this be impossible, a deposit of bone takes place in such a manner
as'to correct the infirmity, and give the patient a limb useful for the
ordinary purposes of life.  The supplementary ossification is found, on
a vertical section of a  long bone, to be chiefly on the concave side; so
that this part of the shaft may present double  and treble the thickness
of  the opposite side.   The structure,  at  the  same time, is very  dense,
and of ivory texture.   In flat bones, as in those of the skull, which is
generally unduly large in rickety  subjects, there is a uniform thicken-
ing which becomes a matter of serious importance in regard to the in-
tellectual development of the individual, when the cranial cavity  is con-
tracted.   That this is  the case in  many  cases of idiocy, and especially
in that form to which cretinism leads, is very probable.  In some in-
stances the thickening of the bone affects the capacity of the foramina;
thus it' has been  observed that  the foramen ovale has been narrowed

 which has crept into his chapter on Rickets (Stanley on the Bones p. 218). He states
 «  ♦ in riJkete it has been shown that the cartilage yields neither chondnn nor gelatin ;
 ^s is based upor? an analysis given in Simon's Animal Chemistry (Syd. Soc. Ed. vol. u.
 p. 407), of a case of osteo-malacia, and not of rachitis. 
698
RACHITIS.
by an  enlargement of the  base of the occipital foramen in  epilepsy.
In this disease, osteophytic projections are frequently met with, which,
however, do not come under the head of rickety productions.  A pecu-
liar form of disease of the  cranium has been described by Elsasser,1 as

                                              Fig. 384.
            Permanent curvature of the spine, with rotation, produced by rickets.

occurring in rachitis, and characterized by softening, thinning, and per-
foration of the occiput.   The bone  is atrophied, soft, and porous;  and
numerous openings are observed along  the  lambdoidal suture, and in
the body of the bone,  with the exception of the oecipital protuberance.
The perforations may amount to as many as thirty; and in place of
bone, they are filled up only by the dura mater  and pericranium, which
are  adherent to one  another.   It  is not  necessarily a fatal  disease;
about one-half of the  cases  are said to  prove fatal under symptoms of
cerebral and spinal irritation.   The  affection commonly manifests itself
between the third and sixth month of infant life; the child exhibiting
much restlessness, and a fear of all  contact with the occiput.   If it sur-
vives, the usual rickety distortions of the skeleton supervene.
   To conclude the subject of rickets, and to avoid repetition, we will at
once examine the malformations  to which  it gives rise in the  various
parts of the skeleton.
   We have  already had  occasion to allude to curvature of the lower

  1 Der weiche Hinterkopf, ein Beitrag zur Physiologie und Pathologie der ersten Kind-
heit.  Stuttgart, 1843.
Fig. 383.
 
RACHITIS.
699
extremities;  it is one  of  the  most ordinary symptoms of rachitis; it
varies in amount from  a slight deviation of the bones of the leg from
their ordinary shape and direction, to the most extravagant  distortion,
instances of  which are preserved in most  anatomical museums.  The
effect of such irregularity  is to diminish the stature of the individual,
and to render his gait clumsy; but even if  the distortion has been  rec-
tified or anticipated, the effect of the constitutional  derangement is to
stunt the growth.  Mr. Stanley  expresses himself thus on the  subject:
" In long bones,  the defective growth in length is often such that they
are not more than half their natural dimension ;  but in the direction of
their thickness it is not so constant; thus,  thigh-bones, a third or even
a  fourth shorter than natural,  are  often  of  their  natural  thickness.
Occasionally, other phenomena  are  observed in the rickety skeleton ;
some of its bones are distorted, whilst others are of  their natural figure

                               Fig. 385.
                   Example of limbs deformed by rickets.—Liston.

and length;  but from the  failure  of growth  in the direction of their
thickness, are so slender as to present the characters of extreme atro-
phy    In the lower limbs the weakness of the system, which gives rise
to curvatures in the bones,  also occasions a yielding of the ligaments of
the knee and ankle-joints;  hence these distortions of these joints, from
the yielding of  their ligaments,  become  part  of the phenomena  ut
rickets.   And there are instances of such distortions of the knee and
ankle-joints,  unaccompanied by any bending of the bones.1
1 Stanley on the Bones, p. 224. 
700
RACHITIS.
   The distortions of the pekis resulting from rachitis constitute a sub-
ject deserving the  serious attention of the  accoucheur; their bearing
upon the health and life of the married female ought to stimulate  the
medical man to have an especial regard to the prevention of pelvic mal-
formation in the female child.   A sort of natural protection appears to
be  afforded to the pelvis  against the inroads of rachitis, for  numerous
instances are recorded in which  indiA'iduals, with well-developed rickets
in the lower extremities and spine,  escaped any distortion of  the pelvic
bones.   With few exceptions,  the irregularities of the pelvic  diameters
are due to rickets; they  are  caused by lateral contraction, by an  ap-
proximation of the acetabula, by antero-posterior narrowing, from an
advance of the sacrum,  or by an  asymmetrical  deformity, due to an
arrest in the growth of one-half of the pelvis.  In all these cases  the
mechanism of parturition will be interfered with in  proportion to  the
amount of malformation,  and it is  the brim which will be found to be
chiefly at  fault, though each part individually, or all collectively, may
be involved in the  deformity.   " In most cases of partial deformity at
the  brim,"  observes Dr.  Ramsbotham,1 " the  lateral  diameter is  in-
creased in size nearly in the same proportion as the conjugate is dimin-
ished;  but however much  the  width from ilium to  ilium may exceed  the
ordinary dimensions, the increased space thus obtained will in  no degree
make amends  for the diminution from the sacrum to the pubes; because
it is necessary that there  should not exist less than a certain quantity
of available room  in every direction to permit  the  child's transit."
From the sacrum having to support the entire spinal column,  the lower
lumbar vertebrae and the base of the sacrum are very apt to be thrown
forward where there is deficient cohesion, and the consequence will be a
diminution of the conjugate diameter.  In this case the diameter of  the
outlet is frequently found  enlarged.  The ilia will  not present the usual
expansion,  the crests of the ilia will be nearer to one another  than in a
normal pelvis, and the female will probably also present a hollow-backed
appearance.  The sacrum  is commonly deprived of its concave  form, and
exhibits a  more rectilinear anterior  surface, or as Smellie has  observed,
the vertebrae that  compose it ride  over  one another, and form a pro-
tuberance  in the part that  ought to be concave.   These malformations
cause those varieties in the form of  the pelvis, which have been termed
the  elliptical, heart, or kidney-shaped, or figure of eight pelves.    An
oblique form, in which the ilio-pectinal eminence of one side approaches
nearer to the promontory on one side than on the other, was first shown
by Nagele to result from anchylosis  of one sacro-iliac symphysis; these
pelves present a very  characteristic appearance, and look as if one half
of the  pelvis and the  acetabulum had been forcibly pushed over to  the
opposite ilium ; hence, the diameter from the sound sacro-iliac union to
the opposite acetabulum will be very much diminished, while the interval
between the anchylosed symphysis and the other acetabulum will be  not
only not  diminished, but even increased.  An excellent delineation of
this  and several other forms of distorted pelvis are to be found in Dr.

          1 The Principles and Practice of Obstetric Medicine, p. 39. 
SPINAL CURVATURES.
701
Ramsbotham's Atlas  of Midwifery.1   The rickety distortions  of  the
pelvis are probably never met with unaccompanied by spinal curvature;
though  the latter may occur without materially influencing the pelvic
diameters.

                      SPINAL CURVATURES.

   To one variety of spinal curvatures we have already alluded, that in
which there is a projection inwards of the lumbar vertebras—lordosis.
This, however, is not  ordinarily a primary affection of the spine,  but
one secondary to a curvature that has formed higher in the column, and,
owing to the sigmoid form of the normal spine, calls  for a compensating
inclination in the opposite direction, which will  necessarily take place
Fig. 386.                           Fig. 387.
Front view of lateral curvature of spine.            Back view of same preparation.
where  there is  a  natural tendency forwards.  It may  also result se-
condarily from obliquities of the pelvis and coxalgia, which would, how-
ever act differently from the last-named lesion, inasmuch as they would
induce a lateral deA'iation, as well as a projection forwards; in so far,
therefore, we differ from Mr. Shaw's views, who states that rickets have
no share in producing lateral curvature in females.  The main primary
curvature of the spine belonging to rachitis, and the one that is more im-

  i The Principles and Practice of Obstetric Medicine and Surgery, &c, by Francis  H.
Ramsbotham, M. D., London, 1841. 
702
SPINAL CURVATURES.
portant than any other, on account of the frequency of its  occurrence,
as well as on account of the misery it inflicts upon the patient, and the
great deformity produced, is  kyphosis, also known as the angular cur-
vature, Pott's malady, or the hump-back.  This is almost  invariably the
result of inflammation and caries of the bodies of one or more of the
dorsal vertebrae, or of their intervertebral substances, causing a collapse
of several vertebrae, and consequent backward projection of their spines,
and an approximation of the corresponding ribs.  This disease univer-
sally commences early in life; preA'ious to, or about the period of, second
dentition.  A backward curvature  occurs later in life as the  result of
senile atrophy of the bodies of the vertebrae, Avhich has nothing in  com-
mon with the angular curvature of rachitis.  Lateral  curvature of the
spine, or scholiosis, is rarely of a rickety character—it may be primary
or secondary ;  and presents an illustration of the law of  compensation,
equally with  the curvatures previously considered.   To avoid returning
to the subject of spinal curvatures, we add the following remarks on this
deformity.  The primary curve generally occurs in the dorsal, while the
compensating curvature, in the opposite direction, is found in the lumbar
region; and  as the former is most frequently to the right, the latter, as
a legitimate consequence,  is most often to the left side.  This distortion
chiefly affects the female sex, and may be brought on by irregular  mus-
cular contraction, or by deficient action of the muscles of one side of the
trunk, whether owing to  want of  exercise, or  actual  disease, such  as
pleurisy,  or  a  paralytic affection.   When  the  deformity results  from
rickets, the primary curvature will probably be found to  have taken
place in  the lumbar region, while  the  dorsal  is  secondarily affected.
The various  malformations of the spine, which we have considered, are
not always isolated;  but may be complicated with one another, as  they
are associated with deformities of other parts of the skeleton. That the
thorax should be implicated whenever the dorsal vertebrae of the spinal
column are affected, may be inferred from the relation the latter bears to
the cavity, as well as to the ribs and the sternum combining to form it.
   The most  common malformation  of the thorax consists  in a flattening
of the  sides, with a projection of  the sternum, and a swelling  of the
sternal ends of the ribs;  this gives rise  to the so-called pigeon-breast.
It is very frequently, but not necessarily, associated with angular  curv-
ature  of the spine; for,  in some cases of this disease, the ribs are
raised and not flattened, and the lower end of the sternum, instead of
being forced out,  is actually drawn in,  owing  to  the ribs not  being
lengthened,  and  the thorax, in consequence, assumes  a  more globular
form.  The  thorax, in all cases of rickety distortion, approaches the
pelvis unduly, and  the abdominal cavity will  thus be diminished.  A
 depression of  the  sternum is  very common in rickety subjects; the
whole length of the bone being marked by a more or less deep furrow,
while the ribs are curved  outwards.   In both cases just mentioned, the
 sternum does not deviate  from the mesial line; a displacement of this
bone, as well as of the thoracic parietes, accompanies lateral curvature
 of the spine; in this case, to employ the description of Rokitansky, the
 thorax seems displaced in the opposite direction to the convexity of the
 dorsal curve, and the whole, or more commonly the  lower  end only of 
SPINAL CURVATURES.
703
the sternum, swerves from the mesial line  in the same direction;  the
axis of  the thorax itself inclines towards the convex side of the dorsal
curve.  One consequence of this deviation is, that that half of the thorax
which is on the convex side  of the curve is lower than the other, and
approaches  the pelvis; when there  is considerable curvature, the false
ribs touch the ilium, or even project into the iliac fossa.  But, in extreme
cases  of combined  lateral  and posterior curvature in the  lower dorsal
region,  the thorax assumes the contrary position; the ribs which pass
from  the concavity of the curve, force the  chest to the opposite,  the
convex  side; the sternum diverges in the same direction, and the sunken
half of the thorax  is  that on the concave side of the curve.  The ribs
are packed closer together on the concave than on the convex side; hence
the dimensions of the two lateral halves of the thorax are much altered ;
the one on the  concave side being contracted in its antero-posterior,  but
enlarged in its  lateral  diameter, while the reverse is  the  case on  the
convex side.  The ribs, independently of any morbid change of structure,
suffer considerable  changes  in form and outline in these  deformities;
becoming more or less flattened, and being more or less turned on their
axis, according to the dislocation of the vertebrae.  The scapulae follow
the distortion of the spine, and also  exhibit other evidence of being  the
actual seat  of  textural derangement.   The  upper extremities  present
similar  distortions  to those  seen  in the lower  extremities in  very  ad-
vanced  cases of rachitis;  the bones are ill developed, flattened, and
variously curved, while the epiphyses are enlarged.  Dr. Farre1 states
that he  has  met cases in which the upper extremities were  bent  by
rickets, when the lower extremities and the  rest of the body exhibited
no signs of the disease.  If any further proof were required that rickets
is essentially a  constitutional disease of the same family as scrofula and
tubercle, and that its phenomena are not the mere result of mechanical
pressure, such  cases as those of Dr. Farre would afford it; still, it is
important not to overlook the physical influence of the weight of  the
body in promoting  distortions, as we thereby obtain a valuable indica-
tion for treatment; for, while everything should be done to correct  the
vitiated state of blood, it is wise at the same time to remove  all unneces-
sary strain or pressure from any part of the frame, and to afford such
support to the weaker points as mechanical ingenuity may suggest.
1 Quoted by Mr. Stanley, loc. cit. p. 226. 
CHAPTER  XLIII.
                   ADVENTITIOUS GROWTHS.

  Under this head we shall consider the various enlargements of an
homologous  character, termed exostoses and  osteophytes, and among
which  we may also class  enchondroma, as well  as  the heterologous
growths met with in bone.   Bony tumors are commonly treated  of as
hypertrophies; we adopt our arrangement  partly for convenience, and
partly because, as we have  already stated, there  is a broad distinction
between the increase of the normal texture from mere hyper-nutrition,
and the grotesque and extravagant forms springing out of various mor-
bid conditions, to which we  shall have  to advert.  Besides, the various
forms of so-called hypertrophy are so frequently complicated with  other
diseased conditions, that it is impossible to determine which group pre-
dominates ;  nor can an arrangement of  the tumors of the bone, as Mr.
Stanley observes, be founded on the place of  their origin, since many
of them, identical in nature, arise indifferently from the periosteum, the
compact, or the cancellous tissue of bone.
                         ENCHONDROMA.

  We follow the example of Mr. Stanley, and consider, first, the abnor-
mal production of cartilage in connection with bone; or, as it has been
termed, by Professor Muller,1 enchondroma.   It consists essentially of
the same chemical and  microscopic  elements as true cartilage, and
occurs more frequently in bone than  in any other physiological tissue
of the body; the bones of the fingers and toes being chiefly liable, though
the ribs, vertebrae, and  sternum are not  exempt;  and cases are re-
corded where the skull, the ilium, and the long bones have been attacked.
  Muller refutes the theory of its belonging to the family of  scrofula,
and attributes it to a peculiar formative process in bone, in consequence
of which the embryonic primitive formation of cartilage takes place, and
is kept up without the attainment of consolidation, or the more perfect
organization of the products.  The enchondroma  appears to possess an
independent vitality;  it is radically cured by amputation, and  appears
never to enter into combination with any other changes in the bone.
  The tumor may originate within the cancellous  tissue, or on  the sur-
face of  the bone.  The rapidity and extent of its growth varies, but
generally it is  of slow progress, and does  not exceed the  size of an

        1 Ueber den feineren Bau der Krankhaften Geschwulste, 1838, p. 31. 
ENCHONDROMA.                       705
orange.   When  seated  within the bone, the latter  gradually expands
with the development of the tumor, yet it is unaccompanied  by pain or
disorganization of  the adjoining parts;  when  external to the bone it
exhibits a lobulated arrangement, and is surrounded by a fibrous sheath.
  The central variety presents a semi-elastic feel, and, on section, the
knife passes through a thin crackling shell of bone, and then exhibits a
white cartilaginous mass, which  is occasionally found to contain some
small cells,  while, in some tumors there is an  interlacement of fibrous
tissue, in which the cartilage is imbedded, thus  approximating to fibro-
cartilage.   They may be solitary, or occur in large numbers in the same

      |                         Fig. 388.
 Enchondroma.  Portion of the tumor removed from the lumbar vertebrae of a soldier, consisting of nodules
of cartilage of various forms, with the microscopic features of fcetal cartilage. In the centre of some of the
nodules there are small portions of cancellous bone; the centres of others are softened.—St. Bartholomew's
Museum, xiv. ii.

individual.   A remarkable instance is  recorded in the Reports of the
Pathological Society of London,1 of a boy, in whom the slightest blow
produced tumors of this kind.   At the time of observation, he presented
fifteen or sixteen of these swellings, on the fingers and metacarpal bones,
one of which had attained the size of an orange, and required  removal,
solely on account of its bulk.   The superficial variety, though microsco-
pically and  chemically identical with the central form, is characterized
by the absence of an osseous shell;  it is met with chiefly in the pelvis,
on the cranium and the ribs.  Lebert, who confirms the descriptions and
all  the details of Muller, gives  some cases which fell  under his own
observation, one of  which is particularly  interesting, as showing  the
development of the cartilage,2 the characters of which were  not at once
apparent to the naked eye from the highly vascular  condition of  the
tumor.   There is, generally, no disposition  to ossification, though Roki-
tansky states that he has observed this metamorphosis in the aggregate
variety.   The disease is  chiefly met with in early life, and  appears to
be commonly due, as Muller has shown, to mechanical injury interfering
with the  due development of bone at that period.   A case, accompanied
by a  delineation, in  which there  was partial ossification, is given in
Vogel's Pathological Anatomy?

                  •  1848-49, p. 113.
                  2  Physiologie Pathologique, torn. ii. p. 212.
                  3  Dr. Day's Translation, 1847, p. 582.
       45 
706
EXOSTOSIS.
                           EXOSTOSIS.

  Osseous growths, consisting of true bone, are divided into exostoses
and osteophytes; the difference being marked rather by their form and
their  cause, than by the etymology of the terms, or their  proximate
constitution.   As no theory is implied, and no false impressions are
likely to arise by their employment, the names are more suitable than
any other that we might select.  Rokitansky defines exostosis as a purely
bony mass, set upon a bone, forming with it  an organic whole, and,
where it is possible, originating or proceeding from the bone; Avhen its
development is complete, and often at the beginning  of its  growth, its
texture  is homologous with that of its base and point of origin, whether
compact or spongy.  The former is the most frequent;  and it attains a

                              Fig. 389.
Several ivory exostoses clustered on the os frontis.
hardness which has given rise to the term of Ivory exostosis; while its
color is generally whiter than that of  the bone from which it springs.
Of the density of these exostoses  the best proof is  that operators are
sometimes unable to remove  them; in  St. George's Hospital Museum
we find an exostosis from the orbit which sloughed off on the application
of caustic, though Sir Astley Cooper had previously  failed in  sawing it
off; there is another specimen in the same museum about one inch and
a half  in diameter, which took one hour to remove, and more than one
saw was spoiled during the time.   The exostosis may be entirely sessile,
or it resembles a mushroom in its mode of growth, presenting a constric-
tion at its base, which, though it may penetrate deeply, is so  fine as to
be imperceptible during life.   Rokitansky so absolutely denies the com-
plication of the compact and  spongy exostosis, that we must  specially
refer to an instance which was exhibited at the Pathological Society of
London,1 in  1850, and which was  remarkable  both  on  account of its
size, and because the base and pedicle were compact, while the remainder
was cellular.   The surface of these exostoses is smooth, and  their out-
line is  commonly a segment of a circle, or of an ellipse;  their cause is
an idiosyncrasy of the individual, not referable, as far as  we can trace,
to any definite constitutional taint.  Some of the  hard exostoses we
1 See Report for 1850-51, p. 149. 
EXOSTOSIS.
707
meet with are manifestly mere hypertrophies of the normal prominences
of the bone upon which they are seated; thus, we see the tuberosity of
the tibia, the styloid process and similar parts, give rise to these forma-
tions ; an instance occurs in the malum coxae senile, where an exuberant
Fig. 390.
Fig. 391.
 Spongy exostosis on the femur, with a broad base and
pointed processes directed downwards; the section
shows a cancellous structure, surrounded by a shell of
compact bone. The walls of the femur and the medul-
lary cavity, in the situation of the exostosis, are per-
fectly sound.—St. Bartholomew's Museum, i. 186.
Exostosis of the femur.
development of bone, probably owing to an arthritic process, takes place
on the trochanter, and round the neck of the former, which it entirely
overhangs.   The bones of the skull are  the  most ordinary site of hard
exostosis; it is also seen in the long bones, and in the pelvis, where they
may prove an obstacle to parturition.  The microscopic appearances are
described by Rokitansky as exhibiting  a very considerable number ot
peripheral lamellae, in which long corpuscles are observed.   The Haver-
sian canals are small, and far apart, many of them being surrounded by
a distinct and  isolated system of lamellae ;  large tracts present no cor-
puscles, while at other spots they are clustered together in dense groups.
No new tissue is discoverable in the ivory exostosis.
   Spongy exostoses differ from the compact variety, in being composed
nf cancelli  containing medullary matter, and  surrounded by a shell of
bone  tW vary much more  in size and outline than  the former; they
soring from the cancellous or compact tissue of the bone, and their sur-
face fs continuous with that of the latter.  In some cases the medullary
cavUy of the bone is immediately continuous with that of the exostosis, 
708
OSTEOPHYTES.
so that this resembles a  diverticulum.   The  spongy exostosis occurs at
all periods of life—when it has attained a  certain  size it generally re-
mains permanent.   Rokitansky describes a process of  condensation
alternating with one of rarefaction; it is by the latter that he considers
the growth of the spongy exostosis outwards  to be  chiefly affected.


                          OSTEOPHYTES.

   The osteophyte was first characterized by Lobstein as a bony vegeta-
tion which grows  from the surface of the bone, or  encircles  the articu-
lations, and offers the most varied forms.   It is distinct from exostosis,
in not forming well-defined local tumors that are  more or less circum-
scribed.   It is not developed between the layers of the compact tissue,
and their surface is rough, while  the texture  appears to differ more
from that of the matrix than  it does in the exostosis.   The  osteophyte
sometimes bears a  close resemblance to certain forms  of coral.   The
osteophyte chiefly  affects  the  more  vascular portions of  bones,  as

                                Fig.  392.
 Osteophytes, occupying the lower end of the femur. The whole exterior of the bones is roughened by the
growth of irregular plates and pointed processes of osseous substance. A large canal, formed by ulceration,
passes through the bone just above the condyles;  around the lower part of each condyle is a broad rim of
new bone.  From a man aet. 35, with long-standing disease of the bone.—St. Bartholomew's Museum, i. 201.

their articular ends, their rough lines, or, in  the  skull, the sutural car-
tilages ;  because, as Rokitansky remarks, it is generally the  product of
an inflammatory process  in the superficial  part of the bone, and in  the
periosteum; and hence  it is very  commonly found  adjoining and sur-
rounding not  only  portions which are inflamed, carious, or necrosed, but
also spots of  bone  affected with various  other diseases,  which,  in  some
stage of their existence,  have occasioned a reaction in the tissue of  the
bone.   Thus, we may refer  the  osteophyte, in  an individual  case, to
simple inflammation, to rheumatic or gouty inflammation, to  syphilis or 
OSTEOPHYTES.
709
other causes.   Gluge1 appears to admit one variety of osteophyte only,
which he describes under the term of osteophyton gelatinosum, as form-
ing by the ossification of a fluid, gelatinous mass, effused on the surface
of the bone; the mass consists of granular cells, which are successively
converted into cartilage and bone-corpuscles, which are disposed in rows,
or layers, forming lamellae or spiculae  at  right angles to the bone; a
reddish jelly-like fluid  continues  to  surround the new bone, which is
sometimes discharged in  large quantities, and thus induces the erroneous
assumption that we have to deal with carcinomatous degeneration.
   The diffused and fibro-reticular  osteophyte of Lobstein, or what Ro-
kitansky terms the velvety villous osteophyte, forms  an osseous layer
investing a bone that is otherwise  healthy, sometimes  removable, some-
times firmly soldered to it; it commonly presents the color of the bone,
or it may be discolored; by a  lens  it is found to present a furrowed
surface, or to be composed of minute upright spiculae; the small chan-
nels which separate the osseous ridges being in the direction of the ves-
sels of the periosteum.   This variety is a very common accompaniment
of  inflammatory affections of the bone—it is the one which Rokitansky
has observed to occur in  females dying shortly after parturition, and
has, therefore, called the  puerperal  osteophyte.  The subject has  not
attracted the notice of English pathologists, but the authority of Roki-
tansky's name renders some attention to it  imperative.  The  layer of
new bone, he says, varies  in thickness from a very thin film to half a
line, and more; generally  occupies the  frontal  and parietal bones, but
is sometimes found covering the whole inner  surface of the cranial vault,
and scattered in patches  over the base of the skull.  It exhibits  the
same mode of  development as other forms of ossification; it  presents
itself in all females who die either of puerperal disease, or from other
causes, after the third month of pregnancy, or shortly after parturition.
The complete  incorporation of  the  exudation with the old bone causes
an increased thickness of  the latter, which is rendered more evident by
repeated pregnancies.   Rokitansky appears to regard  the puerperal
osteophyte as  a uniform  accompaniment of pregnancy; he does  not
seem to refer any of the sympathetic symptoms of this condition to the
deposit, nor does he  state that it is ever reabsorbed; but he enforces
his position by the contrast which the frequency of  this growth in wo-
men who are pregnant,  or have been  recently confined, offers with  its
rarity in other persons.  Exudations,  he says,  are  deposited  on the
vitreous table in both sexes and at all ages,  but  they are less extensive
than the puerperal osteophyte, and  are usually confined to the neigh-
borhood  of the longitudinal furrow.  Rokitansky's  second variety of
osteophyte is the splintered or laminated form, presenting itself in ex-
crescences  and lamellae  several lines  in  length,  of  a conical shape,
and terminating in a sharp point, which are found chiefly m the neigh-
borhood of the cancellous parts of bone affected with caries.
   The next form of osteophyte which we have to consider is that which
appears to be mainly the result of gouty and rheumatic affections; it is
distinguished by forming  excrescences  of a warty and stalactitic cha-
' Atlas of Pathological Anatomy, Art. Osteophyte.  American Edition. 
710
FIBROUS GROWTHS.
racter, which are developed in the vicinity of joints of persons laboring
under those diseases; the articular surfaces may be partially absorbed
and  present patches of  enamel-like  deposit,  while the  new osseous
formations are thrown out, as it were,  to support the defective mechan-
ism.   The osteophyte produced under such  circumstances sometimes
surrounds the joint and gives rise  to a bony anchylosis.   The bodies of
the vertebrae are frequently found united to  one another by osseous
vegetations extending over two or more  bones, like bridges; they are
analogous to the  callus uniting  fractures, but appear to be the result of
some  constitutional  cause.  Similar bony ridges  are  also  observed to
form between the ribs.
   The botryoidal, or cauliflower osteophyte, is described by Lobstein as
a large sessile tumor, which  is more  or less compact at the base, and
becomes spongy towards the surface, sometimes attaining the size of the
head of a seven-months' child;  it occasionally merely forms  a capsule
to other heterogeneous matter, such as scirrhous, fibrous, fungous tumors,
and the like.  Lobstein's  general theory of osteophytic growths is, that
they consist mainly of an ossification of the tissues surrounding  the
bone;  according  to this  view, the diffused osteophyte  is nothing  but
ossification of the cellular tissue, uniting the periosteum to  the bone;
the fibro-reticular osteophyte an  ossification of the periosteum itself;
the flat and styloid form the ossified tendinous  and aponeurotic fibres;
while the botryoidal variety, and that  causing  anchylosis, is  attributed
to ossification of the inter-muscular cellular tissue; he denies the inflam-
matory origin of the malady, and sets it down to a morbid hypertrophy;
though, in  that  case, it would be  scarcely consistent to speak of ossi-
fication of the various tissues ; but we  should regard it as essentially an
outgrowth from the bone itself.   This it certainly appears  to be in the
majority of instances;  the original constitution  or the  morbid taint,
rendering the bone  a nidus for  diseased  growth; the character of  the
latter is determined by its matrix.  Lobstein's  theory, however, may
be held to apply in those rare cases in which we find the osseous growths
produced indiscriminately in the soft parts and upon the skeleton;  Mr.
Stanley1 relates  several instances of this kind, in which bony growths
have appeared in various  situations and in considerable number, either
simultaneously or in quick succession.   They generally occur  early in
life ; an arrest in the development of the morbid formation taking place
at manhood, there is reason for assuming  an hereditary predisposition.
                      FIBROUS GROWTHS.

  Fibrous tissue is developed within or upon the bone, and gives rise to
tumors, which, in the former case, are  surrounded by an  osseous en-
velop ; they present more or  less elasticity,  according to  the density
of the inclosed growth ; offer a gray, opaque character, and yield gelatin
on boiling; they  occur chiefly in spongy bones, as the articular ends of
long bones in the vertebrae, the upper and lower jaw, the scapula and
On the Diseases of Bones, p. 212. 
OSTEOID TUMOR.
711
ossa innominata.  Fibrous tumors may attain an enormous size : thus, a
specimen  in  St. Bartholomew's Hospital, alluded to by Mr. Stanley,
which grew from  the humerus, measured three feet  in circumference.
Though non-malignant, there  seems to be a tendency to reproduction
after  surgical removal, which has not been observed in enchondroma;
in which growth we noticed the occasional development of fibrous tissue,
and the perfect security from relapse.   Fibrous  tumors and enchon-
droma present  no features by which they may be  distinguished during
life;  the  lobulated surface is not peculiar to the  latter.   Mr. Adams1
exhibited a fibrous epuli springing from the cancelli of the lower jaw,
of the size of an orange, forming a large lobulated mass.
OSTEOID TUMOR.
  A transition  form of osseous disease which  intervenes between  the
simple bony tumors hitherto considered, and the malignant affections of
bone, is  the  osteoid tumor of Professor Muller ;  or, as it is called by Mr.
Stanley, the malignant osseous tumor.  It has been alluded to by other
authors  under various terms;  but  their introduction  would only per-
petuate  the confusion which  in pathology cannot be too much depre-
cated.  Muller describes it thus: The osteoid tumor is irregularly lobu-
lated, and is developed with more or less rapidity from the surface of a
bone, and consists mainly of osseous tissue, in the interstices of which a
non-ossified substance is found of the consistency of fibro-cartilage, which
also forms the covering of these growths; the  bony matter  is more or
less porous, and presents all the characters of true bone, while the other
constituent  offers  a grayish-white  color,  is somewhat vascu ar, and ot
firm consistency, and difficult to tear.  The  microscope displays in it a
dense fibrous network, with minute interstices, containing but tew cells
and nuclei; it is not cartilaginous in structure or chemical composition,
containing neither  gelatin nor chondrin.  These tumors result from a
constitutional diathesis (an  osteo-plastic  diathesis, as it  is termed by
Lebert), leading to a local formation of bone, which, in its  turn, is de-
structive to the  system.   One tumor commonly appears on a bone, and
numerous others subsequently form on different parts of the  skeleton,
and, at last, the osteoid growths are even developed in the soft tissues
whether the primary tumor have been surgically interfered with or  not.
Mr Stanley who gives three  cases of the affection, states  the charac-
teristic features to consist in a tendency to  grow round the lower  part
of the femur, just above its condyles and around the upper part  of the
tibia iust below its head; in a tendency to assume an oblong  rather
than the globular form, which belongs to many other tumors  of bone,
and in theSabsorbent glands, when contaminated in this d1Sease, assuming
the form of hard, isolated, movable tumors.
i Report of Pathol. Society, 1847, p. 114. 
712
CANCER.
                            CANCER.

  Of the various forms of cancer, the encephaloid variety is found to
affect bone most frequently; it occurs either in the infiltrated form, or
in the shape of a tumor.  Either may be primary or consecutive, though
idiopathic cancer of bone is of rare occurrence ; it is particularly liable
to follow mammary carcinoma.   Tuberiform cancer, according to Cru-
veilhier,  differs from infiltrated cancer as lobular from ordinary pneu-
monia ;  uncircumscribed  cancer being more  commonly limited  to  one
bone, or  part of a bone, while carcinomatous tumors are commonly the
result of a cancerous cachexia.  Cancer, in blocks, according to the same
author, exclusively attacks the medullary tissue; infiltrated cancer some-
times affects exclusively the periosteum, the bone, or the medulla, or two
or more at once; the same individual may present each variety of site,
showing the identity of the different forms.
  Cruveilhier considers the compact tissue of bones not in  itself  sus-
ceptible of becoming the  seat of tuberiform cancer; in the few cases in
which it has been found affected, he explains the process by a previous
transformation of  the compact  into spongy bone, a notion regarded by
Dr.  Walshe  as  fanciful.    In  the infiltrated  form of  encephaloid, the
cancelli and  Haversian canals are filled with a  reddish, fatty-looking
substance, which causes an absorption of the  cancellar septa, and thus
becomes  one of the various morbid conditions to which  a great fragility
of the bones is attributable.  A case of primary medullary cancer  of the
femur, which has fallen under  our  notice, and was regarded, during  life,
as a rheumatic affection  of the hip-joint,  exhibited at  the post mortem
a remarkable fragility of the  affected  femur, the neck of which was
broken during removal, the cancellar tissue of the bone appeared rarefied
and filled with a reddish fat, and it was only by the microscope  that the
carcinomatous nature of the deposit, which was peculiarly well marked,
was revealed.   It is doubtful whether the infiltrated may be converted
into  the aggregated form; encephaloid tumors, however, in bone, attain
a considerable size, distending into a cyst, or, according to Mr. Stanley,
in some  rare instances, being  accompanied by increase of  thickness of
the bone, which gives to the tumor  the character of a solid mass  of bone.
Cruveilhier remarks that it  is characteristic of cancer not  to give rise
to any new development of bone.  The  shell occasionally yields  and
breaks,  and,  the growth of the cancer being unimpeded, increases with
sudden rapidity, while  the severe pain is lessened.  The tissue  presents
the characters of medullary cancer; it varies in vascularity;  at  times,
either from the large  number of small arteries  passing through the
growth, or from the vicinity of a  large artery, it puts  on the character
of an erectile or aneurismal tumor; the  diagnosis in this case is of great
importance in reference to treatment, as an erroneous assumption of the
vascular nature of the disease would, as it has done, lead to the appli-
cation of ligatures, a proceeding necessarily useless.   The epiphysis of
the long bones, especially of the femur, the tibia, and the humerus, are
chiefly liable to be affected with medullary carcinoma;  the bones of the
head and  face, the ribs, sternum, and pelvis,  are also subject to be 
CANCER.
713
attacked.  The fragility which was noticed in the individual case before
alluded to is  a quality often spoken  of by authors as associated with
cancer, without determining or assuming the existence of actual carci-
nomatous disorganization of the bone; it is also observed in deep-seated
constitutional affections of a syphilitic, scorbutic, and arthritic character,
Fig. 393.                       Fig. 394.
Osteocephaloma of the head of the humerus, with     Section of tumor; upper end and head of hu-
      spontaneous fracture of the shaft.           merus destroyed, but cartilage of incrustation
                                       unaffected. Tumor divided by white vertical
                                       lines—the periosteum, inside which only were
                                       the osseous spiculae found.
and cases are recorded of extreme fragility as a mere result of old age ;
it is not, therefore, inconsistent to assume that, when accompanying carci-
nomatous affections, it may be the result of an atrophic state resulting
from mal-nutrition, without being necessarily accompanied by any actual
carcinomatous degeneration of  the bone.   Lobstein, who devotes  an
entire chapter to the consideration of fragility of the bones, relates a
case of such extreme  fragility, in an adult female,  that pressure of one
finger on  the head of the tibia caused the bone to give way:  the bones
were  very porous, and a white, milky fluid exuded from them when com-
pressed ;  the cartilaginous basis  of the bones seemed altogether to have
disappeared, and, excepting the  glutaeus maximus, the abdominal mus-
cles  and  deltoid, all the muscular tissue was converted into fat.   Roki-
tansky  who gives a similar case, is of opinion that we have to deal with
a peculiar  form of encephaloid  infiltration characterized by the milky

  The areolar or gelatiniform variety of cancer is occasionally met with
in bone.  Mr. Stanley records a  case affecting the bone of a finger, and 
714
TUBERCLE.
another occurring in a rib.   Rokitansky relates one in which the right
upper  maxilla was the  seat  of  the  groAvth,  and where  the peripheral
follicles were developed into  large cysts.
  Mr. Stanley describes as  malignant a peculiar degeneration of  the
tissue of bone, which appears to  commence in the deposit  of a yelloAV
substance into the medullary canals, changing its  color,  and converting
its texture into a soft,  crumbling, greasy substance ;  small cells  filled
with a glairy fluid, and short white  brittle  fibres, as well as  osseous
granules and  laminae, are found  in it;  and as the  disease advances,
which it does with every feature of malignancy, the morbid deposit ex-
tends  beyond the  limits of  the bone in the form of a circumscribed
tumor.  Subsequently, all the surrounding tissues  are  involved,  the cel-
lular tissue and the adjoining absorbent glands  being converted into a
similar morbid mass.
  Rokitansky describes fibrous cancer as being occasionally met with in
bone.  A malignant fusion of the  bones is described by Lobstein (under
the designation of osteo-lyosis) as a rare disease, in which to a  greater
or less extent  the bone deliquesces,  leaving in its  place a  collection of
matter of different color and consistency, but not offering  any  acrimo-
nious character.  The existence of the disease is admitted  by Rokitan-
sky, who adds that it commences in the diploe, where it forms a cavity,
first inclosed between the compact tables; these  gradually disappear,
leaving an irregular gap, which is covered  by the periosteum, destined
in its turn to become involved; in  this way a bladder is formed, which is
filled with gelatinous fluid.   It is commonly combined with the develop-
ment of cancer in the internal organs.
                            TUBERCLE.

  The presence of  tubercle in bone  is an undoubted pathological fact,
but its frequency has been over-estimated  by some  authors, as it  has
been underrated by others.  In the former case, the error has arisen from
every evidence of osseous disease in scrofulous  subjects  having been
regarded as actually resulting from  the deposit of tubercular matter in
the bone, and from  concrete pus having produced  appearances closely
resembling those presented by tubercular matter.  In a question of this
kind the microscope must solve the doubt; the high authority of Lebert1
on pathological microscopy justifies our giving the following extract from
his  remarks on tuberculization of bone :  1.  When the areolar structure
of the  spongy tissue of bone is yet well preserved, and its meshes filled
with pus, which from  having no vent becomes concrete, it is apt to re-
semble  yellow cheesy tubercle;  when a portion of the fatty matter of
the medulla becomes mixed with  this cheesy substance, the latter offers
a somewhat transparent character, so as to resemble gray granulations;
the microscope, however, will detect  nothing but the elements  of  pus
and fat.  2. We occasionally meet with abscesses in the middle of  a
bone, surrounded by a fibrous membrane.   If the  pus  is unable to escape
Pbysiologie Pathologique, vol. i. p. 473. 
TUBERCLE.
715
by a fistulous passage, it becomes concrete, and then assumes the aspect
of what has been described under the name of encysted tubercle of bone.
3. The cavities formed in the vertebrae, in caries of the spine, ordinarily
contain nothing but a portion  of bone more or less detached, surrounded
by sanious pus.   These are to be regarded as osseous  ulcers, in which
we fail to discover the essential element of  tubercular caverns, viz:
tubercle.   4.  It is a common thing to meet with caseous masses occupy-
ing pouches in front of the seat of vertebral caries, from which fistulous
passages extend and open into the inguinal folds, or elsewhere.  These
pouches contain a grumous matter, which is nothing  but concrete pus
mixed with particles of  bone.   5.  M. Lebert denies not only having
found tubercular  matter,  in those cases of vertebral  caries, in which
there were no  pulmonary tubercles, but states that he  has even  failed
to find it in  those cases  in which several organs presented tubercular
 deposit.
   Rokitansky's and  NeTaton's views  differ materially from those ex-
 pressed by the  author  just quoted; and it will  remain with future in-
 quirers to determine  in how far the limitation given by Lebert is correct.
 Still, the general  laws as to the site of osseous tubercle remain  the same
 in either case.  It affects chiefly the  spongy bones, and the cancellous
 portions of long bones.   An instance of crude tubercle presenting itself
 in the shaft  of a long bone is given by Mr. Hewett in the Pathological
 Reports,1 which we quote on  account  of its extreme rarity.  The indi-
 vidual, a man aged thirty, had been laboring, for fifteen months previous
 to his admission into St. George's Hospital, under  a tumor of the mid-
 dle part of the thigh, supposed at first to be malignant, an opinion which
 was modified when the swelling was somewhat reduced under treatment.
 He died eventually of erysipelas—tubercular deposits were found in the
 peritoneum, kidneys, spleen,  and lungs.   In the thigh, there was great
 thickening and condensation about the cellular tissue uniting the mus-
 cles and in  that between the muscles and the bone; the periosteum, also
 much thickened,  presented on its free surface a large patch of tubercular
 matter, enveloped in a dense cyst.   The bone itself was irregular  in
 shape, much hypertrophied,  and very hard; at this part its medullary
  cavity was filled with tubercular matter, surrounded by gray semi-trans-
  parent lymph, presenting very much  the appearance of the well-known
  granule  of the lung.
    According to the prevailing views, tubercle commonly occurs in bone,
  as the yellow opaque  tubercle deposited in the cancelli, and inducing a
  gradual absorption of the bony septa, so as to lead to the formation of
  larger accumulations; this deposit is  liable to softening by being mixed
  with the products of inflammation, and is thus converted into a scrofu-
  lous abscess, surrounded by what Rokitansky terms ^. lardaceo-callous
  cyst, "which," he says, "is  in fact the tissue surrounding  he softemng
  tubercle, infiltrated with lardaceo-gelatmous material.    If  the tuber-
   ukr matter does not soften it  becomes cretified; we must attribute the
  chalky substance often found in the cancelli, to a retrograde  process of
  this kind.  We should be disinclined to admit, to the letter, Mr. Stanley s

               i Report of tbe Pathological Society. 1850-51, p. 147. 
716
VASCULAR TUMORS.
statement, that no reproductive process ever ensues upon the destruction
of bone by scrofulous disease ; the sluggishness of scrofulous affections
of bone  is notorious, and undoubtedly  in the majority of instances,
whether the destructive process affects the shaft of a long bone, or the
cancellar  structure  of a vertebra, the cure is only wrought with a loss
of substance giving rise to some deformity.   One of the most familiar
instances  is that Arariety of spinal curvature known as Pott's malady, in
which the scrofulous destruction of one or more bodies of vertebrae in-
duces a projection  backwards of  their  spines, and a shortening of the
column.   The  adjoining  soft parts are often extensively involved and
secondary effects produced, which do not at first sight appear connected
with the original malady; thus in scrofulous caries of the spine,  abscesses
form in the surrounding cellular and muscular tissues, which may point
in the lumbar,  sciatic, or inguinal regions, giving rise to lumbar or psoas
abscesses, or, in the case  of scrofulous disease of the hip-joint, we have
necrosis extending  to the  pelvis, or sinuses burrowing down to the popli-
teal regions.

                       VASCULAR  TUMORS.

   Tumors of a vascular  character are occasionally met with  in bone,
resembling those composed of  erectile tissue, or rather  of a  congeries
of bloodvessels, in  soft parts.   Mr. Stanley describes a  tumor  of this
kind that fell under his observation, as bearing a close resemblance to
certain naevi consisting  of dilated bloodvessels,  with a fibrous tissue
occupying their interstices ;  hence, in a section, the tumor presented a
cribriform appearance, the orifices being apparently those of divided
bloodvessels.   Mr.  Stanley regards it simply as a local disease, curable
by removal of the affected part; Rokitansky believes that it is of cancer-
ous origin, from having met with cancer in other parts of the  skeletons
in which it occurred.  This tumor must not  be confounded with  those
enlargements of the bone which  are produced by an accumulation of
blood, owing to rupture of the bloodvessels and consequent hemorrhage
into the cancelli, or between the periosteum and the bone.  Cruveilhier,
who inclines to the same view as Rokitansky, gives  delineations' of a
remarkable case, in which a lady, aet. thirty-eight, of a  good constitu-
tion, and without  hereditary taint, the  mother of eight children, pre-
sented a  dozen tumors of the  size of a walnut, situated  on the  head.
They were soft, and pulsated; the beats were, isochronous with  that of
the pulse, and were accompanied with  a blowing  noise,  similar to one
heard  at  the aorta. There were several  similar tumors in  other  parts
of the body, but those  of the head only proved after death to  belong to
the bones.   They  exhibited  on section  a filamentous areolar structure
filled with blood; the  destruction of the bone  penetrated to  the dura
mater; the absorption of the osseous tissue resembled that produced by
aneurism; on  the external surface there was evidence of an attempt at
repair, in the shape of osseous vegetations.  Cruveilhier is of opinion
that in this case the vascular development took place mainly  at the ex-
Anatomie Pathologique, torn. ii. livr. xxxiii. pi. iv. 
VASCULAR TUMORS.
717
pense of the arterial system; he thence infers a general law that there
are two kinds of erectile tumor, one of a venous, the other of an arterial
character.   He regards the latter as  analogous with fungus haematodes.
  Mr. Stanley describes a sanguineous tumor of bone, always originat-
ing in the cancellous texture, by blood being effused into it, and causing
a gradual enlargement of the cells and absorption of the septa.  The
walls of the bone are thus gradually  expanded into a globular cyst  of
varying thickness and extent.  According to the stage of the disease
the blood is found in cells, intersected by fibres or laminae and fibres,
the remains of the original fabric of  the bone; or, in a more advanced
stage, in a single cyst.   A feeling of fluctuation may be thus  produced,
and gradual ulceration may give rise  to a discharge externally.  These
tumors  occur  chiefly in  the articular ends of bones, and  most fre-
quently within the condyles of the femur or head of the tibia.  A form
of sanguineous tumor of  the head, met with in infancy as a  result  of
the  pressure exerted upon the cranial bones during  parturition, and
known  by the term cephalhaematoma, has given rise to much discussion,
as the symptoms have been variously explained by different observers.1
   It consists of an effusion of blood  between the pericranium and the
bone, and  is most commonly met with on  one  of the parietal  bones.
Rare cases are recorded of an internal  cephalhaematoma, in which the
extravasation took place  between the dura  mater and the bone.  All
authors are agreed that external cephalhaematoma occurs most frequently
on the  right side.   Bednar (quoted by Mr. Willshire) found,  that of  74
examples,  40 were on the right, 22  on the left, 6 over each parietal
bone, 4 on the occipital, 1  over  both parietals, and the occipital, and
1 over  the frontal bone, the latter being the smallest.
   Older writers have regarded it as depending upon an essential  disease
of the bone, owing to the hard ring bounding the  tumor, and inducing
the impression that the bone has been excavated.   A  considerable dif-
ference of opinion still exists as to the exact rationale of its production,
and more  particularly as to the point of the maternal organs at which
the pressure is effected  that  produces the  tumor;  but most  observers
agree as to its being immediately connected with hemorrhage from the
torn vessels;  the blood coagulates, and a  reparative process is  set up,
which  causes a fibrinous pad at  the  circumference, which, in its turn,
may ossify, if  absorption  does  not ensue rapidly.   Whether or not a
diseased state  of the fcetal  bloodvessels may predispose to the affection,
is a question which is answered in the affirmative by some, while it is
denied  by others;  it is  certain that  the chief argument of a primary
disease of the  bone  is destroyed by the more careful analysis of cases  by
recent  observers;  showing the ring of bone either not to exist at all, or
else to be a secondary ossification of the coagulum, accompanied by an  in-
flammatory process.  This, according to Rokitansky, commences at the
margin of the  denuded  part, and produces the deposit of bony matter in
the form of a velvety or finely filamentous osteophyte.  It appears that

   1 A good rtsumi of their opinions is given by Dr. Willshire, in the tenth Tolume of the
British and Foreign Medico-Chirurgical Review, July, 1852, p. 6. 
718                           CYSTS.
artificial interference commonly becomes necessary for  the  removal of
the coagula, suppurative inflammation  being otherwise  liable to  set in
and give rise to carious destruction of the bone.
                              CYSTS.

  Cysts  occur very rarely in bone.  A very remarkable instance is
described by Mr. Keate,1 in which a large tumor in the frontal bone of
a young woman, aet. 18, was  formed by the  development  of hydatids
between the plates of the bone.   Frequent attempts to destroy the cyst
and its contents, by escharotics, after removal of  a portion of the ex-
ternal  osseous sheath, failed;  and the  constant  sprouting  out of fresh
hydatids at last induced Mr.  Keate to saw off the entire  tumor, after
which  the  girl  completely recovered.   The  diameters of  the exposed
surface were four and a half by four inches.   In the very compact and
hard bony substance, forming  the  base of the tumor, were five or six
cells containing hydatid  cysts.  It appears  that from these  cells  the
hydatids were constantly regenerated, forcing their way into the large
cavity  of the tumor,  and yielding to no treatment,  as the  remedies
failed to destroy the matrix from which they pullulated.
  Mr.  Stanley quotes some cases from his own experience, and that of

                               Fig. 395.
      Osteocystoma, of large size; occupying lower end of femur.—Prep, in University Museum.

other observers, from which it  appears that  the bones of the skeleton
are all  equally  liable  to  be attacked.   The development of hydatids
1 Medico-Chirurgical Transactions, vol. x. p. 278. 
MOLLITIES  OSSIUM.
719
induces a gradual, painless expansion of the bone, which may thus be-
come perforated and allow of an escape of the hydatids.  The cavity of
the bone in which  the  hydatids form is lined by an adventitious cyst,
and this is said to be liable to excite inflammation in the surrounding
bone, as well as to induce purulent products in the cysts.  Cysts of this
description often contain  matter, to the naked eye, absolutely identical
with laudable pus, which, however, under the microscope, exhibits none
of the characters of pus.  We have recently examined two hydatid cysts
of this kind, removed from the  livers of two patients of St. Mary's Hos-
pital, on which the bright green, semifluid contents showed no trace of
pus, but granular matter, granular corpuscles, varying much in size and
shape, the granules being highly refracting particles of oil, much green-
ish-colored oil and echinococci,  entire or in parts.  Had these cysts been
found to contain pus, where there was no trace of inflammatory action
in the vicinity, it would have been difficult to reconcile its presence with
the usual theory  of suppuration, the more so as  the cyst envelop cannot
be  shown to contain  any vessels.  It is probable, therefore, that, in
those cases in which bone hydatids present puriform  contents, these
must be interpreted according  to  the views suggested by the  above ob-
servations.

                       MOLLITIES  OSSIUM.

   Mollities ossium, osteomalacia, or malacosteon,  is a disease  regarding
which the views of authors differ;  some treating it as essentially distinct
from other known osseous maladies, some as a form of atrophy;  others,
again, as identical with rachitis, except in that it attacks adults instead
of children.   The rarity of  the disease is one great obstacle to  our ar-
riAring at a satisfactory conclusion ; but, so far as the evidence reaches
that we have been able to examine, there appears to  be every reason
for regarding it as much  deserving of a separate place in pathology as
any disease of the bones which we have investigated.
   The disease consists, as the  term indicates, essentially in a softening
of the bones, brought about by an absorption of the earthy matter, and
the substitution of a large quantity of fat.  It is an entire perversion of
the  process of nutrition,  in  as far as  regards the skeleton, the  earthy
phosphates  being eliminated from the system by the  kidneys, while a
deposit of fat takes place into  the cartilaginous matrix, a process which
necessarily induces great pliability and fragility  of the bones.   As the
bones of the trunk are especially liable  to be attacked, the  individual
affected  becomes reduced in  size from  the collapse of the  vertebral
column.   A tall subject may thus be converted into a dwarf; an instance
of which we had  an occasion of seeing  in  the  Clinique of Professor
Kilian, of Bonn.  The individual was a married woman, whose  stature
had diminished in this  manner, and was doubly interesting from having
in this condition  become the subject of a successful Caesarean  operation.
It was subsequent to her  recovery from this  ordeal that we saw her, and
that she was supposed  to be again pregnant.  Dr.  Greenhalgh enabled
us recently to  examine a similar instance, in which the disease was also
followed by contraction of the pelvis, rendering the Caesarean  section 
720
MOLLITIES OSSIUM.
necessary.   Adults, and especially females,  are the  subjects of  the
malady.  It attacks women chiefly after they have  commenced child-
bearing.  Mr. Curling1  has collected  sixteen cases,  thirteen of which
Fig. 396.
  Section of a femur from a lady set. 30, affected for some years with mollities ossium.  The walls of the bone
are thin, soft, and flexible: the place of its medullary and cancellous tissue is occupied by soft, jelly-like,
transparent fat, of various shades of yellow and pink, some of it deep crimson; a similar kind of fat appeared
to be diffused through the proper texture of the walls.—St. Bartholomew's Museum, i. 233.

occurred  in females, and  three in males.   Eleven were fatal between
thirty and forty.  In  none  it  showed itself before  puberty; but two
patients were above  fifty years  of age.   Several of them were delivered
of children during the  progress of the complaint.   It is not associated
with any particular  lesion of the viscera;  neither can an  hereditary or
idiopathic taint, or diathesis, be traced, by which the peculiar symptoms
could be explained or referred to a known type.  Kilian2 treats of mol-
lities ossium  as presenting two varieties—the waxy (cerea), and  the
fragile (fracturosa).   In the former, the bones generally, but especially
those of the pelvis, present a dirty, dark-yellow color.   They lose their
transparency in the  middle, while their weight  is not much  diminished,
and they become flexible, like wax ; in the second, the bones present a
snowy whiteness, and a light transparent, open texture, rendering the
bones  so fragile that they give way under the  mere  pressure  of the
finger.   The first  kind of bones  do not dry clean, but remain greasy ;
the  second dry quickly, and give no  greasy feel.   Both varieties, ac-
cording to Kilian,  exert the same influence upon the pelvis in regard to

  ' Medico-Chirurg. Trans, vol. xx. p. 336.
  2 Kilian, H. F.  Beitrag zu einer genaueren Kenntniss der allgemeinen Knochener-
weichung, &c, Bonn, 1829;  and Die Geburtslehre, &c, vol. ii.  p. 367, 1840. 
MOLLITIES  OSSIUM.
721
the distortions that are produced.   These he describes as consisting in
angular deflections of the individual bones,  and a mutual approximation
of the bones in the  conjugate and transverse  diameters.  If Professor
Kilian's vieAv regarding the two species of the malady be correct, it is
probable  that they would be distinguished by their chemical constitu-
tion, and  this may be assumed as the reason why the chemical analysis
of the bones affected with osteo-malacia ha\re  yielded results so widely
apart.  Thus, in one of the two  remarkable cases detailed by Mr. Solly,1
the analysis of the  affected bone, by Dr.  Leeson, showed 100  parts  to
contain
       Animal matter.........18.75
       Phosphate and carbonate of lime......29.17
       Water...........52.08
100.00
The chemical  examination of a case  (detailed by Dr.  Ramsbotham, in
the Reports of the Pathological Society)2 by Dr. Garrod, yielded,
       Fatty matter.........20.35
       Gelatin yielding matter     .....        .58.37
       Carbonate and phosphate of lime, and phosphate of magnesia   21.28
                                                        100.00
   In the former analysis, we see nearly eight parts more earthy matter
than in the latter;  nor can it be objected that the  analyses were made
at different stages  of the  disease, because, in both instances, the pa-
tients  from Avhom  the  specimens were taken had succumbed to the
malady.  The analysis  given by Dr. Bostock,*  reduces  the  amount of
earthy matter to a yet loAver figure.   In a specimen that he examined,
he found the proportions to  be, in one hundred parts of boner-
        Jelly and oil ..........22.5
        Cartilage..........bJ„f
        Earthy matter.........Z()-zo
Mr.  Stanley quotes  an analysis of Dr. Bostock's, in which the constitu-
tion of the entire bone was,  in 100 parts of oil, about 67 ; of membrane,
about 20;  of earthy salts, about 11.
   The microscope shows the structure of the bone  altered; the corpus-
cles  and their canaliculi having lost their earthy  contents,  are empty
and  transparent, and  only faintly visible; while the  Haversian canals
are unnaturally enlarged.   Dr. Hall Davis, in his  report of the micro-
scopic appearances  of the case of Dr. Ramsbotham, above quoted states
that, besides fat and  blood, he found nucleated cells   Rokitansky ap-
pears to consider it allied to malignant disease, but does not mention
the presence of compound corpuscles; it therefore yet remains to deter-
mine,  as far as the  microscope can do it, the relation  to cancer; and^it
seems probable that, while we may thus establish a true fa ty degenera-
tion of bone, we may also  prove  that  many cases of mollities ossium

             ' Medico-Chirurgical Transactions, vol. xxvii. p. 435.
             2 Reports, &c, 1847-48.
             » Medico-Chirurgical Transactions, vol. iv. p. ob.
        46 
722
THE MEDULLA.
Fig. 397.
      Bone-corpuscles; a, in the normal state; 6, enlarged, as in mollities ossium.—Dalrymple.

are essentially primary cancer of the  skeleton.  We have  ourselves
spoken of a case of this kind (p. 712).
  In a well-marked  instance of mollities ossium, of which  the  history
was given to the  Medico-Chirurgical Society by Dr. T. K. Chambers,1
and which  occurred in a female aet. twenty-six, the bones throughout
the system were soft and yielding, so that a sharp knife could readily
pass through them.   A  portion  submitted to  our examination, which
was removed from the  tibia, resembled rather a piece of muscle than of
bone.  The periosteum was entire, and it was only in connection with it
that a few minute spiculae of bone could  be found.   In these, there was
a faint trace of the bone-corpuscles, but they were  filled with reddish
oil.  The remaining tissue consisted of large, transparent oil-vesicles,
and  minute globules of reddish  oil.  The muscular tissue  examined,
though to the  naked eye healthy,  was entirely deprived of its  normal
structure, and comrerted into reddish corpuscles, of from  T§^§^j of an
inch in diameter, intermingled with large oil-vesicles.   We saw nothing
at all resembling the character of malignant growth.
                          THE MEDULLA.

   The  medulla undoubtedly participates in  the  nutritive and morbid
processes affecting the bones individually or generally;  and  we have
already had occasion to see that, in several of the diseases of the latter,
changes in the medulla form an essential constituent of the malady; as
in encephaloid cancer, or mollities ossium.   It is  yet to be determined
in how far the medulla is liable to become primarily affected.  It varies
in consistency according to the vigor of the  individual; Avhile in drop-
sical and phthisical cases we find it thin and serous, or yellow in icterus,
or very scanty in  ivory  condensation  of a bone;  it  exhibits  greater
firmness, and  a richer pink hue, in  habits tending to an  inflammatory
character.   Lobstein states that  he has repeatedly verified the exist-
ence of inflammation of the medulla,   but  invariably  associated with
inflammation of the reticular tissue of the bone.   Its color, in this case,
resembled that of  kermes, and its density that of fibrin.  He observed
it not only in  the medulla  contained in  the diaphyses,  but  also in the
epiphyses of cylindrical, in the diploe of flat bones, and in the reticular
substance of certain bones at the base of the cranium, such as the basilar

               1 Medical Times and Gazette, March 25, 1854. 
THE MEDULLA.
723
portion of the occipital and of the body of the sphenoid.   In the latter
bone, he states  that  he has met with this condition more  frequently
than in any other region; a remark that deserves attention in reference
to certain observations  of  other  authors  regarding the constriction of
the foramen magnum in producing epilepsy, and the enlargement of the
odontoid process in connection with  chorea.  The real seat of inflam-
mation in bone,  as Rokitansky remarks, is the membrane that lines its
cavities; it is, therefore, fair to infer that, in all diseases dependent
upon the state of the vascular system, whether of an ordinary or of  a
malignant  character, the medulla is  affected coincidently with, if not
previously to, the bony tissue itself. 
/ 
INDEX.
Abscess, metastatic, 355
Acari scabiei, 214
      f'olliculorum, 214
Acephalocyst, or hydatid, 221
Albumen of serum, quantitative variations
  in, 68
Albuminosis, 160
Alimentary canal, pathological anatomy of,
  447
Alternating calculus, 584
Ansemia, causes, symptoms, results, 73, 81,
  85, 87
Anatomy, morbid, definition of, 33
Anchylosis, 675
Aneurism, 344
      by anastomosis, 366
      of the heart, 308
      varicose, 351
Aneurismal hypertrophy of heart, 304
Angiectoma, 175
Anus, imperforate, 501
      lacerations of, 501
      prolapsus, 485
Apoplexy, 251
      cerebral, 251
           sequelae of, 253
      of heart,  301
      of lungs,  402
      of spinal meninges, 271
           cord, 275
Appendix vermiformis, morbid states of, 500
Aphthae, 449
Arachnoid, pathological anatomy of, 230
      cysts in, 245
      effusion beneath, 231
      granulations, 232
      hemorrhage into, 232
      inflammation of, 234
Arachnitis, cerebral, 234
      spinal, 272
Arteries, morbid anatomy of, 332
      aneurism, 344
      atheroma, 338
      fibrinous deposits in,  333
      inflammation of, 332
      ossification of, 341
Arteritis, acute,  332
      chronic, 3;)7
Arthritis, chronic rheumatic, 676
Ascaris lumbricoides, 215
      vermicularis, 216
Asphyxia, production of, 74
Atelectasis pulmonum,  397
Atheroma,  340
Atrophy of brain, 261
      of coats of stomach, 466
      general account of,  162
      of heart, 310
      from inflammation,  141
      of nerves, 280
      of spinal cord,  274
      of tongue, 454
      of valves of heart,  320

                   B

Bacony deposit, 517
Bile, morbid conditions of, 527
Biliary calculi, 529
      matters in blood, 78
      passages, abnormal  conditions of, r>2o
Bladder, morbid anatomy of,  564
       cancer  of, 569
       congenital malformations of,  564
       congestion of, 567
      contraction of, 565
       dilatation of, 564
       displacements of, 566
       diverticula, 565
      hypertrophy of muscular coat, 566
       inflammation of, 567
      inversion, extrophy, 564
       malformations of, 564
       pericystitis, 569
       sacculation, partial dilatations of, 565
       softening of, 569
       tubercle of, 569
Blood, morbid states of, 50
       determination of, 99
       erases of the, 151
Bloodvessels, morbid anatomy of the, 331
Bones, pathology of the, 681-684
       adventitious growths of, 704
       cancer  of, 712
       caries of, 688
       cysts of, 719^
       exostosis of, 706
       fibrous  growths, 710
       inflammation of, 684
       malformations of. '«sl 
726
INDEX.
Bones—
      necrosis, 690
      osteophyte, 708
      rachitis, 695
      softening of, 685-719
      tubercle of, 714
      tumors of,  711
      vascular tumors of, 716
Bothriocephalus latus, 217
Brain, pathology of, 247
      atrophy of, 261
      cancer of, 264
      circulation in, 247
      congestion of, 249
      cysts of, 266
      fatty tumors of, 266
      fibroid tumors of, 266
      hemorrhage of, 238, 250
      hydatids of, 266
      hypertrophy of, 260
      induration of, 259
      inflammation of, 255
      melanosis of, 265
      morbid growths in, 262-266
      oedema of,  255
      softening of, 254-256
      state of, in lunatics, 249, 261
      suppuration of, 257
      tubercle of, 262
      tumors of,  266
Bronchial tubes, pathological anatomy, 384
      calcareous concretions in, 392
      constriction of, 388
      dilatation of, 389
      hemorrhage, 384
      inflammation of, 386
      polypi, 387
      tubercle of, 391
Bronchitis, 386
Bronchiectasis, 389
Bronchocele, 539
Bursse, inflammation of, 679
      melon-seed bodies in, 680
      suppuration of, 679
      thickening of walls of, 679
Calculi, biliary, 529
       of the salivary ducts, 532
       urinary, 581
           alternating, 584
           calcareous, 584
           cystic oxide, 582
           fibrinous, 584
           fusible, 583
           lithate of ammonia, 582
           lithic acid, 582
           oxalate of lime, 582
           phosphatic, 583
           prostatic, 603
           xanthic oxide,  584
Cancerous tumors, 187
               changes in, 208
               development of, 208
Cancerous tumors—
               diagnosis of,  196
               diffusion of, 209
               origin of, 207
               primary and secondary, 209
               saponification of, 209
               varieties of, 190
Cancer of the bladder, 569
      in the brain, 264
      of bone, 712
      cells, 198
      chimney-sweepers', 598
      colloid, 192
      epithelial,  194
      of gums, 448
      in the heart, 311
      of intestines, 499
      of the kidneys, 560
      of the liver, 522
      of the lungs, 431
      of lymphatic glands, 371
      melanoid, 190
      in the oesophagus, 460
      in the ovaries, 650
      of the pancreas, 332
      of the penis, 606
      of the pericardium, 294
      of the peritoneum, 464
      of the pleura, 445
      of the spleen, 538
      of the stomach, 476
      of the supra-renal capsule, 542
      of the testes, 594
      of the thyroid gland, 541
      of the tongue, 453
      of the urethra, 573
      of the urinary passages, 563
      of the uterus, 624
      of the vagina, 613
Capillaries, morbid anatomy of, 365
Capillary phlebitis, 365
Carbonate of lime calculus, 584
Carbonic acid, poisonous  effects of, 73
           in blood, 73
Cartilage, atrophy of, 667
      hypertrophy of, 666
      ulceration  of, 667
Carditis, 296
Caries, 688
      of teeth, 455
Cartilages, loose in joints, 665
Cavities in lungs, 425
Cephalhaematoma, 225
Chancres, 605
Chimney-sweepers' cancer, 598
Cholesteatoma, 174
Chordee, 570
Choroid plexus, morbid anatomy of, 244
Circulation, organs of, pathological anatomy
  of, 287
Cirrhosis of liver, 512
Circocele, 650
Clitoris, morbid conditions of, 609
Colloid cancer, 192
Contractility disordered,  38 
INDEX.
727
Congestion, causes, effects, 92, 96
Coronary  arteries, in fatty degeneration of
  heart, 300
Corpuscles of the blood, 50
Crases of  the blood, 151
Croup, 378
Croupous  exudation, 131
Cyanosis,  326
Cystic oxide calculus, 582
Cystitis, 567
Cysts, arachnoid, 245
       in brain, 266
       in bone, 718
       compound,  183
       in gall-bladder, 530
       in heart, 311
       in kidneys, 555
       in labia, 608
       in  liver, 520
       in lungs, 433
       in  ovaries,  645
       in  pancreas, 532
       in  pleura, 445
       in  spinal cord, 277
       in  spleen, 537
       in  testes, 594
       in  tongue,  453
       in  urinary  passages, 563
       in  uterus, r^fe
 Cysticercus cellulosa, 218
 Cystoid tumors, 181
 Cysto-sarcoma, 186

                    D

 Degenerations,  fatty, fibrous,   calcareous,
   163, 165
 Dental caries, 455
       necrosis, 457
       periosteum, inflamed, 458
       pulp, diseases of, 458
 Derangement, functional, 35, 38
 Diathesis, 36
 Diphtheritic inflammation,  126
 Disease,  organic, 36
       functional, 38
 Dislocations, effects of, 678
 Distoma  hepaticum, lanceolatum, ocuh hu-
   mani, 216
 Diverticula of the bladder, 565
       intestinal, 480
        of the trachea, 382
 Dropsies, 111-114             ,
        composition of effusions in, lib
 Dropsy of the chest, 441
        ovarian, 645
 Ductless glands,  abnormal condition of, 533
 Ductus communis choledochus, inflamed, olo
            obstructed, o2<
 Dura mater of cerebrum, diseased conditions

        of spinal cord, diseased conditions of,

        cancer of, 228, 269
        fibroid tumors of, 221
Dura mater—
      inflammation of, 226
      malformation of, 228
      ossification of, 228
      tubercle of, 269
Dysentery, morbid changes in, 494

                   E

Echinococcus hominis, 219
Elephantiasis of  scrotum, 597
Emphysema, vesicular, of lungs, 394
Empyema, 439
Encephalitis, 255
Enchondroma, 176,  704
Encephaloid cancer, 187
Encysted tumors, 181
Endocardium, morbid anatomy of, 313
Endocarditis, 313
Enlargement of parts from inflammation,
   141
Enteritis, 487
Entozoa, 363-372
       of glands, 372
       in veins,  364
Epidermic and epithelial tumors, 170
Epididymitis, 591
Epilepsy, 267
Epiglottis, morbid anatomy of,  374
       inflammation of, 374
       oedema of, 376
       ulceration of, 375
Epithelial cancer, 194
       tumors, 170
Epulis, 448
Exostosis, 179
Extractive  matters of blood, variations  in,
   69
 Exudation-globule, 138
Fallopian tubes, diseases of, 642
Fatty degeneration, 163
           of choroid plexus, 246
           of heart, 298
           of liver, 515
Fatty tumors, 172, 266, 453, 476
Fauces, pathological anatomy of, 447
Fibroid tumors of dura mater, 227
           of ovaries, 649
           of uterus, 619
Fibrous degeneration, 164
       tumors, 166
Fibro-cystic tumors, 168
       fatty tumors, 168
Fibrin, quantitive, qualitative variations in,
  metamorphoses, 56
Fibrinous crasis, 151
       deposits in lungs, 414
       exudation, 131
Filaria bronchialis,  215
       medinensis, 215
       oculi humani, 215
Flux, active or passive, 110 
728
LNi)
EX.
Foetus, 638
Formations, new, 167
Fibrinous calculus. 584
Fusible calculus, 583

                    G

Gall-bladder, cysts of, 530
      inflammation of, 525
      malformations of, 525
      ulceration of,  526
Gall-stones,  529
Ganglions, 680
Gangrene or mortification, 143
      of heart, 302, 315
      of liver,  512
      of lungs, 415
      of mouth, 450
      of pleura, 442
Gastritis, 466
Generative  organs,  morbid  conditions of
             male, 585
          of female, 607
Glands, lymphatic, carcinoma of, 371
          entozoa of, 372
          melanosis of, 371
          tubercle in, 370
Glandulae Pacchioni,  232
Globule,  exudation, 138
Glottis, affections of, 377
Glomeruli, or granule-cells, 138
Glossitis, 452
Granule-cell, 138
Gums, cancer of, 448
      fibrous tumor  of, 448
      polypous tumor of, 448
      vascular tumor of, 448

                    II

Haemothorax, 442
Haematin, crystals of, 108
Haematocele, 590
Haemoptysis, 384
Haemorrhoids, 361, 502
Hemothorax, 442
Heart, morbid anatomy of,  296
      aneurism of. 304-308
      apoplexy of, 301
      atrophy  of,  310
      cancer of, 311
      congenital malformations of, 329
      congestion of  the, 296
      tatty degeneration of, 208
      dilatation of, 307
      gangrene of, 302, 315
      hydatids of, 311
      hypertrophy of, 303
      inflammation of, 296
      morbid growths in, 311
      ossific deposits in, 311
      rupture  of, 301
      tubercle  of, 311
      ulceration of,  297
      valves of, morbid states of, 319
Heart-clot, 316
Hemorrhage, 106
      into arachnoid, 232
      iu the brain, 238, 250
      in the bronchi. ol-U
      in the ventricles of brain, 238
Hemorrhagic inflammation, 127
Hepatic abscess, 510
      ducts, croupy inflammation of, 527
           inflammation of, 526
           knotty tumors of,  525
           pigmentary deposits in, 526
      vein, phlebitis of, 512
Hepatization of lungs, 405
Hepatitis, 510
Hydrocephalus, 237-240
      composition of effused fluid, 243
Hydrocele, 588
Hydro-sarcocele, 588
Hydrothorax, 441
Hydatids in brain, 266
      in heart, 311
      in lungs, 433
      in spinal cord, 277
Hydraemia, 73
Hydrocele, 588
Hydrops renalis, 561
Hymen, abnormal condifcns of, 610
Hypertrophy, 161
      of brain, 260
      of heart, 303
Hyperaemia, 87, 92, 99
Hypinosis of blood, 160

                    I
Ichor, 137
Icterus neonatorum, 519
Idiosyncrasies, 36
Idiocy, state of brain in,  261
Induration, 162
      of brain, 259
      of spinal cord, 276
Inflammation, 117
Intestinal canal, morbid anatomy of, '80
      abnormal contents of, 505
      ani atresia, 501
      appendix vermiformis, morbid states
        of, 500
      cancer of, 499
      catarrhal inflammation of, 48S
      change of position of, 482
      concretions in, 506
      contraction of, 481
      dilatation of, 481
      diverticula of, 480
      condition of, in dysentery, 494
      false membrane, formation of, in, 491
      fissures of rectum,  502
      gas in, 505
      gelatiniform softening of, 497
      haemorrhoids, 361, 502
      internal strangulation of, 483
      incarcerations of, 4;-<2
      inflammation of, 487 
INDEX.
729
Intestinal canal—
      invaginations of, 483
      malformations of, 480
      prolapsus ani, 485
      softening of, 497
      tuberculous deposits in, 498
      typhilitis stercoralis, 500
      typhoid process, and ulcers,  492
      wounds and lacerations of, 486, 501
Intussusception, 484
Jaundice, 518
Joints, abscess of, 660
       anchylosis of, 675
       arthritis,  chronic rheumatic, 666
       cartilage  of, diseased  conditions of,
         666
       cartilages, loose, in, 665
       degeneration,  pulpy,  of  synovial
         membrane, 663
       dislocations, effects of, 678
       inflammation of, 659
       ligaments of, diseased conditions of,
         665
       malformations of, 659
       scrofulous disease of, 672
       suppuration and ulceration of, 660


                    K

 Keloid tumor, 169
 Kidneys, anaemia of, 545
       abscess of, 546
       adipose   tissue  around, increase of,
         561
       atrophy of, 552
       Bright's  disease, 547
       cancer of, 560
       capsule of, inflamed, 561
       congenital anomalies of, 543
       contracted granular, 552
       cystic formation, 555
       degenerative disease of, 547
       enlargement of, 548
       entozoa in, 561
       hemorrhage, 544
       hyperaemia  of,  547  _
       inflammation of, 545-547
            of capsule, 561
       tubercle of, 560
,  Labia, diseases of, 607
/         encysted growths ot, bus
          hemorrhagic tumor of, 50/
          oozing tumor of, 605
   Lactic acid in the blood, 68
          relation to rheumatism, < f
   Laryngitis, 376   _         ,
   Larynx, inflammation of, o < <>
          ossification ot, oou
          ulceration of, 380
Lateritious sediment of urine, 578
Leucorrhoea, 612, 627
Leucocythemia, leukhaemia, 147
Ligaments of joints, inflammation of, 665
           relaxation of, 665
Lipomata, 172
Liquor sanguinis, 56
Lithate of ammonia calculus, 582
Lithic acid calculus, 582
Liver, abscess of, 510
       adventitious growths of, 520
       atrophy, acute yellow, of, 519
       bacony deposit in, 517
       cancerous tumors of, 522
       cirrhosis of, 512
       congestion of, 507
       fatty degeneration of, 515
       fibroid degeneration of, 513
       gangrene of, 512
       in jaundice, 519
       hemorrhagic effusions, 509
       hydatid cysts of, 520
       inflammation of,  510
       lardaceous, 517
       nutmeg condition of, 507
       phlebitis of, 512
       tubercle of, 520
       waxy, 517
 Lungs, morbid anatomy of, 393
       abscess of, 412
       adventitious deposits in, 417
       apoplexy of. 402
       cancer of, 431
       cavities in, 425
       condensation of  tissue of, 412
       congestion of, 400         ,
       cysts in, 433
       dilatation of air-cells, 394
       emphysema, vesicular, of, 3-4
       fibrinous deposits in, 414
       gangrene of, 415
       inflammation of, 405,  415
       oedema of, 399
       tubercle of, 417
 Lymphatics, inflammation of, 36S
       varicosity  of, 369
 Lymphatic glands, carcinoma of, 371
       entozoa in, 372
       hypertrophy of,  370
        melanosis  of, 371
        tubercle of, 370

                     M

  Mammae,  female, diseases of, 650
        male, diseases of, §67
  Mamma, cancer of, 655
        encysted tumors of, 652
        fibrous tumors of, 654
        hypertrophy of, 651
        inflammation of, 651
        tubercles in, 655
  Mariscae, 502
  Mastoid tumors,  190
  Meatus urinarius, vascular tumor of. 574 
'30
INDEX.
Medulla, pathology of, 722
Melanoid cancer, 190
Melanosis, 171
      in the brain, 265
      of glands, 371
      of spinal cord. 270
Melanotic tumors, 171
Meningitis, cerebral, 235, 239
      spinal, 272
Metastatic abscesses, 355
             of lungs, 413
Metro-phlebitis, 632
Mole, vesicular, 638
Mollities ossium, 719
Morbus  Brightii, 547, 558
Mortification, 143
Mouth, aphthae of, 449
      cancerous tumors of, 448
      diphtheritic exudation of, 448
      epulis, 448
      gangrene of, 450
      inflammation of, 447
      malformations of, 447
      vascular tumors of, 448
Muco-purulent matter, 137
Mucous encysted tumors, 182
Mucus, 139
Muguet, 449
Micoderm of favus, 214
Myeletis, 275
Myeloid tumors, 177 .

                   N
Naevi, 175
Necraemia, 149
Necrosis, 690
Nephritis, 345
Neuroma, 283
Nervous system,  pathology of, 223
Nerves,  pathology of, 279
      atrophy of, 280
      hypertrophy of, 281
      inflammation of, 281
New formations,  167
Nutrition, deranged, 46
Nymphae, diseased conditions of, 609
      enlargement of, 609
0
CBdema of brain, 255
       of epiglottis, 377
       of lungs, 399
CEsophagus, constrictions of, 459
Oily matters of blood, 70
Orchitis, 591
Osseous  svstem, pathological  anatomy of,
         681
       tumors, 179
Osteophyte, 180, 708
Osteoid tumor, 181, 711
Ossification of arteries, 341
       dura mater, 228
       larynx, 380
       lungs, 443
Ossification of—
      trachea, 382
Ovaries, pathology of, 644
Ovarian dropsy, 645
Oxalates, deposits of in urine,  580
Oxalate of lime calculus, 582
Oxalic acid in blood, 79
Pacchionian bodies, 232
Pancreas, abnormal conditions of, 531
       atrophy of,  531
       cancer of, 532
       dilatations of duct of, 532
       fatty degeneration of, 532
       hypertrophy of,  531
       inflammation of, 531
Parasites, animal,  vegetable, 213, 214
Paracentesis thoracis, 440  ,
Penis,  atrophy of,  604
       cancer of, 606
       chancres, 605
       herpes of glans, 605
       hyperaemia  of, 605
       inflammation of, 605
       malformations of,  004
       paraphymosis, 606
       phymosis, 606
       psoriasis, 605
       ulcers (chancres),  605
       warts, 606
Peritoneum, cancer of,  464
       chronic thickening of, 464
       inflammation of, 461
       malformations of,  461
       tubercular inflammation of, 463
Pericarditis, 290
Pericardium, absence of,  289
       air in, 294
       carcinoma of, 294
       fat in, 294
       fibrinous concretions of, 294
       inflammation of, 290
       tubercle of  293
       white patches in, 289
Pericystitis, 569
Peritonitis, 461
       puerperal, 633
Periosteum, morbid states of, 682
Peyerian patches, diseased condition of, 489-
  491
Pharynx, cancer of, 460
       dilatation of, 459
       fibrous tumors of,  460
       inflammations of, 459
       malformations of, 459
       softening of, 460
Phlebitis, 353
       uterine, 632
Phlebectasis, 359
Phlebolithes, 363  •
Phlegmasia dolens, 633
Phosphate of ammonia  and magnesia calcu-
  lus, 583 
INDEX.
731
Phosphate of lime calculus, 583
Phosphates, earthy, deposits of, from urine,
  579-581
Phosphoric acid in urine, 579
Pia  mater,  diseased  conditions  of,  230-
  236
Piles, 361
Pituitary body, morbid anatomy of, 267
Placenta,  diseases of, 636
Plastic exudation, 131
Phthisis, tubercular, 417
Plethora,  causes, consequences, 88-90
Pleura, adventitious products of, 443
       cancer of, 445
       cysts in, 445
       empyema, 439
       gangrene of, 442
       haemothorax, 442
       hydrothorax, 441
       inflammation of, 434
       pneumothorax,  441
       tubercle of, 444
 Pleuritis, 434
 Pneumopericardium, 294
 Pneumothorax, 441
 Pneumonia, 405
       congestive, 412
       chronic, 415
       lobular, 409
       typhoid,  410
 Pneumatoses, 117
 Poisonous matters in blood, 79
 Polypi in the heart, 361
       of rectum, 502
       of uterus, 622
       of vagina, 613
 Portal vein, inflammation of, 357
 Pregnancy, diseases of,  635
       extra uterine, 641
 Prolapsus ani, 485
       uteri, 617
 Prostate  gland, abscess  of,  602
            atrophy of, 599
            calculi of, 603
            cancer of, 602
            concretions in, 603
            cysts of, 603
            fibrous tumours of, 602
            hypertrophy of, 599
            inflammation of, 602
            tubercle of,  602
            ulceration of, 602
 Puerperal diseases, 629
        fever, 629
        inflammations, 629
 Pulmonary abscess, 412
        apoplexy, 402
        congestion, 400
        tubercle, 417
 Pulmonic symptoms in  typhoid and typhus
    fever,  388
 Pus,  133
        in the chest, 439
 Pyaemia, 144, 355
 Pyelitis, 562
R
Rachitis, 695
Ranula, 182
Rectum and anus, lacerations of, 501
Recurring fibroid tumors, 169
Red corpuscles of blood, 50
Reflex action, 44
Renal abscess, 546
      hemorrhage, 544
Respiratory organs, morbid anat. of, 373
Rheumatic arthritis, chronic, 666-676
Rickets, 695

                   S

Salts of blood, variations in, 72
Salivary concretions, 532
       ducts, dilatation of, 532
       fistulae, 532
       glands, abnormal conditions of, 531
Sanies, 137
Sarcomatous tumors,  185
Sarcoptes hominis, 214
Sciatica, 279
Scirrhus, 190
Scrofulous inflammation, 127
Scrotum,  elephantiasis, 597
       epithelial cancer of, 598
       fibrous growths of, 599
       hypertrophy of, 597
       melanotic cancer of, 599
Secretion, deranged, 46
Secondary abscesses,  355
Sensibility, disordered, 41
Serotin, 71
Serum, organic constituents of, 68
Sinuses of brain, inflammation of,  358
Softening, 162
       of brain, 254-256
       of heart, 298
 Solanoid  tumors, 190
 Spanaemia, 81
 Spinal column, diseases of, 673
       cord and membranes, pathology  of,
              268-274
            arachnitis, 272
            atrophy of, 274
            apoplexy  of, 271-275
            cartilaginous deposits on menin-
              ges of,  273
            congestion of, 274
            cysts of, 277
            hyperaesthesia of, 277
            induration of, 275
            inflammation of,  275
            ossific deposits  in  meninges of,
              273
            softening of, 276
        curvatures, 674, 698-701
 Spleen, absence of, 533
        anaemia of, 534
        cancer of, 538
        changes in form, place,  and size, 533
        chronic thickening of capsule of, 537 
732
INDEX.
Spleen—
      cysts of, 537
      enlargement of, 535
      fibrinous deposits in, 534
      hyperaemia of, 534
      hypertrophy of, 535
      inflammation of, 534
      purulent deposits in, 534
      rupture of, 533
      tuberculous deposit in, 537
      wounds of, 533
Steatoma, 173
Stenosis of bronchial tubes, 388
Stomach, atrophy of coats, 466
      abnormal contents of, 480
      cancer of, 476
      caustic fluids, effects of, on, 470
      croupy exudation in, 470
      cysts of, 476
      dilatation of, 465
      displacements of, 466
      fatty change of coats, 476
      fibroid change of coats, 476
      hemorrhagic erosion of, 474
      inflammation of, 466
      malformations of, 465, 469
      mammillation of, 467
      perforation of, 472
      softening of, 474
      tubercle of, 476
      tumors of, 476
      ulceration of, 471
      variations in shape and size, 465
Stomatitis, 450
Stricture of urethra, 571
Strongylus gigas, 216
Supra-renal capsules, morbid conditions of,
  541
Suppuration, 133
      of brain, 257
Sympathetic system, pathology of, 284
      neuroma of, 286
Synovitis, 659
Synovial membrane, diseased conditions of,
           659
      pulpy degeneration  of, 663

                    T

Tionia solium and lata, 216
Teeth, caries of, 455
      inflammation of periosteum of, 458
       malposition of, 455
       necrosis of, 457
       pulp of, diseases of, 458
Telangiectasis, 366
Testes, absence of, 585
       atrophy of, 586
       cancer of, 594
       cysts in, 594
       hematocele, 590
       hydrocele, 588
       inflammation of, 591
           of tunica vaginalis, 587
       loose bodies in, 596
Testes—
       malposition of, 585
       non-descent of, 585
       purulent deposits in, 593
       tubercle of, 593
       varicocele, 596
Tetanus, 208, 282, 285
Textural changes, 161
Thyroid gland, absence of, 538
       cancer of,  541
       congenital development of, 538
       dilatation of vessels of, 540
       enlargement of, 539
       inflammation  of, 539
       tubercle of, 541
Thymus, absence of, 541
       hypertrophy of, 541
       inflammation  of, 541
       tuberculosis of, 541
Tonicity, disordered, 39
Tongue, atrophy  of,  454
       cancer of,  453
       cy3ts of, 453
       fatty tumor of, 453
       hypertrophy of, 453
       inflammation  of, 452
       tubercles of, 452
       ulceration of, 452
Tonsils, inflammation  and hypertrophy  of,
   454
Trachea, pathology of, 380
       extraneous matter in,  382
       hyperaemia of, 380
       inflammation  of, 381
       ossification of, 382
       ulceration of, 381
Trismus neonatorum, 272, 335
Trichina spiralis, 215
Tricocephalus dispar, 215
Tubercle, 153
Tuberculous crasis,  153
       deposition, 131
       diathesis,  153
        and  scrofulous  matter, identity  of,
         157
Tubercular meningitis, 239
Tumors, cancerous,  189
       cystoid, 181
       encysted,  181
        epidermic, 170
       epithelial, 170
       fatty, 172
       fibrous, 167
       keloid, 169
       mastoid, 190
       melanotic, 171
       myeloid, 177
       mucous encysted, 182
        osseous, 179
        osteoid, 181
        recurring  fibroid, 169
        sarcomatous, 185
        vascular,  174
 Typhoid ulcers, intestinal, 492
I Typhilitis stercoralis, 500 
INDEX.
33
                    U
Ulceration, 142
       of epiglottis, 375
       of heart, 297
       of larynx, 380
       of trachea, 381
Ulcer,  typhus, 492
Umbilical vein, inflammation of, 356
Ureters, distended, 561
Urethra, cancer of, 573
       contraction of, 570
       dilatation of, 570
       female, morbid condition of, 573, 609
       inflammation of, 570
       lacerations of, 570
       malformations of, 570
       stricture of,  571
       tubercle of,  573
Urea, 577
Uraemia, different forms of, 70
Urethritis, 571
Uric acid in blood,  76
       crystal deposits of, 577
       or xanthic oxide calculus, 584
Urinary apparatus, morbid  anatomy of, 543
       calculi, 581
       passages,  anomalous conditions of,
             561
           cancer of, 563
           congenital  anomalies, 543
           cysts of, 563
           deposits in, 577
           dilatation of, 561
           hemorrhages of, 544
           inflammation of, 562
           malformations of, 561
       tubercle of,  563
Urine, acidity of, 574
       albumen in,  575
       anazoturia,  577
       azoturia, 577
       chylous, 575
       coloring matter of, morbid changes in,
         576
       deposits of carbonate of lime from, 58
           of cystic oxide, 580
           of earthy phosphates, 579
           of oxalate of lime, 580
           of phosphates, 581
           of uric acid crystals, 577
       healthy qualities of, 574
       phosphoric acid in,  579
       sugar in,  575
Uterine phlebitis, 632
Uterus, absence of, 614
       atrophy of,  615
       cancer of, 624
Uterus—
      cysts in, 623
      fibrous tumors of, 619
      hypertrophy of,  616
      inversion of, 617
      malformations of, 614, 616
      malpositions of,  616
      polypi of, 622
      rupture of,  618
      tubercle of, 623
      ulceration of os, 627
      virgin, 626
      after parturition, 629
Vagina, affections of, 610
       cancer of, 613
       chronic thickening of mucous mem-
         brane, 612
       congenital closure, 610
       inflammation of, 612
       lacerations of, 611
       occlusion or  stricture of, 611
       polypi of, 613
Valves, aneurism of the, 324
       diseased conditions of, 319
       fibrous deposits in, 322
       ossific deposits in, 322
       perforation of,  320
Varix, 359
Varicocele, 360, 596
Varicose aneurism,  351
           of  heart, 310
       veins, 360
           of  labia, 507
Vascular tumors, 174
Vas deferens, absence of, 586
Veins, air in, 364
       carcinomatous matter in, 362
       deposits in, 362
       dilatation of, 359
       entozoa in, 363
       inflammation of, 353
       obliteration of, 362
       rupture of, 359
       umbilical, inflammation of, 356
       varicose, 360
Vena portae, inflammation of, 357
Ventricles of brain, effusions into, 238
Vertebra, diseases of, 673
Vesiculae seminales, morbid conditions of, 599
Vessels, new production  of,  174
Virgin uterus, 626
Voluntary motion, disordered, 43
Water of blood, varying  proportion of, 73
White corpuscles of blood, 50
THE END.
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able to maintain the unexampled rates at which these works are now supplied, and to
succeed  in his endeavor to place upon the table of every reading practitioner in the
United States a monthly, a quarterly, and a half-yearly periodical at the comparatively
trifling cost of Six Dollars  per annum.
  These periodicals are universally known  for their high professional standing in their
several spheres.
                                      I.

         THE AMERICAN  JOURNAL OF THE MEDICAL SCIENCES,

                     Edited by ISAAC HAYS, M. D.,

is published  Quarterly,  on the first  of January, April, July,  and October.   Each
number contains nearly three hundred large octavo pages, appropriately illustrated,
wherever necessary.  It has  now been issued regularly for over forty years, during
nearly the whole of  which time it has been under the control of the present editor.
Throughout this  long period, it has maintained its position in the highest rank of
medical periodicals both at home and abroad, and has received the cordial support of
the  entire profession in this  country.   Among its Collaborators will be found a large
number of  the  most distinguished names  of the  profession  in every section of the
United States, rendering the  department devoted to

              ORIGINAL  COMMUNICATIONS

full of varied and important matter, of great interest to all practitioners.  Thus, during
1868, articles have  appeared in  its  pages from  more  than  one hundred gentlemen
of the highest standing in the profession throughout the United States.*
  Following this  is  the  " Review Department,"  containing extended and impartial
reviews of  all important new works, together with numerous  elaborate "Analy-
tical and Bibliographical Notices" of nearly all the publications of the day.
  This is followed by the " Quarterly Summary of Improvements  and Discoveries
in the Medical Sciences," classified and arranged under different  heads, presenting
a very complete digest  of all that is new  and interesting to the physician, abroad as
well  as at home.
  Thus,  during  the  year 1868,  the  "Journal" furnished  to  its subscribers  One
Hundred and Twenty-two Original Communications,  Eighty-six Reviews and Biblio-
graphical Notices, and Two Hundred and Forty-nine articles in the Quarterly  Sum-
maries, making a total  of over Four Hundred  and Fifty articles emanating from
the best professional minds in America and Europe.
  To old subscribers, many of whom have been on the list for twenty or thirty years,
the publisher feels that no promises for the future are necessary;  but  gentlemen who
may now propose for the first time to subscribe may rest  assured that no exertion will
be spared to maintain the "Journal" in the high position which it has so long  occu-
pied  as a national exponent of scientific medicine, and  as a  medium of intercommu-
nication between the profession of Europe and America—in the words of the " London
Medical Times" (Sept. 5th, 1868) "almost the only one that circulates everywhere, all
over the Union and in Europe"—to render it, in fact, necessary to every practitioner
who  desires to keep  on a level with the progress of his science.
  The subscription price of the "Amkrican Journal of the  Medical Sciences" has
never been  raised, during its long career.  It is still Five Dollars per annum; and
when paid in advance, the subscriber receives in  addition the "Medical  News and
Library," making in all about 1500 large  octavo pages  per annum, free of postage.

                                     II.

                   THE  MEDICAL  NEWS  AND  LIBRARY
is a  monthly periodical of Thirty-two  large  octavo pages,  making  384  pages  per
annum.  Its "News Department" presents the current  information of the day, with
Clinical Lectures and Hospital Gleanings; while the "Library Department"  is de-
voted to publishing standard  works on the various branches of medical science, paged
  * Communications are invited from gentlemen in all parts of the country. Elaborate articles inserted
by the Editor are paid for by the Publisher. 
IIenry C. Lea's Publications—(Am. Journ. Med. Sciences).     3
separately, so that they can be removed and  bound on completion.   In  this manner
Bubscribers have received, without expense, such works as " Watson's Practice,"
"Todd and Bowman's Physiology," "West on Children," "Malgaigne's Surgery,"
<kc. &c.  And with January, 1869,  another  work of similar practical value, on the
" Wasting Diseases  of  Children," by Eustace Smith, M. D. (for advertisement of
which see p. 21), was begun, rendering  this a very eligible period for the com-
mencement of new subscriptions.
  As stated above, the subscription price of the "Medical News and Library" is
One Dollar per annum in advance; and it is furnished without charge to all advance
paying subscribers to the "American Journal of the Medical Sciences."

                                     III.

           RANKING'S  ABSTRACT OF THE MEDICAL  SCIENCES

is issued in half-yearly volumes, which will  be delivered to subscribers about the first
of February, and first of August.   Each volume contains  about 300 closely printed
octavo pages, making about six hundred pages per annum.
  "Ranking's Abstract" has now been published in England regularly for more than
twenty years, and has  acquired the highest reputation for the ability and industry
with which the essence of medical literature is condensed into  its  pages.   It pur-
ports to be uAn Analytical and critical Digest of the principal  British and Conti-
nental Medical Works published in the preceding Six Months," and, in addition to
the matter thus derived from independent treatises, it presents an abstract  of all that
is important or  interesting  in about sixty British  and Continental journals.  Each
article is carefully condensed, so as to present its substance in the smallest possible
compass, thus affording space for the very  large  amount of information laid before its
readers.  The volumes of 1868, for instance, have thus contained
        FORTY-TWO ARTICLES ON GENERAL  QUESTIONS IN MEDICINE.
        ONE HUNDRED AND TWENTY-NINE ARTICLES ON SPECIAL QUESTIONS IN MEDICINE.
        SEVENTEEN ARTICLES ON FORENSIC  MEDICINE.
        EIGHTY-EIGHT ARTICLES ON THERAPEUTICS
        FORTY-ONE ARTICLES ON GENERAL QUESTIONS IN SURGERY.
        ONE HUNDRED AND FIFTY-SIX ARTICLES ON SPECIAL QUESTIONS  IN SURGERY.
        ONE HUNDRED AND TWELVE ARTICLES ON MIDWIFERY AND DISEASES OF WOMEN
            AND CHILDREN.
        SIX ARTICLES IN APPENDIX.
Making in all nearly six hundred articles in a single year.  Each volume, moreover,
is systematically arranged, with an elaborate Table of Contents and a very full Index,
thus facilitating the  researches of the reader in pursuit of particular subjects, and
enabling him  to refer without loss of time to  the  vast amount of information con-
tained in its pages.
   The  subscription  price  of the "Abstract," mailed  free of postage, is  Two
Dollars and a  Half per annum, payable  in advance. Single volumes, $1 50 each.

   As stated above, however, it will be supplied in conjunction with the "American
Journal  of the Medical Sciences" and the " Medical  News  and Library," the
whole free of postage, for Six Dollars per annum in advance.
   For this small sum the subscriber will therefore receive three  periodicals  costing
separately Eight Dollars and a Half, each of them enjoying the highest  reputation in
its class, containing in all over two thousand pages of the choicest reading, and pre-
senting a  complete view of medical progress throughout the world.
   In this effort to bring so large an amount of practical information  within the reach
of every member of the  profession, the publisher confidently anticipates the friendly
aid of all who are interested in the dissemination of sound medical  literature.  He
trusts, especially, that the subscribers to the "American Medical Journal" will call
the attention of their acquaintances to the advantages thus  offered, and that he will
be sustained in the endeavor to permanently establish medical periodical literature on
a footing  of cheapness never heretofore attempted.
   * * Gentlemen desiring to avail themselves of the advantages  thus offered will do
well*to forward  their subscriptions at an early day, in order  to insure the receipt of
complete  sets for the year 186CJ.
   £gf The safest mode of remittance is by postal money order, drawn to the order of
the undersigned.  Where nicuev order post-offices are not  accessible, remittances for
the "Journal"  maybe made at'the risk of the publisher, by forwarding in  registered
letters.  Address,                                HENRY C.  LEA,

                               Nos. 706 and 708 Sansom St., Philadelphia, Pa. 
4              TIenry C. Lea's Publications—(Dictionaries).
J^UXGLISON  (ROBLET),  M.D.,
         Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia.

    MEDICAL   LEXICON;  A  Dictionary  of  Medical  Science:  Con-
       taining a concise explanation of the various Subjects and Terms of Anatomy,  Physiology,
       Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical
       Jurisprudence, and Dentistry.  Notices of Climate  and of Mineral Waters; Formulae for
       Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology ot
       the Terms,  and the French and other Synonymes;  so as  to constitute a French as well as
       English Medical Lexicon.  Thoroughly Revised, and very greatly Modified and Augmented
       In one very large  and handsome  royal  octavo volume of 1048 double-columned pugei, in
       small type; strongly done up in extra cloth, $6 00;  leather, raised bands, $6  76.
  The object of the author from the  outset has  not been to make  the work a mere lexicon or
dictionary of terms, but to afford, under each,  a condensed view of its various medical relations,
and thus to render the work an epitome of the existing  condition  of  medical  science.  Starting
with this view, the immense demand which has existed for the work has enabled him, in repeated
revisions, to augment its completeness and usefulness, until at length it has attained the position
of a recognized and standard authority wherever the language is spoken.   The mechanical  exe-
cution of this edition will be found greatly superior to that of previous impressions. By enlarging
the size of the volume to a royal octavo, and by the  employment  of a small but clear type, on
extra fine paper, the additions  have been incorporated without materially increasing the bulk of
the volume, and the matter of  two or three ordinary octavos has been compressed into the space
of one not unhandy for consultation and reference.
  It would be a work of supererogation to bestow a
word of praise upon this Lexicon.   We  can only
wonder at the labor expended, for whenever we refer
to its pages  for information we are seldom disap-
pointed in finding all we desire, whether it be in ac-
centuation, etymology, or definition of terms.—Neto
York Medical Journal, November, 1865.
  It would be mere waste of words in us to express
our admiration of a  work which is so universally
and deservedly appreciated.  The most admirable
work of its kind in the English language.  As a book
of reference  it is invaluable to  the medical  practi-
tioner,  and in every instance  that we have  turned
over its pages for information we have been charmed
by the clearness of  language and the accuracy of
detail with which each abounds.  We can  most cor-
dially and confidently commend it to our readers.—
Glasgow Medical Journal, January, 1866.
  A work to which there is  no equal in the English
language.—Edinburgh Medical Journal.
  It is something more than a dictionary, and some-
thing less than an encyclopaedia.  This edition of the
well-known work is a great improvement on its pre-
decessors.  The book is one of the very few of which
it may be said with  truth that every medical man
should possess it.—London Medical Times, Aug. 26,
1865.
  Few works of the class exhibit a grander monument
of patient research and of scientific lore.  The extent
of the sale of this lexicon is sufficient to testify to its
usefulness, and to the great service conferred by Dr.
Eobley Dunglison on the profession, and indeed on
others, by its issue.—London Lancet, May  13, 1865.
  The old edition, which is now superseded by the
new, has been universally looked upon by the medi-
eal profession as a work of immense research and
great value.  The new has increased usefulness; for
medicine, in all its branches, has been making such
progress that many new terms and subjects have re-
cently been introduced: all of which  maybe found
fully defined in the present edition.  We know of no
other dictionary in  the English language that  can
bear a comparison with it in poiut of completeness of
subjects and accuracy of statement.—N.  Y. Drug-
gists' Circular, 1865.
  For many years Dunglison's Dictionary has been
the standard book of reference with most practition-
ers in  this country, and we can certainly commend
this work to the renewed confidence  and  regard of
our readers.—Cincinnati Lancet, April, 1865.
  It is undoubtedly the most complete and useful
medical dictionary hitherto published in this country.
—Chicago Med. Examiner, February, 1S65.
  What we take to be decidedly the best medical dic-
tionary in the English language.  The present edition
is brought fully up to the advanced state of science.
For many a long year "Dunglison" has been at onr
elbow, a  constant companion and  friend, and we
greet him in his replenished and improved form with
especial satisfaction.—Pacific Med. and Surg. Jour-
nal, June 27, 1865.
  This is, perhaps, the book of all others which the
physician or surgeon should have on his shelves.  It
is more needed at the present day than a few years
back.—Canada Med. Journal, July, 1865.
  It deservedly stands  at  the head,  and cannot be
surpassed  in excellence.—Buffalo Med. and Surg.
Journal, April, 1865.
  We  can sincerely commend Dr. Dunglison's work
as most thorough, scientific, and accurate.  We have
tested it by searching its pages for new terms, which
have abounded so much of late in medical nomen-
clature, and our search  has  been successful in every
instance.   We have been particularly struck with the
fulness of the synonymy and the accuracy of the de-
rivation of words.  It is as necessary a work to every
enlightened physician  as  Worcester's  English Dic-
tionary is to every one who would keep up his know-
ledge  of tbe English tongue to the standard of the
present day.  It is, to our mind, the most complete
work  of the kind with which we are acquainted.—
Boston Med. and Surg. Journal, June 22, 1865.
  We are free to confess that we know of no medical
dictionary more complete; no one better, if so well
adapted for the use of the student; no one that may
be consulted with more satisfaction by the medical
practitioner.—Am. Jour. Med. Sciences, April, 1865.
  The value of the present edition has beeu greatly
enhanced by the introduction of new  subjects and
terms, and a more complete etymology and accentua-
tion, which renders the work not only satisfactory
and desirable, but indispensable to the physician,—
Chicago Med. Journal,  April, 1865.
  No intelligent member of the profession can or will
be without it.—St. Louis Med. and  Surg. Journal,
April, 1865.
  It has the rare  merit that it certainly has no rival
in the Euglish language for accuracy and extent of
references.—London Medical GazeUe.
R
OBLYN  [RICHARD D.),  M.D.
    A  DICTIONARY OF  THE TERMS  USED IN  MEDICINE  AND
      THE  COLLATERAL  SCIENCES.  A new American  edition, revised,  with  numerous
      additions, by  Isaac  Hays, M.D., Editor of the  "American Journal  of the Medical
      Sciences."   In one large royal 12mo. volume  of over 500 double-columned pages;  extra
      cloth,  $1  SO ; leather, $2 00.
  It is the best book of definitions we have, aad  ought always to be spon the student's table.—Southern
Med. and S'.irg. Journal. 
Henry  C. Lea's Publications—(Manuals).
5
JSJEILL  {JOHN), M.D.,   and   VMITH {FRANCIS G.), M.D.,
"*- '                                    *J  prof of the Institutes of Medicine in the Univ. of Penna.

    AN  ANALYTICAL  COMPENDIUM  OF  THE  VARIOUS
      BRANCHES OF MEDICAL SCIENCE ;  for the Use  and Examination of Students.   A
      new edition, revised and improved.  In one very large and handsomely printed royal 12mo.
      volume, of about one thousand pages, with 374 wood cuts, extra cloth, $4; strongly bound
      in leather, with raised bands, $4 75.
  The Compend of Drs. Neill and Smith is incompara-
bly the most valuable work of its class ever published
in this country.  Attempts have been made in various
quarters to squeeze Anatomy, Physiology, Surgery,
the Practice of Medicine, Obstetrics, Materia Medica,
and Chemistry into a single manual; but the opera-
tion has signally failed in the hands of all up to the
advent of " Neill and Smith's" volume, which is quite
a miracle of success.  The outlines of the  whole are
admirably drawn and illustrated, and the authors
are eminently entitled to the grateful  consideration
of the student of every class.—K 0. Med. and Surg.
Journal.

  There are but few students or practitioners of me-
dicine uuacquainted with the former editions of this
unassuming though highly instructive work.  The
whole science of medicine appears to have been sifted,
as the gold-bearing sands of El Dorado, and the pre-
cious facts treasured up iu this little volume. A com-
plete portable library so condensed that the student
may make it his constant pocket companion.— West-
ern Lancet.
  In the rapid course of lectures, where work for the
students is heavy, and review necessary for an  exa-
mination, a compend is not only valuable, but  it is
almost a sine qua non.  The one before us is, in most
of the divisions, the most unexceptionable of all books
of the kind that we know of.  The newest and sound-
est  doctrines and  the latest improvements and dis-
coveries are explicitly, though concisely, laid before
the student.  Of course it is useless for us to recom-
mend it to all last course students, but there is a class
to whom we very sincerely commend this cheap bouk
as worth its weight in  silver—that class is the gradu-
ates in medicine of more than ten years'  standing,
who have not studied medicine since.  They  wili
perhaps find out from it that  the science is not ex-
actly now what it was when  they left it  off.—Tlu
, Stethoscope.
 ITARTSHORNE {HENRY), M. D.,
          Professor of Hygiene in the University of Pennsylvania.

    A  CONSPECTUS  OF  THE   MEDICAL   SCIENCES;  containing
      Handbooks on Anatomy,  Physiology,  Chemistry,  Materia Medica,  Practical  Medicine,
      Surgery, and  Obstetrics.   In one large royal 12mo. volume of 1000 closely printed pages,
      with over  300 illustrations on wood,  extra  cloth, $4 50 ;  leather,  raised bands, $5 25.
      (Now  Ready.)
  The ability of the author, and  his practical skill  in condensation, give assurance that  this
work  will prove valuable not only to the student preparing for examination, but also to the prac-
titioner desirous of obtaining within a moderate compass, a view of the existing condition of the
various departments of science connected with medicine.

  The immense amount of matter contained in the volume  is thus divided:—
      ANATOMY,  .    .    .     .194 pages, with 93 Illustrations.
      PHYSIOLOGY,   .    .     .106   "
      CHEMISTRY,   .    .     .114   «'
      MATERIA MEDICA, .     .  126   "
      PRACTICE OF MEDICINE,  206   "
      SURGERY,  .    .    .     •  130   "
      OBSTETRICS,   .    .     .123   "
  This work is a remarkably complete one in its way,
and comes nearer  to our idea of what a Conspectus
should be than any we have yet seen.  Prof. Harts-
home, with a commendable forethought,  intrusted
the preparation of many of the chapters on  special
subjects to experts, reserving only anatomy, physio-
logy, and practice of medicine to himself.  As a result
wb have every department worked  up to the latest
date and in a refreshingly concise and  lucid manner.
There are an  immense amount of illustrations scat-
tered  throughout the work, and although they have
often been seen before in the various  works upon geu-
eraiaaid special subjects, yet they will be  none the
     73
  "  17       "
  "  32
  «   2
  «  45       «

  "  48
less valuable to the beginner.  Every medical student
who desires a reliable refresher to his memory when
the pressure of lectures and other college work crowds
to prevent him from having an opportunity to drink
deeper in the larger works, will find this one of the
greatest utility.  It is thoroughly trustworthy from
beginning to end ; and as we have before intimated,
a remarkably truthful outline sketch of the present
state of medical science.  We could  hardly expect it
should be otherwise, however, under the" charge of
such a thorough medical scholar as the author  has
already proved himself to be.—AT. York Med. Record,
March 15, 1869.
J VDLO W  (J. L.), M. D.,

    A  MANUAL OF  EXAMINATIONS  upon  Anatomy,  Physiology,
      Surgery,  Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and
      Therapeutics.  To which is added a Medical Formulary.  Third edition, thoroughly revised
      and greatly extended and enlarged.   With  370 illustrations.   In  one  handsome royal
      12mo. volume of 816 large pages, extra cloth, $3 25; leather, $3 75.

  The arrangement of this volume in the  form of question and answer renders it especially suit-
able for the office examination of students, and for those preparing for graduation.
TANNERS MANUAL  OF  CLINICAL  MEDICINE
  AND PHYSICAL DIAGNOSIS.   Third Amencan,
  Zw the second enlarged and revised English edi-
tion. To which is added The Code of Ethics of the
Americau Medical Association.  In one haudsome
volume 12«uo.  (Preparing for early publication.) 
Henry C. Lea's Publications—(Anatomy).
 QKAY  [HENRY), F.R.S.,
         Lecturer on Anatomy at St. George's Hospital, London

   ANATOMY,  DESCRIPTIVE  AND  SURGICAL.    The Drawings  by
      H. V. Carter, M. D., late Demonstrator on Anntomy at St. George's Hospital;  the Dis.seo-
      tions jointly by the Author and Dr. Carter.   Second American, from the second revised
      and improved London  edition.   In one magnificent imperial octavo volume, of over 800
      pages, with 388 large and elaborate engravings on wood   Price iu extra cloth,  $6 00;
      leather, raised bands, $7 00.
  The author has endeavored in this work to cover a more extended range of subjects than is cus-
tomary in the ordinary text-books, by giving not only the details necessary for the student, but
also the application of those details in the practice of medicine and surgery, thus rendering it both
a guide  for the  learner, and an admirable work of reference for the active practitioner.  The en-
gravings form a special feature in the work, many of them  being the  size of nature, nearly all
original, and having the  names of the various parts printed  on the  body of the  cut, in place of
figures of reference, with  descriptions at the foot. They thus  form a complete and splendid series,
which will greatly assist the  student in obtaining a clear idea of  Anatomy, and will also serve  to
refresh the memory of those who may find in the exigencies of practice the necessity of recalling
the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with
a thorough treatise on systematic, descriptive,  and applied Anatomy, the work will be found  of
essential use to  all physicians who receive students  in  their offices, relieving  both preceptor and
pupil  of much labor in laying the groundwork of a thorough medical.education.
  Notwithstanding its exceedingly low price, the work will be  found, in every detail of mechanical
execution, one of the handsomest that has yet been  offered to the  American profession; while the
careful scrutiny of a competent anatomist has relieved it of whatever typographical errors existed
in the English edition.
  Thus it is that book after book makes the labor of
the student easier than before, tfnd since we have
seen Blanchard 4 Lea's new edition of Gray's Ana-
tomy,  certainly the finest work of the kind now ex-
tant, we would fain hope that the bugbear of medical
students will lose half its horrors, and this necessary
foundation of physiological science will be much fa-
cilitated and advanced.—N. O. Med.  News.

  The  various points illustrated are marked directly
ou the structure; that is, whether it be muscle, pro-
cess, artery, nerve, valve, etc. etc.—we say each point
is distinctly marked by lettered engravings, so that
the student perceives at once each point described as
readily as if pointed out on the subject by the de-
monstrator.  Most of the illustrations are thus ren-
dered  exceedingly satisfactory, and to the physician
they serve to refresh the memory with great readiness
and with scarce a reference to the printed text.  The
surgical application of the various regions is also pre-
sented with force and clearness, Impressing upon the
student at each step of his research all the important
relations of the structure demonstrated.—Cincinnati
Lancet.
  This is, we believe, the  handsomest book on Ana-
tomy as yet published in our language, and bids fair
to become in a short time the standard text-book of
our colleges and studies.  Students and practitioners
will alike appreciate this  book.  We predict for it a
bright career, and are fully prepared to endorse the
statement of the  London Lancet, that " We are not
acquainted with any work in any language which
can take equal rank with the one before us." Paper,
printing, binding, all are excellent, and we feel  that
a grateful profession will not allow the publishers to
go unrewarded.—Nashville Med. and Surg. Journal.
 &MITH (HENR Y H.), M.D.,     and  JJORNER ( WILLIAM E.), M.D.,
   Prof . of Surgery in the Univ. of Penna.,&c.          Late Prof, of Anatomy in the Univ. of Penna., Ae-

   AN  ANATOMICAL   ATLAS,  illustrative  of  the  Structure  of the
      Human Body.  In one volume, large imperial octavo, extra cloth, with about six hundred
      and fifty beautiful figures.   $4 50.
  The plan of this  Atlas, which renders it so pecu-1 the kind that has yet appeared; and we must add.
Marly convenient for the student, and its superb ar- | the very beautiful manner in which it is "got up'*
tistical execution, have been already pointed out. We  is so creditable to the country as to be flattering to
must congratulate the student upon the completion  our national pride.—American Medical Journal.
ef this Atlas, as it is the most convenient work of I
TJARTSHORNE {HENRY), M. D.,
        Professor of Hygiene, etc., in the University of Pennsylvania.
  A HAND-BOOK  OF  HUMAN  ANATOMY  AND  PHYSIOLOGY,
     for the use of Students, with 176 illustrations.  In one volume, royal 12mo. of 312 pages;
     extra cloth, $1 75.  (Now Ready.)
 QfHARPEY (WILLIAM), M.D.,   and     Q DAIN {JONES $• RICHARD).

   HUMAN  ANATOMY.  Revised, with  Notes and Additions, by Joseph
      Leidy, M.D., Professor of Anatomy in the University of Pennsylvania.  Complete in two
      large octavo volumes, of about 1300 pages, with oil illustrations; extra cloth, $6 00.
  The very low price of this standard work, and its completeness in all departments of the subject,
should command for it a place in the library of all anatomical students.
ALLEN {J.M.), M.D.

  THE  PRACTICAL ANATOMIST; or, The Student's Guide in  the
     Dissecting Room.   With 266 illustrations.  In one very handsome royal  12mo. volume
     of over 600 pages; extra cloth, $2 00.
One of the most useful works upon the subject ever written.—Medical Examiner. 
Henry C.  Lea's  Publications—(Anatomy).                 7
\fflTLSON (ERASMUS), F.R.S.
   A SYSTEM  OF  HUMAN ANATOMY,  General  and Special.  A  new
      and revised American, from the last and enlarged English edition.  Edited by \V. H. Go-
      brkcht, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio.
      Illustrated with three hundred  and ninety-seven engravings on wood.  In one large and
      handsome octavo volume, of over 600 large pages; extra cloth,  $4  00; leather, $5 00.
  The publisher trusts that the well-earned reputation of this long-established favorite  will be
more than maintained by the present edition.  Besides a very thorough revision by the author, it
has been most carefully examined by the editor, and the efforts of both have been directed  to in-
troducing everything which increased  experience in its use has suggested as desirable to render it
a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana-
tomy.   The amount of additions which it has thus received may be estimated from the fact that
the present edition  contains over one-fourth  more matter than the last, rendering a smaller type
and  an enlarged page requisite to keep the volume within a convenient size.  The author has not
only thus added largely to the  woTk, but he has also made alterations  throughout, wherever there
appeared the opportunity of improving the arrangement or style, so as to present every fact in its
most appropriate manner, and to render the whole as clear and intelligible as possible.  The  editor
has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased
the number of illustrations, of which  there are about one hundred and fifty more in this edition
than in  the last, thus bringing distinctly before the eye of the student everything of interest or
importance.
 TOY THE SAME AUTHOR.

   THE  DISSECTOR'S MANUAL;  or, Practical and  Surgical Ana-
      to my.  Third American, from the last revised and enlarged English edition.  Modified and
      rearranged by William Hunt, M.D., late Demonstrator of Anatomy in the University of
      Pennsylvania.  In one large and handsome royal  12mo. volume,  of 582 pages, with 154
      illustrations; extra cloth,  $2  00.
 ITODGES,  (RICHARD 31.),  M.D.,
■*-■*-      Late Demonstrator of Anatomy in the Medical Department of Harvard University.
   PRACTICAL  DISSECTIONS.   Second Edition, thoroughly  revised.   In
      one neat royal 12mo. volume, half-bound, $2 00.   (Just Issued.)
  Tbe object of this work is to present to the anatomical student a clear and concise description
of that which  he is expected  to observe in an  ordinary course of dissections.  The author has
endeavored to omit unnecessary details, and to present the subject in  the form which many years'
experience has shown him to be the most  convenient and intelligible to the student.  In the
revision of the present edition,  he  has sedulously labored  to render  the volume more worthy of
the favor with which it has heretofore been  received.
M
ACLISE  (JOSEPH).
    SURGICAL  ANATOMY.   By Joseph Maclise,  Surgeon.   In  one
      volume, very large  imperial quarto;  with 68 large and splendid  plates, drawn in the best
      style and beautifully colored, containing 190 figures, many of them the size of life; together
      with copious explanatory letter-press    Strongly and handsomely bound in extra cloth.
      Price $14 00.
  As no complete work of  the kind has heretofore been published in the English language, the
present volume will supply a want long felt in this country of an accurate and comprehensive
Atlas of Surgical Anatomy, to which the student and  practitioner can at all times refer to ascer-
tain the exact relative positions of the various  portions of the human frame towards each other
and to the surface, as well  as their abnormal  deviations.  The importance of such a work to the
student, in the  absence of anatomical material, and to practitioners, either for consultation in
emergencies or to refresh their recollections of  the dissecting room, is evident.   Notwithstanding
the large size, beauty and finish of the very  numerous illustrations, it will be observed that the
price is so low as to place it within the reach  of all members of the profession.
  We know of no work on surgical anatomy which  refreshed  by those clear and distinct dissections,
can compete with it.—lancet.                     which every one must appreciate who has a particle
  The work of Maclise on surgical anatomy Is of  the  of °nt\n8.iaff m-  Th,e E?glisn medical press has quite
highest  value.  In some respects It i* the best publi-  exhausted the words of praise in recommending this
oafion of its kind we have seen, and U worthy of a  admirable treatise.  Those who have any curiosity
Xe in  the library of any medical man, while  the  to gratify  m reference to the perfectibility of the
stuaent could scarcely make a better investment than  "hographic art in delineating the complex mochan-
T^-TheWtstcr7jLrn,dofMtdicineandSxtrgery.  »»» ?* &* human body, are invited to examine our
tnie.  i«eiTMiw»«      j                  o   specimen copy.  If anything will induce surgeons
  No such  lithographic Illustrations of  surgical  re- I and students to patronize a book of such  rare value
irioiis have hitherto, we think,  been given.  While | and everyday importance to them, it will be a survey
the operator is shown every vessel and  uerve where i of the artistical skill exhibited in these fac-similes of
an operation is contemplated, the exact anatomist is  nature.— Boston Med. and Surg. Journal.

HORNER'S SPECIAL ANATOMT AND HISTOLOGY. I PEASLEES HUMAN HISTOLOGY, in its relatio
  liiirhth edition, extensively revised and modified    to Anatomy, Physiol .gy. and Pathology   Wi
  In 2 vols .svo , of over 1000 pago, with more than    431  illustration*.  In 1  vol. Svo , of over 600 page
  a,u> ur.i.ut.pMta : extra cloth. 4G «0.                 extra cloth, ?3 73.
300 wood-cuts ;  extra cloth, $G 90
  With
> pages 
8                Henry C. Lea's Publications—(Physiology).
 JlfARSHALL (JOHN), F. R. S.
■*■'•*-     Profts-or of Surgery in University College, London, Ac.

    OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE.
       With Additions by Francis Guhney  Smith, M. D., Professor  of the Institutes of Medi-
       cine in the University of Pennsylvania, Ac.   With numerous illustrations.   In one large
       and handsome octavo volume,  of 1026 pages, extra cloth,  $6 50; leather, raised band*,
       $7 50.  (Now Ready.)
  In fact, in every respect, Mr. Marshall has present- fern physiological science, both human and compara-
                                               tive, with which we are acquainted.  T«>  speak of
                                               this work in the terms  ordinarily used on such occa-
                                               sions would not be agreeable to ourselves, and would
                                               fail to do justice 10 its author.  To write such a book
                                               requires a varied and wide range of knowledge, con-
                                               siderable power of analysis, correct judgment, skill
                                               in arrangement,  and conscientious spirit.  It must
                                               have entailed great labor, but now that the task has
                                               been fulfilled, the book will prove not only invaluable
                                               to the student of medicine and surgery, but service-
                                               able to all candidates in natural science examinations,
                                               to teachers in schools, and to the lover of naturo gene-
                                               rally.   In conclusion,  we can only express the con-
                                               viction that the merits of the work will command for
                                               it that success which the ability and vast labor die-
                                               played  in its production so well deserve.—London
                                               Lancet,  Feb. 22, 1S6S.
                                                 If the possession of  knowledge, and peculiar apti-
                                               tude and skill in expounding it, qualify a man to
                                               write an educational work, Mr. Marshall's treatise
                                               might be reviewed favorably without even opening
                                               the covers.  There are few, if any, more accomplished
                                               anatomists and physiologists than the distinguished
                                               professor of surgery at University College ; and he
                                               has long enjoyed the highest reputation  as a teacher
                                               of physiology, possessing remarkable powers of clear
                                               exposition and graphic illustration.  We.have rarely
                                               the pleasure of being able to recommend a text-book
                                               bo unreservedly as this.—British Med. Journal, Jan.
                                               25. 1868.
ed us with a most complete, reliable, and scientific
work, and we  feel  that it is worthy  our warmest
commendation.—St. Louis Med. Reporter, Jan. 1S69.

  This is an elaborate and  carefully prepared digest
ef human and comparative physiology, designed for
the use of general readers, but more especially ser-
viceable to the student of medicine.  Its style is con-
cise, clear, and scholarly; its order perspicuous and
exact, and its range of topics extended. The author
and his American editor have been  careful to bring
to the illustration of the subject the important disco-
veries of modern science in the various cognate de-
partments of investigation.  This is especially visible
in the variety of interesting information derived from
the departments of chemistry and physics.  The great
amount and variety of matter contained in the work
is strikingly illustrated by turning over the copious
index, covering twenty-four closely printed pages in
duuble columns—Silliman's Journal, Jan. 1869.
  We doubt if  there is in the English language any
compend of physiology more  useful to the  student
than this work.—St. Louis Med. and Surg. Journal,
Jan. 1869.
  It quite fulfils, in our opinion, the  author's design
of making it truly educational in its character—which
is, perhaps, the highest commendation that can be
asked.—Am. Journ. Med. Sciences, Jan. 1869.
  We may now congratulate  him on  having  com-
pleted the latest as well as the best summary of mod-
c
ARPENTER  {WILLIAM  B.), M.D., F.R.S.,
     Examiner in Physiology and Comparative Anatomy in the University of London.

 PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with their chief appli-
   cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine.  A new
   American from the last and revised London edition.  With nearly three hundred illustrations.
   Edited, with additions, by Frascis Guknkt Smith,  M. D., Professor of the Institutes of
   Medicine in the University of Pennsylvania, Ac.   In one very large and  beautiful octavo
   volume, of about 900 large pages, handsomely printed;  extra cloth,  $5 50 ; leather, raised
   bands, $6 50.
                                             We doubt not it is destined to retain a strong hold
                                           on public favor, and remain the favorite text-book in
                                           our colleges.—Virginia Medical Journal.
  The above is the title of what is emphatically the
great work on physiology; and we are conscious that
it would be a  useless etfort to attempt to add any-
thing to the reputation of this invaluable work, and
can only say to all with whom  our opinion has any
influence, that it is our authority.—Atlanta Med.
Journal.
  With Dr. Smith, we confidently believe "that the
present will more than sustain the enviable reputa-
tion already attained by former  editions, of being
one of the fullest and most complete treatises on the
subject in the English language."  We know of none
from the  pages of which a satisfactory knowledge of
the physiology of the human organism can be as well
obtained, none better adapted for the use of such as
take up the  study of physiology in its reference tof
the institutes and  practice of medicine.—Am. Jour.
Med. Sciences.
 DY THE SAME AUTHOR.
     PRINCIPLES OF  COMPARATIYE  PHYSIOLOGY.   New Ameri-
       can,  from  the Fourth  and  Revised London Edition.   In one large and handsome octavo
       volume, with over three hundred beautiful illustrations   Pp. 752.  Extra cloth, $5 00.
   As a complete and condensed treatise on its extended and important subject, this work becomes.
a necessity  to students of natural scienoe, while the very low price at which it is  offered place* it
within the reach of all.                     _____
 T>Y THE SAME AUTHOR.
     THE  MICROSCOPE  AND  ITS REVELATIONS.   Illustrated  by
       four  hundred and thirty-four beautiful engravings on wood.  In one large and very  hand-
       some octavo volume, of 724 pages, extra cloth, $5 25.

  TZIRKES { WILLIAM SENHOUSE), M.D.,

     A  MANUAL  OF  PHYSIOLOGY.   A  new American  from  the third
       and  improved London edition  With two  hundred illustrations.  In one  large  and  hand-
       some royal 12mo. volume.   Pp. 586.  Extra cloth,  $2 25;  leather, $2 75.
  It Is at once convenient in size, comprehensive in
design, and concise in statement, and altogether well
adapted for the purpose designed.—St. Louis Med
and Surg. Journal.

  Tbe physiological reader will f nd It a most excel-
lent guide in the study of physiology in its most ad-
vanced and  perfect form.   The author hag shown
himself capable of giving details sufficiently ample
ii a condensed and concentrated shape, on a science
in which it is necessary at once to be correct and not
lengthened.—Bdinburgh Med. and Surg. Journal. 
Henry C. Lea's Publications—(Physiology).                9
 T)ALTON {J  C), M.D.,
         Professor of Physiology in the College of Physicians and Surgeons, New York, Ac.

    A  TREATISE  ON HUMAN  PHYSIOLOGY.   Designed  for the use
      of Students and Practitioners of Medicine.   Fourth edition, revised, with nearly three hun-
      dred illustrations on wood.  In one very beautiful octavo volume, of about 700 pages, extra
      cloth, $5 25 ;  leather, $6 25.  (Just Issued.)
                              From the Preface to the New Edition.
  " The progress made by Physiology and  the kindred Sciences during the last few years has re-
quired,  for the present edition of this work, a thorough and extensive revision.  This progress
has not consisted in  any very striking single discoveries, nor in a decided revolution in any of
the departments  of Physiology;  but it has been marked by great activity of investigation in  a
multitude of different directions, the combined results of which have not failed to impress a new
character on  many  of the  features of physiological  knowledge.  ...  In the revision and
correction  of  the present edition, the author has endeavored to incorporate  all such improve-
ments in physiological knowledge with the mass of the text in such a manner as  not essentially
to alter the structure and plan of the work, so far as  they have been found adapted to the wants
and convenience  of the reader.   .  .  .   Several  new illustrations are introduced, some of them
as additions, others as improvements or corrections of the  old.  Although all parts of the book
have received  more or less complete revision, the greatest number of additions and changes were
required in the Second Section, on the Physiology of the Nervous System."
  The advent of the first  edition of Prof. Dalton's | merits of clearness and condensation, and being fully
Physiology, about eight years ago, marked a new era '
In the 6tudy of  physiology to the American student.
Dnder Dalton's skilful  management,  physiological
science threw off the long, loose, ungainly garments
of probability and  surmise, in which it had been ar-
rayed by most  artists, and came among us smiling
and attractive, in the beautifully tinted and closely
flitting drees of a  demonstrated science.   It was a
stroke of genius, as well as a result of erudition and
talent, that led Prof. Dalton to present to the world
a work on physiology at once brief, pointed, and com-
prehensive, and which exhibited plainly in letter and
drawings the basis upon which the conclusions ar-
rived at rested. It is no disparagement of the many
excellent works on physiology, published  prior to
that of Dalton, to  say that none of them, either in
 Elan of arrangement or clearness of execution, could
 e compared with  his for the use of students or gene-
ral practitioners of medicine.  For  this purpose his
book has no equal in the English language.— Western
Journal of Medicine, Nov. 1867.
   A capital text-book  in every way. We are, there-
fore, glad to see it in its fourth edition.  It has already
been examined at full length in these columns, so that
we need not now further advert to it beyond remark-
ing that both  revision and enlargement have been
most judicious.—London Med.  Times and Gazette,
Oct. 19, 1S67.
   No better proof of the value of this admirable
work could be  produced than the fact that it has al-
ready reached  a fourth edition in  the short space of
eight years. Possessing in an  eminent  degree the
brought  up to the present level of Physiology, it is
undoubtedly  one of the most reliable  text-books
upon this science that could be pla<*<yj in the hands
of the medical student.—Am. Journal Med. Sciences,
Oct. 1867.

  Prof. Dalton's work has such a well-established
reputation that it does not stand in need of any re-
commendation.  Ever since its first appearance it has
become the highest authority in the English language;
and that it is able to maintain  the enviable position
which it has  taken, the rapid exhaustion of the dif-
ferent successive editions is sufficient evidence.  The
present edition, which is the fourth, has been tho-
roughly revised, and enlarged by the incorporation
of all the  many important advances which have
lately been made In  this rapidly progressing science.
—N. Y. Med.  Record, Oct. 15, 1867.
  As it stands, we esteem it the very best  of the phy-
siological text-books for the student, and the  most
concise reference and guide-book for the practitioner.
—N. Y. Med. Journal, Oct. 1867.
  The present edition of this now standard work fully
sustains the  high reputation of its accomplished au-
thor.  It is not merely a reprint, but has  been faith-
fully revised, and enriched by such additions as the
progress of physiology has rendered desirable Taken
as a whole, it is unquestionably the most reliable aud
useful treatise on the subject that has been issued
from the American  press.—Chicago Med. Journal,
Sept. 1867.
 TTkUNGLISON {ROBLEY), M.D.,
JS     Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia.

    HUMAN PHYSIOLOGY.   Eighth edition.   Thoroughly revised and
      extensively modified and enlarged, with five hundred and thirty-two illustrations.   In  two
      large and handsomely printed octavo volumes of about 1500 pages, extra cloth.  $7 00.

 JEHMANN (C.  G.)
    PHYSIOLOGICAL CHEMISTRY.   Translated from the second edi-
      tion by George E. Day, M. D., F. R. S., Ac., edited by R. E. Rogers, M. D., Professor of
      Chemistry in the Medical Department of the University of Pennsylvania, with illustrations
      selected from Funke's  Atlas of Physiological Chemistry, and an Appendix of plates.  Com-
      plete in two large and handsome octavo volumes, containing  1200  pages, with nearly  two
      hundred illustrations, extra cloth.   $6 00.

 T5F THE SAME AUTHOR.
    MANUAL  OF  CHEMICAL  PHYSIOLOGY.   Translated from  the
      German, with Notes and Additions, by J  Cheston  Morris, M. D., with  an Introductory
      Essay  on Vital Force,  by Professor Samuel Jackson, M. D., of the University of Pennsyl-
      vania.  With illustrations on wood.   In one very handsome octavo volume of 336 pages
      extra cloth.   $2 25.           _____________________

 mODD  (ROBERT B.), M.D.  F.R.S.,  and jfiOWMAN (TV.),  F.R.S.


    THE  PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY   OF
      MAN.  With about three hundred large and beautiful illustrations on wood.  Complete in
      one  large octavo volume of 950 pages, extra cloth.  Price  ;?4 75. 
10                Henry C. Lea's Publications—(Chemistry).
JgRAXDE { WM. T.), D. C.L.,  and  mA YLOR (ALFRED S.), M.D., F.R.S.


   CHEMISTRY.   Second  American edition,  thoroughly revised by Dr.
      Taylor.  In one handsome 8vo. volume of 764  pages, extra cloth, $5 00 ; leather, $6 00.
      (Just Issued.)
                              From Dr. Taylor's Preface.
   "The  revision of the second edition, in  consequence of the death of ray lamented colleague,
has devolved entirely upon  myself.  Every chapter, and indeed every page,  has  been revised,
and numerous additions made  in all parts of the volume.   These additions have been restricted
chiefly to subjects having some practical interest, and they have been made as concise as possible,
in order  to keep the book within those limits which  may retain for it the character of a Student's
Manual "—London, June 29,  1867.
  A book  that has already so established a reputa-  |  This second American edition of an excellent trea-
son, as has  Brande  and Taylor's  Chemistry, can  tise on chemical science is not a mere republication
hardly need a notice, save to mention the additions  from the  English press, but Is  a revision and en-
and improvements of the  edition.   Doubtless the  largement of the original, under the supervision of
work  will long remain a favorite text-book in the  , the surviving author, Dr.  Taylor.   The favorable
schools, as well as a convenient book of reference for  opinion expressed on the publication of the  former
all.—N. Y. Medical Gazette, Oct. 12, 1867.           edition of this work is fully sustained by the present
                                             revision,  in which Dr. T. has increased the  size of
  For  this reason we hail with delight the repnblica-  | the volume, by au addition of sixty-eight pages—Am.
tion, in a  form which will meet with general approval  ' j0um. Med. Sciences, Oct. 1867.
and command public attention, of this really valua-  i  _   „            r,       _______c___...
ble standard work on chemistry-more particularly  _ The, Handbook is  Chemistry ok the Sti-dfnt.-
as it has been adapted with such care to the wants of  , Fof clearness of language,  accuracy of description,
the general public  The well known scholarship of  | ex«ent of information and treedom  from pedantry
its authors, and their extensive researches for many  I and. my'tingm, «">■?ther text-book comes into corn-
years in experimental chemistry, have been long ap-  petition with it.—The Lancet.
predated  In the scientific world, but in this work they    The authors set out with the definite purpose of
have been careful to give the largest possible amount  | writing a book which shall be intelligible to any
of information with the most sparing use of technical  ! educated man.  Thus conceived, and worked ont in
terms  and phraseology, so as to furnish the reader,  , the most  sturdy, common-sense method, this book
"whether a student of medicine, or a man of the  gives  in  the clearest and  most summary method
world, with a plain introduction  to the science  and  possible all the facts  aud doctrines of chemistry.—
practice of chemistry."—Journal of Applied Chern-  j Medical Times.
istry, Oct. 1867.                      __________\________

    DLING (WILLIAM).
         Lecturer on Chemistry, at St. Bartholomew's Hospital, A-c.

   A COURSE  OF  PRACTICAL CHEMISTRY,  arranged  for  the Use
      of Medical Students.  With Illustrations.   From the Fourth and Revised London Edition.
      In one neat royal 12mo. volume.   (Just Ready.)
0
jyOWMAN (JOHN E.),M. D.

   PRACTICAL  HANDBOOK OF MEDICAL CHEMISTRY.   Edited
     by C L.  Bloxam, Professor  of Practical Chemistry in King's College, London.  Fourth
     American, from the fourth and revised English Edition.  In one neat volume, royal 12mo.,
     pp. 351, with numerous illustrations, extra cloth.  $2 25.
  The fourth edition of this invaluable text-book of
Medical Chemistry was published in England in Octo-
ber .if the last year.  The Editor has brought down
the Haudbook to that date, introducing, as far as was
compatible with the necessary conciseness of such a
work, all the valuable discoveries in  the science
which have come to light since the previous edition
was printed.  The work is indispensable  to every
student of medicine or enlightened practitioner.  It
is printed  in clear type, and the illustrations are
numerous and intelligible.—Boston Med. and Surg.
Journal.
JDY THE SAME AUTHOR.                  ----

   INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING
      ANALYSIS.  Fourth American, from the fifth and revised London edition.  With numer-
      ous illustrations.  In one neat vol., royal 12mo., extra cloth.   $2 25.  (Just Issued.)
  One of the most complete manuals that has for a
l.ing  time  been  given  to  the medical student.—
Athenaum.
  We regard it as realizing almost everything to be
desired in  an introduction  to Practical Chemistry.
It i« by far the best adapted for the Chemical student
of any that has  yet fallen in our way.—British and
Foreign Medico-Chirurgical Review.
 The best introductory work on the subject with
which we are acquainted.—Edintmrgh Monthly Jour.
 SIR A HAM  (THOMAS), F.R.S.

     THE  ELEMENTS  OF  INORGANIC  CHEMISTRY, including  the
      Applications  of the Science in the Arts.  New and  much  enlarged  edition, by  Henkv
      Watts and Robert Bridges, M. D.  Complete in one large and handsome octavo volume,
      of over 800 very large pages, with two hundred and thirty-two  wood-cuts, extra cloth.
      $5  50.

KNAPP'S TECHNOLOGY ;  or Chemistry Applied to I  very handsome octavo volumes, with 500 wood
  lY •■ Arts,  and to Manufactures.  With American j  engravings, extra cloth, $6 00.
  additions, by Prof. Walter K. Johnson.  In two |

 T\CNGLISON (ROBLEY),  M.D.,

^  NEW REMEDIES, WITH FORMULAE FOR THEIR  PREPARA-
      TION  AND ADMINISTRATION.  Seventh edition, with extensive  additions.  In one
      very large octavo volume of 770 pages, extra cloth.  $4 00. 
Henry  C. Lea's Publications—(Chemistry,  Pharmacy, &c).     11
fifOWNES (GEORGE), Ph. D.

   A  MANUAL  OF  ELEMENTARY CHEMISTRY;  Theoretical  and
      Practical.   With one hundred and ninety-seven illustrations.  A  new American, from the
      tenth  and  revised  London edition.   Edited by Robert  Bridges, M. D.   In one large
      royal 12mo. volume, of about 850 pp ,  extra cloth, $2 75 ; leather, $3 25.  (Jitst Ready.)
  Some years  having  elapsed since the appearance of the last American edition, and severnl
revisions  having  been  made of the work in  England during the interval, it will  be found very
greatly altered, and enlarged by about two hundred and  fifty pages, containing nearly one half
more matter than before.  The editors, Mr. Watts and Dr. Bence Jones, have labored sedulously
to render it worthy in all respects of the  very remarkable favor which it has thus far enjoyed,  by
incorporating in it all the most recent investigations and discoveries, in so far as is compatible with
its design as an elementary text-book.   While its distinguishing characteristics have been pre-
served,  various portions have  been rewritten,  and especial pains  have  been taken with the
department of  Organic Chemistry in which late researches have accumulated so many new facts
and  have enabled the subject to be systematized and rendered intelligible in a manner formerly
impossible.   As only a few months have elapsed since the work thus passed through the hands
of Mr. Wntts and Dr.  Bence Jones, but little has remained to be done by the American editor.
Such additions as seemed advisable have however been made,  and especial care has been taken
to secure, by the  closest scrutiny, the  accuracy  so essential in a work of this nature.
  Thus fully brought up to a level with  the  latest advances of science, and presented at a price
within the reach  of all, it is hoped that the work will maintain its position as the favorite text
book of the medical student.
                                               the General Principles of Chemical Philosophy, and
                                               the greater part of the organic chemistry, have been
                                               rewritten, and the whole work revised in accordance
                                               with the recent advances in chemical knowledge.  It
                                               remains the standard text-book of chemistry.—Dub-
                                               lin Quarterly Journal, Feb. 1869.
  This work is so well known that it seems almost
superfluous for us to speak about it.  It has been a
favorite text-book with medical studeuts for years,
and its  popularity has in no respect  diminished.
Whenever we have been consulted by nredical stu-
dents, as has  frequently occurred, what treatise on
chemistry they should procure, we have always re-
commended Fownes', for we regarded  It as the best.
There is no work that combines  so many excellen-
ces.  It is of convenient size, not prolix, of plain
perspicuous diction, contains all the  most  recent
discoveries, and is of moderate  price.—Cincinnati
Med. Repertory, Aug. 1869.
  Large additions  have been made, especially in the
department of organic chemistry, and we know of no
other work that has greater claims on the physician,
pharmaceutist, or student, than this.  We cheerfully
recommend it as the  best text-book on elementary
chemistry, and  bespeak for it the careful attention
of students of pharmacy.—Chicago Pharmacist, Aug.
1869.
  The American reprint of the tenth revised and cor-
rected  English edition is now issued, and represents
the present condition of the scieuce.  No comments
are necessary to insure it a  favorable  reception at
the hands of practitioners and  students. — Boston
Med. and Surg. Journal, Aug. 12, 1869.
  It will continue, as heretofore, to hold the first rank
as a text-book for students  of medicine —Chicago
Med. Examiner, Aug  1869.
  This work, long the recognized Manual of Chemistry,
appears as a tenth edition, under the able editorship
of Bence Jones and Henry Watts. The chapter on
  There is probably not a student of chemistry In this
country to whom the admirable manual of the laH
Professor Fownes is unknown   It has achieved a
success which we believe is entirely without a paral-
lel among scientific text-books in our language.  This
success has arisen from the fact that there is no En-
glish work on chemistry  which combines  so many
excellences.   Of convenient size, of attractive form,
clear and concise in diction, well illustrated, and of
moderate price,  It would  seem that every requisite
for a student's hand-book has been attained.  The
ninth edition was published  under the joint editor-
ship of Dr. Bence Jones and  Dr. Hofmann; the new
one has been superintended through the press by Dr.
Bence  Jones and Mr. Henry  Watts.  It is not too
much to say that it could not possibly have been in
better hands.  There is no one in England who can
compare with Mr. Watts in experience as a compiler
in chemical literature, and we have much pleasure
in recording the fact that bis reputation is well sus-
tained  by  this, his last undertaking.—The Chemical
News, Feb. 1S69.

  Here is a new edition which has been long watched
for by eager teachers of chemistry.  In its new garb,
aud under the editorship of Mr. Watts, it has resumed
its old place as  the most  successful of text-books.—
Indian Medical Gazette, Jan. 1, 1869.
 pARRISH (ED WARD),
          Professor of Materia Medica in the Philadelphia College of Pharmacy.

   A  TREATISE  ON  PHARMACY.   Designed as a Text-Book for the
       Student,  and as a Guide for the Physician and Pharmaceutist.  With many Formulae and
       Prescriptions.  Third Edition,  greatly improved.  In one handsome octavo volume, of 850
       pages, with several hundred illustrations, extra cloth.  $5 00.

  The immense amount of practical information condensed in this volume may be estimated from
the -feet that the Index contains about 1700 items.    Under the head of Acids there are 312 refer-
ences; under Emplastrum, 36; Extracts, 159; Lozenges,  25;  Mixtures, 55;  Pills, 56;  Syrups,
131;  Tinctures, 138 ;  Unguentum, 57, Ac.
  We have examined this large volume with a good . not wish  it to  be understood as very  extravagant
deal of care, and  find  that tbe author has completely  praise.  In truth, It is not so much the best  as the
exhausted the subject upon which he treats ; a more ! only book.—The London Chemical News.
complete work, we  think, It would be impossible to
find.  To the student of pharmacy the work is indis-
pensable ; indeed, so far as we know, it is the only one
of its  kind in existence, and even to the physician or
medical student who  can spare five  dollar-, to pur-
ebase it  we feel sure the practical  intormation he  mucn a matter oi regret, inasmm
w^U obtain will more than compensate him for the I dlfflc»lt \" think of any point, ho,
out^y-Canada Med. Journal, Nov. 1864.          apparently trivial, connected with he manipulation
ouuay.   ^itfM<«** -"»«•• »     —»                  i ^f pharmaceutic substance- or appliances which has
  The medical student and the practising physician  not been cleitriv Hnd carefully discussed in  this vol-
will find the volume of inestimable worth for study ; ume   Want of  space prevents our enlarging further
and reference.—San  Francisco  Med.  Press, July, i on  tnts valuable work,  and  we must conclude by a
1864.                                          ! simple expre^-ion of our hearty appreciation of its
  When we say that  this book is In some respects I merits.—D"hlin Quarterly Jour, of Medical Science,
the hest which has been published "n the subject iu j August, lio'4.
the English language for a great  mauy years, we do i
  An attempt to furnish anything like an analysis of
Parrish's very valuable and elaborate Treatise on
Practical Pharmacy would require more space than
we have at our  disposal.  This, however, is uot  so
much a  matter of regret, inasmuch as it would  be
                           however minute and 
12     Henry  C. Lea's Publications—(Mat. Med. and Therapeutics).
 &TILLE  (ALFRED),  M.D.,
*-)     Prof ex/tor of Theory and Practice of Medicine in the University of Penna.

   THERAPEUTICS AND  MATERIA MEDICA;  a Systematic Treatise
      on  the  Action and Uses of Medicinal Agents, including their Description and  History.
      Third edition, revised and enlarged.  In two large and hiindsome octavo volume*  of about
      1700  pages, extra cloth,  $10 ; leather, $12.   (Just  Issued.)
  That  two large editions of a work of such magnitude should be exhausted in a few  years, is
sufficient evidence that it has  supplied a want generally  felt  by the profession, and the unani-
mous commendation bestowed  upon it by the medical  press, abroad as well  us at  home, shows
that the author has successfully accomplished his object  in presenting to the profession a system-
atic treatise suited  to the  wants of the practising  physician,  and unincumbered with details
interesting only to the naturalist or the  dealer.  Notwithstanding its enlargement, the present
edition  has  been kept at the former very  moderate price.

                                                 Stille's Therapeutics is incomparably the be«t work
                                               on the subject.—N. Y. Med. Gazette, Sept. 26, 1S68.
  Dr. Stille's splendid work on therapeutics and ma-
teria medica.—London Med. Times, April 8, 1865.

  Dr. Still6 stands to-day one of the best and most
honored representatives at home and abroad, of Ame-
rican medicine; and these volumes, a library in them-
selves, a treasure-house for every studious physician,
assure his fame even had he done nothing more.—The
Western Journal of Medicine, Dec. 1868.

  We  regard this work  as the  best one on Materia
Medica in the English language, and as such it de-
Btrves the favor  it has received.—Am. Journ. Medi-
cal Sciences, July 1868.

  We need not dwell on the merits of the third edition
of this magnificently conceived work.   It is the work
on Materia Medica, in which Therapeutics are prima-
rily considered—the mere natural history of drugs
being  briefly disposed of. To medical practitioners
this is a very valuable conception. It is wonderful
how much of the riches  of the literature of Materia
Medica has been condensed into this book.  The refer-
ences alone would make it worth possessing.  But it
Is not a mere compilation.  The writer  exercises a
good judgment of his own on the great doctrines and
points of Therapeutics  For  purposes of practice,
Stille's book is almost unique as a repertory of in-
formation, empirical and scientific, on the actions and
uses of medicines.—London Lancet, Oct. 31, 1868.

  Through the former editions, the professional world
is well acquainted  with this work.   At home and
abroad its reputation as a standard treatise on Materia
Medica is securely  established  It is second to no
work  on the subject in the  English tongue, and, in-
deed, is decidedly superior, in some respects, to any
other.—Pacific Med. and Surg  Journal, July, 186S.
  Dr. Still6's work is becoming the best known of any
of our treatises on Materia Medica. .  .  .  One of the
most Tiiluable works in the language on the subjects
of which It treats —..V. Y. Med. Journal, Oct. 1S68.

  The rapid exhaustion of two editions of Prof Stille's
scholarly work, and the consequent necessity for a
third edition, is sufficient evidence of the high esti-
mate placed upon it by the profession. It is no exag-
geration to say that there  is  no superior work upon
the subject in  the  English language.  The present
edition is fully up to the most recent advance in the
science and art of therapeutics.—Leavenworth Medi-
cal Herald, Aug. 1868.

  The work of Prof. Stille1  has rapidly taken a high
place in professional esteem, and to say that  a third
edition  is demanded and now appears before us, suffi-
ciently attests the firm position this treatise has made
for itself.  As a work of great research, and  scholar-
ship, it is safe to say we have  nothing superior.  It la
exceedingly full, and the busy practitioner will find
ample suggestions upon almost every important point
of therapeutics.—Cincinnati Lancet, Aug. 1S68.

  It is just eight years since the  first edition of Pro-
fessor Still6's work was presented to the profession,
and we have now to chronicle the receipt of the third.
This, we are certain, is a sure indication of tbe value
in which it is held ;  it speaks more loudly in its favor
than could possibly any words we could write.  We
consider it is of especial value to students, combining
as it does therapeutics with a very excellent descrip-
tion of  the articles of the materia medica.—Canada
Med. Journal, July, 1868.
QRIFFITH (ROBERT E.),  M.D.
    A  UNIYERSAL  FORMULARY,  Containing  the  Methods  of  Pre-
       paring and Administering Officinal and other Medicines.   The whole adapted to Physicians
       and Pharmaceutists.   Second edition,  thoroughly revised, with numerous additions, by
       Robert P.  Thomas, M.D., Professor of Materia Medica in the Philadelphia College of
      Pharmacy.  In one large and handsome  octavo volume of 650 pages, double-columns.
       Extra cloth, $i 00; leather, $5  00.
  In  this volume, the Formulary proper occupies  over 400 double-column  pages, and contains
about 5000 formulas, among which, besides those strictly medical, will be found numerous valuable
receipts for the preparation of essences, perfumes, inks, soaps, varnishes, Ac. Ac.   In addition to
this, the work contains a vast amount of information indispensable for daily reference  by the prac-
tising physician  and apothecary, embracing Tables of Weights and Measures, Specifio Gravity,
Temperature for Pharmaceutical Operations, Hydrometrical Equivalents, Specific Gravities of some
of the Preparations of the Pharmacopoeias, Relation  between different Thermometrical ^ales,
Explanation  of Abbreviations used in Formulae, Vocabulary of Words  used in Prescriptions, Ob-
servations on the Management of the  Sick Room, Doses of Medicines, Rules  for the Administration
of Medicines, Management of Convalescence and  Relapses, Dietetic Preparations not included in
the Formulary, List of Incompatibles, Posological Table, Table  of Pharmaceutical Names which
differ in the Pharmacopoeias, Officinal Preparations and Directions, and Poisons.
  Three complete and extended Indexes render the work especially adapted for immediate consul-
tation.  One, of  Diseases and  their Remedies, presents under the head of each disease the
remedial agents which have been usefully exhibited in it, with reference to the formulae containing
them—while another of Pharmaceutical and Botanical Names, and a very thorough General
Index afford the means of obtaining at once any information  desired.  The Formulnry itself is
arranged alphabetically, under the heads of the leading constituents of the prescriptions.
  This is one of the most useful books for the prac-
tising physician which has been issued from the press
of late years,  containing a vast variety  of formulas
f. r the safe and  convenient  administration of medi-
cines, all arranged upon scientific and rational prin-
ciples, with  the quantities stated in full, without
signs or abbreviations.—Memphis Med. Recorder.
  We know of none in our language, or any other, so
comprehensive In its details.—London Lancet.
  One of the most complete works of the kind in any
language.—Edinburgh Med. Journal.
  We are not cognizant of the existence of a parallel
work.—London Med. Gazette. 
Henry C. Lea's Publications—(Mat. Med. and Therapeutics).    13
J> EREIRA (JONA THA N), M. D., F. R. S. and L. S.

    MATERIA   MEDICA  AND THERAPEUTICS;  being  an  Abridg-
      ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity with
      the British Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists and
      Druggists, Medical and Pharmaceutical  Students, Ac.   By F. J. Farre, M.D., Senior
      Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia;
      assisted by Robert Bentlev, M.R.C.S., Professor of Materia  Medica and  Botany to the
      Pharmaceutical Society of Great Britain; and by Robert Warington, F.R.S., Chemical
      Operator  to the Society of Apothecaries.  With numerous  additions and references to the
      United States  Pharmacopoeia, by Horatio C Wood, M.D., Professor of Botany in the
      University of  Pennsylvania.   In one large and handsome octavo volume  of 1040 closely
      printed pages, with 236  illustrations, extra cloth, $7 00;  leather,  raised  bands, $8 00.
      (Lately Published.)
  The task of the American editor has evidently been
no sinecure, for not only has he given to us all that
Is contained in the abridgment useful for our pur-
poses, but by a careful and judicious embodiment of
over a hundred new remedies has increased the size
of the former  work fully one-third, besides adding
many new illustrations, some of which are original.
We unhesitatingly say that by so doing  he has pro-
portionately increased the value, not only of the con-
densed edition, but has extended the applicability of
the great original, and has placed his medical coun-
trymen under  lasting obligations to him. The Ame-
rican physician  now has all that is needed in the
shape of a complete treatise  on materia  medica, and
the medical  student has a text-book which, for prac-
tical utility and intrinsic worth, stands unparalleled.
Although of considerable size, it is none  too large for
the purposes for which it has been intended, and every
medical man should, in justice to himself, spare a
place for it upon his book-shelf, resting assured that
the more he consults it the better he will be satisfied
of its excellence.—.Y. Y. Med. Record, Nov. 15, 1866.
  It will fill a place which no other work can occupy
in the library of the physician, student, and apothe-
cary.—Boston Med. and Surg. Journal,  Nov. 8, 1866.
  Of the many works on Materia Medica which have
appeared since the issuing of the British Pharmaco-
poeia, none will be more acceptable to the student
and practitioner than the present.  Pereira's Materia
Medica had long ago asserted for itself the position of
being the most complete work on the subject in the
English language.  But its very completeness stood
in the way of its success. Except in the way of refer-
ence, or to those who made a special study of Materia
Medica, Dr. Pereira's work was too full, and its pe-
rusal required an amount of time which few  had at
their disposal.  Dr. Farre has very judiciously availed
himself of the opportunity of the publication of the
new Pharmacopoeia, by bringing out an abridged edi-
tion of the great work.  This edition of Pereira is by
no means a mere abridged re-issue, but contains ma-
ny improvements, both in the descriptive and thera-
peutical departments.   We can recommend it  as a
very excellent and reliable text-book.—Edinburgh
Med Journal, February, 1866.

  The reader cannot fail to be impressed, at a glance,
with the exceeding value of this work as a compend
of nearly all useful knowledge on the materia medica.
We are greatly Indebted to  Professor Wood for his
adaptation of it to our meridian.  Without his emen-
dations and additions it would lose much of its value
to the American student. With them it is an Ameri-
can book.—Pacific Medical and Surgical Journal,
December, 1866.
PLLIS  (BENJAMIN),  M.D.

    THE MEDICAL FORMULARY: being a Collection of Prescriptions
      derived from the writings and practice of many of the most eminent physicians of America
      and Europe.  Together with the usual Dietetic Preparations and Antidotes for Poisons.  The
      whole accompanied with a few brief Pharmaceutic and Medical Observations.  Twelfth edi-
      tion, carefully revised and much improved by Albert H. Smith, M. D.   In one volume 8vo.
      of 376 pages, extra cloth, $3 00.  (Now Ready.)
  This work has remained for some time out of print, owing to the anxious care with which the
Editor has sought  to render the present edition worthy a continuance of the very remarkable
favor which has carried the volume to the unusual honor of a Twelfth Edition.   He ha6 sedu-
lously endeavored to introduce in it all new preparations and combinations deserving of confidence,
besides adding two new classes, Antemetics and Disinfectants, with brief references to the inhalation
of atomized fluids, the nasal douche of Thudichum, suggestions  upon the method of hypodermic
injection, the administration of anaesthetics, Ac. Ac.  To accommodate these numerous additions,
he has omitted much which the advance of science has rendered obsolete or of minor importance,
notwithstanding which the volume has been increased by more than thirty pages.   A new feature
will be found  in a  copious Index of Diseases and their remedies, which cannot but increase the
value of the work as a suggestive book of reference for the working practitioner. Every precaution
has been taken to secure the typographical accuracy so necessary in a work of this nature, and it
is  hoped that the new edition will fully maintain the position which " Ellis' Formulary" has
long occupied.___________________

OARSON (JOSEPH), M.D.,
V/      Professor of Materia Medica and Pharmacy in the University of Pennsylvania, Ac.

   SYNOPSIS OF  THE  COURSE  OF LECTURES  ON  MATERIA
      MEDICA AND PHARMACY,  delivered in the University of Pennsylvania.  With three
      Lectures on  the Modus Operandi of Medicines.  Fourth and revised edition, extra cloth,
      $3 00.   (Just Issued.)         ___________________
BOYLE'S MATERIA MEDICA AND  THERAPEU-
  TICS; including the Preparations of the Pharma-
  copoeias of London, Edinburgh, Dublin, and of the
  Uuited States.  With many new medicines.   Edited
  by Josbph Carson, M.D.  With ninety-eight illus-
  trations.  In one large octavo volume of about 700
  pages, extra cloth.  $3 00.
CHRISTISON'S DISPENSATORY; or, Commentary
  on the Pharmacopoeias of Great Britain and the
  United States.  With copious additions, and 213
  large wood-engravings. ByR. Eglbspeld Griffith,
  M. '*• In one very handsome octavo volume of over
  lix.i<-1 pages, extra cloth. $1 00.
CARPENTER'S PRIZE ESSAY ON THE USE  OF
  Alcoholic Liquors in Health and Disease.  New
  edition, with a Preface by D. F. Condie, M.D., and
  explanations of scientific words. In one neat 12mo.
  volume, pp. 178, extra cloth.  60 cents.
De JONGH ON THE THREE KINDS OF COD-LIVER
  Oil, with their Chemical  and Therapeutic Pro-
  perties.  1 vol. 12mo., cloth.  75 cents.
MAYNE'S DISPENSATORY AND THERAPEUTICAL
  Remembrancer.  With  every Practical Formula
  contained la  the  three British Pharmacopoeias.
  Edited, with the additiou of the  Formulae of  the
  U. S. Pharmacopoeia, by R.  E. Griffith, SI. D.  In
  one 12mo. volume, 300 pp.,  extra cloth.  75 cents. 
14
Henry C. Lea's Publications—(Pathology).
QROSS (SAMUEL  D.),  M. D.,
        Profesrnr of Surgery in the Jefferson Mimical College of Philadelphia.
  ELEMENTS   OF  PATHOLOGICAL   ANATOMY.   Third   edition,
      thoroughly revised and greatly improved.  In one large and very handsome octavo volume
      of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a
      large number are from original drawings ;  extra cloth.  $4  00.
 The very beautiful execution of this valuable work, and the exceedingly low price  at which  it
 offered, should command for it a place in the library of every practitioner.
  To the student of medicine we would  say that we
know of no work which we can more heartily com-
mend than Gross's Pathological Anatomy.—Southern
Med. and Surg. Journal.
  The volume commends itself to the medical student;
it will repay a careful perusal, and should be upon
the book-shelf of every American physician.—Oharleg.
ton Med. Journal.
  It contains much new matter, and brings down onr
knowledge of pathology to the latest period.—London
Lancet.
JONES (C. HANDFIELD), F.R.S., and  SIEVEKING (ED. K),  M.D.,
        Assistant Physicians and Lecturers in St. Mary's Hospital.
   A MANUAL  OF   PATHOLOGICAL ANATOMY.   First  American
      edition, revised.   With three  hundred and ninetyseven handsome wood engravings.  In
      one large and beautifully printed octavo volume of nearly 750 pages,  extra cloth, $3  50.
  Our limited space alone restrains us from noticing
more  at length the various subjects treated of in
this interesting work; presenting, as it does, an excel-
lent summary of the existing state of knowledge in
relation to pathological anatomy, we cannot  too
strongly urge upon the student the necessity of a tho-
rough acquaintance with its contents.—Medical Ex-
 miner.
  We have long had need of a hand-book of patholo-
gical anatomy  which should  thoroughly  reflect  the
present state of that science.  In the treatise before
us this desideratum is supplied.  Within the limits of
a moderate octavo, we have the outlines of this great
department of medical  science  accurately  defined,
and the most recent investigations presented in suffi-
cient detail for the student of pathology.  We cannot
at this time undertake a formal analysis of this trea-
tise,  as it would  involve a separate ind lengthy
consideration of nearly every subject discussed ; nor
would such analysis be advantageous to the medical
reader.  The work is of such a character that every
physician ought to obtain it, both for reference and
study.—N. Y. Journal of Medicine.
  Its importance to the physician cannot be too highly
estimated, and we would recommend our readers to
add it to their library as soon as they conveniently
can.—Montreal Med. Chronicle.
GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY.
  Translated, with Notes and Additions, by Joseph
  Leidt, M. D.  In one volume, very large imperial
  quarto, with 320 copper-plate figures, plain and
  colored, extra cloth.  $1 00.
SIMONS GENERAL PATHOLOGY, as conducive to
  tlie Establishment of Rational  Principles for the
  Prevention and Cure of Disease.  In  one octavo
  volume of 212 pages, extra cloth.  $1 25.
 WILLIAMS (CHARLES J. B.),  M.D.,
          Professor of Clinical Medicine in University College, London.

   PRINCIPLES OF  MEDICINE.   An Elementary View of  the Causes,
      Nature, Treatment, Diagnosis, and Prognosis of Disease;  with brief remarks on Hygienics,
      or the preservation of health.  A new American, from the third and revised London edition.
      In one octavo volume of about 500 pages, extra cloth.  $3 50.
  The unequivocal favor with which  this work has
been received by the profession, both in  Europe and
America, is one among the many gratifying evidences
which might he adduced as going to show that there
Is a steady progress taking place in the science as well
as in the art of medicine.—St. Louis Med. and Surg.
Journal.
  No work has ever achieved or maintained a more
deserved  reputation.— Virginia Med.  and Surg.
Journal.
  One of the best works on the subject of which it
treats in our language.
  It has already commended Itself to the high regard
of the  profession; and we may well say that we
they will  find their labor and study most amply
repaid.—Cincinnati Med. Observer.
                                                 There is no work in medical literature which can
                                               fill the place of this one.  It is the  Primer of the
                                               young practitioner, the Koran of the scientific one.—
                                               Stethoscope.

                                                 A text-book to which no other in our language ta
                                               comparable.—Charleston Med. Journal.

                                                  The absolute necessity of such  a  work must be
                                               evident  to  all who  pretend  to  more than  mere
                                               empiricism.  We must conclude by again express-
                                               ing our high sense of the  immense  benefit  which
                                               Dr. Williams has conferred  on mediciue by the pub-
know of no single volume that will afford the source i lication of this work.  We are certain that in the
of so thorough a drilling in the principles of practice j present state of our knowledge his Principles of Medi-
as this.  Students  and practitioners should make  cine could not possibly be surpassed.—London Jour.
themselves intimately familiar with its teachings— | of Medicine.
HARRISON'S  ESSAY TOWARDS A CORRECT
  THEORY OF THE NERVOUS SYSTEM.  In one
  octavo volume of 292 pp.  $1 oO.
BOLLY ON THE HUMAN BRAIN : its Structure, Phy-
  siology, and Diseases.  From the Second and much
  enlarged London edition.  In one octavo volume of
  500pages,with 120wood-cuts; extra cloth. 4)2 50.
BUCKNILL AND TUKES MANUAL OF PSYCHO-
  LOGICAL  MEDICINE;  containing the History,
  Nosology, Description, Statistics, Diagnosis, Patho-
  logy, and Treatment of Insanity.  With a Plate.
  In one handsome octavo volume, of 536pages, extra
  cloth.  >sl 2.0. 
Henry C. Lea's Publications—(Practice of Medicine).          15
PLINT (A UST1N), M. D.,
-*-       Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y.

   A  TREATISE  ON   THE   PRINCIPLES  AND  PRACTICE  OF
      MEDICINE;  designed for the mse of Students and Practitioners of  Medicine.   Third
      edition, revised and enlarged.   In one large and closely printed octavo volume of 1002
      pages;  handsome extra cloth, $6 00; or strongly bound in leather, with raised bands, $7 00.
      (Just Issued.)

                            From the Preface to the Third Edition.
  Since the publication, in December, 1866, of the second edition of this treatise, much time has
been devoted  to its  revision.  Recognizing in the favor with which it  has  been received  a  pro-
portionate obligation to strive constantly to increase its worthiness, the author has introduced in
the present edition additions, derived from  his clinical studies, and from the latest contributions
in medical literature, which,  it is believed,  will enhance considerably the practical utility of  the
work.   A slight modification in the typographical arrangement has accommodated these additions
without materially increasing the bulk of the volume.
  New  York, October, 1868.
  At the very low price affixed, the profession  will find this  to be one of  the cheapest volumes
within their reach.
  This work, which stands pre-eminently as the ad-
vance standard of medical science up to the" preseut
time in  the practice of medicine, has for its author
oue who is well and widely known as one of the
leading practitioners of this continent.  In fact, it is
seldom that any work Is ever issued from the press
more  deserving of universal recommendation.—Do-
minion  Med. Journal, May, 1869.
  The third edition of this most excellent book scarce-
ly needs any commendation from us.  The volume,
as it stands now, is really a marvel: first of all, it is
excellently printed and  bound—and we encounter
that luxury of America,  the ready-cut pages, which
the Yankees are 'cute enough to insist upon—nor are
these by any meaus trifles ; but the contents of the
book are astonishing.  Not only is it wonderful that
any one  man can have grasped in his mind the whole
scope  of medicine with that vigor which Dr.  Flint
shows, but the condensed  yet clear way in which
this is done is a  perfect literary triumph.  Dr. Flint
Is pre-eminently one of the strong men, whose right
to do this kind of thing is well admitted ;  and we say
no more than the truth  wheu we affirm that he is
very nearly the only living man that could do it with
such results  as the volume before us.—The London
Practitioner, March, 1869.
  This is in some respects the best text-book of medi-
cine in our language,  and it is highly appreciated on
the other side of  the Atlantic, inasmuch as the first
edition was exhausted In a few months.   The second
edition was little more than a reprint, but the present
has, as  the author says, been  thoroughly revised
Much valuable matter has been added, and by mak-
ing the  type smaller, the bulk of the volume is not
much increased.  The weak poiut in maDy American
works is pathology, but Dr. Flint has taken peculiar
pains on this poiut, greatly to the value of the book.
—London Med.  Times and Gazette,  Feb. 6, 1869.
  Published in 1866, this valuable book of Dr. Flint's
has in two years exhausted two editions, and uow
we gladly announce a third.  We say we gladly an-
nounce it, because we are proud of  it as a national
representative work  of not only American, but of
cosmopolitan medicine.  In it the practice of medicine
is young and philosophical, based on reason and com-
mon sense, and as such, we  hope it will be at the
right hand of every practitioner of this vast continent.
—California Medical Gazette, March, 1869.
  Considering the large number of valuable works in
the practice of medicine, already before the profes-
sion, the marked favor with which this has been re-
ceived, necessitating a third edition in the short space
of two years, indicates unmistakably that it is a work
of more than ordinary excellence, and must be accept-
ed as evidence that it has largely fulfilled the object
for which the  author intended it. A  marked feature
in the work, and one which particularly adapts it for
the use of students as a text-book, and certainly ren-
ders it none the less valuable to the busy practitioner
as a work  of reference, is brevity and  simplicity.
The present edition has been thoroughly revised, and
much new matter incorporated, derived, as the author
informs us, both from his  own clinical studies, and
from the latest contributions to medical literature,
thus bringing it fully up with the most recent ad-
vances of the science, and greatly enhancing its prac-
tical utility;  while, by a  slight modification of its
typographical  arrangement, the additions have been
accommodated without  materially  increasing its
bulk.—St  Louis Med. Archives, Feb. 1869.
  If there be among our readers any  who are not fa-
miliar with the treatise before us, we shall do them
a service In persuading them to repair their omissioM
forthwith.   Combining to a rare degree the highest
scientific attainments with the most practical com-
mon sense, and the closest habits of observation, the
author has given  us a volume which not only sets
forth the results of the latest investigations of other
laborers, but contains more original views than any
other single work upon this well-worn theme within
our knowledge.—.y. Y. Med. Gazette,  Feb. 27, 1869.
  Practical medicine was at sea when this book ap-
peared above the horizon as a safe and capacious har-
bor.   It came opportunely aud was greeted with
pleasurable emotions  throughout the land.—Nash-
ville Med. and Surg. Journal, May, 1869.
T)UNGLISON, FORBES, TWEED IE,  AND  CONOLLY.

   THE  CYCLOPAEDIA  OF  PRACTICAL  MEDICINE:  comprising
     Treatises on the Nature and Treatment of Diseases, Materia Medica and Therapeutics,
     Diseases of Women and Children, Medical Jurisprudence, Ac. Ac.  In four large super-royal
     octavo volumes, o 13254 double-columned pages, strongly and handsomely bound in leather,
     $15; extra cloth, $11.
 *** This work contains no less than four hundred and eighteen distinct  treatises, contributed
by sixty-eight distinguished physicians
  The most complete work  on practical  medicine
extant, or at least in our language.—Buffalo Medical
and Surgical Journal.
  For reference, it is above all price to every practi-
tioner.— Western Lancet.
  One of the most valuable medical publications of
the day.  As a work of reference it is invaluable.—
Western Journal of Medicine and Surgery.

  It has been to  us, both as learner and teacher, a
work for ready and frequent reference, one in which
modern English medicine is exhibited in the most ad-
vantageous light.—Medical Examiner.
BARLOW'S  MANUAL OF  THE PRACTICE  OF I HOLLAND'S  MEDICAL  NOTES  AND  REFLEC-
  MEDICINE.  With  Additions by  D.  F.  Condie, I   tions.  From the third and enlarged  English edi-
  M. D.  1 vol. 8vo., pp. 600, cloth.  j2 50.            tion.  In  one  handsome octavo volume of about
                                               |   500 pages, extra cloth.  $3 50. 
16        Henry C. Lea's Publications—(Practice of Medicine).
 fTARTSHORXE (HEXRY),  M.D.,
■*■-*-     Professor of Hygiene in the University of Pennsylvania.

   ESSENTIALS OF THE  PRINCIPLES AND  PRACTICE OF  MEDI-
       CINE.   A handy-book for Student? and Practitioners.  Second edition, revised and im-
       proved.   In  one handsome royal 12mo. volume of 450 pages, clearly printed on small type,
       cloth, $2 38; half bound,  $2 63.   (Now Ready.)
  Ttue very cordial  reception with which this work hns met shows that the author has fully suo-
.ceeded in his attempt to condense within a convenient compass the essential points of scientific
and practical  medicine, so as to  meet the wants not only of the student,  but also of the practi-
tioner who desires to acquaint himself with the results of recent advances in medical science.
  As a strikingly terse, full, and comprehensive em- I nearly than any similar manual lately before us the
bodiment in a condensed form of the essentials in I standard  at which all such books should aim — of
medical science and art, we hazard nothing in saying I teaching much, and suggesting more.  To the student
that it is incomparably in advance of any work of the
kind of the past, and will stand long in the future
without a rival.  A mere glance will, we think, im-
press others with the correctness of our estimate. Nor
do we believe there will be  found many who, after
the most cursory examination, will fail to possess it.
How one could be able to crowd so much that is valu-
able, especially to the student and young practitioner,
within the limits of so small a book, and yet embrace
and present all that is important  in a well-arranged,
clear form, convenient, satisfactory for reference, with
Si> full a table of contents, and extended general index,
with nearly three hundred formulas and recipes, is a
marvel.— Western Journal of Medicine, Aug. 1867.

  The little book before us has this quality, and we
can therefore say that all students will find it an in-
valuable guide in their  pursuit of clinical medicine.
Dr. Hartshorne speaks of it as "an unambitious effort
to make useful the experience of twenty years of pri-
vate and hospital medical practice, with its attendant
study and reflection." That the effort will prove suc-
cessful we have no doubt, and in his study, and at
the bedside, the student will find Dr. Hartshorne a
safe and accomplished companion.  We speak thus
highly of the volume, because  it approaches more
we can heartily recommend the work of our transat-
lantic colleague, and the busy practitioner,  we are
sure, will find  in it  the means  of solving many a
doubt,  and  will rise from the perusal of its pages,
having gained clearer views to guide him in bis daily
struggle with disease.—Dub. Med. Press, Oct. 2, 1867.
  Pocket handbooks of medicine are  not desirable,
even when they are as carefully and elaborately com-
piled as this, the latest, most complete, and roost ao-
curate which we have seen.—British  Med. Journal,
Sept. 21, 1867.
  This work of Dr. Hartshorne must not be confound-
ed with the medical manuals so generally to be fouud
in the hands of students, serving them at best but  as
blind guides, better adapted to lead them astray than
to any useful and reliable knowledge.   The work be-
fore us presents a careful synopsis of the essential
elements of  the theory of diseased action, its causes,
phenomena, and results, and of the art of healiug, as
recognized by the most authoritative of our profes-
sional writers and teachers.  A very careful and can-
did examination of the volume has convinced us that
it will be generally recognized as one of the best man-
uals for the use of the student that has yet appeared.
—American Journal Med. Sciences, Oct. 1867.
 TyATSON (THOMAS),  M. D., Sfc.

     LECTURES   ON   THE  PRINCIPLES  AND   PRACTICE   OF
      PHYSIC.   Delivered at King's College, London.  A new American, from the last revised
      and enlarged  English  edition,  with  Additions, by D.  Francis Condie, M. D., author of
      " A Practical  Treatise on the Diseases of Children," Ac.  With one hundred and eighty-
      five illustrations on wood.  In  one very large  and handsome volume, imperial octavo, of
      over  1200  closely printed pages in small type; extra  cloth, $6 50; strongly bound  in
      leather, with raised bands, $7 50.
  Believing this to be a work which should lie on the table of every physician, and be in the hands
   every student,  every effort has been made to condense the vast amount of matter which it con-
tains within a convenient compass, and at a very reasonable price, to  place it within reach of alL
In  its present enlarged  form, the work contains the  matter of at least three ordinary octavos,
rendering it one of the cheapest works now offered to the American profession, while its mechani-
cal  execution makes  it an exceedingly attractive volume.
DICKSON'S ELEMENTS OF MEDICINE; a Compen-
  dious View of Pathology and Therapeutics, or the
  History and Treatment  of Diseases.  Second edi-
  tion, revised. 1 vol. 8vo. of 750 pages, extra cloth.
  *t 00.
W H AT TO OBSERVE AT THE BEDSIDE AND AFTER
  Death in Medical Cases. Published under the
  authority of the London Society for Medical Obser-
  vation.  From the second London edition.  1 voL
  royal 12mo., extra cloth.  $1 00.
LAYCOCK'S   LECTURES ON  THE PRINCIPLES
  and Methods or Medical Observation and  Rb-
  search.  For the  use  of advanced students and
  junior practitioners. In one very neat royal 12mo.
  volume, extra cloth. $1 00.
■DARCLAY (A.  W.),  M. D.
   A MANUAL  OF  MEDICAL DIAGNOSIS;  being an Analysis of the
     Signs and Symptoms of Disease.  Third  American from  the  second and revised London
     edition.  In one neat octavo volume of 451 pages, extra cloth.  $3 50.
  A work  of  immense practical utility.—London I   Tbe b
Med. Times and Gazette.                        | man.—.
book should be in the hands of every practical
 Dublin Med. Press.
F
    ULLER (HENRY WILLIAM), M. D.,
         Physician to St. George's Hospital, London.

   ON  DISEASES  OF  THE  LUNGS  AND  AIR-PASSAGES.   Their
      Pathology, Physical Diagnosis, Symptoms, and Treatment.   From the second and revised
      English edition.  In one handsome octavo volume of about 500 pages, extra oloth, $3 50.
      (Just Issued.)
  Dr. Fuller's work on diseases of the chest was so | accordingly we have what might be with perfect jus-
favorabiy received, that to many who did not know j tice styled an entirely new work from  his pen, the
the extent of his engagements, it was a matter of won- ' portion of the work treating of the heart  and great
der that it should be allowed to remain three years I vessels being excluded. Nevertheless, this volume is
out of print.  Determined, however, to improve it, I of almost equal size with the first.— London Medioul
Dr. Fuller would not consent to a mere reprint, and i Tines and Gazette, July 2C, 1867. 
Henry C. Lea's Publications—(Practice of Medicine).        IT
 pLINT (A USTIN),  M. D.,
•*-       Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y.
   A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA-
      TION of  the chest and the  diagnosis of  diseases affecting  the
      RESPIRATORY ORGANS.  Second and revised edition.  In one handsome octnvo volume
      of 595 pages, extra cloth, $4 50.  (Jtist Issued.)
  Premising this observation of the necessity of each  American medicine.—Atlanta Med. and Surg. Jour-
itudeut and practitioner making himself acquainted
with auscultation and percussion, we may state our
honest opinion that Dr. Flint's treatise is one of the
most trustworthy guides which he can consult.  The
style Is clear and distinct, and is also concise, belDg
free from that tendency to over-refinement and unne-
cessary minuteness which characterizes many works
on the same subject.—Dublin Medical Press, Feb. 6,
1867.

  In the Invaluable work before us, we have a book
ot facts of nearly 600 pages,  admirably arranged,
clear, thorough, and lucid on all points, without pro-
lixity; exhausting every poiut and topic touched; a
monument of patient and long-continued observation,
which does credit to its author, and reflects honor on

 T>Y THE SAME AUTHOR.
nal, Feb. 1867.
  The chapter on Phthisis Is replete with interest;
and his  remarks on the diagnosis, especially in the
early stages, are remarkable for their acumen and
great practical value.  Dr. Flint's style is clear and
elegant,  and the tone of freshness and originality
which pervades his whole work lend an additional
force to  its thoroughly practical  character, which
cannot fail to obtain for it a place as a standard work
on diseases  of the respiratory system.—London
Lancet, Jan. 19, 1867.
  This is an admirable book.  Excellent in detail and
execution,  nothing better could be desired  by the
practitioner.   Dr.  Flint enriches his subject with
much  solid and  not a little original observation.—
Banking's Abstract, Jan. 1867.
A PRACTICAL TREATISE ON THE  DIAGNOSIS, PATHOLOGY,
   AND TREATMENT  OF DISEASES OF THE HEART.  In  one neat octavo volume of
   nearly 500 pages, with a plate; extra cloth, $3 50.
     P\VY(F.  W.),M.D.,F.R.S.
           Senior Asst. Physician to and Lecturer on Physiology, at Guy's Hospital, Ac.

   A TREATISE  ON THE  FUNCTION  OF  DIGESTION; its  Disor-
      ders and  their Treatment.  From the second London edition.  In one handsome volume,
      small octavo, extra cloth, $2 00.  (Just Ready.)
  A thoroughly good book, being a  careful systematic
treatise, and sufficiently exhaustive for all practical
purposes.—Leavenworth Med. Hern Id, July, 1869.
  A very valuable work on the subject of which  it
treats.  Small, yet It is full of valuable information.
—Cincinnati Med. Repertory, June, 1869.
  It presents the reader with a good summary of what
is at present knowu concerning the physiological pro-
cesses concerned in digestion, the pathological changes
these processes are capable of undergoing, and the
treatment they require.  It is a convenient and prac-
tical work for the library of the practitioner.—Chicago
Med. Examiner, July, 1869.
  The work before us is one which deserves a wide
circulation. We know of no better guide to the study
of digestion and its disorders.—St.  Louis Med. and
Surg. Journal, July 10, 1869.
(1HAMBERS (T. K.), M.D.,
^      Consulting Physician to St. Mary's Hospital, London, Ac.

  THE  INDIGESTIONS; or, Diseases of the Digestive Organs Functionally
      Treated.  Second American, from the second and revised English Edition.  In one hand-
      some octavo volume of over 300 pages, extra cloth, $3 00.  (Now Ready.)
                                              it carefully; have studied every page; our interest
                                              in the subject has been intensified as we proceeded,
                                              and we are  enabled to lay it down with unqualified
                                              praise.—N. Y. Med. Record, April 15, 1867.
  He is perhaps the most vivid and brilliant of living
medical writers; and here he supplies, in a graphic
series of illustrations, bright sketches from his well-
atored portfolio.   His is an admirable clinical book,
like all that he publishes, original, brilliant, and in-
teresting.  Everywhere he is graphic, and his work
Supplies numerous practical  hints of much value.—
Edinburgh Med. and Surg. Journal, Nov. 1867.
  Associate with this the rare faculty which  Dr.
Chambers has of infusing an enthusiasm in his sub-
ject, and we have in this little work all the elements
which make It a model of its sort. We have perused I Med. Mirror, Feb. 1867
  In fact, there are few situations in which I he com-
mencing practitioner can place himself in which Dr.
Chambers'  conclusions  on digestion will not be of
service.—London Lancet, February 23, 1867.

  This is one of the most valuable works which It
has ever beeD our good fortune to receive.—London
 TtRINTON (WILLIAM), M. D., F. R. S.

■^LECTURES ON  THE  DISEASES  OF THE  STOMACH;  with an
      Introduction on its Anatomy and Physiology.   From the second and enlarged London edi-
      tion.   With illustrations on wood.   In one handsome octavo volume of about 300 pages,
      extra cloth.  $3 25.   (Just issued;)
  Nowhere can be found a more full, accurate, plain,
and instructive history of these diseases, or more ra
Oonal views respecting their pathology and therapeu
tic*.— Am. Journ. of the Med. Sciences, April, 1S65.
  The most complete work In our language upon the
diagnosis and treatment of these puzzling and impor-
tant diseases.—Boston Med. and Surg. Journal, Nov.
1865.
HABERSHON ON DISEASES OF THE ALIMENTARY
  CANAL, (ESOPHAGUS, STOMACH, CAECUM, AND
  INTESTINES.  With illustrations on wood.  One
  vol. Svo., 312 pages, extra cloth.  $2 50.
OLYMER  ON FEVERS;  THEIR DIAGNOSIS, Pa-
  thology and Treatment.  In one  octavo volume
  of 600 pages, leather.  *1  75.
 ODD'S CLINICAL LECTURES ON CERTAIN ACUTE
  Diseases. In one neat octavo volume, of 320 pages,
  extra cloth. $2  50.
LA ROCHE ON YELLOW FEVER, considered in its
  Historical, Pathological, Etiological, and Therapeu-
  tical Relations.  In two large and handsome octavo
  volumes, of nearly 1500 pages, extra cloth, $7 00.
LA ROCHE ON PNEUMONIA ; its Supposed Connec-
  tion, Pathological, and Etiological, with Autumnal
  Fevers, including an Inquiry Into the Existence and
  Morbid Agency of Malaria.  In one handsome oc-
  tavo volume, extra cloth, of 500 pages.  Price f3 00. 
18        Henry  C. Lea's Publications—(Practice of Medicine).
 ROBERTS ( WILLIAM),  M. D..
•*- **      Lecturer on Medicine in the Manchester Srhool of Medicine, Ac.

   A  PRACTICAL TREATISE  ON  URINARY AND  RENAL  DIS-
      EASES, including Urinary Deposits.  Illustrated  by numerous  cases und engravings.  In
      one very handsome octavo volume of 516 pp., extra cloth.  $4  50.   (Just Issued.)
  In carrying out this design, he has not only made  «ive work on urinary and renal diseases, considered
good  use of his own practical knowledge, but has  In their strictly practical aspect, that we possess in
brought together from various sources a vast amount !  the English language.—British Medical  Journal,
of information, some of which is not generally pos- j  Dec. 9, 1S65.
sessed by the profession in this country.  We must I   We have read this book  with much  satisfaction.
now  bring our notice of  this  book to a close, re \  It will take its place beside the best treatises In our
gretting only that we are  obliged to resist the temp- :  language upon urinary pathology and therapeutics.
tation of giving further extracts from it. Dr. Roberts ,  Not the least of its merits is that the author, unlike
has already on several occasions placed before the |  some  other book-makers, Is contented  to withhold
profession the results of researches made by him on i  much that he is well qualified to discuss in order to
various points connected with the urine, and had thus  impart to his volume such a strictly practical charao-
led us to expect from him something good—in which j  ter as cannot fail to render It popular among British
expectation we have been by no means disappointed, i  readers.—London  Med. Times and  Gazette, March
The hook  is, beyond question, the most comprehen- |  17, 1866.
MORLAND ON RETENTION IN THE BLOOD  OF
  THE ELEMENTS OF  THE URINARY  SECRE-
  TION.  1 vol. Svo., extra cloth.  75 cents.
BLOOD AND  URINE  (MANUALS ON). By J.  W.
 Griffth, G. O. Reese, and A. Markwick.  1 vol.
 12mo , extra cloth, with plates, pp. 460.  $1 25.
BUDD ON DISEASES OF THE LIVER.  Third edition.
 1 vol. 8vo., extra cloth, with four beautifully colored
 plates, and numerous wood-cuts.  pp. 600.  $4 00.
 TONES (C. HANDFIELD), M. D.,
f      Physician to St. Mary's Hospital, &c.

   CLINICAL  OBSERVATIONS
      DISORDERS.  Second  American Edition.
      extra cloth,  $3 25.   (Just Issued.)
 Taken as a whole, the work before us furnishes a |
Bbort but reliable account of the pathology and treat- i
nient of a class of very common but certainly highly
obscure disorders. The advanced student will find it
a rich mine of valuable facts, while the medical prac-
titioner will derive from it many a suggestive hiut to j
aid him in the diagnosis of "nervous cases," and iu |
determining the true indications for their ameliora-
tion or cure.—Amer.  Journ. Med. Set, Jan. 1867.
  ON  FUNCTIONAL  NERVOUS
  In one handsome octavo volume of 348 pages,


  We must cordially recommend It to the profession
of this country as supplying, in a great measure, a
deficiency which exists  in the  medical literature of
the English language.—New York Med. Journ., April,
1867.

  The  volume is a most admirable one—full of hints
and practical suggestions. — Canada Med. Journal,
April,  1867.
OLADE  (D. D.),
ID.
DIPHTHERIA;  its Nature and Treatment, with an account of the His-
   tory of its Prevalence  in various Countries.  Second and revised edition.  In one neat
   royal 12mo. volume, extra cloth.  $1 25.  (Just issued.)
SMITH ON CONSUMPTION ; ITS EARLY AND RE-
  MEDIABLE STAGES.  In one neat octavo volume
  of 254 pages, extra cloth.  $2 25.
SALTER ON ASTHMA ; its Pathology, Causes, Con-
  sequences, and Treatment. In one volume octavo,
  extra cloth.  $2 50.
BUCKLER ON  FIBRO-BRONCHITIS AND RHEU-
  MATIC  PNEUMONIA.  In one  octavo vol., extra
  cloth, pp. 150.  SI 25.
FISKE FUND PRIZE ESSAYS.—LEE ON THE EF-
  FECTS  OF CLIMATE ON  TUBERCULOUS DIS-
  EASE.   AND WARREN ON THE INFLUENCE OF
  PREGNANCY ON THE DEVELOPMENT OF TU-
  BERCLES.  Together in one neat octavo volume
  extra cloth,  #1 00.
WALSHE'S  PRACTICAL TREATISE ON THE DIS-
  EASES OF THE HEART AND GREAT VESSELS.
  Third American, from the third revised and much
  enlarged London edition. In one handsome octavo
  volume of 420 pages, extra cloth.  $3 00.
 TJUDSON (A.), M. D., M. R.  I. A.,
■*--*-   Physician to the Meath Hospital.

      LECTURES ON THE  STUDY
Cloth, $2 50.  (Now  Ready )
  As an admirable summary of the present state of
ovlt knowledge concerning fever, the work will be as
welcome to the medical man in active practice as to
the student.  To the hard-worked practitioner who
wishes to refresh  his notions concerning fever,  the
book will prove most valuable.....We heartily
opmmend  his excellent  volume to students and  the
profession at large.—London  Lancet, June 22, 1867
  The truly philosophical lectures of Dr. Hudson add
JjYONS (ROBERT D.),  K. C. C.
OF FEVER.   In one vol. 8vo.,  extra
much to our previous knowledge, all of which thfy,
moreover, analyze and condense. This well-conceived
task has been admirably executed iu the lectures. Il-
lustrative cases and quotations being arranged in an
appendix to each. We regret that space forbids our
quotation from the lectures on treatment, which are,
iu regard to research and judgment, most masterly,
and evidently the result of extended and mature e»
perience.—British Medical Journal, Feb. 22, 18GS.
 A TREATISE  ON FEVER;  or, Selections from a Course of Lectures
    on Fever.  Being part of a Course of Theory and Practice of Medicine. In one neat octavo
    volume, of 362 pages, extra cloth.  $2 25.

'ALLEMAND  AND  WILSON.

'A  PRACTICAL  TREATISE  ON  THE   CAUSES,  SYMPTOMS,
    AND  TREATMENT OF  SPERMATORRHEA.  By M. Lallemand.  Translated and
    edited by Henrv J. McDougall.  Fifth American edition.  To which is added-----ON
    DISEASES OF THE VESICUL^!  SEMINALES, and their associated organs.  With
    special reference to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane.
    By Mauris Wilson, M.D.  In one neat octavo volume, of about 400 pp., extra cloth, $2 7a, 
Henry  C. Lea's Publications—(Venereal Diseases, etc.).       19
 ft UMSTEAD (FREEMAN J.), M.D.,
J-'   Professor of Venereal Diseases at the Col. of Phys. and Surg., New York. Ac.

   THE  PATHOLOGY  AND  TREATMENT   OF  VENEREAL DI3-
       EASES.  Including the results of recent investigations upon the  subject.  A new and re-
       vised edition, with illustrations.  In one large and handsome octavo volume of 640 pages,
       extra cloth, $5 00.   (Lately Issued.)
                                                every other  treatise on  Venereal.—San Francisco
                                                Med. Press, Oct. 1864.
                                                  A perfect compilation of all that Is worth knowing
                                                on venereal diseases in  general.  It fills up a gap
                                                which has long been felt in English medical literature.
                                                —Brit, and Foreign Med.-Chirurg. Review, Jan., '65.
  Well known as one of the best authorities of the
present day on the subject.—British and For. Med.-
Chirurg. Review, April, 1866.
  A regular store-house of special information.—
London Lancet, Feb. 24, 1866.
  A remarkably clear and full systematic treatise on
the whole subject.—Lond. Med. Times and Gazette.
  The best, completest, fullest monograph on  this
Bubject in our language.—British American Journal.

  Indispensable In a medical library.— Pacific Med.
and Surg. Journal.
  We have no doubt that it will supersede In America
(1ULLERIER (A.),          and
*-/      Surgeon to the Hbpital du Midi.
  We have not met with any which so highly merits
our approval and praise as the second edition of Dr.
Buinstead's work.—Glasgow Med. Journal, Oct. 1S64.
  We know of no treatise in any language which is
its equal in point of completeness and practical sim-
plicity.— Boston  Medical  and  Surgical Journal,
Jan. 30, 1S64.
                                               T> UMSTEAD (FREEMA N J.),
                                              ■U   Professor of Venereal Diseases in the College of
                                                         Physicians and Surgeons, N.  Y.
AN   ATLAS  OF  VENEREAL   DISEASES.    Translated  and  Edited  by
    Freeman J. Bumstead.   In one large imperial  4to. volume of 328 pages, double-columns,
    with  26 plates, containing about 150 figures, beautifully colored, many of them  the size of
    life; strongly bound in extra cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at
    $3 per part.  (Just Ready.)

  As the successor of Ricord in the  great Venereal Hospital of Paris, M. Cullerier has  enjoyed
special advantages for the present undertaking, and his series of illustrations, though only recently
finished, is already recognized as the most complete and comprehensive that ha? yet appeared on
this subject.  In reproducing these plates every care hns been had to preserve their artistic finish
and accuracy, and they are confidently presented as equal to anything that has yet been produced
in this country.  The reputation of Dr. Bumstead as a writer and syphilographer is too well known
to require other guarantee for the fidelity of the translation or the value of the additions introduced.
  Anticipating a very large sale for  this work, it is offered at the very low price of Three Dol-
lars  a Part, thus placing it within the reach of all who are interested in this  department of prac-
tice.   Gentlemen desiring early impressions of the plates would do well to order it without delay.
  A specimen of the plates and text  sent free by mail, on receipt of  25 cents.
  We wish for once that our province was not restrict-
ed to methods of treatment, that we might say some-
thing of the exquisite colored plates  in this volume.
—London Practitioner, May, 1869.
  As a whole,  it  teaches all that can be taught by
means of plates and print.—London Lancet, March
13, 1869.
  Superior to anything of the kind ever before issued
on this continent.—Canada Med. Journal, March, '69.
  The practitioner who desires  to  understand this
branch of medicine thoroughly  should obtain  this,
the most complete and best work ever published.—
Dominion Med. Journal, May, 1869.
  This is a work of master hands on both sides.  M.
Cullerier is scarcely second to, we think we may truly
Bay is a peer of the illustrious and venerable Ricord,
while in this country we do not  hesitate to say that
Dr. Bumstead,  as an authority,  is without a rival.
Assuring our readers that these illustrations tell the
whole history of venereal disease, from its inception
to its end, we  do  not know a single medical work,
which for its kind is more necessary for them to have.
—California Med. Gazette, March, 1869.
  The most splendidly illustrated work in the lan-
guage, and in our opinion far more useful than  the
French original.—Am. Journ. Med. Sciences, Jan. '69
  The fifth and concluding number of this magnificent
work has reached us, and we have no hesitation in
saying that its illu.-trations surpass those of previous
numbers.—Boston Med. and Surg. Journal, Jan. 14,
18U9.
  Other writers besides M. Cullerier have given us a
good account of  the diseases of which he treats, but
no oue has furnished us with such a complete series
of illustrations of the venereal diseases.  There is,
however, an additional interest and value possessed
by the volume before us ; for it is an American reprint
and  translation  of M.  Cullorier's work, with inci-
dental remarks by one of the most eminent American
syphilographers, Mr. Bumstead.  The letter-press is
chiefly M.' Cnllerier's, but every here and there a few
lines or sentences are introduced by Mr. Bumstead ;
and, as M. Cullerier is a uuicist, while Mr.  Bumstead
is a dualist, this  method of treating the subject adds
very much to its interest.   By this means a liveliness
is imparted to the volume which many other treatises
sorely lack.  It Is like reading the report of a conver-
sation or debate  ; for Mr. Bumstead often finds occa-
sion to question M.Cullerier's statements or inferences,
and this he does in a short and forcible way which
helps to keep up the attention, and to make the book
a very readable  one.—Brit, and For.  Medico-Chir.
Review, July, 1S69.
In
TJILL  (BERKELEY),
            Surgeon to the Lock Hospital, London.
   ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  DISORDERS.
     one  handsome octavo volume ;  extra cloth, $3 25.  (Just Issued.)
                                                The author, from a vast amount of material, with
                                               all of which he was perfectly familiar, has under-
                                               taken to construct a new book, and has really suo-
  Bringing, as it does, the entire literature of the dis-
ease down to the present day, and giving with great
ability the results of modern research, It Is in every
respect a most desirable work, and one which should
find a place in  the  library of every surgeon.—Cali-
fornia Med. Gazette, June, 1869.
  Considering the scope of the book and the careful
attention to the manifold aspects and details of its
subject, it is wonderfully concise.  All these qualities
render it an especially valuable book to the beginner,
to whom we would  most earnestly recommend its
study; while it  is no less useful to the practitioner.—
St.  Louis Med. and Surg. Journal,  May, 1869.
ceeded  in  producing  a capital volume upon  this
Bubject.—Nashville  Med. and Surg. Journal,  May,
1S69.

  The most convenient and ready book of reference
we have met with.—N. Y. Med. Record, May 1,  1869.

  Most  admirably arranged for both student and pr t«-
titioner, no other work on the subject equals it; it is
more simple, more easily studied.—Buffalo Med. and
Surg. Journal, March, 1S69. 
20         Henry C. Lea's Publications—(Diseases of the Skin).


 jyiLSOX (ERA SM US),  F. R. S.,

     ON DISEASES  OF  THE SKIN.   AVith Illustrations on wood.  S*>v-
        enth American, from the sixth and enlarged English edition.  In one large octavo volume
        of over 800 pages, $5.  (Just Issued.)

   A  SERIES  OF  PLATES  ILLUSTRATING "WILSON  ON  DIS-
       EASES OF THE  SKIN," consisting of twenty beautifully executed plates,  of which thir-
       teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin,
       and embracing accurate representations of about one hundred varieties of disease, most of
       them the size of nature.  Price, in extra cloth, $5 50.
  Also, the Text and Plates, bound in one handsome volume.   Extra cloth, $10.

                       From the Preface to the Sixth English Edition.

  The present edition has been carefully revised,  in many parts rewritten, and our attention hag
been  specially directed to  the practical  application  and  improvements of treatment.  And, in
conclusion, we venture to remark that if an acute and friendly critic should discover any differ-
ence between our present opinions and those announced in former editions, we  have only to ob-
serve that science and knowledge are progressive,  and  that we have done our best to move onwaid
with the times.

  The industry and care with which  the author has revised the present edition are shown by th«
fact that the volume has been enlarged by more than  a hundred pages.  In its present improved
form it will therefore doubtless retain the position which it has acquired as a standard and classical
authority, while at tbe same time it has additional claims on the attention of the profession ai
the latest and most complete work on the subject  in the  English language.
  Such a work as the one before us is a most capital
and acceptable help.  Mr. Wilson has long been held
as high authority in this department of medicine, and
his book on diseases of the skin has long been re-
garded as one of the best text-books extant on the
subject.  The  present edition is carefully prepared,
and brought up in its revision to the present time. In
this edition we have also included the beautiful series
of plates illustrative of the text, and in  the last edi-
tion published separately. There are twenty of these
plates, nearly all of them colored to nature, and ex-
hibiting with great fidelity the various groups of
diseases treated of in the body of the work.—Cin-
cinnati Lancet, June, 1863.
  No one treating skin  diseases should be without
a copy of this standard work.— Canada Lancet.
August, 1863.
JfY THE SAME AUTHOR.                 —

   THE  STUDENT'S  BOOK OF  CUTANEOUS MEDICINE  and Dis-
       eases of the skin.  In one very handsome royal 12mo. volume.  $3 50.  (Lately Issued.)
  We can safely recommend it to the profession as
the best work on the subject now in existence In
the English language.—Medical Times and Gazette.

  Mr. Wilson's volume is an excellent digest of tbe
actual amount of knowledge of cutaneous diseases;
it includes almost every fact or opinion of importance
connected with the anatomy and pathology of the
skin.—British and Foreign Medical Review.
  These plates are very accurate, and are executed
with an elegance and taste which are highly ereditabk
to the artistic skill of the American artist who executed
them.—St. Louis Med. Journal.
  The drawings are very perfect,  and the finish and
coloring artistic and correct; the  volume Is an indis-
pensable companion  to the book It illustrates and
completes.—Charleston Medical Journal.
ffELIGAN  (J. MOORE), M.D., M.R.I.A.,

    A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  SKIN
        Fifth American, from the second and enlarged  Dublin edition by T. W. Belcher, M.D.
        In one neat royal 12mo. volume of 462 pages, extra cloth.  $2 25.   (Just Issued.)
  Of the remainder of the work we have nothing be-i  This instructive little volume appears once more.
yond unqualified commendation to offer.  It is so far Since the death of its distinguished author, the study
the most complete one of its size that has appeared, jof skin diseases has been considerably advanced, and
aud for the student there can be none which  can com-1 the results of these investigations have been added
pare with it in practical value.  All  the late disco- by the present editor to the original work of Dr. Neli-
veries in Dermatology have been duly noticed, and <gan.  This, however, has not so far increased its  bulk
their value justly estimated; in a word, the work is as to destroy its  reputation as the most convenient
fully up to the times, and is thoroughly stocked with manual of diseases of the skin that can be procured
most valuable information.—New York Med. Record, by the student.—Chicago Med. Journal, Dee. 1866.
Jan. 15, 1867.                                  |                    *
J£Y THE SAME AUTHOR.                ____

   ATLAS  OF CUTANEOUS   DISEASES.    In  one  beautiful  quarto
       volume, with exquisitely colored plates, Ac., presenting about one hundred varieties  of
      disease.  Extra cloth, $5 50.
  The diagnosis of eruptive disease, however,  under
»ll circumstances,  i6 very difficult.  Nevertheless,
Dr. Neligan has certainly, "as far as possible," given
a faithful and accurate representation of this class of
diseases, and there can be no doubt that these  plates
will be of great use to the student and practitioner in
drawing a diagnosis as to the class, order, and species
to which the particular  case may belong.   While
looking over the "Atlas" we have been induced to
examine also the  "Practical Treatise." aud we are
Inclined to consider It a very superior work, com-
bining accurate verbal description with sound views
of the pathology and treatment of eruptive diseases.
—Glasgow Med. Journal.
  A compend which will very much aid the practi-
tioner in this difficult branch of diagnosis.  Taken
with the beautiful plates of the Atlas, which are re-
markable for their accuracy and  beauty of coloring,
it constitutes a very valuable  addition to the library
of a practical man.—Buff<do Med. Journal.
 TJILLIER  (THOMAS),  M.D.,
•*■-*-      Physician to the Skin Department of University College Hospital, Ac.

   HAND-BOOK  OF SKIN  DISEASES, for Students and Practitioners.
      In one neat royal 12mo. volume of about 300 pages, with two plates;  extra cloth, $2 25.
      (Just Issued.) 
Henry  C. Lea's Publications—(Diseases of Children).          21
 UUITH (J. LE WIS), M. D.,
^         Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N Y.

    A  COMPLETE  PRACTICAL  TREATISE ON THE DISEASES OF
      CHILDREN.  In one handsome octavo volume of 620 pages, extra cloth, $4 75 ; leather,
      S5 75.   (Now Ready.)
  We have no work upon the Diseases of Infancy and ! experience which he has been enabled to acquire in
Childhood which can compare with it.—Buffalo Med. I the treatmeut of infantile diseases, and the care which
and Surg. Journal, March, 1869.                  ! he has accustomed himself to take in the study of the
  The description of the pathology,  symptoms, aud j significant, facts relating to the pathological anatomy
treatment of the different diseases is excellent.-Am.  of <;n« peases of childhood, eminently fit him tor the
Med. Journal, April, 1869.
  So full, satisfactory, and complete is the information
to be derived from this work, that at no time have we
examined the pages of any book with more pleasure.
The diseases incident to childhood are treated with a
clearness, precision, and  understanding that is not
often met with, and which  must call forth the ap-
proval of all who consult its pages.—Cincinnati Med.
Repertory, May, 1869.
  This work is  complete on the subject of which it
treats, and enters more fully, with clearness and pre-
cision, into the diseases of childhood than most other
works which we have seen.  Physiciaus or students
who wish to obtain a work containing the latest views
on the treatment of children will find this one of the
best.—Dominion Med. Journal, April, 1869.
  The author of this volume is  well known  as a
valued coutributor to the literature of his specialty.
The faithful manner in which  he has worked in the
public institutions with which he has been connected,
the conscientious regard for truth which has for years
characterized all his researches, the great amount of
task which he has taken upon himself.  The remark-
able faculty of bringing out salient points and stating
concisely other less important facts, enables  him to
crowd within a small compass a vast amount of prac-
tical information.  The attention given to the treat-
ment of the various maladies, as well as the presenta-
tion of all the recently accepted pathological views,
make it one of the most valuable treatises, within its
present compass, that can be placed in the hands of
any seeker after truth.  The volume as a whole will
still further establish for the writer a permanent and
enviable reputation as a careful observer, an  impar-
tial interpreter, a safe and trustworthy adviser, and
a modest and untiring student.—N.  Y. Med. Record,
March 15, 1869.
  We  have perused Dr. Smith's book with not a little
satisfaction ; it is indeed an excellent work; well and
correctly written; thoroughly up to the modern ideas;
concise, yet complete in its material. We cannot help
welcoming a work which  will be worthy of reliance
as a text-book for medical students and younger phy-
sicians in their investigation of disease in children.—
Boston Med. and Surg. Journal, March 4, 1S69.
ffONDIE (D.  FRANCIS),  M.D.
^ A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN.
      Sixth edition, revised and augmented.  In one large octavo volume of nearly 800 closely-
      printed pages, extra cloth, $5 25 ;  leather, $6 25.    (Now Ready.)
  Dr. Condie has been one of those  who have per-
formed such a service satisfactorily, and, as a result,
his popular, comprehensive, and practical work has
received that  high compliment of approval ou the
pnrt of his brethren, which several editions incontes-
tably  set forth.  The  present edition, which is the
sixth, is fully up to the times in the discussion of all
those points in the pathology and treatment of infan-
tile diseases which have been brought forward by the
German and French teachers.  As a whole, however,
the work is the best American one that we have, and
in its special adaptation to American  practitioners it
certainly has no equal. — New York Med. Record,
March 2, 1868.
  No other treatise on this subject is better adapted
to the American physician. Dr. Condie has long stood
before his countrymen as one peculiarly pre-eminent
in this department of medicine.  His work has been
so long a standard for practitioners and medical stu-
dents that we do  no more now than refer to the fact
that it  has reached its sixth edition. We are glad
once more to refresh the impressions of our earlier
days by wandering through its pages, and at the same
time to be able to recommend it to the youngest mem-
bers of the profession, as well as to those who have
the older editions on their shelves.—St. Louis Med.
Reporter, Feb. 15, 186S.
  We pronounced the first edition to be the best work
on the diseases of children in the English language,
and, notwithstanding all that has been published, we
still regard it in that light.—Medical Examiner.
 TXTEST (CHARLES),  M.D.,
  ' '      Physician to the Hospital for Sick Children, Ac.

   LECTURES ON  THE  DISEASES  OF  INFANCY  AND  CHILD-
       HOOD.   Fourth American from the fifth revised  and enlarged English edition.  In  one
       large and handsome octavo volume of 656 closely-printed pages.  Extra  cloth, $4  50;
       leather,  $5 50.  (Just issued.)
  Of all the English writers on the diseases of chil-
dren, there is no one so entirely satisfactory to us as
Dr. West. For  years we have held his opinion as
judicial, and have regarded him as one of the highest
living authorities in the difficult department of medi-
cal science in which he is most widely known.  His
writings are characterized by a sound, practical com-
mon  sense, at the same time that they bear the marks
of the most laborious study and  investigation.  We
commend it to all as a most reliable adviser on many
occasions when  many treatises on the same subjects
will  utterly fail to help us.— Boston Med. and Surg.
Juirnal, April 26, 1866.                _________
  Dr. West's volume is, in our opinion, incomparably
the best authority upon the  maladies of children
that the practitioner can consult.  Withal, too—a
minor matter, truly, but still not one that should be
neglected—Dr. West's composition possesses a pecu-
liar charm, beauty and clearness.of expression, thus
affording the reader much pleasure, even independent
of that which arises from the acquisition of valuable
truths.—Cincinnati Jour, of Medicine, March, 1866.
  We have long regarded it as the most scientific and
practical book on diseases of children which has yet
appeared in this country.—Buffalo Medical Journal.
 OMITH (EUSTACE). M. D.,
^         Physician to the Northwest London Free Dispensary for Sick Children.
    A  PRACTICAL  TREATISE  ON   THE WASTING  DISEASES  OF
      INFANCY AND CHILDHOOD.   (Publishing in the Medical News and Library for 18C9.)

 UEWEES (WILLIAM P.),  M.D.,
JJ     Late Professor of Midwifery, Ac, in the University of Pennsylvania, Ac.
   A  TREATISE   ON  THE  PHYSICAL  AND   MEDICAL   TREAT-
      MENT OF CHILDREN.  Eleventh edition, with the author's last improvements and cor-
      rections.   In one octavo volume of 548 pages.   $2 80. 
22         Henry C. Lea's Publications—(Diseases of Women).
 /THOMAS (T.  GAILLARD),M.D.,
 -*-       Professor of Obstetrics, Ac in the College of Physicians and Surgeons, N. Y., Ac.

   A PRACTICAL  TREATISE ON  TI1K DISEASES  OF  WOMEN   Se-
      cond edition, revised  and improved   In one large and handsome  ootavo volume of 650
      pages, with 225  illustrations, extra cloth, $5; leather, $6.   (Now Ready.)
                           From the Pre/ace to the Second Edition.
  In a science so rapidly progressive as that of medicine, the profession has a right to expect that,
when its approbation of a work is manifested by a call for a new edition,  the author  should re-
spond by giving to his book whatever of  additional value may be derivable from more extended
experience, maturer thought,  and the opportunity  for correction.   Fully sensible of this, the
author of the  present volume has sought  by a careful revision of the whole, and by the addition
of a chapter on Chlorosis, to render his  work more worthy  of the favor with which it has been
received.—New York, March, 1869.
  If the excellence of a work is to be judged by Its
rapid sale, this one must take precedence of all others
upon the same, or kindred subjects, as evidenced in
the short time from its first appearance, in which a
new edition is called for, resulting, as we are informed,
from the exhaustion of the previous large edition.  We
deem it scarcely necessery to recommend this work
to physicians as it is now widely known, and most
of them already possess it, or will certainly do so
To students we unhesitatingly recommend it as  the
best text-book on diseases of females extant.— St. Louis
Med. Reporter, June, 1869.
  Of all the army of books that have appeared of late
years, on the diseases of the uterus and its appendages,
we know of none that is so clear, comprehensive, and
practical as this of Dr. Thomas', or one that we should
more emphatically recommend to  the young practi-
tioner, as his guide.—California Med.  Gazette, June,
1S69.
  If not the best work extant on the subject of which
it treats,  it is certainly second to none other.  So
short a time has  elapsed since the  medical  press
teemed with commendatory notices of the first edition,
that It would be superfluous to give an extended re-
view of what is now firmly established as the American
text-book of Gynaecology.—N.  Y. Med. Gazette, July
17, 1869.
  This is a new and revised edition of a work which
we recently noticed at some length,  and earnestly
commended to the favorable attention of our readers.
The fact  that, in the short space of  one year, this
second edition makes its appearance, shows that  the
general judgment of the profession has largely con-
firmed the opinion we gave at that time.—Cincinnati
Lancet, Aug. 1669.
  It is  so short a time since we gave a full review of
the first edition of this book, that  we deem it only
necessary now to call attention to the secoud appear-
ance of the work.  Its success has  been remarkable,
and we can only congratulate the author on  the
brilliant reception his book has received.—N. Y. Med.
Journal, April, 1869.
  We regard this treatise as the one best adapted to
serve as a text-book on gynaecology.—St. Louis Med.
and Surg. Journal, iMay 10, 1869.

  The whole work as it now stands is an absolute
indispensable to any physician aspiring to treat  the
diseases of females with success, and according to tl.o
most fully accepted views of their  aetiology and  pa-
thology.—Leavenworth Medical Herald, May, 1869.

  We have seldom read a medical  book in which wo
found so much to praise, and so little—we can hardly
say to object to—to mention with qualified commsn-
dation.  We had  proposed a somewhat  extended
review with copious extracts, but  we hardly  kimw
where we should have space for it.  We therefore
content ourselves  with  expressing the belief thai
every practitioner of medicine would do well to y >■*■
sess  himself of the work.—Boston Med. and  Surg.
Journal, April 29, 1869.
  The number  of  works published  on disease* of
women is large, not a few of which are very valuable.
But of those which are the most valuable we do not
regard the work of Dr.  Thomas as second to any.
Without being  prolix, it treats of the disorders to
which it is devoted fully, perspicuously, aud satisfac-
torily.  It will  be found a treasury of knowledge to
every physician who turns to its pages. Wo would
like to make a number of quotations from  the work
of a practical bearing, but our space will not permit.
The work should find a  place in the libraries of all
physicians.—Cincinnati Med. Repertory, May, 1869.

  No one will be surprised to learn  that the valuable,
readable,  and thoroughly practical  book of  Professor
Thomas has so soou advanced to  a  second edition.
Although very little time has necessarily been allowed
our author for revision and improvement of the work,
he has performed it exceedingly well.  Aside from
the numerous corrections which he has found  neces-
sary to make, he has added an admirable chapter no
chlorosis,  which of itself is  worth the cost of the
volume.—N. Y. Med. Record,  May  15, 1869.
QHURCHILL (FLEETWOOD), M. D., M. R. I.  A.

   ON  THE DISEASES  OF  WOMEN;   including  those  of  Pregnancy
      and Childbed. A new American edition, revised by the Author.  With Notes and Additions,
      by D. Francis Condie, M. D., author of " A Practical Treatise on the Diseases of Chil-
      dren."  With numerous illustrations.  In one large and  handsome octavo volume of 768
      pages, extra cloth, $4  00; leather, $5  00.
JOY THE SAME AUTHOR.                  ----

  ESSAYS  ON  THE   PUERPERAL  FEVER,  AND  OTHER  DIS-
      EASES PECULIAR  TO WOMEN.  Selected from the writings of British Authors previ-
      ous to the close  of the  Eighteenth  Century.  In one neat ootavo volume of about 450
      pages, extra  cloth.  $2  50.
BROWN  ON  SOME DISEASES OF WOMEN  AD-
  MITTING OF SURGICAL TREATMENT.   With
  haudsome illustrations.  One volume Svo., extra
  cloth, pp. 276. $1 60.
ASHWELL'S PRACTICAL TREATISE ON THE DIS-
  EASES  PECULIAR TO WOMEN.  Illustrated by
  Cases derived from Hospital and Private Practice.
  Third American, from  the Third and revised  Lon-
  don edition.  In one octavo volume, extra cloth,
  of 528 pages.  $3 50.
RJGBY ON THE CONSTITUTIONAL TREATMENT
  OF FEMALE DISEASES.  In one neat royal 12mo.
  volume, extra cloth, of about 250 pai.-«.-.  $1 00.
DEWEEs S TREATISE ON THE DISEASES  OF FE-
  MALES.   With illustrations.   Eleventh Edition,
  with the Author's last improvements and correc-
  tions.  In  one  octavo volume of .036 pages, with
  plates, extra cloth, * f 00
COLOMBAT  DE L'ISERE ON THE  DISEASES OF
  FEMALES.  Translated by C. D. MEius, M. D.  Se-
  cond edition.   In one vol. Svo, extra cloth, with
  numerous  wood-cuts.  pp. 720.  %3 75.

BENNETT'S  PRACTICAL TREATISE ON  l.VKI.A.v*.
  MATION OF THE  UTERUS,  ITS CERVIX  ami
  APPENDAGES, and on its connection witu i'i..,,^
  Disease.  Sixth American, from the fourth aud re-
  vised  English edition.  1 vol. 8vo., of about 500
  pages, extra cloth.  $3 75. 
Henry C. Lea's Publications—(Diseases of TFomen).
23
JJODGE  (HUGH L.). M.D.
         Emeritus Professor of Ohsletrics, Ac, in the University of Pennsylvania.

    ON  DISEASES  PECULIAR TO  WOMEN;  including Displacement3
      of the Uterus.  With original illustrations.  Second edition, revised and enlarged.  In
      one beautifully printed octavo volume of 531 pages, extra cloth.  $4 50.   (Just Issued.)
  In the preparation of this edition the author has spared no pains to improve it with the results
of his observation and study during the interval  which has elapsed since the first appearance of
the work.  Considerable additions have thus been made to it, which  have been partially accom-
modated by an enlargement in the size of the page, to avoid increasing unduly the bulk of the
volume.
 From Pbof. W. H. Btfohd, of the Rush Medical
                College, Chicago.
  The book bears the impress of a master hand, and
must, as its predecessor, prove acceptable to the pro-
fession.  In diseases of  women  Dr. Hodge has estab-
lished a school of treatment that has become world-
wide in fame.
  Professor Hodge's work  is truly an original one
from br ginning to end, consequently no oue can pe-
ruse its pages without learning something new.  The
book, which is by no means a large one, is divided into
two grand sections, so to speak: first, that treating of
the nervous sympathies of  the uterus, and, secondly,
that which speaks of the mechanical treatment of dis-
placements of that organ.  He is disposed,  as a non-
believer in the frequency of inflammations of the

 WM (CHARLES),  M.D.~

    LECTURES  ON  THE  DISEASES OF  WOMEN.  Third American,
      from  the Third London edition.  In one neat octavo volume  of about 550 pages, extra
      cloth.  $3 75; leather,  $4 75.  (Just Issued.)
  The reputation which  this  volume  has acquired as a standard book of reference in its depart-
ment, renders it only necessary to say that the present edition  has received a careful revision at
the hands of the author, resulting in a considerable increase of size.   A few notices of previous
editions are subjoined.
uterus, to take strong ground against many of the
highest authorities in this branch of medicine, and
the arguments which he offers in support of his posi-
tion are, to say the least, well put.  Numerous wood-
cuts adorn this portion of the work, and add incalcu-
lably  to the proper appreciation  of  the variously
shaped instruments referred to by our author.  As a
contribution to the study of women's diseases, it is of
great value, and is abundantly able to stand on its
own merits.—N. Y. Medical Record, Sept. 15, 1868.

  In  this point of view,  the treatise of  Professor
Hodge will be indispensable to every student  in its
department.  The large, fair type and general perfec-
tion of workmanship will render it doubly welcome.
—Pacific Med. and Surg. Journal, Oct. 1668.
  The manner of the author is excellent, his descrip-
tions graphic and perspicuous, and his treatment up
to the level of the time—clear, precise, definite, and
marked  by strong common  sense. — Chicago Med.
Journal, Dec. 1861.
  We cannot too highly recommend this, the second
edition of  Dr. West's excellent lectures ou the dis-
eases of  females.  We know of no other book on this
subject from which we have derived as much pleasure
and instruction.  Every page gives evidence of the
honest, earnest, and diligent searcher after truth.  He
Is not the mere compiler of other men's ideas, but his
lectures  are the result often years' patient investiga-
tion in one of the widest fields for women's diseases—
St. Bartholomew's Hospital.  As a teacher, Dr. West
Is simple and earnest in his language, clear and com-
prehensive in his perceptions, and logical in his de-
ductions.—Cincinnati Lancet, Jan. 1862.
  We return the  author our grateful thanks for the
vast amount of Instruction he has afforded us.  His
valuable treatise  needs no eulogy on our part.  His
graphic  diction and truthful pictures of disease all
speak for themselves.—Medico-Chirurg. Review.
  Most justly esteemed a standard work.....If
bears evidence of having been carefully revised, and
(s well worthy of the fame it has already  obtained.
—Dub. Med. Quar. Jour.
 T>Y THE  SAME AUTHOR.                 ----

   AN ENQUIRY INTO  THE PATHOLOGICAL  IMPORTANCE  OF
      ULCERATION OF THE OS UTERI.  In one neat octavo volume, extra cloth.  $1  25.


 MEIGS (CHARLES D.), M. D..
J.U.      Late Professor of Obstetrics, Ac. in Jefferson Medical College, Philadelphia.

   WOMAN:  HER  DISEASES  AND  THEIR  REMEDIES.   A Series
      of Lectures to his Class.  Fourth and Improved  edition.  In one large and beautifully
      printed octavo volume of over 700 pages, extra cloth, $5 00; leather, $6 00.

 T>Y THE SAME AUTHOR.                  ----

   ON  THE NATURE, SIGNS,  AND  TREATMENT OF  CHILDBED
      FEVER.   In a Series of Letters addressed to the Students of his Class.  In one handsome
      octavo volume of 365 pages, extra cloth.   $2 00.

 VIMPSON  (SIR JAMES F.),  M.D.

   CLINICAL LECTURES  ON  THE  DISEASES  OF WOMEN.  With
      numerous illustrations.  In one octavo volume of over 500 pnges.  Second edition, preparing.
  As a writer, Dr. West stands, in our opinion, se-
cond only to Watson,  the "Macaulay of Medicine;"
he possesses that happy faculty of clothing instruc-
tion  in easy garments; combining pleasure  with
profit, he leads his pupils, in spite of the ancient pro-
verb, along a royal road to learning. His work is one
which will not satisfy the extreme on either side, but
it is one that will please the great majority who are
seeking truth, and one that will convince the student
that he has committed himself to a candid, safe, and
valuable guide.—N. A. Med.-Chirurg Review.

  We must now conclude this hastily written sketch
with the confident assurance to our readers that the
work will well repay perusal. The  conscientious,
painstaking, practical physician is apparent on every
page.—N. Y. Journal of Medicine.

  We have to say of it, briefly and decidedly, that it
is the best work on the subject in any language, and
that  it stamps  Dr. West as the facile princeps of
British obstetric authors.—Edinburgh Med. Journal.

  We gladly recommend his lectures as in the highest
degree instructive to all who are interested in ob-
stetric practice.—London. Lancet.

  We know of no treatise of the kind so  complete,
and yet so compact.—Chicago Med. Journal. 
24
Henry C. Lea's Publications—(Midwifery).
JJODGE (HUGH L.), M. D.,

         Emeritus Professor of Midwifery, Ac. in the University of Pennsylvania, Ac.

   THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.   Illus-
      trated with large lithographic plates containing one hundred and fifty-nine figures  from
      original photographs, and with numerous wood-cuts.   In one large and beautifully printed
      quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14.  (Lauh)
      published.)
  The work of  Dr. Hodge Is something more than a
simple presentation of his particular views in the de-
partment of Obstetrics; it is something more than an
ordinary treatise on midwifery; it is, in fact, a cyclo-
paedia of midwifery.   He has aimed to embody in a
single volume the whole science and art of Obstetrics.
An elaborate text is combined with accurate and va-
ried pictorial illustrations, so that no fact or principle
is left unstated or unexplained.—Am.  Med. Times,
Sept. 3, 1S64.
  We should like to analyze the remainder of this
excellent work, but already has this review extended
beyond our limited space.  We cannot conclude this
notice without referring to the excellent finish of the
work.  In typography it is not to be excelled;  the
paper is superior to what is usually afforded by our
American cousins, quite equal to the best of English
books.  The engravings and lithographs are most
beautifully executed.  The work recommends itself
for its originality, and is in every way a most valu-
able addition to those on the subject of obstetrics.—
Canada Med. Journal, Oct. 1864.
  It is very large, profusely and elegantly illustrated,
and is fitted to  take its place near the works of great
obstetricians.  Of the American works on the subject
It is decidedly the best.—Edinb. Med. Jour., Dec.  '64.
  *** Specimens of the  plates and letter-press will be  forwarded to any address, free by mail,
on receipt of six cents in postage stamps.
  We have examined Professor Hodge's work with
great  satisfaction; every topic is elaborated most
fully.  The views of  the author are comprehensivo,
and concisely stated.   The rules of practice are judi-
cious, and will enable the practitioner to meet every
emergency of obstetric complication with confidence.
—Chicago Med. Journal, Aug. 1864.

  More time than we have had at our disposal since
we received tbe great work of Dr. Hodge is necessary
to do it justice.   It is undoubtedly by far  tbe most
original, complete, and carefully composed treatise
on the principles and  practice of Obstetrics which has
ever been issued  from the American press.—Pacific
Med. and Surg. Journal, July, 1S64.

  We have read  Dr.  Hodge's  book with great plea-
sure, and have much satisfaction in expressing our
commendation of it as a whole.  It is certainly highly
Instructive, and in the main, we believe, correct.  The
great attention which the author has devoted to the
mechanism of parturition, taken along with the con-
clusions at which he has arrived, point, we think,
conclusively to the fact that, in Britain at  least, the
doctrines of Naegele have been too blindly received.
—Glasgow Med. Journal, Oct. 1864.
JIANNER (THOMAS H.),  M.D.,
ON THE  SIGNS AND  DISEASES  OF  PREGNANCY.   First American
   from the Second and Enlarged English Edition.  With four colored plates and illustrations
   on wood.   In one handsome octavo volume of about 500 pages, extra cloth, $4 25.   (Just
   Issued.)
  The very thorough revision the work has undergone
has added greatly to its practical value, and increased
materially its efficiency as a guide to the student and
to the young practitioner.—Am. Journ. Med. Sci.,
April, 1868.
  With the immense variety of subjects treated of
and the ground which they are made to cover, the im-
possibility of giving an extended review of this truly
remarkable work must be apparent. We have not a
single fault to find with it, and most heartily com-
mend it to the careful study of every physician who
would not only  always he sure of his diagnosis of
pregnancy, but always  ready to treat all the  nume-
rous ailments that are, unfortunately for the civilized
women of to-day, so commonly associated with the
function.—N. Y. Med. Record,  March 16,1868.

  We have much pleasure in calling the  attention of
our readers to the volume produced by  Dr. Tanner,
the second edition of a work that was, in its original
Btate even, acceptable to the profession.  We recom-
mend  obstetrical students, young and old,  to have
this volume in their collections.  It contains not only
a fair statement of the signs, symptoms, and diseases
of pregnancy, but comprises in addition much  inter-
esting relative matter that is not to be found in any
other  work that  we can name.—Edinburgh Mt,d.
Journal, Jan. 1868.
  In its treatment of the signs and  diseases of preg-
nancy it is the most complete book we know of,
abounding on every page with matter valuable  to the
general practitioner.—Cincinnati  Med.  Repertory,
March, 1868.
  This is a most excellent work, and should be on the
table or in the library of every practitioner.—Hum-
boldt Med. Archives,  Feb. 1868.
  A valuable compendium, euriched by his  own la-
bors, of all that is known on the signs and diseases of
pregnancy.—St. Louis Med. Reporter, Feb. 15,  1868.
M
ONTGOMERY  (W. F.), M.D.,
     Professor of Midwifery in the King's and Queen's College of Physicians in Ireland.
AN  EXPOSITION OF  THE SIGNS  AND SYMPTOMS OF PREG-
    NANCY.  With some other Papers on Subjects connected with Midwifery.  From the second
    and enlarged English edition.  With two exquisite colored plates, and numerous wood-cuts.
    In one very handsome octavo volume of nearly 600 pages, extra cloth.   $3 75.
M
ILLER  (HENRY), M.D.,
   Professor of Obstetrics and Diseases of Women and Children in the University of Louisville.
PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS, &c;  including
   the Treatment of Chronic Inflammation of the Cervix and Body of the Uterus considered
   as a frequent cause of Abortion.  With about one hundred illustrations on wood.  In one
   very handsome octavo volume of over 600 pages, extra cloth.   $3 75.
MOBY'S SYSTEM OF MIDWIFERY.  With  Notes
  and Additional Illustrations.   Second American
  edition. One volume octavo, extra cloth, 422 page*
  12 60.
DEWEES'S  COMPREHENSIVE SYSTEM OF  MID-
  WIFERY.  Twelfth edition, with the author's last
  improvements aud corrections.  In one octavo vol-
  ume, extra cloth, of 600 pages. $3 60. 
Henry C. Lea's Publications—(Midwifery).               25
MEIGS (CHARLES D.),  M.D.,
        Lately Professor of Obstetrics, Ac , in the Jefferson Medical College, Philadelphia.
  OBSTETRICS:  THE  SCIENCE  AND  THE  ART.   Fifth  edition,
     revised.  With one  hundred and thirty illustrations.  In  one beautifully printed octavo
     volume of 760 large pages.   Extra cloth, $5  50;  leather, $6 50.  (Just Issued.)
 ™''_e original edition is already so extensively and  practitioner.  The rapidity with which tbe very large
ftrvorably known to the profession that no recom-
mendation is  necessary; It is sufficient to  say, the
present edition is very much extended, improved,
and perfected.  Whilst the great practical talents and
unlimited experience of the author render it a most
valuable acquisition to the practitioner, It is so con-
densed as to constitute a most eligible and excellent
text-book for the student.—Southern Med. and Surg.
Journal, July, 1867.
  It is to the student that our author  has more par-
ticularly addressed  himself; but  to the practitioner
we believe it would be equally serviceable as a book
<rf reference.  No work that we  have met with so
thoroughly details everything that falls to the lot of
the accoucheur to perform.   Every detail, no matter
how minute or how  trivial, has found a  place.—
Canada Medical Journal, July, 1867.
  This very excellent work  on the science and art of
obstetrics should be in the hands of every student and
editions have been exhausted is the best test of its
true merit  Besides, it is the production of an Ame-
rican who has probably had more experience in this
branch than any other living practitioner of the coun-
try.— St. Louis Med.  and Surg. Journal, Sept. 1867.
  He has also carefully endeavored to be minute and
clear in his details, with as little reiteration as possi-
ble, and beautifully combines the relations of science
to art, as far as the different classifications will admit.
—Detroit Review of Med. and Pharm., Aug. 1867.
  We now take leave of Dr. Meigs.  There are many
other and interesting points in his book on which we
would fain dwell, but are constrained to bring our ob-
servations to a close.  We again heartily express our
approbation of the labors of Dr. Meigs, extending over
many years, and culminating in the work before us,
full of practical hints for the inexperienced, and even
for those whose experience has been considerable*—
Glasgow Medical Journal, Sept. 1867.
RAMSBOTHAM (FRANCIS H.), M.D.
THE   PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI-
    CINE AND SURGERY, in reference to the Process of Parturition.  A new and enlarged
    edition,  thoroughly revised by the author.  With additions by W. V.  Keating, M. D.,
    Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia.  In one large
    and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised
    bands; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in
    all nearly 200 large and beautiful figures.   $7 00.
                                              To the physician's library it is indispensable, while
                                             to the student, as a text-book, from which to extract
                                             the material for laying the foundation of an education
                                             on obstetrical science, it has no superior.—Ohio Mad.
                                             and Surg. Journal.
                                              When we call  to mind  the toil we underwent In
                                             acquiring a knowledge of this subject, we cannot but
                                             envy the student of the present day  the aid which
  We will only add that the student will learn from
It all he need to know, and the practitioner will find
it, as a  book of reference, surpassed by none other.—
Stethoscope.
  The  character and merits of Dr. Ramsbotham's
work are  so well known and thoroughly established,
that comment is unnecessary and praise superfluous.
The illustrations, which are numerous and accurate,
are executed in the highest style of art.  We cannot i this work will afford him.—Am. Jour, of the Med.
too highly recommend the work to our readers.—St. Sciences.
Louis Med. and Surg. Journal.                  I
 fjHURCHILL  (FLEETWOOD), M.D.,  M.R.I.A.


   ON  THE  THEORY AND PRACTICE  OF  MIDWIFERY.   A  new
       American from the fourth revised and enlarged London edition.  With notes and additions
       by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases  of Chil-
       dren," &c.   With one hundred and ninety-four illustrations.   In one very handsome octavo
       volume of nearly 700 large pages.   Extra cloth, $4  00; leather, $5 00.

  In adapting this standard favorite to the wants of the profession in the United States, the editor
has endeavored  to insert everything that his experience has shown him would be desirable for the
American student, including  a large number  of  illustrations.   With  the  sanction of  the authoi,
he has added, in the form of an appendix, some chapters  from a little "Manual for Midwives and
Nurses," recently issued by Dr. Churchill, believing that the details there presented  can hardly
fail to prove of  advantage to the junior practitioner.   The result of all these additions is  that the
work now contains fully one-half more matter than the last American edition, with  nearly one-
half more illustrations; so  that, notwithstanding the use of a smaller type, the volume containi
aimost two hundred pages more than before.
  These additions render the work still more com-
plete and acceptable than ever; and with the excel-
lent style in  which the publishers have presented
this edition of Churchill, we can commend it to the
profession with great cordiality and pleasure.—Ctn-
dnnati Lancet.
  Few works  on  this branch  of medical science are
equal to it, certainly none excel It, whether in regard
to theory or practice, and in one respect it is superior
to all  others,  viz., in its statistical information, and
therefore, on these grounds a most valuable work for
the physician, student, or lecturer, all of whom will
find in it the  information which they are seeking.—
Brit. Am. Journal.
  The present treatise is very much enlarged and
amplified beyond the previous editions bat nothing
has been added which could be well dispensed with.
An examination of the table of contents shows how
thoroughly the author has gone over the ground, and
the  care he has taken in the text to present the sub-
jects in all their bearings, will render thi6 new edition
even more necessary  to the obstetric student  than
were either of the former editions at the date of  their
appearance.  No treatise on obstetrics with which we
are  acquainted can  compare favorably with  this, In
respect to the amount of material which has  been
gathered from every source.—Boston Med. and Surg.
Journal.

  There is no better text-book for  students, or work
of reference and study for  the practising physician
than this.  It should adorn and enrich every iuedioej
library.—Chicago Med. Journal. 
26                Henry C. Lea's Publications—(Surgery).
 S_TROSS  (SAMUEL  D.), M.D.,
         Professor of Surgery in the Jefferson Medical College of Philadelphia.

   A  SYSTEM OF  SURGERY:  Pathological,  Diagnostic,  Therapeutic,
       and Operative.  Illustrated by upwards of Thirteen Hundred Engravings.  Fourth edition,
       carefully revised, and improved.  In two large and beautifully printed royal octavo volumes
       of 2200 pages, strongly bound in leather, with raised bands-  $15 00.
  The continued favor, shown by the exhaustion of successive  large  editions of this great work,
proves that it has successfully supplied a want felt by American practitioners and students.  Though
but little over six years have  elapsed since its first publication, it has already reached its fourth
edition, while the care of the author in its revision and correction has kept it in a constantly im-
proved shape.  By the use of a close, though very legible  type, an unusually large amount  of
matter is condensed in its pages, the two volumes containing  as  much as four or five ordinary
octavos.   This, combined with the most careful mechanical execution,  and its very durable binding,
renders it one of the cheapest works accessible to the profession.   Every subject properly belonging
to the domain of surgery is treated in detail, so that the student who possesses this work may be
said to have in it a surgical library.
  It must long remain the most comprehensive work
on this important part of medicine.—Boston Medical
and Surgical Journal, March 23, 1865.
  We  have compared it with most of our standard
works, such as those of Erichsen, Miller, Fergusson,
Syme, and others, and we must, in  justice to our
author, award it the pre-eminence.  As a work, com-
plete in  almost every detail, no matter how minute
or trifling, and embracing every subject known in
the principles and practice of surgery, we believe it
stands without a rival. Dr. Gross, in his preface, re-
marks "my aim has been to embrace the whole do-
main  of surgery, and to allot to every subject its
legitimate claim to notice;"  and, we  assure our
readers, he has kept his  word.  It is a work which
we can most confidently recommend to our brethren,
for its utility is becoming the more evident the longer
it is upon the shelves of our library.—Canada Med.
Journal, September, 1865.
  The first two editions of Professor Gross' System of
Surgery are so well known to the profession, and so
highly prized, that it would be idle for us to speak in
praise of  this  work.— Chicago Medical Journal,
September, 1865.
  We gladly indorse the favorable  recommendation
of the work, both as regards matter and style, which
we made when noticing its first appearance.—British
and Foreign Medico-Chirurgieal Review, Oct. 1865,
  The most complete work that has yet issued from
the press on the science  and practice of surgery.—
London Lancet.
  This system of surgery is, we predict, destined to
take a commanding position in our surgical litera-
ture, and be the crowning glory of the author's well
earned fame.  As an authority ou general surgical
subjects, this work is long to  occupy a pre-eminent
place, not only  at home, but abroad.  We have no
hesitation in pronouncing it without a rival in our
language, and equal to the best systems of surgery in
any language.—..V. Y. Med. Journal.
   Not only by far the best text-book on the subject,
as a whole, within the reach of American students,
but one which will be much more than ever likely
to be resorted to and regarded as a high authority
abroad.—Am. Journal Med. Sciences, Jan. 1865.
   The work contains everything, minor and major,
operative and diaguostic, including mensuration aud
examination, venereal disea.-es, and uterine manipu-
lations and operations.   It is a complete Thesaurus
of modern uurgery, where the student and practi-
tioner shall not seek in vain for what they desire.—
San Francisco Med. Press, Jan. 1865.
  Open it where we may, we find sound practical in-
formation conveyed in plain language.  This  book is
no mere provincial or  even  national system of sur-
gery, but a work which, while very largely iudebted
to the past, has a strong claim on the gratitude of the
future of surgical science.—Edinburgh Med.Journn/,
Jan. 1865.
  A glance at the work is sufficient to show that the
author and publisher have spared no labor in  makiag
it the most complete "System of Surgery" over pub-
lished in any country—St. Louis Med. and Surg.
Journal, April, 186.5.
  The third opportunity  is now offered during our
editorial life to  review, or rather to indorse  and re-
commend this  great  American work on Surgery.
Upon this last edition  a  great  amount of labor 1ms
been expended, though  to all pthers except the author
the work was regarded in its previous  editions as so
full and complete as to be hardly capable of improve-
ment. Every chapter has been revised ; the text aug-
mented  by  nearly two hundred pages, and a con-
siderable number of wood-cuts have been introduced.
Many portions have been  entirely re-written, and the
additions made to the text are principally of a prac-
tical character.   This comprehensive  treatise upon
surgery has undergone revisions and enlargements,
keeping pace with the progress  of the art and science
of surgery, so that whoever is in possession of this
work may consult its pages upon any topic embraced
within the scope of its department, and rest satisfied
that its teaching is fully up to the  present standard
of surgical knowledge.  It is also  so comprehensive
that it may truthfully be said to embrace all that is
actually known, that  is  really of any value iu the
diagnosis and treatment of surgical diseases and no i-
dents.  Wherever illustration will addclearuess to the
subject, or make better or more lasting impression, it
is not wanting;  in this respect the work is eminently
superior.—Buffalo Med. Journal, Dec. 1864.
  A system of surgery  which we think unrivalled In
our language, aud which will indelibly associate his
name with surgical science.  And what, in our opin-
ion, enhances the value of the work is that, while the
practisiug surgeon will find all that he requires in It,
it is at the same time one of the most valuable trea-
tises which can  be put into the hands  of the  student
seeking to know the principles and practice of this
branch  of the  profession which he designs subse-
quently to follow.—The Brit. Am. Journ., Montreal.
DY THR SAME  AUTHOR.                 ----

  A  PRACTICAL   TREATISE  ON  THE  DISEASES,  INJURIES,
      AND  MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE OLANI\
      AND  THE  URETHRA.   Second edition, revised and  much enlarged, with one hundred
      and eighty-four illustrations.  In one large and very handsome octavo volume of over nine
      hundred pages, extra cloth.  $4  00.
    THE SAME  AUTHOR.                 ----
A  PRACTICAL
    AIR-PASSAGES.
    pp. 468.  $2 75.
TREATISE  ON   FOREIGN   BODIES   IN  THE
In  one handsome octavo  volume,  extra  cloth,  with  illustrations.
MALGAIGNE'S OPERATIVE SURGERY.  With nu- I SKEY's; OPERATIVE SURGERY.  In oae very hand-
  merous illu-trations on wood.  In one handsome   some octavo volume, extra cloth, of over 650 pages,
  octavo volume, extra cloth, of nearly 600 pp.  $2 50. |  with about 100 wood-cuts. #3 25. 
Henry C.  Lea's Publications—(Surgery).                27
 ZJRICHSEN  (JOHN),
-*-'     Senior Surgeon to University College Hospital.
   THE  SCIENCE  AND ART OF SURGERY;  being a Treatise on Sur-
      gical Injuries, Diseases, and Operations.  From the Fifth enlarged and carefully revised
      London Edition.  With Additions by John Ashhuhst, Jr., M. D., Surgeon to the Episcopal
      Hospital, <kc.   Illustrated by  over  six hundred Engravings on wood.   In one very large
      and beautifully printed imperial octavo volume, containing over  twelve hundred  closely
      printed pages :  cloth, $7 50 ; leather, raised bands, $8 50.
  This volume  having enjoyed repeated revisions at the hands of the author has been greatly
enlarged,  and the present edition will thus be found to contain at least one-half more matter than
the last American  impression.  On the latest London edition, just issued, especial care has been
bestowed.  Besides the most minute attention on the part of the author to bring every portion of
it  thoroughly on a level with the existing condition of science, he called to his aid gentlemen of
distinction in special departments.  Thus a chapter on the Surgery of the Eye and its Appendages
has been  contributed by Mr. Streatfeild ; the  section devoted  to Syphilis has been rearranged
nnder the supervision of Mr. Berkeley Hill ; the subjects of General Surgical Diseases, including
Pysemia, Scrofula,  and Tumors, have been revised by Mr. Alexander Bruce; and other professional
men of eminence have assisted  in other branches.  The work may thus be  regarded as embodying
a complete and comprehensive view  of the most advanced condition of British surgery; while
such omissions  of practical details in  American surgery as were found have been supplied by the
editor, Dr. Ashhurst.
  Thus complete in every respect, thoroughly illustrated, and containing in one beautifully printed
volume the matter of  two or three ordinary octavos,  it is presented at a price which renders it
one of the cheapest works now accessible to the profession.   A continuance of the very remarkable
favor which it has thus far enjoyed is therefore confidently  expected.
                                              those enlightened surgeons of the present day, who
                                              regard au acquaintance with the manual part of sur-
                                              gery as only a portion  of that knowledge which a
                                              surgeon  should possebs.—British Medical Journal,
                                              Jan. 2, 1869.
  The high position which Mr. Erichseu'g Science and
Art of Surgery has for some time attained, not only
in this country, but on the Continent and in America,
almost limits the task of the reviewer, on the appear-
ance  of a new edition, to the mere announcement.
Elaborate analysis and criticism would  be out of
place; and nothing remains to be done except to state
in general terms that the author has bestowed  on it
that labor which such a work required iu order to ho
made a representative of the existing state of surgical
science and practice. Of the merits of the book as a
guide to  the "Science and Art of Surgery" it is not
necessary for us to say much. Mr. Erichsen is one of
  Thus the work bears in every feature a stamp of
novelty and freshness which will commend it to those
who are making its acquaintance for the first time,
whilst those who have found  it a safe guide and
friend iu former years will be able to refer to the uew
edition for  the latest information upon any point of
surgical controversy.—London Lancet, Jan. 23, 1869.
JOY THE SAME  AUTHOR.  (Just Issued.)

   ON   RAILWAY,  AND  OTHER   INJURIES  OF   THE   NERVOUS
      SYSTEM.  In small octavo volume.   Extra cloth,  $1 00.
 MILLER (JAMES),
JJ-I     Late Professor of Surgery in the University of Edinburgh, Ac.
   PRINCIPLES  OF SURGERY.   Fourth American, from  the third and
      revised Edinburgh edition.  In one large and very beautiful volume of 700 pages, with
      two hundred and forty illustrations on wood, extra cloth.  $3 75.
DF THE SAME AUTHOR.                   —--

   THE  PRACTICE OF  SURGERY.  Fourth American,  from the last
      Edinburgh edition.   Revised by the American editor.   Illustrated by three hundred and
      sixty-four engravings on wood.  In one  large octavo volume of nearly 700 pages, extra
      cloth.  $3 75.
  It is seldom that two volumes have ever made so I acquired.  The author is an eminently sensible, prao-
profound an impression in so short a time  as the | tical, and well-informed man, who knows exactly
^Principles" and  the "Practice" of Surgery by Mr.  what he is talking about nudexaetly how to talk it.—
Miller, or so richly merited the reputation they have | Kentucky Medical Recorder.
    PIRRIE ( WILLIAM),  F. R. S. E.,
         Professor of Surgery in the University of Aberdeen.
   THE PRINCIPLES  AND  PRACTICE  OF SURGERY.   Edited  by
      John Neill, M. D., Professor of  Surgery  in the Penna. Medical College, Surgeon to the
      Pennsylvania Hospital, Ac  In one very handsome octavo volume of 780 pages, with  316
      illustrations, extra cloth.  $3 75.                                  .

 &ARGENT (F. W.), M.D.

   ON BANDAGING AND OTHER  OPERATIONS  OF MINOR SUR-
      GERY. New edition, with an additional chapter on Military Surgery.  One handsome royal
      12mo. volume, of nearly 400 pages, with 184 wood-cuts   Extra cloth, $1 75.
  Exceedingly convenient and valuable to all mem- I   We cordially commend this volume as one which
bers of the profession.—Chicago Medical Examiner, \  the medical student should most closely stndy;  and
May  1869                                    |  ,0 tne surgeon In practice it must prove itself instruot- 
28               Henry C. Lea's Publications—(Surgery).
TJRUITT (ROBERT),  M.R.C.S., frc.
THE  PRINCIPLES AND  PRACTICE  OF  MODERN  SURGERY.
   A new and revised American, from the eighth enlarged and improved London edition.  Illus-
   trated with four hundred and  thirty-two wood-engravings.  In one very handsome  octavo
   volume, of nearly 700 large and closely printed pages.  Extra cloth, $4 00; leather, $5 00.
  All that the surgical student or practitioner could
desire.—Dublin Quarterly Journal.
  It is  a most admirable book.  We do not know
when we have examined one with more pleasure.—
Boston  Med. and Surg. Journal.
  In Mr. Druitfs book, though containing only some
theoretical surgical opinions, no work that wo are at
present acquainted with can at all compare with it.
It is a compendium of surgical theory (if we may use
tbe word) and practice in itself, and well deserves
the estimate placed upon it.—Brit. Am. Journal.
  Thus  enlarged and improved, It will continue to
seven hundred pages,'both  the  principles and the I rank among our best text-books on elementary sn*
practice of surgery are  treated, and so clearly and ; S"ry.—Columbus Rev. of Med. and Surg.
perspicuously, as to elucidate every important topic, j   We must close this brief notice of an admirable
The fact that twelve editions have already been called ' work by recommending it to the earnest attention of
for, in these days of active competition, would of  every medical student.—Charleston Medical Journal
Itself  show it to possess  marked superiority.  We I and  Review.
have examined the book most thoroughly  and can j   A text-book which the  general voice of the profes-
say that this success is wel  merited   His book ! glon in both Engiand and  America has commended ai
moreover,  possesses the  nestimable  advantages of  one of the mogt admirttble .'mauUals," or, "vwU
having the subjects perfectly well arranged and clas-  mecum .. as lt8 English  title runs, which can  be
sified, and of being written in a  style at once  clear  pUced in the hands of the student.   The  merits of
and succinct.— Am. Journal of Med. Sciences.      ; D.uitt's  Surgery are too well known to every one to
  Whether we view Druitt's Surgery as a  guide to  need  any further eulogium from us.—Nashville Med.
operative procedures, or as representing the latest  Journal.

 TJAMILTON  (FRANK H.), M.D.,
         Professor of Fractures and Dislocations, Ac. in  Bellevue Hosp. Med.  College, New York.

   A  PRACTICAL TREATISE  ON   FRACTURES  AND  DISLOCA-
       TIONS.  Third edition, thoroughly revised.  In one large and handsome octavo volume
       of 777 pages, with 294 illustrations, extra cloth, $5 75.   (Just Issued.)
  In fulness of detail, simplicity of arrangement, and [American professor of surgery; and his book adds
accuracy of description,  this work stands unrivalled, jone more to the list of excellent practical works which
So far as we know, no other work on  the subject in j have  emanated  from his  country, notices  of which
the English language can be compared with it. While ' have  appeared from time to time in our columns du-
eongratulating our trans-Atlantic brethren on  the
European reputation which Dr. Hamilton, along with
many other American surgeons, has attained, we also
may be proud that, in the mother tongue, a classical
work has been produced which need not fear compa-
rison with the standard treatises of any other nation.
—Edinburgh Med. Journal, Dec. 1866.
                                              ring the last few months.—London Lancet,  Doc. 15,
                                              1866.
                                               These additions make the work much more valua-
                                              ble, and it must be accepted as the most complete
                                              monograph on  the subject, certainly in our owu, if
                                              not even in any other language.—American Journal
                                              Med. Sciences,  Jan. 1867.
  The credit of giving to the profession the only com  .,™8 '* thf m08t complete treatise on the subject rn
plete practical treatise on fractures and dislocations  the English l&nga&ge.-Banking's Abstract, Jan. 1SW.
in our language during the present century, belongs!  A mirror of all that is valuable in modern surgery.
to the author of the work before us, a distinguished  Richmond Med. Journal, Nov. 1866.

 flURLING  (T.B.),  F.R.S,
 ^     Surgeon to the London Hospital, President of the Hunterian Society, Ac.

   A PRACTICAL   TREATISE   ON  DISEASES  OF   THE  TESTIS,
      SPERMATIC CORD, AND SCROTUM.  Second American, from the second and enlarged
      English edition.  In one handsome octavo volume, extra cloth,  with numerous illustra-
      tions,  pp. 420.   $2 00.      _______
BRODIE'S CLINICAL LECTURES ON  SURGERY.
  1 vol. Svo., 350 pp.; cloth, $1 25.
COOPER'S LECTURES ON  THE PRINCIPLES AND
  Practice of Scruery.  In one very large octavo
  volume, extra cloth, of 750 pages.  $2 00.
GIBSON'S  INSTITUTES AND PRACTICE OF 8UB-
  »ery.  Eighth edition, improved aud altered. With
  thirty-four plates.  In two handsome octavo vol-
  umes, about 1000 pp., leather, raised bauds. *6 50.
MACKENZIE ON  DISEASES AND  INJURIES  OF
  THE EYE. 1 vol. 8vo., 1027 pp., extra cloth.  $6.
  ASHTON (T.  J.)

   ON  THE   DISEASES, INJURIES,  AND  MALFORMATIONS  OF
      THE RECTUM AND ANUS; with remarks on Habitual Constipation.  Second American,
      from the fourth and enlarged London edition.  With handsome illustrations.   In one very
      beautifully printed octavo volume of about 300 pages.   $3 25.   (Just Issued.)
  We can recommend this volume of Mr  Ashton's in
the strongest terms, a* containing all the latest details
ot the pathology and treatment of diseases connected
with the rectum.—Canada Med. Journ., March, 1866.
  One of the most valuable special treatises that the
physician and surgeon can  have in his library.—
Chicago Medical Examiner, Jan. 1866.
  The short period which has elapsed since the ap-
pearance of the former American reprint,  and the
numerous editions published in England, are the beet
arguments we can offer of the merits, and of the use-
lessness of any commendation on our part of a book
already so favorably known to our readers.— Boston
Med. and Surg. Journal, Jan. 25, 1866.
JLJORLAND (W.  W.), M.D.
DISEASES  OF THE  URINARY  ORGANS; a Compendium of their
   Diagnosis,  Pathology, and Treatment.  With illustrations.  In one large and handsome
   octavo volume of about 600 pages, extra eloth.   $3 50. 
Henry C. Lea's Publications—(Surgery).               29
I
 jyELLS  (J. SOELBERG),
        Professor of Ophthalmology in King's College Hospital, Ac.

   A  TREATISE   ON  DISEASES   OF   THE   EYE.    First American
      Edition, with additions ;  illustrated with 216 engravings on wood, and six colored plates.
      Together with selections  from the Test-types of Jaeger and Snellen.  In one large and
      very handsome  octavo volume of about 750 pages:  extra cioth, $5 00;  leather, $6 00.
      (Just Ready.)

  A work has long been wanting which should represent adequately and completely the present
aspect of British Ophthalmology, and this want it has been the aim of Mr. Wells to supply.   The
favorable  reception of his volume by the medical  press  is a guarantee that be has succeeded in
bis undertaking,  and  in  reproducing  the work in this country every effort has been  made to
render it  in  every way suited to the  wants of the American practitioner.  Such additions as
seemed  desirable have been introduced  by the editor, Dr. I. Minis Hays, and the number of
illustrations has  been more than doubled.  The importance of test-types as an aid to diagnosis
is so universally acknowledged at the present day that it seemed essential to the completeness of
tine work that they should  be added, and as the author recommends the use of those both of Jaeger
and of Snellen for different purposes, selections have been made from each, so that the practitioner
may have at command all the assistance necessary.  The work is thus presented as in every way
fitted to merit the confidence of the American profession.
  His chapters are  eminently readable.  His style is
dear and flowing.  He can be short without over-con-
densing, and accurate without hair splitting.  These
merits appear in a remarkable degree when he comes
to  treat of  the more abstruse departments of his sub-
ject, and contrast favorably with the labored obscurity
which mars the writings of  some greater authorities
in  the aame line.  We congratulate Mr. Wells upon
the success with which he has fulfilled his ideal, as
represented in the preface, in producing " an English
treatise on the diseases of the eye,  which  should
embrace the  modern doctrines and practice of the
British ami Foreign Schools of Ophthalmology." The
new school of Ophthalmology may also be congratu-
lated in having found an exponent who is neither a
bigoted partisan of everything new, nor a scoffer at
everything old.—Glasgow Med. Journal, May, 1869.
rOYNBEE (JOSEPH), F.R.S.,
       Aural Surgeon to and Lecturer on Surgery at St. Mary's Hospital.
 THE DISEASES  OF  THE EAR:  their Nature, Diagnosis, and Treat-
    ment.   With  one hundred engravings on wood.   Second American  edition.   In one very
    handsomely printed octavo volume of 440 pages;  extra cloth, $4.
  The appea ranee of a volume of Mr. Toynbee's, there-
fore, in which the subject of aural disease is treated
In the most scientific manner, and our knowledge in
respect to it placed fully on a par with that which
we possess respecting most other organs of the body,
is a matter for sincere congratulation.  We may rea-
sonably hope that henceforth the subject of this trea-
tise will cease to be among the opprobria of medical
science.—London Medical Review.
  The work, as was stated at the outset o'our notice,
is a model of its kind, and every page and paragraph
of it  are worthy of the most thorough study.  Con-
sidered all in all—as an original work, well written,
philosophically elaborated, and happily illustrated
with  cases and drawings—it is by far the ablest mo-
nograph that has ever appeared on the anatomy and
diseases of the ear, and one of the most valuable con-
tributions to the  art and science of surgery in the
nineteenth  century.—N. Am. Med.-Chirurg. Review.
 A URENCE (JOHN Z.), F. R. C. S,
      Editor of the Ophthalmic Review, Ac.

A  HANDY-BOOK  OF   OPHTHALMIC  SURGERY,  for the  use  of
    Practitioners.   Second Edition, revised and enlarged.   With numerous illustrations.  In
    one very handsome octavo volume.   (Nearly Ready.)
                                              Not only, as its modest title suggests, a  "Handy-
                                            Book" of Ophthalmic Surgery, but an excellent and
                                            well-digested rtsumt of all that is of practical value
                                            in the specialty.—New  York Medical Journal, No-
                                            vember, 1S66.
  No book on ophthalmic surgery was more needed.
Designed, as it is, for the wants of the busy practi-
tioner, it is the neplus ultra of perfection.  It epito-
mizes all the diseases incidental to the eye in a clear
a-ud masterly manner, not only enabling  the practi-
tioner readily to diagnose each variety of disease, but
affording him the more important assistance of proper
treatment.  Altogether this is a work which ought
'certainly to be iu the hands of every general practi-
lixmer.—Dublin Med. Press and Circular, Sept. 12, '66
  This object the authors have accomplished  in a
highly satisfactory manner,  and  we know no work
we can more highly recommend to the "busy practi-
tioner" who wishes to make himself acquainted with
  We cordially recommend this book  to the notice of I the recent improvements in ophthalmic science. Sueh
onir readers, as containing an excellent outline of la work as this was much wanted at this time, and
modern ophthalmic surgery.— British Med. Journal,  this want Messrs. Laurence and Moon have now well
October 13, 1866.                                ' supplied.—Am. Journal Med. Sciences, Jan. 1867.

 TAWSOX (GEORGE), F.  R. C. S., Engl.
JLd      Assistant Surgeon to the Roual London Ophthalmic Hospital, Moorfields, Ac.

   INJURIES OF  THE  EYE,  ORBIT,  AND EYELIDS:  their Imme-
     diate  and Remote Effects.  With about one hundred illustrations.   In one  very  hand-
     some octavo volume, extra cloth, $3 50.  (Now Ready.)
  TUis work will be found eminently fitted  for the general practitioner.  In cases of functional
or structurnl diseases of the eye,  the physician who has not made ophthalmic surgery a special
study can, in most instances, refer a patient to some  competent practitioner.  Cases of injury,
however, supervene suddenly and usually require prompt assistance,  and a work  devoted espe-
cially to'them cannot but prove essentially useful to  those who may at any moment be called upon
to treat  such accidents.  The  present volume, ;is the  work of a gentleman of large  experience,
may be considered as eminently worthy of confidence for reference in all such emergencies.
  It is an admirable practical book in the hi*he»t and b«»t sense  of the phras« — London Medical Times
and  Gatette, May 18, 1867. 
30
Henry  C. Lea's Publications—(Surgery).
TVALES (PHILIP S.), M. D., Surgeon U. S. N.
   MECHANICAL  THERAPEUTICS:  a Practical  Treatise on Surgical
       Apparatus, Appliances, and Elementary Operations:  embracing Minor Surgery,  Band-
       aging, Orthopraxy,  and the Treatment of Fractures and Dislocations.  With six hundred
       and Tony-two illustrations on wood.  In one large and handsome octavo volume of about
       700 pages:  extra cloth, $5 75; leather, $6 76.  (Just Issued.)
  A Naval Medical Board directed to examine and report upon the merits of this volume, officially
states that " it should  in our opinion become a standard work in the  hands of every naval sur-
geon ;" and its adoption  for  use in both the Army and Navy of the  United States is sufficient
guarantee of its adaptation to the needs of every-day practice.
  The title of this book will  give a reasonably good  take charge of  surgical cases, under circumstances
Idea of its scope, but its merits can  only he appreci- j precluding them from theaid of experienced surgeons.
ated by a careful perusal of its text.  No one who un- | —Pacific Med. and Surg. Journal, Feb. lMib.
dertakes such a task will have any reason to com-
plain that the author has not performed his duty, and
has not taken every pains to present every subject in
a clear, common-sense, and practical light.  It is a
unique specimen of  literature in its way,  in that,
treating upon such a variety of subjects, it is as a
whole so completely up to the wants of the student
and the general practitioner.  We have never seen
any work of its kind that can compete with it in real
utility and extensive adaptability.  Dr Wales per-
fectly understands what may naturally be required
of him in the premises, and in the work before us has
bridged over a very wide gap which has alwnys here-
tofore existed between the first rudiments of surgery
and practical surgery proper.   He has emphatically
given us a comprehensive work for the beginner; aud
when we say of his  labors, that in their particular
sphere they leave nothing to be  desired, we assert a
great deal to recommend the book to  the attention of
those specially concerned.   In conclusion, we would
state, at the risk of reiteration, that this is the most
comprehensive book on the subject that we have seen ;
is the best that can be placed in the hands of the stu-
dent in need of a first book on surgery, aud the most
useful that can be named for such general practition-
ers who, without any special pretensions to surgery,
are occasionally liable to treat surgical cases.—N.  Y.
Med  Record, March 2, 1S6S.
  It is certainly the most complete and thorough work
of its kind in the English language.  Students and
young practitioners of surgery will find it invaluable.
It will prove especially useful to inexperienced coun-
try practitioners, who are  continually required  to  ' porter, Feb. 1868.
  This is a most complete and  elegant work of 673
pages, and Is certainly well deserving of the com-
raeudatlon of every American surgeon. This work,
besides its usefulness as a reference for practitioners,
Is most admirably adapted as a text-book for students.
Its 642 illustrations i n wood-cuts, represent every man-
ner of surgical appliance, together with a minute de-
scription of each, the name of its inventor, and its prac-
tical utility in mechanical surgery.  There is, perhaps,
no work in the  English  language so complete in the
description and detail of surgical apparatus and ap-
pliances as this one.  The entire work entitles the au-
thor to great credit for his clear and distinct style as
a writer, as well as for his accuracy of observation
and great research in the field of surgery.  We ear-
nestly recommend every member of the profession to
add a copy of it  to his library, with the assurance
that he will find some useful suggestion in the treat-
ment of almost every surgical case that  may come
under his observation.—Humboldt Med.  Archives,
Feb. 1868.

  The title of the above work is sufficiently indica-
tive of its contents.  We  have  not seen for  a loDg
time (in the English language) a treatise equal to this
in extent, nor one which is  better adapted to the
wants of the general student and practitioner. It is
not to the surgeon alone that this book belongs; the
physician has frequent opportunities to fill an emer-
gency by such knowledge as  is here given.   Every
practitioner should make purchase of such a book—
it will last  him his  lifetime.—St. Louis Med. Re-
B
    IGELOW (HENRY J),  M. D.,
         Professor of Surgery in the Massachusetts Med. College.

   ON  THE  MECHANISM  OF   DISLOCATION  AND  FRACTURE
      OF THE HIP.  With the Reduction of the Dislocation  by the Flexion Method.  With
      numerous original illustrations.   In one  very handsome octavo volume.  Cloth.  $2 50.
      (Now Ready.)
  The reputation  of the  author and the  importance of the subject cannot fail to attract to this
volume  the attention which it deserves.
 /THOMPSON (SIR HENR Y).
 ■*-      Surgeon and Professor of Clinical Surgery to University College Hospital.

    LECTURES  ON DISEASES OF THE URINARY ORGANS.  With
      illustrations on  wood.  In one neat octavo volume, extra cloth.  $2 25.  (Now Ready )
  These lectures stand the severe test.  They are in- , on which Sir Henry Thompson speaks with more a*
rtruciive without being  tedious, and  simple without : thority than that in which he has speciallv fathered
being^diffuse; and they include  many of those prac- | his laurels; in  addition to this, the conversational
                                               style of instruction, which is retained in these printed
                                               lectures, gives them an attractiveness which a sys-
                                               tematic treatise  ean never possess.—Lon.eis>»  Mc,i,„„>
tical hints so useful  for the student, and even more
valuable to the young practitioner.— Edinburgh Med.
Journal, April, 1869.
  Very few words of ours are necessary to recommend
these lectures to the profession.  There is no subject
                 never possess.-
Times and Gazette, April 24,
-London Medical
(Nearly Ready.)
JOY THE SAME AUTHOR.

   ON THE  PATHOLOGY AND TREATMENT OF  STRICTURE  OP

      Zd i^^V^^fv AR\ VlfiTVhM-   ™ P»**" and wood-cuts   From he
      third and revised English edition.  In one very handsome octavo volume.  (Nearly Ready )

• T.hi!uCl1S-|Cai w<?r]klhas  8<\,0nf bee" rfc°gnized a« a standard authority on its perplexing -ub-
je-ts  that  it should be  rendered accessible to the American profession    Having enjoyed  the
advantage of a revision at  the hands of the author within a few months, it will be found to present
his latest news and to be on a level with  the most recent advances of surgical science 
Henry C. Lea's Publications—(Medical Jurisprudence, dec).    31
 /TAYLOR (ALFRED S.), M.D.,
 •*■       Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital.

   MEDICAL  JURISPRUDENCE.    Sixth  American,  from  the  eighth
      and revised London edition.  With Notes and References to American Decisions, by Cle-
      ment B. Penrose, of the Philadelphia Bar.   In one large octavo volume of 776 pages,
      extra cloth,  $4 50 ; leather, $5 50.   (Just Issued.)
  Considerable additions have been made by the editor to this edition, comprising some important
sections from the author's larger work, " The Principles and Practice of Medical Jurisprudence,"
as well  as references  to American law and practice.   The notes of the former editor, Dr. Harts-
horne, have likewise been retained, and the whole is presented as fully worthy to maintain the
distinguished position which the work has acquired as a leading text-book and authority on tbe
Bubject.
  A new edition of a work acknowledged as a stand-
ard authority everywhere within the range  of  the
English language  Considering the new matter intro-
duced, on trichiniasis and other subjects, and  the
elaborate treatises.—New York Medical Record, Feb.
15, 1867.
  The present edition of this valuable manual  is a
great improvement on those which have preceded it.
plates representing the crystals of poisons, etc., it may | Some admirable instruction on the subject of evidence
fairly be  regarded as the most compact, comprehen-
sive, aud practical work on  medical jurisprudence
which has issued from the press, and  the one best
fitted for students.—Pacific Med. and Surg. Journal,
Feb. 1867.

  The sixth edition of this popular work comes to us
In charge of a new editor, Mr. Penrose, of the Phila-
delphia bar, who has done much to render it useful,
not only to the medical practitioners of this country,
but to those ofhis own profession.  Wisely retaining
the references of the former American editor,  Dr.
Hartshorne, he has added many valuable notes of his
own. The reputation of Dr. Taylor's work is so well
established, that it needs no recommendation.  He is
now the highest living authority on all matters con-
and the duties and responsibilities of medical wit-
nesses has been added by the distinguished author,
and some fifty cuts, illustrating chiefly the crystalline
forms and microscopic structure of substances used
as poisons, inserted.   The American editor has also
Introduced several chapters from Dr. Taylor's larger
work, "The Principles and Practice of Medical Juris-
prudence," relating to trichiniasis, sexual malforma-
tion, insanity as affecting civil responsibility, suicidal
mania, and life insurance, &c, which add considerably
to Its value.  Besides this, he has  introduced  nume-
rous references to cases which have occurred in this
couiftry.  It makes thus  by far the best guide-book
in this department of medicine for students and the
general practitioner in our language.—Boston Med.
nected with forensic medicine, and every successive  and Sur9- Journal, Dec. 27, 1866.
edition of his valuable work gives fresh assurance to   Taylor's Medical Jurisprudence has been the text-
his many admirers that he will continue to maintain  book in our colleges for years, and  the present edi-
his well-earned position.  No one  should, in fact, be  tion, with the valuable additions made by the Auieri-
without  a text-book on the subject, as he  does not  can editor, render it the most standard work of the
know but that his next case may create  for him an ' day, on the peculiar province of medicine on which
emergency for its use. To those who are  not the for- j it treats.  The American editor, Dr. Hartshorne, has
tunate possessors of a reliable, readable,  Interesting, j done his duty to the text, aud, upon the whole, we
and thoroughly practical work upon the subject, we  caunot but consider this volume  the best and richest
would earnestly recommend this, as forming the best  treatise on medical jurisprudence in our language.—
groundwork for all their future studies of the more I Brit. Am. Med. Journal.

 MflNSLOW (FORBES),  M.D., D.C.L.,tfc.

      ON  OBSCURE DISEASES OF  THE  BRAIN  AND DISORDERS
      OF  THE MIND;  their  incipient Symptoms,  Pathology, Diagnosis, Treatment, and Pro-
      phylaxis.  Second  American, from the third and revised English edition.  In one handsome
      octavo volume of nearly 600  pages, extra cloth.  $4 25.   (Just Issued.)
  Of the merits of Dr. Winslow's  treatise the profes-1 our conviction  that it is long since so important and
siou has sufficiently judged.  It has taken its place in I beautifully written a volume has  issued from the
the front rank of the works upon the special depart-
ment of practical medicine  to which it pertains.—
Cincinnati Journal of Medicine, March, 1866.
  It is an interesting volume that  will amply repay
for  a careful  perusal by all Intelligent readers —
Ohicago Med. Examiner  Feb. 1866.
British medical press.  The  details of the manage-
ment of confirmed cases of insanity more nearly in-
terest those who have made mental  diseases  their
special study;  but  Dr. Winslow's masterly exposi-
tion of the early symptoms, and his graphic descrip-
tions of the insidious advances of incipient insanity,
together with his judicious observations on the treat-
  A work which,  like the present, will largely aid  raent of disorders of the mind, should, we repeat, be
the practitioner in recognizing and arresting the first  carefuUy  studied by all who have undertaken the
InsidiouR advances of cerebral and mental disease, is  responsibilities of medical practice.—Dublin Medical
one of immense practical value, and demands earnest  press.
attention and diligent study on the part of all who                interesting as well as valnable book
have embraced the medical profession, and have ;  . " ls UV> most interesting as wen as valuable book
im«m»r»iu mc \.Ln„„^y.i\i,i^ i„ TOi,i«h .1,-' that we have seen for a long time.  It is truly fasci-
thereby undertaken responsibilities in which the     .      .   -    Md o-S™,,,,.           '
welfare and happiness of individuals and families | nating.— Am. Jour. Med. Sciences.
are largely involved.   We shall therefore close this    Dr. Winslow's work will undoubtedly occupy an
brief and  necessarily  very  imperfect  notice of Dr. , unique position  iu the medico-psychological litera-
Winslow's great and classical work by expressing ; ture of this country.—London Med. Review.


 TEA  (HENRY C.)

    SUPERSTITION  AND   FORCE:   ESSAYS   ON  THE  WAGER  OF
       LAW,  THE  WAGER OF BATTLE, THE ORDEAL,  AND TORTURE.  In one  hand-
       some volume royal  12mo.,  of  406 pages ;  extra cloth, $2 50.
  The copious collection of facts by which Mr. Lea has ( a humor so fine and good, that he makes us regret it
Illustrated his subject showsln the fullest manner the  was not within his intent, as it was certainly within
constant conllict and varying success,  the advances . his power, to render the whole of his thorough work
■nd defeats, by which the progress of humane legisla- ] more popular in manuer.—Atlantic Monthly, Feb. '67.
tiou has been and is still marked.  This work fills up
with the fullest exemplification and detail the wise
remarks which we have quoted above.   As a book of
ready reference on the subject it is of  the highest
value.— Westminster Review, Oct. 1867.
  When—half  in spite of himself, as it appears—he
sketches a scene or character in the history of legalized
exrorand cruelty, he betrays so artistic a feeling, and I met with.— London Athenaum, Nov. 3,1
  This is a book of extraordinary research.  Mr. Lea
has entered into his subject con amore; and a more
striking record of the cruel superstitions of our un-
happy Middle Ages could not possibly have been com-
piled. ... As a work of curious inquiry on certain
outlying points of obsolete law, ''Superstition aud
Force" is one of the most remarkable books we have 
32                         Henry C. Lea's Publications.
INDEX   TO   CATALOGUE.
Allen's Dissector and Practical Anatomist
American Journal of the Medical Science*
Abstract, Half-Yearly, of the Med Sciences
Anatomical Atlas, by Smith aud Horner
Ashton on the Rectum and Anus
Ashwell on Diseases of Females
Brinton on the Stomach
Bigelow on the nip
Barclay s Medical Diagnosis .
Barlow's Practice of Medicine
Bennet (Henry) on Diseases of the Uterus
Bowman's (John E.) Practical Chemistry
Bowman's (John E.i Medical Chemistry
Brande 4 Taylor's Chemistry
Brodie's Clinical Lectures on Surgery .
Brown on the Surgical Diseases of Women
Buckler on Bronchitis  ....
Bueknill and Tuke on Insanity   .
Budd on Diseases of the Liver
Bumstead on Venereal ....
Bumstead and Cullerier's Atlas of Venereal
Carpenter's Human  Physiology  .
Carpenter's Comparative Physiology .
Carpenter on the Microscope
Carpenter on the Use and Abuse of Alcohol
Carson's Synopsis of Materia Medica .
Chambers on the Indigestions
Christison and Griffith's Dispensatory
Churchill'6 System of Midwifery .
Churchill on Diseases of  Females
Churchill on Puerperal Fever
Clymer on Fevers.....
Colombat de l'Isere on Females, by Meigs
Condie on Diseases of Children
Cooper's (B. B.) Lectures on Surgery .
Cullerier's Atlas of Venereal Diseases
Curling on Diseases of the Testis .
Cyclopedia of Practical Medicine .
Dalton's Human Physiology .
De Jongh on Cod-Liver Oil  .
Deweeb's System of Midwifery
Dewees on Diseases of Females  .
Dewees on Diseases of Children  .
Dickson's Practice of Medicine
Druitt's Modern Surgery
Dunglison's Medical Dictionary  .
Dunglison's Human  Physiology  .
Dunglison on New Remedies
Ellis's Medical Formulary, by Smith .
Erichsen's System of Surgery
Erichsen on Nervous Injuries
Flint on Respiratory Organs .
Flint on the Heart.....
Flint's Practice of Medicine  .
Fownes's Elementary Chemistry .
Fuller on  the Lungs, &c.
Gibson's Surgery.....
Singe's Pathological Histology, by Leidy
Graham's Elements of Chemistry .
Gray's Anatomy.....
Griffith's (R. E.) Universal Formulary
Griffith's (J. W.) Manual on the Blood, Ac.
Grot-s on Urinary Organs
Gross on Foreign Bodies  in Air-Passages
Gross's Principles and Practice of Surgery
Grose's Pathological Anatomy
Hartshorne's Essentials of Medicine .
Hartshorne's Conspectus  of the Medical Sciences
Hartshorne's Anatomy and Physiology
Habershon on Alimentary Canal .
Hamilton on Dislocations and Fractures
Harrison on the Nervous Sysum .
Hoblyn's Medical Dictionary
Hodge on Women.....
Hodge's Obstetrics.....
Hodge's Practical Dissections
Holland's Medical Notes and Reflections
Horner's Anatomy and  Histology
Hadson on Fevers,     ....
Hill on Venereal Diseases
Hillier's Handbook  of Skin Diseases
Joues and Sieveking's Pathological Anatomy
Junes (C. Handfield) on Nervous Disorders
Kirkes' Physiology.....
Knapp's Chemical Technology   .
                                           PAQl
Lea's Superstition and Force     ....  SI
Lallemand and Wilson on Spermatorrhoea .      18
La Roche on Yellow Fever.....17
La Roche on Pneumonia, 4c.....17
Laurence and Moon's Ophthalmic 8urgery  .    .  28
Lawson on the Eye......2S
Laycock on Medical Observation ....  16
Lehmann's Physiological Chemistry, 2 vols.    .   9
Lehmann's Chemical Physiology ....   9
Ludlow's Manual of Examinations               6
Lyons on Fever.......18
Maclise's Surgical Anatomy.....7
Malgalgne's Operative  Surgery, by Brittan .    .  M
Marshall's Physiology......8
Markwick's Examination of Urine   .    .    .18
Mayne's Dispensatory and Formulary     .    .  W
Mackenzie on Diseases of the Eye    .    .    .23
Medical News and Library.....2
Meigs's Obstetrics, the Science and the Art .    .  24
Meigs's  Lectures on Diseases of Women   .    .  29
Meigs on Puerperal Fever.....23
Miller's System of Obstetrics     ....  24
Miller's Practice of Surgery.....27
Miller's Principles of Surgery   ....  27
Montgomery on Pregnancy.....24
Morland on Urinary Organs.....28
Morland on Uraemia......18
Neill and Smith's Compendium of  Med. Science .   6
Nellgan's Atlas of Diseases of  the Skin    .    .  20
Neligan on Diseases of the Skin ....  20
Odling's Practical  Chemistry         .    .    .10
Pavy on Digestion......17
Prize Essays on Consumption    ...    .IS
Parrish's Practical Pharmacy   .    .    .    .11
Peaslee's Human Histology.....7
Pirrie's System of Surgery.....27
Pereira's Mat. Medica and Therapeutics, abridged  IS
Quain and Sharpey'g Anatomy, by Leidy  .    .   8
Ranking's Abstract......3
Roberts on Urinary Diseases.....18
Ramsbotham on Parturition.....25
Reese on Blood and Urine.....18
Rigby on Female Diseases.....22
Rigby's Midwifery .        .    .    .    .    .24
Rokitansky's Pathological Anatomy  .    .    .14
Royle's Materia Medica and Therapeutics  .    .  13
Salter on Asthma.......13
Sargent's Minor Surgery.....27
Sharpey and Qualn's Anatomy, by Leidy  .    .   6
Simon's General Pathology.....14
Simpson on Females......23
Skey's Operative Surgery.....26
Slade on Diphtheria......D3
Smith (J. L.) on Children.....21
Smith (H. H.) and Horner's Anatomical Atlas  .    6
Smith (Edward) on Consumption .    .        .18
Smith on Wasting Diseases of Children    .    .  21
Solly on Anatomy and Diseases of the Brain   .  14
Stille's Therapeutics......12
Tanner's Manual of Clinical Medicine ...    5
Tanner  on Pregnancy......24
Taylor's Medical Jurisprudence  .    .    .    .31
Thomas on  Diseases of Females  ....   22
Thompson on Urinary Organs    ....  30
Thomp-on on Stricture......30
Todd and Bowman's Physiological Anatomy   .   9
Todd on Acute Diseases......17
Toynbee on the Ear......29
Wales on Surgical Operations    ....  SO
Walshe on the Heart......is
Watson's Practice of Physic.....it!
Wells on the Eye......".2°
West on Diseases of Females     .   .   .    .23
West on Diseases of Children    .   .   .    .21
West on Ulceration of Os Uteri  .   .   \    .23
What to Observe in Medical Cases   .   .    .  VI
Williams's Principles of Medicine   .   .   .14
Wilson's Human Anatomy ...           7
Wilson's Dissector.....           7
Wilson on Diseases of the Skin  .'   \   \   !  20
Wilson's Plates on Diseases of the Skin  \   \  20
Wilson's Handbook of Cutaneous Medicine     .  20
Wilson on Spermatorrhoea.....jo
Winslow on Brain and Mind          \        '  l\ 
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