fA*.£>. &r*y TJt.Jf. DUE 'Mi WHB ■■■ LAST DATE AUG 7 • 1963 '/ A MANUAL PATHOLOGICAL ANATOMY. CARL ftOKITANSKY, M.D., CCBJ.TOB OF THE IMPERIAL PATHOLOGICAL MUSEUM, AND PROFESSOR AT THE UNIVERSITY 07 VIENNA, ETC. TRANSLATED FROM THE LAST GERMAN EDITION BY WILLIAM EDWARD SWAINE, M.D., CHARLES HEWITT MOORE, EDWARD SIEVEKING, M.D., GEORGE E. DAY, M.D., F.R.S. FOUR VOLUMES IX TWO. VOLS. III. IV. PHILADELPHIA: BLANCHARD & LEA, 1855. R1VR.& •V£;*2 6'-/ C. 8BERMAN ft SON, PRINTERS, 19 St. James Street. > A MANUAL OF PATHOLOGICAL ANATOMY. BY CARL ROKITANSKY, M.D., CURATOR OP THE IMPERIAL PATHOLOGICAL MUSEUM, AND PROFESSOR AT THE UNIVERSITY OF VIENNA, ETC. VOLUME III. THE BONES, CARTILAGES, MUSCLES, AND SKIN, CELLULAR AND FIBROUS TISSUE, SEROUS AND MUCOUS MEMBRANE, AND THE NERVOUS SYSTEM. TRANSLATED FROM THE GERMAN, BY CHARLES HEWITT MOORE, SURGEON TO TUB MIDDLESEX HOSPITAL J I LECTURER ON ANATOMY IN THE MIDDLESEX HOSPITAL SCHOOL OF MEDICINE. PHILADELPHIA: BLANCHARD & LEA. 185 5. EDITOR'S PREFACE TO VOL. III. A knowledge of the value of Professor Rokitansky's personal instructions increases my estimation of the honor of being called to translate and edit a portion of his writings. I take this opportunity of acknowledging that honor, which has been conferred upon me by the Council of the Sydenham Society, as well as of expressing my thanks for their kind acquiescence in my wish to undertake those chapters principally which relate to the practice of Surgery. The Preface to the Second Volume, by my friend Dr. Sieveking, leaves nothing for those who follow him to add, except, indeed, the testimony of time, that such a work as Rokitansky's "Pathological Anatomy" becomes increasingly valuable to those by whom it is used. But the portion on "Special Pathological Anatomy" must be used, as it was written, less as an elegant essay on disease than as a register of well-observed—well-weighed—well-arranged facts. It is not adapted for the merely classical reader, but is a companion for the museum or pathological theatre,—a Lexicon, in which each case, as it occurs and needs explanation, may be found already at hand and in its place. It is, therefore, an invaluable book of refer- ence for those who, amid the hurry of practice, require prompt and complete information. It should be observed, however, that facts take prominence in it according to their general pathological import. Rare facts, when isolated, too often occupy undue attention; by Rokitansky they are dismissed, perhaps in a few lines,—curtly ex- plained, yet perfectly, because placed in their true relation to other facts. The observation, that Rokitansky has not availed himself of the writings of all British pathologists, may not be without some truth. His work is, however, abundantly original, and cannot fail of being VI editor's preface. yet more highly estimated in this country the more it is known. Were there no other proof of this, it might be found in the needless labor that is still incurred by some English pathologists to arrive at facts and opinions which have been already ascertained, and already weighed, by Rokitansky. From his work, as from a fresh starting- point, such laborers may advance to new discoveries, without the risk of having priority claimed by a foreign observer. I have made an effort, with difficulty indeed, to avoid the intro- duction of new scientific terms, and have therefore ventured to adopt a different title for the chapters from that which has been employed in the previous volume. I have done so, however, with the less reluctance, as either mode of translating the original word " Abnormitaten" is perfectly intelligible, and as none of its general import appears to be lost, though divided between the two words "Anomalies and Diseases." As to the other characters of the present volume, a translator has best fulfilled his duty, if he seem not to intervene between the author and his readers. In the descriptions of microscopic appearances, I have mostly sought the judgment of my colleague, Mr. De Morgan. To him, and to my kinsman, Dr. Moore, I am most happy to offer my grateful acknowledgment of their kind assistance in this, and not only in this, professional effort. C. H. M. MOBTIMEB STBEET, CAVENDISH SQUARE, October, 1850. CONTENTS OF VOLUME III. PART IV. ANOMALIES AND DISEASES OF CELLULAR TISSUE. 1. Varieties in regard to Quantity, ...... 2. Anomalies of Texture, ...-••• 1. Congestion, ....... 2. Inflammation, ....••• 3. Metastasis, ....•••• 4. Gangrene, ....... 5. Adventitious Growths, ...... 3. Anomalies of Secretion, and Collections of foreign Bodies in Cellular Tissue, 17 17 17 1* 21 21 21 22 PART V. ANOMALIES AND DISEASES OF SEROUS AND SYNOVIAL MEMBRANES IN GENERAL: 1. Deficiency and Excess of Development, 2. Deviations of Serous Sacs from their natural Size and Form, 3. Solutions of Continuity, ..... 4. Diseases of Texture, 1. Congestion.—Hemorrhage, 2. Inflammation, . a. Acute Inflammation, .... 6. Chronic Inflammation, 3. Softening, ....•• 4. Adventitious Growths, .... 5. Anomalies of Secretion, and Morbid Contents generally, . 27 28 28 28 28 29 29 32 37 38 43 via CONTENTS. PART VI. ANOMALIES AND DISEASES OF MUCOUS MEMBRANES IN GENERAL. < 1. Defective and Excessive Development, . ? 2. Deviations in the Size, or Superficial Area, and in the Form of Mucous Membranes, ..... 'i :!. Diseases of Texture, . .... 1. Hyperaemia, Apoplexy, Hemorrhage, Anajmia, 2. Inflammations, .... a. Catarrhal Inflammation, . <*. Acute Catarrhal Inflammation, . @. Chronic Catarrhal Inflammation, b. Exudative Processes, . c. Exanthematous Processes, 3. Ulcerative Processes, 4. Oedema, .... 5. Metastasis, ..... 6. Gangrene, .... 7. Softening, ..... 8. The Change of Texture which Mucous Membrane undergoes when preternaturally exposed to Atmospheric Air, and when long sub jected to Distension, . 9. Adventitious Formations, . PAOE ■17 48 49 49 50 50 50 51 54 55 56 57 57 58 58 58 .39 PART VII. ANOMALIES AND DISEASES OF THE SKIN. \\. Defect and Excess in Development, . \ 2. Anomalies in the Size, or Capacity, the Thickness, and the Form of the Sac of General Integuments, \ 3. Anomalies in Consistence, . \ 4. Solutions of Continuity, .... \ 5. Anomalies of Color, .... | 6. Anomalies of Texture, .... 1. Congestion.—Hemorrhage.—Anaemia, 2. Inflammations, .... a. Erythematous Inflammation of Skin, b. Phlegmonous Inflammation of Skin, c. Furuncular Inflammation of Skin, d. Exanthematous Inflammations, 3. Ulcerative Processes, 4. Mortification of Skin, . 5. Adventitious Growths, APPENDIX TO PAKT VII. Anomalies and Diseases of the Sudoriparous and Sebaceous Glands Anomalies and Diseases of the Horny Tissues, the Cuticle, Nails, and Hair 67 68 69 70 70 71 71 72 73 73 75 76 78 79 79 84 8.3 CONTENTS. IX PART VIII. ANOMALIES AND DISEASES OF THE FIBROUS SYSTEM. \ 1. Deficiency and Excess of Development, \ 2. Anomalies in size and Form, § 3. Anomalies of Consistence and Continuity, \ 4. Deviations from Natural Texture, 1. Inflammation, 2. Adventitious Growths, PAGE 93 93 94 94 94 97 PART IX. ANOMALIES AND DISEASES OF THE OSSEOUS SYSTEM. CHAPTER I. Anomalies and Diseases of Bone in General, § 1. Deficiency and Excess of Development, \ 2. Anomalies in Size, ...... A. Hypertrophy.—Hyperostosis, .... o. The Exostosis, ..... 6. The Osteophyte, ..... B. Atrophy, ...... \ 3. Anomalies of Form, ....... \ 4. Anomalies in the Relative Position of Bones, and in their Connection with one another, ...... § 5. Anomalies of Consistence, ...... \ 6. Solutions of Continuity, and the Process by which they are Repaired, Repair of Fracture by the first intention, .... Of arrested Growth of Callus in general, and of New Joints in particular, Union of Fractures by way of Suppuration, Repair of the Bendings and Fissures of Soft Bones, . Repair of Injuries of Bone, complicated with loss of Substance, . Repair of Injuries, in which Bone is denuded of its soft Coverings, \ 7. Diseases of Texture, ...... 1. Congestion.—Hemorrhage, .... 2. Inflammation, ...... 3. Ulceration.—Caries, ..... 4. Necrosis (Mortification of Bone), .... 5. Expansion, Softening of Osseous Tissue, and the consequent Indu- rations (Scleroses), ...... 6. Adventitious Growths, ...... | 8. Foreign Bodies in Bones, ...... An attempt to determine the Characters of the Constitutional Affections of Bone, particularly of the Inflammations and Caries, by reference ^specially to the appearance of the Bone after Maceration, 103 103 104 104 106 109 112 115 115 117 117 118 121 123 124 125 126 126 126 127 131 133 138 147 156 156 X CONTENTS. APPENDIX. Anomalies and Diseases of the Medulla, CHAPTER II. Anomalies and Diseases of Particular Portions of the Skeleton, and of the several Bones composing them, . Sect. I.—The Skull and its Several Parts, . g 1. Deficiency and Excess of Development, g 2. Anomalies in the Size of the Skull, g 3. Deviations of Form, ...••■ g 4. Anomalies in the Mutual Connection of the Cranial Bones, g 5. Solutions of Continuity, . g 6. Anomalies of Texture, ..... 1. Hemorrhage, . .... 2. Inflammation.—Caries, and Necrosis, . 3. Expansion, Softening, and consecutive Induration, . 4. Adventitious Growths, ..... Sect. II.—Of the Trunk and its Several Parts, .... Of the vertebral Column, . .... § 1. Deficiency and Excess of Development, . . . g 2. Anomalies in the Form of the Vertebral Column, and of its several Parts, ....... g 3. Solutions of Continuity—Dislocation—Anchylosis, g 4. Hyperostosis—Atrophy, ..... g 5. Diseases of Texture, ...... The Thorax. g 1. Deficiency and Excess of Development, g 2. Anomalies of Size and Form, ... g 3. Solutions of Continuity, ..... g 4. Hyperostosis.—Atrophy, ..... g 5. Abnormal Changes of Texture, ... The Pelvis. PAGE 160 162 162 162 163 168 170 170 172 172 175 175 176 176 176 176 177 190 191 192 193 194 196 196 196 g 1. Deficiency and Excess of Development, .... 196 g 2. Deviations of Size and Form, . . . . .197 g 3. Anomalies of the Articulations of the Pelvis, and Solutions of the Con- tinuity of its Bones, ...... 202 § 4. Hyperostosis.—Atrophy.—Diseases of Texture in the Bones of the Pelvis, 203 The Extremities. g 1. Defective and Excessive Development, . . 203 g 2. Anomalies in Size, ..... 204 g 3. Deviations of Form, ..... 204 g 4. Solutions of Continuity, . . . . . 204 g 5. Diseases of Texture, .... 208 CONTENTS. xi PART X. ANOMALIES AND DISEASES OF CARTILAGES. g 1. Deficiency and Excess of Development, \ 2. Deviations in Size, . g 3. Solutions of Continuity, ..... g 4. Diseases of Texture, ..... 1. Inflammation, ...... 2. Ossification, ...... 3. Adventitious Growths, ..... Appendix—Anomalies and Diseases of Joints. Si. §2, §3, §4, §5. §6, Defect and Excess in Development, Deviations of Form, ...... Alterations in the Contiguity of the Articular Structures, . Solutions of Continuity, ..... Textural Diseases in Joints, ..... 1. Inflammations, ...... a. Inflammation of Synovial Membrane, 6. Inflammation of the Cancellous Articular Extremities of the Bones, ...... Expansion of the Articular Ends of Bones, 2. Adventitious Growths, ..... Anomalous Contents of Synovial Cavities, .... PAGE 211 211 213 214 214 216 217 217 218 218 220 220 220 220 224 225 226 227 PART XI. ANOMALIES AND DISEASES OF THE MUSCULAR SYSTEM. g 1. Deficiency and Excess of Development, g 2. Deviations in Size, or Volume, and in Form g 3. Alterations of Color, g 4. Deviations in Consistence, . g 5. Solutions of Continuity, g 6. Diseases of Texture, 1. Hemorrhage (Apoplexy), . 2. Inflammation, . 3. Metastasis, .... 4. Gangrene, 5. Morbid Growths, g 7. Foreign Bodies, 231 231 233 233 234 235 235 235 235 239 239 243 PART XII. ANOMALIES AND DISEASES OF THE NERVOUS SYSTEM. CHAPTER I. THE brain. Sect. I.—Anomalies and Diseases of the Membranes of the Brain, !47 xii CONTENTS. The Dura Mater. g 1. Deficient and Excessive Development, g 2. Anomalies in Size, Form, and Position, g 3. Solutions of Continuity, g 4. Diseases of Texture, 1. Inflammation, 2. Morbid Growths, Tlie Arachnoid. g 1. Anomalies in Size, g 2. Diseases of Texture, 1. Hyperemia, 2. Hemorrhage, .... 3. Inflammation, 4. Adventitious Growths, . g 3. Anomalies in the Contents of the Arachnoid, PAGE 247 247 248 249 249 250 252 252 252 253 255 256 258 The Pia Muter. -Hemorrhage, g 1. Diseases of Texture, 1. Congestion, and its consequences. 2. ffidema, 3. Inflammation, 4. Adventitious Growths, Of the Prolongations of the Arachnoid and Pia Mater, within the Bi g 1. Diseases of the Choroid Plexuses, g 2. Diseases of the Lining Membrane of the Ventricles, 1. Hydrocephalus, .... A. Acute Hydrocephalus, B. Chronic Hydrocephalus, a. Acquired Chronic Hydrocephalus, b. Congenital Hydrocephalus, c. Hydroc. occasioned by a Vacuum within the Skull 2. Adventitious Growths, Anomalous Contents of the Ventricles, ,—Anomalies and Diseases of the Brain, Deficient and Excessive Development, Deviations of Form, Deviations in Position, Deviations in Size, 1. Unnaturally large Size of the Brain, Hypertrophy of the Brain, 2. Unnaturally small Size of the Brain, Atrophy of the Brain, § 5. Solutions of Continuity, g 6. Diseases of Texture, . 1. Hyperemia.—Anaemia, . 2. Cerebral Hemorrhage, 3. OSdema, .... Appendix.—Serous Apoplexy, 2 3. Sect. II gl. §2. §3. g 4. 259 259 260 261 264 265 266 267 267 274 274 275 277 278 279 279 279 281 282 283 283 283 286 286 289 290 290 292 304 305 CONTENTS. 4. Inflammation of the Brain, 5. Metastasis, ..... 6. Softening of the Brain, .... 7. Induration (Sclerosis), .... 8. Adventitious Growths, ..... Appendix.—Diseases of the Hypophyses, .... The Pituitary Gland, ...... g 1. Anomalies of Size, ...... g 2. Diseases of Texture, ... 1. Congestion, ....... 2. Inflammation, ...... 3. Morbid Growths, ...... The Pineal Gland,...... CHAPTER II. the spinal cord. Sect. 1.—Anomalies and Diseases of the Membranes of the Spinal Cord, The Spinal Dura Mater. g 1. Defective Development, ..... g 2. Anomalies of Size and Form, .... g 3. Anomalies of Continuity, ..... g 4. Diseases of Texture, ..... 1. Inflammation, ...... 2. Adventitious Growths, ..... The Spinal Arachnoid. g 1. Anomalies of Size, ...... g 2. Diseases of Texture, ..... 1. Congestion.—Apoplexy.—Inflammation (Arachnitis Spinalis) 2. Adventitious Growths, ..... g 3. Anomalous Contents, ...... The Spinal Pia Mater. g 1. Diseases of Texture, ..... 1. Congestion.—Apoplexy, ..... 2. Inflammation.—(Meningitis Spinalis), . 3. Adventitious Growths, ..... Sect. n.—Anomalies and Diseases of the Spinal Cord, g 1. Deficiency and Excess of Development, g 2. Anomalies of Size, ....•• g 3. Solutions of Continuity, . g 4. Diseases of Texture, ..... 1. Congestion.—Apoplexy, . 2. GSdema, ....... xiv CONTENTS. PAGE 3. Inflammation, ....... 336 4. Softening.—Induration, ...... 340 5. Morbid Growths, ....... 340 CHAPTER III. the nerves. g 1. Defective and Excessive Development, .... 340 g 2. Anomalies of Form, Origin, Course, and Subdivision, . . 342 g 3. Anomalies of Size, . . . . . . 342 g 4. Solutions of Continuity, ...... 344 g 5. Diseases of Texture, . . . . . . 345 1. Hyperemia.—Apoplexy, ...... 345 2. Inflammation, ....... 345 3. Morbid Growths, . . . . . . .347 [Though the original of the line at p. 107, to which the foot-note refers, may be translated as in the text, its signification seemed determined by a more complete de- scription of apparently the same growths at p. 167, to be "straight or convoluted eleva- tions" of the surface, not exostoses separate from it.—Ed.] PART IV. ANOMALIES AND DISEASES OF CELLULAR TISSUE. PART IV. ANOMALIES AND DISEASES OF CELLULAR TISSUE. § 1. Varieties in regard to quantity.—The cellular tissue contained in the human body is subject to variations in quantity which come within the sphere of Pathology. In some bodies this tissue is over-abundant, in others its quantity is smaller than usual; neither condition, however, constitutes more than an individual peculiarity. But it may accumulate in excessive quantity in particular parts of the body, entering into the composition of various morbid growths and tumors, or forming a uniting medium between organs which in their natural state are separate from one another. As an areolar callus it may supply losses of substance which are otherwise irreparable, filling up cavities in the injured tissues; or it may become accumulated in excess, i. e. hypertrophied, at parts which have been subjected to con- tinued irritation, as, for instance, in the neighborhood of inflamed spots. And, lastly, it may occupy the place of parts which, in consequence of some fault in their original formation, are wanting; such as the bulb, the rectum, or the thoracic organs in cases of acephalus; the muscles, and even the bones, of incompletely developed limbs, &c. Nevertheless, the presence of a mass of cellular tissue in the spot once occupied by some previously existing organ, cannot always be re- garded as an exuberant growth of that tissue; for that which remains behind after organs have disappeared, whether from primary or secondary atrophy, or in the ordinary course of natural decay (Involutiqn), is no- thing more than the tissue which once formed the connecting medium in their anatomical composition, and which, therefore, then occn^ ia^s^ same place. This is the case with the thymus gland, and tk^tn eitBae, with absorbent glands, with the ovaries, &c. compared Exhaustive diseases produce general diminution of '*, f quP°iity of cellular tissue ; and the same result ensues in particular portions of it, as well as in other organs, from continued pressure and from paralysis, and after suppuration and sloughing. § 2. Anomalies in regard to Texture. 1. Hyperemia, apoplexy of cellular tissue.—Under suitable circum- stances, particular portions of the entire system of cellular tissue are subjected to transient, or to permanent, congestions of an active, a passive, or a mechanical nature. These congestions, especially the two last-mentioned kinds, sometimes occasion spontaneous hemorrhages into the cellular tissue (apoplexia textus cellulosi); the effusions of blood are vol. m. 2 18 ANOMALIES AND DISEASES OF generally small and circumscribed, but sometimes they are large and more extended. The greater and more important extravasations^ occur in the lower extremities, in the sexual organ of the female, and in the abdomen. One of the most interesting cases of the kind was communi- cated to me by Professor Fischer of Prague : the blood was effused into the orbit, and it had coagulated in large, firm, tuberous masses, which forced the eye forwards out of the orbit. 2. Inflammation.—Inflammation of cellular tissue (inflammatio telse cellulosse) is a disease of much importance, not only on account of the circumstances attending its occurrence in that tissue itself, but also be- cause, as a consecutive and as an allied affection, it accompanies the in- flammation of all structures which are imbedded in it. Thus inflamma- tion of serous and fibrous membranes, of muscles, lymphatic glands, ves- sels, nerves, &c, is attended by inflammation of the cellular tissue that surrounds them. Its course is sometimes acute, sometimes chronic. Acute inflammation affects principally large tracts of cellular tissue, such as that beneath the integuments of the trunk and limbs, the cel- lular tissue accumulated in the neighborhood of the caecum and rectum, the deeper layers of the same structure in the neck, and that in the me- diastina : and it is very often remarkable for its great extent, and for the devastations which it causes. Its anatomical characters are as follow: The appearance of the cellular tissue varies according to the degree and the character of the inflammation and the condition of the blood. It is swollen, injected, and of a bright or a deep red color; it has in every case lost its extensile and elastic properties, and may be easily torn; among its fibres, and between its laminae, inflammatory products are effused, which differ in having more or less plastic qualities ; and are, accordingly, either a viscid, and turbid or flocculent, serous fluid of a pale-red, or yelloAV, or grayish color; a yellowish-red, gelatinous, and more consistent exudation; a brownish-red, fibrinous product, which fuses with the tissue into a hard, but yet fragile mass : or a dark-red (hemorrhagic), discolored effusion. The inflammation always involves the adjoining organs, more especially membranous expansions, serous and fibrous membranes, and the integuments. The disease in this last jr "e is that known by the lame of Pseudo-erysipelas. vose tissue presents a similar kind of injection and reddening ; whei. mmation is slight, it is percolated by a viscous, turbid, oleo-se, a6 x- i, which gives the fat vesicles a pale, yellowish-red, translucid, jelL -like aspect. In inflammations of a severer character, the adipose tissue becomes brownish-red; the contents of the fat vesicles liquefy and escape through their walls, and a plastic exudation takes their place, and gives to the whole tissue a uniform granular appearance, and a certain degree of firmness. Acute inflammation of cellular tissue, when moderate in degree, usually terminates in resolution, that is to say, by the complete reabsorption of the inflammatory products; merely some oedematous swelling, or a ten- dency to oedema remaining in the part which has been inflamed. In other cases the inflammation leads to induration and hypertrophy of the tissue. The inflammatory product becomes organized, and the mass of the cellular tissue hypertrophied ; and hence, as well as from the / CELLULAR TISSUE. 19 unnatural adhesion the new substance produces between the old strata of the tissue, the entire structure becomes denser, more compact than natural, or as it is called fibro-cellular. Inflammation, when it reaches a high degree, very often proceeds to suppuration. As the firmness of the inflammatory swelling subsides, a serous exhalation reappears in the tissue, the product of the inflammation becomes resolved into pus, and thus the cellular tissue in the centre of the inflamed spot, and afterwards throughout it, is found infiltered with a sero-purulent, and at length with a purulent', fluid. Yellowish or yel- lowish-red bodies which, though shreddy, are still somewhat compact and tough, are often found mixed with the matter: they are not sloughy cel- lular tissue, but the residue of the inflammatory product, and are there- fore named eiterpfropfe—plugs of purulent matter—though, indeed, fibres of the cellular tissue are certainly interwoven amongst them, or even larger shreddy portions of it may adhere to them. The points of matter, coalescing as the tissue is destroyed, unite into larger collections; and these extend further, either by forming sinuous canals, or by enlarging equally in all directions. If in the latter case, the matter be situated in the subcutaneous cellular tissue, it will separate the integuments to a great extent from the deeper structures, and will perforate muscles and aponeuroses, or open into serous cavities, into the intestines, &c. Matter may also collect in cellular tissue from mere gravitation ; for abscesses are met with, none of the contents of which, or at least but a part, have been produced by inflammation in the spot where they are found: the matter has gravitated thither from some part more or less remote. In whichever way the abscess may have originated, it not unfrequently becomes encysted, that is to say, circumscribed by a cellulo-vascular granu- lating membrane. This membrane is the product of a secondary inflam- matory process at the confines of the suppurating part, and itself secretes pus. It often remains for a long time in this state, and at length usually produces exhaustion by the continued secretion of matter from its walls. Occasionally, however, the formation of matter ceases, the walls become converted into a dense cellulo-fibrous tissue, and the matter is entirely reabsorbed, or part of it is absorbed and the rest inspissated. As these changes take place, the sac gradually diminishes, until at length either its walls unite, or it is reduced to a cyst of trifling size, compared with its previous dimensions; the walls of such a cyst are thick, composed of obsolete callus, and incrusted on their interior; and its cavity is filled with a calcareous pulp or concretion. Lastly, the product of the inflammation is sometimes of a peculiar nature, and leads to destruction and sloughing of the cellular-tissue (to actual necrosis textus cellulosi). The tissue then breaks down, as it were, into a crumbling, or a shreddy, friable mass, and becomes infil- trated with a dirty brown or greenish sanies. Not unfrequently under these circumstances, a quantity of gas is formed, which distends the whole of the diseased part. Inflammation of cellular tissue may be a primary affection, or, as is very frequently the case, it may be secondary. Each form assumes a 20 ANOMALIES AND DISEASES OF serious character in particular localities; as when it attacks the cellular tissue of the trunk or limbs ; or that between the pericranium and the galea aponeurotica of the head; that near the submaxillary (Ludwig), or the thyroid glands ; or that which accompanies the trachea, pharynx, and oesophagus down to the mediastinum; or the tissue upon the lumbar ver- tebrae, or on the iliacus muscle ; or that in the neighborhood of the caecum (perityphlitis), or of the rectum (periproctitis), or bladder (pericystitis): as well as interstitial cellular strata, especially the submucous tissue of the stomach, intestinal canal, &c. The inflammation, whether primary or secondary, may have a more or less distinctly marked exudative character ; as is illustrated by phlegmatia alba, as it is called, amongst the primary inflammations, and by the nu- merous instances of inflammation which occur in cellular tissue by meta- stasis, after acute exanthemata, typhus, &c, amongst the secondary. They are often associated with exudative processes on membranous ex- pansions, especially such as adjoin mucous and serous membranes. Moreover inflammation of cellular tissue is frequently derived from that of other parts. It uniformly accompanies the inflammation of struc- tures which are imbedded in it; especially inflammation of veins, and lymphatic vessels, lymphatic glands, nerves, muscles, serous and fibrous membranes, &c. It is generally subordinate in degree to that which prevails in the actual seat of disease ; though there are occasional excep- tions to this rule, the inflammation in the neighborhood of the actual seat of disease sometimes going on at isolated points to the more ad- vanced degree, particularly to suppuration. Such is the case, for instance, in inflammation of veins. Inflammation of the adipose tissue may subside, occasioning merely some loss of the fat: in process of time, however, the loss is supplied again. But in other cases, severe inflammation is followed by coalescence and obliteration of the fat vesicles, and consequently by a marked shrinking of the part which has been inflamed. Inflammation of this kind often terminates in suppuration ; and the adipose tissue becomes converted into a yellowish-red pulpy mass, which is infiltered with a fatty purulent fluid. Lastly, a fibrinous inflammatory product is sometimes seen in the fat vesicles ; it solidifies in them, changes into a cheesy mass, and in the end even becomes cretaceous. The wall of the vesicle is then found thickened, it contracts upon its contents, and bears traces of its previous congestion in the slate-gray or blackish-blue color with which it is tinged. This change is principally observed on the fatty tissue of the omenta and appendices of epiploacse; especially in tubercular subjects, in whom peritoneal inflammations have occurred and have been attended with tubercular exudation. Chronic inflammation of cellular tissue is distinguished by the follow- ing characters : the tissue is but slightly injected and reddened; though where it is exposed, as it is at the base of the ulcers, its color is a deep red, tinged with various shades of brown, coppery, rusty yellow violet &c.: it is also denser than natural, and contains a viscid serous fluid which when ulcers exist, filters through to their surface. CELLULAR TISSUE. 21 Inflammation of this kind does not proceed to suppuration, except per- haps at a few small isolated spots: it tends rather to induration and that at an early period. The tissue is then very compact, and so tough that it makes a creaking noise when it is cut: it is also pervaded, and as it were identified, with a gelatinous matter, or an albuminous substance resembling lard. The tissue is found in these various condi- tions beneath and around chronic ulcers, in the neighborhood of fistulse, after repeated and habitual, or mismanaged attacks of erysipelas, or as a consequence of mechanical hyperaemia, or' congestions arising from varicose veins in the lower limbs, in cases of elephantiasis, &c. An inflammatory process of a peculiar kind occurs in new-born chil- dren, and is known by the name of induration of the cellular tissue (scle- rosis telae cellulosae). It occurs on the trunk, especially on the whole of the lower part of the abdomen, as well as on the thighs, and the cheeks. The subcutaneous fatty and cellular structures are moistened by a yellow- ish viscid serum, the fat is condensed and forms a yellowish or brownish- red hard granular mass, and the skin covering it is tense, as firm and resisting as a board, glistening and pale or of a yellowish-red color. The numerous theories which have been broached as to the nature of this induration of cellular tissue and its etiological relation with disorders of internal organs are daily proved to be unsound. Thus it has been traced to diseases of the liver or lungs, to permanent patency of the foetal canals and cyanosis, and to irritation of the stomach and intestinal canal. But these conditions, and even the icterus, which is its most frequent asso- ciate, are all accidental complications. The induration is unquestionably an independent disease (occasioned by disorder of the functions of the skin of the new-born child), and, just as in burns of the integuments, its seriousness and danger are directly proportioned to its extent. 3. Depositions, metastases, are very frequent both in the subcutaneous and in the deeper layers of cellular tissue. The deposits are of purulent and ichorous nature, and are often very numerous and extensive. They sometimes result from a primary and spontaneous pyaemia, which has been occasioned by pus or sanies having been taken into the mass of the blood; and sometimes from a state of the circulating fluid, in which other processes, exanthemata, typhus, &c, have led to the generation of pus by the blood in a secondary manner. 4. Crangrene of cellular tissue.—Mortification is liable to take place in cellular tissue, not only as a consequence of inflammation, but under other conditions also, as a primary disease. Sometimes the tissue, at first congested, and dark red in color, changes into a blackish, very moist, shreddy, and friable pulp : at other times, after having formed a blackish- red, viscid pulp, it becomes a dry, tinder-like, crumbling eschar. Lastly, it sometimes degenerates into a white mass, shaded with dirty yellow or greenish, and is moist and extremely easily torn. 5. Adventitious growths.—The adipose and cellular tissue beneath the skin, as well as that which is collected in larger quantity in the inter- nal regions of the body, is occasionally the seat of cysts. The contents of these growths are exceedingly various ; sometimes being serous, some- times resembling synovia, or gum (colloid), fatty, cholesteatomatous, or melanotic. Fibrous tumors occur in the same structures; calcareous 22 ANOMALIES AND DISEASES OF concretions are very seldom met with, the only instances being that in which a fibrinous exudation in the fat vesicles becomes, as has been men- tioned, converted into chalk, and that of cord-like growths, or smooth, or tuberous plates of bone, which occur in the fibroid callus of which the cicatrix of cellular tissue is composed. Tuberculous matter is deposited in young persons usually, and especially in children; the depositions occur in the subcutaneous tissue, and are more or less circumscribed : they soften and form a cheese-like or fatty pulp, and then exciting an inflam- matory process in the integuments, which ends in ulceration, they make their way outwards. They are always associated with tuberculosis of the lymphatic glands, and frequently with the same disease in other paren- chymatous organs. Sarcomatous and cancerous growths are frequent in cellular tissue, and of the latter it is the genuine white medullary form, and the cancer me- lanodes that chiefly occur. Among the entozoa, the filaria medinensis is met with in the subcuta- neous cellular tissue. § 3. Anomalies of Secretion and accumulations of Foreign Bodies in Cellular Tissue.—In the first place, the fat is subject to considerable deviations from its natural quantity and quality. Not unfrequently it is found collected in excessive amount, and at the expense of the nutrition of other structures, especially of the muscles. The excess, when uniform throughout the body, constitutes what is expressed by the general term obesity, and to it the female sex is parti- cularly liable : but in some cases it accumulates at particular spots ex- ternally, and disfigures the body ; or internally in such a manner as to narrow the space of the cavities of the body, and to interfere with the functions of the organs contained wTithin them. Thus it collects at the lower part of the abdomen, on the nates, and on the loins (in which region the rolls of fat are situated, which distinguish the race of Hot- tentot women); it is found, too, in the neighborhood and in the cellular interspaces between the lobes of the mammae in women ; in the medias- tina, and beneath the pleura; in the folds of -the peritoneum ; around, and in the duplicatures of, synovial membranes, &c. The local accumu- lations just mentioned, constitute a sort of transition to the fatty tumor, lipoma. Invested with a cellular sheath, lobulated by interstitial cellu- lar tissue, more or less of which traverses its interior, and resembling adipose tissue in its intimate texture, the fatty tumor chiefly occurs in those regions at which fat is naturally most abundant: it is, however, sometimes found in parts where in the normal state no fat is deposited; as, for instance, in the submucous cellular stratum of the intestinal tract. Yet more frequently, in the emaciation which attends disease, the quantity of fat existing is found remarkably small, and at certain parts of the body, if not everywhere, it may even entirely disappear. Moreover, the fat presents various qualitative deviations from its physical, and no doubt also from its chemical, properties. Sometimes it is remarkably pale, and sometimes, on the contrary, of a very dark color • it may be soft, gelatinous, suety, greasy, like the marrow of bones, and oily; or again, firm, and resembling soap or adipocire. Thus in ad- vanced age, and in persons whose muscular system loses energy and bulk CELLULAR TISSUE. 23 and becomes prematurely aged, the fat is of a deep yellow color and oily; in spirit-drinkers, in persons who are negligent as to the state of their skin, in those whose skin is thick, soft, and dark colored, or in whom the liver is suety, or the heart the seat of fatty metamorphosis, &c, it is usually pale, and resembles mutton suet. In dropsical patients it is often reddish, firm, and granular, the fat vesicles shrinking together, and forming a reddish firm acinus : but other- wise it disappears, and after it has been absorbed, its place is occupied by a fatty, gelatinous, and, at last by a serous, fluid. The serum, which in the natural state, is uniformly diffused through the cellular tissue and moistens it, is subject to similar deviations from the healthy condition. It is almost entirely wanting in cases of considerable general or par- tial emaciation, in the marked collapse which succeeds convulsive diseases, or when, as in serous diarrhoeas and Asiatic cholera, the serum of the blood is rapidly lost, &c. In these cases the cellular tissue is dry and crepitant, and resembles that of plants. In other instances, again, it ex- ceeds the natural quantity: this excess, when general, constitutes leuco- phlegmasia, hydrops universalis, anasarca; when local it is named oedema. The fluid varies much in color, consistence and composition, according to the processes by which its accumulation has been effected, as well as according to the composition of the blood; being either thin and clear as water; or rather thick, and like jelly, from containing albumen ; or yellow, in consequence of the presence of bile ; red, from the admixture of more or less blood with it; or turbid, milky, whey-like, and flocculent, from its containing fibrin or purulent matter. Among the foreign bodies found in cellular tissue are: a. Gras ; which may be either atmospheric air or some of the various animal gases—windgeschwulst, emphysema. Atmospheric air accumu- lates in cellular tissue in consequence of wounds in the circumference of the thorax by which the pleura is opened; and more frequently it suc- ceeds penetrating wounds of the lung, fractures of the ribs by which the costal pleura is torn and the lung injured, ruptures of the lung and pleura occasioned by crushing, mortification of the lung and superjacent pleura, ulcers which perforate the larynx and trachea, and laceration of one or more of the air-cells of the lung (from violent coughing, &c.) The emphysema is occasioned either immediately by the entrance of the atmospheric air at the wound of the chest, or by its escape from the air-passages into the adjoining tissue, or into the cellular structure which intersects the lung itself—emphysema pulmonum interlobulare. When the bowel is perforated either by ulceration or sloughing, its gaseous contents pass out into the cellular tissue: in some cases of mor- tification gas is spontaneously evolved, and the skin over it swells up, and forms a doughy tumor. Lastly, there are a few cases in which, without any of the above-mentioned causes, gas accumulates in the sub- cutaneous tissue, and still more frequently in the interstitial, and espe- cially the submucous, cellular tissue of the bowel: such cases result from acute disorganizations of the blood, and are found when there is no trace of cadaveric decomposition in the body. Transient emphysemas of the same kind are well known to occur in the living subject, in consequence of convulsive affections. 24 ANOMALIES AND DISEASES OF CELLULAR TISSUE. /3. Blood ; which may be extravasated in consequence of injuries of various structures, either from external or internal causes: the extrava- sation may be diffused through the tissue, or circumscribed, or even en- cysted. Purulent matter also may be effused; and, from penetrating wounds, or spontaneous ruptures, or perforating ulcers, of the urinary passages, '&c, urine may be extravasated. Lastly, y. All kinds of foreign bodies may be thrust into cellular tissue through wounds of the integuments, or pass into it from the intestinal tube ; they sometimes wander further in various directions, and sometimes they fix in the cellular tissue within a capsule of false membrane. PART V. ANOMALIES AND DISEASES OF SEROUS AND SYNOVIAL MEMBRANES IN GENERAL. PAET V. ANOMALIES AND DISEASES OF SEROUS AND SYNOVIAL MEMBRANES IN GENERAL. § 1. Deficiency and Excess of Development in the System of Serous Membranes.—There are various kinds of primordial defect in serous membranes. They may be entirely wanting. Sometimes the organs they should enclose are wanting too ; but if these exist, the deficiency of the membrane is supplied by some adjoining serous expansion. They may be but partially developed. This is the case when serous cavities are fissured, or when, in consequence of a partial defect in the wall of sepa- ration between two serous sacs, their cavities have an unnatural communi- cation with one another. Thus the cavity of the pericardium is some- times continuous with that of the pleurae, the peritoneum with the latter or with the tunica vaginalis of the testicle, bursae communicate with the synovial cavities of joints, &c. Moreover, a deficiency in the develop- ment of a serous or synovial membrane may depend upon the absence of the organ usually contained within it; in which case, particular duplica- tures of the membrane do not exist. Wasting of a serous membrane, obliteration of its cavity, degeneration of it into cellular tissue (Ruckbildung), and its destruction by suppura- tion, constitute instances of acquired defect. Excess of development may present itself as a congenital anomaly. It then sometimes assumes the form of unusual saccular prolongations and duplicatures of the membrane, or of folds which, though such as usually exist, are preternaturally developed,—a form of excess which may partly be traced to an arrest of development: sometimes appearing under another form, as a serous cyst, or an aggregation of serous cysts, or as a honey- combed serous tissue, it marks the site of some originally defective part, or of an organ which had been diseased and destroyed during foetal life, —the brain, for instance, in hemicephalus, or the kidneys. It more frequently happens, that new serous tissue is formed at some period subsequent to birth ; it may present the characters of true serous membrane, or may be cellulo-serous or fibro-serous. Thus, a. Bursae, which are the simplest form of the synovial system, are de- veloped beneath the skin, where it is exposed to unusual and permanent pressure and friction, as is the case in clubfoot (Be'clard), over the point of an angular curvature of the spine (Brodie), or on the stump of an am- putated limb ; and they are also observed in deeper parts, between mus- cles and tendons, as well as between them and the unusual protuberances of bone, &c. Moreover, dislocated bones are sometimes firmly fixed by 28 ANOMALIES OF SEROUS a new synovial capsule ; and the preternatural joints formed in cases of ununited fracture, furnish another example of the same new growth. /?. Membranous capsules are sometimes formed around foreign bodies, or around effusions of blood either in cellular tissue, or in various paren- chymatous structures. y. Cicatrices upon mucous surfaces, the lining membrane of abscesses, and the material by which they are finally consolidated and closed, are composed of plates or of capsules of serous tissue. 8. Acquired excess of development includes further the change of tex- ture, and simultaneous alteration of secreting power to which, in some few instances, the skin is liable when excessively stretched ; especially the skin covering broad expanses of tendon (as for instance, that on the ab- domen). The fact is observed more frequently under similar circum- stances in mucous membranes, particularly in the excretory ducts and reservoirs of glands, when they become distended, and in the mucous membrane of the intestinal tube, especially in the appendix vermiformis. s. In like manner, the products of inflammation in serous membranes sometimes become organized into a cellulo-, or fibro-serous tissue, the characters of which, as to extent, intimate structure, and firmness, vary considerably, and give rise to corresponding varieties in the adhesions which they produce between the parietal and visceral layers of the mem- brane. C. The serous cysts, which are found in cellular, and in various paren- chymatous, tissues, belong to the same class. § 2. Deviations of Serous Sacs from their natural Size and Form.— The principal deviations in these particulars are those in which serous sacs are enlarged ; a change to which their great extensibility renders them extremely liable. In enlargements of this kind, the sac may be distended equally in all directions, and thus preserve its natural form ; or being bound down in some situations by fibrous membranes, aponeu- roses, muscular coverings, &c, it may yield at some other circumscribed spot, and give rise to a hernial protrusion or diverticulum, which com- municates with the general cavity of the sac by a constricted neck. § 3. Solutions of Continuity.—Besides being exposed to wounds from fragments of bone and various instruments, serous membranes may burst or be torn by violent concussion and compression, and such rupture may be the only injury produced. Moreover, they are sometimes opened by primary and by secondary ulcerations, but that subject will be referred to again. § 4. Diseases of Texture. 1. Congestion,—hemorrhage.—Serous membranes are liable, under various circumstances, to an increased flow of blood into them and to congestion: the cause may be active, passive, or mechanical; and the extent may be partial, or universal: the walls of hernial sacs and the peritoneum covering the organs protruded into them, sometimes furnish an instance of partial congestion. In proportion to their duration, or to the frequency of their recurrence AND SYNOVIAL MEMBRANES. 29 these congestions occasion more or less of a whey-like, or milky opacity, a loss of transparency, and at last thickening of the membrane. Such changes are sometimes general over the whole sac, and sometimes are confined to a portion of its visceral, or of its reflected, layer : they must be distinguished from organized exudations upon the free surface of the membrane. They give rise to the developments of growths resembling cartilage or bone beneath the serous membrane, and are often accom- panied by an increased secretion of serous fluid, which may be retained and so accumulate. The quality of the fluid varies with the character of the congestion and the constitution of the blood; and may be pure serum, or may contain various coagulable matters, particularly albumen, or the coloring matter of the blood. Such cases constitute dropsies of serous membranes. Congestion is sometimes so intense as to occasion hemorrhage into the sac; but this is a very rare occurrence in serous membranes generally, and can be called frequent only in the sac of the cerebral arachnoid. The bleeding in that case proceeds from the parenchyma, and is capillary; it must not be confounded with that which can be traced to the rupture of larger vessels, whether spontaneous or traumatic; or with that which originates with membranous or parenchymatous structures ; or yet with hemorrhagic products of inflammation. 2. Inflammation of serous membranes.—This is one of the most fre- quent of all diseases : it befalls chiefly the larger sections of the system of serous and synovial membranes of large joints, like the knee and hip. It is sometimes a primary disease, and arises from disordered function of the skin, from mechanical injury, concussion, irritation, or contusion, or from contact with heterogeneous effusions, whether gaseous or fluid. Sometimes it is secondary: and then it is either sympathetic with, and induced by, disease of organs which are invested by the membrane, or con- tained in it, and is in fact merely an extension of the diseased process to the membrane ; or it comes on from the metastasis of anomalous exanthe- matous processes, typhus, gout, and rheumatism; from absorption of pus and sanies into the blood, &c.; in short, as a consequence of any (secon- dary) morbid affections of the mass of the blood which are distinguished by a tendency to exudations. It is very frequently an acute disease, but tolerably often, too, its course is lingering and chronic. In its acute form, and particularly when excited by metastasis, it often assumes an exudative character, which is very remarkable, considering the internal cause of the inflam- mation, viz., the general disease, or the local process itself. a. Acute inflammation.—The anatomical characters of this disease are, a. Redness and injection.—These appearances commence with injec- tion of the subserous tissue, which is seen through the serous membrane; fine hair-like streaks of vessels soon extend here and there to the mem- brane, and when clustered together, give its internal surface an appear- ance similar to the pile of red velvet. At the same time, small quantities of blood (suffusions) escape from the vessels both of the membrane itself and of the cellular tissue beneath it, so that the surface looks speckled as well as red. The hue of the redness depends chiefly upon the dura- 30 DISEASES OF SEROUS tion of the congestion and the constitution of the blood, and varies from a bright to quite a dark color. The extent and the intensity of" the red- ness and injection also differ widely in different cases; sometimes they are partial and scarcely perceptible, sometimes they are universal and stain the membrane through. In many serous membranes, particularly those which, like synovial membranes, or still more the arachnoid, have a very delicate structure, the reddening which takes place is usually very slight, or there may be none whatever : these membranes admit of injec- tion with blood only with much difficulty, and the degree of redness and injection is no criterion of the intensity of the process, so far as regards the quantity of product which the inflammation will supply; for the exu- dation, especially in inflammations of a croupy character, is remarkably disproportioned to the redness and injection of the membrane. /?. Opacity and thiclcening.—In those parts where the membrane is reddened and injected, and still more evidently in the interspaces between them, it becomes dull, loses its lustre, transparency, and smoothness, and acquires opacity and a velvety internal surface. Serous membranes of very delicate structure, such as the arachnoid, become at once opaque, dull, and turbid, like whey or milk. This change, and to some extent also the thickening, are due to infiltration of the membrane; but the thickening is produced rather by the simultaneous affection of the sub- serous cellular tissue; for that tissue is always injected, is early filled with an opaque serous fluid, and is consequently tumid. The infiltration of the subserous tissue extends to the membrane itself, and the two be- come so blended as to lose all trace of separation from one another. From the expansion, or loosening, of the tissues which takes place, the serous membrane is rendered not only very fragile in itself, but also easily separable from the structures beneath it. y. The effusion or inflammatory product upon the free surface of the Berous membrane is sometimes an exudation of plastic nature, but at other times, and especially in inflammations which arise from metastasis, it is diffluent and puriform, or actually purulent, or sanious. In quantity it is usually not very considerable, at least when compared with the amount of effusion attending chronic inflammation, though there are exceptions to this rule, especially in the case of exudations of a croupy character. The plastic exudation is mostly accompanied by an effusion of serous fluid, so that the whole product may be distinguished into a plastic or coagulable portion, and another which is not coagulable. The relative quantity of the two portions varies considerably: there are some exuda- tions which have no serous part whatever, while others contain no more of the plastic matter than suffices to render the serous effusion slightly opaque. An effusion of perfectly clear serous fluid, unaccompanied by any deposit of lymph upon the inner surface of the serous membrane, is scarcely such as can be attributed to actual inflammation. The plastic portion of the exudation is deposited upon the inner sur- face of the serous membrane, and forms there a peripheral fibrinous layer which encloses the serous effusion, if any exist: it is of a grayish-red a yellow, or a grayish color,^ and may vary in thickness from that of a scarcely perceptible film, like hoar frost, to that of several lines. Its inner free surface is sometimes tolerably smooth, sometimes villous, some- AND SYNOVIAL MEMBRANES. 31 • times shreddy, sometimes areolar; occasionally it resembles waves of sand, or the back of a bullock's tongue. When the plastic matter is very abundant, it forms other large masses also of loose texture, and soaked through with more or less of the serum: it may also render the serum opaque, or may lie in it in flakes, which soon become arranged in plates and cords, and form a network or honeycombed cellular structure, the large interspaces of which enclose part of the serum. It may also fall upon the inner surface of the original peripheral coagulum, and form a soft shreddy covering for it; and in that case, the exudation lining the serous membrane consists of two layers :—the original, more consistent, plastic exudation; and the secondary, looser, shreddy precipitate upon it. Inflammations of an eminently exudative character are particularly remarkable— For the inconsiderable reddening and injection of the serous mem- brane : For the disproportion which subsists between the reddening and injec- tion, and the great quantity of exudation deposited at one time : For the marked loosening of tissue, and infiltration observable both in the membrane and in the subserous structure: For their frequently coexisting with exudative processes in mucous membranes, the plastic character of which may differ from that of the inflammation in the serous membrane: And as a general rule also for the homogeneous nature of the whole product, and for the absence or mere indication of a separation of it into one part which is plastic, and another incapable of coagulation: it is a uniform exudation, which coagulates more or less, or degenerates into pus, or is sanious. There is sufficient general connection between the exudations under consideration and another found upon large serous membranes, like the peritoneum and pleurae, to allow of the latter being mentioned here. It is a viscid coating upon these membranes which gives them a dull lus- treless aspect: it is best marked and most constantly seen hi cases of Asiatic cholera, but it occurs also in the course of other exudative pro- cesses which are attended by exhaustion, such, for instance, as the diar- rhoea of children. Plastic exudations very frequently produce adhesions between the walls of a serous cavity and the viscera it contains, as well as of the viscera with one another : but a large quantity of serous effusion holds the lamellae of the plastic exudation apart, and no adhesion can take place unless the^fluid be absorbed before the lymph is completely or- ganized. Absorption commences as soon as the lymph is deposited, and the intensity of the inflammation subsides: it depends, therefore, upon the cessation of the inflammatory process; but it is also influenced by the thickness and density, that is to say, by the permeability, as well as by the stage of organization, of the lymph. In the organization of plastic exudations, new vessels are spontane- ously formed in more or less abundance, and a tissue is produced, which is either cellular, loose, and cellulo-serous; or of closer texture, strong and, as it is called, cellulo-fibrous. If the serous surfaces have been agglutinated together by the exudation, their complete vital adhesion is 32 DISEASES OF SEROUS effected by the formation of a loose filaceous, or of a dense and more compact tissue in the exudation: but in the opposite case, the old serous membrane is either covered with isolated delicate cellular flakes, or with larger shreddy masses of cellular tissue, or with a (second) delicate serous membrane, which can be moved over the original one, or lastly with a thicker, fibro-serous, and firmly attached layer. The layer last mentioned may be uniformly thick, or thinner here and there, and thus acquire a knitted areolar, or cribriform appearance: it may, with a little care, be stripped off the serous membrane, and when confined to small spots, it constitutes the tendinous or white spots (maculae lacteae) which are found on some serous membranes, especially on the pericardium. In some cases, the solid exudation, as it becomes organized, encloses within it a part of the serous fluid, and thus forms delicate transparent vesicles, which are mostly found afterwards attached by a pedicle. These new structures again may themselves be attacked by inflamma- tion : this remark, however, is opposed by an observation made by Laennec upon the pleura; for he found that inflammations of the portion of a serous membrane which had been left unaffected by a previous in- flammation, were usually circumscribed by the new structures, and at the adhesions produced by them. The puriform, the really purulent, and the sanious, exudations, are either deposited as such, or are formed out of the plastic exudation, which degenerates thus in consequence of some peculiar quality inherent in it. Such exudations are rather thick, cream-like, and yellow or greenish; or of a thin fluid consistence, and a greenish, brownish, or reddish color: the serous membrane itself is discolored; both it and the tissue beneath it are opaque and much infiltrated ; and its inner surface is very dull, and appears, particularly when the exudation is purulent, like velvet or spongio-piline. If the inflammation does not destroy life, either of itself, or through the general constitutional disorder which ac- companies it, it usually becomes chronic. b. Chronic Inflammation.—Chronic inflammation presents itself in three different forms or kinds : a. It commences as a latent, and continues as a lingering inflammation : though ordinarily moderate in its degree, from time to time it becomes more severe. It furnishes an exudation that is continually augmenting in quantity by gradual accumulation, and occasionally also by a more sudden increase. It sometimes affects several serous membranes at once ; but sometimes, especially if they should be near together, it attacks them one after another. The redness of serous membranes, which inflame in this manner is dull, and inclines to brown; the injection is coarse, and the membrane is extremely dull and perfectly opaque : its surface is quite lustreless rough, and, as it were, rugous. It is much thickened too, for not only are the membrane itself and the subserous cellular tissue infiltered but also other adjoining structures, especially fibrous structures which are closely connected with the diseased membrane; and the infiltrated matter gradually solidifies in them all. Hence the serous membrane is increased in density and compactness, and cannot be so readily torn as in its natural state, but it may with ease be stripped off the subjacent tissue. AND SYNOVIAL MEMBRANES. 33 The persistency and occasional exaggeration of the process render the exudation always an abundant one ; for the inflammation is on the one hand continually adding to its amount, and on the other preventing its absorption. The exudation is always characterized by the small quan- tity of its plastic portion, and the excess of that which is not coagulable. The former portion consists of a plastic layer upon the inner surface of the membrane, of a pale reddish, or grayish, color, and of slight thick- ness ; the latter is a perfectly clear, a pale yellowish, or a greenish, serous fluid : sometimes it contains a certain quantity of coagulable mat- ters of little plastic power, which swim about as soft albuminous flakes, or form a shaggy precipitate on the inner surface of the original deposit, or lastly coagulate in large lardaceous masses, which usually occupy the deepest space in the serous cavity. When the inflammatory process subsides, the serous effusion is gradu- ally absorbed: if any of it remain and prevent mutual contact of the walls and duplicatures of the serous membrane, the plastic exudation in- creases in density, yields up the moisture (water of crystallization) con- tained in it, and changes into a firm cellular, or rather into a fibro-serous plate : but if the serous fluid be entirely absorbed before the organization of the plastic part is completed, the latter forms a dense fibro-cellular bond of adhesion, with which the serous membrane intimately unites, and seems identified. /5. An inflammation originally acute may, after having deposited its exudation, become chronic. Such a termination of an acute inflamma- tion occurs chiefly when its exudation is one which degenerates into pus or is actually purulent: and there is no question, that the state of chronic inflammation is kept up by the contact of the membrane with the exudation. The serous membrane seems changed into a spongy, granulating layer which is colored with various shades of red ; it secretes a purulent exu- dation, or one that degenerates into puriform matter; and a yellow soft villous coating, which is in process of solution, or a somewhat thick pus adheres to the interior:—the serous sac is converted into a closed or encysted abscess. In the most favorable case, such an effusion is entirely absorbed after the subsidence of the inflammation ; the serous membrane and the or- ganizable substance which clings to and invests it gradually change into a dense fibro-cellular tissue, and the opposite laminae of it unite in one tough adhesion. During this process, the serous membrane, as such, is, in fact, destroyed. In other cases, the exudation, after having lost some of its constituent parts by absorption, and undergone a change in its ingredients and ele- mentary composition, is subjected to various metamorphoses ; while the serous membrane, and the layer investing it, become converted into a dense fibroid plate. The exudation is gradually inspissated, forms a cream-like, and afterwards a cheesy, whitish-yellow, pulp, and in the end becomes chalky: or else there remains behind, within the false mem- brane,—probably as a consequence of the exudation containing an abun- dance of animal lime,—a whitish fluid like lime-water, which incrusts upon the inner surface of the membrane, and renders it smooth and vol. in. 3 34 DISEASES OF SEROUS polished like gypsum, or rough and sandy, like mortar.^ Or lastly, the pseudo-membranous sac contains a fatty glutinous fluid, which is, for the most part, of a brownish-yellow color, and is mixed with numerous minute glittering scales (fat-crystals), which cling in thick clusters to its inner surface. In the most unfavorable case, the purulent exudation becomes sanious, and for the most part, of a greenish color; at the same time, in some instances, gas is evolved, and the exudation assumes a most offensive pungent odor, like that of garlic, phosphate of ammonia, or sulphu- retted hydrogen. Under these circumstances, the serous membrane not unfrequently ulcerates, or sloughs at some small and circumscribed, or at larger spots; sometimes the ulceration extends into the subserous structure, and opening of the serous sac takes place, and its contents are spontaneously discharged, either externally or into another cavity.— (Phthisis membranae serosae ulcerosa.) y. Chronic inflammation may extend from the serous membrane to the pseudo-membranous structure which lines it, and lead to a deposition of its products both within the substance, and on the internal free surface of the new structure ; that is to say, the exudation deposited by one in- flammatory process may itself become the site of a new inflammation dur- ing the time that it is becoming, but is not yet completely, organized. This explains the otherwise unintelligible occurrence of exudations upon the inner surface of serous membranes, which have already been con- verted into thick fibroid rinds, while effusions, to all appearance quite recent, have taken place into the cavity. This secondary inflammatory process, occurring during the progress of organization in the plastic product of a previous acute, or even of a chronic, inflammation, deposits exudation both upon the free surface of that product, and also within its tissue or parenchyma: the former con- stitutes a second free exudation, the latter an infiltration. The infiltered product, during its organization, becomes an integral part of the original exudation, and renders it thick and very dense, compact in its paren- chyma, and of fibroid or fibro-cartiliginiform structure: the stratum thus formed becomes identified with the serous membrane. The free exudation may be, and usually is, a plastic one, with more or less also of an aplastic portion; it may, however, present any of the qualities, and undergo any of the metamorphoses, already detailed: indeed, the inflammation within the parenchyma of the exudation may even have a suppurative tendency, and abscesses may be formed in it, analogous to those which occur in the subserous cellular tissue. The new plastic exudation becomes organized into a cellular tissue, and unites with the older layer of exudation beneath it; and it again may be attacked by inflammation, and become callous and indurated. In this manner tough, fibroid laminae are formed upon serous mem- branes, which, if the process be repeated often enough, may measure three or six lines, and even an inch and more in thickness; they are united externally with the serous membrane, to which they become firmly and immovably fixed, or even with adjoining fibrous expansions, aponeu- roses, periosteum, &c. AND SYNOVIAL MEMBRANES. 35 If no further inflammatory process take place in the last exuded layer, that layer becomes organized to cellular tissue ; and if none of the effused fluid remain at the termination of the process, and the opposed layers come into contact with each other, they unite into a single layer, and the serous cavity is obliterated in whole or in part, according to the extent of the process. But if any of the earlier, or of the more recent, fluid effusion be still left, it is either kept encysted by the impermeability of the fibroid stratum, and the slight power of absorption which it pos- sesses, or else it is slowly diminished in quantity by absorption. Whilst the serum is gradually being absorbed, the plastic (albuminous and gela- tinous) matters which it contains are precipitated upon the walls of the fibroid exudation, and form a loose villous lining for it; or else they accumulate in one shapeless mass, and become encysted in some part, generally the most dependent part of the cavity. If under such circum- stances, the walls of the serous cavity approximate and fall together, the layers of the exudation will be agglutinated to one another by means of a stratum of grayish jelly-like substance, into which the precipitate just described changes, and which Laennec, from his observations of it in pleuritic exudations compares to the central part of the intervertebral substances. In the end it becomes converted into a dense compact cel- lular tissue. This process is mostly observed upon the pleura, and will be more par- ticularly referred to amongst the diseases of that membrane. An exudation of a peculiar nature is very frequently found upon serous membranes, and requires particular notice. Its true character was first discovered by Laennec, who named it the hemorrhagic exudation. It is usually large in quantity, and consists of fibrin, blood-corpuscles, color- ing matter of the blood, and serum mixed in different proportions, and it is chiefly distinguished by its more or less intense red color. The conditions out of which it arises are general and local. Those of the former kind include diseased states of the blood, particularly tubercu- losis ; the anomaly in the composition of the blood, which results from cirrhosis of the liver; the scorbutic constitution; and, that which is allied to the last two, the dyscrasia of drunkards. Besides these, there are, of course, red and variously discolored exudations, which proceed from de- compositions of the blood, such as succeed exanthemata (variola and scar- tina), typhus, &c. The following are the local conditions of its occurrence: The hemor- rhagic exudation, though it sometimes, no doubt, results from primary inflammation of a serous membrane, yet it is far more frequently the product of the third mentioned form of chronic inflammation, i. e. of a secondary inflammatory process occurring in a plastic exudation; and this is, in fact, the cardinal local condition under which it takes place. For the structure in which the inflammation occurs is in course of organi- zation ; its vessels are only just forming, and have as yet no actual coats, or, at any rate, but very delicate and permeable ones ; and they have not yet united into a freely inosculating circulatory system; from such a structure the exudation occurs, without question, repeatedly and at inter- vals, and probably also prematurely before the congestion has reached the degree of intensity which would, in any other structure, be necessary 36 DISEASES OF SEROUS to produce it. The whole process bears throughout it the stamp of an inflammation which has not arrived at maturity: and its product is blood, altered by congestion in the composition, and mutual relation and inter- mixture of its elements. The fibrin, blood-corpuscles, and coloring matter contained in it vary with the state of the constitution, and with the composition, but more particularly with the stage of organization, of the substratum itself. It is remarkable, that it coexists very frequently with tubercle in the same substratum. (Vide Tubercle in Serous Membranes.) Where the hemorrhagic exudation-process borders upon actual hemor- rhage it is manifest, and so is also the mode in which they are to be dis- tinguished. The process is seen upon all serous and synovial membranes, but especially on the pleura and peritoneum; it is met with also in the pericardium, and in the tunica vaginalis testis; and, amongst synovial membranes, principally in the knee-joint. The thickness and consistency of the hemorrhagic exudation are pro- portioned to the quantity and plastic properties of the fibrin it contains: it forms a peripheral coagulum, which cleaves to the walls of the serous cavity, and may contain more or less coloring matter, or may be white. The red fluid effusion is enclosed within the peripheral coagulum, and out of it further plastic ingredients are precipitated. These ingredients in process of time, are converted into a very tough leather-like layer, which undergoes very little or no organization; the fluid effusion gra- dually assumes a chocolate-brown, a plum-sauce, or a yeast-yellow color, and becomes fatty and glutinous ; while the substance precipitated from it degenerates into a loose pulp of the same color; or it deposits its coloring matter, and becomes a clear serous fluid. The hemorrhagic effusion is but rarely absorbed, and with much diffi- culty when it is. The reason of this difficulty is sometimes the continu- ance of a chronic inflammation, and the frequent coexistence of tubercle with it, in the stratum from which it was poured out, and sometimes the density, the impermeability, and the extremely incomplete organization, of the plastic layer that surrounds it. When it occurs on large serous membranes, it usually proves rapidly fatal by the exhaustion it produces, or by its interfering with the function of important organs ; and the more rapidly in proportion to the amount of general disease that coexists with it. It is, however, sometimes borne for a long period, and under fa- vorable general and local circumstances it may be diminished by absorp- tion. If, in the most favorable case, it happen, that the fluid is com- pletely removed and the peripheral laminae are agglutinated to one ano- ther, a rust-colored, or yeast-yellow layer is found interposed between them. In the peritoneum^ chiefly, and more particularly on that part which be- longs to the intestinal canal, the plastic layers of the hemorrhagic exu- dation acquire a bluish color, and after a time the color of Indian ink (melanosis stratiformis). No doubt the discoloration is owing to the action of the intestinal gas. In course of time, the fibroid exudations frequently become the seat of calcareous deposition; and yellow, grayish, or dirty white, cheesy masses of various sizes are not unfrequently found in the cellular as well as in the fibroid, layers of exudation. They are portions of plastic exu- dation which have not been organized; degenerate fibrin, which either AND SYNOVIAL MEMBRANES. 37 decaying further and becoming puriform, excites inflammation and actual suppuration and ulceration in the neighboring tissues, or else changes into a chalky concretion. The termination of inflammation of serous membranes in suppuration has been already considered. Sloughing or necrosis of serous tissue is very rarely met with as a con- sequence, or degeneration, of an inflammatory process, but it frequently results from the membrane being stripped of its subserous tissue, when that has been destroyed by suppuration or sloughing; or from pressure, stretching, or strangulation of the membrane ; or when adjoining struc- tures are also sloughing, or have become gangrenous some time previously, as in the instance of gangrene of the lung. Sloughy serous tissue forms a dirty yellowish, or a whitish, soft eschar, as is seen in the case of per- forating ulcers of the stomach or intestines, or of strangulated herniae ; or else it is a loose shreddy, grayish, or blackish-brown, moist, infiltrated and pulpy mass, which is traversed by a dirty white thready tissue; it has the odor peculiar to slough. The termination of inflammation in tuberculosis, or rather the meta- morphosis of its product into tubercle, will be considered presently. The state of the tissue beneath the serous membrane during inflam- mation is a point of considerable practical importance. The condition of the subserous cellular tissue, as has been already mentioned, is an inte- gral part of the whole process. The more intense the inflammation is, and the longer it continues, so much the more do that and the adjoining tissues take part in it. Inflammatory products of various kinds are de- posited in all of them, and become infiltrated, or give rise to diffused or circumscribed suppuration, or to chronic, and very considerable, thick- ening. The most important part is that which is taken by adjoining fibrous tissues, whether aponeuroses, capsules, or ligaments. Another remarkable fact is, that the tissues lose their vital contractility : muscles, under such circumstances, become paralyzed and lose their color. Very intense and chronic inflammation leads at last to atrophy of the sub- serous structures, partly by the change of texture which is produced by the inflammation, and partly in consequence of their protracted palsy. The viscera contained within an inflamed serous sac are displaced and compressed to a degree and extent corresponding to the quantity and the position of the exudation ; and when this is long continued, they un- dergo various changes of texture, which may be included generally in the terms atrophy, obsolescence, obliteration. Whichever of the forms that have been described the inflammation assume, it may be general in its extent, or only partial and circumscribed. It is remarkable to observe, that usually—though there are various ex- ceptions to this rule—the parietal layer of serous sacs suffers more than the visceral, and that, therefore, the plastic exudations on it are the thicker. 3. Softening of serous membranes.—There is no such disease as pri- mary softening of these membranes : when it does occur, it is consecutive, and in the peritoneum and pleurae, ensues upon prior softening of the stomach, intestine, oesophagus, and lungs. The mode in which the serous membrane suffers is the same as has been described in the account of those diseases. 38 DISEASES OF SEROUS 4. Adventitious growths.—Some of these have been mentioned as pro- ducts of inflammation. There remain to be noticed : a. Lipoma.—This occurs in subserous cellular tissue, but is an unu- sual disease ; it consists generally of a small and lobulated mass of fat, which projects into the cavity of the serous membrane. A somewhat remarkable form is that described by J. Muller under the name of lipoma arborescens; it occurs on synovial membranes, especially in the knee joint. b. Cysts.—These, on the whole, are rare growths on serous membranes ; though there are exceptions to such a rule in the instance of some serous membranes, and even of particular regions and particular prolongations and duplicatures of them. Thus in the peritoneun, for instance, cysts are frequently found on that part which invests the sexual organs of the female, especially on the broad ligaments and peritoneal coverings of the ovaries and Fallopian tubes ; on the great omentum the same is the case, and on the tunica vaginalis of the testicle, which in this re- spect bears a remarkable analogy to the sexual portion of the peritoneum in the female. Equally remarkable is the fact, that when cysts are formed on serous membranes, it is chiefly on portions connected with organs in which cancer is of frequent occurrence. There are two different ways in which cysts are developed ; and in this respect their development is analogous to that of secondary cysts upon and within anomalous serous and fibro-serous membranes. In one case, the cyst is formed upon the inner free surface of the serous membrane, and for the most part is a vesicle with very delicate walls: such cysts are sometimes very numerous; they are usually of small size, and have broad bases, rarely being attached by a pedicle. In the other case it is formed deeper in the parenchyma of the membrane or in the sub- serous cellular tissue—in the wall of the serous sac, and is often situated as in the broad ligaments, between two serous layers ; it thrusts the mem- brane before it, and at length falling into the cavity, remains suspended only by a serous cord or pedicle, which is sometimes several inches long. Cysts of this kind very often have thick walls, and frequently attain a considerable size : they occur singly or in small numbers, and almost only in the neighborhood of the internal sexual organs of the female ; those which have long pedicles are often observed at the fimbriated ex- tremity of the Fallopian tubes. The contents of the cysts are most frequently serous; sometimes they are thin and watery, sometimes thicker and mixed with albumen or with a fluid like synovia; occasionally other substances are found in them, which may be colorless or colored, gelatinous, like gum or glue (colloid), or fatty. Cysts with contents of the last-mentioned kind are often found in the omentum, and sometimes, besides the fat, they contain also hair, bones, and teeth. c. Fibroid tissue.—One form in which this tissue presents itself is that of condensation of the serous membrane, and of the cellular layer beneath it: it assumes the appearance either of milk-white more or less circumscribed stains, which, after a time, become smooth or uneven plates of various thickness ; or of bluish-white, tough, separate granulations (so called cartilaginification of serous membrane). Another form is that of AND SYNOVIAL MEMBRANES. 39 fibroid exudation upon the inner surface of the membrane. The present head might include also the concretions which are found free in serous and synovial membranes, but they will be treated of in a subsequent part of the work. Moreover various fibroid growths found in the syno- vial membranes of joints, are formed from exudation accumulated in par- ticular spots; they are villous and laminated, or they form clusters of small subovate bodies that resemble melon-seeds (Mayo). Bursae are sometimes filled with balls of exudation which are undergoing a change into fibroid tissue. d. Abnormal bony substance,—Ossification, as it is called, of serous membranes.—This, like the adventitious substance last described, is found as a subserous formation, on the outer side, and in the substance of the serous coat, after it has undergone a fibroid condensation of its tissue ; and it also occurs in fibroid exudations upon the inner surface of the membrane. Its usual form is that of nodulated plates or cords of various size and thickness. It appeared to Meckel to be the result of an endeavor to convert a membranous into an osseous cavity, similar to that which pre- vails in the vertebral and cranial cavities. The granular and stalactitic form is less common ; but both are sometimes found together at the same spot. Lastly, some shapeless concretions are met with, which are the chalky residue of fibrinous effusions. The frequency with which serous membrane becomes the seat of ossi- fication is a matter of much variety, depending on the different frequency of the changes of texture which precede it. Ossification occurs chiefly on the pleura, where it is remarkable for its extent and thickness. In the peritoneum it is almost confined to certain investing portions, especially to that covering the spleen; it occurs in the tunica vaginalis of the tes- ticle, and, in the synovial system, sometimes in bursae. e. Tubercle.— Tuberculosis of serous membrane.—Tubercle affects chiefly the larger divisions of the serous system; the peritoneum, pleura, and pericardium. It is ordinarily the product of a general constitutional disease, which has been already localized in some parenchymatous organ, and in this sense the tuberculosis of serous membranes usually has some definite starting-point, or prior cause (Ausgangsherd). It sometimes, however, occurs independently of any such previous and causal deposition, and is the primary and only local affection in which the general tubercu- lar diathesis expresses itself. It is, with very few exceptions, the result of a high degree of the general disease, and hence is associated with tuberculosis occurring simultaneously with, or soon after, it in organs which stand in immediate connection with the membrane. The starting- point for tuberculosis of serous membranes is, in general, a previous af- fection of the absorbent glands, or of the lungs; that for peritoneal tubercle is tuberculosis in the abdominal lymphatic system, in the inter- nal sexual organs of the female, or in the intestines; the cause of tuber- cle in the pleura and pericardium is found in the bronchial glands and lungs ; tuberculosis of the tunica vaginalis testis has the starting-point in the lymphatics of the genital organs, and in the testicle itself; and so on. Peritoneal tubercle is, almost as a rule, associated with the same disease in the spleen, or liver; that of the pleura with recent deposition of tubercle in the lung; and further, tuberculosis not unfrequently appears 40 DISEASES OF SEROUS in nearly all the serous membranes at once, or almost at once, and either in one and the same form, or in the various forms to be described pre- sently. In some few cases the tubercle may occupy the tissue of the membrane itself, and the subserous cellular structure. Generally, however, its site is manifestly the free, smooth surface of the membrane, or it is seated quite within the surface in a false membrane of cellular or cellulo-serous structure that lines the serous membrane. In the former case it may be stripped or broken off from the serous membrane, and leaves behind it a spot of corresponding size, dull, lustreless, often distinctly opaque, and deprived of its epithelium. If it have been of large size, its pressure may have formed a pit, and then it appears as if it had been seated in the tissue of the serous membrane itself. Tubercle presents itself upon serous membranes in the following forms: a. One form is that of the gray, semi-transparent, crude, granular tubercle, the size of which is about that of coarse sand, or millet-seed. When chronic, this form of tuberculosis may originate at several parts of the membrane. Commencing at one or more of these starting-points at the same time, it gradually extends over large portions, or even over the whole of the surface: its advance, however, is not uniform, and hence the original depositions may still be recognized by the close grouping, and by the appearance of the granulations. In the acute form, the tubercles are usually abundant, and are sown evenly and close together over the whole expanse of the membrane, or at least over a very con- siderable part of it. They consist of granular tubercle of the size of millet-seed, or, as is often the case, of transparent, crystalline granula- tions, resembling vesicles, and so fine as to be perceptible only when the light falls favorably. Acute tuberculosis ordinarily arises out of a more or less lingering (chronic) tuberculosis of the membrane: and in that case, as well as in the rarer instances in which it commences on perfectly healthy membranes, it is usually but a partial manifestation of a general tubercular diathesis, which is exhibiting itself in several structures, either together or consecutively. This fact is one of great importance, from the absolutely unfavorable prognosis which it establishes. Dropsy of the serous cavity co-exists with the tubercle, and is directly proportioned in amount to the extent of the deposit over the membrane: general cachexia and dropsy of other cavities and organs follow in the same proportion. The oedema of the serous and adjoining cellular tissues, the infiltration of the parenchyma with serum of the blood, and the loss of its color, as well as the thin fluidity and defibrination of the blood generally, are all proportioned to the acuteness of the disease. This kind of tubercle undergoes scarcely any metamorphosis, for the local disease which gives rise to it, and still more the general, and already far-advanced, constitutional affection, prove too speedily fatal: some- times, however, when the course of the disease is chronic, the tubercle is found here and there obliterated (obsolete). y3. An inflammatory product, deposited upon a serous membrane under the influence of a constitutional affection,—which affection is usually AND SYNOVIAL MEMBRANES. 41 already localized, and very often is even manifested in established phthisis,—may undergo the metamorphosis into tubercle. The change is induced by some inherent anomaly in the quality of the product, and is effected in various ways. Sometimes the exudation in its whole thick- ness degenerates into a uniform cheesy, or caseo-purulent, fissured layer, which agglutinates and connects the organs contained in the serous sac to one another, and to the parietal layer of the membrane: sometimes it is partially organized and gradually converted into a cellular or cellulo- serous tissue, while a more or less considerable portion of it becomes tubercle. The layer of exudation is then found in different stages of organization, and interwoven with isolated or confluent, grayish, fawn- colored, or dirty yellow tubercles, of the size of sand, millet-seed, or hemp-seed, and often with still larger shapeless masses of tubercle. Two species of this form of tuberculosis are in several respects remarkable: (1.) An exudation in the form of a rugged layer, for the most part of considerable thickness, and of fibro-cartilaginous firmness, which consists of a quantity of confluent granular tubercles, and of a grayish-red, moderately vascular, lardaceo-gelatinous, or grayish, pale, slightly vascu- lar, and lardaceo-callous, substance, in which those rugged masses of tubercle are imbedded. A comparative analysis shows that the status of this tubercular layer, as a vascular structure, is secondary, and that it corresponds to the lardaceous infiltration and callous condensation of the tissue of mucous membranes and parenchymatous organs around tubercle, and tubercular ulcers. (2.) In cellular and cellulo-serous tissue recently formed on serous mem- branes, especially on the peritoneum, there occur yellow, cheesy or fatty, brittle masses, of round or subovate form, and of the size of peas or beans: sometimes they are shapeless, and are as large as doves' or hens' eggs- This form of tubercle also rarely undergoes any metamorphosis ; as, indeed, might be expected from the high degree which the constitutional disease (the dyscrasia), the preponderating, internal cause of the exuda- tive process, attains; but sometimes the species just noticed—(2)—is seen, on the one hand, softening and leading to suppuration (tubercular phthisis) of the serous membrane, or on the other hand, becoming chalky. y. Lastly, an exudation upon serous membranes, originally free from tubercle, may, at any stage of its organization, become the nidus of that growth,—a form which, when it is possible, is to be distinguished from that developed in the way described in section /3. That such a form exists is probable from two observations, and is not opposed by any positive facts. (1.) In chronic inflammations of serous membrane, which recur in the exudations, one of the secondary inflammations sometimes furnishes a product upon the free surface of the older exudation; and that product becomes tuberculous in the manner described in section /3; that is to say, a serous membrane is sometimes found lined with an exudation, the outer and older layer of which is free from tubercle, whilst the inner—the pro- duct of a secondary inflammation of the older layer—is tuberculous. (2.) In the cellular false membrane lining a serous cavity, especially the peritoneum, we sometimes see tubercle, usually of considerable size 42 DISEASES OF SEROUS —as large as hemp-seed or peas—from the highest and central point of which loose-walled bloodvessels project, and passing to the outskirts of the tubercle, sink deeply, and so are lost, or else are seen to anasto- mose with other vessels of the false membrane. Indeed, in a few apt cases, the tubercle is found upon close examination to be excavated by a canal or cavity, which forms the centre of this small vascular apparatus. But, in most instances, the canal is already obliterated, the circulation is obstructed, and the vascular apparatus is beginning to waste. When the atrophy is accomplished, the tubercle is found imbedded in cellular tissue, which is streaked with blackish-blue lines. Such an appearance may give rise to the assumption that tubercle is supplied with bloodvessels, especially as I have recommended serous membranes as the structure best adapted for the study of tubercle, because in that system it may best be followed in all directions. The appearance, however, may be safely explained in the following manner: The tubercle is thrown out under the influence of a tubercular diathesis by the vascular centres which are forming in the false membrane, and arranges itself around them : the more abundant—the larger—it is, so much the more promi- nent does it render the vascular apparatus that radiates from its centre. The tubercle formed upon serous membranes is frequently a hemor- rhagic product; especially when it is a result of the processes just de- scribed under sections (1) and (2); indeed this is sometimes the case when it is thrown out by a primary exudative process. The congestion that attends its production not unfrequently degenerates into inflammation, and that, for the most part, furnishes a hemorrhagic exudation, in the same manner, but not to the same extent, as the in- flammation of a false membrane in which tubercle is forming. As has before been explained, the hemorrhagic nature of the exudation is owing to the fact of the blood being impoverished in fibrin by the exu- dation of tubercle, and also in the second case to a local circumstance, viz. the imperfect formation of the vessels in the false membrane. /. Cancer.—Serous membranes are often perforated by malignant growths which originated externally to them: the pleura is invaded by masses of cancer deposited in the mediastina, and by large exuberant growths in the mammae ; and the peritoneum, amongst other growths, by those which Lobstein has named " Retro-peritoneal." But cancer appears on these membranes as a primary disease also. As a general rule, its appearance there has some connection with the existence of cancer in an organ adjoining, or contained within, the serous sac; so that it always shows the cancerous cachexia to be very far advanced. The most common forms of cancer found on these membranes are the areolar and the medullary ; the latter having not unfrequently the me- lanotic character. It consists either of laminae, which vary in extent and are unequal in thickness ; or of small nodules, like tubercle, which ger- minate in the tissue of the serous membrane; or of larger knots and tuberous masses, which shoot forth from the tissue over the surface of the membrane. Moreover, upon the serous layer of the dura mater, nume- rous morbid growths, allied to medullary cancer, are found, the internal and minute construction of which presents very much variety. AND SYNOVIAL MEMBRANES. 43 In large serous cavities, such as the peritoneum, there are somewhat rarely found very large adventitious growths, which have the same general characters as those under consideration, but are very loosely connected with the serous membrane by one or a few points, or are even entirely unattached. If, as often happens, inflammation should attack a cancerous growth on a serous membrane, the result is a hemorrhagic exudation : the ex- planation of the occurrence is found in the very imperfect state of the vascular apparatus involved in the inflammatory process. (Compare what has been said as to the local causes of hemorrhagic exudation.) g. Anomalies of secretion, and morbid contents generally.—Free gas is not unfrequently found collected in different quantities within serous sacs. It is met with chiefly in large serous cavities, such as the pleura and peritoneum, and its presence is due to the escape of atmospheric air from the air-passages, or of intestinal gas from the bowel. It is occa- sionally produced by the decomposition of ill-constituted and long-stag- nated effusions ; or it may be a product of the exudative process itself. In a few cases, it may even be a morbid secretion (exhalation), from the serous membrane during life. Besides this, and the various products of inflammation already de- scribed, there occur also collections of serous fluid, and of blood. Collections of serum constitute dropsy of serous and synovial sacs, and of bursae (Ganglia); the quantity of fluid varies, and with it the en- largement of the cavity ; its color, too, and its consistence and composi- tion, especially in respect to the quantity of plastic material it may con- tain, vary considerably. The remarks already made upon dropsy in general apply also here. The effusion of blood into serous cavities—actual hemorrhage—must be carefully distinguished from hemorrhagic exudation. An account of various other effusions will be found in the chapters on the particular serous sacs. Lastly, the cavities of serous and synovial membranes sometimes con- tain free loose bodies, which have various origins, and differ accordingly in their appearance and construction: those, more particularly, which are met with in the peritoneal cavity vary much in their kinds. They are found in the cavity of the peritoneum, within the tunica vaginalis testis, in the pleura, in the sac of the arachnoid, and in the ventricles of the brain ; they are also particularly common in several of the synovial cavities, especially in the knee, and in bursae (articular mice); they even occur in anomalous serous sacs. Their usual size varies from that of a millet-seed to that of a pea or a bean: it is an exception to find them larger, but they do sometimes reach the bulk of a walnut: they are generally round or oval in shape, but pressed somewhat flat; sometimes their figure is irregular. They are mostly firm and elastic; and from the smoothness of their covering, which glistens like a serous membrane, they acquire a polished appearance, but sometimes there are rough and villous spots upon them. With regard to their origin, the observations of Laennec and Be*clard prove that some of them originate outside the serous membrane; while the internal construction of many others indicates that they were formed within its cavity. 44 DISEASES OF SEROUS AND SYNOVIAL MEMBRANES. The first kind includes the fibroid and fibrocartilaginous concretions, some of which contain bony nuclei.^ They are originally developed in the subserous cellular tissue, or in the serous tissue itself; but as they gradually force the membrane before them, they become invested with a prolongation or duplicature of it, which remains connected with the rest of the membrane only by a pedicle ; at length the pedicle being worn away by friction, the cartilage falls loose into the serous cavity. It has a proper serous covering, which often bears a trace of this mode of development in being deficient at the spot where it was sepa- rated from the pedicle: it is then completed by loose shreds of cellular tissue. Those of the second kind are the fibrillated and albuminous coagulations and precipitates from morbid effusions. They are distinguished by their uniform smoothness throughout, by a delicate albuminous investing membrane, and frequently by their manifest arrangement in concentric laminae. Moreover, free bodies of a different nature are sometimes found par- ticularly in the peritoneal cavity. Some of them are obsolete portions detached from the omentum and appendices epiploacae, which, within a bluish, gray tunic, contain fat that resembles tallow or spermaceti; others are tubercles which have become loose, and which, like the former, may become the nucleus of albuminous coagula : whilst others again are fibroid, or are allied to the fibroid, tumors formed beneath the perito- neum in the uterus or its appendages, but afterwards set free. PART VI. ANOMALIES AND DISEASES OF MUCOUS MEMBRANES IN GENERAL. PART VI. ANOMALIES AND DISEASES OF MUCOUS MEMBRANES IN GENERAL. § 1. Defective and Excessive Development.—Congenital deficiency of a mucous membrane involves deficiency of the apparatus which it com- poses, or which, as the expression is, it invests or lines: always, there- fore, when the mucous membrane is absent, the whole apparatus is absent too. The only instance of acquired deficiency is a partial loss of sub- stance, and it varies in character considerably according to its cause. Preternatural development is sometimes an original anomaly, which may be exhibited in a congenital excess in the length and capacity of mucous canals and cavities, in the existence of unusual appendages and duplicatures, or in the unusual size of prolongations and folds which naturally exist in the membrane. Sometimes such an anomaly is ac- quired : it is exemplified in the similarity that exists between the surfaces of abscesses and fistulae, and mucous membranes; in other words, as Otto describes it, in the development of anormal cavities and canals, which, like normal mucous membranes, are connected, or about to be connected, with the surface of the body : it is further illustrated by the restitution of lost mucous membranes. In regard to the former, whether the lining membrane of the abscess or fistula be composed of cellular tissue, of serous membrane, or of any other structure loosened in its texture so as to resemble cellular tissue, it is at first a granulating vascular layer closely connected with the sub- jacent structures; but afterwards it become a more distinct membrane, and may be isolated from them : its free surface may be smooth, or may be covered with shreddy appendages and prolongations. In its structure it has a general resemblance to mucous membrane; but inasmuch as it has few follicles and no actual villi, it is rather like those of simpler or- ganization, such as the ducts of glands. Moreover, it exhibits patho- logical changes, which are very similar to those of normal mucous mem- branes : sometimes it is pale, and sometimes it is found injected, red- dened, and swollen, just as is the case in acute or chronic inflammations of a natural membrane; polypus-like prolongations are formed upon it, and fungous growths of various kinds; and further, the cellular tissue beneath it becomes thickened and callous, &c. And just as mucous sur- faces never unite together, except after some solution of their continuity, so also the allied anomalous mucous canals can only be closed by laying 48 ANOMALIES OF bare the tissues beneath them, either by laceration, or by compression carried to the extent of producing atrophy. There is a difficulty in the regeneration of mucous membranes in their original form, proportioned to the complexity of structure of the mem- brane that has been lost, to the amount of its substance removed, to the extent to which the submucous tissues have been likewise destroyed, and lastly, to the change of texture which those tissues have undergone during the process by which the loss of substance was occasioned. Re- generation is extremely difficult, therefore, in several respects, but it is most so after deeply-extending ulceration. We shall again have, as we have already had, occasion, when considering the mucous membranes in particular, to observe several most interesting peculiarities in the mode of repairing losses of substance, especially those occasioned by ulceration. In general, the repair of a breach of substance on a mucous membrane is effected in the following manner:—The exposed submucous structures are first condensed to a serous or fibro-cellular (callous) tissue by a reac- tionary inflammation of more or less activity, and then are gradually covered by the adjacent mucous membrane, which is drawn in, and at- tenuated as it is drawn, from the margins towards the centre of the de- fective spot: no actual regeneration therefore, no new growth of mucous membrane, takes place. But occasionally the provisional serous mem- brane that covers the defect is converted into mucous membrane; and in the intestinal canal especially, when the typhous process has been limited by the submucous tissue, that tissue becomes developed at the middle of the ulcer, even to a villous mucous membrane. Extensive and deeper losses of substance are permanently replaced by a callous (cica- trix) tissue, that only occasionally obtains a smooth covering like serous membrane. And the cicatrix is of course more dense and thicker, and the mucous membrane upon it more firmly fixed to the submucous tissues, in proportion to the amount of damage those tissues have sustained, either at first froin the loss of substance, or subsequently from the reac- tionary process which was called forth. § 2. Deviations in the size—superficial area—and in the form of mucous membranes.—The anomalies which may be included under this general head, are the partial dilatations of mucous cavities and canals, and those which relate to the thickness of the membranes. The former are the diverticuli spuria, as they are called, or herniae of mucous membrane. They occur chiefly in the intestinal tract, in the urinary bladder, and also, but less frequently, in the trachea and bronchi. The mucous membrane protrudes, in the form of a rounded, pear-shaped, or cylindrical, saccular appendage, through the separated fibres of the fleshy coats : the appendage is attached by a sort of neck, and the two cavities communicate with one another by a narrow opening, which at first is a mere fissure, or is lozenge-shaped, but afterwards becomes cir- cular, and is bounded by a kind of sphincter. The thickness of mucous membranes may be increased or diminished. Permanent increase of thickness is due not only to various changes of texture, but also to hypertrophy: diminished thickness is a result of atrophy. Either may involve the entire structure of the membrane, or MUCOUS MEMBRANES. 49 may affect one of its component parts only, such as the follicular appa- ratus, or the papillae. Hypertrophy is for the most part produced by well-marked, and either repeated or continuous, states of irritation or of inflammation: it presents several degrees, and I shall treat of it further at a place where its development from these conditions can be more con- veniently shown. Atrophy very rarely occurs as a spontaneous affection in any mucous membrane : it must be distinguished from the softening of mucous tissue, which comes on after exudative processes. The membrane becomes more or less attenuated, and may be easily torn; its folds waste, or with the follicles and villi altogether disappear; its surface is pale and smooth, and glistens like a serous membrane. A similar attenuation is observed in the mucous membrane surrounding various extensive losses of sub- stance, both during and after their repair. And there is yet another instance of the same condition, in which certain parts of the mucous system not only become extremely thin, but also undergo a change of texture: it is a consequence of the gradual and excessive distension which is produced by the accumulation of matters secreted during some occlusion of the cavity. This subject will be further considered. § 3. Diseases of texture.—Both acute and chronic diseases of mu- cous membrane are, as is well known, exceedingly frequent; and hence, as well as from the manifold connections which they maintain, both in their origin and consequences, with other systems and organs, they are diseases of great importance. For the most part, they are the result of that sensitiveness to all changes in the material components of the fluids,—whether immediate (primary), or produced through the me- dium of the nervous system,—as well as to all deviations from the proper evolution and distribution of the imponderable principles, which attaches to mucous membrane, as the most vascular of all structures, and the chief organ of absorption and secretion. Hence almost all acute (febrile), and many chronic, constitutional diseases establish themselves in various ways, the former rapidly, the latter gradually, upon these membranes. There are various processes, irritative and inflammatory, by which this is accomplished; but in the present chapter only the cardinal forms will be treated of, the catarrhal, the exudative, and the pustular ; the other specific processes of the same class will be found described amongst the diseases of the separate portions of the mucous system. 1. Hyperemia, apoplexy, hemorrhage, anosmia.—Mucous membranes are sometimes actively congested, either in consequence of some direct irritation, or from a special relation of the constitution of the blood to a particular portion of the membrane: sometimes the congestion is passive, and occurs as a consequence of marasmus and adynamia, particularly in the tracts of membrane lining the respiratory organs and intestinal canal. Again, it may be mechanical, and extend over large areas, and even over the whole of large divisions of the mucous system: the con- gestions which are found in the respiratory organs and intestinal canal, in diseases of the heart, lungs, and liver, are of this kind. It presents various degrees. In the ordinary and slight degree, it either entirely disappears after death, and the membrane, whatever may vol. iii. 4 50 DISEASES OF have been its state during life, is found pale ; or the ramifications of veins, or perhaps the capillary vessels, are full of blood, and the mem- brane is red and injected. When it has been acute, it leaves the mem- brane swollen and relaxed, and more or less evidently succulent, while the mucous and submucous tissues are slightly cedematous; when chronic, it occasions thickening and hypertrophy of the membrane, and a perma- nent increase of its secretion of mucus. In a higher degree, the congestion advances to vascular apoplexy, and apoplexy is followed by bleeding into the parenchyma, and from the sur- face of the membrane: the more rapidly the congestion has arisen, or been augmented, the sooner does the hemorrhage take place. These occurrences are met with chiefly in the bronchi and alimentary tube, where they may arise either from active or passive or mechanical con- gestion. The mucous membrane appears red and swollen, from its in- jected capillaries standing thick together; or dark-red and tumid, from injection that cannot be distinguished from effusions of blood into the parenchyma; or, lastly, more or less blood is found upon its surface, or collected in the cavity which it encloses, while it is itself either in one of the states just mentioned, or collapsed, pale, and bloodless. It must, however, be remarked, that bleeding from mucous membranes in general, excepting that from the bronchial membrane, is rarely the result of mere congestion; for the most part, and in the case of the stomach and intestinal canal especially, the hemorrhage proceeds from some other part of the membrane, which is diseased in texture, though it very often appears quite trifling in extent, or may be so small as to be scarcely discoverable. Anaemia in mucous membranes is the result of diminution of the gene- • ral mass of the blood, and especially of loss of blood by hemorrhage ; it is, therefore, only a local symptom of general anaemia. The pallor which ensues, under such circumstances, especially in the mucous membrane of the intestinal canal, where it proceeds chiefly from gelatinous softenings, presents a remarkable waxen hue, and a yellowish shade of color. 2. Inflammations.—a. Catarrhal Inflammation.—This is the common inflammation of mucous membrane; it is sometimes an ordinary catarrh, resulting from the known atmospheric influences; sometimes it is the local expression of a constitutional disease, and is then a specific catarrh, either exanthematous, typhous, impetiginous, gouty, or the like: occa- sionally it is produced by direct mechanical or chemical irritants, &c.; moreover, it accompanies the various processes of ulceration and new growth that take place upon mucous membranes, varying in such cases both in intensity and in extent. Its course is sometimes acute, sometimes chronic. a. Acute catarrhal inflammation.—The anatomical characters of this disease are as follows : (1.) Redness, which varies from a pale rosy tint to a deep red: it gra- dually diminishes towards the margin of the inflamed spot, and then passes into the natural color of the tissue. (2.) The injection may involve merely the finer ramifications, or it may amount to a complete distension of all the vascular apparatus, and will, therefore, vary in each membrane according to the special arrange- MUCOUS MEMBRANES. 51 ment of its peripheral vessels. To the unassisted eye, the membrane then appears uniformly saturated with red. (3.) Even with a slight amount of reddening and injection, the inflamed membrane loses its transparency, and becomes cloudy. (4.) Its tissue becomes filled with an opaque, grayish, or a sanguineous grayish-red fluid, and the membrane appears swollen: the papillae and mucous glands being in the same condition, its surface seems warty or papillary, and uneven. Sometimes the epithelium is raised in delicate, translucid, miliary vesicles, which are filled with a serous fluid. (5.) It may be easily torn, and readily separated from the structures beneath. These structures, and especially submucous layers of cellular tissue, are loose, filled with a serous or sanguineo-serous fluid, spotted here and there with small extravasations of blood, and fragile. (6.) At the commencement of the inflammation, the secretion exceeds the natural quantity, and is watery: as the inflammation advances it diminishes in amount, and becomes opaque and viscid: at the acme of the inflammation, it ceases altogether. After this it is gradually restored again, and is frequently streaked with a little blood: it then assumes a purulent appearance, and becomes very abundant: and remains in this condition for some time after all other marks of the inflammation, even the swelling of the tissue, have subsided. This is especially the case in mucous cavities. Moreover, inflammations of very great intensity deposit a more or less plastic exudation upon the free surface of the membrane: the miliary vesicles upon catarrhal mucous membranes which were mentioned above, arise from this cause. Acute inflammation often has a marked tendency to return upon slight occasions; severe attacks of it frequently terminate in superficial suppu- ration, which may even continue habitually. Not uncommonly it becomes chronic. /?. Chronic catarrhal inflammation.—The anatomical characters of this form of inflammation are,— (1.) A dark, dull redness inclining to brown, injection, and a varicose state of the vessels. (2.) Increase of bulk; the mucous membrane becomes thick and tumid ; the swelling of the papillae and follicles renders its surface uneven, especially if the process have been of long duration and the glands be abundant; its tissue, becoming denser and more compact than natural, is hence also— (3.) Tough and resisting, and is with difficulty torn: it is more firmly connected, too, with the subjacent tissues, and they become swollen, dense, and tough (hypertrophied). (4.) The secretion is a grayish or yellowish-gray, opaque, viscid mucus. Chronic inflammation usually leaves behind it a permanent tumefac- tion, or hypertrophy of the mucous membrane, and a continual excessive secretion of a grayish-white and milky, or of a glassy transparent pasty mucus,—a blennorrhcea, which may or may not be attended with an exuberant formation of epithelium, and in Avhich, accordingly, the epithelium is either rapidly thrown off from an almost bare, and, as it seems, excoriated mucous membrane, or accumulates over the Avhole, 52 DISEASES OF or over parts of the surface, and thus forms a complete laminated cover- ing for it, or patches of various thickness here and there upon it. The hypertrophied membrane itself is pale, or more commonly of a rusty brown, or slate-gray, and after a time, of a dark-blue color ; it is thick, compact, and firm: when it is uniform in thickness its surface is smooth; sometimes, from the great increase in the size of its papillae and follicles, it is warty and rugged; and lastly, even various duplica- tures and prolongations may be formed upon it. The two last-mentioned inequalities of the membrane are permanent, immovable folds of the membrane: they constitute what is called the mucous or cellular polypus, or the vesicular polypus. These polypi are processes of the mucous membrane, of various thick- ness and length. In shape they are spheroidal or elongated, or like ninepins or cylinders; and their free extremity is thick and blunted. The mucous membrane and the tissue beneath it becoming hypertrophied at particular round circumscribed spots, form a somewhat flattened convex tumor, and progressively change into a honeycombed cellular tissue. Little by little the tumor drops into the cavity of the organ, dragging with it the surrounding mucous membrane, by which, as by a compara- tively thin, and more or less elongated pedicle, it remains attached. The polypus then consists of a cylindrical prolongation of mucous mem- brane, which contains a cord of submucous tissue, and of a truncated extremity or knob, at which the tissue proceeds to form itself into a honey- combed cluster of vesicles and follicles, and becomes lobulated like a cauliflower; it presents a system of dilated capillary vessels; now and then it becomes turgid; it secretes a jelly-like mucus in its interstices, and when that is discharged, it shrinks. Polypi do not occur with equal frequency on all mucous membranes. They are especially frequent upon those membranes, and parts of mem- branes, that are bulky and thick, and have abundance of follicles, and that are frequently attacked with catarrh. Such are the Schneiderian membrane, the mucous coat of the stomach, especially its pyloric half; that of the large intestine, particularly of the rectum ; and the mucous membrane of the uterus, more especially about its cervix. The cellular polypus occurs, but less frequently, in the pharynx, the larynx, and oeso- phagus, in the small intestines, the urinary bladder and urethra,—though it is somewhat frequent in the female urethra; it is extremely rare, and indeed almost never occurs, in the trachea and bronchi, in the Fallopian tubes, and in ducts generally. The catarrhal origin explains why they occur in such great numbers, whether separately or, as they mostly exist, in clusters, upon one mu- cous membrane. In their thrusting the mucous membrane before them as they enlarge, and in their even protruding into a cavity, and hanging in it by a pedicle of mucous membrane, the form of the polypus is often imitated by various new growths in the submucous structures, especially by lipoma, fibroid tumors, and even by cancer. Several of these new growths have been distinguished from the mucous polypus by the names of fibrous and fleshy polypi. MUCOUS MEMBRANES. 53 A point of some importance is the condition of the submucous tissues during catarrhal inflammation and blennorrhoea. The increased sensi- bility of the mucous membrane gives rise to very frequent reflex move- ments in those which are irritable, and when the course of the process is chronic, they become hypertrophied, as well from the permanent increase in the quantity of fluids arriving in them, as from the process itself. At length, if there be much hypertrophy, the irritable and contractile sub- mucous tissues gradually become paralyzed, and their respective cavities and canals are permanently dilated. Moreover, chronic catarrhal inflammation sometimes terminates in suppuration and ulcer,—an event which more frequently occurs, and with more rapidity, when an acute inflammation supervenes. In that case the redness becomes more vivid, and seems as if it were identified with the mucous membrane, wrhile the membrane itself is changed into a friable tissue, is swollen with blood, and resembles a sponge, or a spongy gland. Matter appears, either extended, as a more or less smooth coating, over the surface of the membrane, or collected in small quantities in its sub- stance ; and in this manner the tissue gradually disappears,—the whole process constituting the catarrhal (simple) suppuration, or catarrhal phthisis of mucous membrane. It leaves behind it an ulcerated breach of substance, corresponding in size to the extent of the inflammatory process,—a catarrhal ulcer, which may be limited by, or may extend deeply into, the adjoining submucous tissue. If, in the former case, the ulcer be small, it heals readily, its base becoming a dense cellular tissue, and the surrounding mucous membrane being drawn in, and at length becoming adherent, over it. An ulcer of larger extent acquires a fibro-callous base, but does not cicatrize; it remains bare, and some- times obtains a smooth covering like serous membrane: in canals with soft walls its tendency to shrink occasions strictures; and it often, from the application of various powerful agents, becomes the seat of chronic inflammation or of gangrene, sloughs away, ulcerates anew, &c. The character of the catarrhal ulcer probably varies according to the nature of the catarrh. Both acute and chronic catarrhal inflammations, and the various pro- cesses in which they terminate, may affect the follicles of a mucous membrane principally or alone. The walls of the follicle then redden, and the parts adjoining, as well as the follicle itself, become injected, tumid, and enlarged: its secretion diminishes in quantity or is suppressed; but sometimes it is more abundant than natural, and either pours freely forth, or being retained in the cavity of the follicle, becomes inspissated, and undergoes various other secondary changes. The result of this pro- cess sometimes is a permanent enlargement (hypertrophy) of the follicle, a dilatation of its cavity, or an habitual profuse secretion of a tenacious glassy mucus—follicular blennorrhoea. Sometimes the process terminates in suppuration of the follicle, and follicular ulcer. It becomes converted into an abscess, which usually bursts through, and discharges itself upon the internal free surface of the mucous membrane: a small, round, crater-like ulcer is then found situated at the top of a rounded conical tumor, and having a hard base : as the suppuration of the follicle proceeds, the ulcer becomes larger and shallower, and when 54 DISEASES OF the follicle is quite destroyed, is encircled by a border of loose mucous membrane ; it then extends superficially, or which is rarer, deeply amongst the submucous tissues. This process is mostly seen on membranes which have follicles in abun- dance, and are disposed to catarrh; on that of the air-passages, for in- stance, particularly in the larynx ; or in the intestinal canal, especially in the large intestines, where it produces very extensive devastations. b. Exudative processes.—Processes of exudation are frequently met with in particular portions of the system of mucous membranes ; but their nature is very various, as their products, and the condition of the mucous membrane in connection with them, manifest. The best known exudative processes upon mucous membranes are those named croupy inflammations, especially those that occur in the pharynx and air-passages. They are characterized by their plastic pro- duct, which varies in consistence from that of cream to the toughness of leather, and is grayish-white, or yellowish and fibrinous ; it sometimes covers the membrane at a few insulated spots, and sometimes forms a more extensive film over it like hoar-frost; occasionally it invests the membrane like a layer of gauze, while in some cases it constitutes a membranous, and very often a tubular, lining for the mucous surface. From all analogy it is probable that, at the commencement of the pro- cess, a serous fluid is effused by which the epithelium of the diseased mucous membrane is destroyed, and that the exudation of the plastic matter takes place afterwards. This matter, the general characters of which have just been depicted, forms in a severe case a membranous coagulum, the thickness of which may vary, but not unfrequently equals, or even exceeds, a line: towards its margin it is thinner and less tough, and it is at length lost in a layer of muco-purulent substance. At first it adheres to the mucous membrane, and on that surface which adheres to the membrane some incipient vascularity is sometimes seen in the form of small bloody points; some of these points are single, others divide into fine twigs towards their peripheral extremity. At a later period, a viscid, muco-purulent fluid is effused beneath the plastic exuda- tion, so that it becomes loose, and is at length set free. The mucous membrane underneath the exudation is variously tinted, but for the most part is of a very pale rosy color: it looks sore and ex- coriated, and is more or less swollen, and its papillae especially are dis- tinctly swollen; its surface is covered with numerous red, soft, bleeding spots like granulations, which correspond to the vascular points on the adherent surface of the exudation. The submucous tissues, especially the cellular tissue, appear infiltrated. Neither during nor after the croupy process does the mucous mem- brane suffer any material injury to its texture; the speedy production of mucus and epithelium prevents any further organization of the plastic exudation beyond the rudimentary condition just described and it never enters into an organic connection with the mucous membrane. The croupy process occurs on all mucous membranes, and sometimes extends over a very wide tract. The mucous membrane of the respira- tory organs shows an especial tendency to it, and we meet accordingly with laryngeal croup, tracheal croup, bronchial croup, and croupy pneu- monia. In those parts, and on the inner surface of the uterus after child- MUCOUS MEMBRANES. 55 birth, it is very often a primary process; while on most other mucous membranes it is only secondary, and occurs principally as a consequence and an expression of the degeneration of an exanthematous, or typhous, or some other process attended with exudation, such, for instance, as the cholera process; it arises also from pyaemia, &c. Other exudative processes give rise, either from the first and exclusively, or else after furnishing, or whilst furnishing, a plastic product, to a loose, pulpy, puriform or sanious exudation, of a variously shaded brown and green color, and a very offensive smell. The mucous membrane, under such an exudation, softens to a pulpy, or a shreddy and crumbling mass, which has an offensive smell and the same color, or may be also dark brown, chocolate-colored, or like coffee-grounds from hemorrhage. These processes are named putrefactive, and may be primary, but they are much more frequently secondary. A special form in which these exudations appear, is that of the benign and malignant aphthae,—exudations, that is, which, at first, at least, are confined to rounded or oval spots. They are most common by far on the mucous membrane of the mouth and pharynx; they do, however, occur on all other membranes, but are then generally secondary. The process of softening that goes on beneath the exudation, occasions a loss of substance in the mucous membrane, that may be called an aphthous ulcer. Other exudative processes, which for the most part extend over large portions, or the whole tract, of a mucous membrane, furnish products that are either albuminous, jelly-like, and pellucid; or milky, mixed with delicate fibrinous flakes, and pasty; or thin fluid, mostly serous, and of a very pale grayish-white, yellowish, or reddish color, or quite colorless. They run their course, sometimes with moderate redness and injection, sometimes with remarkable paleness of the mucous membrane, with tume- faction, infiltration, and at length softening and removal of the epithe- lium, with softening of the tissue of the membrane itself, and degenera- tion of it to a pale-grayish, yellowish, rosy, or dark-red stratum that is apt to bleed, and may be wiped off like pap, and with similar softening of the follicles. Such processes are, for the most part, secondary, and their chief seat is the mucous membrane of the intestinal tract. The most remarkable of them for extent, for quantity of product, and for the rapidity of its course, has been learnt in modern times,—the Asiatic cholera. In very severe cases of the exudative process, the submucous muscular tissues become paralyzed: they are blanched, relaxed, and infiltrated. c. The Exanthematous processes upon mucous membranes are allied to the exudative. They are sometimes the manifestation of a very great degree of constitutional disease, and form a complementary addition to eruptions on the general integuments ; sometimes they are vicarious with the crisis of an exanthema upon the skin, which, from various influences that we are ignorant of, is insufficiently developed ; and sometimes they constitute a specific eruption, arising from a special relation between the general disease and a particular tract of mucous membrane,—mucous exanthema, as it has been lately denominated. The seat of the two former kinds is chiefly mucous membrane where it adjoins skin, but to a 56 DISEASES OF certain extent also it is found where mucous membrane is connected with the original " atriis morbi ;" such as the lining of the mouth, pharynx, tracheal passages, conjunctiva, or urethra: the last kind, on the con- trary, is confined to particular parts of the mucous system, as to the ileum in typhus, and the colon in dysentery. The following are the forms observed: diffused or circumscribed red- ness or spots,—erythema which sometimes, by their various tints, betray the kind of constitutional affection that exists; vesicles of various sizes and number, separate or confluent, and filled with a fluid that is chiefly serous, but passes through sundry changes as the process goes on: and pimples and pustules of different dimensions. As belonging to this class, we may enumerate erysipelatous affections of the pharynx, especially those which take place in scarlatina, and in its anomalies; the miliary eruptions that occur upon mucous membranes affected with catarrhal in- flammation, or at the commencement of dysentery; the affections^ of the mucous membrane of the larynx in measles; the pustules of variola on the pharynx and air-passages, and on the urethra; and herpetic pustules. In many processes, generally enumerated in this class, which assume the form of papules and nodules on the membrane, the principal seat of the affection is the follicular apparatus, as is the case in true intestinal typhus, and in several other processes allied to it. Exanthemata upon mucous membranes pass, in favorable cases, to the same terminations as the corresponding processes upon the integuments; but in acute cases, in which, from any cause, the exanthematous process is concentrated upon one section of the mucous system, it may readily occasion softening of the membrane, and loss of substance by ulceration of its tissue. Of this kind are the ulcerations that occur, rarely indeed, on the mucous membrane of the throat and larynx during and after scarlet fever, measles, and variola; as well as the softening of the mu- cous membrane of the large intestine that constantly accompanies severe cases of dysentery, and the peculiar metamorphosis that almost invariably takes place in the typhous follicle of the intestinal mucous membrane. The study of this portion of the pathological anatomy of mucous mem- brane is attended wit|j great difficulties: for, with the exception of some of the processes that have been mentioned, such as typhus and dysen- tery, they occur so seldom, the products of the exanthema are so delicate, and there is such loss of color and collapse of the membrane after death, that very little is known about it. 3. Ulcerative processes.—Ulcerative processes are very frequent upon mucous membranes; and withal very various in their forms, in regard both to the anomaly of texture which gives rise to them, the mode in which the ulcerative solution takes place, and the form which they derive from the stratum in which they occur, and from the fact of its having been the first diseased part or not, &c. However, therefore, I may think to have increased our knowledge of several of the processes connected with these ulcerations, and to have established the diagnosis of several forms of ulcer, especially upon the mucous membrane of the alimentary tube, yet not more than a few foundation-stones have been laid for a compre- hensive knowledge of the ulcers of mucous membranes. They are sometimes the result of the softening of mucous membrane MUCOUS MEMBRANES. 57 which is induced by the processes just described, the catarrhal, the ex- udative, and the exanthematous. Sometimes they commence upon the surface, sometimes deep in the parenchyma of the membrane : they may attack the whole of a certain circumscribed space at once, or advance from a definite starting-point, as in the case, for instance, when those processes are situated in the follicles. Moreover, though sometimes the immediate result of the process, they are at other times a secondary con- sequence of it, being brought about by the action of matter exuded upon the free surface, as well as in the tissue, of the mucous membrane, after that matter has undergone some solution,—some change of its nature,— some metamorphosis; as is the case, for instance, with aphthae, and with the matter of typhus. Or again, they may be produced by the metamorphosis of some new growth which has been infiltrated into the tissue of the membrane, or of some tumor which has encroached upon it, and by the reaction conse- quent on that metamorphosis : of this kind are the tubercular, and the cancerous ulcer, &c. The various ulcerative processes upon mucous membranes sometimes run an acute course, sometimes a chronic. They sometimes extend readily from the mucous to the submucous tissues; sometimes their tendency is rather to spread superficially, that is, to abrade the mucous membrane, and merely expose the tissues beneath it; sometimes like the fundamental processes by which they are occasioned, as for instance, the typhous process, their progress is limited by the adjoining submucous tissues. This subject will be found to be pursued further where the ulcerative processes of the parts of the mucous system are separately adverted to. 4. (Edema of mucous membranes.—All the processes already de- scribed, especially the exudative and exanthematous, are attended with oedema; and so also is the ulcerative, in various degrees and to various distances from the actual seat of disease ; but oedema may originate also in the submucous cellular tissue, in consequence of many primary and secondary congestions and inflammations which occur in it and in its neighborhood. The usual seat of the infiltration is the submucous tissue. It gene- rally forms a pale yellowish or grayish, translucent and tense, or a flabby and movable swelling, not distinctly circumscribed, over which the upper layer of the mucous membrane is stretched: when it is considerable, it extends through the whole thickness of the mucous membrane also, which then loses the character of its structure, and may be torn with the slightest effort. The oedema reaches its higher degrees chiefly on membranes and du- plicatures of membrane which are extended loosely and movably over thick strata of cellular tissue, especially upon the mucous membrane of the intestines and their valves and folds, and the duplicatures at the orifice of the larynx. Its importance depends upon the processes which occasion it: it is only at certain parts that it becomes at all serious, as at the glottis, where it contracts and at last closes the orifice. 5. Deposition—Metastasis—on mucous membrane.—This, on the whole, 58 DISEASES OF is an uncommon appearance. It sometimes presents the character of a small collection like a furuncle, and sometimes forms a flat scale over the superficial layer of the mucous membrane. It ends in ulceration or in slough, according to the nature of the poison in the blood by which it is occasioned. 6. Mortification of mucous membrane.—Mortification presents itself in various forms : the mucous membrane may become a grayish-white, or whitish-yellow, dry and rotten, or moist and lacerable, eschar : such is the change that results from pressure in strangulated hernia, from ex- cessive distension and extension, or when it is separated from the sub- jacent tissues, through which it is supplied with bloodvessels. Or, after having suffered absolute stagnation of the current of blood, it may degenerate into a dark-brown, or dark-greenish, shreddy friable substance, which gives out the extremely offensive smell of sphacelus, and is more or less infiltrated. Or else, during the softening of an inflammatory product, which is in- filtered through the tissue of the membrane, and generally also is com- bined with an aphthous exudation upon its surface, diffused, or more com- monly circumscribed portions of the membrane degenerate into a shreddy and crumbling, or a uniformly pulpy mass, that is variously discolored, and has a very offensive odor. When affected with the actual sloughing described under the first-named forms, the mucous membrane generally shares that condition with other adjoining structures. 7. Softening of mucous membranes.—If we exclude from considera- tion the relaxations of tissue that mucous membranes suffer from inflam- mation and oedema, and the solutions which take place during and after exudative processes, we shall still find conditions occurring on some mu- cous membranes, particularly in the stomach, oesophagus, and intestinal canal, which differ entirely from the former, both in their causes and in their anatomical characters,—conditions which are included within the term softening in its restricted sense : they will be found treated of amongst the diseases of the apparatus in which they occur. 8. Change of texture which mucous membrane undergoes when pre- ternaturally exposed to atmospheric air, and when long subjected to dis- tension.—a. The mucous membrane of prolapsed and everted organs is liable to the former kind of change. At first an acute inflammation at- tacks it and occasionally rises to considerable severity, but afterwards it becomes chronic, and at length terminates in induration. Such mem- branes become dark red and swollen; their secretion soon increases in quantity, and then they produce a puriform moisture: they may even clothe themselves with a plastic exudation, while underneath they appear raw and excoriated. At length the inflammation moderates the se- cretion just mentioned ceases, and the redness diminishes but the mem- brane remains thickened, and its texture more compact than natural • it is covered with a thick closely-adherent layer of epithelium; and he'nce appears dry on its surface, smooth, and glistening ; its internal texture resembles that of tendon ; and it acquires something of the appearance of the corium, or of a regenerated, or cicatrix, tissue. b. The second change of texture affects the inner coat of the excretory ducts and reservoirs of glands, and of other hollow organs which are lined MUCOUS MEMBRANES. 59 with mucous membrane : and the condition under which it occurs is that of some contraction or closure of the orifice, in consequence of which the secretion of the gland, or of the mucous membrane itself, accumulates, and gradually distends the cavity beyond its normal dimensions. It is observed in the gall-bladder, in the Fallopian tubes, and even in the uterus, in the excretory apparatus of the kidneys, and in the appendix vermiformis of the caecum. This change of texture consists in a slow atrophy of the mucous membrane, and gradual condensation of the submucous cellular tissue to a serous layer, which at last takes the place of the mucous membrane. The tissue being changed, of course the secretion also is gradually altered; and instead of mucus a fluid like synovia, and afterwards a thin serum, are secreted. This condition bears generally the name of dropsy of the respective organs,—dropsy of the gall-bladder, of the Fallopian tubes, of the uterus, &c,—dropsy of the excretory ducts of glands. The mem- brane which usurps the place of the mucous structure is thenceforward subject to the diseases of serous membranes in general; and some of them are remarkable as not occurring to normal mucous membrane, or to submucous cellular tissue; such for instance as ossification. 9. Adventitious formations.—Strictly speaking, very few adventitious growths are developed in and from the parenchyma of mucous membranes themselves : for, with the exception of teleangiectasis, tubercle, and cancer, and of these indeed, only particular conditions and forms, almost all the new growths belong to the submucous cellular tissue. But as that tissue is intimately connected with the mucous membrane over it, so are also the new growths that originate and spread in it. The mucous membrane becomes involved in various ways, as may be deduced from the following remarks. There are, moreover, several other affections of the same class to which mucous membranes are subject only after having undergone a previous change of texture. a. Growths of horn and hair have, in a few cases, been seen upon dif- ferent mucous membranes, particularly on the conjunctiva, the mucous membrane of the intestinal canal, and that of the urinary bladder. b. Lipoma.—This growth is almost confined to the submucous cellular tissue of membranes near which a considerable quantity of fat is occa- sionally deposited. It is by no means rare in the submucous cellular tissue of the intestinal canal, especially of the small intestines ; and it is met with also, but less frequently, in the stomach. It forms a rounded tumor, with a broad, or a somewhat constricted base ; its size is mostly inconsiderable; it protrudes into the cavity, and is covered with the lining membrane of the organ in which it is developed. c. Cysts are formed in cellular or other submucous tissue, but they very rarely occur. They displace and stretch the mucous membrane, and, when of large size, even produce attenuation and atrophy of it. d. Fibroid tissue occurs as— a. An adventitious fibroid growth of various size in submucous tissues : as such it presents itself under two forms, the second of which, for several reasons, is of much importance. One of these forms is that of spherical, oval, or subovate, bluish- white, tough and elastic, concretions, the texture of which is very com- pact. It occurs in extensive tracts of submucous cellular tissue, parti- I 60 DISEASES OF cularly in the stomach and intestinal canal, and forms movable tumors which protrude inwards: they are very seldom larger than a pea. The other form is that which has been named fibrous, to distinguish it from the mucous or cellular polypus; an adventitious growth of fibrous, and for the most part lax, texture, vascular, succulent, apt to swell, and generally more or less lobulated towards its periphery. It takes root by a single or by several stems, in submucous tissues of fibrous or muscular texture ; it then grows towards the cavity of the organ, and thrusts before it a covering of mucous membrane. If it reach a large size, it ex- pands the cavity on all sides; but if there be any hindrance to its in- creasing in the direction of the cavity it will grow principally in one di- rection, in either case destroying the walls of the cavity, even though they be of bone. Of this kind are the large fibroid growths, also named sarcomatous polypi, that spring from the submucous periosteum of the nares and adjoining cavities, from that of the basilar process of the oc- cipital bone (the upper wall of the pharynx), from the perichondrium of the cartilages of the larynx, and from the innermost (submucous) layer of the substance of the uterus. /?. Fibroid tissue occurs also as fibroid and cartilaginiform thickening of the walls of mucous cavities which have been converted in the way al- ready described into serous cavities : the fibroid tissue may then, as in the case of membranes originally serous, be deposited as an exudation upon the surface of the new membrane, or as a subserous production, beneath it. Under the same conditions, that is to say, only after the mucous membrane has undergone this complete change of texture, e. Anomalous bone is formed upon it, or ossification, as it is called, takes place: and this again may be a subserous production or an ossified exudation on the surface. Cavities of mucous membrane are in this manner sometimes converted into bony capsules; but the only instance in which I have observed it is the gall-bladder. /. New growths of cellular tissue, or condylomata, occur upon some mucous membranes, especially upon the female organs of generation, in the mouth, &c. g. Teleangiectasis.—Congenital vascular naevi are, on the whole, a rare occurrence in mucous membrane, especially if those be excepted which extend from the skin to adjoining mucous textures, as, for instance, from the skin of the face to the mucous membrane of the lip. When they do occur, it is usually in the form of bluish-red, flattened or irregular, ele- vations of various sizes, and rarely in that of actual tumors or excres- cences : they may be most frequently observed on the inner membrane of the intestinal canal. h. Tubercle.—Tuberculosis is one of the most frequent, and, at the same time, most destructive diseases of mucous membranes : its frequency, however, is not the same in all of them. The devastations which it pro- duces, too, though they vary considerably in their degree, are greater, on the whole, than those which result from any other process upon mu- cous membranes. The tubercle is deposited in the parenchyma, i. e. in the corium of the membrane, and in the immediately adjoining stratum of submucous cellular tissue, «. Either gradually and at intervals, for the most part without any MUCOUS MEMBRANES. 61 manifest congestion and stagnation, in the form of isolated or clustered gray crude granulation; /5. Or, with evident symptoms of inflammation, as an inflammatory product, infiltered into the parenchyma of the membrane, and partly also exuded upon its free surface. The product in this case, either has from the first the character of yellow tubercle about to soften; or it be- comes rapidly discolored, and soon acquires that character. Large tracts of mucous membrane degenerate into a lardaceo-caseous and firm, but friable layer, and the submucous tissues become dense, callous, and thickened. Acute tuberculosis, in the form of extremely fine, transpa- rent, and crystalline, or of opaque, wheylike, grayish granulation, seems not to occur on mucous membranes, at least, not in the marked degree in which it prevails on serous membranes, and in certain parenchymatous organs. Precisely the same forms of tuberculosis seem to occur in the follicles and glandular apparatus peculiar to certain mucous membranes, such as those of the mucous membrane of the bowel. Of the several large sections of the mucous system, the most frequently diseased is the intestinal tract; next come the air-passages, and after them the lining membrane of the sexual organs of the female, the semi- nal ducts of the male, and the urinary passages in both sexes. And it is chiefly certain parts of these membranes that are subject to the disease, as will appear in the consideration of the diseases of the several organs; for there are some parts which rarely, and others that never become tu- berculous. Those to which the former observation applies, are certain portions of several mucous membranes, which, in the abundance of their glandular apparatus, approximate to the character of so-called parenchy- matous organs; but still there are remarkable exceptions to this rule. Thus, in the intestinal mucous membrane, the disease occurs chiefly in the ileum, which has an extensive follicular apparatus, and in the follicles themselves ; and, in the mucous membrane of the air-passages, principally at the posterior wall of the larynx, which is so rich in glands; in the sexual organs of the female, on the other hand, the cervix and vaginal portion of the uterus, and the vagina itself, all which are richly supplied with follicles, are exempt from tuberculous disease; the glandular mucou3 membrane of the stomach is rarely the seat of it, &c. Tuberculosis of mucous membranes is sometimes a primary disease, as is the case particularly when it occurs on the inner coat of the Fallopian tubes and uterus; but far more frequently it is a secondary and depen- dent affection, occasioned by previous, and for the most part advanced, tuberculosis of some parenchyma which stands in close relation with the diseased membrane, or of some generally important parenchymatous organ, such, for instance, and, above all, as the lungs. This condition of tuberculoses in mucous membrane, viz. their origi- nating from a considerable amount of constitutional disease, which is already manifested by an advanced tuberculous affection of a parenchy- matous organ, is the reason why tubercle in that membrane undergoes scarcely any other metamorphosis than that of softening, and gives rise to tubercular phthisis of the membrane. The gray granular tubercle softens in the substance of the mucous 62 DISEASES OF membrane, and forms a small vomica. Opening on the free surface of the membrane, the vomica becomes a small circular ulcer, the margin of which is sometimes flabby, but usually is hard and prominent: its base is composed of a stratum of mucous membrane, or of submucous cellular tissue ; and it also may be soft and lax, but it is usually callous and con- densed. This primary minute tubercular ulcer enlarges superficially as well as in depth, by coalescing with neighboring ulcers, and by the softening of tubercles which have been deposited secondarily, during its progress, at its border and base. It thus exchanges its original form for a secon- dary and still more characteristic one ; for it acquires sinuous, serrated, jagged, and gelatino-lardaceous borders, and a dense callous base, beset with islands and far-jutting promontories of mucous membrane; while the tissue of the base, as well as of the borders, appears interwoven with tubercles, for the most part yellow and softening. The tuberculous infiltration of mucous membrane burrows in different directions, and becoming caseo-purulent, degenerates, together with the tissue which it involves, and which has lost its characteristic structure, to a tubercular sanious matter. From the mucous membrane, and especially from the base of the tuber- cular ulcer, the deposition of tubercle advances into the different submu- cous tissues, and gives rise to a destructive ulceration that in membranous canals and cavities leads to perforation. The tubercular ulcer of mucous membrane very rarely heals, as may be supposed from what has been said. When it does so, it always leaves at its borders, and still more in the structures that formed its base, a permanent callous condensation, corresponding to the original size of the ulcer. But for an account of this, and of several essential peculiarities which tubercle and the tubercular ulcer present on different mucous membranes, I must refer to the description of the diseases of particular mucous organs. i. Cancers.—Mucous membranes are very subject to cancerous affec- tions ; some are more frequently diseased than others, and especially the mucous lining of the whole alimentary tube. It would, however, be erroneous to regard every such affection as a primary affection of the mucous membrane; for in the majority of cases, the cancer originates in the subjacent cellular tissue and the mucous membrane is diseased secon- darily and by contiguity. Although any of the various cancerous growths may occur in mucous and submucous tissues, yet, so far as I am aware, nothing definite, nothing supported by numerous observations, can be brought forward to prove the occurrence of cancer primarily in mucous membrane, or to show the condition of that membrane, when the cancerous growth ap- pears originally in the submucous tissue, except in the cases of areolar, medullary, and fibrous cancers. The areolar and the medullary are the forms of cancer in which pri- mary cancerous degeneration occurs in the tissue of the mucous membrane. They are rather frequent. The areolar is known by its characteristic degeneration : it extends for the most part, over large tracts of mucous membrane, especially in the stomach and intestinal canal. MUCOUS MEMBRANES. 63 The medullary presents itself,— a. Sometimes as nodules, which are of a round, or slightly convex form, or which even produce a navel-like depression on the free surface of the mucous membrane; they are situated in its parenchyma, but pro- ject more or less above its free surface: and they have a lardaceous, or medullary (encephaloid) appearance. Cancer of the mucous membrane in this form is scarcely ever the primary cancer in the system, but is almost always a consecutive affection, combined with some previous cancerous disease of the adjoining submucous tissues. j3. Another form of cancer which occurs more frequently, and particu- larly on certain mucous membranes, is looked upon most properly as a kind of medullary cancer. When in an advanced state, it forms more or less extensive spherical tumors (fungi), which are attached by a con- stricted neck-like base, or even what might, with reference to their bulk, be named a pedicle. They take root in the parenchyma of the mucous membrane and the immediately adjoining cellular tissue. They are for the most part loose, very vascular, abundantly supplied with blood, and of a bluish-red color; and they readily swell, and bleed frequently and severely. They are composed of a delicate membranous texture, that sometimes breaks down into fibres, sometimes into laminae, and is filled with a whitish or whitish-red marrow, or a similar encephaloid juice. In many cases, the mucous membrane is affected in this manner at some one cir- cumscribed spot; in other cases the growths spring up on a membrane in the form of smaller excrescences which are attached by a pedicle, and at their free extremities are shreddy and grow like a cauliflower, and are clustered so closely together, that the whole tract of membrane which they occupy seems to be degenerated into them. Their elementary tex- ture, and their development from their mother soil, has been already de- scribed, and a special form has been mentioned as an epithelial fungus. I have also shown their alliance with the cauliflower excrescences that occur on anomalous serous membranes, i. e. on the inner surface of cys- toid growths; and, lastly, have mentioned, that they no doubt constitute for the most part the erectile cancerous tumors, as they have been called, particularly by French observers. They are often found in the mucous membrane of the stomach and intestinal canal; but they are particularly frequent within the urinary bladder. Frequently, and indeed generally, they constitute the primary cancer, that is to say, that which first appears in the organism ; and they continue the only one, until by their sanious discharge and hemorrhage, they prove fatal. Mucous membrane is always affected by fibrous cancer secondarily, being destroyed by the advance of that growth from the submucous tissues. The mucous membrane may be in various conditions: of these some have been described already, and others will be mentioned in the account of the particular organs in which they occur; but there is one character which may be spoken of in this place, Avhich it shares with other structures that become involved by contiguity in cancerous diseases, and more particularly Avith the skin, namely, that when encroached upon by a mass of cancer, mucous membrane becomes adherent to it, united with it, and at length entirely lost in it. PART VII. ANOMALIES AND DISEASES OF THE SKIN. VOL. III. PART VII. ANOMALIES AND DISEASES OF THE SKIN. § 1. Defect and Excess in Development.—Congenital deficiency of the integuments is extremely rare, whether extending over the whole, or only over parts of the body. An instance of the former kind was ob- served by Bartholin; and Cordon met with a case in which the skin was wanting from the knees to the toes. Upon the skin of new-born children there are often seen circumscribed spots, the complete development of which has been arrested by some pressure during foetal life. It is uncommonly thin and transparent, and its defect appears proportioned to the closeness of its union with the fibrous and serous membranes beneath it. Instances of this deficiency are seen in hemicephalus, in spina bifida, and in several of the fissions of the anterior wall of the trunk. A congenital defect of another kind has also been met with, in wrhich the general sac of the integuments is so small at particular spots as, according to an observation of Otto's, on the lower extremities of new-born children, to form strictures. An acquired partial deficiency of skin is produced by wounds, burns, suppuration, sloughing, and other causes from which losses of substance ensue. A preternatural growth of skin may occur as a congenital condition and produce an increase in the capacity of the general sac. The addi- tional skin is loose and movable, and hangs in folds and appendages; thus at the end of the spine it forms a sort of tail. Instances of an ac- quired excessive growth of skin are furnished by several of the encysted tumors : they usually present here and there spots that resemble cutis ; and they are the tumors in which the hair that grows in cysts is chiefly found. The same class includes all cases of regeneration of skin, whether de- stroyed by wounds, burns, or cauterization, by the various ulcerative processes, or by mortification. The loss is in general easily repaired, but always in a form that differs more or less from the original skin. The new structure consists of a dense cellular layer of various thickness and of epidermis; but it has neither papillae, sebaceous glands, hair follicles, nor sudoriparous glands. It is usually tightly stretched and whiter than natural: sometimes it is smooth and shining, sometimes it has a rugged and uneven, stellate, knitted, or areolar surface : very often it is but slightly movable over the subjacent structures, and occasionally 68 ANOMALIES OF is intimately united with them. It lies beneath the level of the surface of the rest of the skin. § 2. Anomalies in the Size (capacity), the Thickness, and the Form of the Sac of general Integuments.—In regard to size, the congenital anomalies already mentioned belong also to this section. Further in- stances of acquired anomaly in this respect are found, on the one hand, in the contractions, shortenings, &c, which result from various losses of substance and cicatrization consequent upon them; and on the other hand, in the dilatations to various amounts, which are produced, for the most part, by gradual distension or traction. Moreover loose, or soft and elastic, pendulous growths of various sizes are formed upon the skin; within an attenuated corium they enclose a delicate cellular tissue, most of which is newly formed (molluscum simplex), and occasionally they contain also some adipose tissue, wdiich has protruded through the meshes of the deeper layer of the corium. The form of the cutaneous sac is disfigured not in these cases only, but also in a more or less striking manner when there exist, or have existed, many diseases of its texture. The skin deviates from its natural thickness in both directions. An abnormal thickness is sometimes occasioned by congestion or in- flammation of the skin, and attended with expansion and moistness of its texture: sometimes it is the result of a continuance or repetition of the same processes, in which case the deposition of their plastic pro- duct in the tissue of the skin adds condensation of texture and firmness to the increase of its thickness: sometimes the cause is hypertrophy, which again may chiefly affect the papillae or the deeper layer of corium: and, lastly, it is sometimes the effect of the development of adventitious growths in the corium. Hypertrophy of the skin is in many naevi a congenital affection ; but more frequently it is extended over wide tracts of skin, and is a result either of stagnation in the venous or lymphatic system, or of habitual inflammatory processes, particularly those of exanthematous and impeti- ginous nature. It accompanies, on the one hand, under the name of elephantiasis (Pachydermia of Fuchs), exuberant growths—hypertrophies —of the subcutaneous cellular tissue ; and on the other hand, most pro- bably all, but particularly the more important, anomalies of the secretion of epidermis. The form it presents is very various. Sometimes the hypertrophied portion of skin is smooth, sometimes the irregularity of the hypertrophy renders the surface rugged and tuberous : the skin may be movable over the subjacent structures, but in advanced degrees of the disease it is stiff and adherent, especially to fibrous structures; and the diseased part, the leg for instance, then becomes immovable; its muscles, and even its bones shrink, and the articular extremities of the latter become anchylosed. The papillae become hypertrophied in various degrees and forms: sometimes they resemble the villi of the intestines: sometimes they con- stitute excrescences which are attached by a pedicle, and truncated or split like a tassel at their free extremity, or are sessile, rounded and like a mushroom, &c. Hypertrophy in these forms are seen on naevi THE SKIN. 69 and on portions of skin which have long been withdrawn from the atmo- spheric influence, and exposed to that of warmth and moisture, or have been covered with emollient and slightly irritating plasters, &c. It is noticed also in parts at which the skin has been in contact for a length- ened period with its own secretion, as it is in the deep fissures between the rolls and knots of skin in cases of elephantiasis ; in the neighborhood of chronic ulcers; and on spots of skin covered with scaly eruptions: the hypertrophy of the papillae is very marked also in decided cases of ichthyosis. Lastly, it is found,—at least it is assumed as probable,— that the genuine common Avart (Verruca vulgaris) is a hypertrophy of the papilla beneath a very thick layer of epidermis, which dips in sheath- like processes into the deeper parts of the growth. Warts are exceed- ingly common upon the hand, especially on the fingers; occasionally too they occur in other parts, as, for instance, on the forearm. The skin may yield to distension or traction from within, and become unnaturally thin. Instances of this are met with in cases of dropsy of very dilatable serous sacs, of the peritoneum, for instance, or the tunica vaginalis testis: in anasarca; or when large tumors are growing in the subcutaneous cellular tissue. The fasciculi of fibres that compose its deeper layers separate from one another, its exterior dense stratum be- comes so thin as to be transparent, and even at last to suffer gradually a solution of continuity. In the foetus, under these circumstances, it as- sumes the character of a serous or a fibro-serous membrane, and uniting intimately with the subjacent membranous structures, appears, as was before said, to be deficient at such spots. When long-continued pressure is exerted upon one fixed spot of skin, such, for instance, as is produced by a tumor, complete atrophy some- times takes place : the skin is gradually reduced to a thin vascular stra- tum, which secretes a viscid epidermal mucus, and at length is completely perforated. Primary atrophy of the general integuments, strictly speaking, does not occur; but they become atrophied rather frequently as a secondary consequence of repeated attacks of inflammation, especially those of im- petiginous character. The skin becomes thin and vascular, acquires a dirty brownish or bluish color, and generally gives way upon very slight injury; at last it changes into a dense white cicatrix tissue. § 3. Anomalies in Consistence.—Laxity of the corium exists congeni- tally in cases of naevus ; and congestion or inflammation will, after birth, bring on a state in which the texture of the skin is loosened or expanded. It becomes loose also in parts which are withdrawn from the air, and continually exposed to moisture; in parts where perspiration is con- stantly taking place, and in the hands of little children, who have a habit of sucking them, &c. But, again, cutaneous tissue is sometimes increased in density and hardened; it becomes hypertrophied and thickened, or without being thickened, it may be hypertrophied, dry, and harsh. A certain amount of softness of the skin, as well as of hardness and dryness, is sometimes merely an individual peculiarity of the whole organ. 70 ANOMALIES OF § 4. Solution of Continuity.—The general integuments are, in the first place, liable to very numerous and very varied mechanical injuries: solutions of continuity may also be produced in different Avays by the action of chemical agents upon the skin; and, lastly, the same result ensues from the many ulcerative processes that take place in this struc- ture. We must, however, notice the various forms of separation of the epidermis from the corium (spontaneous excoriations), that are occasioned and kept up by diseases of the skin, the spontaneous lacerations already alluded to, that are produced by extreme distension, and the fissures ex- tending into the corium, which, in many chronic diseases, proceed from the splitting of an extremely dry epidermis (chaps—Rhagades). They heal in the usual manner, either by immediate cohesion of the lips of the wound, or by granulation and cicatrization. § 5. Anomalies in Color.—The deviations from the natural color of the integuments are very numerous. They are, in general, either an ab- sence of color or pallor; or a deepening of it; or Avith one or other of these may be combined a discoloration. Sometimes they are universal, at other times they are confined to larger or smaller tracts, or even to points, of the skin, in Avhich case they are often almost peculiar to par- ticular regions of the body. Their site may be the cutis vera, and their principal cause an anomaly in the quantity of blood circulating in its vessels, or rather a transient or permanent alteration in the constitution of the blood ; or they may be situated in the epidermis, especially in the innermost—the Malpighian—layer of it, and may proceed either from the removal of the fibrin from the elementary cells of which the layer is composed, or from their containing an excessof fibrin, or some un- usual pigment. Their cause is, in some cases, an anomaly in the con- stitution of the blood ; in others it is some external influence affecting the skin during life: but in neither case is the mode in Avhich the cause operates fully understood. Lastly, all diseases of the texture of the skin are, of course, attended and followed by changes of its color. Pallor, or change of the color to a variously tinted white, is observed during the lack of blood that succeeds hemorrhage and exhausting dis- eases ; it occurs in dropsy, and in a very marked degree in cases of chlo- rosis. In Albinoes (Leucaethiopia) it is the result of a congenital defi- ciency of pigment, while in Achroma, the same defect is acquired. The latter condition may ^ be seen in Negroes, and indeed in Europeans, wherever the surface is naturally dark-colored; as, for instance, at the parts of generation in either sex, where it appears in the form of white spots of various size, that gradually spread, and at last, in some few cases, amount to a general discoloring. Yellow, either pure or mixed with green, is the well-known color in cases of icterus. A similar hue, but inclining to brown, arises from the deposit of pigment in the epidermis, either in small stains, or in large discolored tracts, or even over the whole surface of the body : the cause of this deposit is still partially obscure. The uniform embrowning of the skin, brought on in parts that are exposed especially to the light of the sun, is of this kind also; as well as the spotted stains of summer freckles T n E SKIN. 71 (ephelis); and the liver spots (chloasma) which depend upon anomalies in the biliary system, and in the sexual system of the female. The color of the skin generally becomes dark, when with neglect of it and indul- gence in alcohol are combined infiltration of the liver with fat, and a tallowy state of the adipose substance, particularly of the subcutaneous layer of fat. The skin, in the last case, feels fatty, soft, and velvety, like that of a negro ; its color proceeds from the deposition of a pigment containing fat in the deepest layer of the epidermis,—a fact of particu- lar interest, on account of the combination, just mentioned, in which it stands. Red coloring of the skin appears in extremely numerous forms, and with various shades of yellowish, bluish, livid, coppery, brown, and so on, which are well known as pathognomonic of various diseases. It occurs in cases of mere congestion, in inflammation, in exanthematous and im- petiginous processes, in teleangiectasis and many of the diseases of the textures of the skin. The redness inclines to blue, and even to black, in hemorrhages into the cutaneous tissue, or upon its surface, in sugilla- tions, ecchymosis, vibices, petechiae, &c. In cases of cyanosis there is a general bluish or blue color of the in- teguments ; but it is principally marked in situations where the skin is delicate and highly vascular, and in the extremities. The blue tint, when limited to certain spots, is a result of local congestion. A transient blue- ness of the skin has also been noticed, in a few cases, at various parts of the surface, but its internal cause is unknown (Otto). Spots (livores) of a bluish-red, a livid, or a blackish-blue color, appear upon the body soon after death. Various shades of bronze are produced upon the skin by the long-con- tinued use of nitrate of silver: they sometimes gradually disappear, but occasionally they remain permanently. No evidence has yet been ob- tained as to the seat of this discoloring: it appears first, and has its deepest hue, on parts of the body which are exposed to light. A black color is observed principally in old cachectic persons, in whom it is sometimes diffuse and extends over large tracts of skin, especially in the lower limbs, and sometimes appears in the form of black nodules, which are deposited chiefly on the face. It has in a few cases been seen gradually spreading over the whole body. It is named me- lasma, and is a different affection from cancer melanodes of the skin. Almost all these discolorings occur also, as congenital and partial ap- pearances, in the various naevi. A tawny color, a dirty gray, a dirty bluish, a leaden hue is by far the most frequent of all the changes in the color of the skin: it is an ex- pression of dyscrasia, and of faulty chymification, and is found in the course of acute and chronic diseases. § 6. Anomalies of Texture. 1. Congestion,—hemorrhage,—ancemia.—A passive congestion, limited to certain parts of the skin, may be constantly observed on the dead body. It is seen, too, on the Avhole integuments, as a dark redness, with a blue or black tint, in the course of acute and chronic adynamic dis- eases, and in most instances of agony : it is very marked in parts of the 72 DISEASES OF body that are at a distance from the heart, and becomes extremely so if there be any mechanical interruption of the circulation. Congestion in a higher degree gives rise to hemorrhage into the tissue of the skin ; sometimes in small circumscribed spots, sometimes in streaks, and sometimes to a large extent; it may take place upon the surface of the corium beneath the epidermis, or in the tissue of the former; and, in the latter case, it is usually associated with hemorrhage into the sub- cutaneous tissue also. The bloody spots in Werlhof's morbus maculosus1 and in scurvy, the petechiae in the course of typhus and typhoid fevers, &c, are instances of such hemorrhage. Its occurrence is facilitated by delicacy and susceptibility to injury on the part of the walls of the capillary vessels, and by a tendency to transudation on the part of the blood. Anaemia of the general integuments is a local part of a universal anaemia, and is always accompanied with collapse and pallor of the skin; the pallor acquires a waxen character when the skin is delicate, and especially if at the same time it be rendered tense by the presence of fat or oedema. 2. Inflammations.—Inflammation of the skin (dermatitis) may result from very various external influences, which are but partly known, and be an idiopathic, substantive disease : it also very frequently occurs as a symptomatic and dependent affection,—a reflex of other morbid processes. Regarded in an anatomical point of view, it is found sometimes diffuse, and extending over large tracts of skin ; sometimes it is circumscribed, and confined to one or more small spots. In the first form, the true cutis is the part attacked, and sometimes only its external layer and papillae—erythema: at other times the deeper layer also, that is to say, the whole thickness of corium is affected; and that constitutes phlegmonous inflammation. From it, and particularly from the erythematous form, there are several transitions to the circumscribed inflammation of skin. The simplest form of the circumscribed is furuncular inflammation. Allied to this are several of the acute and chronic exanthematous processes. I proceed now to speak of them in detail.1 a. Erythematous inflammation of skin.—Erythematous inflammation, as has been said, is an inflammation of the outermost layer of skin, which contains the papillae; and it includes not only the slight inflammation produced by external agents, such as the heat of the sun, fire, cold, irri- tating plasters, trifling injuries, the stings of insects, &c, but also spon- taneous inflammations of exanthematous nature, which are essentially connected with other morbid processes such as the various erythemata, erysipelas, scarlatina, measles, intertrigo, &c. Erythematous inflammations usually run an acute course, but several of them are apt to recur, and to become habitual. The following are the anatomical characters of the disease. The red- ness is for the most part bright and uniform, but sometimes it is irregular, presenting here and there various forms and outlines of a deeper hue, 1 [Vide Behrens' Dissert. Epistol. de Affectionibus a Comestis Mytulis Hanover 1735 p. 3.—Ed] THE SKIN. 73 and very frequently it has a shade of yellow: the color gradually dimi- nishes towards the border of the inflammation, and passes imperceptibly into that of health: it disappears upon pressure, and quickly returns when the pressure is remitted. There is mostly but trifling swelling, such as can be perceived only by the touch, and at the border of the dis- eased spot. The exudation is determined by the intensity of the pro- cess : sometimes there is none ; sometimes a watery fluid, effused slowly or very rapidly, raises the epidermis in small and scattered, or in con- fluent, vesicles. The under surface of the skin is reddened, has a gra- nular or uneven glandlike appearance, and is covered more or less dis- tinctly with a grayish-white, soft, gelatinous, plastic exudation, which is sometimes perforated and cribriform, and sometimes is reticulated on the surface next the skin. If the inflammation still increase after this product is deposited, the redness becomes darker and the exudation reddish, milky, and at last purulent. After death the redness has generally disappeared, but the swelling is still perceptible; the epidermis is either easily separable or actually separated, and the surface of the cutis is moist, and covered with a viscid and more or less puriform exudation. The redness is seen on a transverse section to be confined to the outermost thin layer of the cutis; the deeper layer is pale, and is somewhat infiltrated only when the inflammation is intense; the subcutaneous cellular tissue is then in like manner slightly infiltrated. Erythematous inflammation generally terminates by resolution, the epidermis peeling off one or more times, according to the severity of the inflammation, in the form of a mealy powder, or a bran-like scurf, or of larger scales and laminae, until the skin, covered with a new thin epider- mis, looks smooth and shining and of its healthy color. b. Phlegmonous inflammations of skin. (True dermatitis.)—Phleg- monous inflammation extends beyond the papillae into the deeper strata of the corium, and sometimes involves not only the entire thickness of that part, but also more or less of the subcutaneous cellular and adipose tissue. It arises very often from the contact of powerful external appli- cations, like burning or cauterizing bodies, with the skin; and some- times, Avithout manifest external occasion, from an internal cause; some- times, again, it is produced by the extension of inflammation from subja- cent structures, from cellular tissue, muscles, veins, or absorbents. Just as, under certain circumstances, the phlegmonous arises out of the erythematous inflammation, so also has it several degrees of its own, which pass perceptibly into one another. Its course is in most cases acute, but it is often chronic, and then usually becomes acute from time to time. The following are the anatomical characters of acute phlegmon of the skin. The redness of the inflamed spot is generally deep (saturated) and dark, it varies in its tint according to the state of the blood, and does not disappear upon pressure; the swelling is moderate, but the firmness of the skin amounts to decided hardness: the tissue of the cutis is found upon section to be red, and to have a homogeneous fleshy appearance ; its reticular structure has disappeared ; the fat con- tained in it has lost its characters; and it is also easily torn: the sub- 74 DISEASES OF cutaneous cellular and adipose tissue is minutely injected, and infiltered with a serous fluid. The under surface of the skin presents more or less redness, and a shreddy, granular appearance, and is covered with a viscid exudation, that as it softens becomes purulent. Chronic phlegmonous inflammation of the skin, such as is developed gradually out of repeated attacks of erythema, and is kept up by various constitutional affections that arise from the suppression of normal or of anomalous excretions, presents very different characters according to the degree of the inflammation, and the circumstances by which it is occa- sioned and maintained. The redness is usually dull, and inclines to a bluish, brown, or bronze color. The tumefaction of the cutis itself is slight: its density is sometimes increased, sometimes decidedly diminished; and it is accordingly firmer than natural, or loosened in texture, and spongy. The cutis when exposed is sometimes found smooth, uniformly softened and spongy, sometimes it is unevenly granular, and either soft or rather hard. It is covered with a limpid, watery, and colorless, or with a yel- loAvish, yellowish-red, and bloody, or with a thick, viscous, clear or tur- bid, and yellowish-white, or a yelloAV purulent, moisture: these products soon change to dirty white, asbestos-like, epidermal scales, and then peel off; or, becoming thickened and dried, form a covering like various kinds of bark. The subcutaneous cellular tissue is sometimes infiltrated with a viscid serous fluid, and injected; sometimes it is denser than natural, hard and lardaceous, &c.; as the fat disappears, the inflamed spot is depressed beneath the surface of the adjoining healthy skin. This inflammation terminates in various ways. Acute phlegmonous inflammation sometimes terminates in resolution, but it leaves the diseased part of a bluish-red color, very susceptible of external influences, and liable to a recurrence of the inflammation for a long time afterwards. It often gives rise to destructive suppuration of the superficial layer, or of the Avhole thickness, of the corium. That coat is then replaced by a cicatrix, which becomes more or less fixed to, and blended with, the subjacent structures: if inflamed and suppurating surfaces of skin be brought into mutual close contact, they may even unite with one another. Extensive phlegmonous inflammations and suppurations of the skin, particularly those which are produced by burns and scalds, very often lead to a fatal result, either speedily by exhaustion of the vital powers during the violence of the fever, or more slowly by their drain upon the blood, by congestions, inflammations of internal organs, especially of the lungs (hypostasis), or by exhaustive serous exudations, particularly on the mucous membrane of the intestines. Burns, and especially, as I have observed, burns of the skin of the abdomen, are in a few instances attended by fatal hemorrhage from the bowels, which is most probably introduced by an exudative process. Now and then, acute phlegmonous inflammation of the skin terminates in mortification: but of this hereafter. The consequences of chronic cutaneous phlegmon do not cease with THE SKIN. 75 the permanent anomalies to Avhich it gives rise in the stratum beneath; these are in themselves of a serious character, but they obtain greater importance from their relation to the integrity of the Avhole organism. At one time it leaves behind it a condensation and thickening of the skin, in which the subcutaneous cellular tissue also is generally involved, —hypertrophy with induration, and adhesion of the skin to the subja- cent structures. Under certain etiological circumstances, the inflamed spot becomes a vicarious organ of secretion. The exposed skin, having thrown out a few granulations, secretes a thin fluid, which is often very acrid and corrosive, and gradually eats away the substance of the cutis. If at length, the conditions being favorable, the secretion should subside, and the part heal, the cutis is replaced by a dirty brown, vascular, very vul- nerable and frail stratum, which, for the most part, produces large scales of epidermis in considerable quantity and is very long in turning pale, and in acquiring the firmness of a sound cicatrix tissue. The whole me- tamorphoses is a secondary atrophy of the cutis occasioned by the inflam- mation. Chronic inflammation of the skin frequently ends in ulceration, and especially is this the case when, from some internal or external cause, the chronic is rapidly exaggerated to a more intense degree of inflam- mation, or when inflammation returns at a part where the change into cicatrix tissue is going on. Suppurative and sanious destruction, in vari- ous forms and to different extents, that is to say, ulcers, then ensue with more or less rapidity. It may happen that several of these terminations of inflammation exist near together, or are associated with a continuance of the inflam- mation. c. Furuncular Inflammation.—The forms in which this kind of in- flammation occurs are furuncle and anthrax; it occupies the deeper, areolar layer of the corium, and the cellular tissue filling the interspaces of its netAVork. A circumscribed swelling at first presents itself, no larger than a hemp-seed or a pea, which, as it gradually increases in size, becomes remarkable for the (reactionary) inflammation that attends it: for the inflammation forms proportionally a wide halo around the swelling, corresponding with the pain and the marked degree of tension that exist; it reaches also into the deeper structures, and fixes the swell- ing of the skin to the subcutaneous cellular tissue. Before reaching its highest point of severity, it furnishes a product that is knoAvn by the name of a (Pfropf), core or plug. This product has been regarded as sloughy cellular tissue ; but, upon more thorough examination it is found to be a product of the inflammation going on in the cellular tissue con- tained in the meshes of the corium, and to resemble false membrane,— to be, therefore, exudation. It occupies the whole thickness of the corium, and exists there before the swelling is very perceptible: at first, it is closely connected with the surrounding injected tissue, but, as the (reactionary) inflammation around it produces suppuration, it is thrown out. The core has in fact nothing in common with separated sloughy cellular tissue, it is exudation; though it certainly may contain a few fibres of cellular tissue interwoven with it, Avhich have been severed 76 DISEASES OF from the rest by the suppuration going on around it. (Gendrin, Ascher- sohn.) In furuncle only one such product is formed; in anthrax there are several of them near together. The reactionary inflammation around and beneath is very considerable, corresponding in degree to the pain and the feeling of tension. If before the commencement of suppuration, and consequently before the loosening of the cores, an incision be made into an anthrax, a uniformly red, spongy, or reticular tissue is ex- posed, the meshes of which are filled with cores. At a later period, when the cores are loosening from the inflamed tissue, and suppura- tion is just coming on, each core is found surrounded by a substance like jelly. When, at length, suppuration is established, the cores be- come completely separated, and, by the destruction of the meshes of the network, cavities of different sizes are formed, in which they freely swim. Instead of leading to the production of matter, and suppurative de- struction of the tissues, the process sometimes terminates in another way; for, under a combination of excessive local tension, and unfavorable general circumstances, viz., in the condition of the individual, and in external influences, mortification takes place, especially in the skin cover- ing the carbuncle. Furuncle very rarely terminates in induration ; it might, when such is the case, be confounded with several other circumscribed inflammations of the skin. There are various other inflammations of the skin allied to furuncle, but differing from it: some are primary, others secondary (or, as they are called, metastatic, critical). Some are parenchymatous, others pro- ceed from particular parts of the structure of the skin, especially from the sebaceous glands. They may terminate in suppuration or in in- duration. d. Exanthematous Inflammations.—To this class belong all acute and chronic exanthematous processes which present the following gene- ral characters. They are preceded or accompanied by symptoms of in- flammation : either at one spot, or at several, separate or clustered points, they furnish a product: sometimes that product takes the form of vesicles and bullae, and lies between the cuticle and cutis; sometimes it occupies the parenchyma of the cutis, being effused amongst the papillae, or in the deeper layer, and forming nodules that either subside again, or suppurate and produce small abscesses or pustules; and sometimes, lastly, it gives rise to induration of the skin, to nodules and nodular thickening of the subcutaneous cellular tissue, and their usual consequences, suppuration, ulceration, or hardening. The present appears to be the most convenient opportunity for allud- ing to these processes ; for anatomy has not yet furnished satisfactory evidence as to their real site, whether it be the different glandular organs of the skin and their ducts or not. I venture, however, to omit giving any minute description of them, not for this reason merely, but also because we possess only a few fragments of anatomical information re- specting their products; and further because the changes in the internal organs, which have hitherto been observed after death,—changes, that is, essentially connected with the disease of the skin, and constant in THE SKIN. 77 their occurrence in many of these cases, though not, indeed, in all of them,—do not furnish facts in sufficient number and of a kind to allow of our constructing an account of their pathological anatomy, that would make any pretensions to truth and to practical utility. The last remark applies particularly to those exanthematous diseases which are usually treated of amongst chronic diseases of the skin, for several of those which are now under consideration, as well as of the acute processes spoken of under the head of erythematous inflammations, are frequently fatal, and consequently become the subjects of pathologi- cal examination, especially true variola and scarlatina. Although much has already been said, and some remains still to be said on the subject, it will be proper to mention here, in general, some of the principal results of examinations of the body in the cases of exan- thema, that have been mentioned. With an exanthema upon the skin that is discolored, collapsed, and sometimes scarcely perceptible, are connected erythemata and exuda- tive and pustular inflammations upon the several mucous membranes adjoining the external integuments. They take place especially on that of the mouth, pharynx, trachea, and bronchi, as well also as that of the urethra and vagina; they are complementary to the cutaneous eruption, and may be more or less substantive in their character; but frequently they are extremely developed both in extent and in the degree of their intensity. Next in order may be placed the more or less palpable developments of the follicles of the intestines, especially those of the ileum; _. after these, similar developments of the mesenteric glands : and then conges- tions and enlargements of the spleen. These may be followed by congestions of the central organ of the ner- vous system, and of its membranous investments ; and very commonly, too, by increased density of the cerebral substance, with the exception of cases to be mentioned afterwards. And next may be mentioned exudative processes upon mucous and serous membranes, especially on the former: some of these are genuine croupy exudations on the divisions of the mucous system above men- tioned, as croupy pneumonia, croup in the oesophagus, stomach, and in- testines ; others are gelatinous, purulent or serous exudations, and are found particularly on the mucous membrane of the bowel, and in the parenchyma of the lungs,—pulmonary oedema; others, again, are exuda- tions upon serous membranes, especially upon the arachnoid, where they are accompanied with a turgid, moist, and loosened state of the cerebral substance,—oedema of the brain; some are met with on the pleurae, &c, and even upon the internal surface of the vessels (phlebitis). The acute black softenings of the cardiac portion of the stomach, and of the oesophagus may be arranged next; and then— Gangrene on the general integuments and in the internal organs. Changes of the mass of the blood take place in the dead body parallel with these processes in the solids. The fibrin has a marked tendency to coagulate; the blood is deprived of its fibrin; or the latter is fluid; or the blood contains no coagulable part, but is either no thicker than water, or thick, viscid, like tar, and of a purple-red color, inclining to bluish, violet, 78 DISEASES OF black, &c. With the changes last described, are connected marked collapse of the body, lividity of the integuments (especially of the exan- thematous part), and of the muscles, red transudations into the serous cavities and into the tissues, and particularly the escape of blood into the parenchyma of membranous expansions, in the form of ecchymoses, petechiae, suffusions, &c, especially on the skin. As the exanthematous, especially the acute exanthematous processes are allied in their nature to the exudative, I must here refer to yet one septic exudative process which takes place upon skin deprived of its epi- dermis, and which is closely analogous to sloughing croup1 (Bretonneau's Dyphtheritis): it is that which is named hospital gangrene. 3. Ulcerative processes.—The ulcerative processes are, for the most part, results of inflammations already described; and they are especially liable to occur when those inflammations, having been raised to unusual intensity by some unfavorable external influences, either continue intense or repeatedly become so; or when they are called forth by some internal constitutional cause (dyscrasia); or when running their course under such constitutional influence, they give rise to a special product by which the tissues are in a peculiar manner consumed (dissolved). As the in- flammations, especially the various exanthematous forms of inflammations present numerous characters, which more or less distinctly manifest the nature of the constitutional affection, so also, and still more, are these characters usually stamped upon the ulcer. Again, many ulcerations of the skin are produced by the metamor- phosis of known adventitious growths in the skin itself or in the tissues beneath it; others are secondary stages of various changes in the texture of the cutis, with which we are not as yet acquainted. Of this kind the following are examples, although most of them still require minuter anatomico-physical investigation : All ulcers connected with disorder of normal, or Avhat have become normal excretions: all those which originate in a congenital or hereditary, or in an acquired dyscrasia, whether the latter be simple, or combined and modified: all menstrual, hemorrhoidal, and urinary ulcers, as they are called, are therefore of this .kind; so also are the abdominal, the gouty, and the scorbutic ulcers, those which exist in psoriasis, the syphilitic and syphi- loid, the leprous, scrofulous (tubercular) and cancerous, and the numer- ous cancroid ulcers. They present many more or less characteristic differences in site and in form, i. e. in the state of their margins and bases, in their disposition to extend superficially or deeply, and in the amount, and especially in the quality of their product: hence the known divisions of ulcers into round, oval, and sinuous; into callous and fun- gous ; into moist and dry, &c. As the ulcer presents various characteristic peculiarities, so also does the cicatrix. It is important and interesting to observe the relation subsisting be- tween inflamed and ulcerating integuments and certain subcutaneous struc- tures, especially periosteum and bone: it is seen, for instance, on the cranium and shins, and prevails chiefly in the inflammation and ulcer arising from constitutional causes. 1 [ Gangrenous stomatitis ?—Ed.] THE SKIN. 79 4. Mortification of Skin.—Mortification is not an unfrequent occur- rence in the skin; it arises from congestion and inflammation, and takes place more readily the more insuperable the mechanical interruption to the circulation, and the greater the exhaustion of nervous power either in the system generally, or—in consequence of extreme severity of the inflam- mation or unfavorable external circumstances—in the part itself. Some- times it takes the form of moist, sometimes of dry gangrene,—sphacelus —mummification. In the former, the epidermis is raised in vesicles of various size, which are filled with a discolored sanguineo-sanious fluid, and the tissue of the skin degenerates to a loose, pulpy, and offensively smelling mass of a brownish, brownish-green, or blackish color: in the latter the cutaneous tissue changes to a black, pretty firm, dry eschar, which is frequently puffed out with gas, developed in the subcutaneous tissues, when they are affected with moist gangrene. The mortification may extend from the skin to the subcutaneous tis- sues or vice versd, or again it may attack both structures, however hete- rogeneous, together. Examples of primary gangrene, as well as of the secondary proceeding from inflammation, are furnished by gangrena senilis, by the bluish-red congestion and gangrene that occur, often at several spots, on paralyzed limbs, by the sphacelus accompanying or following typhus and typhoid fevers, by bed-sloughs, anthrax (pustula maligna), cancrum oris (noma), by the mortification that takes place from various internal or external causes in inflamed skin, in ulcers, and in wounds, and by hospital gan- grene. Besides these two forms of mortification, a third is sometimes observed, which has been termed white gangrene (Mayo, Aschersohn). The skin becomes converted into a dirty yellowish-white, or grayish-white, friable eschar. A similar form of necrosis of cellular tissue has been pointed out already, and a similar eschar on serous and mucous membranes. It may arise from the stretching—which is equivalent to compression—of the tissue, or rather of the capillary vessels by an inflammatory swelling, or from the vessels being destroyed in necrosis of the subcutaneous cel- lular tissue (pseudoerysipelas). 5. Adventitious Gfrowths.—Here again I cannot avoid remarking that, whether from the apparent insignificance of these growths in them- selves, or from the regard paid to that affection of the internal organs which gives occasion for the examination of the body, the most accessible of them have received as yet but casual anatomical notice, and the dis- tinctions between them have continued based upon their external cha- racters only. a. New growth's of cellular tissue occur as : a. Soft wartlike growths, attached by a pedicle, which constitute Avhat is called the Molluscum simplex: the saccular dilatations of the corium are occupied by some cellular tissue at various stages of its de- velopment. They occasionally also contain fat. /?. Fleshy excrescences on the nose—exuberant or bottlenose: these are composed of a luxuriant growth of corium and of cellular tissue. y. Condylomata are common about the organs of generation and the anus, especially on the mucous membrane of the former. Some of them 80 DISEASES OF are soft, others firm: in their form they may be broad and pointed: sometimes they are attached by a pedicle, and very often their extremities resemble a mulberry, a cauliflower, or a cock's comb. They are composed of an investing layer of epithelium and of newly formed cellular tissue ; and they originate in the corium, where their points, which, as is well known, are the more unmanageable part, take deep root (Simon). With these most probably we may connect those out-growing tumors which occur in the Pian of tropical climates, and have by many been regarded as syphiloid; as well as various affections that are met with on the coasts of Europe, for instance, the Radesyge, &c. b. Fatty tumors are usually congenital: sometimes only one exists; at other times there are several, which are situated at other parts of the body. They form rounded, globular excrescences, which are, for the most part, truncated and attached by a pedicle, and sometimes grow to a considerable size. They consist of a prolongation of cutis, and enclose some fatty tissue, which seems like a protruded lobule of subcutaneous fat; for at the base or neck of the excrescence it is continuous by a sort of pedicle with the general subcutaneous adipose stratum. The epider- mis covering them is sometimes dark-colored, and pigment (Naevus lipo- matodes of Walther), and unnatural hair often grows upon them. When it is a congenital disease, it is often associated with naevus in other parts of the skin. In some few cases, these lipomatous growths are developed in later periods of life. c. Fibroid tissue occurs in skin thickened by repeated, or by chronic, attacks of erythema; in the wheals and knolls of the skin in cases of elephantiasis, &c. It also constitutes cicatrix tissue. d. The growth which Alibert has denominated cheloid may probably be placed in connection with the last named; for it appears to consist of fibroid callus, and with that appearance its external cicatrix-like aspect corresponds. There are several varieties of cheloid; it may be a simple hardness or callosity of the skin, either flat, somewhat raised, or de- pressed, and white or pale rosy-colored; or it may be cord-like: in either case it frequently terminates in white or red elevated lines or processes (the spider-like pimple of Warren), and is of considerable extent. It occurs, for the most part, singly at the upper part of the trunk, on the extremities, or on the face ; in very few instances does any large number exist. It very rarely ulcerates ; when it does so, the sore may now and then have a malignant (bosartig) character. Some constitutional disorder lies at the root of every case, but the nature of it is unknown; that it is cancerous is altogether problematical. e. Anomalous bony substance is extremely rare in the skin. I once found, in the substance of a scar on the trunk, an oval, yellowish, hard, rugged, osteoid plate, about the size of a thaler.1 It corresponds pre- cisely with the calcareous growths occurring in fibroid exudations upon serous membranes. /. Teleangiectasis in skin is the well-known vascular naevus; it is almost always congenital. Sometimes it forms deep-red, or bluish-red, stains of extremely various size and form (Feuermal,—moles), and sometimes red ' [About the size of an English half crown.—Ed.] THE SKIN. 81 tumors, which are shaped like cherries, strawberries, mulberries, &c, and are capable, more distinctly than the former kind, of a transient swelling (Dupuytren's erectile tumors,—splenoid tumors of other au- thors). But they do also commence in after-life, and in themselves are at first quite of a benignant, that is to say, not of a cancerous, nature. Nevertheless, if there be a cancerous cachexia, the teleangiectasis may unquestionably become the seat of a cancerous growth ; and, under such circumstances, it has been taken for a special form of cancer—Fungus haematodes cutis: it is not, however, an essential form of that disease, but is merely an accidental complication. Teleangiectasis consists of a network of enlarged capillary vessels, im- bedded in a delicate, and partly undeveloped cellular tissue. g. Melasma, (benignant) melanosis includes both the black coloring which is observed, in some few cases, spread over the whole body, but more frequently limited to certain parts, especially the lower extremities; and also more particularly the accumulation of deep black pigment, in small raised points and berry-like tumors on the trunk and face. The pigment is deposited on the surface of the cutis, and in the latter case in its tissue also. Melasma occurs only in aged, decrepit, and cachectic persons, and must, of course, not be confounded with cancer melanodes. h. Cysts.—Newly formed cysts do not occur in the skin itself; but, instead of them, the sebaceous glands not unfrequently degenerate into cysts of large size, of which I shall speak presently. There are often also cysts in the subcutaneous cellular tissue which become, in various ways, closely connected with the corium. Such cysts very commonly contain cholesterine, which is also quite constant in the morbidly enlarged sebaceous follicles. i. Associated with these is the occurrence of cholesteatoma, as a stra- tum covering open ulcers of the skin. I have not only met with this upon carcinomatous ulcers, as others have observed it, but have also seen it produced exuberantly, in large masses, on an ulcer of the skin of the right knee, arising from burn. j. Tubercle.—There appears to be no tuberculosis of the skin corre- sponding to that which occurs in and upon mucous and serous membranes, parenchymatous structures, &c.; at least its existence is altogether pro- blematical. Upon ulcers, however, which arise from various exanthe- matic cutaneous affections of what is called scrofulous character, a pro- duct resembling softening tubercle, or puriform tubercular matter is seen, from which the ulcer obtains a character approaching that of the ordi- dary tubercular ulcer upon mucous membrane, particularly the intestinal ulcer. The skin is subject, also, to ulcerative softening of a less definitely tubercular character during the softening of tuberculous lymphatic glands, and of tubercular depositions in the subcutaneous cellular tissue, as well as when there is ulcerating tubercle in bone. k. Cancer, and cancerous ulcer, are of frequent occurrence in the skin. Cancerous degeneration and ulceration of subcutaneous tissues very frequently involve the skin over them, and cancers of the subcu- taneous cellular tissue, and of glands imbedded in it, particularly of the mammae and lymphatic glands, usually become at an early period very VOL. III. 6 82 DISEASES OF closely connected with the cutis. But cancer also originates in the skin, presenting itself, according to my observations, under the forms of fibrous (scirrhous), and of medullary cancer. a. The form which fibrous cancer assumes in the skin is that of a rounded, or rounded and tuberculated nodule ; very often it is flattened, or even depressed beneath the surface of the skin, and then it lies in a sort of umbilical fossa. It is generally single, about the size of a hemp- seed, pea, or hazel-nut, firmly fixed, and as hard as cartilage: sometimes it is smooth and shining externally, and sometimes covered with a hard laminated crust of epidermis; and frequently it is somewhat darker than the skin around it. When examined closely, the outer strata of the nodule are occasionally found transparent. It occurs principally on the face, lips, and nose, but is occasionally found on other parts of the body: it is generally the primary cancerous growth, the first of a series of cancerous formations in different organs of the body. In some few cases it reaches a considerable size, growing out into a tuberous mass that projects beyond the skin. /?. Unlike fibrous cancer, the medullary kind is usually a secondary formation, and associated with large cancerous growths, which first ap- pear just beneath the skin, or if they come from a greater distance in- volve the subcutaneous structures first, and then the skin itself: in either case it grows in the skin in isolated or confluent nodules near the primary mass. At other times it comes on in skin after cancer has been already localized in one, and still more when it exists in several organs ; it then .constitutes one part of an extensive, or it may be, of a general, produc- tion of cancer. The nodules which it forms are mostly numerous, and about the size of peas or hazel-nuts; they are scattered over large tracts of the body, especially over the trunk, and near similar growths in the subcutaneous cellular tissue. It is distinguished in the skin, as well as in that tissue, as a whitish or whitish-red growth, Avhich is sometimes tolerably firm and lardaceo-medullary, and sometimes softer, looser, and resembling cerebral substance, or even diffluent like milk, and which grows to considerable size. It frequently corresponds with a cha- racter which may be possessed by the fundamental or primary growth, in also containing pigment; and in that case it constitutes cancer me- lanodes of the skin. The layer of skin which at first existed above the medullary nodule, becomes stretched, and sometimes is shining and transparent, sometimes rough from having lost its covering of epidermis: at a later period, as it is being perforated, it becomes moist, and furnishes the nodule with a cortical covering; and a remarkable villus-like develop- ment of its papillae takes place, which appears, from the result of obser- vations upon chimney-sweeper's cancer, to occur in an especial degree in that disease. Sometimes the elementary particles of the disease are de- posited in a pre-existing teleangiectasis, or, as the deposition takes place, there happens an excessive development of the vessels of the skin: the result, especially in the former case, is a cancerous structure of un- common vascularity, which then receives the name of fungus hosmatodes. Chimney-sweeper's cancer, and Alibert's eburnated cancer of the skin must be referred to as special varieties of the disease. Chimney-sweeper s cancer appears to be of medullary nature. It almost always begins, as is well known, on the scrotum with a tolerably THE SKIN. 83 firm, small nodule, or a warty excrescence, which, after having existed for some time, becomes red, excoriated, moist, and covered with a cortex : the papillae beneath it enlarge considerably, and at length the whole be- comes an ulcer with irregular, hard, raised edges. Fresh nodules form around it during its progress, and, by the ulceration of these, the ori- ginal sore enlarges, for the most part superficially : the nodules at the same time become developed into fungous cauliflower excrescences, and at last the metamorphosis extends deeply. After infiltration and induration have taken place in the dartos and tunica vaginalis, and the latter has become adherent to the testicle, that gland itself ulcerates, while the adjoining lymphatic glands and the vas deferens degenerate quite up to the abdominal cavity. The eburnated cutaneous cancer of Alibert is a diffused degeneration which occurs, without doubt, only as a secondary affection, the skin being destroyed in the degeneration of cancerous growths beneath it, at an advanced stage of the cancerous dyscrasia. Over a scirrhous subcu- taneous cellular tissue, the cutis is stiff and immovable, white, glistening, and somewhat transparent, and the whole mass is uncommonly firm. Although the disease is very rarely observed with so marked a character as Alibert has seen, yet now and then an opportunity occurs of examin- ing cancerous degenerations of the skin, which in some degree approach what Alibert has described as carcine eburnee. It is quite uncertain, from its elementary structure, to what form of cancer it belongs, but, from the state of the disease with which it is connected, it should be the fibrous form. From any of these cancerous growths a cancerous ulcer may be formed. Congestion and inflammation come on in and around the growth; and, while it becomes turgid, dark-colored, and vascular, and a fungous growth protrudes, it softens and splits, and, producing a cancerous sanies, breaks down. At the same time, new cancerous matter is deposited, either by infiltration or in nodules, in the tissue forming the margins and base of the principal ulcer. This metamorphosis of the cancer, as well as the softening of the secondary deposition in the ulcer, may run its course either Avith or without a fungous protrusion. The former is particularly characteristic of the ulcer of medullary disease ; while, on the contrary, there are some remarkable cancerous ulcers, by which tissues are eroded not only without visible previous cancerous degeneration, but even with- out any considerable production of sanies. Ulcers of this kind do un- questionably often originate with one of the cancerous growths already mentioned; though not always, for they are sometimes developed secon- darily from some injury or ulceration. They frequently produce exten- sive devastations, especially upon the face, and commonly attack and destroy all structures without distinction ; for which reasons, as well as from their ungovernable nature, they are regarded as cancerous; but varied and accurate investigations of all their characters are still required. I. Parasites.—Several kinds of pediculus, the itch insect (acarus scabiei), and without doubt other acari also, occur both in and upon the skin: the subcutaneous cellular tissue is infested with the filaria medi- nensis already alluded to (p. 22). Among vegetable productions may be mentioned the thread fungi 84 DISEASES OF (fadenpilze), Avhich are formed in the pustules in cases of porrigo favosa. They are the primary anomaly, and constitute unquestionably the essence of the whole disease. Appendix.—Anomalies and Diseases of the Sudoriparous and Sebaceous Glands. A. In several of the exanthematous processes the sudoriparous glands and their ducts are unquestionably subject to frequent and various dis- eases, both primary and secondary, but the anatomical investigation of their diseases is attended with many difficulties, and no advance has yet been made in it. Our knowledge is limited to the anomalies in the quantity and physical properties, most of them, therefore, symptomatic anomalies, of their secretion, i. e. of the perspiration: but chemistry has hitherto supplied information in some striking cases only, and the inves- tigation is beset with as many hindrances as before. B. The sebaceous follicles and their excretory ducts are certainly the true and the original seat of many exanthematous processes; but their most frequent morbid condition is enlargement, arising from the accu- mulation of thickened secretion within them. The least degree of the affection, and a very common one, is dilatation of the duct of the gland, and is known by the name of Mitesser,—maggots (Comedones). The accumulation of the secretion in the sudoriparous sac itself produces white rounded tumors,of the size of gravel, or millet-seed. When di- lated to a greater, the sac degenerates, either alone or together with its excretory duct, into a cyst as large as a pea or a hazel-nut, or even larger; when it is diseased alone it is opened externally; but in the latter case it separates from its duct, and completely closes: it contains a whitish, laminated, firm substance, like adipocire, or a pulpy substance, viscid like fat, and consisting of strata of epidermis, and crystallized fat. In all these forms the disease occurs principally in the larger sebaceous follicles on the face, at the upper part of the trunk, on the back, and in the neighborhood of the parts of generation. The diseased sebaceous glands frequently give rise to inflammation of the adjoining corium—to acne,—an inflammation that sometimes goes on to suppuration of the follicle, as well as frequently of the bulb of the hair with which it is connected, and sometimes to induration (acne indurata), and thereby to a slow cure. In large sebaceous cysts the epidermal mass sometimes takes the form of a horny excrescence,—a growth to which I shall advert presently. In other cases their contents become inspissated, and form calcareous concretions. The occurrence of a condyloma in the sac of one of these glands__ condyloma subcutaneum of Hank—is a very interesting phenomenon which for that reason requires further investigation. The secretion of the gland is sometimes more abundant than natural and is poured out upon the surface of the skin (seborrhagia): it dries there in thin whitish, glistening laminae, or in thicker, dirty strata or scabs, which feel like fat. THE CUTICLE. 85 Anomalies and Diseases of the horny tissues,—the Cuticle, Nails, and Hair. A. The Cuticle is subject to several anomalies, but they are not accu- rately known; and their relations to diseases of the cutis require especially to be explained. § 1. It is very often formed in excess; and then either its outer layers are thrown off in the form of bran, scales, larger coherent masses, &c.; or its elementary structures, accumulating upon and beside one another, produce very various secondary formations, such as callosities, corns, and crusts, flat, convex, or concave scutes, cylindrical or angular, tessel- lated growths, and others which resemble stalks and thorns. Anoma- lies of this kind may be limited to certain circumscribed spots, or may extend over the whole body. On the other hand, the cuticle is sometimes remarkably thin and deli- cate, and, therefore, transparent,. at spots where it has been recently cast off. § 2. An unnatural aggregation of the elementary constituents of the cuticle, and a simultaneous excess of its growth, produce the anomalies in the form of the epidermal tunic which have been already mentioned. I shall refer to this again amongst the anomalies of its structure. § 3. Anomalies in the color of the skin reside for the most part in the epidermis. Its cells contain a pigment, perceptible chiefly in the deeper layers, which varies in quantity, and may be yellow, brown, or black. Such varieties in its color constitute the distinctive peculiarities of cer- tain individuals, and certain races, but sometimes they are acquired. In the latter case the change may be limited to particular spots, or may ex- tend over the whole body; and it presents considerable interest from its involving not only marked alterations in the condition of the organ, and in its secretion, but also anomalies of internal organs which indicate a revolution of the entire vegetative system. Pigment accumulates and discolors the skin in a remarkable manner in congenital naevi. Total absence of pigment is a congenital defect in cases of Albinois- mus, and an acquired in cases of Achroma or Vitiligo. The former may be general or partial; the latter is at first always partial, but may at last become general. § 4. The epidermis deviates from its normal consistence in being some- times more or less moist, but more commonly very dry and harsh. It is the latter condition that produces its tendency to break and peel off in the form of bran or scales, as it is observed to do in many substantive diseases of the skin, and in cases in which it is a symptomatic occurrence and the skin is destroyed, especially by cancer. In those cases, likewise in which epidermis has accumulated in a thick layer over a diseased spot of skin, its dry condition occasions cracks, fissures (chaps, rhagades), which not unfrequently extend through its entire thickness, and even into the cutis. § 5. The mutual relations, as to position, which subsist naturally be- tween the elementary structures of the epidermis, are frequently dis- turbed, not only in consequence of their simple accumulation, but also by a simultaneous excessive development of the papillae of the cutis, and 86 DISEASES OF by various other accidental circumstances. Such anomalous relations of structure may be reduced generally to the two forms of a more developed laminated arrangement, and an apparently fibrillated structure. Inis class includes the anomalies in the shape of the epidermal tunic already mentioned,— The callosity,—tyloma,—which consists of a simple accumulation of epidermis in the form of strata lying over one another : The corn,—clavus,—a small circumscribed painful callus that projects like a wedge into the corium; The crusts, and the convex, flat or hollowed (concave) scutes^ exhibit a laminated structure, though the granular accumulations of dried exu- dation and pus frequently render it indistinct: but the cylindrical and an- gular formations resembling pavement, stalks, and thorns, though they also consist of lamellae of epidermis, are fibrillated, and the horny excrescences have a similar structure. The cutis upon which they grow is always dis- eased, though not, indeed, to the same degree in all cases; but beneath such growths it is unusually succulent, loosened, vascular, and hypertro- phied, and is developed, especially at its superficial lamina, into mush- room-like, cuneiform, thready, villous or even cleft, papillae. It is evi- dently so in genuine ichthyosis, and very probably in the milder allied forms of pitiriasis, psoriasis, and lichen. The primary and the secondary changes in the tissue of the skin in lepra are alike unknown. Horns—cornea cutanea—either grow upon a cutis, diseased in the way just described, or spring from its deeper part, out of a cyst, which is, in fact, a degenerate sebaceous follicle. They have been met with at various parts of the body, but their principal site is the hairy part of the head, and the forehead: they occur sometimes even on the prepuce and glans penis. Usually only one exists, but sometimes there are two or more. Their length is occasionally very considerable, even as great as several inches ; and they may be as thick as a finger : some of them are straight, others are twisted or curved ; most of them are single, a few are cloven; their broadest part is always the base, the shaft is cylindrical or obtuse- angled, and the free extremity is generally pointed. As to color, they are mostly dirty brownish or black. They have been several times observed to be repeatedly shed at regular intervals. And when thus shed, or when accidentally or designedly removed, they are reproduced, provided the spot of skin which they spring from—the matrix—be not destroyed. They are somewhat more frequent in the female than in the male sex, and are common to old age rather than to other periods of life. B. The Nails. § 1. These have in some few cases been found wanting in all, or in some of, the fingers and toes. They are very frequently absent in ill-deve- loped supernumerary fingers and toes. When such parts coalesce, the cor- responding nails unite into one plate. There are various forms in which a preternatural number of nails exists: not only are they in excess when there are supernumerary well-developed fingers and toes, but even when a duplication of the last phalanx is but just indicated; and even without having any trace of being double, a finger or a toe sometimes has a double nail. After the loss of THE HAIR. 87 the terminal phalanx a new nail is sometimes formed over the second or first joint, or even upon the knuckle. § 2. The size and form of the nails are subject to several congenital and acquired anomalies. Those of the latter class are particularly fre- quent and interesting; for from them arise the excessive groAvth, com- bined with thickening and deformity, which the nails sometimes present in a striking degree. They reach a length of several inches, become mis- shapen and thick, and twisted and curved like horns and talons. The principal cause of this deformity of the nails is a want of care of them, especially when to that is added neglect or inability to employ the limbs. Of other causes we are ignorant;—a remark which applies particularly to those cases in which an exuberant growtb of the nails concurs with the development of horns, &c. On the other hand, the growth of the nails is arrested in paralyzed limbs, and during the repair of fractures (Giinther). They shrink too, and at the same time may be deformed or may retain their shape. When the phalangeal bones waste, the nails merely diminish in a corresponding degree ; but simultaneous diminution and deformity is a state, the cause of which, and its connection with other diseases that sometimes coexist with or precede it, are still matters of conjecture. Both in old and in young persons some of the nails, and at last all of them, may lose their smoothness and polish, and cease to grow in length, while they increase in thickness. They then become dry, and split; first the upper shorter lamellae are thrown off, and at last the whole nail; and the subjacent matrix gradually assumes the nature of the other general integuments, and never produces a new nail. Sometimes the disease is limited, not indeed permanently, but yet for a considerable time, to a state in which small rugged stumps of the nail remain, together with its root: in other cases the nail withers at its lateral margins first, separates from the skin beneath, becomes everted, &c. Again, the nails present several anomalies in respect to their form, amongst which the convex shape, in cases of extreme cyanosis, is parti- cularly marked. In lepra, in plica polonica, in syphilis, &c, the nails are, in various ways, deformed ; and newly formed nails, as is well known, are usually at first misshapen. § 3. The consistence and texture of the nails are frequently altered, sometimes independently of disease of the epidermis, sometimes in conse- quence of it. In the aboA'e-mentioned diseases of the skin and hair more especially, they become loose, soft, succulent, and at the same time dis- colored, or on the contrary dry, as brittle as glass, fissured, &c. The corium which surrounds the nail is often the seat of an acute, or of a chronic inflammation, which usually ends in suppuration and loss of the nail; and in the toes, when the nail grows in, as it is called, is now and then attended with a very considerable growth of granulations (pa- ronychia). In some individuals the inflammation terminates in an ulcer- ation which has the specific character of scrofula or syphilis. C. The Hair presents various anomalies: § 1. It may be congenitally deficient in whole or in part (Alopecia connata): the deformity which is thus produced lasts only so long as the 88 DISEASES OF growth of the hair is delayed ; sometimes, however, it continues through- out life. Partial deficiency involves in some cases all the hair of the head, in others all that in the pubic region; or it may affect small circum- scribed spots which remain bald. Allied to this is another condition in which the hair grows sparingly. Deficiency of the hair is more commonly acquired (Alopecia, Calvities), and may be transient, the lost hair being replaced by new, or it may prove a permanent defect. When the gray hair of the aged person falls out, it is permanently lost; in younger persons the loss is not preceded by any change of color, and is often limited to certain circular spots, which become bald, and increase in extent, though there be no disease in the growth of the hair. Moreover, the hair is sometimes permanently lost in consequence of various diseases and disorganizations of parts of the skin which are naturally covered with it, or in consequence of general weakness and cachectic states of the system, such as syphilis, &c. But again, there sometimes occurs an exuberant growth of hair; it may be very thick (numerous) at the parts where it is usually found, and grow to an uncommon length; or it may present itself in an unusual situation; or it may appear at an unusual time, either coming forward prematurely or growing anew in advanced life. Thus the hair of the head is sometimes uncommonly thick and long in women, and that of the beard in men ; and in the former sex particularly, that on the pubes sometimes presents the same peculiarity. Occasionally the whole body is covered with hair (hirsuties), and sometimes particular parts of it, as the shoulders, the back, the abdomen (Osiander met with a case in which hair began to grow above the navel in a pregnant woman), or the lower limbs in both sexes : sometimes a beard grows in women : in cases of hemicephalus, the hair reaches down to the eyebrows and root of the nose; a long streak of it is found on either side of the spina bifida; hair exists also on naevi, &c. Sometimes children are born with an unusual quantity of hair; or again the hair appears on the pubes at an early age, the hair of old persons grows again, &c. Moreover, the hair is sometimes exuberant at certain parts, while at others it is thin; thus the beard is occasionally strongly grown in persons who have always had a scanty covering of hair upon the head, or from whom it has prematurely fallen off. Here, too, may be mentioned the occurrence of hair upon mucous membranes, and on the inner surface of encysted tumors. In the latter case, it is almost invariably accompanied by a growth of fat, and very frequently of teeth;—a peculiarity which reminds us of the concurrent deficiency of both teeth and hair, which is sometimes observed (Danz), and of the renewed dentition which is associated in the aged with a new growth of hair. Cysts of this kind are most common in the female sex, especially in the ovaries. _ Most of the hair, or all of it, lies loose, and steeped in the fat which is present with it, or rolled up in coils within the cysts: plates resembling cutis, however, are sometimes seen on the inner surface of the cyst, and upon them the pores are apparent out of which the hair has grown,^ or in which it is still inserted. Its develop- ment in that situation is similar to that of the natural hair. THE HAIR. 89 Lastly, microscopic^ hair has been discovered in anomalous secretions of the skin and of various mucous membranes. j} 2. The hair sometimes presents an excessive growth in length and thickness, especially the hair of the head, where the thickness of the shaft is sometimes considerable. Usually the hair is not only hypertro- phied but closely set, and in women the growth may be so abundant as to diminish the embonpoint of the body. It more frequently happens that, in consequence of atrophy of its matrix, the hair becomes thin : it ceases to grow, and becomes somewhat lighter colored than usual, and dry, at last it falls out, and never grows again. This atrophy may be idiopathic, or it may be secondary, and occasioned by various diseases of the skin. Moreover, there are sometimes found amongst the natural hair, some which are unusually thick, stiff, and brush-like. Albinoes, on the other hand, originally have uncommonly thin soft hair, like the Lanugo. § 3. An interesting anomaly in the form of the hair is that in which it bends or breaks, and swells at the broken part into a kind of knot; or, again that in which it splits at its free extremity, and looks like a brush. In a few cases curly hair has usurped the place of smooth; and in one case the hair of the head became curly during an attack of gout in the head. Peculiarities of this kind depend on the state of the medullary contents of the cylinder of the hair. § 4. Its color is subject to many changes, some of which are observed only in extremely rare cases. The soft, thin hair of albinoes is white, and has a silky gloss. In Achroma the hair becomes colorless upon spots of skin that have lost their color ; but a far more frequent instance of acquired discoloring is its change to gray without previous or simul- taneous alteration of the skin. It is chiefly observed in aged persons, in whom it gradually extends from the hair on the head to that on the rest of the body; when it occurs in young persons, it is generally limited to the head. Small circumscribed spots of gray hair are occasionally seen in childhood and youth, and this lack of color is generally persis- tent ; under certain circumstances, however, hair that has turned gray becomes colored again. But not only is it exposed to a gradual loss of its early hue as old age advances, it sometime also changes suddenly to gray, in consequence of extremely depressing affections of the mind. Still more uncommon are the cases in which the hair assumes a deeper shade than natural, or undergoes an actual change of color. Paroxysms of certain diseases, of gout, of quartan ague, and even the period of ordinary pregnancy, have been stopped by it. Isouard relates, that the blond hair of a woman whom he observed, turned somewhat red as often as she had fever, &c. § 5. Faults in the consistence and texture of the hair sometimes present themselves as unnatural dryness, and occasion it to break and split, and, at last, to fall out; at other times, as a morbidly moist and loose condi- tion. The latter results from the deposition of a viscid purulent matter in the pore, and is seen in cases of favus, but is far more distinct, and reaches its extreme in elf-lock (Plica polonica,—Cirrhagra). The hair capsule or pore in this case is tumid, injected, and filled with a pasty, 90 DISEASES OF THE nAIR. opaque fluid, Avhile the hair itself, from the root upAvard, is thickened, soft, and full of moisture, and its canal is dilated. It grows rapidly during life; the product just mentioned is effused at its roots upon the surface of the skin, and trickles also out of the hair itself: in this manner the hair on the head, beard, or pubes, sticks together in inextri- cable tangles, Avhich resemble in shape queues, Avreaths, caps, &c. This genuine plica polonica must be distinguished from the similar tangling which takes place in the course of acute, and especially of typhous diseases. PART VIII. ANOMALIES AND DISEASES OF THE FIBROUS SYSTEM. PART VIII. ANOMALIES AND DISEASES OF THE FIBROUS SYSTEM. I SHALL confine my observations, in the following chapter, to the mem- branous, and the fasciculated fibrous structures, except in the instance of periosteum, which I shall consider as fully as can be done, without enter- ing into the subject of diseases of bone. The morbid conditions of the remaining fibrous structures will be duly noticed, according to their im- portance, in connection with those organs and apparatus, of which they form either the capsules, the connecting medium, or the fundamental structure. § 1. Deficiency and excess of development.—Fibrous membranes are completely wanting in all cases in which the organs or apparatus to which they belong do not exist: and, in like manner, a ligament or the tendon of a muscle is sometimes absent altogether. But occasionally there is no actual deficiency of either kind of fibrous structure ; it is merely back- ward in its development, and is thin and weak, and resembles cellular tissue. When double organs or apparatus exist, the fibrous structures are double too; and accessory ligaments, additional tendons of muscles, &c, afford other instances of plurality in this system. Moreover, there are many circumstances under which fibrous structures are developed in un- natural situations ; of which we find instances in the new articular cap- sules of false joints ; in the thick dense plates, the tough bands, and the firm, rounded or branched, callous masses of fibroid tissue into which products of inflammation and coagulable lymph are converted, when they are effused upon serous and synovial membranes, upon the internal coat of the vessels, or within parenchymatous tissues; in cicatrices generally; in the anomalous callus of bone; in the abnormal synchondroses formed after fractures; and lastly, in the fibroid tissue which composes the walls of cysts and cystoid growths. § 2. Anomalies in size and form.—Congenital anomalies of size are presented both by fasciae and ligaments, the former being unnaturally contracted, the latter too short: and in the instance of ligaments, it may happen that one or all of the ligaments of a joint are shorter than natu- ral. Sometimes the shortening of ligaments or tendons is brought on after birth by some loss of substance, or want of extending power, or by a change in their texture. 94 ANOMALIES OF At any period of foetal, or of subsequent life, fibrous membranes may become enlarged; and this will occur, whatever be the cause of the dis- tension or swelling of the cavities or organs they enclose; thus the^ scle- rotica, the fibrous capsule of a joint, &c, may be found enlarged, borne- times the membrane becomes proportionally thinner ; at other times it increases in thickness and is hypertrophied, just as is the case, under similar circumstances, with the capsule and fibrous structure of certain parenchymatous organs, of which the chronic enlargements of the spleen are an example. Moreover, the ligaments of joints are liable to relaxation if they be immoderately stretched for some time: and in paralyzed limbs they lose their tone, and elongate. Fibrous membranes sometimes yield only in one direction; thus in hernia cerebri the dura mater expands only where there are apertures in the skull. The anomalies of form are merely such as may be deduced from what has been said already, or such as consist of a few rare varieties in the shape of ligaments; any of which may be fissured or subdivided. § 3. Anomalies of consistence and continuity.—With the exception of a somewhat looser or closer texture of the ligaments, no alterations take place in the consistence of fibrous structures, Avhich are not consequences of palpable disease of texture. Amongst the solutions of continuity, those lacerations of ligaments and tendons are worthy of remark which are produced by external force and by excessive muscular action: they are more likely to happen if the tissue of these parts have been previously softened by inflammation; when indeed they may occur upon the slightest movements. Fibrous membranes may be ruptured by excessive distension of the cavities which they enclose, or by immoderate congestion of a paren- chyma contained within them, such for example as the spleen; and the same accident may result from their being struck or crushed. Concus- sion and contusion also sometimes lead to serious consequences when they separate periosteum, or the dura mater, from bone, as they give rise to hemorrhage into the interspace, and subsequently to inflammation and the effusion of a sanious product, as well as to necrosis. Incised wounds of fibrous structures, especially of tendons, readily heal, as recent experience proves. An exudation from the wounded ten- don and other injured parts fills the space which is left between the sur- faces of the wound by the retraction of the muscle, and at first unites together all the neighboring structures that take part in the reactionary process; but afterwards it gradually becomes isolated, and new fibrous tissue is formed within it. Losses of substance are repaired in the same way, not only those which have been produced by external violence, but such also as have been caused by an ulcerative process. This fact may be observed in periosteum, or in the dura mater. § 4. Deviations from natural texture. 1. Inflammation.—Inflammation in fibrous structures is a frequent result of stretching and various kinds of injury, as well as of mere expo- THE FIBROUS SYSTEM. 95 sure. Not less frequently it extends to them from other organs, such as bones and parenchymatous structures, in which inflammation or suppura- tion is taking place; and, as fibrous structures sometimes lie immediately beneath a serous membrane, they may become involved in an inflamma- tion of it in the way described at p. 30. Lastly, fibrous structures may themselves inflame: in which case, several parts of the system are usually attacked, either together or in succession. Inflammations of this kind are attributed to rheumatism, and to many other constitutional maladies which are described as gout, syphilis, and so forth, but they still require much elucidation. Inflammation in fibrous tissue is sometimes an acute disease, but very frequently its course is chronic. Its characters are as follow: It begins with the appearance of streaks of injection, and here and there of red dots which consist of small quantities of extravasated blood : the diseased structure loses its peculiar lustre, and becomes tumid, being infiltrated with a fluid of a grayish or yellowish color, and partly jelly- like and coagulating. If the inflammation be violent, it gradually obli- terates more and more, the longer it continues, all appearance of fibrous texture; the structure becomes easily lacerable, and the inflammatory product in it, most of which has coagulated, changes its color to a dirty yellowish-red, or reddish-brown. In this state it resembles, as has been remarked by Gendrin, an inflamed lymphatic gland,—i. e. chronic inflammation of a gland. The neighboring tissues always share in the inflammation of a fibrous structure, but their relations to each other are altered in various ways. The homologous cellular tissue adjoining is usually inflamed in a consi- derable degree; and it becomes so confounded with the fibrous tissue, that the limits of either cease to be distinguishable. It is in this manner that inflamed fibrous structures—tendons and ligaments—are sometimes fixed in their bed of cellular tissue. But inflamed periosteum, on the other hand, and inflamed dura mater may be easily separated from the bone to which they belong; and some of the tunicae albugineae can be torn from their proper parenchyma, as if it were heterologous tissue. The loosening of the connection is proportioned to the acuteness and violence of the inflammation in the fibrous structure. If inflammation attack any fibrous structure, such as the dura mater or the capsule of a joint, in consequence of its being laid bare and exposed to contact with the air, it first becomes reddened, dull and villous, and then granulations appear on its exposed surface, which unite with it into a uniform, red, flesh-like, soft mass. Sometimes, especially in tendons, this does not take place until a superficial layer has perished and been cast off. The granulations change into cicatrix tissue, and by it the fibrous structure unites with, and is fixed to, the cicatrix in the other injured organs, muscles, integuments, &c. There are numerous terminations of inflammation in fibrous structures, and their occurrence is determined by various circumstances. Suppuration ensues chiefly Avhen the inflammation has been caused by exposure to the atmospheric air, and various other external irritants. And, under similar circumstances, the inflammation leads to ulceration. Such is the result of inflammations which have been produced by the 96 DISEASES OF advance of some neighboring ulcerative process to the fibrous structure; as is instanced in ulcerations of periosteum or of the dura mater, when caries encroaches upon them; or of fibrous capsules, Avhen suppuration is taking place in the serous and synovial membranes which adjoin them. The suppuration and ulceration, in such cases, mostly advance from the surface to the deeper parts of the fibrous tissue; while, at other times, collections of pus and sanies are found in its interior. An ulcer in fibrous structures sometimes has a sarcomatous or fungous appearance, in con- sequence of the flesh-like substance with Avhich the tissue around it is infiltrated, and of the granulations which project from it. Slight relapsing inflammations, and those which run a chronic course, end in induration and thickening. The soft, red, flesh-like tissue, infil- tered with inflammatory product, becomes pale and contracted, and gradually changes to a white, dense, firm, fibroid mass, which looks like cartilage. This mass generally unites closely with any neighboring tissue, with bone, for instance, which has been inflamed at the same time, and can then be separated from it only with much difficulty; but the adhesion afterwards becomes much less strong, and may, indeed, at length be entirely destroyed, if the change now described in a fibrous membrane, and the contraction and obliteration of vessels to which it leads, produce attenuation of the tissue which the membrane encloses, or if, as sometimes happens, the inflammation of an organ enveloped in a tunica albuginea be followed by a secondary atrophy of its parenchyma. Fibrous tissue, when indurated in the manner just described, not un- frequently becomes the seat of ossification : that is to say, of a calcareous deposit. It is observed especially in fascicular structures, such as the ligaments, but is very rarely met with in fibrous membranes, though we find it now and then in the dura mater. Primary inflammation of a fibrous tissue very seldom terminates in gangrene ; but it is a frequent occurrence when other neighboring struc- tures, integuments, cellular tissue, muscles, &c, are sloughing too: it is so in the instance of bed-sloughs. The natural fibrous tissue changes into a blackish-brown mass, which is soaked through with sanies of the same character, is as soft as tinder, and may be torn in any direction. It degenerates in the same manner when it has been crushed or stretched, or when those tissues which convey its bloodvessels are torn off from it, and particularly when the removal of the cellular tissue exposes it to the external air. Inflammation frequently takes place in periosteum. In its origin and character it corresponds with what has been said of inflammation of fibrous structures in general. It may coexist, even from its commence- ment, with inflammation of the bone, but it often originates as a substan- tive disease in the periosteum itself, and in that case always extends to the surface of the bone; or again, it may spread to the periosteum, either from the bone within, or from the soft parts without, especially from cellular tissue, ligaments, and fasciae. It is distinguished by the same characters as inflammation of other fibrous structures. The membrane unites closely with the cellular tissue which takes part in the process, and thus with the adjoining structures with sheaths of muscles, aponeuroses, integuments, &c. : but from the THE FIBROUS SYSTEM. 97 bone it can be stripped with ease, especially if the inflammation have been at all intense, or have extended along the prolongations of the membrane into the bone, and have led to any exudation on its inner surface. Sometimes, indeed, the periosteum is found separated from the bone by a considerable quantity of purulent or sanious exudation. Under whichever of the above-named conditions inflammation of peri- osteum occur, it frequently proceeds to suppuration and ulceration. There are various ways in which these results may ensue: sometimes they commence at the outer surface of the membrane, sometimes in its interior, sometimes between it and the bone; sometimes again they take place in circumscribed spots, which gradually enlarge and coalesce, while at other times extensive tracts of the membrane are found rapidly under- going solution. (Schmelzung). Periosteum is easily replaced when it has been lost by injury; and even when it has been destroyed by ulceration, so soon as the constitu- tional cause of the inflammation of the bone has ceased. The new mem- brane is formed out of a plastic exudation from the bone. Chronic inflammation often leaves behind it thickening and indura- tion of the periosteum. That membrane is then found changed into a whitish layer, which may be several lines in thickness: its texture is very close, and it is as tough as leather, or fibro-cartilage. It adheres closely to the bone, and seems intimately united with it. The condition of the bone under such circumstances varies considerably, and will be described in another chapter. 2. Adventitious growths are, on the whole, but rarely found in this sys- tem, though there are some fibrous structures which form an exception to the rule in the instance of particular new growths. Such is certainly the case with the dura mater in respect to sarcomatous and cancerous growths. And it must also be remembered, that in all cases in which fibrous membranes are implicated, it is extremely difficult to determine whether the new, and the degenerated growths which are imbedded in their tissue, were originally formed in them, or were developed, as un- doubtedly may be proved to be far more frequently the fact, in the parenchymatous organs which those membranes enclose. a. Cysts. a. Single cysts of small size are not uncommon in the structures be- longing to the fibrous system. Their contents may be serous, or like synovia, viscid, or gum-like, or they may consist of cholesterine. Cysts with serous contents occur chiefly in tendons in and between aponeurotic expansions and fasciae, and in periosteum: those which contain choles- terine are most common in periosteum, where they are known by the name of encysted cholesteatoma. /?. Compound cystoid growths are very rare : I am acquainted with but one such case. It is that of an old and ill-preserved specimen of cystoid growth, some of which adhere to the periosteum, while others are contained in the muscles of the same lower extremity. b. Fibroid tissue is formed in fibrous structures, especially in ligaments and periosteum, when they have been swollen and thickened by chronic inflammation: it is also found in what are called fibrous tumors. These tumors are met with chiefly in periosteum, and in the dura mater : and VOL. III. 7 98 DISEASES OF they present the various characters of the soft, succulent, and delicately fibrillated tumor, filled Avith numerous elementary cells; of the spongy tumor composed of interwoven celled fibres, and of that which is dense and compact, and consists of well-formed fibrous bands. Their size is very uncertain, varying from that of a pea to that of a walnut or a fist; in a few cases, especially of genuine compact fibroid tumors, they are even as large as the head of a child. c. Fibrous structures ossify in various ways. Not only are they liable to calcareous deposition, but when hypertrophied and indurated after inflammation, they sometimes have osteoid tissue developed in them. Sometimes it is formed in the substance of the fibrous structure, and re- sembles needles, cords, or plates, or is altogether shapeless; at other times it is a more or less complete incrustation upon its surface. Under such circumstances, a certain amount of vascularity is observed in the fibrous structure; it becomes of a brownish-red color, and remains, after the bony matter has been deposited, blackened with pigment, and un- commonly dry. Bony growths of this kind are formed for the most part in the fibrous capsule of the spleen, in the dura mater, and in the fasci- culated articular ligaments. Of course similar productions are found in the fibroid tumors of fibrous organs. But not only is osteoid tissue produced in fibrous organs; in some cases we find true bone in them. The exudations from periosteum and from the dura mater on the surface next the bone, become, when they ossify, normal bony tissue. They form broad, thin layers, or thicker, circumscribed plates and shapeless masses, and enter, for the most part at once, into organic connection with the bone beneath them. They are all included under the name of osteophyte and exostosis, whether occur- ring as a growth of bone in various tendons, as ossified callus in articular capsules after the occurrence of fractures within joints, or as ossification of fasciculated ligaments in cases of anchylosis, &c. d. Tubercle.—Tubercle is on the whole but rarely met with in fibrous organs : and when it does occur, it is almost only on the periosteum of spongy bones, and on the dura mater. In the usual mode of its origin, inflammation gives rise to a tubercular product, which is deposited in the tissue of the membrane, or on that surface of it which adjoins the bone; it degenerates into a mass of caseo-purulent matter, and being enclosed in a capsule of fibrous structure, which is infiltrated withlardaceo- gelatinous substance, it forms loose, pulpy swellings. By the progressive formation and degeneration of tubercles in the adjoining fibrous tissue it advances in the membrane, and to the bone ; and frequently produces, especially in the spine, destructive ulceration of the periosteum and liga- mentous apparatus along an extensive sinuous track, as well as caries of the bones. Occasionally these sinuses close, and their contents become chalky. They are very commonly associated with tubercle in the cellular tissue, and in the lymphatic glands, and very often with tubercle in the lungs. This subject must be resumed in the chapter on the Diseases of Bone. e. Sarcoma and cancer.—All fibrous structures may be destroyed by adjoining cancerous disease. In periosteum and the dura mater it occurs also as a primary disease, and from the former structure especially, it THE FIBROUS SYSTEM. 99 soon advances to the bone. Fibrous and medullary cancer are the kinds mostly observed in periosteum, but those which occur in the dura mater are very various, and differ remarkably in their elementary structure. Further remarks on this subject will be made in the chapters on the Dis- eases of the Bones, the Joints, and the Dura Mater. Note.—Some diseases have been described under the names of gum- mata, periostoses, and Cooper's cartilaginous and fungous exostoses; they will be found to be either a circumscribed inflammatory swelling and induration of the periosteum, or one of the adventitious growths which have been already described as occurring in it, or they will corre- spond with some of those to be hereafter brought forward amongst the diseases of Bone. PART IX. ANOMALIES AND DISEASES OF THE OSSEOUS SYSTEM. PART IX. ANOMALIES AND DISEASES OF THE OSSEOUS SYSTEM. CHAPTER I. ANOMALIES AND DISEASES OF BONE IN GENERAL. § 1. Deficiency and excess of development.—The entire bony fabric of the body has been found wanting in some few cases of monstrosity, and even in some individuals whose development in other respects was quite natural. A partial deficiency of the skeleton is less unfrequently ob- served, as it occurs in various parts of the body where development gene- rally has been arrested; in the thorax, for instance, and the pelvis, and especially in the limbs. There is very commonly no bone in supernu- merary peripheral parts, whether fingers, toes, or limbs. Moreover, the skeleton very often falls short of its complete develop- ment, in being altogether cartilaginous, or at least very imperfectly ossi- fied, at the time of birth. This condition, known as congenital rickets, sometimes continues to a later period of life, and betrays itself by in- sufficient firmness and power of resistance in the bones, by persistence of those characters which belong to the skeleton in childhood, by the apo- physes remaining separate, &c. It is very commonly combined with hy- pertrophy of the white substance of the brain. In some cases the com- plete formation of the bones is retarded by long-continued and'exhausting diseases, and in some parts of the skeleton it is very frequently arrested, to a great extent, by pressure from within ; as, for instance, in the skull. An excess of development is exhibited, on the one hand, when the whole skeleton, or parts of it, are completely formed at an unnaturally early period; as when the fontanelles close, the sutures disappear, the epi- physes unite with the diaphyses, the teeth are cut, &c, prematurely; and, on the other hand, it is seen, also, when the bones are unnaturally dense and hard, when they grow out and enlarge in some unusual direction, or when various new bony formations are found upon them. The bones may vary in number either way; they may be more numer- ous or fewer than natural. When certain parts are wanting, or exceed their natural number, the corresponding bones are wanting or supernu- merary too: but this may be the case also when a part appears to be naturally formed, as we find exemplified in the toes and sesamoid bones, in the vertebrae, and the ribs. The most frequent instance in which the number of the bones is usually great (although it is only an apparent excess), is when the pieces of which a bone is composed con- 104 ANOMALIES OF BONE. tinue separate, or when, in the skull more particularly, unusual sutures, or sutural (Wormian) bones exist. The want of a bone is sometimes made up for by a supplementary increase in the bulk of a neighboring bone. § 2. Anomalies in size.—Hypertrophy and Atrophy in particular. —The anomalies of this class present many varieties, both when the volume of the bone is greater than natural and when it is less. An increase in the size of the bones occurs in various forms. ^ 1. They may grow to a greater length than natural. ^ In giants this excess prevails in the whole skeleton; but sometimes it is observed only in particular fingers, toes, or limbs; in the latter case, it may be con- genital, or may come on after birth, during the period of childhood or youth. 2. The increase may take place in the breadth and thickness of a bone, at the same time that its texture becomes more dense, and its weight greater. This is hypertrophy, hyperostosis ; it may extend over the whole of a bone, or be confined to particular parts of it. 3. The enlargement of a bone may be a consequence of expansion of its texture—of dilatation of its Haversian canals, and, in long bones, of the medullary cavities. It is by this change that the enlargement of caA'ities which are made up of bones, especially of the skull, is effected: it arises from pressure on the bones from within. 4. Enlargement is sometimes occasioned by the development of vari- ous kinds of adventitious growths and tumors in bone. The volume of bones is less than natural,— 1. When the whole skeleton or a part of it, as the head, or one or more of the limbs, has failed in attaining its full groAvth, whether its small size be observable at birth, or be first exhibited at a later period in a dwarfish growth of the body. Congenital dwarfishness is distinguished gene- rally by an arrested development of the extremities in length, which is at once seen on comparing them with the skull and vertebral column ; by the striking appearance of thickness which the articular ends of the bones consequently obtain; and by their deformity generally. Although con- genital dwarfishness manifests on the whole a seeming alliance with those changes which are produced by rickets in the growth and form of bones, yet it cannot be certainly said to be due to the existence of that disease in the foetus: its pathology is still unsettled. 2. Or else the small size of bones proceeds from atrophy. a. Hypertrophy—Hyperostosis.—Bone increases in substance in two ways, which are not essentially different from one another. 1. In the one case, while the density of the bone remains unchanged, new osseous substance is deposited on its surface, beneath the periosteum and augments it in breadth and thickness. The size of the medullary canal remains the same, but the compact substance around it is thicker than before (External hyperostosis). 2. In the other case, the increase of substance is internal, proceeding from the Haversian canals, and in the end from the whole medullary system. The bone becomes more dense, not only in its compact layers but also in its cancellous part; the walls of its cells, and the bony ANOMALIES OF BONE. 105 threads of which its network is composed, increase in thickness; and, by a kind of concentric hypertrophy, as it were, the medullary cavity diminishes in size, and the diploe disappears. \We may call this state an internal hyperostosis; it constitutes also the induration (sclerosis) of bony tissue. The two forms very commonly occur together, and thus in a twofold manner augment both the bulk and the weight of the bone. Each is the result of the gradual formation of too great a quantity of the cartilage of bone, in which the normal salts of lime become deposited: both affect compact bones, as the cranial bones, the central piece of the long bones, chiefly but not exclusively; for a somewhat striking density and resistance of the spongy bones also, especially of the vertebra, is frequently observed in persons about the period of youth and manhood. They become very important diseases, when they proceed to any great extent, or involve important parts of the skeleton, such, for instance, as the skull; or when they affect large portions, or the whole, of the skele- ton. No previous disease has occurred in the texture of the bone, Avhich can be regarded as a preliminary or a causative process : its surface is level and smooth, the periosteum is natural, and even when the indura- tion attains the density and hardness of ivory, the bony texture is, in other respects, natural. Nevertheless, it must be remarked, that in advanced cases of hyperostosis, the new ossifying substance is very commonly deposited unevenly, more at one part than at another, and that thus, at length, the bone acquires a misshapen and coarse appear- ance. It is sometimes observed, that while one bone is in a state of hyperos- tosis, another is wasted: this is frequently the case in the skull, where, when the cranial vault is hypertrophied, the bones of the face and of the base of the skull are atrophied. In other cases, the increase of substance, both the internal and the external, is occasioned by an inflammatory process. Sometimes the in- flammation attacks the outermost layer of a bone and the periosteum; sometimes it affects the deeper seated capillaries, and sometimes the me- dullary membrane. In the first cases it produces an exudation on the free surface of the bone, which becomes converted into an osseous layer, compact like the surface on which it is effused, though sometimes sepa- rated from it by diploetic spongy substance. In the last two cases, the increase of substance is within the bone, and leads to induration, either of the compact tissue, or of the inner spongy portion. These con- ditions have been called by Lobstein, sclerosis supra-corticalis, corticalis, and centralis respectively; they are, however, very rarely independent and separate, though one form frequently predominates in one or other portion of the bone. Generally, before they take place, the texture of the bone becomes expanded in consequence of swelling and infiltration of the tissue which connects the capillaries of the medullary canals and cells —that is, those spaces are dilated: and as the process usually occupies only single bones, and is not uniform in its degree at all points, the hyperostoses Avhich result are also confined to single bones, the diseased bone is thicker than natural, and very often is, from the first, of unequal thickness and coarse: its external surface is uneven and rough, nodu- 106 ANOMALIES OF BONE. lated and full of fissures, like the bark of a tree, or covered with thin, leaf-like inequalities ; it is rendered porous by the permanently dilated orifices for its vessels, &c. ; and the periosteum, and its prolongations inward, are thickened and hypertrophied. The hyperostosis and indurations belonging to this class, are for the most part results of chronic inflammations, especially those of a syphilitic or gouty character. I shall have some general remarks to make upon them in a more suitable place, when considering the question, whether the hyperostoses, which these diseases set up, bear any marks by which they can be distinguished from one another. Lastly, there are yet other cases in which hyperostosis, especially the internal (the induration), is occasioned by previous softening and expan- sion of the texture of the bone. The secondary indurations will be considered with the diseases of the texture of bone, that they may be arranged amongst, and shown to arise from, them ; for those indurations have their origin, not merely in the ordinary ossification, within the bone, of a too abundant cartilage, but most probably, either in the ossification of a diseased cartilage, whilst the earths and salts which are deposited, are abnormal as well as normal, or in overloading the cartilaginous base- ment with salts, which yet are normal. In either case the anomaly is one of texture. Hyperostosis presents itself further in different forms as a local disease, confined to small spots on one or more bones. Its two principal forms, though intermixed in some respects, by their transitions into one another, are yet, in many essential points, distinct: they are the com- mon exostosis or bony excrescence, and the new growth, which has been named by Lobstein, the osteophyte, a. Exostosis.—By the term exostosis should be understood 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. When its development is complete, and often at the beginning of its growth, its texture is always homologous with that of its base and point of origin, whether that be compact or spongy. Hence all new growths upon or within a bone, which hold any other relation to it, are excluded, although they be composed more or less of normal bony texture, and even although composed of such texture altogether. Bony growths, however, which proceed from the periosteum, but sooner or later become united with the bone, are admitted. The most important varieties in an exostosis relate to its texture, to the point from which it originated (though in many cases this cannot be determined with certainty), and to the mode of its development. To these varieties the sundry and wide differences in its size, form, mode of attachment, &c, are mainly referable. Exostoses are composed sometimes of compact, sometimes of spongy bony substance ; and although some are made up of both these substances, yet the division into those which are compact and those which are spongy is so far valuable, that it expresses their original condition and their development. a. The most frequent of the exostoses is the compact. It occurs on compact bones and parts of bones, particularly on the outer table of the cranial bones. ANOMALIES OF BONE. 107 It appears as if it had been planted on the surface of the bone from without: in general it is a plane convex nodule, the margin of which is abrupt, and often separated from the bone beneath by a furrow. This furrow is generally narrow, sometimes being but just perceptible, and about the thickness of a hair; but frequently it is deep, and forms a fissure between the tumor and its basement. It gives the exostosis the appearance of having been glued on, or of sitting, mushroom-like, on a very short stalk. Not only is this exostosis in all cases compact, but it often exceeds in density the bone from which it springs: it is then known as the ivory exostosis. It is especially liable to be formed on bones which are them- selves indurated. It is compact from the very first; and grows in such a way that the layers which are added to it always at once become as dense as ivory. Neither the most superficial and most recent strata, nor the smallest of those exostoses, which form near larger ones, even though. no larger than hemp-seed or a lentil, is ever seen to contain any spongy structure. New layers and old, large exostoses and small, are equally dense and hard. When they are minutely examined, the number of peripheral lamellae is found to be very considerable; and the corpuscles lying amongst them are long. The Haversian canals are small and far apart, and many of them are surrounded by a distinct and completely defined (vbllig abgeschlossenen) lamellar system. With regard to the corpuscles, we find large tracts without any of them, while at other spots they are clus- tered together in dense groups. The number of these exostoses occurring in one person, and even on the same bone, is sometimes very considerable; especially if the very small ones, which are easily overlooked, be also enumerated. I have met with them almost exclusively on the skull, where, like induration, they do, in fact, most frequently occur; but they are likewise observed on the long bones, and on the bones of the pelvis. They vary in size from that of a flattened hemp-seed or a lentil, which is scarcely perceptible, to that of a walnut, or a hen's egg, and even to greater dimensions. Their most common size ranges between that of a pea and that of a hazel-nut. While their usual form is that of a plane convex nodule, their surface, whether even or uneven, is always smooth and polished. If they grow beyond the ordinary size, they become round, or oval, or, as they gene- rally rather increase in length, they form a more or less cylindrical, horn-like projection. There is another form which occurs with them on the inner table of the skull near the frontal crest: it has a peculiar humifuse1 character, or the appearance of a convoluted wreath. The color of these exostoses is white or yellowish-white,—whiter than that of the bone to which they are attached. As we cannot associate exostoses, in respect to their cause, with the various inequalities and nodules that occur on bones from constitutional disease, especially from syphilis, the occasion of their origin must be 1 ["Humifuse"—growing parallel to the surface, but attached only at its point of origin, like the stems of plants which creep along the ground without taking root. (Palmer's Pent. Diet.)—Ed.] 108 ANOMALIES OF BONE. said to be unknown. As I have already remarked, they are very generally found on the bones of the skull, of which one or more are at the same time the seat of induration, and not unfrequently bony forma- tions are found also on the dura mater. ft The spongy exostosis proceeds from a circumscribed rarefaction, or expansion, of the bony tissue (osteoporosis); it forms a tumor of cel- lular texture abounding with marrow, which is surrounded by a compact layer or rind. It is sometimes developed from compact bony tissue, sometimes from spongy substance, and either from the peripheral laminae of the bone, or from its interior. It presents, accordingly, many striking varieties of external form and of internal structure. Its rind or exter- nal layer unites with that of the bone ; its surface is uneven. Sometimes it forms a slight, rounded elevation, above the surface of the bone, sometimes a more sharply circumscribed, hemispherical tumor; or it has a still narrower base, and is globular. We not unfrequently find, near or upon the articular ends of long bones, and especially on the tibia and femur toAvards the knee-joint, a rounded, gnarled, and uneven excrescence, sometimes lobulated, or branched, and set upon a well-formed stalk; sometimes it has the form of rounded or angular, thorn-like processes. Such excrescences may be occasionally found near the articulations on most, if not all, the long bones of a skeleton. Lastly, there is another form of exostosis allied to the spongy form, which has not only a spongy texture within its compact rind, but also a well-formed medullary cavity communicating with the medullary tube and cells of the bone; and thus presenting, as it were, a dilatation of the medullary cavity beyond the surface of the bone. Whether such really be the mode of origin of this form of exostosis, and a central cavity of this kind, communicating with the medullary tube of the bone, really exist from the commencement of the disease (in which case this exos- tosis would clearly rank with the spongy form), or whether the central cavity be formed in it subsequently, as it is in callus, is as yet unknown. In the skull, the expansion of the diploetic structure sometimes dis- tends both the compact tables, and thus there is an internal exostosis corresponding with the external. The spongy exostosis continues for an indefinite period in its original spongy state: not unfrequently perhaps it may remain so permanently; but more commonly new substance is deposited in its interior, and more or less induration ensues. The compact exterior wall acquires consi- derable thickness, and encloses a mass of cancellous substance, or a well-formed central cavity: sometimes spots in its interior are found compact too, or it may even become uniformly solid throughout. In some parts, and even in the whole of the exostosis, a renewal of rarefaction, or osteoporosis, very often appears to succeed this process of condensation. It may be in this manner that the growth of the spongy exostosis from within outwards is chiefly effected. They very often groAv to a considerable size. Exostoses are formed, as a general rule, in the outer layers of a bone, and they grow and project outwards: but, in a few cases, they have been seen to advance in the opposite direction, and protrude within the ANOMALIES OF BONE. 109 medullary canal. They are then named enostoses,—a name which we are accustomed to give to exostoses which project into a cavity, such as the skull, the orbit, or the pelvis. Sometimes both are met with together. An exostosis which encircles a cylindrical bone more or less completely, is called periostosis ; and so on. The cause of exostosis is not yet ascertained. It occurs, but not con- stantly, under certain local circumstances, as after a blow or a fracture; in the latter instance, it is merely exuberant callus ; and no definite and clearer cause for it can be assigned. In most cases the periosteum covering the exostosis is in its natural condition; sometimes it is thicker than natural, and hypertrophied, and adheres with unusual firmness. Exostoses are found in every period of life ; those of the spongy kind occur even in children and new-born infants. Usually, when they have reached a certain bulk, they-eontinue for the remainder of life unchanged. Sometimes, and even in cases of the ivory exostosis, they have been observed to diminish in size, either by absorption, or, as it were, by contracting, while, at the same time, their structure increases in density. Spongy exostoses sometimes become carious and are destroyed; while, in a few cases, the ivory exostosis appears to have been attacked with necrosis, and thrown off. The callus deposited around fractures frequently resembles the\xos- tosis; and one form of the osteophyte resembles it still more: it is that which is occasioned by a circumscribed chronic inflammation of the outer layer of a bone, and which finally becomes condensed (sclerosed), and adheres to its surface. Lastly, there is one form of bony growth yet to mention, which is produced at first by the dura mater or the periosteum on the side next the skull, and afterwards unites with the bone. It is generally flat, and the surface by which it adheres to the periosteum is rough: it is most frequently found on the inner table of the vault of the skull, where, as a product of the dura mater, it fits into the depressions of the vitreous table, and becomes flrmly soldered on. b. Osteophyte.—Although no well-marked line of distinction can be drawn between the exostosis and the osteophyte, yet the latter presents such striking peculiarities, that, in the majority of cases, it may at once be recognized, and is but rarely liable to be confounded with the former. Unlike exostosis, the osteophyte mostly occupies extensive tracts on a bone, investing or springing from it in a great variety of forms. More- over, it is generally the product of an inflammatory process in the superficial part of the bone and in the periosteum, and hence is very commonly found adjoining and surrounding 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 occa- sioned a reaction in the tissue of the bone. This explains why the osteophyte is found chiefly upon and near vascular portions of bones; as on and near their articular ends, on their rough lines, &c.; and why in the skull it mostly occurs near the sutural cartilages. Regarded in this view, the osteophyte acquires a further and special interest; for as certain processes in bone, arising from a constitutional affection, appear to produce a definite and peculiar osteophyte, the nature of a disease 110 ANOMALIES OF BONE. can be determined by the characters which the osteophyte presents. I shall have an opportunity hereafter of introducing what I have observed on this subject; it may, perhaps, be deemed a contribution to our know- ledge of diseases of bone, in its present incomplete state. In the first place, Lobstein has conceived that a distinction should be drawn between exostosis and what he denominates osteophyte. I shall not, however, follow his subdivision, but shall attempt to give a more practical representation of the disease. a. The velvety villous osteophyte sometimes appears as a single and very thin layer, resembling a coating of hoar-frost; sometimes it mea- sures one or two lines or more in thickness. It seems to be composed of delicate fibrils and lamellae, which are fixed at acute angles on the surface of the bone, and give it the appearance of velvet, or of felt with a very fine nap. As it increases in density it gradually acquires a smooth exterior, which is pierced with very numerous fine pores; while its deeper structure is more distinctly laminated. Although, at first, in contact with the bone, it is usually almost entirely unattached to it, and can easily be raised in large pieces from its surface. The osseous sur- face under it is sometimes as smooth as in the natural state; but some- times we find, upon close examination, that it has lost its smoothness, and is distinctly rough, the pores for its vessels being somewhat en- larged, and its outermost layer here and there expanded into filaments. At a later period, the osteophyte is found attached to the bone by some intervening minute round pillars and plates: after having gradually become compact, it unites with the bone. A layer of cellular (diploetic) substance forms for some time a line of demarcation between it and the bone, but when this disappears, the osteophyte and the compact surface of the bone compose one uniform whole. It corresponds to the " osteo- phyte diffuse et fibrillo-reticulaire " of Lobstein. Sometimes, as an ex- ception, it is produced in more considerable quantity, and forms an intimate connection with the bone, uniting with the filamento-cellular structure into which the outer layer of the bone expands. Should the periosteum have taken part in the process by which the osteophyte is produced, that portion of the exudation which attaches to it, becomes organized into a vascular cellular tissue, while that which belongs to the bone, and which ossifies, forms a compact osseous layer: the surface of the latter presents a great number of pores, and of ex- ceedingly tortuous and convoluted half canals, which have been occupied by the newly-formed cellular tissue, and its vascular twigs. We notice this chiefly when such an osteophyte is situated on the inner table of the skull. The color of this osteophyte in the recent state depends on the intensity of the process which produced it, on the period of its existence, and on the progress of its ossification: and it varies accordingly from bluish or rosy-red to yellowish and dirty white, or it may be a dazzling white, and glisten like silk or asbestos. At its commencement it is a soft, gelatinous exudation; afterwards it becomes tough and elastic, like cartilage; and finally it ossifies. This kind of osteophyte is seen chiefly on compact bones. It accom- panies almost all inflammatory processes, abscesses, and necrosis in bone, ANOMALIES OF BONE. Ill especially in young persons with abundant fluids (succulent): it fre- quently extends from the diseased spot over considerable portions of the surface of the bone, while it accumulates in greatest quantity in the im- mediate neighborhood of the disease, and occasionally on the rough lines, &c. It is very frequent in the skull, especially on its inner table; and on that part particularly there is a bony growth, which has some connection with pregnancy, and Avhich we call the puerperal osteophyte. It possesses great interest, and will receive a fuller consideration when we come to treat of the diseases of the cranial bones. ft Allied to this osteophyte is another which I will call the splintered and laminated osteophyte. It presents itself in the form of rather large excrescences and lamellae, which measure several lines in length, are conical in shape, and mostly terminate in a sharp point: they are composed of a compact wall, pierced with fine pores, which encloses a coarsely cellular, osseous tissue, or even a single (medullary) cavity. It is chiefly, and indeed commonly, abundant in the neighborhood of the cancellous parts of a bone affected with caries, especially caries of the articular ends of bones in young subjects, which is generally considered to be of scrofulous nature. y. Warty and stalactitic osteophyte.—This is a bony growth either of excrescences resembling warts and attached sometimes by a broad base, sometimes by a pedicle, or of larger, irregular, rugged masses resem- bling stalactites. It seems to be found only in the neighborhood of the joints; it accumulates particularly around enlarged articular concavi- ties, forms a tuberculated addition to the margin of articular heads, which have been flattened out like a mushroom, and thence extends in abundance also to adjoining rough parts of the bone. They generally consist of a chalky, white, very brittle substance; they occur most commonly on the hip bones, and appear to be connected with gouty metamorphosis of that joint. 3. The osteophyte in the form of thorny or styloid, single or branched plates, or of rounded, gnarled, and pediculated processes, occurs chiefly on spongy bones, on the vertebrae, and the bones of the pelvis, selecting in both these instances the neighborhood of the synchondroses. It occurs also on the articular ends of bones, and very frequently follows, as it grows, the direction of the fibres of the periosteum, ligaments, tendinous insertions of the muscles, intermuscular septa, interosseous membranes, &c. When growths of this kind spring from two adjoining bones, they frequently meet somewhat in a symmetrical manner, and unite together: in this manner they enclose the synchondrosal cartilage in a more or less complete bony capsule, and give rise to a peculiar kind of anchylosis, which is often observed on the bodies of the vertebrae. Not unfrequently they supply the place of callus which has been arrested in its development, and imperfectly unite the ends of broken bones. Similar formations are sometimes seen around the cloacal openings in the capsule of a sequestrum. They arise from a chronic inflammation of the bones, in which the periosteum and ligamentous apparatus become involved: they are often found on the vertebrae of old persons, and while the bone to which they are attached, as well as some others, or even the whole skeleton, is atrophied, the osteophyte itself is of dense structure, and hard. 112 ANOMALIES OF BONE. e. There is another osteophyte, which looks as if a quantity of bony matter had been poured over a bone, and had coagulated as it flowed. It forms masses Avhich sometimes give the impression, that the bony sub- stance had been dropped upon a bone, and had then solidified ; in which case the surface of the mass, whether even or uneven, is smooth: at other times it appears as if the bony matter had been poured in a stream over larger surfaces of a bone, and had then coagulated. This osteo- phyte is compact. I have seen it on the inner table of the skull, when the cranial bones were indurated; and have met with it still more fre- quently covering a considerable extent of the anterior surface of the ver- tebral column in old persons, and producing anchylosis of the vertebrae. In accordance with the foregoing descriptions, I exclude from amongst the osteophytes all those bony growths which form a more or less com- plete external capsule, or an internal radiated thorn-like skeleton, for the various adventitious structures that occur in bone, whether enchon- droma, osteosarcoma, or cancer; as well as those which are found at the base of similar adventitious structures in the softer organs. Osteophytes have in some few cases been observed covering large por- tions, and even almost the whole of a skeleton. Sometimes they are accompanied by hypertrophy, sometimes by atrophy of the bones. We are quite ignorant of any general diseased condition of the system to which this can be attributed. The periosteum may not share in the diseased process going on in the exterior of the bone, and then it remains nearly unaltered; but if it do take part, it becomes vascular, reddened, infiltrated, and thickened (hypertrophied), and furnishes sheath-like prolongations, which invest the more bulky of the bony excrescences. The changes which the osteophyte undergoes in the course of time have been already partly noticed. The fibrils and lamellae which com- pose the velvety osteophyte approach each other and increase in size, and, at the same time, assume a position parallel to the lamellae of the bone beneath them; the whole osteophyte becomes more dense, and unites either immediately or by an intervening layer of diploe, with the bone. Hence the bone becomes a layer of compact tissue thicker— Lobstein's " supracorticale osteoscleroses' In other cases, as the vel- vety, or the splintered and laminated, osteophyte becomes condensed, its fibrils and lamellae retain their relative position to the bone, and the osteophyte becomes a compact osseous mass, which, though attached to the bone, can be distinguished from it by the different direction of its lamellae and the course of its medullary canals. Sometimes the osteo- phyte appears to be diminished by absorption, but it can hardly disap- pear altogether. _ B. Atrophy.—Atrophy of bones occurs under many forms and various circumstances. (1.) After a long-continued and exhausting disease of bone, such as^ caries, after exhaustive healing processes, such as fractures (and injuries generally), or in consequence of palsies, neuralgia, or anchy- losis, single bones, or large portions of the skeleton may diminish m volume. They retain their normal texture, but diminish in length, and still more in thickness; an entire bone becomes small, and ANOMALIES OF BONE. 113 its medullary canal contracted,—it is in a state of concentric atrophy. And in connection with this fac#, and in opposition to that increase in the volume of bones to Avhich I have before adverted as a consequence of distension of the cavity which they form, I may mention that bony cavities diminish, or sink in, when atrophy or loss of substance happens to the organs contained within them. (2.) Bones are subject in old age to a form of atrophy (senile atrophy), in which their consistence and strength are so far changed that they not only become soft and flexible, and are easily indented, but rather acquire something of the brittleness of glass. (Fragilitas Vitrea. Osteo- psathyrosis of Lobstein.) Atrophy appears always to commence with the medullary tubes and diploetic structure : the cells of the latter enlarge, and its walls, as well as the bony threads composing the cancellous tissue, become attenuated, and at length disappear entirely. The compact substance yielding next, is all changed into spongy, diploetic tissue, except its outermost layer, but though that remains compact, it becomes extremely thin, and is sometimes scarcely as thick as a sheet of paper. As the atrophy of this once solid, but now spongy, substance becomes more complete, the outer- most layer alone remains, encompassing either a cavity, which contains some mere traces of spongy tissue at its periphery,—a cavity relatively dilated (excentric atrophy), or a soft substance, with very coarse cells ; or lastly, when the diploe is entirely removed, the extremely thin remain- ing parts of the walls of the bone approach each other, and coalescing form a single thin plate. Examples of the first change are presented by the larger medullary tubes ; the second is seen in the smaller cylindrical bones, in the pelvic bones, ribs, and vertebrae; while the bones of the face, and small spots, which are limited to the top of the parietal bones of aged persos, exhibit the last. Finally, should the atrophy proceed to an extreme degree, and involve the last remaining thin layer of the Avail of the bone, its surface becomes rough and porous ; and, however easily the periosteum may be stripped off elsewhere, it cannot be removed from this spot without bringing away a layer of bone with it. The medullary tubes and dilated cellular interspaces are filled with marrow, which is usually of a dark, and often of a brownish-red, or a chocolate color. The description given above sufficiently explains how it is that the bones become unusually flexible, and easily crack when they are bent; that upon making moderate pressure on spongy bones the finger breaks into them; that the cylindrical shafts, being reduced to a thin compact wall, break upon the slightest occasions; and that, in advanced age, the well-known curvatures of the vertebral column occur, and other portions of the bony fabric of the body become, under certain circumstances, crooked and deformed. As the bones lose substance in their interior, they shrink in their ex- ternal bulk : and hence the skeleton in old age becomes smaller in all its dimensions, and the weight of the body less. Senile atrophy runs a chronic course, and is unattended with pain; in its earlier stages the muscles also waste and the lungs become atrophied; and afterwards the diminution of the bones is attended with decay (invo- lution) of all the other organs: the muscles are sometimes the seat of VOL. III. 8 114 ANOMALIES OF BONE. fatty degeneration. There are some diseases of bone, which, in their anatomical characters, present considerable resemblance to this form of atrophy; but, although hitherto thought much of, those characters are in themselves unsatisfactory. They are diseases which affect persons unlike those in whom senile atrophy is met Avith, and in their symptoms and course they materially differ from it. As they are processes con- nected with constitutional disease (dyscrasia), and we partly recognize in them, and partly have reason to assume, the existence of important quali- tative deAdations from a healthy state of the organization, I shall speak further of them under the head of Morbid Expansion and Softening of Bones. (3.) A third form of atrophy is that in which bone_ is worn away or absorbed (Usura, detritus ossis). Being occasioned either by uniform and permanent, or by repeatedly renewed (pulsatile), pressure upon the bone, the breach of substance is always circumscribed. Various tumors, which form in the soft parts adjoining a bone, especially in periosteum, produce this effect with different degrees of force: the Avails of the skull, for instance, are pressed upon by the Pacchionian bodies, by sundry ad- ventitious growths, commonly known by the collective name of fungus of the dura mater, by tumors in the brain, even by the brain itself, when enlarged or displaced, by large apoplectic cysts, by an enlarged and dis- eased pituitary gland, &c.; the bones of the face suffer from the pres- sure of fibrous tumors (fibrous polypi), of sarcoma, and cancerous groAvths developed in the nostrils, frontal sinuses, antra Highmoriana, or orbits; but the most frequent cause of pressure is aneurismal tumors, and the common seat of it is the bones of the trunk and limbs. The degree and the extent to which the bone is worn away varies in different cases, the former depending on the amount and duration of the pressure, the latter on the size of the tumor: one or more bones may be entirely destroyed, or a bony wall may be perforated, as is often strik- ingly illustrated in the progress of aneurismal tumors. As large tumors press unequally, the destruction of bone, when very extensive, is generally not uniform: for the same reason its boundaries are not sharply defined. Small tumors, which exert uniform and very moderate pressure, and even larger tumors, when they grow slowly, occasion, first, flattening, and then an excavation of the bone on which they press, but do not dis- turb the smoothness and polish of its surface. The bone immediately around bulges out, and appears not as if it had sustained an actual loss of substance, but rather as if its substance had been merely thrust aside. When pressure is made on one of twTo compact tables, especially in the skull, it is not so much that table which seems to be absorbed, as the layer of diploe beneath it; the two tables are in this manner gradually brought nearer together, and at length come into contact and unite. I find this borne out by many well-marked cases in the University Museum at Vienna; as well as by most of the pits on the inner surface of the skull, in which Pacchionian bodies have been imbedded. If the compact wall of a bone be subjected to considerable pressure it disappears layer by layer, becomes rough on the surface, and when at length entirely absorbed, leaves the cancellous tissue beneath it exposed. A very manifest effort of nature is then often perceived to resist the injury, and to maintain the integrity of the inner texture of the bone. ANOMALIES OF BONE. 115 The cancellous substance, increasing in density by the addition of bony matter to its lamellae and threads, strives to become compact, and ex- posesto the pressure a stratum as capable of resistance as possible. This wearing down (detritus) of bone may easily be confounded with the loss of substance which results from caries; and the difficulty of dis- tinguishing between them is sometimes augmented by their both occur- ring together. For, to take a frequent instance, that of softening malig- nant tumors, not only is the bone worn away by the pressure which such tumors exert, but inflammation and suppuration are set up in its exposed spongy texture, or corrosion on its surface, by the ichor which they discharge. Absorption (detritus) is distinguished from caries by the absence of any change of texture, either at the spot itself, or around it; and by there being neither purulent nor sanious product, nor any osteophyte. The tendency to condensation which is exhibited in the substance exposed to pressure furnishes a further distinctive mark of the detritus. Finally, bone may be absorbed in consequence of pressure from within: the various tumors developed in the spongy substance, and medullary cavity, the fibroid tumors, enchondroma, osteoid growths, sarcoma, cancer, and the dilatations of the capillary system of the vessels, known by the name of teleangiectases or erectile tumors, all commence their ravages within the bone. § 3. Anomalies of form.—The deviations from the natural shape of the bones are many and various; in some instances they are congenital, very frequently they take place after birth. When congenital, they sometimes occur independently and alone, sometimes an apparatus with which the altered bone stands in intimate relation is malformed too; at other times the change of form, whether congenital or acquired, results from some disease in the bone itself, or in other structures. To avoid repetition, I do not enumerate them here; for the most important of them will be more conveniently described amongst the anomalies of the several parts of the skeleton, and of the bones composing them, as well as in the chapter on the Joints. § 4. Anomalies in the relative position of bones, and in their connec- tion with one another.—The connection between bones is sometimes un- naturally close and intimate, and sometimes unnaturally loose: when the latter condition is very decided, it is usually combined with some devia- tion from their relative position, that is, with dislocation. The former state, or that in which bones are bound too closely together, is found, both when their articulation with each other is movable, and when it is immovable. It is known as synostosis or anchylosis, though the latter term is chiefly employed to designate the fixed state of a joint. Synostosis is sometimes congenital, but much more frequently it is ac- quired. Congenital synostosis may be the result of an unnatural fusion of points of ossification belonging to separate bones ; it is then almost always manifestly prejudicial to the full development of one or both of the united bones, and it accompanies other and more important malfor- mations, such as acephalus, cyclopia, &c.: or it may consist of premature 116 ANOMALIES OF BONE. union of bones, which do not naturally unite till various periods after birth: thus the cranial bones are sometimes found united even in the foetus. Allied to this, is the case in which certain bones coalesce at some period subsequent to birth, but earlier than that at which their union normally takes place. Thus the cranial bones sometimes unite prema- turely with each other, and so do the two halves of the loAver jaw, epi- physes with their diaphyses, &c. Synostosis, when acquired, is either incomplete, that is to say, adjoin- ing bones become bound together by bridges of new bone (osteophytes), which pass over the intervening synchondroses and articular^ cavities, and enclose them in a more or less perfect bony capsule: or it is com- plete ; the synchondrosal cartilages, or the soft tissues of a joint, haying been removed by atrophy, suppuration, &c, the bones are brought into immediate contact Avith one another, and become conjoined. Vertebrae, the pubic bones, or the bones composing a joint, unite thus with one an- other ; so too does the sacrum with the ossa innominata. Other bones, also, when brought into permanent and close mutual con- tact, may become fixed together in the same manner; the ribs, for in- stance, in cases of lateral curvature. Synostoses are to be met with under any of the above-mentioned cir- cumstances, sometimes between single bones only, sometimes at several parts of a skeleton; and sometimes they are almost universal. Phoebus has recently seen and described an example of congenital synostosis, in which there had been a fusion of original points of ossification. There is a very similar case in the museum at Vienna, of congenital fusion of the second and third cervical vertebrae ; only it obtains further impor- tance from the fact, that the atlas is also congenitally united with the occiput. In another specimen the bones of the right forearm are con- tinuous with the humerus, without the intervention of a joint. A simi- lar synostosis, and one presenting considerable interest, is that of Nagele's obliquely narrowed pelvis, in which the sacrum is united with one of the innominata. Anchylosis, in the restricted sense of extinction of a joint, especially that which is acquired, will be considered in the chapter on Joints. Loosening of the natural connection of bones which are immovably articulated to each other, is denominated Osteodiastasis: when the same thing occurs between bones which move upon upon one another, the re- sult is dislocation. In diastasis the change produced in the connecting medium depends upon circumstances : it is either stretched, attenuated and loosened in texture, or torn through. Gradually increasing exten- sion leads to the first change, as is instanced by the cranial bones in cases of hydrocephalus, by the bones of the face, when stretched over fibrous polypi, or by the pelvic bones in parturition; while the second is caused by quickly acting force, and is exemplified by disjunction of the sutures when the skull is shattered, by the laceration of the synchon- droses of the pelvis in very difficult parturition, or by the separation of the epiphyses in consequence of injury. ^ Moreover, the occurrence of diastasis is not only favored by previous disease, especially by inflammatory softening and loosening of the con- necting substance, but it maybe the immediate result of destructive sup- INJURIES OF BONE. 117 puration of _ that substance, as is shoAvn by the consequences which the pelvis sustains from the worse forms of puerperal disease. The subject of dislocations will also be considered in the chapter on Joints. § 5. Anomalies of consistence.—These anomalies, expansion of the tissue, and so-called softening of bone, on the one hand, and induration on the other, are, essentially, changes of its texture, and of its chemical composition: the latter involve as well the mineral constituents as the animal basement, and they must therefore be treated of amongst the dis- eases of texture. § 6. Solutions of continuity, and the process by which they are re- paired.—The solutions of continuity in the osseous system, which result from injury, present many varieties. Bones may be laid bare by the re- moval of their periosteum, and of the soft parts covering them: they may be wounded by more or less sharp penetrating instruments; from whence ensue the various kinds of punctured, incised, and shot wounds, by which the bone is either partly or completely perforated, as well as the wounds inflicted in operations, as amputation, trephining, in the re- moval of portions of bones, &c. They may be broken, and, as is well known, the fracture may be transverse, oblique, or longitudinal; there may be but one fracture, or several, in the same bone: and sometimes a bone is shivered, or crushed, and the fracture Avhich results is commi- nuted. Incomplete fractures or fissures are, for the most part, met with in the skull; as when only one of the compact tables is fractured, or when the inner table is disunited, while the outer remains uninjured. There is a remarkable form of incomplete fracture, in which a bone *- becomes bent. It occurs on flat bones, like the skull, as well as on long bones. It is produced sometimes by sudden and violent mechanical force, sometimes by more gentle means, which act through a longer period either uniformly or with intermissions. Its occurrence is favored by the softness of the bones, which in foetal life and in childhood exists natu- rally, but in subsequent periods of life is a morbid condition. These in- flections of bone are chiefly observed in the skull of the new-born child as a consequence of the pressure which the head has undergone from the pelvis of the mother, or the forceps of the accoucheur: they may, how- ever, be occasioned by accidental or intentional violence after birth ; or they may take place in the bones of the limbs of persons who are af- fected with rickets or osteomalacia. They may be brought on by me- chanical violence, or by excessive muscular contraction. Any of these injuries may occur alone, or be combined in various ways with loss of substance : and further, they may be either simple, or com- plicated with considerable injury, bruising, and laceration of the soft parts, with shattering or splintering of the bone, with the presence of foreign bodies, with excessive degrees of inflammation of the soft parts, with gangrene, necrosis, &c. In proceeding to the subject of the modes in which the most important injuries of bone are repaired, that by first intention, and that by way of suppuration, or second intention, I must refer, in order that the subject 118 INJURIES OF BONE. may be thoroughly understood, to what is said below on inflammation, suppuration, and necrosis of bone. The attention which has always been paid to the mode of union in cases of simple fracture has rendered that the foundation, as it were, upon which our ideas, as to the mode of re- pair in all other injuries of bone, have been based; and I,_therefore, make it, both in its successful and unsuccessful issue, the subject of the following remarks. Repair of fracture by the first intention.—When the extravasation produced by the fracture of the bone and simultaneous injury of the soft parts, and the Arascularity of the soft parts, of the lacerated periosteum, the surrounding cellular tissue, and the adjoining muscles and their sheaths, have in some degree subsided, a reactionary process of inflammation is set up. The soft parts around the fracture, some of which have been injured by the same violence that produced the fracture, and others by the broken bone itself, become swollen and so blended as to constitute one uniform red, firm mass, infiltrated with inflammatory product, which encloses the broken part in a more or less smooth and round, or in an elongated, swelling. In the same manner, the medullary membrane be- comes tumid and red; and, after a time, puts forth a red loose mass, which clings to the broken surfaces of the jDone, but soon coalesces with the surrounding soft parts (Breschet's substantia intermedia). Thus each of the fractured ends lies in a sort of capsule of swollen soft parts. The innermost layer of the capsule is the periosteum, which, having sepa- rated from the surface of the bone to a greater or less distance from the fracture, is so intimately united with the surrounding soft parts as to be no longer distinguishable: a viscous reddish fluid exuding on its inner surface, fills up the space between it and the ends of the fragments. Meanwhile, commencing at different distances from the seat of frac- ture, along the line where the periosteum remains connected with the bone, a reddish, semi-fluid, gelatinous substance exudes, which is greater ^ in quantity the nearer the fracture: it is evidently connected more inti- mately with the bone than with the periosteum, but the former is entirely unaltered beneath it. Where it adjoins the bone it become cartilaginous, and subsequently ossifies; it then adheres intimately to the osseous sur- face, and if stripped off, leaves it perceptibly rough, and with its pores dilated. This substance, as it increases in quantity, advances from the point at which the bone and periosteum are connected towards the seat of frac- ture, keeping close to the inner surface of the capsule of soft parts, and leaving a space between itself and the bare extremities of the bone, which is filled with the reddish viscid fluid before mentioned. At the same time, as it ossifies, it gradually assumes a more definite internal struc- ture. If the fragments of the bone be in faATorable position, the masses of callus, as they grow, assume a cylindrical shape, and arrive at the septum formed by the substantia intermedia. The septum has already acquired a cellulo-fibrous texture; but now it is gradually removed by absorption, and the masses of callus from the opposite ends of the bone coalesce over the fractured spot. What takes place outside the bone goes on also in the medullary cavity ; a substance is effused, which every- where ossifies and obliterates the cavity of the medulla. These changes constitute what is called the formation of early callus. INJURIES OF BONE. 119 This callus gives some firmness to the fracture, and the time occupied in completing rt—from thirty to forty days—forms, in a practical point of view, a very important period in the whole reparative process. It is named by Dupuytren the provisional callus. Long before it has reached the state of completeness aboAre described, a later growth, or formation of definitive callus, commences. The fluid before spoken of as occupying the space between the broken ends of the bone and the callus (and a similar fluid which may be found also between the callus and the soft parts) becomes gradually more firm, receives vessels, and acquires a structure which at first resembles granu- lations, but at a later period is cellulo-fibrous. A small quantity of a reddish exudation appears beneath it on the denuded ends of the bone, and gradually unites with the granulation-like substance. As a vascular communication is thus established between the surface of the bone and the surrounding soft parts, a formation of new osseous substance commences all round the fractured ends : it resembles the first formation of callus, but proceeds with less energy. Both the earlier and the later callus increase in quantity, and at length unite together. They are, hoAvever, distinguished from each other by the difference of their texture, particularly of the softness of the second callus, when compared with the fully formed earlier growth. In this manner the broken extremities of the bone are surrounded by an uninterrupted osseous sheath which adheres to them both. Last of all, in four or five months or more after the injury, the broken surfaces themselves unite within this sheath, though, indeed, the first traces of exuding osseous substance are sometimes perceptible much ear- lier, beneath the substantia intermedia, where it clings to the margins of the fracture. The substantia intermedia then disappears, and the frac- ture is completely repaired. The edges of the fracture are pretty fre- quently, though not always, distinctly rounded off. During this consolidation, the remaining swelling of the soft parts subsides, and the medullary cavity begins to be restored at the fractured spot. The Haversian canals, in the mass of bone with which the cavity is filled, are gradually enlarged to such an extent as to render it cellular and areolar instead of solid ; by further absorption it is entirely removed, and a new medullary cavity occupies its place. Sometimes a thin layer of the mass remains behind, united at the seat of fracture with the bony substance exuded from the broken margins, and for a long time obstructs the canal. The callus, which was more or less uneven externally, has by this time become smooth. It is invested with a fibro-cellular membrane, which consists partly of the old periosteum of the bone thickened, and partly of the exudation poured out by the soft parts: the latter forms a neAV periosteum, unites into one membrane Avith the old one, and gradually becoming thinner, at last precisely resembles healthy periosteum. Although the callus even Avhen completely ossified, is at first clearly distinguishable from the old bone by the arrangement of its canals and lamellae, yet in the end it acquires precisely the same characters as the bone. It is more than probable, that in process of time the callus dimi- nishes in bulk, very gradually indeed, but yet so far as the relative posi- tion of the fragments of the bone, and its OAvn original size, allow. Thus 120 INJURIES OF BONE. where simple transverse fractures have united, it shrinks so much a,s to form at last an inconsiderable elevation, which points out the original seat of fracture. But this is by no means to be regarded as an atrophy of the so-called provisional callus : no such decay, or involution, ever takes place, though it has been asserted by Dupuytren, and admitted by several others after him: there is no provisional callus, in the sense of a material for temporarily uniting or soldering the fragments together; and the reabsorption of the mass of bone which fills the medullary canal near a fracture, is to be regarded as one of the phenomena in the progress of the formation of a bone. The firmness of the union is generally proportioned to the length of time that has elapsed since the occurrence of the fracture. The process just described, in which bones reunite by first intention, is on the whole the same as that which takes place in injured soft parts. I have now to refer briefly to some points connected with the process, which have long been subjects of dispute; to describe what is observed when fractures unite under other, and especially under less fa- vorable conditions than those which we have supposed in the^ foregoing delineation; and lastly, to treat of more important anomalies in the pro- cess, such as arrest, and the formation of new or false joints, repair by way of suppuration, and necrosis. Long as the contrary opinion has been entertained, it is now beyond doubt, that in the formation of callus, no ossification of the periosteum takes place, any more than of the surrounding soft parts; but that, in the first formation of callus, the development of the whole osseous mass pro- ceeds from the bone only is not fully ascertained, probable though it be. For, not to mention other facts, bone is sometimes found on the inner surface of periosteum ; and the dura mater particularly, which is virtually a periosteum, frequently presents bony growths on its outer surface, which do not adhere to the bone at all, or do so very loosely, and only at a later period become closely connected with it. During the whole process of forming callus, the old bone undergoes very trifling change; and it requires close examination after the removal of the exudation, to discover that the pores on its surface are somewhat enlarged, and that the surface itself is rather rough, in consequence of some of the new matter remaining adherent to it. There is no greater change even when the exudation has ossified. When the formation of callus is complete, and the fragments have reunited, the bone sometimes shrinks, and becomes palpably thinner, and its cavity smaller than before. When only one of two adjoining bones is broken, as in the forearm or leg, the uninjured one takes part in the process of forming callus. Os- seous matter is exuded by it near the fracture, Avhich unites with the callus of the broken bone; for just as the substantia intermedia disappears when the broken surfaces of the bone unite, so the periosteum covering the callus of the uninjured bone is absorbed, and the two growths of callus coalesce. But still more frequently is this the case when both bones of the forearm or leg are broken, or whenever there is a fracture of two or more adjoining bones, such as the ribs. In fractures in the neighborhood of joints, fears may even be entertained, lest union between the articular ends of the bones be occasioned by the callus. INJURIES OF BONE. 121 Long oblique fractures involve a mass of soft parts in the reactionary process, and are attended by the formation of a quantity of callus, pro- portioned to the extent of the fractured surfaces. So, too, the greater the displacement of the fragments, the greater and at the same time the more misshapen, will be the swelling of the soft parts, and the subsequent callus. The same occurs when the fracture is comminuted. The great extent to which fragments, when displaced, are denuded occasions a difficulty in the formation of the secondary callus, and retards the process of repair; but in all essential particulars the process is the same. The callus encloses the fragments, and generally forms a bulky mass, which connects the opposite surfaces of the bone together. The medullary cavities, at first open, become blocked up with callus, which unites intimately with the SAVollen soft parts around; but gradually opening again, they become continuous with a new medullary cavity, which forms in the callus. Sometimes even when contiguous walls of the bone are firmly'consolidated together, they and the intervening callus are absorbed, and the continuity of the original tube is restored by means of a new transverse or oblique canal. A remarkable analogy to the mode in which bone is originally developed is observed in the uni- versal tendency to form medullary cavities in the interior of all large masses of callus, as in exostosis, and the more bulky osteophytes. Separate fragments unite within the callous enlargement in more or less favorable positions. The surface of large masses of callus is marked with grooves in which tendons or large vessels lie; and sometimes they are even perforated in various directions by small canals which those structures traverse. Of arrests of the growth of callus in general, and of new joints in particular.—The modes and degrees in which the formation of callus may be arrested, are very various. The quantity formed may be in- sufficient for its purpose, or there may be none at all: it may undergo the change which is incident to it \rery tardily, and not be ossified till a very late period; or may be imperfectly, or but partially, ossified: or the exudation, instead of becoming cartilaginous and bony, may assume and retain an apparently ligamentous structure. Such arrests may take place on both fragments, or predominate on one: and further, the anomaly may extend to both the first and second growths of callus, but usually it occurs in the latter only. In such cases, days and even weeks after the occurrence of a simple fracture, neither the bone nor the soft parts around it exhibit well-marked, or indeed any traces of reaction; and if the fracture should at last unite, it does so by the Avay of suppu- ration. In other cases, the growth of callus may be insufficient, the masses first formed may meet each other only at a few points, or may even not meet at all; as is the case when there is great displacement of the fragments. The secondary callus may not unite completely with the primary, and may remain soft and cartilaginous, or there may be too little of it formed, especially at the fractured extremities of the bone; in which case, its metamorphosis may be arrested or anomalous ; or there may be no callus formed at that part at all. It is in the last-mentioned circumstances that the cause is found for the formation of new, or false joints. (Articulus novus, spurius, prae- ternaturalis ; pseudarthrosis; articulation surnumeraire of Be'elard.) 122 INJURIES OF BONE. The unnatural joints, which result from fracture, are of two different kinds: one more or less resembles a synchondrosis; the other is like a diarthrosis, and is accordingly, in its proper sense, a new joint. In the former case, the fractured ends of the bone are held together by a ligamentous tissue. Either a disc of ligament, the thickness of which may vary, is interposed between them, and allows of but little movement; or, as occurs when there has been loss of substancej either from injury, from considerable absorption of the fractured ends, or other- Ayise, ligamentous bands connect the fragments, and allow them to move freely on each other. The connecting substance appears to be nothing but the substantia intermedia mentioned above, which, as the formation of the secondary callus has failed, or been insufficient, remains in its first state. In the second case, a ligamentous articular capsule is formed, and is lined by a smooth membrane, which secretes synovia: the fractured sur- faces adapt themselves to each other, and become covered with a layer of tissue, which is fibro-ligamentous, or more or less fibro-cartilaginous, or which resembles, and sometimes (Howship) really is, cartilage: they may articulate immediately with one another, or may have between them an intervening layer of ligament, which corresponds to an interarticular cartilage; and their movement upon each other is more or less free, ac- cording to the size of the articular capsule, and the form of the articu- lating surfaces. These last are sometimes horizontal and smooth ; they glide over each other, and allow of restricted motion: sometimes one surface becomes convex, and the other concave: sometimes both are rounded off, and lying within a capacious articular capsule far apart, they come in contact only during particular movements. The articular capsule is the product of the inflammation of the soft parts: the cartila- giniform layer, which covers the ends of the bone, is secondary callus arrested in its metamorphosis and converted into a fibroid tissue: the other ligamentous cords, which are sometimes present, and the structures resembling an interarticular cartilage, are remnants of the substantia intermedia. Both forms of new joint, but more particularly the synchondrosal form, have an analogue in the lateral new joints sometimes found between the masses of callus which are thrown out around two adjoining fractured bones. In the forearm and leg, and between the ribs, for instance, new joints are sometimes met Avith between the masses of callus after frac- tures have united. Between that kind of new joint which constitutes a firm synchondrosis, and that which as nearly as possible resembles a natural diarthrosis, there are numerous gradations. The circumstances which arrest the growth of callus generally, and give rise to the formation of false joints, are as follow: advanced age and senile atrophy of the bones; emaciation in consequence of disease, or loss of the fluids; cachexia generally; diseases of the bones in parti- cular, such as rickets, osteomalacia, too severe inflammation, suppuration, caries, and necrosis at the broken spot; paralysis, and similar affections (on which subject reference may be made to Roechling's experiments on animals); pregnancy; any improper bandage which stops the access INJURIES OF tfONE. 123 of the fluids to the part (a circumstance which is explained by Brodie's experiments of tying the crural artery in animals, in which the femur was broken); inquietude of the limb; considerable displacement of the fragments, and the occurrence of the fracture within the capsule of a joint. But these conditions do not always put forth their power of arresting the formation of callus and the repair of fractures; certainly they do not always act equally. Thus the fractures of bones affected with rickets or osteomalacia are not very unfrequently united by a mass of callus, which not only is sufficient to repair the fracture, but even has a more perfect internal structure than the other bones: fractures very often unite at every period of pregnancy; and the neglect of quietude is unquestionably rather a grave impediment to the reunion of fragments in proper posi- tion than to the formation of callus and the repair of a fracture generally. Fractures within the capsule of a joint require more particular notice. It is a fact ascertained from much experience, and now established as a rule, that fractures within the capsules of joints very rarely unite com- pletely : the fragments become bound either firmly or loosely together by a ligamentous apparatus; or, their surfaces becoming eburnated or covered with membrane, they form an articulation with each other within the old joint. Many reasons have been assigned for the great deficiency in the formation of primary callus around these fractures, as well as for the arrest of the growth of secondary callus; but which of them is to be regarded as the true and the universally applicable one is not ascertained. As fracture of the neck of the femur is the principal instance of the kind, and is that which has led to all the investigations that have been instituted on the subject, I shall enter more particularly into the consideration of it when treating of Diseases of the Bones of the Lower Extremities. Union of fractures by suppuration.—Compound fractures unite in a different manner from that by first intention: yet the repair by suppurative inflammation, in its essential particulars, has been far too little investigated. It is analogous on the whole to the repair by first intention, certain stages of the latter always occurring in the course of it; only, as must be obvious, the repair is effected with more difficulty and at a later period, and sometimes is never completed. In this as in the other process, a capsule of soft parts forms around the broken ends of the bone, but the inflammatory product contained within it is pus, just as in any wound which may exist at the same time in the soft parts, and the capsule being lined with a grayish-red, trans- lucid, jelly-like, granulating layer, which is covered with pus, is in fact a closed abscess. The early callus, as in union by first intention, appears as a gelatinous exudation, Avhich subsequently becomes a cartilaginous, and then a bony stratum. It springs from the bone, at the part which has remained covered by periosteum; and then, keeping off from the denuded ends of the bone and from the fracture itself, it advances on the inner wall of the capsule towards the broken part, the ossifying cartilage being developed from the granulating layer. The broken ends of the bone, so far as they are denuded of their peri- 124 INJURIES OF BONE. osteum, are washed in the pus: they lose their natural color, and look bleached and dull Avhite, but are otherwise unchanged—even at the sur- faces and margins of the fracture. It is not usual to see any plastic exudation in the open medullary cavity: the fractured surfaces are everywhere washed in the pus : the internal surface of the bone—that which faces the medullary cavity—appears dull white and dead to a greater or less depth on one side, or for the greater part, or the whole, of its circumference : the cells and spongy tissue are in the same state; and the medulla at that part is collapsed, soft, and discolored, and is dissolving in the pus. Beyond the confines of this change, however, the medulla is swollen and reddened, and if the necrosis have not extended all round the bone, it protrudes, as it does in the process of union by first intention, beyond the fractured surfaces. Now, it is more particularly the growth of secondary callus which is late in commencing, which very often suffers more or less considerable interruptions in its progress, and which differs most from that which is formed in union by first intention. The ends of the bone being washed in pus, and thus kept in contact with a fluid incapable of organization, die : and the extent of the necrosis, whether it shall be superficial, shall be confined to the inner layer of the bone, or involve its whole thickness, is unquestionably determined by the extent to which the periosteum is stripped off, and the medullary membrane destroyed. As soon as the necrosed part has exfoliated, granulations appear on the bare surfaces and margins of the fragments, and become the basement in which the new bony substance, or secondary callus, is deposited. It is by the very slow manner in which the exfoliation of the necrosed bone takes place, that the formation of the secondary callus is delayed: and as not unfrequently the powers of the system are almost exhausted before it is completely formed, it is often produced in insufficient quan- tity, or arrested in its perfect internal development, that is, in its ossification. Moreover, as soon as the exfoliation and entire removal of the necrosed piece are effected, the inflammation ceases, and a great part of the granulations which were exuded for the purpose of producing new bone, goes to form on all sides a cellulo-fibrous, ligamentous, and cicatrix tissue: hence it is, that the repair of fractures in this manner is so often incomplete, and is attended Avith so extensive and perma- nent a loss of substance. Whatever the condition of the early callus, whether it be abundant in quantity and thoroughly organized, or other- wise, the granulations supply an inadequate substitute for the bony sub- stance which has been lost by exfoliation : instead of changing into carti- lage and bone, they become converted into fibroid tissue; and thus the repair which ensues is attended with shortening, with disfiguring cica- trices, or with an artificial joint. Repair of the bendings and fissures of soft bones.—When the bones of children or of persons affected with rickets have been slightly and gra- dually bent, and the bony tissue and periosteum have been stretched without suffering a breach of their continuity, they are gradually restored to their natural direction without giving any sign of reaction. And those injuries also in Avhich the bones of children are rapidly and violently bent, are easily repaired. But when bones are bent to an angle by a INJURIES OF BONE. 125 greater and more sudden force, and a real, though not always perceptible, solution of continuity takes place, whether it be on the one side a tear- ing asunder, or on the other a crushing, of the outermost layers of the bony tissue, the injury is repaired like a fracture by first intention. When bones affected with rickets and osteomalacia are bent in this manner the callus generally continues in a soft half-cartilaginous state, and does not obtain its perfect internal structure till the disease is cured. To this, however, there are exceptions, for bones affected with these diseases, When bent and partly fractured, and also when broken quite through, are sometimes reunited by bony callus : and it is not till after it has reached a certain stage of development, especially in osteomalacia, that the callus undergoes the peculiar metamorphosis. Repair of injuries of bone complicated with loss of substance.—The mode in which wounds of bone combined with loss of substance are re- paired is, on the whole, the same as that by which fractures unite. Under favorable circumstances it is effected by the first intention, and the osseous mass exuded from the surfaces of the wound in the bone serves not merely to reunite the bone, but also to supply the place of the part which has been lost. This is true of loss of substance as well of one bone as of another, and in whatever degree, or in whatever form it may have occurred. Irrespectively of unfavorable general conditions, it may be said that the greater the loss of substance, and the more the repair pro- ceeds by way of suppuration and granulation, the less complete will be the reproduction. Hence it happens that injuries of this kind are followed by permanent loss of more or less of the substance of the bone, and that in long bones shortening, or a false joint is produced. Wounds of the skull made with a trephine are extremely seldom closed by bony substance altogether, but the circumference of the opening mostly exhibits a growth of bone which may be compared to the two for- mations of callus. It proceeds from the surfaces of the compact tables as well as from the surfaces and margins of the wound ; but is insufficient to close the opening, and the defect is, and continues to be, for the most part supplied by a ligamentous (fibroid) plate, which adheres closely to the dura mater on the one side, and to the pericranium on the other; the trifling amount of (secondary) callus which proceeds from the sur- faces of the wound juts into the substance of this plate. The adjoining part of the wall of the skull is not unfrequently at the same time considerably attenuated, so that the fibroid layer which closes the opening is continuous with a margin of bone, towards which both sur- faces of the skull are bevelled off. In some cases true bone is developed in this fibroid plate. It assumes the form of needles and small plates, and gradually becoming identified with the callus which is growing inwards from the margin, it at length effectuates the closure of the opening by bone. Similar bony growths are met with in false joints in the ligamentous structures by Avhich the fragments are connected together. The way in which the wounds of bone made in amputations are healed accords with what has been described above : the medullary canal closes, the stump becomes rounded off, and unites with the soft parts and their 126 DISEASES OF BONE. cicatrix by an intervening cellulo-fibrous tissue, which supplies the place of a periosteum. If the inflammatory process should lead to suppuration in the bone, and still more, if suppuration take place in the periosteum and medulla, necrosis ensues to a corresponding extent; and when the dead piece has exfoliated, the cure is effected by way of granulation. Under such circumstances, the condition of the stump is sometimes un- favorable : the callus may be insufficient in quantity and density, and therefore incapable of enough resistance : the stump may be attenuated and end in a point; or, on the contrary, the callus may grow from it exuberantly in the form of some of the various osteophytes. Repair of injuries in which bone is denuded of its soft coverings.— There is no question that injuries of this kind are repaired by first in- tention. The soft tissues and the bone together furnish an exudation which becomes organized at one part into a layer of callus and at another into a cellular or cellulo-fibrous tissue ; and it will be observed, that the connection between the two new products is considerably closer than that which exists between bone and its periosteum in their normal condition. But in the unfavorable circumstances under which these accidents occur, and in which they remain, for a more or less lengthened period, until the arrival of surgical aid, such injuries are more frequently repaired by sup- puration and granulation, after the exposed layer of the bone has ex- foliated. Not unfrequently, indeed, they lead to a fatal termination, by the extensive suppuration in the soft parts, and the necrosis of the bone, which, like other injuries of bone complicated with wounds of the soft parts, they set up. § 7. Diseases of Texture.—Although diseases of bone generally, and those of its texture especially, have been the object of much valuable in- vestigation, both clinically and anatomically, yet our knowledge of them is still very defective; and perhaps nowhere amongst the diseases of the solid organs is the need of chemical research keeping pace with anatomi- cal inquiry niore perceptible than in the subject now before us. And another circumstance, which renders it extremely difficult for the patho- logical anatomist to deduce his single results from numerous investiga- tions, is the want of accurately distinguishing between different affections of bone, according to their local characters, as well as to the general symptoms, on the living patient; for regard is usually confined to syphilis, scrofula, and particularly to gout, when subsequent anatomical examina- tion discloses changes of an entirely different nature. 1. Congestion of bone, Hemorrhage.—Bones, like every kind of soft part, are subject to congestion, though, on account, probably, of the little attention which is generally paid to them in examinations after death, changes of their vascular condition are seldom noticed and estimated. Congestion is most frequently observed in the bones of the skull, the vertebral column, and the spongy articular extremities of long bones. In new-born children, and during childhood, considerable congestions of the cranial bones are met with: passive and mechanical congestions of the vertebrae, especially of the lumbar portion of the column, occur, eAren in advanced life, when the circulation through the ascending cava and vena portae is impeded : and cases of osteoporosis, rickets, &c, are DISEASES OF BONE. 127 accompanied by extreme congestion. There is no question that habitual congestions not unfrequently lead to hypertrophy of bone, especially in the form of induration: in cases of atrophy, where congestion coexists with expansion of bone, that is, with enlargement of its Haversian canals and cells, it may be produced by the wasting of the tissue of the bone. Hemorrhage takes place from bone under various circumstances. The vessels of bone, periosteum, and medullary membrane pour out their blood when torn in the various injuries which happen to them. Occa- sionally very considerable bleeding takes place under the periosteum, in the spongy tissue, or in the medullary cavity, from the exposure and corrosion of vessels of various sizes, by caries. But the most interesting cases are those in which spontaneous hemorrhage, resulting from extreme congestion, originates from the delicate vessels that pass between perios- teum and bone, and ramify in the grooves or half canals on the surface of the latter. The principal instance is that met with on the cranial bones of the new-born child, which is known by the name of Cephalhae- matoma. I shall have to advert to it again amongst the Diseases of the Bones of the Skull, where it can be more conveniently described. 2. Inflammation of bone.—Inflammation of bone (ostitis) is sometimes evidently the result of external causes, of various injuries, for example, most of which have been already enumerated, of concussion of the bone, or of cold; sometimes it arises from internal conditions, as when some constitutional affection, whether syphilis, the mercurial cachexia, scurvy, gout, and the like, or an exanthematous process, fixes itself in a bone. But the etiology of inflammation of bone is a subject which requires, more than many others, to be cleared up. Moreover inflammation of bone is frequently a secondary disease pro- pagated from neighboring tissues, especially from the periosteum. It is sometimes an acute inflammation, especially when produced by external injury; very frequently it is chronic, and is almost always so when it arises from any constitutional affection. It is sometimes con- fined to one bone, or to one circumscribed spot on a bone; sometimes it attacks several bones, or most, or nearly all of them, not perhaps all at once, but one after another in more or less rapid succession. At one time it affects the outer layer of a bone, and is combined with periostitis; at another the inner strata, when it is associated with in- flammation of the medullary membrane: the accompanying inflamma- tion of the periosteum and medullary membrane may be an original part of the inflammation, or a later addition to it. Lastly, there is a third case, in which a bone is inflamed in its whole thickness: in some in- stances it is so from the first, in others the inflammation reaches that extent later in its course. It is situated sometimes in compact substance, in the compact por- tion of a bone; sometimes in spongy substance, in spongy bones, and spongy parts of bones; and, external causes being excluded from con- sideration, the selection of its seat depends in a remarkable manner on the constitutional affection which gives rise to it, a peculiar prefer- ence being manifested sometimes for one portion of the skeleton, some- times for another, and sometimes for particular bones. Inflammations 128 DISEASES OF BONE. of bone vary much, and, in a practical point of view, materially in the degree and nature of the inflammatory process; and exhibit it first in the composition of their product (the exudation), and then in their consequent terminations. It would be inconsistent with nature, and in fact impossible, in an anatomical delineation of inflammation of bone, to make a broad division of it into acute and chronic; I shall, there- fore, be careful only at the proper points to mark the transitions of one into the other, and the characteristics by which they are distin- guished. A very moderate degree of inflammation, in the outer lamella of a bone, for instance, produces a gelatinous, dark-red exudation, which gradually changes its color to bluish-red, yellowish-red, and reddish- white, and at length becomes quite Avhite: at the same time passing from its original gelatinous condition, it forms a coagulum like white of egg, then becomes a soft, flexible cartilage, and, finally, reddish-white, succulent bone. In this state it invests the bone, and constitutes, ac- cording to its quantity, either a white, porous, and scarcely perceptible film, or a thicker layer, that resembles fine felt or velvet. The perios- teum appears at first injected, bluish-red, infiltrated, and decidedly swollen, and generally has but a loose connection with the exudation; for the latter, especially after it has ossified, adheres somewhat closely to the bone : sometimes, however, when the periosteum is peeled off, part of the exudation comes away Avith it. There is no change in the bone till the process is advanced, and then its grooves and the pores for its vessels are manifestly widened. The ossified exudation after- wards unites with the surface of the bone, and either forms uninter- ruptedly an addition to the thickness of the compact wall, or is con- nected with it by a layer which remains spongy (diploetic). In some of the thicker layers of bony exudation, occasional voids of various dimensions are met with, which are filled with a vascular tissue contain- ing medulla: they may, on the macerated bone, be easily taken for the losses of substance produced by caries; but without doubt they are merely the result of absorption in bone already formed, and are analogous to the formation of cancellous tissue, and a medullary cavity in callus. (Compare with this and with the following, what has been said on the subject of the osteophytes.) The principal opportunities of seeing this process are obtained in the neighborhood of more intense spots of inflammation, and around caries. The inflammation may recur in the exudation at any period of its ossification, and lead to a corresponding increase in the size of the bone. There are other inflammatory processes, some of them more acute, which return from time to time, and appear to be of a specific nature. Like those already described, they extend sometimes to several bones, and they deposit abundant exudations, which may assume the form men- tioned above, or the various other shapes delineated in the section on the osteophytes: the periosteum, at the same time, becoming hypertrophied, acquires a fibro-lardaceous, callous structure, and sometimes an enor- mous thickness. An inflammation of this kind may be often observed beneath chronic DISEASES OF BONE. 129 ulcers on the inner surface of the tibiae. The periosteum and adjoining cellular tisue, having been converted into a lardaceo-callous substance, form the base of the ulcer, and coA'er a luxuriant growth of curled bony plates, like madrepore, which are arranged perpendicularly upon the bone : the periosteum sends processes between, and forms sheaths around the separate plates. A villous, or a spavined and laminated, osteo- phyte is usually seen in the neighborhood, and hence, as the new tissue becomes indurated, a circumscribed portion of the bone is increased in bulk. When the inflammation is seated in the inner lamella of a long bone, or in the diploetic substance, it pours forth its product on the inner sur- face of the medullary tube, or on the walls of the cells of the spongy substance; and the tube becomes narrowed, and the spongy substance condensed. The process of exudation very often occurs on both the outer and the inner lamella of a bone together; and sometimes the intermediate substance also shares in the process, and the ossifying exudation, deposited on the walls of the Haversian canals, produces in- duration (sclerosis) of the bone. Besides these there are, no doubt, inflammations of bone, especially such as are slight in degree, and chronic in their course, which give rise to products that become organized in various other ways. Some change into osseous substance, the texture of which deviates from that of healthy bone; while others form fibroid, or cellular tissue, or a substance which resembles the jelly of spongy bones. Such products occasion a loosen- ing and expansion of the bone proportioned to their quantity; and many of the osteoporoses, which are attended with increase of the volume of the bone, are, no doubt, due to such processes of inflammation, or as they are called, irritation. A high degree of inflammation in bone leads to the effusion either of a fibrinous product, which more or less rapidly softens ; or of a purulent exudation, which varies in fluidity, according to the quantity of serum it contains, and is yellow and frequently tinged by an admixture of the coloring matter of the blood, and of blood itself; or, lastly, of a greenish or brownish discolored sanies. There are some striking instances of this kind of inflammation, which run their course very rapidly: they occur not only after injury of a bone, especially after concussion, but also in consequence of cold ; and they are associated with endocarditis and seve- ral other exudative inflammatory processes. The periosteum in these cases is loose and movable to some extent over the bone, the exudation being poured out beneath it: in well-marked cases, it becomes loose all round the bone, and distended into a fluctuating sac, which contains a large quantity of the exudation. The tissue of the periosteum is loos- ened and infiltrated: the bone is of the same color as the exudation, and has accordingly a dun, a dirty yellowish or a greenish or reddish ap- pearance, which results from all its spaces being occupied by the exuda- tion. The exudation is deposited in greatest quantity in the cancellous structure; but when the compact tissue is minutely examined, the Haver- sian canals are found to contain it too. The surface of the bone, espe- cially when the exudation is sanious, appears rough, that is to say, its outermost layer is eroded, and the loss of substance is produced by the VOL. III. 9 130 DISEASES OF BONE. solution of its tissue during the process of exudation itself, and by con- tact with a product which exerts an absolute dissolving power. The walls of the Haversian canals exhibit similar loss of substance, and are rough and eroded, or completely perforated. The cells of the cancellous struc- ture show it still more clearly, and the membrane Avhich covers its cells and network is opaque, dull, and discolored like the exudation, and is easily torn. It is this form of ostitis which, if it do not prove fatal by its coexistence with other exudative processes, very commonly puts life in the greatest danger, or actually destroys it by leading to absorption of the purulent and sanious matter into the circulation (the coats of the veins probably being dissolved in the exudation around them), and by metastasis. When the case is favorable, necrosis of the diseased bone, or portion of bone, is inevitable. But inflammations of bone, Avhich are accompanied by the production of pus and sanies, are more frequently chronic. The suppurative inflam- mation mostly occurs as a consequence of complicated injuries of bone and of necrosis: the chronic inflammation with an ichorous product, arises from internal causes, sometimes commencing spontaneously, sometimes being excited by injury to the bone, and sometimes, under the influence of the internal causes just alluded to, being an early or a late degenera- tion of the suppurative inflammation. It produces loss of the substance of the bone by ulceration, and constitutes Caries (Vereiterung—Beinfrass). In suppurative inflammation, especially in cases of considerable injury of bone, exposure, for instance, for a lengthened period, there very com- monly takes place, in the benumbed tissue, a visible exfoliation of a layer of bone of various thickness. When the necrosed portion is very thin, exfoliation is rightly assumed to be going on imperceptibly by the sepa- ration of small and scarcely discernible particles. But there are several cases in which symptoms have been ascribed to necrosis and insensible exfoliation, merely as it appears, for the sake of the theory, and in which no such process occurred. The circumstances were in reality more fa- vorable ; for as, when suppuration in its most benignant form takes place anywhere, the first secretion of pus is attended by some breach of sub- stance—by some solution—of the tissue in which it occurs, so is it in these cases. The softening Avhich many observers have adduced as a constant phenomenon in the suppuration of a layer of bone, must be re- garded as such a process of solution: a portion of bone disappears, and the exudation beneath it, like that beneath exfoliated bone, becomes or- ganized into granulations, which spring from the tissues lining the Haver- sian canals. This view is supported generally by the process of sanious destruction, which is allied to the suppurative, and is only distinguished from it by the relatively greater amount and the progressive increase of the solution; while it is upheld more particularly by the state in which a bone is found when this peculiar loss of its substance is the consequence of an acute inflammation attended by the production of pus or sanies, or when it results from caries: and lastly, it is further borne out by the condition of a sequestrum : but this is a subject to which I shall revert when speaking of necrosis. A spot of suppuration in bone is always skirted by an inflammatory process, which leads to an exudation of bone. If the affected part be DISEASES OF BONE. 181 the outer layer, an osseous exudation is found not only encircling the suppurating spot, but also on the inner table of the bone, and vice versd. When suppuration takes place in spongy bones, this process occasions so much condensation, that in a few cases an abscess becomes enclosed within a capsule of compact bone. This capsule is lined by a cellular membrane which is richly supplied with vessels, and it resembles an abscess in the soft parts enclosed within callous walls. Abscesses of this kind have been pretty frequently observed in the extremities of the tibia (Brodie, Mayo); and on a few occasions they have been met with in the compact substance of the shaft of that bone and of the femur (Arnott). Having hitherto treated of those terminations of inflammation in which bone is increased in volume and density (sclerosis, which is equivalent to induration in the soft parts), and in which suppuration ensues ; I am induced by the importance of the subjects to bestow separate sections upon the consideration of caries—chronic inflammation Avith production of sanies—and necrosis. 3. Ulceration of bone,—Caries.—This disease corresponds to ulcera- tion in the soft parts. It is sometimes the immediate result of an inflam- matory process of Ioav type (dyscrasia), the product of which exerts a solving power upon the bony tissue : the scrofulous and syphilitic ulcera- tions of bone are of this kind. Sometimes it arises out of simple suppu- ration in a bone in consequence of local or general (internal) causes. It is, moreover, frequently set up by ulcerative processes going on in adjoining soft parts; a frequent instance of which is presented by the caries of the articular ends of a bone, which ensues upon disorganization (Verjauchung) of the soft tissues of a joint. Lastly, it results also from the softening and ulcerative inflammation of morbid growths in bone, such as tubercle, cancer, &c. Caries is sometimes situated at the surface (caries superficialis, peri- pherica), and sometimes originates in the interior of a bone—in its medulla (caries centralis, profunda). In its extent it may be total or partial: it may involve a whole bone, as one or more of the vertebrae, of the carpal or tarsal bones, or the whole of a finger or toe; or it may attack a portion only of one of the larger bones, such as the end of one of the long bones composing a joint, or a circumscribed spot on the shaft of a bone. Though it chiefly affects spongy bones and parts of bones, it is not altogether rare in the compact tissue; indeed, certain forms of dyscrasia establish their ulcerative inflammation by preference in that tissue: gene- rally speaking, we may say that there is no bone which may not be the seat of the disease. It is most frequently met with in young persons as a scrofulous affection. It may come on Avhether the tissue of the bone in which it occurs be in its original healthy state, or have been previously diseased; it may occur, for instance, in a rickety bone. Its course is generally chronic ; but in the extensive devastations which it commits, and the fatal exhaustion which it sometimes produces within a short period, it frequently exhibits the character of an acute disease. It often threatens life, moreover, less by its own progress than by exciting inflammation in neighboring important organs; it does so, for example, when it occurs in the skull. 132 DISEASES OF BONE. An ulcer in bone presents numerous varieties corresponding with the kind of constitutional affection which gave rise to it. I shall, however, first treat of the process of ulceration in bone generally, without refer- ence to its varieties, as there will be an opportunity in another part of detailing the characters and differences which the ulcer obtains from the several processes of dyscrasia in which it originates. The appearances presented by an ulcerated bone when examined in the recent state, vary according to the progress which the disease has made; and in every stage of the affection its characters are far better marked in a spongy than in a compact bone. When caries is superficial, the compact bone is found covered with ichor, and rough, as if it had been gnawed: this appearance is given by the unequal loss of substance which the outward lamellae havesustained. The Haversian canals are enlarged, but not uniformly: the tissues con- tained 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 con- tents 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 skele- ton, and is easily cut with a knife, or yields to light pressure with the finger : lastly, it becomes swollen. In cases of central caries, the swelling sometimes produces expansion of the bone, especially if it be a spongy bone, for the thin wall gives way and becomes distended. The loss of substance which the bone sustains is occasioned by its so- lution in the sanious product which is effused by the inflammation into the Haversian canals. These canals enlarge in all directions, though not uniformly, and contain in different proportions, on the one hand, sanies and the soft parts which naturally fill them, discolored and disor- ganized (verjaucht) ; and on the other hand, granulations. It is thought by Delpech and Berard, Pouget and Sanson, and by Mouret, that a peculiar fatty matter is generated in carious bones; Mouret differs from the others, however, in believing that the organic principle (the gelatin- ous portion) does not disappear from the bone. The sanies produced by the bone is an acrid fatty fluid, itself dis- colored in various ways, and which, as is well known, blackens silver probes and linen. It almost always contains small particles of bone, discolored and brittle, which look as if they had been calcined, and are, in fact, loosened remains of the bony tissue, which is being destroyed. They are, without doubt, minute portions of necrosed bone; for in every form of caries, small imperceptible particles of bone die and are cast off. More rarely it happens, that necrosis of a larger piece of the ulcerating bone takes place (caries necrotica). In that case the portions of bone die sometimes without partaking at all in the inflammatory process, and DISEASES OF BONE. 133 simply from the access of their fluids being cut off by the carious destruc- tion which is going on around them ; and sometimes they die from the inflammation and disorganization. Whilst this disorganizing process (Jauchung) is going on in the bone, more or less of the adjoining osseous tissue and soft parts are always in- flamed to a greater or less distance. The inflammation is sometimes chronic, and the soft parts become infiltrated with a gelatinous or gela- tinous and lardaceous product, and indurated ; at other times it is acute, and leads to suppuration and ulceration. The periosteum, and the liga- mentous tissues connected with the bone, are, of course, involved in this change in the soft parts. The mode in which the ulcer of the bone opens externally, varies according to circumstances: sometimes one large ab- scess is formed ; at other times, one or more straight or tortuous, single or branching, long canals (fistulae, sinuses), either lead directly outwards, or not unfrequently pass to very remote distances; the orifices of the ! sinuses are usually marked by rather a hard margin, which surrounds them like a rampart. The carious bone, when macerated and dried, looks rough, and as if corroded: from being perforated in various ways by the unequally-en- larged Haversian canals, it has a spongy, porous, worm-eaten appear- ance ; the cells of its cancellous structure are enlarged; its walls and network are attenuated or demolished; and hence it is lighter than natural, discolored, expanded, and very brittle. New osseous substance, which assumes the form of some of the dif- ferent osteophytes, is sometimes deposited around the ulcerated spot, both on the surface of the bone, in its medullary canals, and in the cells of its spongy substance. And bone is deposited not only on the diseased bone, but on others also which are near it. In other cases the neighboring bones are found in a state of rarefac- tion (osteoporosis), of areolar expansion, combined with hypertrophy, or inflammation of the soft parts of the bone, and, at length, of atrophy of their tissue. Caries will heal, even in cases where it has committed great devasta- tions, by a change of the ulcerative into a healthy suppurating and gra- nulating process. The subsequent reproduction of bony substance is small in proportion as the amount of destruction has been great, and hence there will be more or less deformity, as well as variety of size, in the cicatrix. Caries, as has been partly mentioned already, and will also be further pointed out hereafter, must be carefully distinguished from several other losses of substance in bone. 4. Necrosis (mortification of bone).—Necrosis in bone corresponds to mortification in the soft parts, more particularly to dry gangrene, or mummification. It has in general a less serious character than the latter, inasmuch as by the application of appropriate artificial remedies, it very commonly, though slowly, gets well; and is only fatal in the few cases in which the strength of the patient is exhausted by the excessive secre- tion of matter that takes place, for the purpose of removing the dead piece of bone. Necrosis sometimes arises from external causes, such as injuries of various kinds, by which the bone is shaken, crushed, or laid 134 DISEASES OF BONE. bare,from the influence of severe cold, heat, &c.; and sometimes it is de- veloped, as is said, from internal causes, amongst which various kinds of constitutional disorder are enumerated, especially scrofula, syphilis, the state of constitution resulting from the abuse of mercury, gout, scurvy, &c, and the cachectic state succeeding acute exanthemata, especially variola and measles. An internal cause of this kind, in producing ne- crosis, may do so, not only by exciting inflammationand suppuration of the periosteum or medullary membrane, but also, as is extremely proba- ble from analogy, by leading to inflammation of the bone. Necrosis may affect either the whole of a bone (necrosis totalis), or, which is more frequent, only a part of one (necrosis partialis). In the latter case the outer lamella may be alone involved (necrosis externa superficialis), or only the inner layer of a cylindrical bone, or diploetic substance of a broad bone (necrosis interna, centralis); or again the whole thickness of a bone, within certain limits, may be necrosed. But it is very rarely that a necrosed piece admits of its whole extent being so accurately defined; that which at one part includes the whole thick- ness of a bone, runs out at its extremity into a superficial necrosis. In- ternal necrosis, too, occupies a bone very unequally, and at some parts frequently extends nearly through its whole thickness. Moreover, the boundaries of a piece of dead bone are irregular in every direction; its margins are notched and sinuous; and its thickness, espe- cially if the piece be peripheral or central, is very unequal in different parts. The less vascular compact bones are those which are chiefly liable to necrosis ; and of such the shafts of the long bones, more particularly the tibia, and after it the femur, humerus, ulna, radius, and fibula, and the bones of the skull, are most affected. Unlike caries, it rarely occurs in spongy tissue. Necrosis of the long bones very commonly terminates at their cancellous articular extremity, or at the junction of the epiphysis with the shaft. Every period of life is subject to it, though it is most frequent in young persons; and in them it occurs as scrofulous necrosis, or necrosis based upon a scrofulous constitution. Necrosis sets up an active inflammation in the adjoining healthy bone and surrounding soft parts, which goes on to suppuration, and continues until the dead piece is removed either by nature or art. Separation in the former manner is very seldom completed, for the suppuration rather exhausts and destroys the patient. The matter discharges itself exter- nally by one or, more commonly, by several ulcerated sinuses. The purpose designed in the suppurative inflammation is to separate, and finally to throw off, the dead portion of bone, which then obtains the name of sequestrum. The necrosed piece is at first distinguishable, to a certain extent, from healthy bone by its bleached and somewhat dis- colored appearance, but its boundaries are at that time indistinct, inas- much as the discoloration of the dead part blends gradually with the color of the healthy bone. All around the necrosed portion, that is to say, at its margins, and at the part where its surface is opposed to that of the healthy bone, the latter undergoes a gradual expansion or rarefaction of its tissue by the enlargement of its Haversian canals, assumes a rosy color, and DISEASES OF BONE. 135 becomes succulent. It acquires gradually an areolar structure, and is thus more rarefied: at length it disappears altogether, and a red soft spongy substance, a layer of granulat\ons, occupies its place. This change is produced by an inflammatory process, which gives rise to suppuration and granulation: the bony tissue, beginning with the Haver- sian canals, is dissolved by the matter secreted within them, while the granulations which shoot forth at the same time, fill up the enlarged canals. The immediate result of this process is the formation of a furrow of demarcation which encircles the margin of the dead bone, and is filled 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. In this process, that is, in the solution of the layer of healthy bone adjoining the dead by means of the purulent matter, and in the attendant formation of granulations, I find enough to account for the demarcation and separation of the sequestrum; and the absorption which has been assumed to go on at the borders of a portion of necrosed bone I hold to be incompatible with the inflammatory process, while the analogy of the process by which mortified soft parts are cast off renders such a view inadmissible. The granulations not unfrequently perforate the sequestrum where parts of it are thinner than the rest; and if this should occur at several spots, the dead bone may be completely covered by them. They have the appearance of being developed from the bone, and they fix it so as to delay its removal. It cannot be admitted, even in this case, that the sequestrum undergoes any absorption, but its perforation maybe effected by the solving or corrosive power exerted on its tissue by the matter; and this further fact may be attributed to the same power, that, indepen- dently of those irregularities on the sequestrum which arise from the unequal thickness of the bone that has perished, that side of it which faces the suppurating tissue appears rough, worm-eaten, discolored, and black. There can be little doubt, indeed, that a sequestrum might be removed in this manner altogether; although at present we are without any observations on the subject made with sufficient care and accuracy to establish it as a fact. While this process is going on, the dead bone is being replaced by a process of regeneration, which I proceed to describe as it takes place in the different forms of partial necrosis. In superficial necrosis, the inflammation that takes place in the bone around leads to an exudation, which afterwards ossifies upon its surface under the periosteum; and as the inflammation extends more deeply, reaching through the whole thickness of the bone to the inner surface of the medullary canal, and to the spongy diploetic tissue, bone is de- posited in those parts also. At the same time, pus and granulations are produced beneath the dead lamella, and the latter form a basis for a new layer of bone. The peripheral exudations first mentioned very frequently grow to considerable dimensions. The earlier the seques- trum is completely removed, so much the sooner does the suppuration cease, and with it the formation of granulations. The latter unite with the cica- trix of the soft parts, and as only a thin layer of them ossifies within the cavity, the scar is generally depressed, and is rendered still more so by the heaping up of exudation upon the healthy bone around. 136 DISEASES OF BONE. The muscles remain connected with the old bone for some time after it is dead, reaching it through the openings which are left in the new: but they gradually separate from it, and become implanted in the newly- formed bone (Meckel). In internal necrosis, new osseous matter, generally in considerable quantity, is furnished, chiefly by the outer surface of the bone, and de- posited beneath the periosteum, while that membrane becomes closely adherent to the inflamed soft parts around. In the interior of the bone, the separation of the dead piece from the living proceeds in the manner already described, and at length the sequestrum is found enclosed in a shell which consists of a layer of the old bone and a stratum of newly formed osseous substance, and is lined by granulations. This is the sequestral capsule. If this form of necrosis, occurring in a long bone, should involve only a portion of its shaft, the rest of the medullary canal becomes filled up with new bone: should it extend the whole length of the shaft, the exudation then occupies the adjoining spongy tissue of the epiphysis. The sequestral capsule, so long as the sequestrum remains in it, is perforated by openings, which vary in number, size, and form, and are named cloacce by Weidmann, and by Troja, foramina grandia. Their usual form is round or oval; in size they equal a pea or a bean; and they lead into the cavity of the sequestral capsule directly, or some- what obliquely through a short funnel-shaped canal: the inner opening of the cloaca is the narrower, and the outer, Avhich is the wider and the more dependent, runs out, in well-marked cases, into a low rim, the lips of which are rounded off. Besides these, there are sometimes other irregular gaps in the new bone, Avhich may be small or very extensive, and the margins of Avhich are sinuous. Most of these openings commu- nicate with abscesses in the soft parts Avhich open externally, whilst others are continuous immediately Avith fistulous canals that lead outwards through the soft parts. The openings last named are situated at parts where the necrosis, as it extended from within outwards, has advanced to the outermost lamella of the bone, and where consequently no new bone has been deposited; whilst those first described are formed in connection with the suppura- tion, and they serve for the discharge of the matter, and for the escape of the sequestrum. All these openings are lined with granulations which secrete pus, and are continuous with the inner membrane of the sequestral capsule. As soon as the sequestrum is removed from its shell, the granulations rise from the inner surface of the caA'ity and fill it, and the secretion of matter ceases. This mass then gradually ossifies, and instead of a medullary tube there is produced a solid cylinder of bone. At a later period, a gradual enlargement which takes place in the Haversian canals of the new bone, changes its structure into cellular, and incompletely supplies the place of a medullary tube. Thus, when the process of regeneration is completed, the bone consists, from without inwards, of the bone exuded beneath the periosteum, of a layer of the old bone, and lastly, of the central mass of bone Avhich has been produced in the granulations, and which fills up the medullary tube. DISEASES OF BONE. 137 At first it has a coarse exterior, is misshapen, thick, and uneven, and a marked boundary is clearly distinguishable between its outermost layer and the surface of the old bone: but as the outer layer becomes more dense and homogeneous with the old bone, this boundary line gradually disappears, the whole cylinder gradually loses its misshapen, thick, and coarse look, and acquires the natural form. This, however, is far from being invariably the case, for sometimes at irregular spots adjacent or superjacent to one another, the tissue of the outer new lamella, as well as of the old compact bone, becomes loose and expanded, and its Haver- sian canals widened: sometimes its actual mass is increased by internal deposition (hyperostosis interna), the bone retains its coarse appearance externally, becomes very dense in its texture, and is uncommonly heavy. It frequently happens, that the two states are found together, and the latter appears as if it had been developed from the former. In J. Miiller's opinion, the so-called new bone, which is produced after internal necrosis, proceeds for the most part from the old bone, the outer layer of which becomes swollen, and grows uninterruptedly during the con- tinuance of the suppuration by the dilatation of its Haversian canals and the formation of new bone in their interstices. In any case, this increase of bulk or swelling of the old bone is to be distinguished from that expansion and swelling upon which Scarpa grounds his theory of regeneration (Miescher). The mode in which regeneration takes place, when the whole thick- ness of a bone is dead, corresponds with what has been already men- tioned. An osseous exudation takes place upon the outer surface, as well as in the medullary canal of the healthy bone; and after the seques- trum has been removed, granulations continue to rise from the surfaces of the wound, and new bone is formed in them. The regeneration is in most cases incomplete; the growths from the two ends unite too soon, and the bone is diminished in length, and frequently a false joint is formed. Necrosis of a whole bone is an extremely rare occurrence. From what has been said, it appears that the regeneration is accom- plished 'by that part of the old bone which has remained healthy; but there can be no question that the periosteum and other surrounding soft parts, and even newly-formed vascular tissue, are capable of furnishing an exudation which will become bone. This is clearly proved by the few cases in which spontaneous necrosis of a whole bone has occurred; by the fact that reproduction ensues in animals when a bone has been entirely removed (Heine); by the appearance of bony substance in the middle of openings made in the skull by necrosis, or by injury, as well as by the occurrence of growths of bone in periosteum and espe- cially in the dura mater. The foregoing remarks have been directed especially to the long bones, but they apply to necrosis and the process of regeneration in other bones also : only it must be observed, that there is very seldom complete re- generation of any part of a cranial bone lost by necrosis ; and when it does occur, it ahvays takes place very slowly (p. 125). The suppurative process, which ensues upon the death of a bone, may, under various unfavorable local and general conditions, degene- 138 DISEASES OF BONE. rate into an inflammation, attended Avith an ichorous product, and into caries. A form of necrosis, differing from that to which the foregoing obser- vations have been especially applicable, is a gangrenous ulceration of spongy bones corresponding to humid gangrene in the soft parts: it is met Avith chiefly in hospital gangrene, in bed sloughs, &c. The bone is soft and brittle, is filled with dirty greenish shreds of soft parts in a state of slough, and is saturated with a similar sanious fluid. 5. Expansion, softening, of the tissue of bone, and the consequent indurations.—Expansion, or rarefaction, though often combined with softening of bone, must yet be distinguished from it. The former is pro- duced by dilatation of the Haversian canals and cells, and constitutes the disease which is named osteoporosis ; whilst in the latter there is a deficiency of the mineral constituents of the bone, and some disease of its fundamental cartilage. Osteoporosis consists, then, as has been said, in an enlargement of the Haversian canals and cells of the bone. a. This state may result from excessive development of the medulla of the bone, or of the tissues which occupy its canals and cells; while, at the same time, the actual quantity of bony substance remains unaltered. By a rarefaction of its tissue of this kind the bone becomes increased in volume,—expanded. The walls of the enlarging cavities become thinner and thinner, till at length apertures are formed in the interior of the bone, as well as in its outermost lamella, and the cavities commu- nicate with one another. The expanded bone is soft, coarsely porous, and spongy, and more or less so in proportion to the degree of the dis- ease ; it yields to the pressure of the finger, and may be easily cut with a knife: its cavities are filled with a large quantity of darkish-red or reddish-brown medulla, which is traversed by dilated vessels, and con- tains here and there loose or firm clots of extravasated blood. Osteoporosis may affect the outer compact portion of a bone, and then, in a cylindrical bone, the dilatation of the longitudinal canals gives it the appearance of being split into filaments; or the disease may be developed in the interior in the medullary cavity of a long bone. In the latter case, as the rarefaction advances gradually towards the outer layers of the compact wall, the peripheral lamellar system, though pre- serving its compact state, becomes distended and bulges all round, the cavity exceeds its natural size, and the bone loses its proper form. The bone is swollen out into a rounded, holloAV-sounding, thin-walled cylinder, which is filled with marrow: at its inner wall are found irregularly dilated longitudinal canals, while nothing remains of the spongy tissue and the network in its interior, but a few delicate lamellae and threads of bone, which pass across the plug of marrow that fills the canal; so that after maceration, the medullary canal is a mere dilated cavity. Of course, the bone is uncommonly fragile, as it is in the allied disease, ex- centric atrophy. Lastly, osteoporosis sometimes affects a bone in its whole thickness; and then the disease may have commenced in its interior in the medul- lary cavity or diploetic substance, or at the exterior, or at all of these points at once. DISEASES OF BONE. 139 This kind of rarefaction usually affects the whole of a single bone, or single portions of the skeleton which are intimately associated together, such as the bones of a limb or of the skull; and it affects such bone or bones throughout; more rarely it is partial, i. e. confined to one spot on a bone; the most unusual instance of all is to find it in several bones together. When it is partial it gives rise to the spongy exostosis. It is most frequently observed in the skull, and advances in that part to a very great degree, the cranial bones in the adult reaching, and sometimes exceeding, a thickness of six or ten lines. It may occur at any period of life, but it is found chiefly in childhood or old age. This form of osteoporosis, as has been pointed out, is a consequence of excessive development of the medulla of the bone, and of the soft parts which fill its cavities. No distinct general constitutional disease (dys- crasia), can be assigned as its cause, though it is very important to observe, that osteoporosis, whilst it is one way in which rickets exhibit itself, also frequently recurs in old age, in persons who have other marks of rickets upon them. ft Osteoporosis sometimes arises from an inflammation of the bone and medulla, which furnishes a product in the cavities of the bone, differ- ing in its nature from the ordinary ossific exudation (p. 129). This may be inferred from the traces of recent bony exudation, which are found on bones affected with osteoporosis, and from the fact of the bone beneath soft parts which are in a state of inflammation and ulcera- tion, and that in the neighborhood of caries, being similarly rarefied (p. 133). Moreover, that very painful disease, the malum coxae senile (which, by the Avay, occurs in other joints also), appears to originate in a process of this kind: I hold it to be an inflammatory process of a gouty character, which gives rise to rarefaction, swelling, and a peculiar deformity of the head of the femur and acetabulum,—an osteoporosis succeeded by induration. These cases of osteoporosis are curable. y. A large class of osteoporosis is occasioned by atrophy of the bone. The enlargement of the Haversian canals and the cells, is, in such cases, the result of attenuation of the bony lamellae which form their walls. There is no increase in the volume of the bone, but rather a diminu- tion : it shrinks and becomes smaller : the enlarged cavities of the bone are filled Avith a gelatinous or fatty substance, which is mostly of a dirty red, brown, or chocolate color. The long bones which have a very thick compact wall, are easily fractured; and spongy bones may be broken into by slight pressure with the finger (osteopsathyrosis). The bones have lost more or less of their weight, according to the degree which the disease has reached, and the patients themselves are specifically lighter than Avater (Saillant). Senile atrophy of the bones, as it is the most common instance, may serve also as the type of this form of osteoporosis. But it occurs also in youth and manhood, and is then a painful disease, A\Thich usually extends over the whole skeleton, and which it is the custom to ascribe to gout, rheumatism, mercurial cachexia, syphiloid disease, and lepra. In the per- sons we have mentioned, it sometimes proceeds to such an extent, that in spongy bones considerable cavities are formed, which are filled with the 140 DISEASES OF BONE. diseased marrow above described; and it predisposes to the occurrence of fractures upon the slightest occasions. The part of the skeleton which suffers least in this form of the disease, is the skull. Like molli- ties ossium, it has proved up to the present time incurable. b. There are two forms in Avhich softening of bone presents itself, namely, rhachitis and mollities ossium. Some rarefaction is always pre- sent in both, but the essential part of the disease is a return of the bone towards its original cartilaginous structure; while at the same time it may be altered in its chemical composition or not. Hence the bones are not brittle, but soft and flexible; they become curved and misshapen, and are much more easily bent than broken. a. Rickets (rhachitis juvenilis in contradistinction to rhachitis adul- torum and rhachitis senilis, which are equivalent to mollities ossium) is a disease of early childhood. It is, in most cases, developed first in the lower extremities: after having reached a certain degree in them, it extends to the pelvis; and advancing from thence to the other bones of the trunk, it at last pervades the whole skeleton. Sometimes it is more prominently marked in one portion of the skeleton, while the rest of the bones are but slightly affected; and then a rickety thorax or skull constitutes nearly all the disease. It is combined with preterna- tural development of the glandular system, with hypertrophy of the white substance of the brain, with deficient involution, or even with hypertrophy of the thymus gland, with hypertrophy of the spleen, spare muscular development, and a pale and flabby condition of the muscular fibre. It is associated with tubercle very rarely, considering that the deformity of the thorax which rickets frequently occasions, brings on con- ditions suited to the development of that disease. It interferes with the growth of the bones in length, and with the development of certain portions of the skeleton in their proper relations as to capacity. Some of the deformities which it occasions are produced only in this way, such as shortness of the long bones, and .narrowness and small size of the pelvis; whilst sometimes there are other conditions which essentially co-operate in effecting them. Thus the weight of the body pressing perpendicularly on the pelvis and lower extremity gives rise to the sabre-shaped curvatures of the latter, and the flattening ante- riorly, the narrowing of the conjugate diameter, and the great inclina- tion of the former; and this is the case whether the deformity be symme- trical on the two sides, or whether it predominate on one side, and the pelvis be oblique or inclined. Lordosis or scoliosis of the vertebral column follows upon the deformity of the pelvis, and the degree of either is proportioned to that in which the vertebrae are affected with rickets. Consequent upon the deviation of the spinal column from its natural direction, ensues corresponding deformity of the thorax. If the muscles of the thorax—the pectorales and serrati—be in a very undeveloped state, a deformity results which is known by the name of the (rickety) pigeon's breast. In the^skull, the hypertrophy of the cerebrum, espe- cially of its anterior lobes, moulds the bone into the peeculiar correspond- ing shape. The necessary description of all these changes will be given hereafter; only it must be remarked that, as the deformities which are produced by rickets in the lower extremities and the trunk, depend upon DISEASES OF BONE. 141 causes that vary much in the degree, the duration, and the manner of their action, so they do not follow constantly any definite type, but rather present, especially in the pelvis, frequent exceptions to any forms which may be set down as the rule. The bones appear swollen out; the angular shaft of the long bones becomes round and cylindrical; and their articular extremities, as well as other broad bones which contain much diploetic tissue (such, for instance, as the bones of the pelvis), become unusually thick. The texture of the bones is affected in two ways, of which sometimes one preponderates, sometimes the other. In the first case the bone is rarefied and increased in size—expanded in fact. A pale yellowish-red jelly is effused into its enlarged canals and cells, into the medullary cavi- ties, and even under the periosteum. The bone itself is abundantly sup- plied with vessels and full of blood, and its color is therefore darker than natural, and red. Occasionally this change reaches such a degree that the cells of spongy bones, and those in the interior of medullary tubes, become excessively distended, and, as their walls disappear, are merged in larger cavities: medullary cavities at last become single spacious chambers, and the bones uncommonly soft and fragile (Gue'rin's Con- somption Rachitique). In the second case the bone is, in addition, de- prived of more or less of its mineral constituents ; and sometimes it is completely reduced to its cartilaginous element, and appears like a bone that has been steeped in acid. The bony corpuscles are empty, and their rays have disappeared, and when this is the case, the lamellar structure is here and there obliterated; at other parts the lamellae appear as it were, to have fallen asunder, and the corpuscles are seen quite distinctly interposed between them. It is upon this condition that the softness, the flexibility, &c, of rickety bones depends. These two conditions exist together, as has been remarked, and some- times one preponderates, sometimes the other ; it is, however, remarkable, that in cases of general rickets, the reduction of a bone to its cartilagi- nous element so preponderates in some bones as to go on, even to com- pletion, without any trace of rarefaction. The periosteum of rickety bones is palpably more vascular than natural, and tumid; it clings to the bone so closely that a layer of the expanded spongy tissue always comes away in the attempt to strip the membrane off. Rickets is not a painful disease. It is usually developed in the second year of life, and leaves traces behind it corresponding to the degree it had attained. In small degrees it is capable of cure by the reabsorption of the substance which has been effused into the cavities of the bone, and the subsidence of the swelling of the bone. In more advanced degrees the cure is effected by that substance becoming more and more firm, and at last ossifying. The bone then remains enlarged and becomes uncommonly dense (Guerin's Eburne'ation), and the Haversian canals contract, especially on the concave side of the curves. When the dis- ease reaches its highest degree, the rarefaction which it has occasioned and the fragility of the bone are permanent. ft Mollities ossium (Osteomalacia, Malakosteon, Rhachitismus adulto- rum, and senilis), is quite a different disease*from true rickets, and affects 142 DISEASES OF BONE. grown persons in the period between early manhood and old age. It occurs chiefly in the bones of the trunk, to one portion of which it so tar confines itself as to proceed to a very great degree in that portion, whilst mere traces of it only are found in other bones. When the bones ot the skull and of the extremities are affected, they are so always m a very subordinate degree. It is more frequent in the female sex than in tne male; and several times it has been met with coming on after cnilabea. Not unfrequently it is associated with cancer of the internal organs (a fact which reminds us of the old observation as .to the brittleness of the bones in cancer). Sometimes it exists when there is a great production of fat, especially in advanced life: and it is often found when there is also fatty degeneration of the muscles: the import of this last combi- nation is not yet understood, whether it is occasioned by insufficient action of the muscle, or has any essential connection with, and is pro- duced by, the general disease. Compared with rickets, and considering how rarely the disease occurs, its advance to a very considerable degree may be said to be frequent. The deformities which result from mollities ossium are restricted to the trunk, as has been mentioned above. They take place upon the bed to which the patients are confined, and it is this mode of origin that determines the peculiar shape which results from the disease, and which in the pelvis is regarded as characteristic. The two ends of the trunk approach each other by the vertebral column arching backwards ; the thorax sinks in, especially at the sides, the ribs becoming curved and bent in various ways; and the pelvis acquires a triangular form, like that of the heart on cards. But these are not the invariable shapes; and the peculiar form of the pelvis is not exclusively a result of mollities ossium, but is met Avith sometimes in bedridden persons, Avho are the subjects of rickets in a high degree. The bones diminish in size, and their texture is rarefied and atro- phied ; they become saturated with fat, and reduced to their cartilagi- nous element. In this condition their corpuscles are empty, and when viewed by transmitted light, diaphanous: there are no canaliculi (kalk- kanalchen), and the lamellar structure is lost. The bone at the same time undergoes a striking change in its chemical composition, the extract produced by boiling being not only different from chondrin, but also from the animal matter of bone. Upon this last-mentioned character of mollities ossium very probably depends not only an essential difference between it and rickets, but also its malignancy: it is a very painful disease, and hitherto has never been cured. Consecutive induration appears to me to be the mode in which one of the described processes of expansion and softening of bone subsides or heals. The previous occurrence of such a process is at once sufficient to distinguish it from other indurations, but it is characterized also by pecu- liarities in the texture, and no doubt also in the chemical composition of the bone. The anomaly in the texture of the indurated bone is owing to the rarefaction itself, and to the vascularity of the medulla which occupies the enlarged cavities in the bone, and it consists in the arrangement of the elements of the new osseous tissue upon the old DISEASES OF BONE. 143 bone and around its vessels, in abnormal relative positions. By this anomaly of texture alone, without reference to any change in chemical composition, an explanation is afforded of several varieties in the physi- cal condition of the bone, such as the peculiarity of its fracture, the appearance of its broken surface, and of a thin section, and its color. Varieties of this kind in a bone, which originate in some peculiarity in the relative position and arrangement of its elementary constituents, have their analogues in inorganic nature, in the different physical con- dition of bodies which in their chemical composition are alike. The anomaly in chemical composition may consist in the fundamental cartilage of the indurated bone being overfilled with mineral constituents, the usual proportions of which to each other may be either maintained or altered; or in the presence of unusual salts; or further, in some abnormal condition of the fundamental cartilage itself, of its blastema, &c. Bones affected with consecutive induration, retain the increased size which they had acquired during their previous expansion, and are there- fore of course augmented in weight by the induration. a. Well-marked specimens of induration may be observed succeeding the expansion which has occurred in advanced life; such cases are most frequent in the skull. A series of skulls of this kind is preserved in the museum at Vienna, and shows, in a most instructive manner, the gradual advance of induration in the expanded cranial bones. Externally, and still more on the cut surface, they present a dull white color, and a chalky appearance; and their fractured surface is coarse. A minute ex- amination of a transparent slip of such bone exhibits wide, irregular, i. e. angular, and sinuous Haversian canals : the lamellar structure deficient, or only here and there perceptible; and bony corpuscles, which are mostly round, lying in disorder one over another, and crossing or obliterating each other. b. Similar characters are presented in the malum coxae senile, by the indurated head of the femur, and the stalactitic, chalky osteophytes which surround it. It is observed, moreover, that this mass of bone acquires a polish like gypsum. Upon minute examination a close lamellar struc- ture is found : the lamellae are very numerous, but the bony corpuscles, on the whole, are few, though at some spots they are crowded together in dense groups. The osteophytes present a similar close lamellar structure, and their corpuscles are very numerous and thick, and mostly round and quite black. c. The induration (eburneation) in which a high degree of rickets ter- minates is distinguished by the hardness of the bone, by its glass-like brittleness, and the laminated appearance or leaf-like splitting of its fractured surface. When minutely examined, the Haversian canals are found small, and surrounded by large and widely extending systems of lamellae, but by few bony corpuscles ; those which do exist are small, and, which is remarkable, for the most part transparent, and they have but few canaliculi. Note.—To this chapter, which contains the greatest quantity, and the most important part of the matter, I subjoin the results of the analyses 144 DISEASES OF BONE. of several bones, which Dr. Ragsky had the goodness to undertake at request. 1. Osteoporosis of the skull of an old person. Specific gravity, .... Cartilage, fat, and vessels, . Basal phosphate of lime and phosphate ) 55.30 of magnesia, . . . • ) r Carbonate of lime, and other salts, o-o9 2. Slight induration, consequent upon osteoporosis. Specific gravity, . Cartilage, fat, and vessels, . Basal phosphate of lime, with phos- ) 4g 2Q phate of magnesia, . . • ) Carbonate of lime, .... ^'™ Salts soluble in water, 3. The same advanced to a higher degree. Specific gravity, .... Cartilage, vessels,..... Basal phosphate of lime, with phos- ) g0.2g .' ' 7-20 phate of magnesia, Carbonate of lime and salts, 4. The same at its most advanced degree. Specific gravity, .... Cartilage, vessels, ..... Basal phosphate of lime, with phos- ) gj,^ phate of magnesia, Carbonate of lime, . Salts soluble in water, 595 026 . 0-909 3861 organic constituents. 6139 inorganic constituents. . 0-854 44-10 organic constituents. 55-90 inorganic constituents. . 1-842 42-51 organic constituents. 57-49 inorganic constituents. . 1-751 38-27 organic constituents. -61-73 inorganic constituents. 5. A tibia indurated, also probably in consequence of osteoporosis. Specific gravity,.......1*490 Cartilage, vessels,......38-49 organic constituents. Basal phosphate of lime, with phos- phate of magnesia, . . . Carbonate of lime, .... 53-21 8-30 61-51 inorganic constituents. 6. The gypsum-like coating of the head of a femur affected with so-called " malum coxa senile." Specific gravity,.......0-845 Cartilage, vessels, . .....3390 organic constituents. 59-10 Basal phosphate of lime, with phos phate of magnesia, Carbonate of lime, . . . . 657 Salts soluble in water, . . . 0-43 J Uric acid, which was looked for particularly, was not present, 66-10 inorganic constituents. 7. A dried scapula, softened by rickets, and a humerus. Scapula, specific gravity, . Cartilage, vessels, fat, . . 0-612 81-12 organic constituents. 15-60 Basal phosphate of lime, and phosphate of magnesia,..... Carbonate of lime, .... 2-66 Salts soluble in water, . . . 062 J The humerus contained 1054 per cent, of partly fluid, partly crystalline fat. ■ 18-88 inorganic constituents. 8. Portion of a rib from a skeleton affected with mollities ossium,—the piece was too small for complete investigation. Specific gravity, ....... 0-721 Cartilage, fat, vessels,......76-20 organic constituents. Basal phosphate of lime, and phosphate ) . _ . _ } of magnesia, .... 5 \ 23-80 inorganic constituents. Carbonate of lime and other salts, . 632 S DISEASES OF BONE. 145 . 1-432 39-63 organic constituents. 57-20 9. The rib of a skeleton in which all the bones were attenuated. Specific gravity, ..... Cartilage and vessels, .... Basal phosphate of lime, and phosphate of magnesia,..... Carbonate of lime and salts soluble in "i water,......j 10. Syphilitic induration of the skull in a high degree. Specific gravity, .... Cartilage, vessels, ..... Basal phosphate of lime, and phosphate of magnesia, ..... Carbonate of lime, . . . . 6-50 ) 11. Simple benignant induration of the skull of a lunatic. Specific gravity, ..... Cartilage and vessels, ...... Basal phosphate of lime, traces of fluo- ride of calcium, .... Carbonate of lime, .... Phosphate of magnesia, . Salts soluble in water, N.B. Before determining the weight, each bone was sawn into thin slips, dried quickly in an oil-bath, pulverized, and again dried in the oil-bath at 106° Cels. 60-37 inorganic constituents. . 1-613 36-30 organic constituents. 63-70 inorganic constituents. . 1-911 33-41 organic constituents. 54-10 10-45 ^66-59 inorganic constituents. 1-00 | 1-04 J VOL. III. 10 Tabular view of the properties of the animal matter from the Bones examined. Mode of formation and character of the Animal Matter. Glue slowly formed. Solution was whit- ish, turbid, gelatinous. Changed slowly into glue. Solution con- tained much fat, and was white, turbid, and gelatinous. Changed slowly. Solution was whitish, turbid, gelatinous, and contained fat. Changed slowly. Solution of a pale yel- low color, rather turbid, had little tendency to become gelatinous. Changed readily. Solution brownish, turbid, and slightly gelatinous. Changed with much difficulty. Solution brownish-yellow and translucid, had little tendency to become gelatinous. Changed into glue. Solution brownish, translucid, became slightly gelatinous. Changed into glue. Solution was whitish, turbid, and slightly gelatinous. Dissolved quickly. Solution was gelati- nous, and had a yellowish opacity. Glue formed slowly. Solution was whitish, opaque, and gelatinous. The cartilage changed slowly. Solution was whitish, turbid, and gelatinous. EFFECTS OF REAGENTS ON SOLUTION OF THE ANIMAL MATTER. Alcohol. Thick Precipitate T;iick P. Moderate P. Turbidity Slight P. Moderate P. Turbidity Turbidity Slight P. Consid'ble turbidity. Acetic acid. Tincture of galls. Thick P. Thick P. Thick P. Thick P. Thick P. Thick P. Thick P. Thick P. Thick P. Thick P. Thick P. Neutral acetic oxide of load. Basal Oxy- acetic oxide sulphuret of lead. of iron. Thick P., which was not dissolved either in acetic acid or by boiling. Solution of alum. Chloride of mercury. Moderate P. Soluble P. Moderate P. Moderate P. Slight P. Slight P. Chloride of' Ferr°- cyanurct of potash. platinum. Moderate P. Thick P. Turbidity Thick P. Thick P. Thick P. Thick P. Thick P. Thick P. Thick P. Moderate P. Thick P. Slight P. Thick P. OS o a o « DISEASES OF BONE. 147 6. Adventitious Growths.—These formations are, on the whole, a rare appearance in the bony system; by far the most frequent of them is cancer. Those which originate in some general diseased condition, are usually the expression of a high degree of it, especially when such dis- eased condition has the character of dyscrasia: it is, however, a fact of great importance, though it has not yet received much notice, that the dyscrasia, which has established itself in a bone, usually remains fixed there for a long time, and spreads, for the most part, only upon some evident cause, such as forcibly effacing its localized character, that is extirpating the local affection. With regard to that disease, which old writers named spina ventosa, and which has, since their time, been represented in such different forms, I think it best to remark at once, that expansion of bone, from the eventual production of which spina ventosa obtained its character as a disease, is a condition common to several of the morbid growths about to be described. To the actual new formation in bone, I prefix an account of the morbid development of its system of capillary vessels. a. Teleangiectasis.—It consists in an enlargement of the system of arterial and venous capillary vessels within the bone. It forms rounded soft tumors, which sometimes pulsate, and which attain various, and oc- casionally very considerable, size. The dilated vessels produce enlarge- ment of the Haversian canals and cells, expansion of the bone, and sub- sequently by their pressure, absorption of its substance. Generally, also, the vessels become ruptured and hemorrhages ensue; the extrava- sated blood forms roomy cavities for itself in the cellular tissue that connects the convoluted vessels, and there coagulates in layers, just as in the sac of an aneurism (Breschet). From special examination of the disease itself, as well as from having met with cancer in other parts of the skeletons in which it occurred, I have been led to believe that it originates in cancer of the bone. In the skull, moreover, I have observed a cavernous structure developed from the diploe. b. Cysts.—My own experience agrees with published observations of these growths, as to the rarity of their occurrence in bone. a. The simple cyst, containing a serous or synovial fluid, may occur in any bone, but it is chiefly met with in those of the face, the lower jaw being the most subject to it, and next the upper jaw. In size it may equal a hen's egg, or even exceed it (Dupuytren). By its pressure it produces atrophy of the osseous tissue, and expands the compact tables of the bone to a thin-walled bladder, which crackles under the finger like a piece of parchment. When this layer is also consumed, the cyst pro- trudes through and beyond the bone, and its wall becomes strengthened by the periosteum, &c. /3. Compound cystoid growths are very rarely seen in bones. Some cases, however, recorded by old observers, undoubtedly belong to this class; especially one or two of those which Lobstein has collected from his own experience and that of others, and has described under the name of osteolyosis. y. Acephalocysts have been observed in bone eight times. Of these eight cases one, which is preserved in the Vienna Museum, presents con- siderable interest, from the premises which it affords with regard to the 148 DISEASES OF BONE. cause of the disease. They have been met with in the humerus, the tibia, the ilium, and the diploe of the skull. In most of the cases recorded by foreign observers, the disease had been developed in consequence ot injury. The following is an account of our own case. The patient, a laborer, aged 42, had, in his youth, suffered from swellings of the cervical and axillary glands; and five years before his death from gonorrhoea and chancre, and consequent bubo, btill later, his penis had been amputated on account of malignant (bosartig) ulcerations; and one year before his death the disease, which was after- wards found in his bones, commenced with pains of a tearing and boring Oil 21.Tfi.OtPT* When the body was examined, the left ilium was found converted into a fibrous sac as large as a man's fist, which, besides containing numerous splinters of bone, small and large, sticking in the inner wall of the sac, was also filled with echinococcus-bladders (acephalocysts), varying from the size of a millet-seed to that of a nut. Similar sacs, but less in size, were found also in the pubes, ischium, and sacrum, from which bones they projected into the pelvis. Some of the echinococci were free ; but others, especially the smaller ones, were situated either singly or in clusters in the dilated pores and cells of the bare and broken-up pieces of the bone. The bottom of the acetabulum was completely destroyed, and the head of the femur projected into an acephalocyst sac, which occupied its place. c. Abnormal fibrous tissue.—To this class belong, a. Fibroid tissue, originally deposited as a product of inflammation or exudation, but arrested in its development into bone ; fibroid callus. /?. Fibroid tumors. These occur most in spongy bones, in the articular extremities of long bones, the vertebrae, and the phalanges of the fingers, in the bones of the skull, the lower jaw, and the bones of the pelvis. They sometimes reach a very large size, and distend the bone into a bladder, or so break it up, that it is found scattered in separate frag- ments through the tumor. The fibroid tumor sometimes has a very dense structure; at other times it is looser, soft, and elastic, and then merits particular notice, inasmuch as it may be easily mistaken in the living subject for other softer—chiefly cancerous—growths ; especially if it should have attained a large size, and produced inflammation, sloughing, and ulceration of the integuments by the chafing and pressure which it occasion. d. Enchondroma.—This growth is incomparably more frequent in bone than in any other structure, and presents in the osseous system all those numerous varieties which are incident to it both in its OAvn internal construction, and in the condition of the bone around it. It is met with chiefly in the bones of the fingers and toes; it occurs also in the ribs and sternum, and has, moreover, been observed in the bones of the skull, the ilium, and the long bones. Its commencement dates mostly from the period of youth, even though it may have first attracted attention by its enlargement at a later period of life : I have however, seen cases in which there can be no doubt that it had been developed at an advanced period of life. The variety of aggregated enchondroma I have seen combined with an extensive formation of osteophytes. DISEASES OF BONE. 149 Like the permanent cartilages, it generally remains for a long time, and even throughout life, in its original condition; sometimes it ossifies, and I have observed this metamorphosis affecting the last-mentioned variety of the disease in a very remarkable manner; it has been already described. Lastly, an entire enchondroma is sometimes involved in in- flammation of the surrounding soft parts, and destroyed (wird verjaucht). e. Osteoid.—There can be no question that several of the new growths which occur in bone, though they differ in their nature, may be included under this title. Passing by mere concretions, I may observe, that fibroid growths in bone ossify as well as those in other structures : but to be more particular, a spherical osseous tumor may be developed by the progressive ossification of a newly-formed cartilaginous basement in an old bone; and it may be distinguished from the normal bony tissue by the difference of its elementary structure. A most remarkable speci- men of this kind is preserved in the Vienna Museum. It is the skull of a person of 26 years of age, who died suddenly whilst suffering from Exophthalmos. In the anterior fossa of the base of the skull on the left side there is a tumor, nearly as large as a duck's egg, which appears slightly lobulated on its surface, and is composed of a very dense, dull white, bony structure: a portion of it as large as a walnut projects into the orbit, and forms one process with another portion, of about the size of a hazel-nut, which extends into the zygomatic fossa. This mass of bone springs from the diploe of the frontal bone, forces its compact walls asunder, and perforates them on both sides. There are other tumors near it, similar but smaller in size, which spring from the diploe of the frontal, and greater wing of the sphenoid, bones. A different osteoid tumor may be developed also from the enchon- droma at any period of its existence. /. Cholesteatoma is rarely seen in bone, and I am aware of but one in- stance, which is in the Vienna collection. It is that of an encysted cholesteatoma, occupying the mastoid portion of the temporal, and the adjoining occipital bone. g. Tubercle.—The frequency of tuberculosis in the bony system is unquestioned. The tubercle either assumes the granular form, or, as very frequently occurs, it is a product of inflammation of the bone, and presents the characters of softening tubercle. Tuberculosis affects chiefly cancellous bones, and portions of bone; the bodies of the vertebrae; the spongy articular extremities of the long bones,—especially the lower end of the femur and upper end of the tibia, and the ends of the bones which compose the elbow-joint; the carpal and tarsal, the metacarpal and metatarsal bones, and the phalanges ; and the sternum: more rarely the ribs are attacked, and the cranium: while the parts least frequently affected are the shafts of the long bones. Its seat is sometimes the outer layer of the bone and the periosteum, and sometimes the deeper bony tissue. Moreover it very commonly occupies several adjoining bones at once, as for instance, the ends of the bones which form a joint, the whole ap- paratus of the carpal and tarsal joints, the vertebrae, &c. Young persons are especially subject to it in the years of childhood, and at puberty; but it is also frequent in later, and even in advanced life. 150 DISEASES OF BONE. a. Tubercle in the state of gray crude separate granulations can be detected only by close examination of the spongy tissue of a bone in the vicinity of a tubercular abscess. It usually occupies the membrane which lines the Haversian canals and the cells. As the granulations ac- cumulate, they form larger masses of tubercle, and partly compress the bony structure, and partly include necrosed fragments of it amongst them. The aggregate morbid growth is sometimes found as a yellow, lardaceous and cheesy mass; much more frequently it is softened, and consists of a cream-like grayish-yellow pulp, or a thinner, flocculent, tubercular pus. It is contained within a more or less complete lardaceo- callous cyst, which is, in fact, the tissue surrounding the softening tuber- cle, infiltrated with lardaceo-gelatinous material. If, as is frequently the case, the tuberculous disease should occupy the outer part of a bone and the periosteum, the latter, with the cellular and ligamentous tissues upon it, partakes in the formation of this cyst; and if the tuberculosis advance deeply into the bone, it is mostly the only rudiment of the cyst that can be clearly proved to exist. The best opportunity to observe it, is frequently afforded by the vertebrae. The degree of congestion which gives rise to primary tubercle, may vary in bone as well as in other tissues; for the development of the dis- ease is, in many cases, unnoticed, while in others it is ushered in with very marked symptoms. The usual metamorphosis of tubercle in bone is softening ; but it some- times also becomes cretaceous. (1.) When it softens, a tubercular ulcer is formed in the bone, which corresponds in extent with the quantity of substance the bone may have lost. The loss of substance arises from necrosis of the portion included in the tubercular mass ; and it may die either when first involved in the mass of tubercle, or at a later period : but in either case, it is in conse- quence of its vessels becoming obstructed, or destroyed in the suppura- tion. Softening of tubercle at the surface of a bone, produces a superficial breach of its substance, which has the appearance of being unevenly cor- roded ; when a larger and more deeply situated mass softens, the bone is excavated, and a cavern—a tubercular cavern in bone—results. The greater the number of caverns which are found in a macerated bone, or set of bones,^ the more safely may it be concluded that they originated in the softening of tubercle. The cavern contains a fluid, which presents the character of tubercular matter, and is mixed up with numerous particles of bone. Sometimes the particles are small, and resemble crumbled mortar ; when larger, they are seen distinctly to be necrosed bone ; they are usually of a dirty white color, soaked through with tubercular matter, and not so brittle as the sequestrum produced by other processes in a spongy bone. The A-arious processes which are usually found in the neighborhood of a softening tubercle, occur in bone also. First, there is a secondary deposition of tubercles, which, as they soften, increase the size of the cavern. The congestion to which the secondary deposition of tubercle is owing, usually advances to the degree of inflammation (reaction), and leads to the formation of a gelati- DISEASES OF BONE. 151 nous granulating product which lines the wall of the cavern, and as the tubercle softens, always breaks down too. Should the tuberculosis have attacked the peripheral layer of a bone, the congestion, vascularity, and product just spoken of, are seen with remarkable distinctness in the peri- osteum which immediately covers the diseased spot, and may be found also in the adjoining cellular and fibrous tissues. The periosteum is covered and infiltrated with this product, which, gelatinous at first, gra- dually assumes a lardaceous appearance. The tubercular matter col- lected under the membrane swells it out like a saccular appendage. Oftener still, the inflammatory process becomes more intense, and under the influence of a highly advanced state of the general disease, pervades the osseous tissue throughout with a yellow cheesy product, which breaks down at once. Further remarks on this subject will be given below. It occasions a rapid enlargement of the ulcer in the bone, and extensive destruction, not only of the bone in which it originates, but of other tissues into which it may advance. When the circumstances of the case are more favorable, and the for- mation of tubercle has ceased, the inflammatory product at the wall of the cavern becomes organized into a fibroid, lardaceo-callous tissue, and that in the bone itself, into bone ; and the cavern changes into a thick firm capsule, which becomes surrounded by an indurated (sclerosed) bony tissue. Its contents are then partly reabsorbed, and partly, as the cap- sule shrivels and diminishes in size, they become inspissated, and form a greasy calcareous pulp, of a grayish-yellow color, or a mortar which incrusts the walls of the capsule, or a chalky concretion: and thus the tubercular disease is cured. (2.) Under favorable circumstances, tubercle in bone becomes con- verted into chalk. A chalky concretion is found in the interior of the bone, enclosed within endurated osseous tissue: if the tubercle have been situated on the surface of the bone, the concretion is covered on the out- side by thickened periosteum. /?. A form of tuberculosis, common in young persons, is comprised, in great part, of what are known by the general term of scrofulous in- flammations. The inflammation furnishes a tuberculous product by which the actu- ally inflamed spot becomes infiltrated. It may be a primary affection of the bone, or may come on around an abscess already formed from the tubercle above described. Spongy bones affected with this disease are found at first partly of a dark-red color, injected, and extruding a fatty or gelatinous matter from their cells ; and partly pale, and having their cells filled with softening tubercular exudation: both bone and periosteum are frequently swollen, and the former is elastic and soft, and yields easily to pressure or the knife. Ulceration presently begins to destroy it, and the fluid discharged is either thin, grayish, or yellowish in color, and mixed with cheesy flakes, and with particles of necrosed bone; or it is colored of a dirty brown by hemorrhagic exudation, or else is highly discolored, and blackish-green, extremely offensive to the smell, and mixed with black fragments of bone, and with particles of the soft parts destroyed by sloughing. When this process affects a compact bone, a bone of the skull for in- 152 DISEASES OF BONE. stance, its cavities appear filled with tubercular exudation; it becomes of a dirty yellowish-white color, and is, in fact, necrosed—a tuberculous sequestrum. Similar tubercular product is exuded between the surface of the bone and the periosteum. If the process involve only a superficial layer, the bony tissue is partly lost amid the softening of the tuberculous product, and is partly thrown off in particles which are sufficiently large to be palpable; and thus an uneven rugged surface of bone is exposed, from which the process extends more deeply; the osseous tissue pre- viously becoming indurated, and the bone increasing m volume and thickness. ■ . , , ., i A The abscesses which are produced by the process just described ad- vance in various directions from the bone into the soft tissues, which are infiltrated with the gelatino-lardaceous matter; after having given rise to other secondary (congestive) abscesses in those tissues, they open externally at a part which is often very far removed from their origi- nal seat. This is noticed particularly in abscesses in and about the vertebra* After the contents of the abscess have been evacuated, or perhaps have partly cretified, the tuberculous caries heals, leaving an indurated cicatrix in the bone, which deforms it in proportion to the amount of substance it has lost: the cicatrix has a rugged and nodular, streaked, and radiated or knitted appearance, and adheres to the thickened and callous periosteum. The inflammation of the bone which is attended with the production of tubercle, and the caries which thence ensues in the spongy articular portions of the long bones, in the carpal and tarsal bones, and in the phalanges, passed among old writers by the name of Paedarthrocacia, while the same affection of the vertebrae is known by the name of " Pott's disease." h. Sarcoma and cysto-sarcoma occur in bone pretty frequently; they are sometimes situated on its surface, and sometimes developed in its in- terior. When deeply seated, they usurp the place of the natural bone, and produce atrophy of it by their pressure; or else distend it so that it forms a more or less complete shell. Just as, usually, the tissue of the bone in the neighborhood of the growth acquires increased density (sclerosis), so, when the morbid growth is superficially seated, a develop- ment of new bone takes place, which projects into it in processes like thorns and leaves. And when the morbid growth is of the sarcomatous kind, it is not only encased in an osseous shell, but the bone adjoining the shell enlarges sometimes very considerably, and especially in thick- ness, while knotted cords of new bone are developed in the tumor, and traverse it in different directions. i. Cancers. Numerous growths of cancerous nature are met with in bone; they are distinguished from one anotherby their internal structure and external configuration, as well as by the mode in which they destroy the tissue of the bone. a. The least frequent is areolar cancer. It forms tumors of greater or less dimensions which protrude from the interior of the bone, and sometimes it exhibits in bone, as in other structures, its remarkable cha- racter of developing its peripheral follicles into large bladders or cysts. DISEASES OF BONE. 153 I have met with a case of this kind in the right superior maxillary bone. In the neighborhood of the canine fossa, a white and densely honey- combed tissue sprang out of the bone, within the small cells of which a grayish jelly was enclosed : internally it filled the cavity of the antrum Highmorianum, while externally it grew in the form of bladders, which attained such a size, that at length those at the periphery of the growth would have contained a hen's or goose's egg, and the whole mass was as large as a man's head. /3. Fibrous cancer appears sometimes in the form of a nodule, of about the size of a walnut or a hen's egg, which is developed mostly in the medullary canal of the long bones : it displaces the bony tissue, and pro- ducing atrophy of it by pressure, is frequently the cause of one or more spontaneous fractures of the bone, which occur upon the most trifling occasion. Sometimes it springs from a broader basis on the surface or in the interior of a bone, becomes a tuberculated and uneven, lobulated mass, and often reaches a very large size: it splits the tissue of the bone asunder into filaments and laminae; and new osseous substance, com- mencing on them at the base of the growth, and developed continuously along the principal fibres in its interior, forms for it a bony skeleton. This kind of cancer is noticed mostly in the bones of the skull and face, and in the long bones. y. Medullary cancer appears in the following forms : (1.) In one, which is a rare form, the bone is infiltered with a milk- white sap,—a fluid encephaloid mass. A case which was long since de- scribed by Saillant, and which has been copied by Lobstein into his chapter on Osteopsathyrosis, ranks, as I believe, in this class: and I am the rather inclined to think so because my own experience furnishes me with a similar case. Its rarity will excuse me for detailing it here, in- stead of that which Saillant has already published. A silk weaver, aged 61, had suffered twenty-five years before death from haemoptysis, and twelve years before from typhus ; since then, from repeated attacks of influenza, and as long as he could recollect, from rheumatic pains in his limbs. In the last year of his life he was afflicted with very severe sharp pains in his lower extremities, and transient oedema of the feet. The pains at length extended to the trunk, and affected the thorax more especially. Fever, cough, and dyspnoea came on; diarrhoea supervened, and the patient died in an extreme state of marasmus. Examination of the body.—It was emaciated in every part, and pallid. The bones of the trunk, especially the ribs, sternum, and vertebrae, were softer than natural: the vertebrae could be easily indented, and contained a whitish, milky, and thin or somewhat thick, and creamy fluid, com- posed of round elementary cells. It was mostly unmixed, but here and there it was streaked with some dirty brown medulla. Some of it, in the latter condition, was contained in enlarged cells of the bones of the pelvis, and of the articular extremities of both femora and tibiae. The inner surface of the whole vault of the skull was lined with a pale red, lardaceo-medullary (cancerous medullary) adventitious growth, spread out in a layer of considerable thickness ; into one side of it was inwoven a growth from the vitreous table, of partly reticular, partly filamentous 154 DISEASES OF BONE. bone, while on the other side it adhered to the dura mater. All the lumbar lymphatic glands had coalesced into one whitish lardaceo-medul- lary succulent mass. . , , Moreover, on the inner surface of the dura mater covering each nemi sphere, there was a vascular exudation. In each pleura there were a pound and a half of serum, and that on the right side was mixed with a flocculent exudation. The lower lobe of the right lung was covered with a delicate exudation, and was hepatized in several spots, which were as large as peas or walnuts. , Several of the mesenteric glands were infiltrated with the^ lardaceo- medullary matter: the mucous membrane of the rectum was injected and of a bluish-red color, and was covered with islands of exudation as large as linseed. The calyces and pelves of the kidneys were dilated, and contained some very fine yellow urinary sand. (2.) It usually appears in masses, which very often reach an astonish- ing size. Sometimes these masses undoubtedly commence as an exten- sive infiltration, while at other times they consist at first of a morbid growth confined to one small point. In the former case, they forcibly split up the bone into delicate layers, in which regularity of position and of laminar arrangement is less distinct in proportion to the rapidity (tumultuousness) of the growth of the tumor. In the latter case, as the mass makes its way out from the interior of the bone, it distends the compact tables into a bony shell. Sometimes they thus become merely a simple shell; at other times, they are developed into a framework of laminated bony fibres. Moreover, in medullary cancer, a skeleton of divergent laminae often forms upon the filamentous basis of the growth. In other cases, of that part of the bone in which the morbid growth originated, a few small fragments only are found scattered through the mass ; or it may have entirely disappeared, and no trace even of frag- ments may remain. This form of the disease mostly affects the long bones, from the articu- lar ends of which it is developed ; it occurs also in the flat cranial and pelvic bones, and in the sternum and ribs. (3.) The infiltration with encephaloid juice or sap above described— cancer-cells contained in a fluid blastemata—is the lowest degree of con- sistence which medullary cancer presents; but it occurs in bone in vari- ous degrees of consistence, from that of brain to that of a lardaceo-medul- lary or of a lardaceo-cartilaginous substance. The soft loose parenchyma of genuine encephaloid is observed in bone, as in other organs, to be very richly beset with vessels; and they are remarkable for their large size and for the thinness of their walls : the blood escapes from them by repeated hemorrhages; it collects in cells which it forms for itself by thrusting the substance of the growth some- times far asunder, and in these cells it forms laminated coagula. Cancer melanodes is found in bone, as well as the white medullary cancer. (4.) There is a peculiar form of cancer, which Otto describes as a gnawing or erosion of bone: Lobstein speaks of it under the title of Osteolyosis; but he includes amongst his cases some which were ex- amples of cystoid disease and cystosarcoma, and perhaps also of areolar DISEASES OF BONE. 155 cancer. On ^ the broad bones of the skull,~or on the ossa innominata, spots are noticed in which a foreign substance occupies the place of the natural bone. Besides other peculiarities, this substance presents very various degrees of consistence, sometimes being lardaceo-cartilaginous, and white or whitish-red ; sometimes a fleshy-fibred, red substance; some- times a gelatinous, an albumino-serous, or a fatty and serous fluid, of a yellowish-red or grayish color, or altogether colorless. It commences in the diploe, which it soon eats away, forming a cavity which, in the bones that have been mentioned, is at first enclosed within their compact tables. This covering disappears at several points, and leaves a smooth, round, an oval, or an irregular sinuous opening, or a gap, which is covered on both sides by periosteum. The morbid growth then interweaves itself with this membrane, especially with the dura mater when the skull is affected ; and not unfrequently advances in it beyond the margins of the opening in the bone. The diploe is usually eroded to a greater extent than the compact walls of the bone, and hence it is that the margins of the opening are so often uneven and jagged, and the compact tables bevelled from within outwards. There is generally no elevation of the diseased spot above the level of the bone, or at most it is very slightly raised ; yet I have observed, that the growth which fills the cavity in the bone does sometimes rise above the surface, and form a tumor, which, in a flat bone, projects on both its sides. And especially when the morbid growth consists of a gelati- nous fluid, it expands the tables of the bone, in the form of a bladder, and in that state is probably the disease first seen by Van Wy, and named by him Hydrosteon. It must not be confounded with cysts, and cystoid disease of bone. This form of cancer does not differ in its elementary composition from that of fibrous and medullary cancer: every variety, indicated above, in the aggregation of the elementary parts—in consistence—is sometimes met with in the same individual. There can be no question as to the cancerous nature of the disease: it is quite common to find it combined with a very extensive production of cancer in the internal organs. The nidus in which the cancer growths originate are the Haversian canals, the tissues lining the cells and medullary cavities of the bones, the medullary system generally; and it is from these points that the compression, the erosion of the bony substance by pressure, and the for- mation of skeletons in the morbid mass proceed. Cancer almost always originates in the diploe, in cancellous bones and parts of bones, or in the medullary cavities. The state of the bone in the neighborhood of the cancer varies in dif- ferent cases. Sometimes it is affected with hyperostosis,—on its outer surface, widely spread bony exudation, and induration Avithin; sometimes with osteoporosis, atrophy and brittleness ; and sometimes it is softened. Under what condition any of these states exist we are at present igno- rant, but it is worthy of remark, that they are not confined to bones immediately adjoining the cancerous disease; for when the mammae, for instance, are the seat of cancer, not only may the ribs and other bones of the thorax be softened, but distant bones, and even the whole skeleton. 156 DISEASES OF BONE. Besides the primary cancerous diseases of which we ^\^^° been speaking as affecting bone, this system is subject also to secondary career" Instances of & secondary affection may be^observed in the ribs and sternum when the mamma is occupied by cancerous disease m the skull when a primary growth is situated in the dura mater or bram and sometimes in the bones of the pelvis, when the same disease affects the uterus. The bone becomes involved, not by mere pressure, though that may be exerted, but by the advance of the groAYth into, it the disease is implanted in the tissue of the bone, which degenerates, and suffers a breach of its continuity. Bone undergoes a peculiar destructive process, when the soft parts covering it are affected with those phagedaenic ulcerations which are usually held to be of cancerous nature. They are mostly observed on the bones of the face, and we shall speak of them hereafter, when taking a comparative glance of the diseases of bone. Cancer of a bone is sometimes the only instance of the disease m the organism; sometimes, and indeed, very often, several bones are affected together. It is moreover frequently combined with the same diseases in various soft tissues, with cancer in the liver, breast, lung, pleura, uterus, &c. The extirpation of large cancerous growths in bone is usually followed by a very rapid and extensive production of cancer in several internal organs. It sometimes occurs in early life, but is generally more frequent in adults. § 8. Foreign bodies in bones.—In some cases in which mercury has been medicinally employed, either internally or externally, particles of the metal have been found in bone. Fragments of all kinds of instru- ments by which bones have been wounded, may be left behind in the wound,—as broken points of knives and swords, and bullets which have been shot into a bone. They give rise to tedious inflammation, suppu- ration, and necrosis, and are often thus loosened and cast out; but some- times they remain firmly fixed in the bone during the remainder of the life of the individual, surrounded by indurated tissue. An attempt to determine the characters of the Constitutional Affections of Bone, particularly the Inflammations and Caries, by reference especially to the appearance of the Bone after Maceration.1 It appears to me to be a matter of much interest to determine in what manner the processes of inflammation and suppuration in bone, which arise from constitutional causes, may be distinguished from one another, and how they may at once be recognized by the characters of the preparation alone: inasmuch as the discovery of certain definite types not only makes us better acquainted with the peculiarities of those processes, but may also assist us in distinguishing them on the living, or at least, in clearing up doubtful cases of diseased bone when examined on the dead. Oesterreichische Med. Jahrbucher, vol. ix. p. 4. DISEASES OF BONE. 157 The distinctive marks of these processes, so far as they are stamped upon the bone, are comprised in change in its texture at the diseased spot, in some alteration of its shape, in the form and boundary of the ulcer of the bone and the necrosis, in the condition of the neighboring osseous tissue,—that is, in the different degrees, or total absence of in- flammatory reaction, and the quantity and arrangement of its product, &c,—and in the character of the cicatrix. Moreover, although it has only a secondary bearing on our present subject, yet some attention must be paid to the relation which subsists between different constitu- tional processes and different bones and parts of bones, to their appa- rent or palpable tendency to affect compact or spongy, broad and flat, or long bones. In order to render the subject practical, it is necessary to compare as much as possible corresponding bones. This, however, can be carried, out only to a partial extent, inasmuch as several of the processes occur very rarely or not at all, in particular bones; and it is, therefore, the more important to bring together marked examples of the several dis- eases referred to. Syphilis, as is well known, most commonly attacks the flat cranial bones, then the tibia and clavicle, and sometimes the sternum,—in general, therefore, bones which are but thinly covered with soft parts, and com- pact osseous tissue. It makes its appearance as a painful inflamma- tion, which is more severe at some spots than at others. Where it is most severe, it gives rise to a swelling of the bone (tophus), and to an exudation into its interior, which ossifies and produces a local condensa- tion and permanent thickening of the bone; sometimes, but rarely, exudation takes place on the surface also, which soon hardens in the same manner, and unites with the bone. If the bone be diseased through- out, it swells into numerous confluent bosses, which correspond to the several seats of more severe inflammation, and it becomes shapeless, thick, coarse, and heavy. Or after having effected this metamorphosis, it terminates in caries. Ulceration attacks an indurated bone. Sometimes, especially on the cranium, it spreads over a large extent of the outer table of the bone, while at other times it rather commits its ravages deeply, and, in the skull, often perforates the bone. In the former case, the destruction of the soft parts discloses a large ulcerating surface, covered with a layer of lardaceous jelly, which is softening and becoming purulent, and beneath which the indurated bone appears rough and uneven, and, as it were, gnawed. If the ulcera- tive process stop, the layer covering the bone becomes organized into a very delicate cicatrix, and the bone recovers, not with a smooth, but with an uneven nodulated surface, which subsequently becomes somewhat eburnated, but never quite loses its rugged character. If the sutures still exist, their sharp indentations become thick and blunted. These changes may be readily detected on the living patient through the inte- guments and their cicatrix. A circumscribed ulcer has the circular or sinuous form of syphilitic ulcers, and swollen thick margins, which in an ulcer that has perforated the cranium, may be rounded off abruptly or bevelled from without inwards. 158 DISEASES OF BONE. An ulcer which has occasioned a superficial loss of bone, heals m the same manner as the analogous process in the soft parts ; its cicatrix is de- pressed in the centre, nodulated, and shining. If the bone be destroyed in its whole thickness, the margin of the opening becomes rounded, swelled, and coarse, and here and there somewhat inverted. _ Perforation from this cause happens in the cranial and nasal bones, and in the palate. And lastly, if the inflammation end in necrosis, the syphilitic seques- trum, especially if it include the whole thickness of the bone, presents the same characters of induration, thickening, and uneven, gland-like ruggedness of surface. The most palpable characters of syphilitic bones are the hypertrophy, and especially the density of their tissue, and the absence of deposition of bone upon their surface in any of the known forms of osteophyte. Under minute examination of a section of a very compact syphilitic skull, numerous Haversian canals were discovered lying far apart, and separate groups of unusually large and black corpuscles, from which a great number of rays diverged. In a section of a piece of syphilitic skull which appeared porous externally, but Avas, in fact very compact, the Haversian canals Avere found wide, the corpuscles mostly large, and some of them placed at right angles to the canals : in the neighborhood of particular canals the innermost lamella was transparent, and con- tained a single roAV of corpuscles, but it was surrounded by a dark stratum interwoven with very numerous corpuscles, which were thickly set with rays. The lamellar system of some of the larger Haversian canals was uncommonly developed (machtig). A bone which has been indurated by the syphilitic process is unques- tionably liable, at a later period, to expansion of its texture. It seems, however, to happen but rarely; I have observed it once in the tibia, but nowhere else,—never in the cranial bones. Scrofulous inflammation of bone, as it is called, that is, inflammation resulting in tubercular product, and scrofulous caries, have been described already (p. 151), with tubercle of bone, and the tuberculous abscess pro- duced by its softening: the chief characters of the macerated bone are all that require notice in this place. Caries, when it has arisen from inflammation, is surrounded by a super- ficial deposition of new bone, which in compact structure, like the cra- nium, assumes the villous form of velvet, and in spongy bones, especially the articular ends of the long bones, becomes a splintered and plated osteophyte. This deposition is the more distinct, as there is no hyper- ostosis, no induration in the interior of such a bone until the ulceration begins to heal: and then it commences at the base and circumference of the ulceration. But cases of caries frequently run their course with- out any such production of bone. They are those which occur in per- sons exhausted by tubercular phthisis of the lungs and intestines; or when caries in the same kind of persons is secondary, when for instance the articular extremities of bones are affected in consequence of inflamma- tion and suppuration of the adjoining synovial membrane; when the ribs and the sternum are eroded by the compression of pulmonary or glandular abscesses: and also when softened tubercle of the dura mater corrodes and perforates the skull, &c. DISEASES OF BONE. 159 Superficial caries, like the analogous ulceration in soft parts, leaves behind it a hardened cicatrix of a round or elongated form, pitted and uneven on its surface, and having a corded appearance, as if it had been knit. The bone often continues permanently diminished in size. Tubercle, when it softens in spongy bones, as in the bodies of the ver- tebrae, destroys the bone in rounded spots, which are clustered together so as to give it a honeycombed appearance. The destruction to which the bones of the face and cranium are sub- ject from so-called facial cancer is altogether different from both these processes. Equally unlike them and every other destructive process, it is distinguished by mere negative marks, and may be recognized at the first glance. The surface of the bone and its diploe are successively de- stroyed by a kind of dissolution or corrosion; nothing is seen in any part but normal bony tissue laid bare; nowhere is there any obvious trace of expansion of the bone, of induration, or of new bony tissue (osteophyte). The solution in cases of noma (Wasserkrebs, cancrum oris), affects principally the animal part of the bone, and is very similar to that just described; the bone looks as if it had been calcined (Froriep). But the most difficult point to determine is the changes which are pro- duced in the structure of bone by genuine arthritis. For there are so many anomalies in those affections of the bones Avhich, on the living subject, are attributed to uncomplicated gout, that one is compelled to doubt whether they are all connected with one and the same process. Adventitious groAvths of various kinds and metamorphoses of apparently syphilitic nature, are ranged together, under this head, with primary in- durations, osteoporoses, with consecutive indurations, atrophy, mollities ossium, with different osteophytes, ivory exostosis, &c. The following changes may, I believe, be looked upon as arising from gout. There is a metamorphosis in the bony structure of joints, especially in those of the hip-joint, which I agree with some older observers (Portal, Koehler, Austin) in attributing to an arthritic inflammatory process. It is the same as that which the English denominate " malum coxae senile." It presents the following characters. a. The cavities of joints (acetabula) become enlarged, and mostly flat- tened. /9. The head or convex part within the joint, acquires a flattened sur- face, and an overhanging margin: in the instances of the head of the femur, of the humerus, of the radius, &c, it assumes the form of a mush- room. y. The cartilage which covers the bone is removed, and the cancellous tissue to a varying depth underneath it converted into a dense white, chalky mass, which is polished like marble on its articular surface by constant friction. 8. An exuberant growth of bone takes place around the joint, in the form of a cup-like and warty stalactitic osteophyte ; similar masses accu- mulate outside the joint, which all consist of the same white, chalky sub- stance as the overhanging margin at the head of the bone. The process by which this change is produced, is a painful one, con- 160 DISEASES OF THE MEDULLA. sisting, without doubt, in an inflammatory rarefaction, swelling and soft- ening of the bone. After furnishing an osseous exudation within the tissue of the bone and all around,—an exudation which may be distin- guished by its form and chemical composition,—it terminates in consecu- tive induration. It occurs most frequently in the hip-joint, but it is also observed in the shoulder, elbow, and knee, and in the joints of the fingers, and odon- toid process. The whole joint become^ misshapen with the excrescences projecting around it. The disease in the bone is, moreover, sometimes accompanied by simi- lar osseous depositions in the fibrous capsule of the joint, and in neigh- boring fibrous structures; they assume various forms, like cups or thorns, or are rounded and bossy. That inflammation seems to me to belong to the same class, which affects long bones, and besides producing induration of their substance, gives rise to a warty and stalactitic osteophyte upon their surface, which renders them rough, like the bark of a tree. And this may be the case also with the osteophyte that grows in cup-shaped, plate-like, thorny or gnarled, processes, in the substance of ligamentous structures near joints, or on the bodies of the vertebrae. They are very often composed of an indurated chalky substance. Lastly, under circumstances at present unknown, but especially in aged persons, gout produces a painful atrophy, and concomitant brittleness of the bones, rendering them liable to fracture. Whether rheumatism gives rise to an inflammation that can be dis- tinguished by any definite characters of its products or to any peculiar caries, is not yet ascertained, however positively assertions be made on the point. There is probably no such thing as rheumatic caries. The abscesses upon and within bone, which have been given out as such, I have always recognized as tubercular. Rheumatic inflammation appears gene- rally to attack the periosteum and outermost laminae of the bone, and to produce induration of its tissue, and a warty plated osteophyte on its surface. It is evidently a change closely allied to that which arises from gouty inflammation. Appendix.—Anomalies and Diseases of the Medulla. Although it is highly probable that the medulla is the part in which all pathological plastic processes in bone originate, yet very little is known of its diseases. And upon this deficiency of information it no doubt de- pends, that, on the one hand, our opportunities of investigating the dis- eases of the medulla are almost entirely confined to very advanced cases —cases in which the whole bone is involved in the disease,—and- hence that on the other hand, whilst studying the changes in the actual bony tissue, we are m the habit of paying less attention to the medulla. m Oftentimes, in consequence of hypertrophy, it is augmented in quan- tity, and its increase occasions dilatation of the Haversian canals, the cancelh and the medullary cavities, in which it is contained. Such hy- pertrophy is unquestionably the cause, either by itself or in combination with other processes, of many of the osteoporoses, both those which are DISEASES OF THE MEDULLA. 161 circumscribed, and those Avhich extend throughout a bone. While in- creased in its quantity, it may retain or depart from its normal texture and composition. Thus instead of the jelly which fills the cells of the spongy tissue of some portions of bones, of the diploe of the bones%f the skull, for instance, actual medulla is sometimes found, even in the form of compact lobular masses. Its excessive accumulation leads at length to atrophy of the spongy and reticular bony substance, and to expansion of the compact walls of the bone. On the other hand, when the bone is affected with concentric atrophy, the medulla shrinks as well as the bony tissue, otherwise its place is taken by a gelatinous, fatty, or serous fluid. In color and consistence it very frequently deviates from its usual con- dition, and so also in its texture and composition. The former changes are usually mainly dependent upon the latter in relation to their cause. The color is sometimes unusually pale or Avhite, sometimes it is a dark yellow; and it frequently acquires various hues of red, rusty brown, yeast- yellow, or chocolate, from mixture with blood; it is variously discolored when caries is going on in the bone. In consistence it is sometimes too thin, being liquefied by serum, or oleaginous ; in other cases it is unusually firm, it resembles suet or adi- pocere, and may be broken. In reference to its texture, it is liable to congestion and to hemorrhage, by which it may be discolored, and assume a dark-red, chocolate, rusty brown, or yeast-yellow, hue. The real seat of inflammation in bone is the membrane which lines its cavities. The inflammation of this membrane leads to an exudation which sometimes becomes organized into bone, and sometimes is converted into cellular or fibroid tissue, as may be seen after injuries of bone, or, more rarely, in consequence of spontaneous inflammatory processes; i. e., the medullary membrane and its prolongations undergo fibroid thickening : lastly, the products of the inflammation are sometimes purulent or ichorous, and in various ways destroy the structure in which they are deposited, and the bony tissue. The anatomical marks of these processes are self- evident ; they may be recognized also by reference to what has been said about inflammation of bone and its consequences. In dropsy, the place of the fat of the medulla is gradually taken by a thin, gelatinous, and finally serous fluid. There are some remarkable changes already alluded to, which the mar- row undergoes in osteoporosis and mollities ossium, but their exact na- ture is still unknown. Finally, the medullary membrane is the structure in which all adven- titious'growths in bone originate. Tubercle and cancer afford easy proofs of this remark, especially many forms of the latter, such as encephaloid infiltration of bone, and the cancerous diseases named erosion by Otto, and osteolyosis by Lobstein. vol. in. 11 162 ANOMALIES OF CHAPTER II. ANOMALIES AND DISEASES OF PARTICULAR PARTS OF THE SKELETON, AND OF THE SEVERAL BONES COMPOSING THEM. SECTION I.—THE SKULL AND ITS SEVERAL PARTS. § 1. Deficiency and Excess of Development.—In cases of Acephalus, the skull is altogether wanting, or is reduced to a merely rudimentary con- dition. It is liable, also, to various degrees of defect, in Acrania being without any vault, and in Encephalocele and Anencephalus presenting various, but less degrees of the same anomaly. Defects of other parts of it are noticed when the cranial or facial bones are fissured, when cer- tain portions of the brain are wanting, or symmetrical parts of it are fused together, as happens in Cyclopia, &c. Examples are also met with in which the development of the skull is arrested in a less degree, aper- tures closed by membrane being found in its bones, or large membranous interspaces between those that form the cranial vault: the fontanelles are large, or unusual ones exist, or certain sutures continue permanently unclosed. The cases of this class mostly OAve their origin to a preter- naturally large size of the brain—to Hypertrophy or Hydrocephalus. The number of bones composing the skull is occasionally incomplete ; particular bones are wanting altogether, and sometimes their place is sup- plied by the enlargement of those in the neighborhood; thus the nasal processes of the superior maxillaries may occupy the space which is left by deficiency of the nasal or lachrymal bones. An excess of development is observed in those cases where more or less of a second head is formed; and premature closure of the sutures and fontanelles constitutes another, but a less degree of the same general condition. When certain sutures, such as the frontal, do not close, when there are unusual accessory sutures, such, for instance, as a horizontal one through the parietal bones, but especially when Wormian bones exist, the number of the bones of the skull is increased. The Wormian bones are most common in the lambdoidal suture, and in the squamous; they are less frequent in the coronal and sagittal, and are most rare where the wings of the sphenoid meet the parietal and temporal bones, and the roofs of the orbits. In the lambdoidal and squamous sutures they are not unfrequently very numerous, and even form two or three rows and as many sutures. When they occur in the other sutures they are often only single; and this is true especially of the sutures surrounding the wings of the sphenoid bone. In their situa- tion, as well as in their dimensions and form, they are usually symme- trical, though there are some interesting cases in which those of the one side do not correspond with those on the other. A Wormian bone situated over a fontanelle receives the special denomination of a fonta- nellar bone. Finally, the outer layer of the Wormian bones is usually broader than the inner: sometimes they form part of the outer table THE SKULL. 163 of the skull only, and, in rare instances, only of the inner. Their existence is chiefly to be accounted for by the large interspaces which are left between the cranial bones in congenital hypertrophy of the brain and in hydrocephalus. § 2. Anomalies in the Size of the Skull.—The skull, like the brain, may deviate in either direction from its proper size. In some cases it does not reach, in others it exceeds, its natural dimensions. Smallness of size may be general over the whole skull, or may be confined to some particular portion of it. Except when it is occasioned by protrusions of the brain beyond the bounds of the skull (encephalocele), it necessarily involves that the brain generally be small, or that portion of it be defi- cient or undeveloped; and in the latter case, the corresponding part of the skull is also wanting or but partially developed. The skull may be only relatively small, or it may be absolutely so: in the latter case the smallness of size occasions idiocy, and is a congenital state; a partial diminution is sometimes acquired subsequently to birth, particular parts of the skull becoming small and flattened, sinking in, and shrinking, when the corresponding portions of the brain are in a state of atrophy. The bones of the face are of small size in cases of congenital hydro- cephalus, and their smallness is more striking in proportion to the en- largement of the cranium. A diminution in the size of the bones of the face is also observed in old age: it is chiefly due to wasting of the maxillary apparatus. And a similar attenuation is observed on one side of the face as a consequence of paralysis or neuralgia. Increase of the size of the skull, when congenital, involves an exces- sive development of the brain, or, what is more frequent, hydrocephalus. The enlargement is mostly uniform and symmetrical, but in some excep- tional cases the skull bulges in one direction or another, a particular section of it is more capacious than the rest, &c. The dimensions of the skull rarely enlarge at any period after birth —that is, in the sense of increase of its capacity—without some appear- ance of absorption of the vitreous table, or separation of the sutures ; still more rarely does it occur at mature age when the bones are completely formed, and almost never when the sutures are closed. It is seen occa- sionally at certain parts of the skull. The bones of the skull and face are subject to many considerable variations in their thickness, sometimes being enlarged (hyperostosis), and sometimes attenuated. Hypertrophy usually commences with the bones of the cranium, it occurs in them frequently, and advances to a very considerable extent; whilst atrophy, especially that form which is peculiar to old age, is more common in the facial bones. Hyperostosis almost always presents itself in both its forms, namely, that of deposition externally upon the bone, and simultaneous conden- sation of its tissue (sclerosis): in a few cases it goes on to such an ex- tent, that the skull is not only, according to Jadelod and Ug, larger than natural, misshapen, and uncommonly thick (9 lines to 1J or 2 inches), but it also acquires a weight that is almost incredible. In the later periods of the disease, if not at its commencement, the thickening takes place at the expense of the cranial and adjoining cavities,—orbits, 164 ANOMALIES OF nares, labyrinths, and antra Highmoriana,—as well as of the foramina and fissures which are traversed by the nerves and vessels: the sutures also disappear. Other bones, and even the whole skeleton, may be increased in bulk, when the skull is thus affected; but the disease may be entirely confined to the skull, or even to the cranial bones alone, and those of the face, of other parts of the body, and the base of the cranium itself, may remain of their natural size. Not^ unfrequently, indeed, this hyperostosis of the cranium is associated with atrophy of the bones of the face and of the rest of the skeleton. In any case, it reaches its greatest extent in the cranial vault, and at its frontal and occipital portions: when it occurs in the bones of the face, it is most developed in the lower and upper maxillary bones. It may occur in early youth, in adult, or in advanced life,—a circumstance which depends partly upon the nature of the process. a. It is sometimes the consequence of an overgrowth or excessive nutrition of the bone, the conditions of which are as yet unknoAyn to us. It is generally developed slowly. It occurs chiefly in adult life; and frequently is associated with ivory-like exostosis on the outer table of the skull, with enlargement and prominence of the inner table, espe- cially near the frontal ridge, and with a growth of bone upon the dura mater. ,?. At other times it arises from an inflammation of the bone, which may be acute and recur from time to time, or may be chronic and con- tinued. The pericranium on the one side, and the dura mater on the other, take part in the inflammatory process. The first of these forms furnishes an exudation of bone upon the sur- face of the cranial bones, which varies in thickness, and presents the characters of the velvety, finely filamentous, and reticulated osteophyte: it gradually becomes identified with the bone, either Avith or without the intervention of a newly formed layer of diploe. Processes of this kind mostly take place on the inner table of the skull, and especially upon and near those spots which are best supplied with vessels; they are, therefore, common along the sinuses and the sutural margins of the bones, and furnish the bone at those parts with a neAV vitreous table. Moreover, they are processes which occur chiefly in young persons. The exudation of bone, which is met Avith on the inner table of the skull in pregnant women, deserves an especial notice. It is so frequently observed in women under such circumstances, and advances in them to so great an extent, compared with what it reaches in other cases, that some connection between it and pregnancy must be admitted; and as it has been regarded with interest, since the time of its discovery in this Institution,11 devote the following paragraphs to an account of it. t The puerperal osteophyte, as it is usually termed amongst us, because we commonly observe it in persons who have died in consequence of the puerperal state, generally occupies the frontal and parietal bones : some- times it is found covering the whole inner surface of the cranial vault, and in that case it may be noticed scattered in patches over the base of the skull also. But it does not usually occupy large extents of surface 1 Oestr. Med. JahrbOch., vol. xv. p. 4. THE SKULL. 165 completely, even when it is of considerable thickness, the eminences on the inner surface of the skull, and more rarely the depressions, being left uncovered. Such bare spots on the vitreous table, Avhether they be situated on the eminences or depressions, are parts at which their OAvn pressure, or that of the brain, has prevented the deposition of the exu- dation, and they are at once distinguished by having lost their polish and natural color. The layer of new bone varies in thickness, from that of a very thin film to half a line, a line, or more. It is usually thickest along the sutures, the longitudinal furrow, and the grooves for the arteria meningea media ; it always becomes thinner towards its margins, and is lost in a delicate film. Its color presents various shades and modifications of red; it almost always becomes paler towards its margin, and at that part is reddish white, white with red beneath, shining through it, or quite white. This depends on the age of the exudation, on the progress which it has made in its change into cartilage and bone, and on the development of a diploetic tissue within it. It exhibits in its texture the same stages of development as any other ossific exudation. (1.) It is at first a whitish-red or yellowish-red, gelatinous exudation, which is becoming vascular ; it can be easily removed from the bone, and the vitreous table beneath is found to be natural, or to have merely lost some of its polished appearance. (2.) It is a soft, flexible, cartilaginous lamina, full of minute pores; the vitreous table beneath is generally distinctly rough, or at any rate has its pores manifestly enlarged. (3.) At the commencement of this stage it forms a flexible lamina, which is smooth and very finely porous, where it is opposed to the dura mater, while on the side which joins the vitreous table it is rough, cellu- lar, and partly cartilaginous, partly osseous. A sanguineo-serous fluid oozes, under pressure, out of its numberless minute pores ; and the cel- lular spaces on the opposite side are filled with a yellowish-red jelly, and sometimes with a clear-red bloody fluid. It is firmly adherent, and is seen, when an attempt is made to remove it, to be united to the vitreous table by. the numerous lamellae and meshes of the cancellous, succulent tissue before mentioned; both these and numerous vessels are torn in separating the osteophyte. The new growth is not developed beyond this point during pregnancy, or during any morbid puerperal condition which may succeed parturi- tion ; but at a later period it ossifies completely, and forms an integral part of the wall of the skull; it becomes, in fact, a new vitreous table, in some instances being dense (sclerosed) all through, in others united to the old vitreous table by an intervening cancellous layer. Generally, when the calvarium is removed, the new growth clings to the inner sur- face of the skull; but sometimes it separates from the skull, and remains adherent to the dura mater. When the exudation is more than usually thick and extensive, a simi- lar, but thinner, stratum is found on the outer table of the skull: at this part, also, as on the inner table, it appears to select the frontal and 160 ANOMALIES OF parietal bones, and is deposited chiefly along the coronal and sagittal sutures, and along the part at which the temporal muscle is attached, and the linea semicircularis; it may even be found on the external surface of several of the bones of the face, especially on the superior maxillary and nasal. That there is no connection whatever between this new growth and the puerperal diseases of which the patients died, will be perceived from the following observations. It presents itself in all its varieties of extent, thickness, and internal development, in the most rapid instances of puerperal disease : it is met with in cases of speedy death from rupture of the uterus during parturi- tion, and when hemorrhages from that organ, during or after labor,_ have quickly exhausted the patient, as well as when Asiatic cholera, in its swiftest course, has carried off a woman during her pregnancy. The fact is more clearly proved from these growths being found in per- sons who, either during their confinement, or soon after it, have died of a disease quite independent of the generative organs, and one which may have arisen a long or a short time before the end of pregnancy, or even during labor, such, for instance, as pneumonia, phthisis, cholera, or apoplexy. Again, there are other cases still more convincing, in which the growth is found in healthy pregnant persons, who have met with un- expected and sudden death at an advanced period of pregnancy. But the fullest conviction is afforded by the discovery of this growth in females, who, at any period of their pregnancy, back to the third month, have died in a rapid or sudden manner. The osseous groAvth under consideration, therefore, in pregnant and parturient Avomen, is a phenomenon which, under circumstances hitherto unknown, is attendent on, and originates from, the pregnant condition. The question as to the period of pregnancy at which the growth com- mences, is answered by the fact of its having been met with in every month as far back as the third : on one occasion, in AArhich pregnancy was over, and the woman had been confined, it was but little developed, and existed only at a few small spots; on other occasions, at early periods of pregnancy, it extended over large tracts of the skull, its thick- ness was considerable, and its texture well developed. Its commence- ment, therefore, cannot be fixed at any definite period of pregnancy. The exudation when completely ossified, and united with the old vitre- ous table, increases the mass of the skull in a degree commensurate with its own thickness; and this, of course, is very evident in cases of re- peated pregnancy, in which several exudations have been deposited. And a highly instructive fact may be noticed in cases of this class, that some one of the more recent laminae of bone does not lie in immediate contact with the older layer, but is connected with it by an intervening stratum of diploetic tissue. In those cases in which the dura mater shares in the process, that portion of exudation which it supplies becomes a vascular cellular tissue, and is either spread out as such uniformly, or collected in patches here and there; and the new osseous lamina, being both perforated by the numerous vessels of the cellular tissue and grooved by them as they wind along its surface, does not possess so THE SKULL. 167 smooth and polished a surface as the original vitreous table; the dura mater and the skull, therefore, are more intimately connected, and adhere to each other more closely than natural. This connection is most firm, as might be gathered from my earlier remarks, along the sutures and sinuses, and especially near the longitudinal sinus. What has been said establishes the existence of a puerperal hyperos- tosis of the skull, and its connection Avith repeated pregnancies. In contrast with the frequency with which this growth is found in the bodies of women who either are pregnant or have been recently confined, it is quite rare in other persons, especially in men, to meet with a new formation of bone resembling it in situation, extent, or form. I can recall altogether but eighteen such cases, and the persons in whom it oc- curred were most of them young, and had died of very various diseases. Exudations indeed 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 neighborhood of the longitudinal furroAV. And very frequently, and even commonly, they are already transformed into a layer of bone, are porous, and covered with serpentine furrows, and have adherent to them a growth of organized cellular tissue, which springs from the dura mater. The remaining exudations of bone Avhich take place upon the inner surface of the skull resemble needles, splinters, and plates; or they appear as if they had been dropped or poured upon the bone in a fluid state, and had then coagulated. Chronic inflammation gives rise to a considerable thickening and indu- ration of the walls of the skull, and irregularity and roughness of their surface, with, sometimes, an almost monstrous thickening and fibro-lar- daceous condensation of the pericranium on the one side and the dura mater on the other. This class of disease includes also the hyperostosis of the cranial bones, which originates in their infection with syphilis. y. Lastly, the increase of volume, or hyperostosis, may be the indu- ration consecutive upon a rickety state of the bones of the skull, or upon the expansion of bone which resembles that of rickets, but com- mences at later periods of life. The latter cases are distinguished by the chalky appearance and dull white color of the substance of the cranial bones, and by the coarse grain of their fracture : their surfaces are rough, and the inner table especially exhibits permanently enlarged pores and deep impressions for vessels. The most extreme cases of hyperostosis are those of chronic inflamma- tion, and the last mentioned consecutive induration. All the rare in- stances of enormous thickening and induration of the cranial bones ap- pear to be of that nature. The principal example of partial hyperostosis is the ivory-like exos- tosis Avhich is frequently observed on the skull. It is almost always com- bined Avith considerable induration of the cranial bones. On the inner table, in the neighborhood of the frontal suture, there frequently exist smooth, or rough and striated elevations, which are produced by local expansion and subsequent induration of the skull. Finally, plates or rounded masses of bone, mostly of small size, are sometimes found glued 168 ANOMALIES OF on, as it were, in rugged depressions, on the inner table: they were originally productions from the dura mater. By far the greatest number of cases of atrophy of the skull are those which are peculiar to old age. The bones chiefly affected are the facial, and of these most commonly the maxillary bones. It is an atrophy asso- ciated with wasting of the whole skeleton. A remarkable attenuation of the wall of the skull occurs symmetrically at the top of the parietal bones in old and decrepit persons. At an oval or elliptical spot, the diploe shrinks to such an extent, that the two com- pact tables unite with one another, and constitute a translucid layer not thicker than a sheet of paper. The diploe around accumulates, so that the bone is thickened externally by an uneven SAvelling. No internal cause for the appearance has as yet been discovered, though it ap- pears to me not improbable, that it has some connection with inveterate syphilis. Atrophy is, in some instances, confined to certain portions of the skull; it then presents itself either in the form of diminution of particular parts of the cavity of the skull, or of other cells and cavities in the cranial and facial bones; or it arises, as has been already remarked, from palsy, neuralgia, exhausting reparative processes after injuries' caries, &c. Absorption of bone (Usura, Detritus) occurs very frequently, and reaches a very advanced degree, in the bones of the skull. In the cra- nium, when confined to circumscribed spots, it is mostly induced by can- cerous growths, such as fungus of the dura mater, or by morbid enlarge- ment of the pituitary gland: when it extends over the whole inner surface of the skull, it arises from hypertrophy, or some displacement of the brain. r § 3 Deviations oj"Form.-The skull is subject to very various devia- tions from its healthy form. It will be sufficient to furnish a general account of them, without entering into a detailed description of any but tne most important. J tiJff ^v^w6 maIformations> ^th of the cranial and facial por- tions of the skull, form an essential part of the conditions already de- JS "if 5 hemir?hal"s' encephalocele, and hydrencephalocele, of con- genital hydrocephalus, fissures of the facial bones, cyclopia, &c. In hronrfb.T °f/rphali°Cele' In Which the Protrusion takes place t:::i^,tzL\7^vault of the skul1 sinks d°- ^ * In congenital hypertrophy of the brain, but especially in congenital hydrocephalus, the size of the cranium is strikingly disp^oportToned to he small dimensions of the facial skull. The crafium mayTe exTuded to a circumference of two feet or more • the fronts oJ y ^expanded especially being very large, as iX^^^^^ spaces between them: the forehead proiects ^rentlJ tZ «V* 7? are forced downwards, and so 00^8^^^^ 7lLP ^ mere narrow transverse fi«„rp,. *CT 0rblt.s that theJ become bones, ^itoTZ^Zit^^ZZT 1 **:i.*?*0™} Section, to e^nafn.eatus oA^^t^^t^Tft THE SKULL. 169 the skull, besides being depressed, is remarkably small in proportion to the_ cavity of the skull. If, despite the large size of the skull, its ossifi- cation should be completed, the margins of the bones reach each other by means of long, ray-like denticulations, or they just meet along a sinuous suture (Harmonia), or else ossa triquetra are developed in the interspaces between them. One of the parietal bones, or one half of the frontal, may be increased in size, whilst the other remains unaltered, and then the sutures follow an unusual direction. This is the ordinary form in chronic congenital hydrocephalus; but if, during some interrup- tion of the disease, certain sutures should have closed, a recurrence of the hydrocephalus will produce material alterations in it; the distension will take an unusual direction, and the head deviate, accordingly, from the ordinary hydrocephalic form. Deficiency in the development of certain parts of the brain produces important deformities of the skull; such as flattening, or receding of the forehead, flattening of the back of the head, &c. The deformity is very striking, when it occurs only on one side. The most frequent deformi- ties are those in which there is a preponderance of some one diameter, so that the skull is longer, broader, higher, or, in some other direction, greater than natural. Allied to these are the rormd, the blunt, four- cornered, and similar skulls, and those which are oblique. At one time the obliquity is found to consist in a displacement of the halves of the skull in a logitudinal or a vertical direction: and in this way the law of compensation is carried out, the apparently greater width of the cranial 1 cavity on one side being made up for by its condition on the other. When the obliquity is considerable, the facial skull shares in it. At another time, the obliquity is occasioned by a lateral displacement of the several cranial vertebrae (which Carus names Scoliosis of the skull), so that the mesial line of the base of the skull is curved or serpentine. Other obliquities arise from the atrophy of the bones on one side; they are most marked in the face. Malformations of a peculiar kind, are produced by great projection of the cerebral skull above and in front of the facial; or, as is more fre- quently the case, by its receding behind the face; the facial angle is consequently either too great or too small. The base of the skull is sometimes pressed in, in a remarkable manner, by the cervical vertebrae. The skulls in which I have observed this deformity were large, and were those of persons who had suffered, very probably during foetal life, from a moderate degree of chronic hydroce- phalus. The portion which encroached upon the cavity of the skull was, in all cases, very thin. The special conditions under which this malfor- mation occurs are unknown. Lastly, the skull becomes misshapen in various ways, from fracture, indentation, depression, &c. The shape of the cavity generally corresponds with the external form of the skull, though it may be altered without any deviation from the natural appearance of the exterior. The inner table is sometimes, as in rickets, unusually smooth and polished; and, sometimes, the elevations and depressions are unusually marked. The elevations and some pro- minences, such as the clinoid processes, or the eminentia innominata, are 170 INJURIES OF occasionally developed into thorn-like, pointed processes, sharp ledges, or shapeless swellings. Sometimes, thorns of this kind are found^ at unusual places, such as the sella turcica, or on its pommel, on the basilar process, &c. When deformities of this class occur in cases of hydrocephalus and hypertrophy of the brain, and especially Avhen, at the same time, the subject of them is rickety, the condition of the sutures is peculiar. In a few cases the denticulations form long radiating processes, but_ generally they are Avanting, and the sutures are a mere sinuous apposition of the bones. In hyperostosis of the skull, especially in cases of syphilitic induration, the sutures become changed into a similar "harmonia." § 4. Anomalies in the mutual connection of the Cranial Bones.—The connection between the bones of the skull may be loosened, and their sutures separated (diastasis). This separation very rarely occurs, and is less important as a result of violent injury to the skull from falls, blows, &c, than when it takes place in consequence of a rapid advance and extreme degree of hypertrophy of the brain, or of hydrocephalus. The opposite anomaly is that of a premature closure of some, or all, of the sutures. From the thinness of the cartilage the sutures generally unite first at the inner surface of the skull. Of the bones of the face, the lower jaw may be dislocated, or its joint anchylosed. § 5. Solutions of Continuity.—The skull is very liable to solutions of continuity, in consequence of its exposure to mechanical injuries. In the infant it may be indented and fissured, or simply indented by the pelvis of the mother, or by the misapplication of instruments to facilitate the birth of the child. Various kinds of punctured and shot wounds, fracture and crushing of the skull, may take place at the spot to which violence has been directly applied ; and at the same time bone may be depressed or fragments driven in (impressio et depressio); the tables may be separated and splintered; there may be fissure and contrafissure; the bones may be denuded of their covering of soft parts, or there may be simply concussion of the bone within a circumscribed space. Lastly, the openings made in the skull artificially with the trepan belong to the same class. „ _ All these injuries are of a grave character, not only on account of the violence done to the brain and its membranes by the penetrating instru- ment or by depressed fragments of bone; but also independently of such complication, from the concussion which the brain and its mem- branes frequently suffer at the time of injury, as well as on account of the extravasation of blood which takes place immediately beneath the bone, or dura mater, or into the pia mater, or the brain. They may be rendered further serious, irrespectively of the foregoing causes by the supervention of inflammation of the bone and dura mater, which is usually so much aggravated by the contusion and concussion that have generally happened as to go on to the production of pus and sanies, and readily pass from the external parts to the inner membranes of the brain. Nevertheless, punctured wounds, fractures, and considerable injuries THE SKULL. 171 to the walls of the skull, even when combined with displacement of the fragments, do often heal by first intention, or by the way of suppuration. Fractured surfaces become soldered to each other by bony callus; or, after being rounded off by absorption or exfoliation, they are held to- gether by means of a fibroid callus; and the fragments which perish, and are thrown off during the process of suppuration, are replaced by a simi- lar tissue, in which new bone is sparely formed. Sometimes one fissure exists alone, sometimes there are several; and, in the latter case, they may all start from one spot on a bone, or may be multiplied by the branching of a single fissure. They often termi- nate in a suture, Avhich is then usually separated (diastasis), but not unfrequently they are continued across the suture into the adjoining bone. They generally do not unite for a considerable time, and may, even after the expiration of a very long period, exhibit no tendency to union; the rough edges of the fissure are merely rounded off by absorption. If they should then heal, the void is filled up by fibroid callus, which unites Avith the pericranium and dura mater. They are seldom repaired by means of bony callus, on the contrary, they are sometimes fatal; for the inflam- mation and suppuration which occur in their vicinity, and in which the inner membranes and the brain become involved, destroy life, it may be after a long period ; or the same result ensues, sooner or later, from the various injuries which the brain and its membranes have sustained from the original violence. Large and numerous fissures are generally rapidly fatal, especially such as extend deep into the base, and those which take place from the skull being crushed. A fall or a blow very frequently produces contusion, separation of the periosteum, or concussion of the bone at a circumscribed spot, while, at the same time, there may be no injury perceptible externally. The conse- quence is, that the periosteum inflames, pus or sanies is effused, and the outer lamella of the bone may die and exfoliate; or if the bone have been violently injured, it may inflame in its whole thickness, and the periosteum and dura mater with it, and pus or sanies may be produced, both upon the surface and in the substance of those structures : the bone then be- comes discolored, and has a dirty grayish-green appearance, all its pores are filled Avith purulent or sanious matter, its surfaces particularly are rough, and seem corroded, and at length it perishes in its whole thick- ness. The inflammation of the dura mater very often spreads from its original seat to a considerable extent, and leads to the formation of numerous abscesses, which, after a time, become confluent, and also erode the vitreous table. At length the inflammation spreads to the inner membranes of the brain, or—the pus and sanies being taken up into the veins of the diploe,—either by meningitis or by metastasis, the injury proves fatal. Openings in the skull, made with the trephine or by necrosis, are closed, as has already been remarked, by means of a fibroid plate, which usually ossifies incompletely or not at all. Complete ossification, when it does take place, ahvays occupies a very long period. The difficulty with which injuries of the skull are repaired by bony callus is worthy of remark; but the cause of the difficulty still requires a satisfactory explanation. Fissures are sometimes met with in the cranial bones of new-born chil- 172 DISEASES OF dren, which extend several lines from the margin into the bone, and usually run a little obliquely through its thickness. Ut is important to mention them, in a forensic point of view, inasmuch as they bear con- siderable resemblance to the clefts and fissures which are produced by external violence, and may be confounded with them. § 6. Anomalies in the Texture of the Cranial Bones. 1. Hemorrhage.—Under this head, a disease is included which is of frequent occurrence in the skull of the new-born child, namely, the san- guineous tumor—thrombus neonatorum, cephalhaematoma,—a disease on which far too much has been Avritten. It consists of a circumscribed collection of blood, which is poured out beneath the pericranium, in sufficient quantity to form a swelling, that feels doughy or fluctuating. It is distinguished by its situation from the extravasations, which so commonly occur in the new-born child between the pericranium and the aponeurotic expansion above it; ^ and by the quantity of blood extravasated, and the consequent swelling which is formed, it may be distinguished from another extravasation, which forms a thinner layer, with an indistinctly defined margin, on the cranial, and especially on the parietal bones, and is extremely frequent, and indeed almost constant, in new-born children. This last extravasation is indeed of considerable importance, inasmuch as it is only a less degree of that hemorrhage which constitutes the thrombus. The usual situation of cephalhaematoma, is the parietal bonesy and, as it seems, particularly the right: on this bone, too, it attains its greatest size. It is found with less frequency on the frontal bone, and still more rarely on the occipital. Usually only one exists, and that on one or other of the parietal bones; but cases are not altogether uncommon, in which a second smaller thrombus is found on the frontal bone, and there may be even a third on the occipital. In size it may not exceed a hazel- nut, or it may form a tumor extending over the whole parietal bone. When cephalhaematoma reaches a considerable size, its shape is re- markable. On the parietal bone, especially, it generally resembles a kidney: its greater and arched margin lies along the sagittal border of the bone, and its concave edge or hylus embraces the parietal promi- nence. Neither on the parietal, nor on any of the other bones, which have been mentioned, does it probably ever commence on the "punctum ossificationis," but ahvays external to that point. Not unfrequently, however, it spreads over the punctum as Avell as the rest of the bone. The cephalhaematoma is constantly circumscribed near the margin of the affected bone, and does not pass beyond the sutures. It is a circumstance of considerable importance, though it has hitherto been almost unnoticed, that in very many cases in which there is a col- lection of blood on the outer surface of the skull, there is also a corre- sponding extravasation between its inner surface and the dura mater. The inner accumulation is, as a general rule, the less extensive ; but there are pases in which the reverse is the fact. Of course, if a bone be laid bare in this manner on both sides for a length of time, the prog- nosis is unfavorable. Cephalhaematoma originally is nothing more than an accumulation of blood beneath the pericranium: there is no essential anomaly either in that THE CRANIAL BONES. 173 membrane or on the bone: most of the blood is usually loosely coagu- lated, and is of a blackish-red color: and a pale-red fibrinous coagulum, stained with the coloring matter of the blood, frequently adheres to the inner surface of the pericranium, and to the bone. The examination of a recent thrombus is of itself sufficient to deter- mine as to the truth or error of various statements and opinions that have been put forth, according to Avhich cephalhaematoma arises from certain anomalies in the development and texture of the bone, and to settle the true nature of the disease and the source of the bleeding. Most of the hypotheses have been based upon examinations made at late periods of the disease, so that folloAving in our description the course of the disease, we shall come in succession upon the various appearances which have been detailed, and which, though correctly observed, have been erroneously interpreted. When the cephalhaematoma has existed a short time, appearances are presented precisely similar to those that folloAV any separation betAveen a bone and its periosteum. An inflammatory process commences, at the margins of the denuded part, and bony matter is deposited in the form of a velvety and finely filamentous osteophyte. The osteophyte extends to a breadth of several lines beyond where the pericranium and the bone remain connected, but it is thickest just at the margin, and there forms an elevation, which rises abruptly around the denuded surface, but ex- ternally is gradually bevelled off. This exudation is what has been much spoken of as the bony margin of the cephalhaematoma, and until quite recently was erroneously regarded as proving some original deficiency, or some loss from disease, of the outer layer of the bone at the base of the cephalhaematoma. Upon the exposed bone, and inner surface of the pericranium, a fluid next exudes, which is at first gelatinous, but gra- dually becomes more dense; and it may be observed that the bony mar- gin, just spoken of, becomes continuous with the layer of exudation that adheres to the pericranium, while, at the base of the tumor, it meets that Avhich covers the bone. Should the extravasated blood be removed by absorption, or evacuated by an artificial opening in the tumor, the pericranium and bone unite together in a simple manner by means of the exudation. But if this do not occur, a very remarkable appearance is presented in a few cases,— few, inasmuch as thenceforward the inflammation usually becomes sup- purative. The layers of exudation covering the bone and the peri- cranium gradually ossify. The denuded surface of the bone and the inner aspect of the pericranium are then each covered with a very deli- cate and finely reticulated osseous stratum, and the extravasated blood is enclosed between them, and altered to a dirty or rusty brown color. The ossification of both layers of the exudation is sometimes limited to particular spots, and sometimes partial ossification is met with only on that layer which lines the pericranium. In the latter case, plates of bone are found scattered over the surface of the tumor. The sanguineous tumor then exhibits a certain firmness, a kind of rigidity of its walls, and Avhen firmly pressed gives an impression of crepitation like the crackling of parchment. This state of parts may lead to the error, that the outer table has separated from the bone, and adheres to the peri- cranium. « 174 DISEASES OF Far more frequently, when the swelling is not opened and its contents evacuated, the inflammation becomes suppurative, the extravasation changes to a chocolate brown, discolored, fluid pulp, and ulceration or caries, and partial necrosis ensue. The pericranium is attacked Avith a similar inflammatory process, its inner surface is covered with purulent matter, and the bone becomes rough, unevenly exfoliated, and worm-eaten, and its pores and grooves enlarge. If the tumor, when in this state, be not opened artificially, or if the pericranium and the other soft parts above it do not ulcerate and make a spontaneous opening in it, the caries which has already commenced at the denuded surface of the bone extends more deeply, an effusion of pus takes place beneath and loosens the dura mater, and at length the bone perishes in its whole thickness. Generally, when this takes place, the pericranium, and the soft integuments covering it, suppurate extensively, and become discolored and easily lacerable. At such a stage as this, cephalhaematoma generally proves fatal, sometimes by exhausting the strength, but more frequently by the extension of inflammation to the dura mater and inner membranes, and to the brain itself. The fatal result is occasionally brought about by purulent matter being taken into the circulation, and by consequent pyaemia and metastasis. But even when cephalhaematoma has reached these advanced stages, a cure is sometimes effected. Healthy suppuration succeeds the evacua- tion of its contents, and the pericranium unites with the exposed surface of bone through the intervention of a layer of granulations, which after- wards ossifies. The portion of bone which the cephalhaematoma occu- pied appears for a long time enlarged, thicker than natural, and some- what uneven on its external surface, but in process of time this disap- pears. Even when an extension of suppuration here and there through the bone, and an effusion of purulent matter upon the dura mater, have produced necrosis, and a portion of bone has exfoliated, repair may take place; for granulations arise from the healthy bone which cover the dura mater, and uniting with those that spring from the pericranium, become a basement in which new bone is formed both at the margin of the open- ing and at other isolated spots. When there is an effusion of blood upon the dura mater, as well as beneath the pericranium, the exposure of the bone on both sides renders the prognosis of course unfavorable, and the more so in proportion to the extent of the effusions. Thus, then, cephalhaematoma consists of an effusion of blood between a cranial bone and its pericranium, and frequently, at the same time, between the bone and its internal covering of dura mater also ; and the source of the bleeding is the delicate bloodvessels which pass from those membranes upon and into the bone, and which have been ruptured. Any essential anomaly in the development of the bone, or morbid affection of its texture, is merely an occasional and exceptional occur- rence: the principal anomaly, when any does occur, is that isolated spots of the bone affected with cephalhaematoma, or of some of the other bones composing the cranial vault, are thinner and softer than natural. In a recent cephalhaematoma, however, a manifest congestion of the \^ bones of the skull is pretty constantly observed, and thin straty of ex- THE CRANIAL BONES. 175 travasated blood may be noticed beneath the pericranium, near it. There is no question that the final rupture of the vessels is due to this conges- tion ; and it is the more certain, from the fact that in ordinary cases there is no other abnormal appearance to which the hemorrhage could be attributed. Moreover, the bone beneath the extravasated blood ap- pears pale, especially Avhen there is an effusion also on the dura mater ; and this results from the emptiness of its vessels. It is an interesting circumstance, that cephalhaematoma sometimes co- exists with effusions of blood betAveen tissues, that have the same relation to each other as bone and periosteum. Thus peripheral apoplexy of a congested liver, or an extravasation of blood beneath its peritoneal in- vestment, is not an unfrequent accompaniment of cephalhaematoma. In the great majority of cases, cephalhaematoma most probably com- mences during birth, and increases to a palpable tumor soon afterwards. But instances do occur, in which the swelling is not perceptible till several days after birth; and there is nothing against the opinion, that it may form on the skull subsequently to the birth of the child.. Its du- ration may extend over three or four months, or more. It is most frequently found in first-born children. 2. Inflammation, caries, and necrosis of the bones of the skull.—The cranial bones are frequently the seat of these processes, which may be set up not only by violence, but by many other external influences, and very frequently by some internal cause. Sometimes, also, they are occasioned by a previous disease of the bone itself, or by inflammation, suppuration, ulceration, &c, of neighboring parts. I have stated, in my previous remarks, that inflammation frequently gives rise to an increase of bulk, to hyperostosis of the skull (p. 129). Syphilis, which is a very frequent cause of the enlargement, attacks par- ticularly the frontal and parietal, amongst the bones of the skull, and the nasal bones and alveoli, in the face ; and it very generally leads to extensive caries and necrosis. Caries and necrosis, when induced by tuberculous disease, are also observed on the frontal, parietal, and nasal bones ; but they are more frequent at the base of the skull, especially in the body of the sphenoid. As, on the one hand, inflammation may extend from the seat of these processes to the meninges and the brain, so on the other, are they some- times themselves occasioned by inflammation of the membranous parts of the internal ear, or of the nares and adjoining cavities, or by inflammation of neighboring ligamentous tissues and bones. Thus, for instance, caries of the occipital bone may be caused by inflammation and suppuration of the cervical vertebrae, and of their ligamentous apparatus, and the bones of the face suffer almost incredible devastations from so-called facial cancer. 3. Expansion, softening, and consecutive induration.—Rickets not unfrequently, Avhen met with in the infant, exists in a pre-eminent de- gree in the skull. It may be recognized by the great development of the prominences of the cranial bones, by the small denticulations and sinuous line of the sutures, and by the great thickness, the succulence, the cancellous expansion, the softness, and the great vascular fulness of the bones. It extends to the base of the skull, and, in a small degree, 176 ANOMALIES OF to the bones of the face also. The swelling of the wall of the skull effaces the inequalities of its inner surface, and it is remarkably smooth : the processes which are situated at the inner surface of the base of the skull, are unusually thick and smooth. No less uncommon is that form of expansion (osteoporosis) resembling rickets, which affects the skull chiefly, and is indeed generally confined to that part, but which prevails at a later period of life than rickets, and occurs even in advanced age. It reaches, as has been already re- marked, a very considerable degree, and terminates in a peculiar and very marked induration of the cranial bones. When mollities ossium is general throughout the rest of the skeleton, it may affect the skull also; but it always does so in a subordinate degree. 4. Adventitious growths.—After the statements which have been made with respect to the occurrence of these groAvths in the osseous sys- tem generally, it is unnecessary, in this place, to do more than to remark, that cancerous groAvths do frequently form in the skull, as well on the calvarium as at the base : they may all be included, in brief, in the term " Fungus Cranii." They are commonly supposed to be malignant, i. e. cancerous, diseases of the cranial bones; but the above-mentioned dis- tinguishing term was given them at a time when an attempt was made to prove the existence and the origin of the same morbid growth in the skull, as had before then been considered peculiar to the dura mater, and had long been named "Fungus Durce matris." The two diseases may be readily confounded during life, especially when the disease of the bone commences in the diploe; for it breaks through the outer table as it grows, and spreads through an aperture bounded by bone over the surface of the skull. SECTION n.—OF THE TRUNK AND ITS SEVERAL PARTS. OF THE VERTEBRAL COLUMN. § 1. Deficiency and Excess of Development.—Deficiency of the whole vertebral column is met with only in monsters which are very incom- pletely developed; more commonly, only a portion of it is wanting. The latter deficiency occurs in cases of acephalus, and corresponds in extent with that of the concurrent defect in the neck or trunk. An allied but less deficiency, in which one or more vertebrae or half vertebrae are of small size, or altogether absent, sometimes co-exists with other malformations of the skull and vertebral column, with hemicephalus in the cervical portion of the spine, and with spina bifida: sometimes it is unaccompanied by any anomaly of the kind, occurring in persons who are otherwise naturally formed. In well-formed persons a cervical ver- tebra is sometimes, but very rarely, wanting; a similar deficiency in the dorsal or lumbar region is less unfrequent. Moreover, the absence of a dorsal vertebra is usually made up for by a supernumerary one in the loins, and the deficiency of a lumbar is supplied by an additional sacral vertebra. It is interesting to observe, in persons who are in no other way deformed, how the want of one half of a vertebra, in the same manner as a half too much, produces congenital lateral curvature. THE VERTEBRAL COLUMN. 177 A faulty and insufficient development of the spinal column may arise from an original fusion of the bodies of two or more vertebrae; this con- genital anchylosis is sometimes associated with other malformations, especially with spina bifida and hemicephalus, but sometimes it occurs in persons Avho are otherwise well formed. Fission of the vertebral column, spina bifida (Hydrorachis), is an ano- maly of great importance belonging to this class. In its nature it re- sembles hemicephalus, with which it is very frequently combined. It presents several degrees, which are discernible on the skeleton of the vertebral column : sometimes it involves the whole, sometimes only parts of the spine ; and its extent, when partial, varies greatly. In its least degree, the half arches are developed, and occupy their natural situation; but, as they have not united, an aperture or fissure remains in the proper seat of union, the length of which depends on the number of ver- tebrae involved. In a higher degree, the half arches are incompletely developed, more or less of their extremities being deficient, and thus the fissure has a greater transverse diameter than in the preceding degree: usually, also, a larger number of vertebrae is affected. In a condition allied to this, the half arches are fully developed, but stand off from each other to a considerable extent, and are so turned round to the side of the bodies of the vertebrae, that the line of their direction becomes, at length, continuous with the posterior surface of the bodies: they are usually then flattened from before backward; and, as in the form already men- tioned, are here and there united with one another. Although there is no actual deficiency of development, the fissure becomes very wide> and diminishes in depth. In a still higher degree, the fissure involves not the half arches alone, but also the bodies of the vertebrae; and, in the highest degree of all, one of the half arches may be wanting, and a part, or even the entire half, of one or of several of the bodies. Fission of the vertebral column in its whole length, or of its cervical portion, scarcely ever occurs, unless hemicephalus and hydrencephalocele exist also. The most common situation of spina bifida is the lower dorsal and lumbar region. Fission of the sacral vertebrae is more rare: sometimes it occurs in two places together, and then usually one fissure is in the neck, and combined with hemicephalus, while there is another in the lumbar or lower dorsal region. Excess of development is exemplified in the presence of an unusual number of whole or half vertebrae. In the former case, there are some- times thirteen dorsal, or six lumbar vertebrae; the vertebral column is, to a corresponding extent, longer than natural; and, connected with the supernumerary dorsal vertebra, there is an additional rib. An excess of one or more halves of vertebrae occasions a congenital lateral curvature, in the same manner as a deficiency of halves of vertebrae; and it consti- tutes a most remarkable instance of scoliosis, of which I shall treat more at large hereafter. § 2. Anomalies in the form of the Vertebral Column, and of its several Parts.—Deficiencies of development involve, as has been stated, various anomalies in the shape of the several vertebrae, and also, as will further appear, deformities of the whole column. Moreover the ap- vol. in. 12 178 ANOMALIES OF proximation to each other in form, which the vertebrae exhibit at the limits of the natural divisions of the column, sometimes gives the appear- ance of a vertebra being deficient. In this manner the last dorsal assumes much of the character of a lumbar vertebra, and more ire- quently the last lumbar becomes a sacral bone: this transference from the lumbar to the sacral region may be symmetrical, and occur on both sides, or may take place on one side only. On the contrary the first lumbar may approach a dorsal vertebra in character, and sometimes it bears the rudiment of a thirteenth rib: or the first sacral vertebra may resemble the last lumbar. Finally, the vertebrae are subject to manifold deformi- ties at different periods of life, in consequence of exostosis, osteophyte, and partial absorption of the cicatrization which succeeds the loss of substance occasioned by caries and necrosis, &c. Some of the deformities of the vertebral column are congenital; others, and those the greater number, come on at different ages after birth, and consist of various forms of curvature of the column. Those of the former class are for the most part occasioned by so serious affec- tions of the central organs of the nervous system (hydrorachis combined with anencephalus, encephalocele, &c), that they very rarely come under observation at the later periods of life. The deformities produced by high degrees of fission of the vertebral column, and the curvatures Avhich accompany them, are instances of this kind. In other cases the curva- ture of the spine, and the other deformities coexisting with it, are pro- duced by the contraction of muscles, to which certain diseases of the nervous centres give rise. Sometimes the curvature results from defi- ciency of the lateral half of a vertebra, or from unequal development of the two halves of the column, or from the presence of one or more half-vertebrae too many. Lastly, fission of the thorax or abdomen, or eventration, may make the spinal column deviate from its natural direc- tion. The form of the deviation may vary ; it may be a simple curva- ture, or, as is the case with those which come on after birth, it may be a compound of two or more curves, &c. I venture to introduce in this place the description of three cases of original deformity of the spinal column: they are of rare occurrence, and the first of them is perhaps unique.1 Case I.—Compound Scoliosis, occasioned by the presence of super- numerary lateral halves of vertebras, which compensate each other.— The spine of a woman, aet. 46, a very old preparation in the Museum at Vienna, but unfortunately not made with care proportioned to its value. The sacrum and coccyx are united into one bone, on the right side of which there are four sacral foramina, and five on the left; for the first sacral vertebra is higher on the left side than on the right, and, as is evident, from its left spinous and articular processes being double, it consists on that side of two lateral halves of vertebra fused together. The fifth lumbar is developed on the right side to a sacral vertebra, and thus the height of the left half of the sacrum is level with the right. The first lumbar vertebra, in the concavity of the lumbar curve on the left side, appears very depressed, being not more than eight lines in 1 Oesterr. Med. Jahrb. vol. xix. THE VERTEBRAL COLUMN. 179 height, and is concave from above downwards; while on the right side it is convex, and more than two inches high, and has a horizontal groove filled with an ossified intervertebral body, which indicates that it is double on that side. On the left side there is but one half arch, on the right there are two; there is also a small supernumerary intervertebral foramen on the same side (the right), and a half spinous process which has no fellow. This odd half spinous process alters the position of the bodies of the vertebrae, and more particularly of their spinous processes ajbove and below, in such a manner, that the laminae, more or less displaced and overlapping, terminate in a row of unsymmetrical spines. Inferiorly, the derangement stops at the second lumbar vertebra; but above, it reaches to the eighth dorsal; the right half spines of the first and second lumbar vertebrae lie beneath those of the left side: but the right half spines of the twelfth, eleventh, tenth, ninth, and eighth dorsal, are placed above those of the left side; hence they either appear unsymme- trical, or here and there one of the right half spines comes in contact with the left one of the vertebra next above. The left half of the seventh dorsal vertebra, on the convex side of the inferior dorsal curve, is very high; it is pretty distinctly marked with a horizontal fissure in the same way as the first lumbar vertebra, and has two half arches instead of one, just as the first lumbar has on its right side. The lower one, which is the thicker, unites with the single arch that exists on the right side, and both together form a complete spinous process; the upper one terminates in an odd spine. There is an inter- vertebral foramen between the double arches, which is rather smaller than the foramina adjoining it above and below. The sixth dorsal ver- tebra has an apparently odd arch on the right side, which is adapted to the supernumerary half spine of the seventh dorsal vertebra, while the left arch, as will presently appear, is shrunken and combined with the corresponding arch of the fifth. Between the sixth and fifth dorsal vertebrae, on the right side (at the convexity of the upper dorsal curve), another, a fourth, half vertebra is intercalated, which has a half arch on the right side. Its spinous pro- cess unites with the combined left half spines of the fifth and sixth dorsal vertebrae. The fifth dorsal has an arch, the left half of which (at the convexity of the upper dorsal curve) is increased in breadth by union with the left half arch of the sixth dorsal. It has but one transverse process, and it unites with the half arch of the intercalated half vertebra to form one very broad, flat, spinous process; while it forms another, and more slender one, with the corresponding right half arch of the fifth. The half arches of the fourth dorsal vertebra lie one over the other, the left uniting with the slender spinous process of the fifth (fifth and sixth), whilst the right terminates in a half spine. The third dorsal is tolerably well formed ; but the right half arches of the second and first coalesce, and their single spinous process joins with that of the left half arch of the second, while the other half of the first terminates again in an odd spine. According to this, therefore, there are in the dorsal, lumbar, and 180 ANOMALIES OF sacral parts of the column, four half vertebrae, with their half arches and processes, too many. They are so placed on the two sides as fully to compensate one another; for upon the duplication of the left half of the first sacral vertebra there follows duplication of the right half of the first lumbar: and then, as the left half of the seventh dorsal is double, there is half a A'ertebra interposed on the right side between the sixth and fifth dorsal. And with regard to the arches,—the half arches of the sixth and fifth dorsal coalesce on the left side, and those of the second and first dorsal on the right. Lastly, as has been already pointed out, there result from the position of the abnormal half vertebrae the following curvatures of the whole column: a. Curvature of the sacrum, with the convexity towards the left, in consequence of duplication of the left half of the first sacral vertebra: the development of the fifth lumbar vertebra to a half right sacral com- pensates this curve. /?. Slight curvature in the lumbar and lower dorsal regions, in conse- quence of duplication of the right half of the first lumbar vertebra: the convexity at this part is directed towards the right. y. Considerable curvature in the middle dorsal region produced by the left half of the seventh dorsal vertebra being double : here the convexity is towards the left. d. Considerable curvature in the upper dorsal region, which is caused by the half vertebra interposed between the sixth and fifth dorsal ver- tebrae : the convexity here faces the right. The last two form a very compressed S curvature; and the vertebrae are twisted upon their axes, and project backwards (kyphosis). Corresponding to the anomalies in the vertebral column, there are some very remarkable peculiarities in the number, form, and attachment of the ribs. As there are two supernumerary half vertebrae in the dorsal region, one on the right side, and the other on the left, that is, one super- numerary dorsal vertebra, and the number of articulating surfaces on the bodies and transverse processes being in accordance with that number of vertebrae, there should be thirteen ribs on each side: but there is another attached to the seventh cervical vertebra, and there are actually fourteen more or less complete ribs on each side. The_ first rib on the left side is attached by two heads, the upper one of which articulates with the seventh cervical vertebra just above its loAyer border, and the lower with the first dorsal: the two heads unite in a single neck; the tubercle divides, and is applied to the transverse processes of the seventh cervical andfirst dorsal vertebrae ; and the rib then ends in a single shaft. The first rib on the right side is also attached by two heads: the upper, which is the thicker, and has a cloven neck, joins the seventh cervical vertebra opposite the upper head of its fellow; the lower head is more slender, but sinks deeper into an excavated articulating fossa between the first and second dorsal vertebrae. The three necks soon unite into a single broad one, which is attached by one tubercle to the transverse process of the seventh cervical vertebra, and by two others to a very large articular process on the coalesced right half arches of the first and second dorsal vertebrae ; it then separates into two distinct shafts. THE VERTEBRAL COLUMN. 181 The third and fourth, or rather, if we enumerate by the heads of the ribs, the fourth and fifth, ribs on the left side have but one neck, and for a short distance also, only a single body. At the single very thick transverse process of the united left half arches of the fifth and sixth dorsal vertebrae, two ribs are attached, namely the sixth and seventh. Moreover, anchylosis has taken place between the odd half arches and bones next adjoining them, between several of the bodies of the vertebrae, especially in the concavity of the curvatures, and also between the second and third cervical vertebrae. Case II. Scoliosis produced by deficiency of one half of a Vertebra.— The spine of a tailor 70 years of age. It consists of the cervical skeleton (excepting the atlas), of twelve half dorsal vertebrae on the left side, and eleven on the right, of four ab- dominal and four sacral vertebrae. The six inferior cervical vertebrae form one curved hump : their bodies and articular processes are united, each to each, into one piece, of coarse cellular structure, the anterior surface of which looks as if the bony ma- terial had been poured over it in a fluid state and had then coagulated ; while a tense, and partly ossified, ligamentous tissue, stretches down over the arches. The sixth and twelfth dorsal vertebrae form the extremities of a slight curvature to the left, in the concavity of which (on the right side) there is half a vertebra wanting. For only the left half of the ninth dorsal vertebra exists, which is united to the eighth dorsal, and Avith it com- poses one very high body and a similar half arch on the convex side of the curve. There are two transverse processes of nearly equal size upon the half arch, and two spinous processes which lie one above the other, but are fused together. All the dorsal vertebrae, from the sixth to the twelfth, are connected together, anteriorly, by a mass of bone, partly cellular and partly com- pact, which is most abundant over the intervertebral bodies, and looks as if it had been poured out upon them. Their articulations, also, are more or less completely anchylosed. The spinous processes of the last two (the third and fourth), lumbar vertebrae, and the left transverse processes of the second and third, are driven upwards by a deviation of the sacrum considerably backAvards and a little to the left; and the third and fourth spines are, at the same time, pressed together. The last lumbar is converted into a sacral vertebra. The sacrum curves strongly backwards and to the left: it consists of four vertebrae ; the last two of which, especially on the right side, in con- sequence of the displacement of the anterior and posterior sacral fora- mina from their natural positions, resemble a sieve perforated with large holes. Case III. Angular Curvature (kyphosis), produced by the twelfth dorsal Vertebra consisting of two divided lateral halves.—The spine of a woman, set. 55. The two portions form triangular rudiments inserted laterally between the eleventh dorsal and first lumbar vertebrae, with their points directed inwards: and they are united with the first lumbar in such a manner, that its body is very high at the sides, whilst in the 182 ANOMALIES OF middle it seems low, and is in contact with the eleventh dorsal. In con- sequence of this deficiency in the mesial line, the vertebral column is bent backward at a very obtuse angle. The arch of the divided tAvelfth dorsal vertebra is completely united into one piece Avith that of the first lumbar ; but the half spines of the latter are so twisted, that the right one appears to be higher than the left. The last right rib is connected, by two heads, with the twelfth dorsal vertebra. The curvatures which are acquired may be divided, as they are natu- rally, into the three cardinal forms : of curvature to either side, lateral curvature—scoliosis; curvature backwards, or angular curvature, the hump—kyphosis; and curvature forwards, sinking of the back—lordosis. Scoliosis, as will be seen in the sequel, may be combined with the other two curvatures. Moreover, it is of importance to distinguish the primary deviation from those which are consequent upon it, and compensatory. a. Scoliosis is by far the most frequent of the three. There is some- times only one curve: but more commonly a second, a compensatory in- clination towards the opposite side at some other portion of the spine, renders the deviation sigmoid : in some cases there are several curves, and in others the scoliosis is combined with obliquity of the pelvis. When the lateral curvature is double or sigmoid, it is usually the dorsal region and the lumbar that are bent; and though the primary curvature may be in either region, it is far more frequently in the dorsal than in the lumbar. And further, the deviation in the dorsal region inclines most fre- quently towards the right side; whilst the compensatory curvature in the lumbar region to the left is itself compensated by a corresponding obli- quity of the pelvis. In order to make even the little that has been said intelligible, as well as the statements which follow, it is necessary to point out the chief causes of scoliosis. Attention has already been directed to the deviation of the spine which results from original inequality in the lateral halves of the verte- bral skeleton. ^ It is that to which Gue'rin attributes those cases of he- reditary scoliosis which become perceptible between the ages of 7 and 10 years, and are generally unaccompanied by any trace of a rickety con- stitution. There is also a curvature to which the female sex is liable, in which Gue'rin ascertained that a disproportionate groAvth or elongation of the vertebral column, takes place at the period of puberty. But late- ral curvature of the spine may come on at various periods of life subse- quent to birth, under other conditions, which are as follow: a. Active muscular contraction, arising from some idiopathic and sub- stantive, or from a secondary, affection of the nervous system, especially of the nervous centres, and usually combined with other deformities of the skeleton, contractions, palsies, &c, which also owe their origin to muscular contraction. /9. In most cases it arises from neglecting or impeding the action of the muscles of inspiration of one side. All the scolioses traced by Stro- mayer to paralysis of the muscles of inspiration on one side are of this class, as well as those in which the spine is bent in consequence of chronic pleurisy, and narrowing of one side of the thorax. In such cases, the primary curvature is at the dorsal part of the column; and as, in most occupations, it is the left side of the thorax, the function of which is im- THE VERTEBRAL COLUMN. 183 peded or neglected, the spine inclines far more frequently towards the right side than towards the left. y. The curvature may be in consequence of rickets : the pelvis deriv- ing some one-sided deformity from the lower extremities, propagates it to the vertebral column. The first curve is then in the lumbar region, and that in the dorsal region is consecutive, and slighter than the other. The fatty degeneration which is brought on by a sedentary and luxu- rious mode of living, and by spirit-drinking, is, for the most part, accom- panied by a great development of fat throughout the system ; the liver usually contains a quantity of tallowy substance, the heart is loaded with fat, and its muscular tissue is more or less metamorphosed into the same substance : moreover, in old people more particularly, the medulla of the bones connected with the altered muscles is in excess, and the bones are in a state of osteoporosis, or excentric atrophy, and are easily broken. The fat by which the muscular tissue is supplanted varies in its cha- racter. In some instances it resembles ordinary healthy fat; sometimes, especially in persons advanced in years, it is of a dark yellow color, loose and diffluent; and sometimes, in its consistence and whiteness, it is remarkably like mutton suet. It assumes this last character, particu- larly when the change results from anchylosis. /5. There is another form of degeneration which has not been hitherto observed, and to which the muscular structure of the heart is liable, par- ticularly when hypertrophied : it is met with, also, but not so frequently, in the muscular coats of other organs when they are hypertrophied, but is very seldom seen in the muscles of animal life. It is characterized by the development of minute particles of free fat between the primitive muscular fibres. At the same time the striated sheath of the fibre dis- appears, and the muscle changes to a dirty yellow or fawn color, and becomes friable. I once met with the disease in the muscles of the calf, in which it had given rise to considerable pain: this fact coincides with the experience of other observers. c. Cysts.—With the exception of cysts which enclose entozoa, these growths are very rare in the muscular system. Even the large sized acephalocyst sacs are very seldom found. And this recalls the fact, that cancerous growths also are extremely uncommon in muscles, although a comparison of this sort leads to no result, inasmuch as muscles are rarely the seat of morbid growths of any kind. d. Fibroid tissue- is found in muscles Avhich remain indurated with callus after inflammation, and in those which are spasmodically con- tracted. e. Bony growths (1,) not unfrequently exist in muscles in the form of calcareous concretions, which have been developed in the fibroid tissue just mentioned. In some few cases, whole muscles have been found thus ossified. Muscles sometimes contain also the cretaceous remains of pus, of tubercle, and of the shrunken sacs of the cysticercus and acephalo- cyst (echinococcus). (2.) True bone is less frequently met with in muscles. When it occurs, it assumes a rounded form, or is flattened and elongated, but still rounded. Sometimes it is spongy, and sometimes of more compact structure. The drilling bone (Exercirknochen), as it is called, in the left deltoid muscle, is of this nature, and numerous other growths of the same kind are to be met with. In the museum at Vienna, a very large, egg-shaped, piece of bone is preserved, which Avas taken out of the biceps of a woman's left arm. /. Tubercle.—Primary tubercle scarcely ever occurs in the muscular vol. in. 16 242 DISEASES OF m- system, least of all in the form of gray granulations. Even those flammations of muscles which have been already mentioned as leading to tubercular deposition, and as connected with similar affections ot bone, are, generally, secondary inflammations; they almost always occur in combination with tuberculosis of parenchymatous organs, and especially . with already established tuberculosis of the lungs. Under similar cir- cumstances, and according to my observations when phthisis already exists, inflammations now and then arise independently of diseased bone, in the interior of the bodies of different muscles: they furnish an exuda- tion of tubercular nature, and as this breaks down, they give rise to the formation of a tubercular vomica in the muscle. But muscles sometimes become the seat of tubercle and tubercular softening, in consequence of their vicinity to other affected organs ; and this is especially the case with organic membranous muscles, particularly with the fleshy coat of the intestinal canal. The fact is seen in the muscles surrounding the thorax when there has been tubercular softening of the lung and pleura, in the muscular coat of the bowel beneath a tubercular ulcer of its mucous membrane, &c. g. Cancer.—In whatever form this disease presents itself, it is scarcely ever the primary cancerous affection in any muscle of animal life, except the tongue. One or more cancerous growths are almost always found elsewhere, and that in the muscular system is the secondary affection. Of those organs even which are entirely composed of organic mus- cular fibre, nearly the only one which is ever primarily attacked by cancer is the uterus; and it is the cervix and vaginal portion of the uterus,—the muscular development of which is in the unimpreg- nated state very subordinate to that of its body,—that is especially subject to the disease. But muscular tissue, is more frequently involved in the degeneration of adjoining organs affected with cancer, and to this secondary affection both animal and organic fibre is subject; the pectoral muscle, for instance, in cancer of the breast, and the muscular coat of the alimentary canal, in cases of cancer of the stomach or bowel. The forms of cancer which are most frequently observed thus attack- ing the muscular system, are the fibrous and medullary. A firmly fixed knotted tumor, imvoven with the muscular tissue, and sending out branches in all directions, is sometimes the distinguishing character of the fibrous kind of cancer; but more frequently, when the muscle is diseased in consequence of its proximity to some other affected organ, it produces a characteristic degeneration of the muscular tissue. This degeneration is mostly seen in cases of secondary disease of the pectoral muscle, or middle coat of the intestines, and it leads to the conversion of the muscular tissue into a white, fibrillated, reticular structure, in the interspaces of which a pale reddish, or yellowish-red substance resembling firm jelly is lodged. The muscular coats of organs, under such circumstances, are palpably increased in size. Degenera- tion of the same kind is observed not only in fibrous, but also in medul- lary cancer. The medullary form is not unfrequently associated in muscles with a very extensive growth of cancer. It sometimes presents its genuine white character, sometimes that of melanosis; and it grows in rounded, THE MUSCULAR SYSTEM. 243 circumscribed, encephaloid knots in one or in several muscles. When the muscle is diseased in consequence of the degeneration of adjoining organs, encephaloid matter seems to be infiltrated throughout it amongst the muscular fibres, some of which are blanched and others degenerated in the same manner as in fibrous cancer. Like other structures, muscle sometimes resists for a long period the advance of large cancerous growths; it becomes thin and atrophied from the pressure and stretching, but undergoes no actual change of texture. h. Entozoa.—The entozoa which occur in the muscles of the human subject, are— a. The echinococcus, which inhabits the acephalocyst. It is seldom met with. The sac is situated between the fibres, and forces them more or less asunder. {3. The cysticercus (Blasenschwanzwurm) is somewhat frequent. It is very often found in several or in most of the muscles, as well as in the heart of the same individual, and not very rarely in the brain too. The number existing in a single muscle, and in one individual, is sometimes quite extraordinary. The cysticercus seems to share with the trichina spiralis the remarkable character of being confined to voluntary muscles (muscles with transverse striae); the distinction is not perhaps so strictly marked as in the instance of the trichina, but it has been observed in several cases. When the cysticercus dies, its tail-vesicle shrinks, and the contents become inspissated, and at length cretaceous. Chalky concretions en- closed in a thick cyst are often found in muscles, which are the remains of cysticerci. y. The trichina spiralis is an entozoon which is strictly confined to the voluntary muscles. Upon its death it leaves an encysted chalky concre- tion behind. i. Foreign bodies.—All kinds of extraneous bodies are introduced into muscles by natural or unnatural means, such as needles, bullets, fish- bones, &c. PART XII. ANOMALIES AND DISEASES OF THE NERVOUS SYSTEM. V PART XII. ANOMALIES AND DISEASES OF THE NERVOUS SYSTEM. The abnormal conditions of the nervous system may be subdivided into those of the brain, those of the spinal cord, and those of the nerves. To the description of the two former I shall prefix an account of the disorders of their investing membranes. CHAPTER I. THE BRAIN. SECT. I.—ANOMALIES AND DISEASES OF THE MEMBRANES OF THE BRAIN. The membranes of the brain become involved both in faulty develop- ment, and in structural diseases of the cranium on the one side, and of the brain on the other. They are liable also to many idiopathic diseases. DURA MATER. § 1. Deficient and excessive development. 1. This membrane is sometimes entirely wanting in consequence of the absence of the brain; and portions of it are deficient, when the development of the brain is in any way arrested; thus the tentorium or the falx is sometimes wholly or partially wanting. 2. When the brain is double, there are two more or less complete sacs of dura mater. § 2. Anomalies in Size, Form, and Position.—These include the unnaturally small or large capacity of the sac of the dura mater, which results from corresponding anomalies in the formation of the brain, whether want of symmetry between its two halves, or displacement of them from their natural situation; or which results from an unnatural direction of the falx, from partial dilatation and (hernial) protrusion through the cranium, &c. And at any period of life, the dura mater may be distended and more or less attenuated, and its internal processes displaced in various directions by hypertrophy of the brain, hydroce- phalus, morbid growths in the brain, &c. The thickness of the dura mater is often manifestly increased, not only in consequence of inflammation, but also in persons Avho are ad- 248 ANOMALIES OF vanced in life. Sometimes also it becomes thin, either in its whole extent, as when the brain is hypertrophied; or at certain parts where it is subjected to pressure; thus it is found thin and cribriform where it has been exposed to the pressure of the Pacchionian bodies. § 3. Solutions of Continuity.—Under this head we class together anomalies in the adhesion of the dura mater to the cranium, and solu- tions of the continuity of the membrane itself. Besides the thickening which the dura mater undergoes in advanced life, it acquires also a closer adhesion to the cranium; for as new bony matter is at different periods deposited on the inner surface, especially of the vault of the cranium, and the number of vessels Avith their in- vestments passing between the membrane and bone becomes increased, the union between them is rendered more intimate. The adhesion gene- rally commences, and continues strongest, along the sutures. ^ In very old age the adhesion is often remarkably less firm than it is in middle life; the cranial bones are then atrophied. The adhesion between the dura mater and cranium is frequently ren- dered much looser, or even entirely broken for a more or less'considera- ble space, by concussion of the skull; the separation may take place at the part where the blow was struck, or on the opposite side of the head. Its extent is often increased by subsequent extravasation between the membrane and the bone. Purulent and sanious effusions gradually force the dura mater and the bone apart. The dura mater and cranium are frequently found separated from one another in cases of cephalhaematoma, by an extravasation of blood, which takes place spontaneously from the bone. Various kinds of solution of continuity befall the dura mater from in- cised, punctured, and gunshot wounds, and from injuries which break and shatter the skull. The membrane may split also, from being much distended by pressure from within in cases of hydrocephalus ; and these ruptures of the dura mater are not limited to cases of hemicephalus ; in some extremely rare instances, rupture occurs in hydrocephalus during extra-uterine life. Such a case is preserved in the Vienna Museum; it is a rupture of the dura mater, near the right parietal protuberance, more than an inch in length; it occurred in a hydrocephalic boy, and was followed by the extravasation of blood and of serum from the ven- tricle, between the dura mater and the cranium, and thence under the pericranium. The Pacchionian bodies very often exert such pressure on the dura mater, as to give rise very gradually to solution of its continuity and concomitant atrophy. They force the fibres of that membrane asunder, and having pressed through it, lie in immediate contact with the skull. Somewhat rarely it happens, that the dura mater is forcibly separated into layers by an extravasation of blood within it after concussion of the skull: such a separation is still more rare as a consequence of sup- puration. Those extravasations which have been supposed to be collec- tions of blood between the serous and fibrous strata of the membrane, with the exception of a few cases in which a small effusion has raised its innermost layer, must have been extravasations into the sac of the arach- THE DURA MATER. 249 noid, which, after acquiring an adhesion to the dura mater, have become encysted: they will be considered among the diseases of the arachnoid. § 4. Diseases of Texture.—A distinction will be drawn in the follow- ing remarks, wherever it is possible, between the actual dura mater, and its innermost shining stratum. For, though the latter cannot be demon- strated as a separate serous layer, we are compelled to adopt the dis- tinction by the substantial difference which is exhibited, at least at first, by morbid processes in the two layers. Inflammation, for instance, attacks one of the layers independently of the other, and presents dif- ferences accordingly in its course, in its proneness to extend along the surface, and in the products it furnishes, which manifest the analogy between that layer and serous membranes in general. I shall not at present enter into these, or into several similar subjects, as it would be interfering with diseases that are evidently connected with the arachnoid membrane. 1. Inflammation.—With the exception of those which are brought on by injury, primary inflammations of the dura mater to any extent, such, for instance, as would lead to the formation of matter, are of rare occurrence. Inflammations of slight degree, on the other hand, and usually com- bined with moderate inflammation of the cranial bones, are frequent. These processes are characterized by vascularity and rosy reddening of the dura mater, and by softening of its texture; and they give rise to interstitial infiltration of the membrane, as well as to exudations upon that surface of it which adjoins the bone: such exudations become organized into loose cellular, or thick fibrous tissue, or at length, especially if there be any inflammation of the bone besides, into bone; and they produce an unnatural adhesion to the vitreous table of the skull. They are gene- rally widely spread, especially along the sutures; but sometimes they are confined within a smaller compass, so that they form at one time extensive tracts, at another circumscribed islands. Exudations Avhich, ossify, very commonly present themselves spread out as a layer, that, like the puerperal osteophyte, is at first spongy, but gradually becomes compact: sometimes they form a mass of bone which looks as if it had flowed or dropped upon the membrane, and then coagulated; while, not unfrequently, they are circumscribed osseous plates or nodules, which, though, in course of time, intimately united to the bone, yet originally adhered firmly to the dura mater. When the inflammation is more intense, and runs a chronic course, the dura mater acquires an increase in thickness, sometimes to the extent of three lines, and even more; it becomes indurated and callous, and usually adheres more closely than natural to the bone. I met with an instance of this effect of inflammation in the dura mater lining the right occipital fossa, in which inflammation came on in the adjoining lateral sinus, and led to its obliteration. When inflammation is brought on by injury, or passes to the dura mater from neighboring tissues, it frequently terminates in the production of matter, and in suppurative degeneration of the membrane. These latter cases, therefore, are of great importance, for they are 250 DISEASES OF brought on by inflammation and suppuration of the bone, or of neighbor- ing ligamentous structures. They are especially apt to occur in par- ticular localities ; thus the dura mater inflames, suppurates, and sloughs from caries of the internal ear, and the labyrinth of the ethmoid bone, from caries of the upper cervical vertebrae, and suppuration of their liga- ments. In the dura mater these processes continue circumscribed, but when they reach the inner membranes, they usually spread rapidly into general meningitis. The characteristics of inflammation of the dura mater are those which are common to all inflamed fibrous tissues: I refer on this point to what has been said at page 94. 2. Adventitious growths. a. Cysts.—Cysts properly belonging to the dura mater are extremely rare ; though some examples have been met with in its substance of fat- cysts containing hair. I have in some cases seen tumors attached to the inner shining surface of the dura mater, which resembled lipoma; they were enclosed in a cellular sac, and more or less distinctly lobulated. b. Fibroid tissue.—Besides the fibroid thickening of the dura mater which is found after inflammation, tumors of fibrous structure occur in that membrane. They are, however, very rare ; in a great number of tumors I remember only some few which exhibited a genuine, developed, and undoubted fibrous structure. Very many growths in the dura mater have indeed an intermixture of fibres with their structure, differing in various cases in arrangement and degree, Avhich gives them the appear- ance of a fibrous tumor. There is no doubt that the tumors on the petrous bone, particularly examined by Cruveilhier, were structures of this class supposed to be purely fibrous. c. Productions of bone.—What are called ossifications of the dura mater, are known to be very common. By these are generally meant the bony growths situated on the inner surface of the dura mater, espe- cially of the falx. I do not, however, believe that these belong to the dura mater itself. From their analogy with similar formations on the cerebral, and especially on the spinal, arachnoid, as well as from special examination of their relations, I infer that they are connected with the arachnoid layer of the dura mater. They will be noticed more com- pletely among the abnormal conditions of that membrane. There are, however, some bony formations which undoubtedly belong to the dura mater._ The osseous plates before alluded to, which become united to the cranial bones, and which are true bone, and the bony con- cretions sometimes developed in the dura mater, when it has become thickened and callous from inflammation, are of this kind. d. Tubercle.—Primary tuberculosis is as rare in the dura mater as it is in the fibrous system generally. The tubercles, which are often found adhering to the inner surface of the dura mater, are such as were origi- nally developed in the peripheral cerebral substance, and subsequently came into connection with the dura mater by the formation of adhesions between them and the inner membranes. They do not belong, therefore, to the present section. On the other hand, the dura mater is not unfre- quently the seat of tubercular deposit and tubercular suppuration, when the cranial bones are carious from tubercular disease. THE DURA MATER. 251 e. Carcinoma.—Even excluding from consideration the various growths of cancerous nature, and those more or less allied to cancer, which pre- sent themselves on the internal shining surface of this membrane, we yet find cancer of the actual dura mater to be of rather frequent occurrence. It sometimes exists primarily, that is originates, in the dura mater ; but much more frequently the membrane becomes diseased secondarily by its contiguity with the cranium,—cancer of the bone implanting itself in the dura mater after having perforated the vitreous table. Even cancers of the brain sometimes implicate the dura mater. Primary cancer appears— a. In the form of cancerous infiltration of the tissue of the dura mater, in tracts which are mostly considerable in extent. The membrane is thickened to a corresponding extent, and the surface next the bone is often covered with a layer of cancerous matter, which makes its way into, and destroys the cranial bones: at length the disease appears also on the inner surface of the dura mater, destroys its arachnoidal layer, and spreads out in the sac of the arachnoid in the form of one uneven rugged stratum, or of separate nodulated protuberances. It is always combined with cancer in other organs, and assumes the form of white encephaloid, or of cancer marked with black pigment. /?. In the form of rounded tumors, which commence in the fibrous tissue of the dura mater, and protrude, as they grow, either outward or inward, or in both directions. It is sometimes found alone ; very com- monly it is of the medullary kind ; it is often characterized by fibrous ar- rangement, and often, too, by considerable vascularity ; or it resembles in its structure the parenchyma of some glands. This last form exactly corresponds to the morbid growth which has been, and indeed is still, known by the name of fungus of the dura mater. The question, as to whether the dura mater or the calvarium be its primary seat, is no longer important, as it is settled in what has just been said: and the discussion which has been carried on upon the subject has now only an historical value. If the fungus grow outward, it makes its way, by the pressure and absorption which it occasions, through the skull, and appears under the integuments: after a time it perforates them also. The loss of substance is more extensive at the inner than at the outer table ; and as the fungus, after having perforated the skull, swells out and grows without re- straint, it is girt by the sharp bevelled margin of the bone, and a con- striction, or kind of neck, is produced. This condition of parts has been looked upon as very characteristic of these cases, it is, however, far from being universal; it is not found, for instance, when the bone de- generates together with the fungous growth, when it is by the malignant degeneration of the bony tissue that the fungus makes its way to the surface ; still less is it found in cases in which the fungus of the dura mater was originally a fungus of the cranium, or in the stage of soften- ing of the fungus, in which the aperture becomes enlarged by corrosion of the bone. The usual situation of cancer of the dura mater is the vault of the skull; it seldom happens at the base. If it spread as a fungus inward, the bone beneath it commonly becomes thickened and dense, or the fungus springs from the dura mater just over a plate of neAV bone. 252 ANOMALIES AND DISEASES OF THE ARACHNOID. The arachnoid is a shut sac, the visceral or cerebral layer of which is, for the most part, blended with the pia mater in the same manner as serous membranes are with the tissue which lies beneath them: but in some parts, which vary in extent, it departs from this relation to the pia mater, and is thereby distinguished from serous membranes ; that is to say, by being unconnected with any subjacent tissue, and by haA'ing a double smooth surface. And corresponding to this peculiar anatomical arrangement, there are various features in diseases of the inner mem- branes (arachnoid and pia mater), Avhen regarded as one organic whole, by which they are distinguished from diseases of other serous membranes. It is desirable that the diseases of the arachnoid should be considered apart from those of the pia mater, because the former, especially in its parietal layer, is subject to many affections which are peculiar to itself, and because the diseases of its visceral layer also are in many respects independent of the pia mater: moreover, there appears to be less con- fusion in studying the relations of two things in separate and adjoin- ing sections, than in overwhelming one section with differences and peculiarities, and speaking sometimes particularly of one, sometimes of the other, and sometimes of both. § 1. Anomalies in size.—To this head belong congenital enlargements of the arachnoid ; they are produced by what is called external or me- ningeal hydrocephalus, and are either partial (local) or general. The former are cases in which sacs of a dropsical arachnoid protrude through an aperture in the skull. I shall have to treat of these cases among the Anomalies of the contents of the arachnoid sac. § 2. Diseases of Texture. 1. Hypero?mia.—We very rarely have an opportunity of seeing the vessels of the arachnoid in a state of congestion, or, indeed, of detecting any injection of them that is perceptible with the naked eye. But changes, nevertheless, are frequently discovered in the membrane, which can be attributed only to congestion, or to slight and passing attacks of inflammation, and which are always accompanied with changes in the pia mater of a similar nature, and arising from the same source. _ These changes increase in degree with each recurrence of the conges- tion, but they are found to be most marked when it has become habi- tual. The cerebral arachnoid is the most frequently affected, espe- cially that portion of it which covers the convexity of the cerebral hemi- spheres. The changes consist in opacity, thickening, and hypertrophy. Sometimes large extents of surface are pretty uniformly affected, at other times separate spots are more prominently, or are alone altered. The arachnoid tissue is opaque, dull like whey or milk, tumid and white, and it has the appearance and density of tendon. One form which the affec- tion assumes is remarkable for its frequency ; it is well known by the name of the Pacchionian bodies. They are merely a granulated form of fibroid thickening of a serous membrane. The granulations are found THE ARACHNOID. 253 both singly and in groups, and when they exist in any number, they are generally situated upon an arachnoid membrane that is cloudy and thick- ened. By their pressure they force the fibres of the dura mater asunder, and become imbedded in it'; then perforating that membrane, they occupy small pits and fossae of their own in the cranial bones, and in this manner give rise to an unnatural adhesion between the cerebral arachnoid and the dura mater. They are usually found at the margin of the hemi- spheres adjoining the falx, and in that situation they often perforate the wall of the superior longitudinal sinus, and project within its cavity. Opacity and thickening of the arachnoid are very common post-mor- tem appearances: after middle life, a moderate degree of them is almost constantly found, and their absence is the exception; x for at that period every one must have been exposed to repeated congestions of the brain and its (inner) membranes. This is especially true of the Pacchionian bodies, which, as is well known, are scarcely ever absent, even in earlier life. In persons who have suffered from frequent, intense, and protracted congestions, they are more considerable; but the most marked examples succeed the congestions produced by frequent intoxication, and repeated attacks of delirium tremens. Moreover, the arachnoid membrane is found augmented in actual bulk, and containing within its cavity an increased quantity of serous effusion, in cases of atrophy of the brain, and, indeed, in combination with various other appearances, which are all occasioned by the tendency to a vacuum within the cranium, and will all be detailed in the sequel. 2. Hemorrhage.—Spontaneous extravasations of blood into the sac of the arachnoid are by no means uncommon. They mostly happen on the convex surface of the hemispheres ; at least, in the more extensive effu- sions, it is always in this situation that the largest quantity of blood is accumulated; small effusions frequently take place at the base of the skull, but larger ones occur there very rarely. They are seldom met with while in the recent state; and from their having usually existed for a long period before they are examined, the effused blood is found to have already undergone considerable changes. I will begin by depicting a well-marked example, and afterwards analyze its appearances. Lying beneath the dura mater that covers one of the hemispheres, is found a sac or cyst, which resembles in form a flattened cylinder, some- what curved from before backward in correspondence with the arch of the cranial vault, or resembling in shape what results from the forcible separation of two layers of a tissue by an effusion which commenced at some single point, and then spread out between them. The figure first described involves an excess in the measurement from before backward over the transverse and the vertical diameters. The sac adheres by its outer surface to the dura mater, but its inner wrall is free, or nearly free, from any connection with the cerebral arachnoid, and is consequently more or less smooth, and moist. Its adhesion with the dura mater, too, is but loose ; it partly sticks on, and partly is connected with the mem- brane by a few small vessels. Both walls of the sac are usually of a brown, rusty color, and tenacious ; they may often be separated into several layers, Avhich vary in thickness, but the inner of which are the more thin: at the margin of the sac they coalesce and form one lamina, 254 DISEASES OF which soon becomes reduced to a thin, brown, rusty-colored membrane, and spreading out further on the cranial vault, reaches to the base, and at length terminates in a thin, rusty-colored, gauze-like film. Loose shreds of plastic lymph hang on the inner surface of the walls, and (which is remarkable) principally on the wall which adheres to the dura mater ; within these the sac contains a more or less thick fluid, of a dark and various color, like chocolate, or plum-sauce, rust, or yeast: in course of time the lymph is gradually removed, the inner surface of the sac becomes smooth and polished, and the contents are changed into a color- less, thin, clear, serous fluid. The corresponding hemisphere becomes plane or slightly hollowed, its convolutions flattened, and its ventricle narrowed, while the serum of the ventricle is forced over into that of the opposite side. The pressure of the cyst sometimes diminishes the thick- ness of the parietal bone. On closer examination, the outer layers of the wall of the sac are found to be vascular. At the margin of the sac, just Avhere its two walls unite into one stratum, numerous small trunks may be seen, send- ing branches and twigs both upon and into the walls, especially that wall which adjoins the brain. Here and there also other vessels pass into the convex surface of the sac from the dura mater. The walls are com- posed of plastic lymph, and contain various quantities of modified red particles of the blood; in their outermost layers fibrils like those of cel- lular tissue are being developed. The coagulation of this lymph at the periphery of the effusion, is the occasion of its becoming encysted. These sacs are usually borne for a long time, and they do not present any proof of having diminished from their orginal size ; for the imper- meability of the wall of the sac materially interferes with the absorption of its fluid contents. Occasionally, however, cases do occur, in which a sac that originally was of large size, has undoubtedly become smaller, some of the fluid part of the contents having been at length absorbed, and the cavity diminished by the approximation of the two walls to each other, and by their cohesion at the margin of the sac. In some cases it has even completely closed in this manner, and is wasted. The walls of the sac, especially that one which adheres to the dura mater, sometimes become the seat of ossification, that is, of bony concre- tions in the form of plates. In a considerable number of observations, I have seen but one case in which the sac was of a cylindrical form, and filled, like a sausage, with a dark, reddish-brown plug of coagulated blood. Some rare instances occur of large circumscribed extravasations into the arachnoid sac, in which the fibrin does not disengage itself, and coagulate at the surface, and thus enclose the extravasation ; such cases present to view a rounded and irregular mass of coagulum. Small effusions, which spread out and form a thin stratum, leave be- hind them a correspondingly thin, single lamina, of a rusty brown, or yeast-yellow color, which lines the dura mater. It is very often a mere film, and can be detected only by the closest examination. # According to my observations, these extravasations occur pretty often m adults and especially during and after the best years of manhood: isartnez, Kilhez, and Legendre, have not unfrequently noticed them in THE ARACHNOID. 255 young persons and children. It has been my uniform experience, that the large encysted extravasations over the hemispheres, induce a marked degree of weakness of intellect. They have much general interest, as rare examples of hemorrhage into a serous cavity. The source of the bleeding cannot usually be discovered. In persons who are advanced in life, it may, perhaps, arise from the congestions which are occasioned within the skull, by atrophy of the brain. It should be remarked, that old effusions may be mistaken for hemor- rhagic exudations ; but such an error may be obviated by observing the following particulars : a. At whatever period the extravasation may be examined, no change of structure, such as accompanies inflammation, will be found in the arachnoid, even in its parietal layer, to which the extravasation is attached. /9. In the recent state, it is clear that the effusion is pure blood. y. Further distinctions may be noticed, in the peculiar change of struc- ture which has been described as taking place in the extravasated fibrin, and in the want of any intimate organic connection between the sac and the dura mater. Lastly, it is these encysted extravasations which have hitherto, for a long time, been erroneously looked upon as extravasations between the two layers of the dura mater. 3. Inflammation (Arachnitis, Arachnoditis).—The condition of the pia mater subjacent to an inflamed arachnoid membrane, produces sundry peculiarities in inflammation of the cerebral layer of the arachnoid. In the first place, inflammations of the parietal layer of the arachnoid are, on the whole, of frequent occurrence; their pathological import, however, is mostly subordinate, for they are a secondary appearance, or, as it were, a complementary localization of the general disease ; they occur in the course of processes attended with extensive exudations, par- ticularly of those which take place on serous membranes ; they are met with also, in cases of what is called a phlogistic state of the blood, and in pyaemia, in the course of acute exanthemata, of Bright's disease, of acute biliary dyscrasia, &c.; and they are commonly slight in degree. The inner surface of the dura mater appears streaked Avith delicate vessels, and is of a clear, rosy red tint; it is lined with an exudation, that may be delicate, grayish, and soft, like a layer of mucus, or more consistent, and membranous, or yellow, loose, and puriform. In some rarer cases, the inflammation of the parietal layer has all the appearance of being primary, and, judging from the amount of its pro- ducts severe also. The inner surface of the dura mater is found lined with a false membrane, from half a line to seA'eral lines in thickness ; it is of cellular structure, and is mostly remarkable for its vascularity, and for a corresponding degree of redness. It is attached to the dura mater by means of its vessels. Sometimes it contains yellow cheese- like masses of disorganized fibrin, which vary in size, and in shape are rounded or irregular, and branching and coalescing. Still more rarely, the exudation becomes a dense, fibroid membrane, in Avhich plates of bony concretion are developed, as so often occurs in false membranes on the pleura. 256 DISEASES OF These processes usually take place, and furnish their products with- out being accompanied by any similar disease in the cerebral layer: even in the intense primary inflammation mentioned last, the change which takes place in the cerebral layer, is limited to cloudiness and thick- ening ; the false membrane very rarely produces any adhesion between the two surfaces. Inflammations of the cerebral layer of the arachnoid membrane pre- sent peculiar characters in respect to the condition of the pia mater. We find, on the one hand, that, as arachnitis is usually not fatal of itself, or at least not in an early stage, it sometimes leaves traces of its previous existence, in pretty extensive thickenings of the membrane, in free exudations on its surface, which become converted into circum- scribed tendinous patches, or diffused false membranes, &c.; whilst very trifling changes are discoverable in the pia mater, to indicate that an in- flammatory process occurred at the same time in it. When, on the other hand, the pia mater is acutely inflamed, and there is profuse exudation into its tissue, the superjacent arachnoid is in no marked degree affected, and its surface is entirely without any free exudation. The products and consequences of these processes are, considerable thickenings of the cerebral arachnoid, adherent exudations of areolar or dense fibroid texture, which may be smooth, or are granulated like clus- ters of Pacchionian bodies, insulated shreds of false membrane, or broader and more extended membranes of the same nature, and adhesion of the cerebral arachnoid to its parietal layer. At a later period, plates of bone are sometimes formed in these exudations. Purulent exudation on the free surface of the arachnoid takes place on the parietal layer, only when the dura mater is very acutely inflamed in consequence of injury of the skull, and caries; and on the cerebral layer, only when a simultaneous acute inflammation of the pia mater also gives rise to an exudation of pus. It is remarkable that true tubercular exudations do not occur in this membrane. On whichever layer of the arachnoid these processes take place, that portion of it is exclusively affected which corresponds to the convexity of the hemispheres ; and, in proportion as they approach the base of the brain (which they occasionally do), the intensity of the processes, and the quantity of their products, is palpably diminished. 4. Adventitious Growths.— Cysts, and lipomatous tumors, are rarely formed in the arachnoid; but both they and the fibroid growths, ascribed to the dura mater (p. 250), when they occur, may sometimes belong rather to the parietal layer of the arachnoid. a. Besides them, concretions of cholesterine, cholesteatoma may be mentioned here. I have repeatedly met with them in the arachnoid at the base of the brain, forming aggregations of delicate white scales, that shine like tendon or asbestos, and are as large as a bean or a hazel-nut, or of still larger accumulations enclosed within epithelial cysts. In one case they were interwoven with extremely fine (microscopic) hair. b. Fibroid tissue is developed in the diffused and circumscribed opaque thickenings of the cerebral arachnoid; in the instance of the Pacchionian bodies it constitutes a granular form of thickening of the membrane. THE ARACHNOID. 257 c. Bony formations.—Independently of the concretions of bone, which are found in the walls of encysted extravasations of blood, and in fibroid exudations, osseous growths are also developed in this membrane. They are commonly knoAvn as ossifications of the dura mater, but in my opinion they appertain rather to the arachnoid. I gather this both from direct examination, and from the fact, that they occur also on the cerebral arachnoid, and on the free layer of the spinal arachnoid. They are almost always situated on the parietal layer of arachnoid lining the dura mater, and much more rarely on its cerebral layer. They occupy the falx usually, the convex part over the hemispheres, and the ten- torium very seldom, other parts almost never. Their form is mostly that of plates, as broad as a lentil or a zwanziger1 piece; their attached surface is smooth and shining, on their free surface they are convex, un- even, and nodulated; their thickness is greatest in the. middle, and amounts to two or three lines, their edges are bevelled, irregular, and indented; they are sometimes of a reddish or bluish-red color, some- times yellowish-white, or white, like a compact bone. They often re- semble needles lying singly or joined in groups together; and in this form particularly they are found lying beside the vessels of the falx, or in that part of the dura mater over the hemispheres which adjoins the convex margin of the falx. They may easily be separated from the dura mater ; and under the larger plates that membrane appears atro- phied. Bone is rarely formed upon the cerebral layer of the arachnoid; when it is found there, it is almost always over the convexity of the hemispheres, and in the shape of plates, which are smooth on their free surface, and rough on that by which they are attached. The so-called ossifications of the dura mater are met with mostly in advanced life ; their essential importance is far less than that which is usually attributed to them, and they become still more insignificant in pro- portion as the atrophy, to which the brain is liable at this period of life, increases. As a general rule, they are certainly of moment, when found before the thirtieth year of life. They very commonly coexist with hyperostosis of the cranium, thickening of the vitreous table, especially near the forehead, with adhesions between the dura mater and the skull, cloudiness, and thickening of the inner membranes, &c. They are composed of true bone, and usually have also a very com- pact texture. In some very rare cases bony formations of other kinds are found scattered over various parts of the inner surface of the dura mater, and the opposite layer of the arachnoid. They are crumbling or firm concre- tions of a reddish, or a white color, and resembling mortar, and are most probably cretified fibrinous exudations. d. Cancers.—Adventitious groAvths which belong to the present sec- tion, frequently occur on the inner surface of the dura mater ; they are quite remarkable for the variety of their external appearance and of their elementary structure. Thus, in regard to the former particular, we meet with delicate villous, vascular, fungous growths, with thoroughly 1 [The third part of a florin, and of about the size of an English shilling.—Ed.] VOL. III. 17 258 DISEASES OF encephaloid formations, with tumors minutely divided into acini, like some glands, with lobulated masses variously streaked with fibres, and so forth. e. Tubercle.—The rare occurrence of exudations to any amount on the free surface of the arachnoid, while they are quite common in the tissue of the pia mater, probably explains why the arachnoid, unlike other serous membranes, should scarcely ever be the seat of tubercular deposit,—why meningeal tuberculosis in every form is restricted to the deposition of tubercle in the tissue of the pia mater. § 3. Anomalies in the Contents of the Arachnoid.—Some of these anomalies have been already detailed : the accumulation of serous fluid in the arachnoidal sac in any beyond the natural quantity, constitutes another instance of them. When the accumulation is considerable, it constitutes the disease which is known as external, or meningeal, hydro- cephalus. Sometimes it is congenital, and is then remarkable for the great quantity of the serum. It appears in two forms : a. In that of dropsical sacs, which consist either of arachnoid mem- brane alone, or, as is more common, of dura mater also, identified with the arachnoid, and attenuated in an extreme degree: they protrude through an aperture in the skull, and form a diverticulum of the arach- noid sac, which communicates with the general cavity by a narrow canal. If, as is very commonly the case, there be no complication with hernia of the brain, such sacs are undoubtedly curable by being emptied and tied. b. The second is a uniform accumulation of serum in the arachnoid sac, by which the brain is displaced and compressed towards the base of the skull, and the cranium is, at the same time, uniformly enlarged. Although there are some cases, and one in particular in the Vienna Museum, which show that this hydrocephalus may attain very consider- able dimensions, yet such an enlargement is extremely rare. There is an excessive accumulation of serum in the arachnoid sac, which comes on very frequently during extra-uterine life, and calls for some remark. The normal quantity of serum in children is just sufficient to keep the free surfaces of the arachnoid membrane moist; it may be a few drops, but it does not exceed a drachm; in adults it amounts to three or four drachms. This quantity is found collected in the posterior fossae of the skull; and if the brain have been carefully removed, it remains in its natural clear and colorless condition: but as in examining and taking out the brain, some blood is usually mixed with it, it appears turbid, and is more or less tinged red. When there is an excess of this serum, not only has a greater quan- tity gravitated to the base of the skull, but a part of it also pours out when the dura mater is slit at the mid-height of the brain, along the line where the skull has been divided by the saw. The whole amount may often be estimated at an ounce, an ounce and a half, two ounces, or even more. The conditions under which considerable quantities are found, are principally two : they may occur, THE PIA MATER. 259 1. In consequence of frequently recurring habitual congestion of the membranes, or of a varicose state of the vessels of the pia mater. 2. As a result of atrophy of the brain. Under both conditions the excessive accumulation of serum in the arachnoid sac, is combined with thickening of the inner membranes—the cerebral arachnoid, and pia mater,—with infiltration (oedema) of the pia mater in atrophy of the brain, with accumulation of serum in the ventricles, and sometimes with a state of infiltration or oedema of the brain. It is always important to notice that serum is accumulated at the same time beneath the bridge- like expansions of arachnoid at the base of the brain, especially in the cerebellum; and the more so as the fluid escapes from the latter situa- tion when the brain is removed, and augments the quantity which is found in the arachnoid sac. This serous effusion into the arachnoid sac, is essentially chronic ; but it is subject to sudden or to gradual increase with every attack or aug- mentation of the congestion, with every advance in the varicose state of the vessels, and in the case of atrophy of the brain, as the vacuum be- comes greater within the skull. It is an important question whether there are any acute effusions of this kind which are rapidly fatal; and whether it is possible to recognize them on the dead body as the cause, or as part of the cause, of that form of sudden death which is usually designated "serous apoplexy." That there are such effusions, which may quickly destroy life by paralyzing the brain, can certainly, in the present state of our knowledge, not be denied; but the diagnosis of this mode of death is just as uncertain on the dead body as on the dying patient, for the serum which is found in the arachnoid sac, may be a chronic accumulation that has existed there for a long time, just like that which is contained in the ventricles, or in the tissue of the pia mater, or that which produces oedema of the brain itself. Moreover, the coexistent congestion of the membranes of the brain is usually but slight. And lastly, there are, for the most part, in such cases, various other morbid affections elsewhere, by which the sudden death can be otherwise explained. I shall have occasion to make some further re- marks on this subject at another more suitable place. Not unfrequently the quantity of this serum is uncommonly small, and the surfaces of the arachnoid appear to be without moisture. This is the case in marked enlargement of the brain, especially in hypertrophy. THE PIA MATER. (THE CHOROID COAT.) The intimate relation subsisting between the pia mater and the brain, and the frequent coexistence of disease in the latter with that of the former, render the affections of the pia mater those of the greatest im- portance. In accordance with what has been said of the arachnoid, and in opposition to the general relations of subserous tissue to serous mem- branes, the most important processes that occur in this situation, viz., those attended with exudation, greatly preponderate in the tissue of the pia mater. § 1. Diseases of Texture. 1. Congestion and its consequences:—Hemorrhage.—There is no 260 DISEASES OF question that congestion of the pia mater (commonly called congestion of the membranes, or inner membranes of the brain) is a very frequent occurrence ; and we have already (p. 252) arrived at the same conclusion from our observations on the arachnoid. Yet, on the whole, if we except the "post-mortem" congestion of the pia mater covering the posterior lobes of the cerebrum, any considerable degree of congestion is far less commonly met with in the dead subject than is usually supposed; and there is, perhaps, no respect in which moderation in estimating appear- ances needs so much to be impressed upon the unpractised observer as in regard to the quantity of blood contained in the vessels of the pia mater: as a general rule, a very moderate injection of these vessels is erroneously looked upon as congestion. The marked congestions which are met with in the brain and its mem- branes in very delicate children form an exception to this rule. Much interest attaches to these instances, from their being associated with more or less striking general plethora in children who are usually ema- ciated. The congestions are, in general, active, or mechanical, i. e. resulting from disease of the heart, or obstruction in the lungs : sometimes they are passive. They are generally combined with a corresponding degree of congestion of the brain; and sometimes they destroy life, either of themselves, as vascular apoplexy, or by causing an effusion of serum into the tissue of the pia mater and substance of the brain. The terminations and consequences of congestions vary according to the frequency and the duration of their cause. They consist of thicken- ing and condensation (increase of volume) of the pia mater and arach- noid, of permanent infiltration of the former, and a varicose condition of its vessels. Such a state of the inner membranes is well marked after the congestions which are produced by continued and forced ex- ertion of the mind, or by repeated intoxication, especially with alcoholic drinks. Congestions from the latter cause leave behind them an ex- tremely varicose state of the vessels. The (mechanical) congestions, infiltrations, and thickenings which the pia mater suffers when atrophy of the brain has formed a vacuum within the skull, also require particular notice in this place. Spontaneous hemorrhages into the tissue of the pia mater (apoplexy of the vascular coat), though they rarely take place in adults, are fre- quently met with in new-born children and in the delicate period of childhood. In the latter, the part which mostly suffers from hemorrhage is the pia mater at the base of the brain. Cases of this kind must be distinguished from those in which the pia mater is infiltrated with the blood that escapes from an apoplectic spot, whether peripheral or deeply seated. Except in some rare instances, in which a large vessel, or an aneurism of one of the large arteries is ruptured, the source of the bleeding is the fine vessels of the pia mater. Hemorrhages which result from the skull being shattered, or otherwise injured, are mostly accom- panied with bruising and hemorrhage on the surface of the brain. _ 2. (Edema of the pia mater.—The infiltration of the tissue of the pia mater with serum, which I have just brought forward as one result of congestion, constitutes oedema of the membrane. It is most com- monly chronic: it may be combined with the other changes which have THE PIA MATER. 261 been enumerated as consequences of repeated and continued congestion; and it may advance till the pia mater measures several lines in thickness, and the serum pours forth in large quantity, when the membrane is cut or torn off. This is especially the case in atrophy of the brain. The infiltered pia mater may be easily separated in large pieces from the brain. (Edema generally involves the entire pia mater, but it reaches by far its greatest amount over the convexity of the cerebral hemispheres. It may affect merely a very small section of the membrane; and it is thus strictly local when only a part of the brain is atrophied: when the wasting is limited to a few of the convolutions, the oedematous pia mater hangs over them like a loose bag. In those situations where the cerebral arachnoid is stretched separately and like a bridge over certain parts of the brain, most of the serum is poured out in the free space between it and the pia mater. The discrimination of an acute oedema, as ever proving the fatal result of an acute congestion of the membranes, is attended with difficulties of precisely the same nature as those which surround the question about the existence of such a disease as serous apoplexy. (Edema of the pia mater is associated with that disease. 3. Inflammation.—Inflammation of the pia mater (true meningitis) is the most important of the inflammatory affections of the membranes of the brain. In its essence it is inflammation of a loose areolar tissue. It is impossible to depict its general features without distinguishing two totally different forms of the disease. a. The first form. a. Its product is, in general, a yellow or yellowish-green, fibrinous, or purulent exudation into the tissue of the pia mater. This product is effused according to the circumstances of the case, sometimes at separate spots, as between some of the convolutions, or along the course of the larger venous trunks of the pia mater, while the membrane itself is else- where infiltrated with an opaque grayish serum : at other times the exudation is made up of flakes of fibrin, and is diluted with a consider- able quantity of serum ; it is of a grayish-yellow, or variegated greenish color, and pervades the pia mater uniformly; or it may contain but little serum, and be pure fibrin, or pus, diffused in large quantity through the pia mater and its prolongations between the convolutions. In the last case the membrane is manifestly increased in thickness, and may be easily separated from the brain, sometimes without injury, but at other times not without scaling off the surface of the brain with it. It may also be easily torn. /9. In this form the disease usually extends over the convexity of the hemispheres and as it approaches the base of the brain, diminishes in in- tensity. It rarely occurs at the base of the brain at all. y. The individuals who present this form of disease, are in the youth- ful period, the bloom of life; they are usually strong, at any rate they show no trace of the tubercular dyscrasia. 8. The disease is usually unaccompanied Avith (acute) hydrocephalus; at least the exudations found in the ventricles are mostly slight: so also softening of the stomach does not ordinarily result from it. e. Except at its periphery, the brain is unaltered by the disease. 202 DISEASES OF This form of meningitis is very frequently a primary and idiopathic disease; at times it is met with frequently, and according to Forget and others, is even an epidemic: and further, it is the usual result of con- cussion of the brain. Sometimes it is a secondary affection, and as such, it succeeds other inflammations, extensive exudations on serous mem- branes, for instance, pneumonia, &c, or it is induced by the contiguity of the membrane to circumscribed inflammation going on in the dura mater and cranial bones, by phlebitis of the venous trunks of the pia mater, or of the sinuses of the dura mater by the advance of inflamma- tion or abscess of the brain, and so on; or, lastly, it may be excited by the irritation which adventitious growths of various kinds produce within the cranium. It usually, as I have already pointed out, spreads over a large artifi- cial area, and is sometimes accompanied with inflammation of the mem- branes of the spinal cord: even when the inflammation has advanced from some other tissue merely to circumscribed spots of the pia mater, it usually spreads out very rapidly into an extensive (general) meningitis. To this, however, there are occasional exceptions; for inflammation and even suppuration sometimes continue to be limited to their original site; as, for instance, is sometimes the case with the inflammation and sup- puration dependent on caries of the skull. The inflammation is always acute, and more acute in proportion to its intensity, and to the abundance of the exudation. What is called chronic meningitis is really nothing but the various terminations, and the me- tamorphoses of the products, of an acute inflammation. Much as it might have been expected, yet are arachnitis on the one hand, and inflammation of the periphery of the brain on the other, far from being constant accompaniments of inflammation of the pia mater. Exudation on the free surface of the arachnoid very rarely occurs, and it is found only when meningitis reaches its most intense degree: the surface of the brain, on the contrary, is certainly more frequently in- volved. In some rare cases it may be concluded from the terminations and consequences of the inflammation, that it has extended from the pia mater to the surface of the brain in one direction, and in the other to the arachnoid and dura mater, and even to the bones of the skull. This form of meningitis is frequently fatal; but it often terminates in resolution. When its products change into a cellular or fibroid tissue, the inflammation leaves the pia mater a thickened, whitish, tough, dense membrane; the arachnoid shares in the thickening, the pia mater ac- quires unnatural connections with the surface of the brain, the cerebral arachnoid adheres to the dura mater, and at length even the dura mater and the skull unite. In some rare cases of this kind, the surface of the brain and skull are bound together by a series of successive normal and false membranes. Such terminations of meningitis are frequently found in mental disease, especially in cases of secondary imbecility. Meningitis terminates in suppuration only when the inflammation is local, and passes to the pia mater from other contiguous structures. b. The second form. «. The products of the second form of inflammation of the pia mater, though commonly mixed with yellow or yellowish-green spots of fibrin, THE PIA MATER. 263 consist in greatest part of an opaline, flocculent, albumino-serous, gela- tinous, sero-purulent, and usually very abundant exudation, the color of which is grayish, sometimes shot with yellow or faint green. The opacity of the infiltrated tissue of the pia mater, and of the arachnoid, is palpa- ble in consequence of the transparency of the product. The first-men- tioned fibrinous exudation very often assumes the form of granular, plastic nodules, which become tuberculous. /?. It occurs almost exclusively at the base of the brain: and the peculiar product, Avhich was mentioned second, especially accumulates between the hemispheres of the cerebrum on each side, from the optic commissure in front, to the pons, and even over the medulla oblongata behind. In this situation it is deposited amongst the numerous vessels and bands of cellular tissue which pass across the spaces between the pia mater and the bridge-like arachnoid. From thence it may be traced into the fissures of Sylvius, and the longitudinal fissure of the cerebrum, and so on to the convex surface of the hemispheres; for the fibrinous pro- duct (that which tends to become tubercle) accumulates along the vascu- lar trunks which run in the fissures, viz.—the arteries and veins of the fissures of Sylvius and corpus callosum, and the latter often appear com- pletely enveloped in the exudation. y. From these points the inflammation always extends also to the choroid plexuses and the lining membrane of the ventricles, particularly the lateral ventricles, and there gives rise to the exudation of a similar product, from Avhich a distinct purulent sediment is often deposited: thus it is combined with acute hydrocephalus; and very often it is asso- ciated also with softening of the stomach. 8. The brain is always in a state of (acute) oedema or serous infiltra- tion, and of (hydrocephalic) swelling. (Compare Hydrocephalus, treated of below.) At those parts where the process is most intense, and par- ticularly in the fissures of Sylvius, the cerebral convolutions, especially at their superficial parts, become the seat of red or yellow softening. e. The subjects of this form of the disease are mostly children, although it is frequent also at later periods of life. I shall have again to notice that the individuals Avho are attacked Avith it are mostly persons of bad constitution, especially of a tubercular dyscrasia, or those in whom tubercle is actually deposited. This form of meningitis is sometimes primary, sometimes secondary ; when attended with tubercular exudation, it is generally secondary, and combined with tuberculosis of other organs. Frequently also, more fre- quently than the first form, it comes on secondarily as an attendant on various diseases of the brain, such as adventitious growths, particularly tubercle, inflammation, abscess, softening of the brain, and so on, in broken-down constitutions. The peculiarity of the product of this meningitis appears therefore to arise from exhaustion of the fibrin of the blood by previous exudations of tubercle, or from hwmatosis, resulting from the influence of some of the above-named diseases, pre-existing in the brain. Both in its quality, and in the condition on which that quality depends, the product is strik- ingly analogous to the gelatinous pasty products which are furnished by pneumonia under the like circumstances of a defibrinated condition of • 264 DISEASES OF the mass of the blood, and are attended Avith considerable hepatization and extensive tuberculosis. Though convinced that in distinguishing two forms of inflammation of the pia mater, and in my portraiture of them, I have been perfectly true to nature ; yet I must say expressly that the disease presents other ex- ceptional characters. a. Instances occur, on the one hand, of meningitis at the base of the brain, in Avhich the exudation is fibrinous (plastic), and even purulent; ft. And on the other hand, it is by no means rare for meningitis, on the convex surface of the-hemispheres, to furnish a tubercular exudation. Isolated spots of inflammation are then found scattered through the pia mater, especially through the part of it which dips between the convolu- tions, and it appears infiltrated with a yellow granular exudation. The spots of inflammation are very commonly, too, the seat of hemorrhage, and the membrane adjoining the tubercular mass appears quite filled with coagulated blood. The adjacent surface of the brain is generally in a state of red (inflammatory) softening. These processes are, almost without exception, combined Avith tuberculosis of other organs, especially with tubercle in the brain; and they appear to be analogous to the lobular pneumoniae which are attended with tubercular exudation—tubercular infiltration of the lungs. The meningitis which occupies the base of the brain, very often ex- tends into the neurilemma of the cerebral nerves, as they pass off through the inflamed part. 4. Adventitious Growths.—Exclusively of growths, which originate in the brain, and implant themselves secondarily, and in part only, in the pia mater, this class of disease is restricted in the pia mater to tubercle. Tuberculosis of the Pia Mater.—It is very frequent, and is, of course, one of the most important of all the tuberculoses. It is met with as a chronic disease, but more frequently it assumes the forms of acute tuberculosis, and of meningitis, with tubercular exudation. a. Chronic Tuberculosis.—In this case the tubercle is found in the form of gray granulations, which, sooner or later, become yellow tubercle. The granules are always grouped or clustered together. They are con- fined to no particular region. They are constantly combined with tuber- culosis of other organs, and they commonly form the starting-point for meningitis and acute tuberculosis of the pia mater. I have never met with complete softening or suppuration of this form of tubercle. b. Acute Tuberculosis.—Tubercle of this kind appears in the form of the finest granules, scarcely as large as poppy-seed; it may be grayish and opaque, or quite clear and pellucid, like a vesicle. More rarely it assumes the form of larger, miliary, and separate granulations. It needs not merely familiarity with their appearance, but also a close search of the pia mater in order to find them. The congestion to which they owe their origin is often no longer discernible on the dead subject; but they remain always in large numbers, and always occupy a large section, and not unfrequently, indeed, the whole cerebral part of the pia mater: while together with them, and as the product of the same congestion, a considerable quantity of serous, sero-albuminous, and more or less turbid THE ARACHNOID AND PIA MATER. 265 exudation are found at the base of the brain, within and about the circle of Willis. The base of the brain is the chief seat of this form of tuberculosis: from thence it extends towards and over the hemispheres; it is rare to find the convex surface of the hemispheres the principal seat of its de- velopment. With a little attention the granules may be easily discovered at the base of the brain by removing the bridge of arachnoid, but it re- quires the closest search to detect them in the pia mater, covering the convexity of the hemispheres: in this situation they are clustered in the intervals between the convolutions, and are very often further concealed by a good deal of congestion of the membrane. The amount of the accompanying (acute) hydrocephalus and oedema of the cerebral substance bears a direct relation to the extent to which this form of tuberculosis is developed. It is most frequent in children and young persons, but it may occur at any period of life. It is very rarely the primary disease, but almost always depends upon some pre- vious tuberculosis, either chronic tuberculosis of the pia mater, tubercle of the brain, or the like disease of the lymphatic system, or lungs. Not unfrequently it forms part of a general acute tuberculosis which has at- tacked the most different organs and tissues, either all at once, or quickly one after another. c. Meningitis, with tubercular exudation, so called tubercular menin- gitis. This is the second form of meningitis with a fibrinous, yellow, granular product, which was described at p. 262. Sometimes it is com- bined with an acute exudation of gray granular tubercle (acute tubercu- losis). Sometimes also it appears in the form of isolated spots of in- flammation of the pia mater covering the convex surface of the hemi- spheres (described at p. 264). In both forms it has the same combina- tions and starting-point, as the acute tuberculosis. It is remarkable that the pia mater of the cerebellum is very rarely the seat of tubercle. On one occasion I met with a tumor in the pia mater consisting of a cavernous tissue; it was a specimen of teleangiectasis (splenic naevus, Aftermilz), and was situated at the upper part of the left cerebral hemisphere. OF THE PROLONGATIONS OF THE ARACHNOID AND PIA MATER WITHIN THE BRAIN. § 1. Diseases of the Choroid Plexuses.—The choroid plexuses are sub- ject to congestion, opacity, and thickening, and to a varicose state of their vessels: and these changes are mostly observed when the pia mater and arachnoid are in a similar condition. The choroid plexuses share more or less also in the processes of exudation, which arise from meningitis and acute hydrocephalus, and are then opaque, swollen, infiltrated, and covered with flocculent pseudo-membranous fibrin, or with purulent ex- udation. Cysts and calcareous formations are the principal adventitious products in the choroid plexuses, and they are frequently met with. The cysts, vesicles, or, as they are sometimes named, hydatids, of the 266 DISEASES OF choroid plexuses, are frequent and Avell known. Various misconceptions have prevailed as to their nature and cause, and undue importance has been attached to their presence. They have been taken for dilated lymphatic vessels, for enlarged capillary vessels (or terminations of arteries), and for new growths; and their value, in the scale of post- mortem appearances, has been commonly over-estimated. They form bladders, sometimes with very thin, sometimes with pretty thick, vas- cular walls; they may be loose and pendulous, or filled and tense; they vary in size, equalling a poppy-seed, millet-grain, or bean; and when very numerous, they give the choroid plexus the appearance of a bunch of grapes. They occur only in the lateral ventricles, at least none that occur elsewhere are large enough to be detected in making the post-mortem examination with an ordinary amount of care, that is to say, none above the size of millet-seed. They occupy the convex portion of the plexus, especially towards the posterior cornu of the ventricle. They appear to me to be a disorder of the gland-like acini and villous appendages of the choroid plexuses, and, therefore, to bear a close analogy to the cysts, which are so often developed from the Malpighian bodies of the kidneys, especially in consequence of inflam- mation and Bright's disease. In young persons they are almost constantly absent; but they are very frequent in those Avho are advanced in life, and in whom there is hydro- cephalus arising from vacuum, or thickening and oedema of the inner membranes of the brain, &c. These cysts, for the most part, have but one chamber, but they are often divided into compartments by delicate partitions. They gene- rally contain a clear serum, but the fluid they enclose is often turbid, whitish, and like lime-water, and at last there is often whitish or yel- lowish bone-sand in them besides. These concretions incrust the cells, and are analogous to the sand met with in the brain; they are found, too, when there are no cysts, in the texture of the villi of the choroid plexuses. Tuberculosis.—This is an extremely rare occurrence: even when there is an exuberant production of tubercle in the tissue of the pia mater of the base of the brain, there is very rarely any trace of it in the adjoin- ing choroid plexus. Cancer.—This disease, occurring alone in the choroid plexuses, is one of the very rarest ever met with. I have seen a medullary degeneration of the choroid plexus of the fourth ventricle. § 2. Of the Lining Membrane of the Ventricles.—The internal mem- brane of the ventricles of the brain is composed of a very delicate con- tinuation of the arachnoid and pia mater, and a layer of epithelium. The most frequent and most important diseases to which it is liable, have, from one most striking characteristic which they present, viz., an'exces- sive accumulation of cerebro-spinal fluid, been included together under the title of hydrocephalus. m Although it is true that the presence of an excessive quantity of fluid in the ventricles, and structural disease of their lining membrane, are not essentially characteristic of all cases of hydrocephalus, but are some- times secondary, and occasioned by disease of the brain, and therefore THE ARACHNOID AND PIA MATER. 267 that all the forms of hydrocephalus do not rightly belong to the present section, yet I prefer treating of them altogether, for two reasons : (1.) Because the most important of all the forms, viz., acute hydroce- phalus, arises from disease of the lining membrane exclusively; and (2.) Because, in spite of their differences, it has become a prevalent custom to associate them together, both in thought and in description. Though, for the sake of convenience, I thus disarrange the subject, it will be restored again by referring to each of the forms I am about to describe in the place to which it properly belongs. 1. Hydrocephalus.—I would here offer the following general remarks: that, in accordance with what has been already said, by the term hydro- cephalus is meant " Hydrocephalus stricte sic dictus internus,"—dropsy of the ventricles: and that I retain the usual division into acute and chronic hydrocephalus, as it appears to be that which still possesses the most practical value. The chief seat of hydrocephalus is generally the lateral ventricles, and they are for the most part symmetrically affected. Exceptions will be pointed out in their places. A. Acute hydrocephalus.—This is both the most frequent and the most important of the forms of hydrocephalus—the acute dropsy of the ven- tricles. Anatomy discloses two essentially different forms of it. a. The first form. Its anatomical characters are— a. The effusion of a fluid which is thin or somewhat thick, of a grayish color, or grayish-yellow tinged with green, and more or less turbid, in proportion to the quantity it contains of plastic matters capable of as- suming some of the primary forms of organization. It is very often found to have separated into two parts—one fluid, and the other of more consistent and deeper color: it has, in fact, become clear from certain of its elements having fallen to the bottom as a sediment. These elements are usually found in the most dependent part of the lateral ventricles; viz., their posterior cornu. On minute examination of the effusion, its opacity is found to arise from the presence of the elements of a plastic exudation, nucleoli, nuclei, cells at various stages of develop- ment, and true pus-cells; and of them the sediment, distinguished by the deeper yellowish or greenish color which it presents, is, for the most part, composed. But cast-off epithelium in course of solution, shreds of the lining membrane of the ventricles, and even shreds of nerve-tubes, are also found in the effusion, and all contribute to its opacity. In some few cases a more solid exudation is observed besides the fluid effusion; it adheres here and there, especially on the corpora striata and optic thalami, in membranous plastic flakes to the lining membrane. ft. The quantity of the morbid effusion cannot be accurately deter- mined, because of our uncertainty as to the pre-existing or normal quantity of fluid in any particular case. The whole quantity, however, inclusive of that which previously existed, is generally not considerable, and usually does not exceed an ounce; oftentimes it is scarcely half so much. On the other hand, in a few cases in which acute hydroce- phalus supervenes upon chronic (whether the latter be congenital, or have come on early in life), the quantity of opaque contents of the ven- tricle is very considerable, and the greater part of it appears to have been produced by the recent process. The enlargement of the ventricles 268 DISEASES OF corresponds to the quantity of their contents, and in ordinary cases is but slight. y. The lining membrane of the ventricles becomes opaque, soft, and dissolved, and shreds of it consequently appear in the effusion. The choroid plexuses become opaque and softened, and are very com- monly enveloped in a villous and slightly shreddy layer of grayish, or grayish-yellow exudation. 8. From this point further changes extend in tAvo different directions, to the cerebral substance, and to the inner membranes at the base of the brain. The affection of the membranes is the more essential part with respect to the nature of the process. (1.) In the neighborhood of the ventricles the cerebral substance is percolated with serous fluid—infiltrated—to such a degree, that it seems as it were in a state of watery softening ; very often, too, it is streaked or dotted with ecchymoses. The cerebral substance is thus affected wherever it adjoins the lining membrane of the ventricles ; but very com- monly the fornix and septum are softened to the greatest degree, and the latter is sometimes quite broken down and perforated. From this spot the oedema extends through the whole of the cerebral hemispheres, always, however, diminishing gradually as its distance from the ventricles increases, and always being greatest close to them. Hence the cerebrum swells, and increases in actual volume ; its convolutions are forced against the walls of the cranium, and flattened; and in the same manner the cerebellum and pons are depressed and flattened in a marked degree. The inner membranes covering the convex surface of the hemispheres, being involved in the pressure against the cranium, appear bloodless. The cerebral substance also is bloodless and pale; it has a singular dull white appearance, and a peculiar soft and doughy consistence arising from its uniform moistness. (2.) With the affection of the lining membrane of the ventricles and choroid plexuses, the diseased condition of the inner membranes at the base of the brain, forms one entire disease, not only by continuity, but in essence also. It takes the form of meningitis, especially of that de- scribed at page 262 as the second form of meningitis ; or else it appears as acute tuberculosis of the pia mater at the base of the brain. In speaking of the serious character of these processes, I have already grounded it on their extension to the lining of the ventricles, that is, to their combination with acute hydrocephalus. b. The second form. Its anatomical characters. a. Effusion of a clear, colorless, serous fluid into the ventricles; some- times it is slightly turbid, from being mixed with shreds of the lining membrane and of cerebral matter. ft. The effusion varies in quantity, being sometimes slight, but more frequently considerable, amounting even to six ounces. y. The cerebral substance around the ventricles is generally in a state of watery softening, in which the rest of the cerebral mass shares, only in a less degree, the change in it not exceeding ordinary oedema. The whole brain presents the same swelling and the same general condition as have been described of the first form, but generally, even to a more THE ARACHNOID AND PIA MATER. 269 marked extent. The cerebral substance surrounding the ventricles and the lining membrane, may sometimes be found in the dead subject in a normal or nearly normal condition ; but this happens only in some ex- tremely rare cases, in which the disease is known to have run an acute course. The most remarkable, and one of the most important of the post-mor- tem appearances, in both the principal forms of acute hydrocephalus, is this almost constant softening, or, as it is called, maceration of the cere- bral substance about the ventricles. Before proceeding to any general remarks, some notice of the nature and import of this appearance is indispensable. In so far as regards anatomical disorganization, I hold it to be in itself no very essential part of the disease; it is, however, certainly very impor- tant, and perhaps even more so than the effusion into the ventricle itself. For first, it involves cerebral substance, and secondly, it attacks that substance in a very acute manner, and rapidly produces disorganization of it. It is, in fact, nothing more than an acute oedema of the highly delicate and easily injured texture of the brain, and the equally delicate lining membrane of the ventricles ; but so rapid, occasionally, is its pro- gress, and to such degrees does it advance, that it gives rise, for the most part, to countless lesions of continuity, and thus, in the form of softening, disorganizes the brain and destroys life : if it should advance more slowly, or to a less degree, it may very often continue a long time without marked symptoms. The mode of origin, and the import of this oedema, will be more dis- tinctly understood from the following particulars : (1.) It corresponds entirely to the oedema which surrounds every spot of inflammation, and to that which ensues upon acute congestions. (2.) And further, it is in my opinion worthy of remark, that if an effu- -'sion takes place so rapidly that room cannot at once be obtained for it in the .ventricles, by displacement of the brain, the resistance from within is so great as to hold, or press back, the exudation, and a portion of that which should be exuded from the lining membrane of the ventricle, is poured into its tissue, and into the adjoining part of the brain. The greater the intensity of the process, and the quantity of its products, the sooner does infiltration ensue, and break down the textures ; and it will the more readily take place, if the brain have been oedematous before, or the cerebral mass around the ventricles have been distended by a pre- existing effusion. (3.) In the first of the two forms of hydrocephalus, especially in that with which true meningitis is combined, the serous exudation which gives rise to softening of the cerebral substance around the ventricles is sure to contain a portion of coagulable or plastic materials, capable of assum- ing a primary organic form; in the second it is entirely, or almost en- tirely, composed of pure serum. This accounts for the circumstance that in many cases, the macerated cerebral substance, when minutely exa- mined, is found to contain the so-called exudation-corpuscles, exudation- cells, nucleated and primary cells (pus-cells), while in other cases these are entirely wanting. (Gluge.) This state of the brain, then, may be suitably classed, as has been 270 DISEASES OF done already, with the termination in softening, and may be named white softening, hydrocephalic softening. I shall have some further remarks to offer upon it when treating of oedema, especially in tne article of Softening of the Brain. This white softening of the cerebral substance is sometimes accom- panied with yellow softening, more particularly when the case is one ot the first form of hydrocephalus, and combined with meningitis. Moreover, I have alluded above to the softened cerebral substance being sprinkled or streaked, as it were, with red ecchymoses : both forms of this disease present this feature, but it is more common m the first form. It arises from the laceration of the delicate vessels,_ which are torn when the cerebral texture is broken down; but there is very often far less of it than the degree of disorganization would lead us to expect. The question which this suggests, admits as yet of no other solution than that the simultaneous swelling of the whole brain so ob- structs, and precludes the injection of, the cerebral vessels, that those which are torn are empty. # # With respect to the nature of acute hydrocephalus, an inquiry which has led to so much discussion, that of the first form of the disease is per- fectly clear : it is either an extension of meningitis of the base to the ependyma of the ventricles,—of a meningitis attended with an exudation that contains less than the average of plastic material, that bears traces of a faulty constitution of the blood, and that, in its fibrinous portion, is very often tuberculous; or it consists of a supplemental, and, for the most part, serous exudation, accompanying an acute deposition of tuber- cle in the pia mater, at the base of the brain. This form of acute hydro- cephalus, therefore, is either actual inflammation, or an exudative pro- cess having a general connection with it. Although I cannot coincide in the opinion of several French observers, who think that acute hydro- cephalus is never anything but meningitis,—by which term acute tuber- culosis is also meant,—yet I so far agree with them as to believe, -that in the great majority of cases such is the fact, and that the meningitis is very commonly of a tuberculous character. This form of hydrocephalus occurs both as a primary and substantive, and as a secondary affection. When secondary, it attends the diseases of the brain which have been mentioned already, at p. 263 ; viz., inflam- mation, abscess, and a yellow softening, adventitious growths within the skull in general, but more than all, with tubercle of the brain: with that disease it associates itself, either in the form of meningitis with tubercu- lous exudation, or in that of acute tuberculosis. It is very frequently the means by which those diseases of the brain destroy life. The hy- drocephalus which originates with tubercular meningitis, or with acute tuberculosis, is very rarely a primary disease, but supervenes upon some previously existing tuberculosis, upon that in the brain particularly, as well as that in the glands or in the lungs: when connected with acute tuberculosis, it forms one of the many local parts of the general disease. (Compare p. 265.) The subjects of it are, for the most part, children; but adults, and even persons advanced in life, suffer from the secondary form, especially when it is a process connected with tubercle. THE ARACHNOID AND PIA MATER. 271 The second form, though an acute hydrocephalus, cannot be admitted to be inflammatory: it bears, in fact, none of the characters which mark inflammatory states or products. It arises from congestions of various kinds : such as are connected with the development of the brain in child- hood, or those produced by chronic eruptions on the scalp, by the irrita- tion of morbid growths within the skull, &c. These congestions are analogous to those from which acute dropsies of many of the serous and synovial membranes result,—dropsy, for instance, of the tunica vaginalis testis, and the acute oedemas. It may be occasioned, too, by the conges- tions which follow concussion of the brain, or mechanical obstructions, such as disease of the heart, rickets of the thorax, impermeability of the lungs in tuberculosis and phthisis, chronic catarrh of the bronchi, chronic pneumonia, &c. The result of these congestions is an excessive effusion of serum, first from an apparatus especially adapted for that purpose, viz. the lining membrane of the ventricles, and then into the brain itself. These effusions, if the process which gives rise to them be very intense, destroy life at once, upon their first occurrence; otherwise they are fatal only after being several times repeated. Hence it is that the quantity of fluid found in the ventricle varies so much: the larger accumulations, those which amount to as much as six ounces, are apparently the sum of several smaller effusions, occasionally repeated. The enlargement of the ventricles corresponds to the quantity of serum within them ; and the skull enlarges in an equal degree until the sutures are closed. This form of hydrocephalus, then, not unfrequently runs a protracted, subacute course; and it tends the more to do so, in proportion as the several exudative processes are slight in degree, and as the skull retains more of its early elasticity. And further, the less distinguishable the several exudations are from one another, the more this form is allied to chronic hydrocephalus. It is sometimes a primary and substantive disease, sometimes a secon- dary. . When primary, it is in childhood, like chronic hydrocephalus, remarkable for its combinations, of which I have to speak hereafter; and for being intimately connected with a deeply-lodged anomaly of the general vegetative processes. When secondary, it is frequently occa- sioned by various diseases of the brain, as inflammation, abscess, and by morbid growths in the skull. Considered apart from chronic hydrocephalus, which stands in close proximity to its subacute variety, it is certainly, on the whole, more rare in childhood than the first form; but then it may occur much earlier, being met with in the first year of life, and doubtless, also, in the foetus. Moreover, it is not very rare at any later period of life, up to old age, for it is occasioned by mechanical congestions in the course of various chronic adynamic diseases, which are attended with a dropsical crasis of the blood. Both forms of acute hydrocephalus are attended by certain combina- tions, some of which are common to both, while others are peculiar to one of them. They are partly constant and essential, and partly neither constant nor essential. The first form is, in the great majority of cases, combined with a tuberculous diathesis, and the local tuberculoses, mentioned at p. 265: these constitute the fundamental anomaly. 272 DISEASES OF The second form combines with it several abnormal conditions, espe- cially in children ; and very often all the disorders enumerated below occur together, and form one complex morbid state, that manifests a thoroughly depraved working of the vegetative process. They are— (1.) Hypertrophy of the whole system of lymphatic glands, and of the follicular apparatus of the intestinal mucous membrane. (2.) Arrested decay or involution of the thymus gland. (3.) Chronic catarrhs, especially of the bronchi. (4.) Rickets and its attendants. One coincidence, which deserves special attention amongst these com- binations, is that of hydrocephalus with hypertrophy of the brain. The latter is well known to be very commonly associated with general rickets; but the former is so constantly found to be connected with rickets of the thorax, that Engel has given the name of hydrocephalic to that particular distortion of the chest. A very common and essential combination with both forms of the dis- ease, and one with which the fatal result is frequently connected, is soft- ening of the stomach. , The following are unessential, and, to a certain extent, merely acci- dental combinations: hypostatic congestions of the lungs, lobular pneu- monias, slight pleuritic exudations, enlargement of the liver, &c. Intus- susceptions are very frequently met with in the intestines : but, although Abercrombie attributes them to the same cause as the vomiting which occurs in the course of the disease, they have certainly not existed for any length of time, and must rather have arisen during the agony ; for they present no trace of any congestion or swelling of the bowels from the strangulation of those vessels of the mesentery which are invaginated with the bowel. Terminations.—The great fatality of acute hydrocephalus is well known, and may be accounted for. The first of the two forms, when a tubercular process, is undoubtedly always fatal; but Avhen it is a simple meningitis, it may, as well as the second form, be outlived and cured, provided it be moderate in degree, and especially if the brain have escaped complete destruction by white softening. This termination, in a more or less complete cure, may be reduced to the following particulars: (1.) The products of the process may be entirely reabsorbed, and the brain be restored to its natural consistence, size, and figure. (2.) A part of the effused fluid, or the whole of it, may remain in the ventricles, and both they and the skull may be permanently enlarged. This can only be conceived to take place in the child just before the skull is completely ossified. The acute hydrocephalus thus becomes a chronic accumulation, which is capable even of further gradual increase. (3.) In that case, the lining membrane of the ventricles very often remains thickened in various forms and degrees. The quantity and density of its tissue are increased, and the plastic exudations remaining upon its surfaces become converted into a cellular or fibroid tissue, and covered with a layer of tesselated epithelium ; thus both contribute to the thickening of the wall of the ventricle. The new tissue assumes various forms, similar to the false membranes which occur on serous surfaces. THE ARACHNOID AND PIA MATER. 273 As its presence on so delicate a substratum as the ependyma is of some interest, and as it may be the means of leading to a more accurate examination of the cases in question, I will give a more detailed descrip- tion of it. a. The lining membrane sometimes appears covered with a granular film, like the finest sand, which has a transparent crystalline, or an opaque, grayish-white appearance, and can be detected only by looking carefully while the light falls favorably upon it. It may occasionally be seen at every part of the lateral, third or fourth ventricles, but it is gene- rally most developed at particular spots, as the corpus striatum, and taenia semicircularis, and especially in the anterior cornu of the lateral ventricle. ft. More rarely it forms coarser granulations, which are then more prominent, and in time become nodules attached by a pedicle. These granulations, more particularly, are analogous to the false growths of the same kind, which occur on other serous membranes, and to the Pacchionian bodies on the arachnoid. y. Sometimes the new tissue is smooth, membranous, and superficially attached, and forms separate, round, white, opaque, islands, or "plaques," which are not unfrequently thinner in their middle, and, as it were, per- forated (gefenstert, latticed): this form is analogous to the tendinous spots. 8. At other times the tissue is similar in its character, but instead of forming separate islands, it is continuous, and the whole seems knitted or areolar, and forms an adherent'network of false membrane, which may generally be easily raised from the surface. e. Or, lastly, it forms false membranes of considerable and nearly uniform thickness, which are for the most part, intimately united with the lining membrane. In these last sometimes bony concretions are developed. In some very rare cases of chronic hydrocephalus in children, espe- cially of congenital but advancing hydrocephalus, in which, also, the thickenings just described exist, a peculiar appearance is met with on the walls of the ventricle. The cerebral substance protrudes into the ven- tricle at various spots, probably those where the ependyma is relatively thinner, and forms rounded, smooth bosses, with broad bases, as large as hempseed or peas. I have had two opportunities of observing this peculiarity. (4.) Does it happen, as Otto, I believe, first asserted, that hydroce- phalus (of course I mean the second form, that which is allied to chronic hydrocephalus), is ever cured by the supervention of hypertrophy of the brain ? I have already (p. 272) considered the combination of hydroce- phalus and hypertrophy of the brain, which is occasioned by rickets: I believe, further, that the hydrocephalus (the hydrocephalic process) may itself sometimes give the first impulse to hypertrophy of the brain: but that any compensation for, or cure of, hydrocephalus is effected by hy- pertrophy, appears to be altogether problematical. Such an opinion is founded upon the fact, that in some large skulls, of hydrocephalic shape, the brain exceeds the normal size and weight. But, I believe, that these are cases in which the hypertrophy having taken place in childhood, has vol. in. 18 274 DISEASES OF continued ever since; and that belief is confirmed by the resemblance, in shape, which subsists between the skull in hypertrophy and the hydro- cephalic skull, as well as by the difficulty which the similarity in the symptoms of hypertrophy and hydrocephalus imposes, upon our deter- mining positively what disease of the brain did exist in childhood. _ So far as I am aware, the morbid increase in the volume of the brain in hydrocephalus, as well as its normal growth, takes place always in the neighborhood of the enlarged ventricles; it is a peripheral deposition around them: and the skull goes on increasing in size to whatever ex- tent its closure may be prevented by the hydrocephalus. B. Chronic hydrocephalus may be subdivided into congenital hydro- cephalus, and that Avhich commences at various periods of extra-uterine life : besides these, there is a third and entirely different form, hydroce- phalus ex vacuo. The distinction between the first two forms is not made by any essential difference between them, for in the most impor- tant particular, viz., their cause, they are undoubtedly alike; but con- genital hydrocephalus presents such very marked peculiarities that the distinction appears justifiable. The general anatomical characters of chronic hydrocephalus are a large accumulation in the ventricles of clear and colorless serum, which contains very little animal matter, and a thickening and toughness of their lining membrane, for the most part to a considerable degree. a. Chronic hydrocephalus, commencing after birth.—This is either a termination or continuation of acute hydrocephalus, especially of the second form of it; or else it is chronic from the first. The symptoms during life in the latter case were not such as to indicate the existence of any acute disease of the brain ; they were rather those of a long-con- tinued disease which occasionally underwent exacerbations. This form of hydrocephalus may occur at any period of life; but it is most frequent in the first years, and then attains its most advanced degree. The quantity of serum accumulated varies considerably, and depends upon the duration of the disease, and especially on the circum- stances of the skull being closed, or not, when it commenced, and whether its origin date from early childhood. In the first case it amounts to two or four ounces; while in children, and in adults who have had the disease since childhood, it may be as much as six, eight, or ten ounces, or even more. In children the skull increases in volume in proportion to the quantity of serum and the enlargement of the ventricles, and, at the same time, acquires the well-knoAvn hydrocephalic form, which so often continues throughout the remainder of life. This hydrocephalus then precisely resembles the congenital disease, and might in any case be taken for it, were there no certainty that it had come on since birth. The anatomical description of it agrees entirely with that of the con- genital disease. In respect to its causes, and the mode of its development, it essentially corresponds with the second form of acute hydrocephalus; oftentimes it is a primary and substantive disease, but very frequently it is secondary and symptomatic. Thus in the child as well as in the adult it arises as a primary disease from repeated and continued active congestions, such as, in the former, occur during groAvth, and in the latter, more frequently from excessive exertions of mind, repeated intoxication, &c. As a secon- THE ARACHNOID AND PIA MATER. 275 dary affection, it is a consequence of different diseases of the brain, par- ticularly of adventitious groAvths within the cranium ; or it comes on in the course of chronic diseases of the lungs, &c. Some growths are so situated that their pressure renders a sinus, particularly the straight sinus, impervious, and thus gives an especial occasion to chronic hydro- cephalus (Barrier). What has been said of the combinations of the second form of acute hydrocephalus applies to the chronic disease also. When thus combined it runs a lingering course, and has the character of a constitutional affec- tion. Terminations.—a. Two circumstances may interfere with a complete cure of the disease by the reabsorption of the fluid, the great quantity accumulated, and the extent to which the skull is correspondingly en- larged. The only real cure is a cessation of the process, and then the quantity of this fluid continues undiminished throughout life. The ques- tion, as to a cure being brought about by means of hypertrophy of the brain, has been already met at p. 273. ft. The disease may terminate fatally— (1.) By pressure, and consequent palsy of the brain, after having reached a certain degree, and having sometimes, in adults, occasioned absorption of the inner table of the skull; (2.) By the supervention of, or advance of the process to, a consider- able acute exudation into the substance of the brain, by oedema of the brain, and hydrocephalic softening; (3.) By an attack of acute hydrocephalus and meningitis. b. Congenital hydrocephalus.—This form of hydrocephalus is one of an eminently chronic character; it exists at birth, and usually has then already made considerable progress; but, if not, it soon increases, and, by the extraordinary size which it attains, and the amount of deformity it produces, it constitutes the most striking example of the disease. It is then distinguished by the large quantity of serum which the ven- tricles contain, and by the extent to which they and the skull are en- larged. Those cases in which no monstrosity of the brain coexists, may be portrayed as folloAvs: The quantity of serum contained in the ven- tricles amounts to several pounds, 6-10, or even more: the ventricles are expanded into large elliptical caA'ities, or membranous sacs; and their ependyma or lining membrane is generally much thickened. The cerebral mass around the ventricles, especially towards the top of the head, is attenuated, and sometimes measures scarcely a line in thickness : it may be even so reduced as to be but a lust perceptible layer covering the membrane. In one case, which is preserved in the Vienna Museum, it is broken quite through, at the upper part of the hemispheres, by the thickened membranous walls of the ventricles, and has receded from them to a considerable extent. Internally and inferiorly, the serum by its pressure flattens the corpora striata and optic thalami, and passing into the third ventricle, it forces those bodies asunder also; the corpora quadrigemina become smoothed, the commissures stretched, and the gray commissure very commonly wasted; the pillars of the fornix are forced apart, and, with the septum, driven up against the corpus collosum ; they are also either all much raised, or the septum is enlarged, very 270 DISEASES OF much thinner than natural, and broken through in one or more places of various size. The floor of the third ventricle is thin and transparent, the cerebellum is flattened from above: the pons is flat and spread abroad; the crura cerebri are separated; the pituitary gland is flat, or even concave, and wasted from pressure. The size of the cerebrum is greatly disproportioned to that of the cerebellum, the parts at the base of the brain, and the nerves. The surface of the cerebrum is flat, its convolutions are but just indicated, and could not be recognized ; and all the membranes of the brain are unusually delicate and thin. The head is quite remarkable for its size and its deformity. (Compare p. 168.) _ Congenital hydrocephalus is far from constantly agreeing with this picture: on the one hand, the quantity of serum, and the enlargement of the ventricles and skull, may be less than has been stated, and may indeed only just exceed the normal standard: while, on the other hand, under certain conditions, the development of the brain may be faulty, even to monstrosity. The mode of origin, or pathogenesis, of congenital hydrocephalus dif- fers most probably in no essential particular from that of the chronic hydrocephalus Avhich commences in the extra-uterine periods of life. It may come on in the foetus as acute hydrocephalus, or appear originally in the chronic form. The general arrangement of the skull of the foetus, and the manner in which the cerebrum itself is developed, are both highly favorable to an excessive accumulation of serum. And I believe, that the really essential part of congenital hydrocephalus, that which arrests the development of the brain, is the affection of the ependyma; that, in proportion to the degree to which the hydrocephalus has ad- vanced, and according to the period of foetal life at which it commenced, it does, in various manner, and to different extent, arrest the development of the brain, and occasion monstrosity of it; and so far contains the ground of its alliance with hemicephalus, hydrencephalocele, singleness of the cerebrum (cyclopia), &c. What has been said of the combinations of acquired chronic hydroce- phalus, describes those of the congenital disease also. A congenital dwarfish growth sometimes takes the place of rickets. Terminations.—The hydrocephalus of the foetus, even when it has reached a considerable extent, is not unfrequently inherited by the child, the youth, and even the adult. During the intervals in which the disease is quiescent, the brain grows, and acquires its normal volume, and the skull, continually advancing over it, at length closes. In some rare cases, growth passes beyond its normal bounds into hypertrophy; but with regard to the cure of hydrocephalus by hypertrophy, what has been said at p. 273, may be applied in this place. The disease sometimes proves fatal by the pressure which the continual accumulation of water exerts upon the brain. Frequently, too, acute inflammation of the ependyma, and meningitis arise in its course. I have, moreover, seen it terminate by rupture of the brain and dura mater, and extravasation of the serum of the ventricle beneath the pericranium and adjoining aponeurosis. Finally, considerable importance attaches to the hemorrhages which take place in the course of the disease : they are met with both in the THE ARACHNOID AND PIA MATER. 277 arachnoid sac and also, and more especially, in the dilated ventricle. They are remarkable for the length of time during which they are borne, as is attested by the metamorphoses of the extravasation. The way is most probably prepared for their occurrence by the stretching of the vessels of the membranes that cover the brain and line the ventricles, during the distension of the latter; and it is by the final rupture of those Aressels that they are actually produced. c. Hydrocephalus occasioned by a vacuum within the skull.—When an empty space is formed within the skull by a reduction of the volume of the brain, it is filled up (as already pointed out, pp. 253 and 260), by an increase of the volume of the inner membranes of the brain, and espe- cially by an extraordinary exhalation of serum into the tissue of the pia mater, the sac of the arachnoid, and the internal cavities of the brain, more particularly the lateral ventricles. These changes result from the congestion of the vessels which the vacuum produces. The most com- mon instance of effusions of this kind into the ventricles, is that which occurs when the brain is atrophied in old age; a condition which has obtained the title of hydrocephalus senilis. From the process of invo- lution of the brain, which gives rise to the affection in this instance, being so free from complication (einfach), from its uniform occurrence in both halves of the brain, and, lastly, from its frequency, it may serve as an example of this species of hydrocephalus. But the same condition is met with also in all cases of premature senility of the brain (senium praecox cerebri) and in every spontaneous and primary, as well as in every consecutive atrophy. Examples of the latter kind occur after recovery from repeated attacks of apoplexy, after inflammation of the substance, which has terminated with induration and wasting of the diseased portion, after the closure of an abscess, the healing of a wound attended with loss of substance, &c. Hydrocephalus is symmetrical, or otherwise, according to circum- stances. The quantity of serum contained in the ventricles, and the dimensions to which these cavities are enlarged, are measured by the degree to which the brain is atrophied: the former very commonly equals an ounce and a half, it often amounts to £ or 4, and may reach even 6 ounces, or more. As the quantity of serum increases, it accumulates in greater proportion in the dilated third ventricle, and produces especial attenuation of the gray commissure, the pillars of the fornix, and the septum ventriculorum : the septum may even be more or less perforated. The serum in the ventricles, like that contained in the sac of the arachnoid, and that infiltrated through the tissue of the pia mater, is remarkably clear. As the membranes at the periphery of the brain increase in volume, so also does the lining membrane of the ventricles become thicker than natural; and it often bears on its surface some analogue of the Pacchio- nian corpuscles of the arachnoid ; for the membrane is covered over with fine granules, Avhich are either clear like crystals, or opaque and white. This thickening is the principal cause of the resistance which is experienced in slitting up the Avails of the ventricles. Serous cysts on the choroid plexuses are frequently found in hydroce- phalus senilis. 278 DISEASES OF Though, from what has been said, it will be perceived, that in none of these cases is the watery effusion the essential disease, yet the false meaning Avhich is often attached to it, especially in senile hydrocephalus, renders it necessary to remark expressly, that the Avhole gravity of the case rests with the disease of the brain to which the effusion is owing. And so, too, the symptoms during life, and the usual mode of death, are to be comprehended and estimated by the same rule; the latter, for instance, is not to be sought in the effusion, but is to he looked upon as the final consequence of an atrophy of the brain, which has arrived at its relative maximum. All these forms of hydrocephalus, as I have already partly explained, combine with one another. Thus the acute disease not unfrequently supervenes upon the chronic, whether the latter be the congenital or the acquired; the hydrocephalus ex vacuo may associate itself with any of the other chronic forms. The chief seat of all the forms of hydrocephalus, as I remarked at the commencement, is the lateral ventricles; when the effusions are large they always advance into the third ventricle, but the fourth is even then involved in a very subordinate degree, and may not be involved at all. An accumulation of serum in the ventricle of the septum, is far more frequently met with than is generally supposed, especially in cases of chronic hydrocephalus; but it is decidedly rare for the accumulation to be at all great, and for the cavity to be very considerably enlarged. The enlargement of the lateral ventricles is chiefly confined to their body, and the anterior and posterior horns; that of the inferior horn is usually less in proportion. As a general rule, hydrocephalus is a symmetrical disease; but in some of the chronic forms the dilatation predominates on one side, and in the hydrocephalus ex vacuo it is sometimes entirely confined to one side. Slighter degrees of inequality on the two sides not unfrequently exist in senile hydrocephalus, especially in the instance of atrophy of the brain following the closure of an apoplectic cyst. 2. Adventitious growths. a. Cellular and fibroid formations have already been mentioned to occur as inflammatory products on the free surface of the ependyma, and to occasion the increase in the volume of the membrane itself (p. 272). A few cases have been noticed in which flat, or rounded, or irregular nodulated tumors of fibroid structure were developed in the lining membrane, independently, so far as could be traced, of any in- flammatory process. Sometimes free bodies of a similar fibroid texture, and the fibr o-car til agin ous appearance, are found in the ventricles; they are, most probably, merely tumors of the same kind which have been loosened from the ependyma, or the pedicle of Avhich has been broken. b. A production of bone takes place occasionally in the more bulky growths of the kind just described. In some few cases I have noticed here and there traces of a formation of bone in the fibroid products of inflammation attached to the ependyma; and in one well-marked case delicate plates of bone were formed so extensively in a knitted (areolar) false membrane of that kind, that the lining membrane seemed to be incrusted with them. THE BRAIN. 279 c. Tuberculosis.—I have neA^er met Avith tubercle on the lining mem- brane of the ventricles. The exceptional character, which the membrane assumes in this particular from other serous membranes to which it is allied can as yet only be accounted for with any probability, by supposing that in the process of softening, which goes on in acute tubercular exu- dations in this situation, the delicate structure of the lining membrane is destroyed too soon for the coagulation of the fluid blastema of tubercle to take place. d. Morbid growths of cancerous nature, or of a nature allied to cancer, though they certainly do occur upon and within the ependyma, are ex- tremely unfrequent in that structure, as well as in the choroid plexuses. I met with a very remarkable case of encephaloid degeneration diffused over the lining membrane of the cerebral ventricles, and encephaloid cancer of the tuber cinereum, in a girl of 10 years of age. The lining membrane of the enlarged dropsical ventricles was converted into a tolerably thick, Avhite stratum of medullary disease, which formed round, and conical, nipple-like processes growing in towards the cavity. e. On one occasion I met with an animal, resembling the cysticercus, with a large moderately filled bladder (Schwanzblase) attached to it, lying free in the right ventricle of a young person. 3. Anomalous contents of the ventricles. As the most important of the unnatural contents of these cavities may be gathered from what has been already said, or from what will yet be mentioned, there needs no special enumeration of them. The results of chemical examination of the effusions in hydroce- phalus, afford but little interest; they have been made without suffi- cient attention to, and distinction of, the different forms which the disease presents. SECTION II.—ABNORMAL CONDITIONS OF THE BRAIN. § 1. Deficient and excessive Development.—Acephalus, or deficiency of the head, affords an instance in which the brain is entirely wanting. In such a case more or less of the spinal marrow and vertebral column, especially, of their upper part, is generally Avanting too. And Avith this deficiency is combined absence of the heart, of great part of the vascu- lar system, of the lungs, and of the principal abdominal organs, so that, while the urinary and genital organs exist, nothing else can be found within the peritoneal sac, except a rudimentary intestinal canal. In cases allied to this an extremely rudimentary and simple brain is enclosed in a very small cranium, in a mere shapeless, and very small, bony capsule : monstrosity of the face exists also. Sometimes a part of the brain is wanting. It may be the whole cere- brum or any large section of it, as the anterior lobes with the organ of smell, the optic thalami and optic nerves, the posterior lobes, the fornix, the septum, the corpus callosum, the cornua ammonis, &c. The skull is then small in proportion to the deficiency, and the face Avanting or mal- formed : or, again, it may be some smaller and less essential part of the brain, as the hippocampus minor, or the gray commissure; or single convolutions, so that the white substance is exposed, &c 280 DISEASES OF Again, the brain may be generally of small size, though it exists in all its parts; and the skull is diminished to a corresponding extent: but of this state, microcephalus, as well as of several other instances of defi- cient development of the brain, a further account will be given amongst the anomalies in its form. There is, besides, one instance of congenital deficiency of more or less of the brain, which I have not put in the same series Avith those already mentioned, because, to say the least, it is highly probable that it owes its origin to an attack of hydrocephalus at some period (generally a very early period) of foetal life. It is the instance known as anencephalus, hemicephalus, and also as acrania. There is much difference in the extent to which different cases of hemi- cephalus proceed, depending partly on the extent of the previous hydro- cephalus, but principally upon the period of foetal life at which the dis- ease of the brain commenced. Sometimes that organ is Avholly wanting, and only the membranes are found at the base of the skull, with the cere- bral nerves sunk into them: sometimes a few rudiments of the brain exist, particularly those structures which compose its base ; while it is covered with a membrane, formed of much attenuated skin, and dura mater, which exhibits traces, more or less distinct, of having been ruptured. The vessels of the inner membranes are generally numerous and gorged, the membranes themselves are filled with extravasated blood, they pre- sent a honeycombed arrangement of their structure (which has been compared to hydatids), and contain some grayish-red cerebral substance. The brain itself is unusually vascular and soft, and appears as if it had been macerated. The roof of the skull is almost entirely wanting ; for the usually expanded frontal and parietal bones form mere small and slender streaks, or irregular triangular plates of bone, and are sunk down upon the base : and the broad occipital plate is shrunk to a few rudi- ments, or severed by wide fissures. A vault may be formed to the skull by these rudiments of the bones, but it is very low, and divided by wide fissures from before backwards. The bones at the base, if they are not divided also, are small like the occipital bone, but very thick and coarse. In other cases, only a small part of the cerebrum is destroyed; and, as the greater part of the brain remains, the cavity of the cranium is proportionally capacious, and the deficiency of bone is confined to its uppermost part. Hemicephalus is allied to a certain stage of hydrocephalus. Within a skull of normal size or enlarged, but which is closed, there exist no cerebral hemispheres, but a sac, surrounded with the cerebral mem- branes, and filled Avith serum, while the base of the brain lies at the lower part of the skull, more or less rudimentary and misshapen. Such a case exhibits clearly the alliance which subsists betAveen hemicephalus and hydrocephalus, and the foundation of the former in the latter; but the combination of hemicephalus with encephalocele, that is, its origin from hydrencephalocele, exhibits it more clearly still. In this instance of hemicephalus, a part or even the whole of the brain, destroyed in the manner above described, lies outside the skull; the cranial vault is split along the mesial line by a greater or less fissure, and is low in every case, but it is sometimes quite sunken to the base. THE BRAIN. 281 But further, we have an opportunity sometimes of demonstrating this cause of hemicephalus, by direct observation at the time of its occur- rence. The skull of a foetus, at such a time, is found distended and hydrocephalic, and at the vertex a slough is seen, produced by the pressure and stretching. Lastly, hemicephalus is very frequently combined with the same in- stances of arrested development as the higher degrees of congenital hydrocephalus. It is often accompanied, too, by fissure of the vertebral column (spina bifida): when the occipital bone is split completely through, the cervical vertebra are nearly always fissured also. When the brain is developed in excess, it becomes more or less com- pletely double. It is very rarely found that any one part is double while the remainder of the brain is single: though such is sometimes the case, with the gray commissure, for instance. The cerebrum and cerebellum sometimes have an unusual number of lobes, and thus appear to be deve- loped in excess. § 2. Deviations of Form.—The form of the brain generally corre- sponds to that of the skull, but anomalies occur, principally in the cere- brum. In the first place, the brain is subject to variations, in respect to its length, its breadth, and its height: in the next place, some of the larger portions of it, the anterior or posterior lobes, for instance, may exceed, or come short of, their normal development: the two halves of the brain may be unsymmetrical, in consequence either of inequality of size generally, or of a difference in a particular diameter, or in conse- quence of a change of relative position in the horizontal or in the vertical direction, &c.; and lastly, its form varies in respect to the stronger or fainter marking out of the separate lobes, and to the number, depth, and symmetry of the convolutions of the cerebrum, and laminae of the cerebellum. Alterations of shape, similar to these congenital deformities, occur also, as results of disease of the brain: the principal instances are those in which the symmetry of the two halves is deranged, by an increase or diminution in the volume of the whole, or of part of one side, as well as by flattening, and loss of the convolutions, &c. The most striking deformity of the brain is that in which the cerebrum is single; it occurs in conjunction with cyclopia, and with partial or total absence of the face. (Ateloprosopia ; Aprosopia.) The brain forms a single sac, open behind, but completed by the arachnoid, and filled with serum: its posterior lobes are so defective, that the cerebellum, corpora quadrigemina, and even the optic thalami, appear uncovered; whilst many other parts, the fornix, corpus callosum, septum, small commis- sures, &c, are also wanting. The cerebrum is sometimes thus single in cases of hemicephalus, and this combination associates the latter with cyclopia. (Otto.) Another anomaly, observed in the interior of the brain, is allied to that which has just been mentioned: it is that in which the optic thalami and corpora striata of the two sides are fused together in the middle: a double or a large commissura mollis is a modification of the same anomaly. From the opposite condition, deficiency of the commissures, a division of the brain results. The fornix is very rarely Avanting, while, on the 282 DISEASES OF other hand, deficiency of the soft commissure of the optic thalami is not unfrequent. The other smaller organs of the brain are rarely misshapen from any fault in their original formation. § 3. Anomalies of Position.—Disregarding, for the time, the displace- ments within the skull to which the brain is subjected by various growths, we find the most striking anomaly in respect to the position of the brain to be hernia,—encephalocele,—extrusion through an aperture in the skull. Congenital hernia of the brain is occasioned by an extreme increase of the organ in bulk. In most cases it is undoubtedly the consequence of hydrocephalus (hydrencephalocele), the pressure of which interferes with the development of the bones generally, and, at some particular spot, arrests it altogether. The size and form of the congenital hernia of the brain bears a certain relation to the dimensions of the aperture in the skull, as well as to the quantity of the protruded cerebral mass, and of water accumulated in it: the size of the hernia, however, and the dimen- sions of the aperture in the skull, are very often proportioned inversely to one another. The hernials sometimes as large as the head, or larger; more frequently it is below that size. Its form is that of a round tumor, or of an appendage to the skull; and when it is large, and the aperture in the skull small, it appears attached by a neck or pedicle. The protruded mass of brain is covered externally by the general in- teguments, which are mostly thin, and without hair; internally, the inner cerebral membranes are in immediate contact with it, while, between the two, the pericranium and dura mater are intimately united with each other. True hernia of the brain must not be confounded with saccular protrusions through the skull, which, though similar, are merely herniae of the arachnoid: they are sometimes so far combined with hernia of the brain, that, as they increase, a portion of that organ may project within their pedicle. The protruded portion of brain is sometimes in the same state of de- struction, and consecutive malformation or vitiation of its growth (Ver- bildung), as in the case of hemicephalus, the hernia is then combined with hemicephalus, the former passing into the latter. The situation in which hernia occurs is also very various. Most com- monly it is at the occiput; and next, though much less frequently, it oc- curs further upwards in the mesial line, at the anterior fontanelle. More rarely still, it happens in the lateral regions of the skull, and on the forehead: while sometimes, but most unfrequently, the brain protrudes into the nostrils, or sphenoidal sinuses, and forms a tumor at the root of the nose, or in the pharynx. The skull, in these cases, is altered in size and shape. As more of the brain protrudes, the cranium becomes generally smaller, and its vault flatter; and if, at the same time, the aperture be large, that form of the head predominates which is exhibited in hemicephalus. But this rule has its exceptions; for if the hydrocephalus be very large, the great quantity of the serum may, in spite of the size of the tumor, not only preserve the skull at its normal dimensions, but even enlarge it beyond THE BRAIN. 283 them. When the hernia protrudes through the cribriform plate into the nostrils, the vault of the skull sinks, in the form of a saddle. Hernia of the brain rarely comes on after birth, for it is then only through accidental openings of the skull and dura mater, or those made designedly by art, that the brain can protrude. The hernia is effected by the congestion and turgescence of the brain, which are excited by the external injury, by swelling of the brain arising from acute oedema, by acute hydrocephalus, &c. The protruded portion of brain takes the form of a sausage; it sometimes reaches a considerable size, and measures several inches in length. It is liable to be strangulated by the aperture in the skull and dura mater, and then frequently becomes congested, and mortifies; and injuries to its free extremity may be followed by inflam- mation and suppuration. § 4. Deviations in Size.—Many individuals present peculiarities in respect to the size of their brain; but the organ is subject to other and more essential deviations from its natural bulk. I shall treat first of unnatural excess, and then of unnatural diminution of its volume. 1. Unnaturally large size of the brain.—Many morbid conditions augment the volume of the brain, as hyperaemia, hydrocephalus, and oedema, adventitious growths, and hypertrophy, or a combination of any of them with one another. I have here to treat of increase of volume by hypertrophy, which is the most important of these morbid conditions; the others have already been, or will be, mentioned in their place. Hypertrophy of the brain.—Its general characters are, unnatural size and weight of the organ. It varies in degree ; and its importance de- pends partly upon this variety, but mainly on the condition of the skull. The most serious conditions under which it occurs, are when the hyper- trophy is far advanced, and the sutures are closed, as the skull then resists the increase of the volume of the brain. The best plan will be to begin by depicting such a case. When the skull-cap is removed, the brain, closely covered by the dura mater, swells up palpably (turgescirt) ; on slitting open the dura mater, the swelling is still more distinct, and it costs some trouble to fit the skull-cap on again. All the membranes of the brain are remarkably thin; the dura mater especially is delicate, pale, reddish, and transpa- rent. The inner membranes lie close upon both the dura mater and the surface of the brain. Their lack of the fluid Avhich usually moistens the arachnoid, and occupies the tissue of the pia mater, is quite conspicuous; they are dry, and their vessels are bloodless and flattened. Before further dissection and comparison the cerebral hemispheres ap- pear large. Their convolutions are compressed and flattened, and the sulci between them are scarcely discernible. The usual horizontal section through the hemispheres, a little above the level of the corpus callosum, displays a centrum ovale of unusual size. The ventricles are remarkably small. When the whole brain is removed from the cranium, the size of the cerebrum again arrests attention, especially when compared with the cerebellum and other parts at the base of the brain, and with the nerves. It is quite clear throughout the examination that it is the white sub- 284 DISEASES OF stance that is increased in volume, the white substance of the cerebral hemispheres. The cineritious matter is generally of a pale grayish-red color, the medullary is always dazzling white, and remarkably pale and anaemic; *a circumstance both of interest and importance, because it distinguishes the increase in the volume of the brain occasioned by hypertrophy, from that Avhich is produced by congestion. The consistence of the hypertrophied white substance is quite peculiar; it is elastic, and has the somewhat firm resisting feeling of rising dough. Having thus sketched the most essential and most striking of the ap- pearances in hypertrophy of the brain, I proceed to detail some results which attend it in advanced degrees of the disease, and at particular periods of life. a. When the hypertrophy is very far advanced, and the sutures are closed, the pressure sets up some absorption at the inner table of the skull, and it becomes rough : the absorption may even go so far as to make the wall of the cranium distinctly thinner than natural. Inferiorly the cerebellum and the structures at the base of the brain are flattened and spread out, evidently by pressure from above. The absorption of the inner table generally begins and goes farthest at the vault of the skull, though it appears indeed, to be most advanced at the base, as the bone, which was there originally thin, is in some parts perforated with holes, produced by the absorption; the orbital and cribriform plates, and the roof of the sphenoidal sinuses, are thus perforated. ft. Enlargement of the skull, as a consequence of hypertrophy, takes place only in the child ; but it occurs, whether the bones be held together by interstitial membranes still, or by sutures. The enlargement of the skull, and the hypertrophy of the brain, vary together. In its general form, the skull resembles the hydrocephalic skull. y. In some rare cases, among children in whom the disease has rapidly advanced to a considerable extent, the sutures of the skull become loose and separate, especially at the upper part of the head, and the sutural cartilages become suffused, and are of a reddish color. Hypertrophy of the brain is sometimes congenital, and is then often combined with hydrocephalus ; it more usually comes on during extra- uterine life, but is almost exclusively confined to the period of childhood. It is occasionally met with about the time of puberty, and sometimes even in manhood; but at the latter period it is extremely rare. Congenital hypertrophy is accompanied by very various degrees of arrested development of the vault of the skull, and sometimes, indeed, that part is entirely wanting (acrania), it is attended, also, by general dwarfish growth, and by various faults in the development of the brain, as well as of other organs. When it comes on in childhood and at pu- berty, it is combined with general enlargement of the lymphatic glands, and but partial obliteration (involution) of the thymus gland: in child- hood it is also combined with rickets and a feeble muscular development. And it supervenes upon hydrocephalus, both the cong aorta, or adventitious structures in the mediastina, and generally from any kind of accumulation within the thorax. If there be no pre-existing adhesions in the last-named case to oppose the displacement, the lung, as has been already remarked, is con- stantly pressed inwards and upwards towards the mediastinum and ver- tebral column. A similar change in position occurs when obsolescence takes place from internal conditions, since the lung is then retracted on the bronchus. § 4. Diseases of Texture. We shall commence with a description of two very simple alterations of tissue, which, although not very striking in themselves, lead to very important consequences, which, singularly enough, resemble each other; these are rarefaction (vesicular emphysema) and condensation of the pulmonary tissue. a. Rarefaction of the Pulmonary Tissue.—Emphysema.—Under the term pulmonary emphysema we comprehend, according to Laennec, two different conditions, of which one (and by far the more important one) is not fairly entitled to this name; but this inaccuracy leads to no error, because, in using the terms emphysema vesiculare and emphysema inter- lobular, we indicate the seats of the two diseases, and thus distinguish one from the other. In emphysema vesiculare we have a morbid condition of the peripheral THE RESPIRATORY ORGANS. 53 portion of the respiratory organs analogous to that which we have already described as dilatation of the bronchi, and even of the trachea. Had Laennec done nothing else for medical science, his discovery of this diseased-condition, and of the causes giving rise to it, would have sufficed to render his name immortal. Vesicular emphysema consists in a permanent dilatation of the pul- monary vesicles, and the respired atmospheric air is actually contained within them, and does not, as in ordinary emphysema, become extrava- sated into the interstitial texture. It not unfrequently arises very rapidly as a vicarious development of pulmonary parenchyma in cases where a great portion of the lung has become impermeable ; and it appears more especially to be produced in a high degree during the last moments of existence, as a consequence of the labored inspirations which then occur. Thus in diffused hepatisation we find the edges of the inflamed lobes puffy and emphysematous, and in the higher degrees of pulmonary tuberculosis, the same condition is observed in the interstitial parenchyma between the tubercles, and in the superficial stratum of the lung. In like manner it developes itself as a sequence of those acute and chronic diseases which prove fatal by paralyzing the nervous apparatus presiding over the chemical process, and in which there is the most laborious action of the respiratory mus- cles, deep inspiration, and an insatiable thirst for air ; or it arises as a consequence of a sudden check to expiration, as in hemorrhages from the air-tubes, when the bronchi become obstructed by blood. In such cases we observe the following appearances : the emphyse- matous portion of the lung is puffed up, and conveys to the hand a pecu- liar feeling, which may be compared to that of a cushion filled with air; is pale, varying in tint, from a palish red to a dull white color, and is perfectly anaemic; is dry, collapses rapidly on being cut, but on pressure crepitation is indistinct and dull; it floats on the surface when placed in water; its cells are more or less dilated, and their walls are attenuated in proportion to the rapidity with which the morbid change has been developed. Finally there is sometimes extensive laceration of the di- lated cells, and the emphysematous portion of the lung then presents the appearance of a torn network swollen with air. This form of em- physema seldom attains this degree, except on the anterior edge and towards the base; and at these parts it gives rise to the escape of air beneath the pulmonary pleura, which consequently peels off from the lung. This form of emphysema, in so far as relates to the attenuation of the walls of the dilated cells, presents an analogy with senile atrophy of the lungs. Another form of vesicular emphysema developes itself slowly, gra- dually spreading itself over a large portion of the lung, till it finally involves the whole organ; it arises, in part, from other causes than those already mentioned, and constitutes a substantive disease of the lung, which, as Laennec remarks, unquestionably gives rise to most of the so- called nervous asthmas. It presents many varieties in degree and extent. By degree, we refer to the extent of the dilatation of the pulmonary cells; it must, however, 54 ABNORMAL CONDITIONS OF be remarked, that in emphysema of long standing, we always simultane- ously find several degrees of dilatation, and that it is only during the commencement of the disease that the dilatation is observed to be uni- form. The pulmonary cells may be dilated to the size of a millet-seed or pin's head, or to that of a hemp-seed, a pea, or even a bean, and, in proportion to the size which they attain, they deviate the more from their original shape. At first the disease is a genuine, simple dilatation of the cells, and when the cell-walls become to a certain extent thickened and rigid, it may be regarded as an active dilatation of the cells some- what analogous to hypertrophy of the lungs. In higher degees, on the contrary, the dilatated cells unite to form larger spaces, their Avails be- coming atrophied by the pressure they :exert on one another. Such hemp-seed, pea, or bean-sized* cells always present a very irregularly sinuous, but on the Avhole a roundish form, and exhibit a singular arrange- ment ; for on their inner surfa.ee there are elevated ridges, projecting to various heights Avithin the cavities of the dilated cells, traversing them in various directions, and forming boundaries and imperfect partition- Avalls to the different sinuosities. We likewise perceive delicate threads, either extending across the cells, or hanging free in their cavities: these cover the elevated ridges and the remains of the contiguous Avails of the pulmonary cells. The pressure exerted on the adjacent tissues, which giA^es rise to their atrophy, is proportional to the dilatation of the cells; and the cell-walls becoming thick and rigid, the emphysematous lung, when a section is made, either does not collapse at all, or collapses very slowly. Moreover, this form of emphysema occurs most frequently, and is most highly developed, in the peripheral portion, and along the edges of the lungs : it is not unfrequently associated with bronchial dilatation; and this, amongst other signs, establishes the affinity of these two dis- eases. It either attacks a small portion of the lung only, being con- fined especially to the anterior edge of one or other of the upper lobes, or else it spreads over a whole lobe, or a whole lung, or even both lungs. In cases of emphysema of both lungs, the association of all the ana- tomical signs presents the following picture of the disease: Barrel-shaped dilatation of the thorax, with permanent depression of the intercostal spaces ; great dorsal curvature of the spine ; hypertrophy of the respiratory muscles; and a clear sound on percussion. On opening the thorax, the lungs expand beyond the walls of the chest, are seen to be remarkably large, and do not collapse under the pressure of the atmosphere. On their surface, and especially at their anterior edges, we find round prominences as large as a hemp-seed or a pea, either standing alone or arranged in groups, and which are nothing more than the dilated pul- monary cells which have been already described. The lungs have a very peculiar, soft, elastic feeling, which may be compared to that of a cushion filled with down. On being cut they collapse very slowly, and the air escapes sluggishly, with a very diffused sound, scarcely amounting to crepitation, and some- what resembling that of air sloAvly escaping from a pair of bellows. Their tissue is pale throughout, anaemic, and singularly dry. THE RESPIRATORY ORGANS. 55 When only one lung is emphysematous, then only the corresponding half of the thorax is dilated; but an important fact in this case is the displacement of the mediastinum and the heart towards the opposite side. Finally, if only individual portions of the lung are emphyse- matous, they may, if they are very numerous, and the disease is highly developed, prevent by their pressure the expansion of the neighboring healthy cells, and thus retain them in a state of persistent compression. The conditions giving rise to the production of emphysema, and its pathogeny in general, although much labor has been devoted to the affection, are still far from clear. Laennec regards it as a consequence of his so-called dry catarrh with pearl-colored secretion, and explains it in a mechanical manner: this secretion, and the catarrhal puffiness of the mucous membrane, obstruct the bronchi in such a manner, that although they allow the inspired air to enter the pulmonary vesicles, the diminished energy of the act of expiration presents an impediment to its escape, and hence a portion of it is retained. In the succeeding inspirations new air is again conveyed to the pulmonary vesicles, whose dilatation is thus effectually accomplished, the expansion of the inspired air, from its elevated temperature, doubtless contributing to the result. Moreover, a prolonged retention of the breath during parturition, a stool, or in blowing Avind-instruments, may give rise to emphysema. In opposition to the view that emphysema is a consequence of catarrh, cases have been adduced in which either no catarrh had existed, or when it only followed the dyspnoea as a symptom of pre-existing emphysema; in reference to the last-named causes, it is alleged to have occurred in persons Avho have never been exposed to these diseases. Hence, a spon- taneous dilatation of the pulmonary vesicles has been assumed, which at one time occurs as premature atrophy with attenuation of the cell- walls, while at another time, from equally unknown causes, it is asso- ciated, as in other hollow organs, Avith hypertrophy of the cell-walls. Laennec's view regarding the former mode of development of the affection, is essentially an important one. We do not, however, believe that the long retention of the breath is, in itself, the principal cause of forcible expansion of the air-cells; we are much more inclined to attribute it to the very deep and forcible inspirations which at length follow the expirations, and, in illustration of this view, we may refer to the nature of the inspirations in croup, in the bronchial catarrh of children, and in hooping-cough. Besides inducing forcible dilatation, they may also cause a paralysis of the contractility of the pulmonary tissue, and, consequently, a stagnation of air in the dilated pulmonary vesicles. Emphysema may, however, be developed in cases where none of these injurious influences have been present; and it may occur gradually in persons leading a sedentary life. In these cases the less frequent but the proportionally deeper inspirations are the more to be regarded, be- cause they take place with very little action of the diaphragm (abdo- minal respiration), as the occupation of such persons requires a bent position compressing the abdominal cavity, and, at the same time, power- ful exercise for the arms. A paralyzed and atrophied condition of the diaphragm is here of the greatest importance; for the hinderance to the abdominal respiration thus induced is compensated by the strained 56 ABNORMAL CONDITIONS OF activity of the other great respiratory muscles; and this circumstance is in accordance with the facts that the dilatation of the thorax is most marked in its upper segment, and that emphysema is primarily and most fully developed in the upper lobes, and especially in their anterior por- tion. The thickening of the walls of the dilated air-cells arises, in our opi- nion, principally from the tissue adjacent to them becoming broken down by compression, and fusing with the cell-walls themselves; nevertheless if the dilatations increase from the persistent pressure exercised by the dilated cells on one another, atrophy of the contiguous walls will ensue, and the cells will unite to form larger cavities, much in the same way as we occasionally observe to occur in contiguous bronchial sacs. The dyspnoea, conditional on emphysema, depends on several causes. a. The excessive accumulation of air in the pulmonary vesicles hinders the proper filling of the capillaries ramifying on their walls by the pres- sure it exerts on them, and thus interferes with the vitalization of a suffi- cient quantity of blood. ft. In the higher degrees of emphysema numerous capillaries become obliterated, not only in the walls of the dilated cells, but also in the sur- rounding atrophied tissue,—a condition which induces the above conse- quence in a still higher degree. y. The diminished contractility of the pulmonary tissue and the con- stantly labored inspirations which then become necessary in consequence of the imperfection in the chemical process of respiration, allow of only a very imperfect emptying of the pulmonary cells and consequently give rise to the permanent stagnation of air no longer fit for the purpose of respiration, which, in its turn, also tends to prevent a sufficient ventaliza- tion of the mass of the blood. The impermeability of the capillaries depending on the two first-named conditions gradually, but unfailingly, leads to disease of the right side of the heart in the form of active dilatation, which proceeds to affect the venous system; the venosity and cyanosis which ensue from these changes constitute the leading grounds for the immunity of asthmatic persons from tuberculosis. The impermeability of the capillary vascular system, moreover, gives rise to the anaemic state of emphysematous lungs, thus rendering it an impossibility that oedema, stasis, hemorrhage, or pneumonia, should be developed in them. It is easy to understand how it proves fatal. It kills by finally induc- ing paralysis of the lungs, by asphyxia from the accumulation of air no longer fit for the process of respiration, by paralysis of the heart, or by vascular apoplexy of the brain. Emphysema interlobulare is the only form which, strictly speaking, deserves the name of emphysema ; it consists in an accumulation of air in the cellular interstices of the pulmonary lobules. It can only result from the rupture of one or more pulmonary vesicles, and the escape of air from them into the adjacent cellular interstices, if, indeed, we except the spontaneous development of gas into the interlobular cellular tissue, which is not altogether impossible. We consequently find air-bladders in the cellular interstices, and espe- THE RESPIRATORY ORGANS. 57 cially on the surface ; they vary in number and size, and are characterized by their paleness, transparency, and round or rather oblong form ; they may be made to move in the direction of the interstices, and to run into one another, so as to form ridges which ramify in the same direction su- perficially, and into the body of the lung; sometimes they circumscribe and, as it were, insulate the lobules, and as they are broadest on the surface, and as their size diminishes in proportion to the depth to which they penetrate within the substance of the lung, they present a wedge- like shape. When they are very small and closely crowded together, they present the appearance of froth. On making a section of a portion of dried lung, we find the interstitial tissue presenting irregular cellular spaces of larger or small size, heaped, without order, on and around one another, and perfectly different from the adjacent air-cells. As has been already mentioned, most of the air is usually found accumulated in the peripheral interstices, so that the pleura presents a puffed up, vesicular appearance. The air often makes its way into the cellular tissue uniting the pleura to the lung, peeling off large patches, and form- ing flattish, convex, movable air-bladders ; and, in these cases, it is to be feared that some of these bullae may be ruptured, and that the air may be extravasated into the pleural sac. In other cases the extravasated air may penetrate into the substance and towards the root of the lungs, and pass into the cellular tissue of the mediastinum, and from thence into the neck, and thus cause general emphysema. This condition usually co-exists with a puffy state of the lungs, but never with well-marked vesicular emphysema. It is most common in children; and is occasioned in them, as well as in the rarer instances in which it occurs in adults, by very rapid, deep inspirations, or by long retention of breath when great muscular exertions are made, requiring a fixed condition of the thorax. It is most commonly situated in the upper part of the lobes, and especially along their anterior edges. b. Condensation of the Pulmonary Tissue.—A certain degree of con- densation is natural to the lungs of children ; it sometimes occurs in adults as an individual peculiarity, and is then often associated with smallness of the lungs and pleural sacs. It is also present as a transitory condition during pregnancy. It only comes within the limits of pathology, when it has become per- manent and highly developed, and offers a persistent impediment to the capillary circulation through the lungs. Such a degree of condensation may arise when the abdomen becomes enlarged and encroaches on the thoracic cavity, but in children it is more frequently dependent on lateral depression of the thorax consequent on atrophy of the great respiratory muscles, or on rachitis affecting the chest; it may also arise from spinal curvature, distension of the peri- cardium, enlargement of the heart, large aneurisms, adventitious products, &c. ; or from the pressure exerted by an accumulation of air or fluid in the cavity of the chest, from pleuritic exudation, or from bronchial dila- tation ; and, according to the various exciting causes, it may occur simul- taneously in both lungs, or only in one, or merely in certain portions of the pulmonary tissue, as in cases of rapidly developed emphysema, where we not unfrequently find single lobules compressed in the centre 58 ABNORMAL CONDITIONS OF of the emphysematous portion, or in cases of atrophy of the external respiratory muscles, where single circumscribed portions of lung are found in a state of condensation under the bent anterior ends of the ribs. There are different grades varying from simple increase of density cha- racterized by augmented consistence and compression of the pulmonary tissue, and by a stasis and hyperaemia depending on obstructed circu- lation, to such a degreee of compression as to destroy the air-cells, to arrest the capillary circulation, and to give rise to atrophy of the texture of the lung. The most intense compression of the lung occurs in cases where there is abudant pleuritic effusion. With the alterations in position and form, to which allusion has already been made, the lung ahvays becomes denser and gradually becomes impermeable to air, and, finally, eA'en to the pas- sage of blood along its capillaries. If the lung still contains blood, its red color gives it such a similarity to flesh, that this condition has re- ceived the name of carnificatio pulmonis, but at a subsequent period it becomes of a dirty brown, or, more commonly, of a bluish-gray or lead- color, and is tough and leathery, and sinks in water. If the state of extreme compression persist for a length of time, the pulmonary tissue finally becomes obsolete, that is to say, it becomes con- verted into a cellulo-fibrous tissue,—a condition altogether distinct from atrophy of the pulmonary tissue. Excessive condensation of the lungs gives rise to consequences similar to those of emphysema; it impedes the capillary circulation, and thus occasions stasis in the trunk of the pulmonary artery, giving rise to active dilatation in the heart, and consequently to venosity and cyanosis. Hence, like emphysema, it affords a remarkable immunity from tubercu- losis, especially when associated Avith curvature of the spine. There is a peculiar form of anomalous condensation of the pulmonary tissue, probably dependent on a congenital bronchial catarrh or catar- rhal pneumonia, and consisting in a deficient development of the lungs of new-born children, in which certain portions of those organs retain their foetal condition after birth. It is termed atelectasis of the lungs, and presents various degrees of obstruction to the closure of the foetal passages, namely, the ductus arteriosus and the foramen ovale, thus giv- ing rise to predominance of the right side of the heart and to cyanosis. c. Hyperosmia ; Stasis—Apoplexy of the Lungs.—No organ with the exception of the brain, is so frequently the seat of hyperaemia as the lung. It occurs in various degrees, and developes itself either gradually or with intense rapidity, and is the anatomical basis of most sudden deaths. In a lesser degree, as simple hyperaemia, it is frequently an habitual, and not rarely a periodic affection of an active nature; it often ensues with great rapidity, and may prove speedily fatal by itself, or more fre- quently by the superaddition of acute oedema. We then find both lungs uniformly puffy, and of a dark-red color ; their vessels, even to the capil- laries, being filled Avith dark blood, and their tissue being succulent and softened, but still crepitating. In the bronchi we find a grayish, some- times reddish mucus mixed with air-bubbles. The heart is usually some- THE RESPIRATORY ORGANS. 59 what dilated, and always contains a large quantity of thin liquid or slighty coagulated dark blood, especially in its right cavities. The veins of the membranes of the brain are usually full to distension, and serous effu- sion into the cerebral ventricles frequently occurs as a consecutive compli- cation. The outer surface of the body is characterized by livor, and by the rapid occurrence of extensive and very dark-colored death-spots ; the face in particular is very puffy, and of a more or less bluish tint; the eyes and mouth are generally more or less open, and the conjunc- tivae injected; the mucous membrane of the mouth is livid, and that of the throat is covered with tough mucus. Grayish or pale reddish, frothy mucus is found in the trachea. In a higher degree hyperaemia amounts to stasis. In this stage the parenchyma of the lung is of a purple or black-red tint, and, as it were, saturated with blood; and as it somewhat resembles the sub- stance of the spleen, this condition has received the name of spleniza- tion. SeAreral of the other characters of this condition are subject to various modifications, depending primarily on the degree and the dura- tion of the hyperaemia, but to a lesser extent on the nature of the stasis and the composition of the blood. When it is recent and comparatively slight, the parenchyma is denser, but easily torn; it crepitates, although less clearly than in the normal state; on cutting it, a large quantity of fluid blood escapes; the diseased portion is puffy, and floats on water. In a higher degree, and when the stasis has continued for a longer period, the Avails of the air-cells and the interstitial tissue become swollen, so that the former may become perfectly impermeable to air: the paren- chyma consequently become denser, hard, and heavy, and ceases to crepitate; and on making an incision only a comparatively trifling quantity of thick fluid blood escapes. The blood appears, as it were, fused into the tissue of the lung, the whole affected portion having a somewhat shrunken appearance. The blood contained in the splenified portion of the lung presents various shades of discoloration, viscidity, fluidity, or gaseity, according to the nature of its composition and the character of the stasis. According to circumstances Ave occasionally find in the bronchial tubes either a sanguineo-mucous or sanguineo-serous fluid. Stasis is the result of an active or passive, or of a mechanical hyper- aemia ; either of these may prove fatal by itself, especially A\\hen exten- sively developed; and either may sooner or later pass into inflamma- tory stasis and inflammation. It never attacks both lungs simultane- ously and in an equal degree; it generally exhibits a preference for the loAA'er lobes, and when it extends over a whole lung, usually commences inferiorly. Stases of a passive nature in the most dependent posterior and infe- rior portions of the lungs, such as are developed in bedridden old persons, or in individuals confined to bed for a length of time in con- sequence of cerebral disease, typhus and typhoid affections, any ady- namic diseases, and especially paralyzed conditions of the lungs, are im- portant. They constitute the pulmonary hypostasis of Piorry. 3Iechanical stasis is most commonly dependent on organic diseases of the heart, although excessive density of the lungs may give rise to it. 60 ABNORMAL CONDITIONS OF It is developed, according to circumstances, either in the arterial or the venous portion of the capillary system of the lungs. It is of great importance to distinguish, as clearly as possible, be- tween these conditions and the stasis which is developed in the body after death,—cadaveric hyperemia of the lungs, more especially as this is very frequent and is often combined with the former. The latter is ahvays most marked at the posterior portion of the lungs, gradually diminishing in the superior and anterior directions. The lung is soft and crepitates, and apparently is not so much saturated with actual blood, as with a sanguineous, dark-red, frothy, discolored serosity, which is poured forth in abundance from the cut surface, and may be entirely removed by moderate pressure, after which there remains a pale, dis- colored parenchyma compressed in proportion to the pressure empr&yed. In consequence of prolonged imbibition, the pleural sacs not only become discolored, but a certain quantity of sanguineous discolored serosity makes its Avay into their cavities. Different Ariews have been held, especially in recent times, since doubts have been entertained regarding Laennec's theory of haemoptoic infarctus, respecting the relation which these conditions bear to pulmonary hemor- rhage and apoplexy of the lungs. For our own part, on the one hand, we regard them as representing hyperosmia of a lower or higher de- gree, which, under certain conditions, may give rise to haemoptysis, and, on the other hand, it appears clear to us that they also represent apo- plexies, namely, in a less degree a vascular apoplexy, and in a higher degree an apoplexy with effusion of blood into the parenchyma of the lungs; but as the blood is not at all events originally effused into the cavities of the air-cells, apoplexies are not necessarily associated with haemoptysis, and hence must be distinguished from it. The latter variety, namely, hemorrhage into the cavities of the air- cells, corresponds with Laennec's pulmonary apoplexy or hosmoptoic in- farctus. Our OAvn experience confirms the views of that great physician regarding the existence of this morbid change, and the manner in Avhich it is produced. When highly developed, it is attended Avith laceration of the texture of the lungs. The apoplexy of Laennec is characterized by the following signs:— We find blackish-red patches in the substance of the lungs, which attract attention not only by their color and consistence, but also by their definite outline. On examining the cut, or, what is better, the torn surface of the diseased portion, we observe it to be more or less coarsely granular and dry, the granulation being often very irregularly distri- buted. The tissue itself is tough and yet easily torn, and presents throughout, both at the centre and at the periphery, the same con- sistence. The whole represents an effusion of blood into the cavities of the air-cells, which distends them to a certain extent and then coagulates within them, thus giving rise to the granular texture of the haemoptoic infarctus. The interstitial tissues are compressed, and infiltrated Avith blood, and hence the color of the diseased part is uniform throughout. The terminations of the bronchial tubes are also filled with the extrava- sated blood, their walls being reddened by imbibition, just as we ob- serve in the case of bloodvessels. On scraping the infarctus with the THE RESPIRATORY ORGANS. 61 back of a scalpel, there is poured forth a very slight quantity of thick blood intermixed with numerous, black, grumous flocculi. Haemoptoic infarctus bears the greatest similarity to red hepatization of the pulmonary tissue ; none but very inexperienced persons can, how- ever, mistake one for the other, for each of the above properties of in- farctus presents a distinguishing sign from hepatization. These, briefly summed up, are the well-defined limitation of the infarctus, the homo- geneity of its consistence and color throughout its whole extent, the coarse and irregularly granular appearance and the dry fragility of its cut or torn surface, and the nature of the product obtained on pressing or cut- ting its surface. The pulmonary tissue in contact with the infarctus is either in a per- fectly healthy condition or else in a state of some other pre-existing or consecutive disease; in every case it is clearly separated from the in- farctus. Amongst the pre-existing diseases Ave must especially mention tuberculosis and pneumonia, whilst the most common consecutive affec- tions are emphysema and oedema of the lungs. It occasionally happens that this limitation of the haemoptoic infarctus cannot be detected without a somewhat close examination. This is the case Avhen the parenchyma surrounding it to a certain distance, is the seat of an effusion of fluid blood, whose limitation is by no means sharply defined, since it changes towards its periphery into a palish, sanguineo- serous infiltration, and thus gradually loses itself in the normal tissue. Still, by a careful inArestigation, Ave may discover the infarctus seated within the fluid effusion, and plainly separated from it by its consistence and darker color. The size of the haemoptoic engorgement is seldom very great, for while, as Laennec observes, it scarcely ever exceeds four cubic inches, it is frequently less than one. We often find only one infarctus ; some- times, however, several are simultaneously present in one or both lungs. They are deeply seated in the parenchyma of the lungs, near their roots, or in the posterior portion of the lower lobes ; they are, however, occasionally found near the surface, and may be recognized through the pleura by external inspection. It sometimes happens that when they have existed for a considerable period, the pleura above them becomes inflamed. They are often, but by no means always, accompanied by considerable haemoptysis; their size stands in no relation to its amount, indeed there may have been very considerable haemoptysis, without a trace of haemop- toic infarctus being perceptible after death ; thus, when the effused blood has coagulated rapidly and completely in the pulmonary cells, notwith- standing the haemoptoic infarctus, there will be no haemoptysis; in another case the blood does not coagulate at all, but is coughed up in a fluid state, and then, notAvithstanding the haemoptysis, there is no haemoptoic infarctus; or, again, the primary effusion may coagulate and form an infarctus, while hemorrhage in the surrounding parenchyma may be the source of haemoptysis (see above). This form of apoplexy is very frequently found to be associated with active dilatation of the right side of the heart, and it seems to bear the 62 ABNORMAL CONDITIONS OF same pathogenetic relation to this cardiac affection as cerebral apoplexy bears to active dilatation of the left side of the heart. In recent times some doubts have been suggested regarding the true connection between haemoptoic infarctus and pulmonary hemorrhage, and it has been regarded as the result of hemorrhage of the finer bron- chial ramifications, that is to say, as depending on the coagulation of the blood which has escaped from the bronchi into the pulmonary vesicles. Although we fully believe that this may sometimes be the case, yet in the absence of any positive proof we prefer adopting Laennec's view, in relation to the assumed bronchial hemorrhage, for the following reasons: (1), because haemoptoic infarctus very often occurs without haemoptysis, while a bronchial hemorrhage could hardly take place without any san- guineous expectoration; and (2), because if, as is reasonable, we recog- nize the influence of hypertrophy of the right side of the heart, we shall see that this influence, notwithstanding the anastomoses of the two systems of vessels, is especially exerted on the pulmonary arteries, and that it will thus serve to elucidate true pulmonary hemorrhage. When this form of apoplexy is very much developed it is accompanied Avith laceration of the pulmonary tissue ; we find a cavity in the lung similar to those which are met with in cerebral apoplexy, and containing a certain quantity of more or less coagulated blood. The surrounding pulmonary texture is torn, suffused with blood, and presents, to a certain degree of thickness, an appearance of haemoptoic infarctus. The position of these cavities coincides with that of the haemoptoic infarctus; it has, in rare cases, happened that when situated in the peri- pheral portion of the lungs, they have opened by a rent into the pleural sac, thus giving rise to the free effusion of blood into that cavity, and to pneumothorax. The size of these cavities varies, but it scarcely ever exceeds that of the haemoptoic infarctus. Gangrene of the lungs sometimes, however, gives rise to very considerable accumulation of blood. Simple hyperaemia and stasis are easily reduced to the normal state, especially under proper and judicious treatment; but they leave a great predisposition to relapses, and hence they usually require a prolonged prophylaxis. The following questions suggest themselves:—what alterations do haemoptoic infarctus and apoplexy with laceration undergo in the progress of time ? and in what way is the tendency to cure and its successful accomplishment evinced ? It is only very rarely that experience presents us with pure indisputa- ble facts bearing on the various stages of the healing process, necessary for the solution of these questions; still from the scanty materials in our possession, and by a comparison with analogous processes in other organs, we arrive at the following conclusions: ' The effusion in haemoptoic infarctus either (1) quickly becomes fluid, assumes a blackish-brown, rusty, and wine-lees tint, and in this state is partly absorbed and partly excreted through the bronchi (thus, doubtless, causing the peculiar expectoration sometimes observed to follow haemop- tysis), the parenchyma remaining for a time moist, soft, lacerable, and of a rusty or wine-lees color, and gradually returning to its normal THE RESPIRATORY ORGANS. 63 state; or (2) the effusion is only partly removed in this manner, and there remains a tough fibrinous coagulum, which gradually becomes per- fectly decolorized, or a loose glutinous coagulum, saturated with black pigment, the surrounding parenchyma becoming shrivelled up, and de- generating into a cellulo-fibrous tissue of either a white or a blackish tint. Apoplexy with laceration heals, after the absorption of the effusion, either by a direct agglutination of the walls of the sac, or by the con- traction of the parenchyma round a fibrinous coagulum, which finally becomes cretified, or by the conversion of the parenchyma into a cellulo- fibrous capsule, enclosing a glutinous coagulum, consisting for the most part of pigment. d. Anosmia of the Lungs.—There are various conditions which may give rise to a deficiency of blood in the lungs. It may depend: a. On exhausting hemorrhages. b. On wasting of the blood, consequent on various acute and chronic diseases. c. On the inspissation of the blood, consequent on rapid and great loss of serum, and on the inability of the blood, in this condition, to enter the capillaries; this is especially the cause of the anaemia of the lungs in Asiatic cholera. d. Finally it occurs in association with pulmonary atrophy, with em- physema, and with the higher degrees of compression of the lungs. e. (Edema of the Lungs.—Pulmonary oedema is a very frequent and extremely important disease. Its essential and primary symptom is the infiltration of the parenchyma Avith a serous fluid, which is obvious even from an external inspection, and much more so on examining the inte- rior of the viscus, which pours forth a serous fluid when a section is made into it. The serum, hoAvever, does not vary only in regard to its quantity (that is to say, not only are there differences in the degrees of the oedema), but it likewise presents many differences in relation to its properties. In order to understand the importance of pulmonary oedema under all conditions, it is necessary for us to direct attention to the information which we have acquired from clinical observation, and from careful ex- amination and experimental investigation of the dead body in relation to the seat of the serous effusion. We thus ascertain that the serum is effused into the cavities of the air-cells, where it accumulates, either alone or mixed with varying quantities of air, according to circumstances. From hence it flows in greater or less quantity, either mixed with air and frothy (as bronchial foam), or unmixed with air, into the bronchial tubes. The walls of the air-cells and the interstitial tissue are also more or less saturated and infiltrated with serum, but the true seat of the fluid which so often escapes in astonishing quantities from the cut surface of the parenchyma of an oedematous lung is in the air-cells and the bronchial canals. Pulmonary oedema occurs both in an acute and in a chronic form, and between these extremes there are many transition stages presenting mere 64 ABNORMAL CONDITIONS OF shades of difference. In acute oedema the lung appears swollen, does not collapse, feels puffy, and Avhen we press it Avith the finger we detect a fluid which escapes with a crackling noise ; its elasticity isonly slightly diminished, so that scarcely any perceptible pitting remains after the pressure; it is of a pale reddish colour, very pale and deficient in blood when anaemia is present, and more or less red and congested if there be hyperaemia; the serum which is effused from the cut surface is mixed with much air, which renders it frothy, and is usually of a pale red color; but in oedema arising from prolonged stasis and simultaneous decompo- sition of the blood, it is red and discolored, having an icteric tint. The parenchyma is softer than usual, very moist, singularly yielding, and easily torn. If" the oedema lasts for a longer time, the pulmonary tissue gradually loses its elasticity, the lung pits more distinctly on pressure, becomes paler, assumes a faded, dirty gray color, and becomes opaque and dull; the air is gradually pressed out of it; it crepitates less, when cut; and the serum is less frothy, gradually loses its color, and becomes clear and limpid. The parenchyma becomes gradually infiltrated with serum, the walls of the air-cells and the interstitial tissue become swollen, and hence the lung becomes denser and more resistant. Finally, in cases Avhere chronic oedema has been very fully developed from its commencement, the lung appears pale, of a dirty gray color, anaemic, not swollen, but heavy, dense, and resistant, pitting on pressure and no longer crepitating; a grayish or someAvhat greenish serum un- mixed with air flows from the cut surface. Dropsical accumulation in the pleural sac is almost always simultaneously present. CEdema of the lungs, like acute oedema of the glottis, is often very rapidly developed; from an active hyperaemia or a passive or mechani- cal stasis, it quickly reaches a high degree of intensity, extends simulta- neously over both lungs, and in a short time causes death by suffocation. This is frequently the cause of the suffocation of adults and of new-born children, and is often combined with hyperaemia and serous effusion within the cavity of the cranium. The dead body usually presents the same appearances as those which we have described as occurring in pul- monary apoplexy ; the lungs in particular exhibit oedema, and a frothy serous fluid is accumulated in the bronchial passages, which is frequently seen as a thick, white, or whitish-red froth, at the oral and nasal cavities. It may also be developed as a consequence of acute or chronic bronchial catarrh, or of exudative processes (croup) on the tracheal and bronchial mucous membranes ; it is a constant symptom in acute pulmonary tuber- culosis, in acute decompositions of the blood and after the retrogression of erysipelas, scarlatina, variola, rheumatism, miliaria, &c. In the form of more or less developed acute oedema it accompanies the various stages of pneumonia and the metastases : and is associated with haemoptoic in- farctus, Avith pulmonary cancer, and especially with pulmonary tubercu- losis. Lastly, it appears as a consequence of cerebral diseases, of gene- ral anaemia and tabes, and occurs towards the end of almost all chronic diseases. Chronic oedema, moreover, exists with general dropsy, with dropsy of the great serous sacs, with chronic diseases of the heart and great vessels, &c. It is rarely an idiopathic and independent disease. THE RESPIRATORY ORGANS. 65 The extent of oedema is various; the very acute and rapidly fatal oedema generally attacks both lungs almost equally; in other cases it is limited to individual portions of them. The oedema in cases of pneu- monia commonly affects the circumference of the inflamed part; that Avhich occurs as a consequence of chronic diseases, for the most part, attacks the posterior and inferior parts of the lungs, which are most exposed to the influence of gravitation. /. Inflammations of the Lungs (Pneumonias).—Pathologists are in the habit of recognizing only one form of pneumonia. It is true that this is by far the most frequent form ; but even in regard to this there are several points in which we cannot agree with the accepted view. We may provisionally and very briefly remark that the evidence of its croupous nature will be the more manifest in proportion to the epidemic constitution and the special cause of the disease, the rapidity of its course, the degree of its intensity, &c. We shall treat of this, the most com- mon form of pneumonia, under the designation of: 1. Croupous Pneumonia.—The course of this disease is divided, as is well known, into three stages, Avhich have received the names of inflam- matory engorgement, hepatization, and purulent infiltration. We shall first consider the case in Avhich a whole lung, or at least a whole lobe is affected. The first stage, inflammatory engorgement, is always preceded by the above described condition of simple stasis and splenization of the parenchyma ; but, conversely, this condition is not always developed into inflammatory stasis or engorgement. This affords the explanation of the contested question regarding the inflammatory nature of simple stasis and its significance as a stage of the inflammatory process. It is only by a careful examination that Ave can distinguish inflammatory engorge- ment from simple stasis. The lung is generally of a dark red color, heavy and tough; it pits on pressure, and Ave perceive that it contains a fluid and little or no air. On cutting it we find its substance denser than in the normal state, in consequence of the swollen condition of its tissues and of its being filled with a sero-sanguineous fluid; and accord- ing to the degree of this state the lung may either crepitate and swim in Avater, in consequence of its still containing a little air, or it may sink and not crepitate; it is easily torn, very moist, and pours forth a sero- sanguineous fluid, which is sometimes rather frothy and sometimes not at all so. This condition has, as we have already remarked, the greatest simi- larity and affinity to simple stasis, especially when the latter is combined with oedema. We will now direct attention to the characteristic symptoms by which inflammatory engorgement may be distinguished from the above-named similar condition. Amongst them we may mention the color tending to a brownish-red, and the moisture of the parenchyma, which in itself is sufficient to distinguish the inflammatory from the simple stasis, and also from that combined Avith oedema, by the special circumstance of its de- pending on the tissue being filled with blood that has already undergone the inflammatory metamorphosis, or, in other words, with a brownish or brick-red, thin but viscid fluid mixed with black, crumbling flocculi. As vol. iv. 5 66 ABNORMAL CONDITIONS OF soon as the transition to the second stage commences, there is a secretion of a very viscid, tough, reddish-brown fluid,—the characteristic sputum, as may be proved by an examination after death; and, finally, there is the true exudation with which appears— The second stage, or that of hepatization, in Avhich the lung appears both externally and internally of a dark brownish-red color, is solid but friable, does not crepitate, and sinks when placed in water. On exa- mining the cut surface we either observe the above color uniformly dis- tributed, or it is deposited in the form of irregular spots amongst the black pulmonary tissue; while the pale red interlobular tissue presents ramifications, and the whitish bronchial tubes and the bloodvessels form stripes or islands which destroy the uniformity of the coloring, and give the cut section a marbled appearance. Further, the cut or torn surface presents a change of texture which is perfectly characteristic; when the light falls obliquely on this surface we perceive that it has a granular appearance, which is the special reason why it resembles the tissue of the liver, although the similarity is aided by the firmness, fragility and color of a hepatized lung. Hence the origin of the term hepatization, which is now generally adopted and understood. The character of the granulation is uniform, and the individual granules are roundish.— Scarcely anything exudes from the cut surface, and it is only by a cer- tain amount of pressure, or by passing the scalpel over it, that a brownish- red, turbid, sanguineo-serous fluid escapes, mixed with blackish-brown and a few reddish-gray flocculi. The volume of the hepatized lung does not in general exceed that of the healthy lung in a state of full inspiration; hence its surface is smooth, and never indented by the ribs, and there is no dilatation of the thorax. Sometimes, however, we find single lobules projecting higher above the surface than others, in consequence of a want of uniformity in the progress and the degree of the exudation; and the granulation of these tissues is coarser in consequence of the products of inflammation being here deposited in greater quantity than in other parts. This form of hepatization is named the red, to distinguish it from those varieties in which this color is no longer present, although the granular texture remains. On what does the granular texture of the hepatized lung" depend ? This is a most important question; the ordinary answer to which is, that it results from so great a swelling of the walls of the air-cells that their cavities become obliterated, each granulation being thus represented by an air-cell. We can by no means give our assent to this generally re- ceived opinion, for we are convinced that the granulations are produced by the inflammatory product deposited in the cavities of the air-cells; we shall, however, postpone bringing forward our evidence on this point, since the perfect solution of the question is intimately connected with the determination of the seat and nature of the pneumonic process. Each granulation is a hardish, fragile, dark-red, roundish plug, which adheres so closely to the dark-red, swollen wall of the air-cell, that it is difficult to separate and extract it. Pneumonia passes from the stage of red hepatization through several Bcarcely distinct transition-stages till it finally attains the true third THE RESPIRATORY ORGANS. 67 stage. These transition-stages are characterized by alterations of con- sistence and especially of color. The red, hepatized lung gradually be- comes paler, assumes a brownish-red, then a grayish-red or gray, and finally a yellowish color, and thus presents the condition to which the term gray hepatization has been appropriately given. We can recog- nize this coloration externally, but far better on examining a cut surface; and we can perceive that in many cases, the tint is not monotonous, but that the black pulmonary tissue is more or less uniformly sprinkled over the grayish-red, gray, or yellowish-gray ground, which is also marked by the white projecting cut vessels, so that the whole presents a granite- like appearance. The granular texture is still present, and even becomes decidedly more distinct at the commencement of the third stage, especially when the progress of the disease has been rapid and tumultuous ; the consis- tence diminishes and the decoloration increases the nearer the disease approaches to the third stage; although the lung feels tolerably firm, it remains pitted after pressure, and is yielding and easily torn, and a grayish-red, very turbid, flocculent, viscid fluid exudes from its cut or torn surface. If we examine the granulations in these transition-stages, we perceive that they have become more marked, larger, and more independent of the surrounding structures; and that they can be more easily separated and removed, as they only adhere loosely by a glutinous substance to the walls of the cells. Third Stage, Purulent Infiltration.—At its commencement the change of color of the hepatized tissue to a yellow tint (to which we have already adverted) becomes more or less uniform, the granular texture very rapidly disappears, and is succeeded by a purulent infiltration of the parenchyma. The lung then becomes heavy; any pressure on it forms and leaves a distinct pit; the cut surface is yellow or straw-colored, with inter- spersed spots of black pulmonary tissue, and effuses a large quantity of a very viscid, purulent fluid of the same color as the surface, and of a sickly odor; the parenchyma is extremely yielding, gives way on the slightest pressure, so that if not carefully handled, cavities are easily formed in it, which are the more likely to be taken for abscesses, as they actually are very similar to fresh accumulations of pus. The gra- nular texture has now altogether disappeared, and, on removing the pus from a piece of lung by careful pressure and washing, we perceive that its substance has again assumed its spongy, cellular tissue. The bronchi present several changes, especially in their final ramifi- cations ; in the first stage their mucous membrane is reddened and swollen, subsequently however it becomes paler ; and they almost always contain first a reddish, and afterwards a whitish, purulent, fluid exudation. The vessels are frequently clogged by exudations of this nature. These are the three stages through which well-marked cases of acute pneumonia run; the last is the ordinary and natural mode of termina- tion, and is frequently although by no means necessarily fatal, for, partly by expectoration and partly by resorption of the pus, the lung may re- turn to its normal condition. There is no other and earlier stage than that which we have described as the stage of stasis, for the condition 63 ABNORMAL CONDITIONS OF described as such by Stokes is in no respect inflammatory. The bright- red color of the lungs or of portions of them, which Stokes regards as the earliest stage of inflammation, and attributes to arterial injec- tion, is;— . (a.) Always dependent on anaemia, which is frequently very highly developed. (b.) The lungs, or the affected parts of them, are puffed up, but are devoid of turgor and resistance in consequence of their capillary ves- sels not being duly filled; they collapse readily, and not a trace of a swelling of the tissue remains. . (c.) This condition always occurs when, in consequence of paralysis of the heart or of excessive thickness of the blood, the capillaries of the lungs can no longer be injected, and the little blood occurring in them is repeatedly exposed to the chemical influence of the atmospheric oxygen by the inspirations during the death-struggle. In this way we observe this condition either distributed over large portions of the lungs, or con- fined to small spots of lungs otherwise healthy, or associated Avith hyper- aemia and stasis in many cases of asphyxia in new-born children and adults, in consequence of rapidly exhausting diarrhoeas, of Asiatic cholera, after extensive burns of the general integument, kc.^ Before entering into any further discussions, it will be most expedient that Ave should add to the above sketch the conclusions regarding the seat and nature of the pneumonic process, at which we arrive from an accurate anatomical investigation after death, and a review of the physical phenomena during life. These conclusions will not only find an influential application in what is to follow, but will also receive cor- roboration from it. In relation to the first point, we have already stated, in our remarks on the formation of the granular texture of the hepatized lung, that the granulations are formed by the inflammatory product deposited in the cavity of the air-cells. Their formation, or, in other words, the exuda- tion, is preceded by the secretion of a viscid, tough, reddish-broAvn fluid in the cavities of the cells, which gives rise to the crepitation well known to auscultators: as the stage of hepatization advances this fluid disap- pears, and the air-cells become filled with plastic exudation. The gra- nulations are roundish, and at first of a dark-red color, hardish, and fragile ; they appear to have uniformly coalesced with the swollen, dark- red Avails of the cells, from which it is difficult to isolate and extract them. The inflammatory turgor and the redness of the tissue become then moderated ; the granulations become paler, of a grayish-red, and finally a grayish-yellow tint, while they appear less dense in structure, and become someAvhat swollen. The secretion of a glutinous mucus is established around their circumference, Avhich loosens their connection with the cell-wall, thus rendering themselves and the swelling more obvious: they appear surrounded by a light reddish cell-wall, and their distinctness is proportional to its paleness. Finally, they break down into a purulent fluid, mixed with this glutinous, mucous secretion. Hence the seat of the pneumonic process is on the walls of the air-cells—that is to say, on the pulmonary mucous membrane, and its product is de- posited in the cavities of the air-cells; from this period—that is to say, THE RESPIRATORY ORGANS. 69 from the stage of red hepatization—the process consists in a metamor- phosis tending to the fusion and breaking down of the exudation, under the influence of an inflammatory process, which is now declining in intensity. These conclusions are further strengthened by the following considerations: (a.) If the granulations Avere regarded as swollen, and consequently obliterated, air-cells, they could neither exhibit the above anatomical relations, nor could they present the metamorphoses which, regarding them as inflammatory products, we have represented that they undergo; that is to say, if Ave take an unbiassed view of the subject. (b.) Even the greatest swelling of the air-cells could not modify the volume of the hepatized lung, while our theory perfectly explains this % phenomenon. (c.) If the third stage, or that of purulent infiltration, were a suppura- tion of the interstitial tissue, a recovery from it without abscess and solu- tion of continuity could not be possible; whereas it takes place by par- tial expectoration and partial absorption of the dissolved exudation, Avith- out any ulcerous destruction of tissue, in Avhich case anatomical investi- gation shoAvs, that, in purulent infiltration of the lungs the texture is altogether undestroyed, and of a spongy, cellular nature. (d.) Finally, the same process, as a general rule, extends to the ter- minal ramifications of the inflamed lung. Even from what has been already said, it appears that, in relation to its anatomical elements, we may regard pneumonia as a croupous pro- cess on the pulmonary mucous membrane,ov, in other words, as a paren- chymatous croup. It exhibits, even within the limited circle of its anatomical relations, a perfect identity with the croupous process on other mucous membranes; Ave shall, however, subsequently develope this view in a more extended and general manner. We very often find the three stages coexisting, and can observe all the transition-stages passing into one another. Purulent infiltration and gray hepatization generally predominate in the central and inferior part of the inflamed lobe ; there is grayish-red or red hepatization towards the periphery; above this there is inflammatory engorgement; while, finally, simple stasis, and very frequently acute oedema in different stages, are present in the adjacent tissue. Pneumonia may prove fatal in any of these stages; it may also retro- grade from each to the normal condition. Besides the above-described termination in purulent fusion of the inflammatory product (purulent infiltration), it may in rare cases give rise to abscesses or induration, or may end in other ways, which can be more suitably noticed in a future part of the Avork. If the pneumonia has reached the third stage, and is proceeding toAvards a cure, we observe the following phenomena:—The purulent fluid is gradually removed, and an exhalation of serum commences from the pulmonary mucous membrane ; the pus Avhich still remains is gradually rendered thinner by this admixture, and is finally converted into a floc- culent, turbid serosity, which becomes mixed with air-bubbles as soon as the air again begins to penetrate. The parenchyma, at the same time, becomes paler, and of a grayish-yellow tint, and retains this color for 70 ABNORMAL CONDITIONS OF a considerable time; it crepitates less distinctly than in the normal state, is softer and moister, is more or less oedematous, and easily torn. The lung can also retrograde from the second stage, that of hepatiza- tion, to the normal state, without the purulent liquescence of the exuda- tion. This process is undoubtedly one of the most difficult which the healing powers of nature can accomplish ; for it always takes place some- what slowly, and undoubtedly the more so in proportion, on the one hand, to the plasticity of the product, and, on the other, to the exhaustion fol- lowing the effusion, whether the exhaustion be dependent on the disease, or be induced by the activity of the treatment. The granulations, to- gether with the tissue, gradually become paler, and a serous fluid, which is secreted in the cells, seems by degrees to cause a fusion of the gra- nulations, layer by layer. The tissue still retains a granular character, but the granulations always become smaller, of a pale red or reddish- gray color, and are bathed in a serous fluid, which is mixed with toler- ably consistent, pale reddish or whitish flocculi, and which gradually be- comes frothy from the entrance of air. When the granulations are thus finally melted down, the parenchyma remains for some time in a state of serous infiltration, and is redder, firmer, and more resistant than in the normal state, owing, apparently, to a still existing infarctus of the walls of the air-cells and of the interstitial tissue. This retrograde pro- cess does not go on with equal or uniform rapidity at all parts ; and we can often confirm our diagnosis by finding dense and still hepatized patches in tissue which has more or less returned to the normal state. Finally, pneumonia retrogrades from the first stage—that of inflam- matory stasis—to the normal condition ; this is very frequently the case when those favorable influences are present which it is the great object of the healing art to induce. The inflammatory stasis, after it has depo- sited a moderate infiltration of turbid serous fluid, is converted into sim- ple stasis, and after this is resolved, the tissue again becomes normal, but remains for some time the seat of hyperaemia which may easily relapse into inflammatory stasis. Pulmonary Abscess.—We have already described the termination of pneumonia in purulent infiltration, that is to say, in purulent solution of the inflammatory product, which occurs without any separation of con- tinuity or ulcerous destruction. The reverse takes place when accumu- lations of pus are formed in the lung. This termination of pneumonia is extremely rare ; but this rarity need not excite our wonder, nor do we require the explanation attempted by Laennec, if Ave adhere to our view of the pneumonic process. The conditions giving rise to the forma- tion of pulmonary abscesses and the mode in which it is formed are, however, little known. Of all the theories which have been advanced, that is most conformable with the nature of the pneumonic process, which regards it as a consequence of a peculiar character of the inflam- matory process, causing the pulmonary mucous membrane, which has been deprived of its epithelial investment, and the other tissues entering into the composition of the parenchyma, to become disintegrated and to suppurate,—a process analogous to that which occurs in many cases of true croup of the mucous membrane, and still more so to other exudative processes occurring on the same structure. THE RESPIRATORY ORGANS. 71 A recently formed, fresh pulmonary abscess presents the appearance of a cavern of irregular form filled with pus formed from the disintegration of the lung and surrounded by a softened parenchyma infiltrated with pus, and in some places hanging in shreds. It is perfectly similar to those rents which may be produced by pressure, when we are carelessly handling a lung in the stage of purulent infiltration, or on attempting to separate it from adhesions to the costal wall, and which Ave have already warned our readers against mistaking for pulmonary abscess. The abscess either enlarges in the same way in which it originated, by the continued solution of the inflammatory product and of the tissue of its walls, or else by the confluence of other neighboring abscesses. As a general rule the suppuration extends over the whole of the inflamed portion of the lung, and hence the abscesses consequent on the lobular inflammation (of which we have already spoken) are always very consi- derable. According to their size we observe one or more bronchial tubes opening into them with transverse or oblique mouths, and their tissues also become the seat of purulent solution. These abscesses repre- sent the true but very rare ulcerous pulmonary phthisis which is based on inflammation. It proves fatal either by the supervention of fresh pneumonia around it, or pleuritis, or by the absorption of pus into the blood, with the symptoms of pyaemia and hectic fever. In rare cases it perforates the pulmonary pleura, and causes suppuration of the adjacent tissues, after having given rise to pleuritis and adhesion of the lung to the wall of the chest. Finally, in some very rare cases, it opens freely into the thorax before pleuritis and adhesion of the lung to the walls of the chest have been established; a general or circumscribed pleuritis then follows. If any of the bronchial tubes open into the abscess there will also be pneu- mothorax, and it may happen that the pleuritic effusion will be ejected through the air-passages,—a phenomena which however occurs much more frequently as a consequence of a reverse succession of the pro- cesses, namely, from primary pleurisy and consecutive corrosion and suppuration of the pleura. (See Pleuritis.) Finally, pulmonary gan- grene sometimes arises in its vicinity, and the purulent solution of the tissues is converted into gangrenous ichor. When the abscess has existed for a long time, its inner wall appears smooth, and its form is as nearly as possible round, and in the surround- ing parts a secondary, interstitial inflammation may be observed, in con- sequence of which the parenchyma becomes converted into a cellulo- fibrous tissue, which surrounds the cavity of the abscess, and isolates it from the remainder of the pulmonary tissue. When an abscess is large, its perfect closure is very difficult; the process by which this is effected is by agglutination of its walls, which causes the obliteration of the bronchi entering into it; when the abscess has been a very large one, there is a depression of the thorax over it; and when its position is near the surface of the lungs, there is a puckered cicatrix left. A pulmonary abscess may be confounded with a tuberculous vomica, and with certain accumulations of pus, which are developed from a se- condary inflammation of the capillaries of the pulmonary tissue, of which we shall speak presently, and also with saccular dilatation of the bronchi. 72 ABNORMAL CONDITIONS OF The diagnosis may be established from a comparative A'iew of the posi- tive signs attending each of their conditions. Induration.—There are certain conditions under which hepatization does not pass into a state of purulent solution, but into induration. The red inflammatory product becomes of a grayish-red tint, and finally gray, but instead of becoming dissolved, it becomes compact and indurated. This is Avhat has been termed indurated hepatization, a condition which has sometimes, but incorrectly, been regarded as chronic pneumonia. The lung is compact, but fragile and pale, and has lost some of the in- creased size Avhich it has attained during the stage of red hepatization ; it still, however, retains its granular texture, Avhich even becomes more obvious, in consequence of the granulations becoming more marked owing to their increased density, although they are somewhat smaller. This condition may exist for a long time, and is always followed by cachexia, and especially by dropsical symptoms, and it often proves fatal; or the induration may be gradually resolved, or merge into oblite- ration of the air-cells and atrophy of the tissue. The curative process in indurated hepatization is somewhat analogous to the resolution of the pneumonia in the second stage, for an exhalation of serous fluid takes place from the inner wall of the air-cells and acts as a menstruum, Avhich gradually corrodes and absorbs the indurated granulations. As the granulations become smaller it becomes turbid and flocculent, and when the pulmonary cells are again permeable to air, it gradually assumes a frothy appearance. In other cases the air-cells contract over the granulations, coalesce with them round their circumference, and become obliterated, their tissue being changed into a cellulo-fibrous structure, in which from the similarity of their organizations, the granulations are most probably also merged. Unless a serous effusion occupy the empty space, this termina- tion causes a depression of the thorax, or bronchial dilatation, or both simultaneously; and it appears to be on the whole less frequently the result of the croupous pneumonia which has already been described than of an insidious inflammation of the interstitial tissue,—interstitial pneu- monia. The above is a sketch of croupous pneumonia in general, when it occurs as a primary disease; but it also very frequently occurs as a secon- dary process. It most commonly runs an acute course, usually passing through its different stages in from two to three weeks, and in extremely rapid cases even in three or four days ; these are, hoAvever, of rare occur- rence. Sometimes, on the other hand, it runs a chronic course, being either nearly uniformly prolonged in all its stages, or one or other of them being especially protracted. It presents, however, no special rela- tions essentially different from the sketch Ave have already given; for, like the acute form, it usually ends in purulent infiltration, and rarely in abscess or induration ; and it is totally different from the affection which we commonly find described in pathological treatises as chronic inflam- mation of the lungs, and with which we shall become acquainted when treating of inflammation of the interstitial tissue. We observe variations in regard to the original extension of pneumonia, which are of importance chiefly in consequence of their connection with the inner nature of the disease. THE RESPIRATORY ORGANS. 73 Pneumonia, according to its variety, attacks, as Ave have already described, the whole of one of the larger divisions of the lung, that is to say, a whole lobe, or a great part of one, and it is then termed lobar. It often attacks a whole lobe, and extends to the adjacent ones, and does not prove fatal till at length the remaining healthy lobes begin to be affected. It usually appears in this form as a primary affection; • its most common seat is in the lower lobes, and the right lung is more frequently attacked than the left; both these rules present, however, many exceptions. Or it attacks only smaller portions of the lungs, a number of individual lobules or single aggregations of lobules, between Avhich Ave find the paren- chyma in a comparatively normal state. It is then termed lobular pneu- monia ; it must be distinguished from the lobular hepatizations which are produced by irregularity in the progress of a lobar pneumonia in the individual lobules, while the rest of the parenchyma remains in a state of inflammatory engorgement. Or, finally, the seat of pneumonia is confined to single air-cells; we then have what is termed vesicular pneumonia. The disease passes through the stages of inflammatory engorgement, of hepatization, and of purulent infiltration in a single air-cell, or it causes induration, and, finally, obliteration of it. The indurated hepatization of single air- cells is undoubtedly the same condition that has been described by writers on pathological anatomy, as Bayle's pulmonary granulations, and regarding whose nature there has been much unnecessary dispute. It is undoubtedly the result of inflammation, and so far Andral is cor- rect in his view; but inasmuch as the inflammatory product, under certain conditions, assumes the character of tuberculous matter, it may also be regarded as partaking of the nature of tubercle (Laennec and Louis). It represents, as we shall presently show, the tuberculous infil- tration of single air-cells. Lobular and vesicular pneumonias are usually secondary processes. It is very important that we should understand the differences presented by the inflammatory product in regard to its plasticity, inasmuch as they are most intimately associated with the condition of the blood (the gene- ral disease). Instead of the plastic, hepatized product, we meet under various conditions with serous, flocculent, and turbid, or gelatinous and glutinous or sero-purulent, or even ichorous infiltrations, which, in conse- quence of their deficiency in coagulable matters, can never give rise to a granular texture of the parenchyma (hepatization). The lung adjacent to the infiltration is dense and spleen-like, and in addition to the other marks of the inflammatory stasis, is generally discolored, somewhat resis- tant to the touch, but on closer examination is found to be yielding, and is easily torn. Primary acute pneumonia usually deposits a plastic, hepa- tizing product, which goes through the metamorphoses which have already been described; while, on the other hand, the last-named products are often the result of sluggish, asthenic (hypostatic) inflammations, and even, more frequently of secondary pneumonic processes; they repre- sent secondary exudative processes which not unfrequently degenerate into gangrene. One of these pneumoniae infiltrations, namely the gelatinous, must here be especially noticed. It is altogether different from the condition V 74 ABNORMAL CONDITIONS OF to which Laennec applied the denomination of gelatinous tuberculous infiltration, and Avhich Andral, Avithout hesitation, put down as the pro- duct of inflammation, and which we regard as the product of an inflam- mation of the interstitial tissue (see p. 78). In place of the plastic hepatizing product, the air-cells are found to contain a gelatinous, viscid fluid, sometimes almost resembling frogs' spawn, and of a grayish, grayish-yellow, grayish-red, or brownish-red color, and either clear and transparent, or flocculent and turbid, while the parenchyma is of a pale red tint, or more frequently of a reddish-brown color, and is easily torn. The pneumonia which deposits this non-plastic product is chiefly observed around pulmonary tubercles, and especially around infiltrated tubercles and hepatizations which are undergoing meta- morphosis into tuberculous infiltration ; it is developed towards the end of the disease, and sometimes involves all the parenchyma which had remained free from tubercle and tuberculous infiltration ; moreover we sometimes observe it in the vicinity of extensive hepatization, espe- cially on the border of a hepatized lung in which emphysema has been developed, and Avhich is impervious to a dense injection. Finally, it occurs whenever there is a deficiency of plastic matter for the deposition of a coagulable, hepatizing product, either from some primary cause or in consequence of too profuse previous exudations. Finally, we must here offer a few remarks on certain metamorphoses which constitute a hitherto undescribed termination of pneumonia, and which the plastic (fibrinous) hepatizing product of inflammation under- goes in consequence of an inherent peculiar constitution depending on a general dyscrasia. These are its very frequent conversion into tubercle in the form of tuberculous infiltration or of infiltrated tubercle, and its very rare transformation (organization) into medullary cancer, as cancer- ous infiltration or infiltrated cancer of the lung, to which we shall again return in our remarks on tuberculosis and cancer of the lungs. There is a peculiar form of pneumonia to which the term hypostatic has been given by Piorry, and which is developed from the passive stasis which occurs in the most dependent parts of the lung, and to which the term pulmonary hypostasis has been assigned (see p. 59). It pre- sents the thorough stamp of asthenic inflammation ; for it is usually inert in its course, and lingers for a prolonged time in the stage of stasis, the parenchyma being of a dark livid color, and gradually de- veloping from isolated spots a lax, soft, livid-broAvn hepatization, which may either be general or limited to several foci, while a considerable portion, and occasionally even the whole, may become the seat of an inflammatory product in the form of a sero-purulent or gelatino-puru- lent infiltration Avithout a trace of hepatization. It constitutes the foundation of most of Avhat are called latent inflammations of the lungs. Primary pneumonia especially attacks vigorous adults, although deli- cate persons are also liable to this disease, and, indeed, not unfrequently seem decidedly predisposed to it; up to advanced age it is generally lobar,^ attacking at the least the whole of a lobe, and depositing a plastic, hepatizing product in it. It further occurs in children, and even in new- born infants, presenting in this case several peculiarities ; the granular texture of the hepatized lung is generally only indistinctly seen, oAving most probably to the density of the organ and the smallness of its cells; THE RESPIRATORY ORGANS. 75 moreover the termination in abscess is relatively more frequent in chil- dren than in adults, and the lobular form is more frequently met with at this early age, although the simple catarrhal pneumonia is often mis- taken for it. It arises in consequence of the influence of a peculiar atmo- spheric condition which predisposes to inflammation accompanied with abundant plastic exudations, and it may then be excited by many even very trivial causes; and in this point of view a notice of the combina- tions into which the primary pneumonic process enters is of importance, since they proceed from a common primary cause, namely a peculiar, spontaneous, morbid change in the blood. One of the constant symptoms is the sympathetic affection of the vis- ceral surface of the pleura of the inflamed lobe, in the form of a thin plastic exudation investing it. The anomalous condition of the blood which occurs in the pneumonic process, as well as in the other primary exudative processes, is a subject of much importance, since in this affection the change occurs in the most marked form and in the highest degree. In consequence of this cir- cumstance we always find fibrinous coagula in the cavities of the heart as well as in the large vessels and their branches, and not unfrequently in those ramifications of the pulmonary artery which supply the inflamed lobe; they are distinguished by their yelloAvish and greenish color, by their firmness, by a more or less decided metamorphosis into pus in their interior, by their similarity to the exudations on membranous ex- pansions, and by their being woven among the trabeculse of the heart; and their partial coalescence with the endocardium and the inner mem- brane of the Aressels, together with an obvious appearance of a secondary irritation in them, combine to show that they, at least in part, originated during life. Pneumonia, if Ave except the pleurisy which coexists with it, very fre- quently occurs as an independent disease (an exudative process) upon an extensive surface of mucous membrane, and may become more widely diffused in the lobar form, although it may, on the other hand, often be combined with similar processes upon other structures. Of these processes croup in the final ramifications of the bronchi is far the most common (Lobstein), and is indicated by the presence of creamy, purulent dissolv- ing coagula in them. In children it occurs in combination with croup on the tracheal and other mucous membranes, and with exudations on serous membranes, as pleuritis, pericarditis, meningitis, &c. Much interest attaches to the combination of pneumonia with secondary inflammations of the lining membrane of the blood-vessels, such as arise either from spontaneous coagulation of the fibrin in high degrees of haemitis, and its becoming dissolved into pus, or, above all, such as occur in inflammations of the spleen terminating in ulcerous splenic phthisis. Primary pneumonia proves fatal by inducing paralysis of the lungs ; also from the supervention of pulmonary oedema or of other complica- tions, from the high degree of blood-disease and the occurrence of spon- taneous coagulations in the heart and vessels, and from acute softening of the stomach and oesophagus. Secondary pneumonia is frequently developed as a result of inflamma- tions in other organs, when they cause the blood to assume a consecutive 76 ABNORMAL CONDITIONS OF disease similar to the spontaneous affection which we have already noticed; it frequently also accompanies specific processes Avhich in their nature are allied to the exudative, and hence it especially occurs in the acute exanthemata. In both these cases the pneumonia is usually lobar. Finally, secondary pneumonia may occur as a metastasis towards the ter- mination of various forms of acute dyscrasia of the blood, Avhich, in their course, degenerate into a croupous diathesis; amongst these we must place many exanthematous, and the typhous and tuberculous pro- cesses ; the pneumonia in these cases is generally lobular and may even be vesicular. Under this class Ave may also place many of the so-called latent, symptomatic, and, as has been already remarked, the metastatic inflammations. They are combined, especially under the circumstances Avhich we have just mentioned, with exudative (croupous) processes of various degrees of plasticity on other mucous and serous membranes. From all that has been stated, the croupous nature of the pneumonic process in general is sufficiently clear; being always based either on a peculiar primary (spontaneous) or on a secondary disease of the blood. There can be no doubt that this condition constitutes the basis both of secon- dary pneumonia and of the other metastatic croupous processes so fre- quently combined with it, and it may also, in all essential points, be looked upon as the foundation of primary pneumonia and other primary croup- ous processes on the mucous membrane of the mouth, throat, and respi- ratory organs. But as there are variations in the individual peculiarities, the age, and the external influences, under which croup of the mouth and pharynx, tracheal and bronchial croup, and, finally, croupous pneumonia are de- veloped, so also may the diseased condition of the blood vary in these affections, although probably only in a slight degree; and pneumonia, if Ave consider it as pulmonary croup, and if we take into consideration the plasticity of the exudation, may be regarded as occupying, in adult life, the same place which in earlier life is held by pharyngeal and tracheal croup; while bronchial croup, especially in adults, forms the transition between the two latter varieties and pulmonary croup (croupous pneu- monia). We now proceed to the consideration of typhous pneumonia, in consequence of the similarity of its anatomical relations to those of croupous pneumonia. Typhus Pneumonia (Pneumotyphus).—The pneumonic process is very frequently associated Avith the typhous; but its relation to the latter, and especially to the local typhous process on the mucous mem- brane of the ileum, is not always the same, and hence its importance varies. In all cases of typhus, and especially Avhen there is well-marked ileo- typhus, there is hypostasis in the lower lobes; and this not unfrequently becomes developed into pneumonia, which deposits a gelatinous, glutinous, soft product, similar to the typhous, bronchial, and intestinal secretion, and corresponding to the existing typhous dyscrasia. It is the result of an adynamic state of the system, and bears no further definite relation to the typhous process, which is seated on the intestinal mucous mem- brane. A more intimate relation, however, exists when the typhous process THE RESPIRATORY ORGANS. 77 has been originally localized in the pulmonary mucous membrane to the exclusion of other structures, especially the intestinal mucous membrane, namely, in primary pneumotyphus; and when, in consequence of its absolute intensity or its relatively imperfect localization on the intestinal mucous* membrane, it also appears in the lungs, and completes the local process on the intestinal mucous membrane, as secondary pneumotyphus. Primary Pneumotyphus is a (croupous) lobar pneumonia characterized by the livid and almost violet color of the parenchyma during the first stage, and by a dirty brownish-red or chocolate-colored, very yielding inflammatory product (hepatization), which soon breaks down when there is great disease of the blood, and extreme absence of plasticity. It seems to be always combined Avith bronchial typhus, and the bronchial glands exhibit the characteristic relations of this affection. It exists either without or with only a slightly marked secondary affection of the intestinal mucous membrane, and, in association with bronchial typhus, doubtless constitutes most, if not all, of those cases of typhus,—and espe- cially exanthematous typhus,—which run their course Avithout any local intestinal affection. Like genuine pneumonia it is usually combined with the pleurisy yielding a similar product. Secondary Pneumotyphus in its genuine form consists of an imper- fectly developed local typhous process on the intestinal mucous mem- brane, has the same anatomical characters, but does not, as a general rule, attain the same degree of intensity and extent, which is presented by the primary form Avhen it meets with no obstruction to its original local deA'elopment. It also enters into the same combinations, and is very frequently associated with genuine secondary laryngotyphus. Secondary pneumotyphus occurs, however, much more frequently in a degenerate form, as a local expression of the degeneration of the collective typhous process, and, indeed, in the form of a lobular or vesi- cular pneumonia yielding a purulent and diffluent product, and very fre- quently associated Avith a form of laryngotyphus Avhich has degenerated into croup; or it occurs in the form of purulent, diffluent deposits in the interstitial tissue, with inflammation of the capillaries of the lungs (purulent metastasis); or finally in the form of pulmonary gangrene. 2. Catarrhal Pneumonia.—Catarrhal pneumonia has hitherto re- ceived little attention, in consequence of its resemblance to the croupous variety, for which it may easily be mistaken, and on account of its rare occurrence in adult life. It is, however, comparatively common in chil- dren, in consequence of the large amount of undeveloped granular tex- ture that is observed in hepatization of their lungs. It constitutes the first of the series of catarrhal affections to which the respiratory mucous membrane is exposed during childhood, and is succeeded in later years by bronchial and, finally, by tracheal catarrh; in this respect it is the opposite to croup, which begins in childhood as pharyngeal and tracheal croup, and which, in the form of pulmonary croup, terminates the series of croupous inflammations in adults. Catar- rhal pneumonia is always lobular, and associated with a catarrhal affec- tion of the bronchial tubes pertaining to the diseased lobules ; it is fre- quently found in the various catarrhal affections of children, especially in pertussis and catarrhus suffocativus. Its usual position is in the super- 78 ABNORMAL CONDITIONS OF ficial lobules, of which a very considerable number are often affected. They present, for the most part, a bluish-red tint, and are dense and somewhat firm; the walls of their air-cells are swollen, till no^ internal cavity remains, or if the swelling be less considerable, their cavities con- tain a watery, mucous, and slightly frothy secretion; there is no trace of granular structure. As the°lung-substance in the immediate vicinity of the diseased lobules is usually emphysematous and pale, they appear to be a little depressed below the level of the surrounding lung if they are situated near the surface, and they may be further recognized by their dark color. This disease frequently becomes fatal by the supervention of pulmo- nary oedema and paralysis, or by the stasis induced in the heart by the emphysema. 3. Inflammation of the Interstitial Tissue of the Lungs. Interstitial Pneumonia.—This is a disease whose anatomical characters are not properly recognized in pathological treatises, for it is commonly described as chronic inflammation of the lungs consequent on ordinary croupous pneumonia, without any reference to its seat in a special tissue. The seat of this inflammation is the interstitial cellular tissue of the lungs, although the walls of the air-cells are also implicated, in which case the pneumonia sometimes assumes the croupous form. Its course is, as a general rule, chronic, and it is only very rarely that we have the opportunity of studying it, except in its final effects. So far as we can conclude from our few observations, it appears to com- mence in the tissue lying in the interstices of the pulmonary lobules and between the smaller groups of air-cells, which, if too much black lung- substance be not present, becomes of a pale red color, and is sAvollen by albuminous infiltration, Avhile the air-cells are either pale and more or less compressed in proportion to the swelling ; or, if they are involved in the inflammation, they appear reddened and, in accordance with what has been already stated, sometimes finely granular. In the progress of time the infiltration within the interstitial tissue becomes organized and coalesces with the latter, so as to form a dense cellulo-fibrous substance, which compresses and obliterates the air-cells, and finally converts them into a similar cellular tissue. We then find either whitish, hard stripes, which not unfrequently grate under the knife, or irregular masses inter- woven in the lung-substance. This is the ordinary metamorphosis consequent on chronic pneumonia; in some cases, however, it may terminate in suppuration which isolates the individual lobules; and some pulmonary abscesses probably originate in this manner. It is not very frequently a spontaneous affection, insidiously spreading from one lobule to another; it is commonly seated in the apices of the upper lobes, and as we may infer from the coexisting cellular adhesions cor- responding to their seat and distribution, it is frequently combined with circumscribed pleurisy. The affected portions of the lung become depressed, and draw down the surrounding parenchyma in the form of cicatrix-like folds, which may sometimes be observed on the apices of the lungs in cases where there is no trace of the pre-existence of the tubercle. A further consequence THE RESPIRATORY ORGANS. 79 of this process is a depression of the thorax at the corresponding spot, and, internally, a dilatation of the bronchial tubes. More frequently, however, it is a consecutiA'e affection, arising from reaction, and leading to the production of cyst-like formations around the seat of old apoplexies, abscesses, tuberculous caverns, gangrene, &c.; its products then resemble the tissue of which cicatrices are composed. This tissue sometimes contains a considerable quantity of pigment (the black pigment of the lungs); it then presents blackish-gray stripes and spots, or else is uniformly of a blackish-blue tint. g. Deposits in the Lungs. Metastatic Processes.—As a consequence of the absorption of a pseudoplastic process into the living blood, or, more rarely, as a consequence of the spontaneous disease of that fluid, there is a process developed which is fully discussed in its general bear- ings under the head of "the diseases of the blood:" it, however, affects the lungs more frequently than any other organ, and usually occurs simultaneously at several circumscribed spots. It consists in the deposi- tion of a fibrinous product in the lung-substance, or of a coagulation in its capillaries (phlebitis capillaris), either of Avhich undergoes matamor- phoses corresponding to the principle taken up into the blood. As, on the one hand, the veins seem to be the seat in which delete- rious substances are produced, or in which they are collected from with- out, and as, on the other, the whole of the venous blood passes through the lungs,—the principal organ in the process of haematosis,—it is easy to understand why it is that in general these deposits are most frequent and most abundant in the lungs. As is generally the case in all parenchymatous organs, these deposits almost always occur in the superficial layers of the lungs. We find deposits of various dimensions, from the size of a millet-seed to that of a lentil, a pea, a bean, or even a nut, scattered through the tissue of the lung, and separated from one another by large patches of healthy tissue; the smaller they are, the more they resemble, in form, a roundish granulation, while on the other hand, the larger they are, the more they lose the round form, and appear as irregular, angular, rami- fying masses. Large deposits, when lying near the surface, and press- ing upon the pulmonary pleura, like those occurring in the spleen, have a wedge-like shape, being thick externally, and growing small towards the interior. They are at first of a blackish-red or brownish-red color, and firm although fragile, and can be distinguished by their sharply defined outline, and by their apparently homogeneous structure, from the surrounding tissue, which at the commencement is normal, or at most the seat of hyperaemia and oedematous infiltration; but subse- quently, when the deposit begins its progressive metamorphoses, a reac- tive inflammation, in the form of croupous pneumonia and hepatization, is set up in the lungs, and its extent is usually proportioned to the size of the deposit. The deposit subsequently becomes of a lighter color, and undergoes one of the following metamorphoses: In one case (and this is what commonly occurs), the deposited mass becomes more or less decolorized, and dissolves into a cream-like, puru- lent, or ichorous fluid, which destroys the tissues. This process com- 80 ABNORMAL CONDITIONS OF mences in the centre of the deposit, much as Ave observe to take place in secondary phlebitis of one of the larger veins, and we then find the above-named fluid enclosed within the outer remains of the deposit, around Avhich a reactiAre inflammation is established. In the course of time these, and the adjacent tissue also, undergo a similar process of fusion, and the extent of this change is proportional to the destructive tendency of the product of the reactive inflammation. _ Moreover, this process is very often essentially of a septic nature, and is based on the absorption of gangrenous ichor, or, on the other hand, it often undergoes degeneration, and gives rise to gangrene of the surrounding tissues. These deposits are very frequently combined, from the first, with a se- condary pleurisy of a croupous nature; sometimes, however, the latter occurs as a consecutive affection, arising from the inflammatory reaction that is set up around the superficial deposits, or as a purulent or ichorous abscess in the immediate Aricinity of the pleura. In the latter case, we observe the abscess as roundish, nodular, furuncular, yellow prominences, or if gangrenous destruction has occurred, as dirty greenish or brownish collapsed spots, shining through the pulmonary pleura, which itself un- dergoes destruction from suppuration or gangrene, with or without perfo- ration, and gives rise to general pleurisy. In the other metamorphosis, which, however, is extremely rare, the deposit, without dissolving or undergoing any intermediate change, passes directly from its crude state into that of obsolescence, that is to say, it shrinks into a callous, grayish nodule, which is sejtfted in a capsule of cellulo-fibrous tissue, and in the course of time becomes converted into an osseous concretion. Many of these peripheral deposits, after their conversion into concretions, have doubtless been mistaken for chalky tubercles. The more complicated retrograde process which is sometimes manifested in deposits in other parenchymatous organs, as for instance the spleen and the kidneys, namely, the cheesy disintegration of the product, and its subsequent conversion into chalky matter, may, as Ave should presume from analogy, also occur in the lungs ; but in the whole course of our observations, Ave cannot recollect a single case in which it has occurred. We have spoken in the first volume of the rarity of obsolete deposits in the lungs, and have also accounted for it. We have already explained how these deposits become combined with pleurisy; they are also associated with similar deposits in other paren- chymatous structures—as thfe spleen, kidneys, liver, brain, and thyroid gland, in the tissue of mucous membranes, especially that of the intes- tines, in the skin, the subcutaneous cellular (areolar) substance, and all interstitial cellular layers, and in the muscles ; also in the exudative processes on mucous, serous, and synovial membranes (as, for instance, metastases in the joints). They must be carefully distinguished from lobular pneumonia, for which they have sometimes been mistaken. h. Gangrene of the Lungs is an affection of not unfrequent occur- rence, and one which, as Laennec very correctly remarks, must not be regarded as the result of an excessively acute inflammation. We do not, however, intend to assert, that it cannot by any possibility occur in an THE RESPIRATORY ORGANS. 81 inflamed lung, for under certain conditions hepatization of a portion of the lung is unquestionably the most common complication. We will first consider it in an anatomical point of view, and then pro- ceed to notice the conditions under which it is developed. There are two perfectly distinct forms of gangrene of the lungs, namely, diffuse gangrene and circumscribed gangrene or gangrenous eschar. In diffuse gangrene, we find a portion of the lung presenting an ab- normal greenish or brownish tint, filled with a similarly colored, some- what'frothy, turbid serosity, soft, rotten, and readily breaking down into a PulPy> shaggy tissue. The whole evolves the characteristic odor of sphacelus. ToAvards the outer portion the discoloration, infiltration, and alteration of consistence are less marked, and finally become impercep- tible ; and there is no line of demarcation between the gangrenous and the adjacent tissue, which only differs from the normal state in being oedematous and anaemic. It corresponds to diffuse gangrene of the bronchial mucous membrane, with Avhich it is almost always associated. Upon the whole it is a rare affection; but when it does occur, it always attains a considerable extent, as it commonly attacks the whole of a lobe, or, at all events, its greater part. It especially attacks the upper lobes, when, in consequence of excessive activity, they have become the seat of emphysema and anaemia, the lower lobe being at the same time in a state of passive stasis. It is perhaps scarcely entitled to rank as an essentially independent affection, inasmuch as it is almost always asso- ciated with gangrenous eschar of the lungs; and hence it is the more readily developed from the contact of the ichorous, gaseous, and fluid products of the gangrenous eschar coming in contact with the bronchial and pulmonary mucous membrane, inasmuch as in all probability the disease extends from the bronchi to the lung-tissue. The above descrip- tion of gangrene, as it occurs in the upper lobes, is sufficient to render this form intelligible, as well as to explain why there is no inflammatory reaction, and consequently no line of demarcation around the affected tissue. As we have already remarked, it must be carefully distinguished from softening of the lungs. Circumscribed or partial Gangrene of the lungs appears in the form of gangrenous eschar, and is incomparably more frequent than the former variety. We find the parenchyma, at some spot of varying size, con- verted into a blackish or brownish-green, hardish, but moist and tough eschar, which adheres to the surrounding tissue, evolves, in a very marked degree, the peculiar odor of sphacelus, and, as Laennec observes, is extremely similar to the eschar produced on the skin by nitrate of silver. It is sharply defined, and, as we shall presently show, the surrounding parenchyma may be in various conditions. The eschar becomes gradually loosened from the surrounding tissue, and rests in an excavation corresponding to it in size and form; it may be described as a blackish-green plug, which superficially is soft, shaggy, moist, and bathed in an ichorous fluid, but, towards its centre, is of a denser structure. More frequently, however, the whole or the greater portion of the eschar softens and becomes dissolved into a greenish-broAvn, VOL. iv. 6 i 82 ABNORMAL CONDITIONS OF very fetid, ichorous pulp, mixed with rotten, shaggy fragments of tissue, and enclosed in a cavity whose Avails are lined by a shaggy tissue infil- trated Avith ichor. The size of the gangrenous portion, at its commencement, varies from that of a bean to that of a hen's egg, or may be even larger; it is most commonly not smaller than a hazel-nut or larger than a walnut. The form is on the whole irregular, with a tendency to roundness. It is much more commonly seen in the superficial than in the deep layers of the lung, and more frequently in the lower than the upper lobes. _ These eschars may either occur singly, or several may be simulta- neously present. The number and size of the bronchial tubes attacked by the gangre- nous destruction, are usually proportional to the size of the original gangrenous centre ; these bronchial tubes constitute the passage through which the gangrenous exhalation and the eschar itself, in the respective form of an intolerably fetid atmosphere around the patient, and of gangrenous, ichorous sputa, make their escape. The gangrene proceeds outwards, and attacks the pulmonary pleura the more quickly the nearer it was originally seated to the surface of the lung. If the gangrenous eschar becomes detached, it falls into the cavity of the thorax, unless there are firm adhesions at the spot; or else it becomes dissolved, and the ichorous semi-solid matter is effused into the pleural sac, and gives rise to pleurisy with ichorous exudation, and to pneumothorax, since the fetid gas evolved from the gangrenous mass either collects alone in the thorax, or atmospheric air finds its way through the bronchial tubes which open into the abscess, and thus mixes with the aforesaid gas in the thorax. These superficial gangrenous caverns may be recognized at a glance, for at these spots the pleura is either converted into a blackish- green eschar, whose inner surface is shrivelled and hard; or, if the eschar has already dissolved, the pleura is of a blackish-green color, rotten, and moist, and appears distended by the gas evolved from the abscess; or, finally, if the pulmonary pleura be ruptured at certain spots, or be per- forated, or even perfectly destroyed, in consequence of spontaneous fusion, we shall observe the open, sunk cavern, either covered by the remains of the pleura, or thoroughly exposed, and more or less completely emptied. A primary gangrenous abscess must be distinguished, when possible, from one that has undergone subsequent enlargement; very large abscesses are, as a general rule, not primary, but are formed by the corroding action of circumscribed gangrene, and do not, as we shall presently show, present the distinct line of demarcation which is observable in primary abscesses. The lung-substance surrounding the gangrenous abscess is sometimes normal, with the exception of a serous or sanguineo-serous infiltration; but when the gangrenous eschar dissolves, diffuse gangrene may be developed in it to a greater or less extent. More frequently, however, we see it in a state of reactive inflammation, varying in extent and character. Very often there is a simple stasis of an asthenic character; this gradually assumes an inflammatory type, which it retains for a long time, and then the stage of hepatization slowly and imperceptibly ensues. From a want of energy in this process of reaction, the primary gangre- THE RESPIRATORY ORGANS. 83 nous abscess may extend in various directions, so as often to attain the size of a man's fist, or even of a child's head, while the surrounding tissue becomes more or less rapidly discolored, without presenting any decided stratified appearance, and finally breaks doAvn into a gangrenous, ichorous pulp. In this way the gangrene may extend outAvards, until it reaches the pulmonary pleura, when it may give rise to the consequences which have been already enumerated; and indeed, if the lung be adhe- rent, the costal pleura at the corresponding spot may be involved in the metamorphosis. We often find a higher degree of inflammation set up in the surround- ing tissue; it is in a state of decided hepatization, which sometimes extends over the whole of the lobe which is affected by gangrene. The disease not unfrequently proves fatal through this excessive reaction. The most important process, however, occurs in the layer of tissue immediately surrounding the cavern, and is obviously an effort of nature to promote a cure. The reaction here appears as an inflammation of the interstitial tissue of the lungs, which, together with the cavernous walls, undergoes suppuration, and thus effects the removal of the sphacelated tissue which was adhering to the Avails of the abscess. In this process Ave find that at first only single or isolated patches of tissue become gangrenous, and the pus which is secreted from the walls of the abscess is still mixed with ichor, and gangrenous fragments of tissue. As the process advances, however, suppuration predominates, and after the gangrenous tissue has been ejected through the bronchi the cavern is converted into an ordinary suppurating abscess, whose inner wall is infiltrated with pus ; externally, for a distance varying from three to six lines, the tissue is of a grayish-red color and firm ; and if croupous exudation in the air-cells be associated with the inflammation of the interstitial tissue, we observe a scarcely perceptible, very delicate granu- lation. If the suppuration in the inner stratum of the capsule now diminishes, the result of the whole process is a cavity, with whitish, cellulo-fibrous, callous walls, which sooner or later coalesce, leaving merely a cicatrix, like ordinary abscesses or tuberculous vomicae. In some rare cases circumscribed pulmonary gangrene undergoes a cure in this manner. If the eschar breaks down, and dissolves very rapidly, and little or no reaction be developed in the surrounding parts, or if the primary cavern enlarge very quickly at the expense of the surrounding parts, the gan- grenous destruction not unfrequently involves large, unobliterated blood- vessels, and gives rise to exhausting haemorrhages into the cavern, the bronchial tubes, or even into the thoracic cavity, when the abscess has opened into the pleural sac. Partial gangrene often arises in the perfectly healthy lungs of weak, decrepit, cachectic persons from general depressing influences, and is developed from a circumscribed passive stasis. Under similar circum- stances, we find it associated with pneumonia in its various stages, with pulmonary abscess, with pulmonary tuberculosis and tuberculous vomicae, with bronchitis, especially when it is developed in the course of exanthe- matous diseases, both in adults and children, &.c. Finally, it appears among the sequelae of typhus, as a manifestation that the typhous process 84 ABNORMAL CONDITIONS OF is spontaneously degenerating into a state of putrescence; or it may be produced by the absorption of gangrenous ichor from gangrene of diffe- rent parts into the blood, in which case Ave have diffluent gangrenous deposits, or septic capillary phlebitis. i. Softening.—Softening of the lung-tissue is of very rare occurrence; it is altogether distinct from pneumonia, and must not be confounded with Andral's ramollissement (red and gray hepatization); like softening of the stomach, it is a peculiar spontaneous process, and appears under precisely the same conditions as that affection : indeed, as a further proof of their identity, we may add that this disease is almost always combined with gastric softening. In any part of the lungs we may find an undefined patch of a dirty brown or blackish color, according to the state of the blood at the com- mencement of the process, and which is so very moist and soft that on the slightest pressure it breaks doAvn into a pulp, which is mixed with a serous fluid and contains black flocculi of carbonized blood. The bron- chial mucous membrane is found in the same state for some distance around the diseased spot. In consequence of the considerable quantity of blood which is always contained in the lungs, there is a resemblance between softening of the pulmonary tissue and the black softening of the stomach, which proceeds from a disease of the blood itself. It may be easily mistaken for diffuse pulmonary gangrene; indeed in very intense cases the diagnosis must depend on the absence of the gangrenous odor, and on the lesser degree of discoloration. k. Adventitious Products. 1. Cysts are of extremely rare occurrence in the lungs, which in this respect present a marked contrast with many of the other parenchyma- tous organs. Simple Serous Cysts may, doubtless, occasionally be found in the lungs, but sacs containing Acephalocysts are of less rare occurrence. The rarity of the latter cysts in the lungs contrasts strongly with their fre- quency in the liver, and this is very important Avhen we consider the frequency of pulmonary tuberculosis, for this, in addition to the inverse ratio of the frequency of these secondary products in other organs, espe- cially in the liver, constitutes one of the most important objections to the theory that tubercle has a hydatid origin. Hitherto only single sacs of acephalocysts appear to have been found in the pulmonary tissue ; they have varied from the size of a pigeon's egg to that of a man's fist, and have occurred sometimes in the upper and sometimes in the lower lobes. They are undoubtedly developed in the interstitial tissue of the lungs, and occasion, according to their size, more or less compression of the pa- renchyma, which is thus gradually converted into fibro-cellular tissue (obsolescence). The parent sac is surrounded by and adherent to this tissue, and contains, in its interior, the acephalocysts, which vary in number and form, and either swim freely in a serous fluid or are attached to the walls. It is important to recollect that in rare cases the parent sac may be destroyed by inflammation and consequent suppuration, and a communi- THE RESPIRATORY ORGANS. 85 cation may thus be established between the cavity and the bronchi, through which the acephalocysts may be ejected, especially as in less rare instances acephalocysts are ejected from the liver by this compli- cated route. The pulmonary sac containing acephalocysts often communicates with a similar sac in the liver. Cysts containing other substances, as for instance cholesterin, with or without hair, are even rarer than cysts with serous contents. 2. Anomalous Fibrous or Fibrocartilaginous Tissue occurs— a. As callous condensation arising from chronic inflammation of the interstitial tissue; it likewise occurs as cicatrix-callus around old abscesses, tuberculous cavities, apoplectic effusions, &c. b. Fibroid Tumors are incomparably rarer. They never attain any considerable size, being seldom larger than a bean or a hazel-nut. They are either bluish-white, firm, elastic, very dense and flat bodies, or, as is more frequently the case, they are of a pale yellow or dirty white color, flabby, soft, and puckered, and resemble the structure of the mammary or salivary glands. 3. Anomalous Osseous Substance occurs not only in the bronchi (see p. 35) and bronchial glands, but under various circumstances, in the lungs, especially in the form of ossification of anomalous fibrous tissue or of the chalky metamorphosis of an unorganized structure. To the first belong many either flat or roundish and nodular, yellow, and generally very compact concretions, which are developed in and from all the forms of anomalous fibrous tissue, but especially in the callous stripes, capsules and cicatrices ; to the latter belong the chalky, whitish or grayish nodu- lar, brittle, and even friable masses into which tubercle and tuberculous pus are, under certain conditions, metamorphosed. 4. Black Pigment is more frequently and abundantly deposited in the lungs and bronchial glands than in any other organ, except the mucous membrane of the intestinal tract. It occurs, with rare exceptions, in the lungs of all adults, and increases with advancing years. Hence it can properly be only regarded as a pathological appearance, either when it occurs in the earlier periods of life or in excessive quantity. The pigment which occurs in the form of molecules is either deposited in a, free state in the interstitial tissue and in the walls of the air-cells, or else it is combined, as a new formation, with some older deposit. In the first case it is found according to the extent of the accumula- tion, in blackish-gray, blackish-blue, or ink-black points, or in patches, as if laid on with a brush ; or if very abundantly present, it is diffused over the interstitial tissue in large ramifying streaks, which appear as islands in the cellular tissue under the pulmonary pleura, and are uni- formly infiltrated, blackened, and as it were inked, and are thickened and tough. This thickening of the interstitial cellular tissue is important, since it impedes the development of the air-cells, and likewise gradually obliterates their vessels, and in this manner causes their atrophy. We must here especially notice a metamorphosis which not unfrequently occurs at the apices of the upper lobes, and is unassociated with any other anomaly ; we refer to the deposition of large quantities of pigment which give a black color to the tissue, and increase its firmness, its struc- 86 ABNORMAL CONDITIONS OF ture being either normal or presenting at some spots an irregular reti- culated appearance in consequence of atrophy. Senile atrophy of the lungs is undoubtedly often induced by an excessive accumulation of pig- ment in the interstitial tissue. The deposit usually takes place through the whole lung, but is most abundant near the surface and in the upper third of the superior lobes. It is the result of slight irritative processes and of transient stases; the pigment is conveyed by absorption to the bronchial glands, and is thus deposited in them. It must be decided by further and more careful observations whether the larger deposits of pigment which are so frequently noticed in the lungs of persons engaged in working both coal and coal dust, depend upon the actual absorption of these extraneous matters into the tissue, or whether, as we are more in- clined to believe, they are the results of the continued irritation to which the pulmonary mucous membrane of such persons is necessarily subjected. In the second case the pigment is the result of a chronic pneumonia, and we find it infiltrated in various quantities into an indurated and cal- lous parenchyma. We meet with it in the vicinity of tuberculous depo- sits, especially of hemorrhagic tubercle, and in certain cancerous deposits, especially in cancer melanodes. 5. Tubercle.—Pulmonary tuberculosis, which is the most frequent of all the tuberculoses, is one of the most common and likewise the most fatal of the diseases of the lungs. For general information on tubercle and tuberculosis we must refer to what has been stated in the first volume; we shall here endeavor to apply those general principles to a special case, and at the same time shall attempt to elucidate certain points, which, from presenting some peculiarity, require a fuller notice. Tubercle does not primarily occur in the lungs in the numerous forms which have been described, but only in two forms, which are most essen- tially connected, both in relation to its mode of formation and its seat. To these two forms we apply the respective terms of interstitial tubercu- lous granulation and infiltrated tubercle or tuberculous infiltration. a. Interstitial Tuberculous Granulations occur in the pulmonary tex- ture in the form of roundish, originally gray, semi-transparent bodies, varying from the size of a hemp or millet-seed to that of a barleycorn; these minute bodies either occur singly and in an isolated state, or seve- ral are collected into a group, or finally they may coalesce and form a large continuous mass. They are seated, as is shown both by special ana- tomical investigations and by numerous analogies, in the interstitial tissue betAveen the smallest lobules and the air-cells, and on the walls of the cells themselves; that is to say, they are altogether external to the cell-cavi- ties ; but by pressure on the cell-wall they sometimes induce a corres- ponding internal prominence, or, if they be of larger size, they exert such pressure on the walls, that in every group or confluent mass of tubercles we find a number of cells more or less completely obliterated. It is the result of a chronic or acute tuberculous process, which is accom- panied by local congestion or hyperaemia. We have now sufficiently in- dicated this form of tubercle, but we shall hereafter return more fully to it. For the sake of brevity we shall always name it tubercle, or tubercu- lous granulation, and it must be carefully distinguished from the second THE RESPIRATORY ORGANS. 87 form, which we shall invariably term tuberculous infiltration, or infil- trated tubercle. b. Infiltrated Tubercle, unlike interstitial tubercle, is actually depo- sited in the cavities of the air-cells. It arises from a more or less ex- tensive croupous pneumonia whose products, under the influence of a tuberculous infiltration, become variously discolored, and converted into yellow tubercle, instead of being absorbed or dissolving into pus. Hence tuberculous infiltration presents the form of hepatization, or more strictly speaking is hepatization, induced by a tuberculous product. The pneu- monic product, which was at first red and granular, gradually becomes of a paler and grayish-red color with a tinge of yelloAV, and is dry and fragile ; it finally becomes yellow, moist, of a soft, fatty, cheesy charac- ter, and sooner or later becomes disintegrated into tuberculous pus. The granular texture, in the mean time, gradually disappears, whilst the tissue forming the air-cells becomes tuberculous, and the diseased por- tion of lung appears to be actually changed into a connected fatty-cheesy tuberculous mass,—a condition which Lobstein doubtless observed, and mistook for fatty metamorphosis of the lung-substance. This form of tuberculosis may attack a whole lobe uniformly, or even a whole lung, according to the extent of the local pneumonic process; it is, hoAvever, much more frequently confined to one or several larger or smaller separate portions of lung, and very often occurs as a lobular tuberculous infiltration, and in both these cases it is generally sharply defined; finally, it may occur as vesicular tuberculous infiltration, in which case it is the same thing as Bayle's pulmonary granulations, regarding which there has been much discussion. It very often attacks the superficial parts of the lungs, as lobar and lobular infiltration, and may then be at once recognized by its external characters, by the pneumonic tendency, and the peculiar color of the diseased portion. It is always the result of a high degree of tuberculous dyscrasia, and hence it only rarely occurs as primary tuberculosis, but is as a general rule, associated Avith advanced stages of interstitial tubercle. It giA'es rise to a form of phthisis Avhich is tumultuous and acute, is accompanied with repeated attacks of pneumonia, and is attended with much pain and distress. It is especially frequent in young persons and children, and presents an analogy with bronchial tuberculosis, with one of the forms of tubercu- losis of the intestinal mucous membrane, with the tuberculous metamor- phosis of exudations on serous membranes, &c. It is always combined with a high degree of tuberculosis of the bronchial glands, and very often with tuberculosis of the intestinal mucous membrane. These are the two principal forms of pulmonary tuberculosis, and all other varieties of tubercle, such, for instance, as depend on physical pecu- liarities, hoAvever important they may individually be, are unimportant in reference to the local process, depending either on different modifica- tions of the general disease or on mere changes in the tuberculous matter. There are no organs excepting the spleen and serous membranes in which tubercles occur in such great numbers as in the lungs. They ap- pear either as separate granulations or seA'eral of them are accumulated into one group. In the first case each granulation is isolated from the 88 ABNORMAL CONDITIONS OF others by an extent of lung-tissue proportional to the number of the tubercles. This takes place either in a comparatively uniform or in an irregular manner; the latter occurring when in one part of the lung we find a large number of tubercles Avith little intervening parenchyma, and in another a few tubercles interspersed among much healthy tissue. When the tubercles are present in large numbers they become pressed upon one another, and finally coalesce in the form of irregular masses, as may be especially observed in the apices of the lungs, where the dis- ease is usually the most developed. In many of the more common cases we find an uniform increase in the number of tubercles, and a corres- ponding approximation of them to one another as we advance from the lower portions of the lungs towards their apices. This accumulation of tubercles into irregular masses, such as occur in the apices of the lungs, which are the usual starting points of pulmonary tuberculosis, and occasionally at other spots, must be carefully distin- guished from the primary development of tubercle in tolerably regular groups. Under certain local and general conditions which are not yet altogether understood, tubercles are originally deposited at different spots in groups of a roundish form, and of the size of a pea, a bean, or a hazel-nut, or even larger, while around them there are usually other iso- lated tubercles in greater or less number. In extreme cases of this kind the tubercles are deposited around a central nucleus of pulmonary tissue, from which processes run into the tuberculous groups, dividing them into several compartments. Pulmonary tubercles originally appear either (1) as the well-known gray, semi-transparent granulations of the size of a millet or hemp-seed, or in many cases of acute tuberculosis as still smaller-sized granules, which are clear, transparent and vesicular; or (2) in high degrees of tuberculous disease, especially when it is running an acute course, they are separated from the blood as yellow tubercle. On a cursory exami- nation they appear almost or quite round; on closer investigation, however, we find that their outlines are not sharply defined, but that delicate prolon- gations extend from their surface into the surrounding tissue, which ac- cording to their size, may enclose one, two or more air-cells. These cells are most commonly obliterated, but not unfrequently appear dilated. In examining the lungs we not unfrequently meet with extensive, roundish, or irregularly ramifying or lobulated tuberculous masses, which are produced either by the confluence of several tubercles which were originally in the same group, or by the subsequent deposition of tubercles in the same immediate neighborhood. The tissue at these points is completely wasted away, so that nothing but the pigment re- mains, and the air-cells and extremities of the bronchial tubes are oblite- rated. These tuberculous masses must be distinguished as carefully as possible from tuberculous infiltration. The whole of the upper lobes are not unfrequently so thickly strewed with tubercles as to present the ap- pearance of having degenerated into a tough, resistent, uniform tubercu- lous mass. In the ordinary course of the disease the principal seat of the tubercles is in the upper third or apices of the superior lobes; it is here that they are deposited first and in the greatest quantity, and that they first begin to undergo their ordinary changes. The apices of the lungs must there- THE RESPIRATORY ORGANS. 89 fore be regarded as the usual starting point of tuberculosis, which gradu- ally extends from thence to the lower portions of the lungs. Exceptions to this rule are, however, not unfrequent; we sometimes meet Avith tu- bercles in the apices and others far away from them, even in the lower lobes, or they may even occur in the latter portion while the upper parts are perfectly free from them. In this respect there is a contrast between pulmonary tuberculosis and pneumonia, at all events in a great majority of cases, for pneumonia most commonly commences in and starts from the lower lobes, while tuberculosis has its origin in the upper lobes, and even in their highest parts. Many attempts have been made to account for the preference which tubercles exhibit for the upper parts of the lungs, but none of them satis- factorily explain it; they are based either on mere hypothesis, or the cause and the effect have been confounded. We confess our ignorance on this point, and can no more explain it than we can account for the pre- ference shown by certain exanthematous and impetigenous affections for particular regions of the general integument. Pulmonary tubercles pass through the different metamorphoses which are described in the first volume. 1. They very frequently soften, and this change gives rise to tubercu- lous suppuration of the lungs, tuberculous ulcers, tuberculous abscess (vomica pulmonis tuberculosa, caverna tuberculosa), and tuberculous phthisis. The separate, gray tuberculous granulations begin to soften in their centres, which become turbid, opaque, yellowish and cheesy, and finally undergo purulent solution. The groups of tubercles break down at several points simultaneously, corresponding to the different separate tubercles of which they are composed. Hence, in the first case, we have a small primary tuberculous ulcer ; and in the second case, after the final solution of the whole mass, a much larger one, whose further progress we shall consider in the following remarks. It is especially important to understand the manner in which the pri- mary tuberculous ulcers enlarge, and give rise to such peculiar and exten- sive destruction of the lungs. This is elucidated by the process which goes on in the tissue surrounding the softened tubercle. The breaking doAvn of tubercles is always followed by a secondary deposition of tuber- cle in the surrounding parenchyma, the extent of this secondary deposi- tion being proportional to the intensity of the general disease. More- over these secondary tubercles and the tissue in which they are depo- sited likewise break down with a rapidity which stands in a direct ratio to the intensity of the dyscrasia, and in this way the tuberculous ulcer becomes enlarged. If this process goes on in so tumultuous a manner as to exhaust the powers of reaction and the supply of organic matter, the ulcer usually extends unequally in various directions, and forms an irregular, sinuous, and apparently lacerated cavern whose walls consist of lung substance plugged up with softened tubercle, and whose internal surface presents, as it were, a gnawed appearance, without a trace of any inner lining except a coating of adherent tuberculous pus. The small quantity of parenchyma occurring between the tubercles is in a state of compression and dirty brown discoloration (carnification), while that in the surrounding neighborhood exhibits no trace of reaction, except a certain degree of hyperaemia. If this, as is usually the case, takes place 90 ABNORMAL CONDITION? OF simultaneously at several spots, tAvo or more caverns will come in contact and will finally unite, and we then have either a number of caverns com- municating with one another by means of sinuses of varying width, and either straight or tortuous in their course, or else the whole represents a large abscess with sinuosities in various directions. This cavity is inter- sected in various directions by bridges or rafters of rotten tuberculous lung-substance, which is likewise dependent in the form of shreds from its roof and walls. This form of phthisis corresponds to the acute form of tuberculous intestinal ulceration, which runs its course without any reaction. In other more common and less rapid cases, an inflammatory process, which must certainly be regarded as having a curative tendency, is esta- blished in the parenchyma around the softening tubercle or the primary tuberculous ulcer, and in the interstitial tissue amongst the secondary deposit. It gives rise to an albuminous grayish-white or somewhat red- dish, tenacious and viscid product, which occasions the closure and finally the atrophy of the air-cells, and is identical with Laennec's infil- tration tuberculeuse gelatiniforme. (See pp. 78, 79.) During this pro- cess the inner surface of the cavern becomes smoother and more uniform, and very often becomes covered with a thin grayish or grayish-yellow, thin, adhering investment of an apparently loose texture. This coating may sometimes, according to Andral, consist merely of the more solid portion of the pus contained in the cavity; in most instances this is, however, certainly not the case, but, as Laennec was the first to observe, there is a tirue exudation from the walls of the cavern like that which exposed or wounded animal tissues deposit on the surfaces of wounds or ulcers. This exudation is, doubtless, repeatedly thrown off, for if the process of tuberculous softening go on, neither it nor the adjacent wall of the cavern can meet Avith the conditions necessary for organization; it melts or becomes disintegrated, and mixes with the pus in the cavern, and another membrane is formed in its place, so long as the tuberculous process on the one hand, and the reactive inflammatory process on the other, continue in the tissue in a certain antagonistic degree and pro- portion. The caverns enlarge, in the manner we have already described, by the softening and breaking down of the secondary tuberculous deposit in the tissue of their walls, and by the confluence of several neighbor- ing caverns into one. The parenchymatous bridges which traverse them are in a state of gelatinous infiltration, and contain tubercles, while externally they are coated by the above-named exudation. In consequence of this process the lung-substance in the walls of the caverns becomes atrophied and converted into a more or less pigmentary, bluish-gray or blackish-blue, dense and tough layer of various thickness, the portion next to and lining the inner surface of the cavern being chiefly a whitish cellular tissue. To this the above-described exudation adheres, and through both these shine the bluish atrophied parenchyma and the vessels which are laid bare and obliterated by the caArern, and which appear as yellowish-white ramifying streaks; scattered crude or yellowish softened tubercles may also be observed. These tubercles gradually soften, and lead, on the one hand, to a gradual enlargement of the cavern, while, on the other hand, they impede any comprehensive THE RESPIRATORY ORGANS. 91 process of consolidation, since they perforate the cellular investment of the cavity. The internal surface of the whole cavern is even and toler- ably smooth, except at the spots Avhere there are these new tuberculous excavations. The pulmonary vomica in this condition is analogous to the tubercu- lous ulcer of the intestine with gelatino-lardaceous thickening of the submucous tissue on which it is situated. The caverns naturally present the most manifold differences in refe- rence to their size and number. The cases are not rare in which an abscess attains the size of a duck's egg, or of the fist, or even involves a whole lobe. When it is very large, the probability is that it has been formed by the confluence of several smaller caverns. The largest ab- scesses occur, with few exceptions, in the upper lobes, where, as we have already remarked, and especially in their upper third and at their apices, tuberculous deposits usually first occur, and where they first begin to soften. It is a question of especial interest to ascertain how far the individual structures entering into the composition of the lung are involved in this destructive process, and above all, how the bronchi and blood-vessels within the tuberculous abscess are affected, what mode and form of de- struction they undergo, and what destructive consequences follow when the cavern, in making its way outwards, finally reaches the pulmonary pleura. The capillary bronchi undergo the same softening as the true lung- substance, for they, or at least their Avails, are the seat of tuberculous deposition, and their mucous membrane becomes the seat of tuberculous infiltration (bronchial tuberculosis, p. 38) during the softening of the pul- monary tubercle, just as we observe in the larger bronchial tubes in the neighborhood of a tuberculous abscess. The capillary vessels become obliterated in the tubercle, and are exposed to the same softening process as the cellular strata surrounding them. If the cavern should now enlarge, the bronchial tubes become destroyed in the same proportion with the surrounding parenchyma, and it is only when the destruction of the tissue has attained a certain degree that an opening is effected into the tubes, and a communication established between the bronchi and the cavern. We only find bronchial tubes of a comparatively large size opening into the caverns, for the smaller ones are compressed by the tubercle deposited in their walls and in their immediate vicinity, or by the products of interstitial inflammation, or they are closed by catar- rhal tumefaction of the mucous membrane, or by tuberculous infiltration. Their mouths remain freely open in places where compression cannot affect them, in consequence of greater and more resistent thickness of their walls, or of their having a larger calibre. The number of bron- chial tubes opening into a cavern is generally proportional to its size. They constantly open with a round or an oval fissure-like mouth, accord- ing as they are more or less transversely or obliquely situated in relation to the walls of the cavern, or are only ulcerated on one side. When the bronchial opening is recent, it commonly presents an ulcerated ap- pearance, but subsequently, when the cavern has acquired a dense callous wall, it is bounded by a puckered border of mucous membrane in a state of gelatinous infiltration, which is analogous to the serrated, puckered, 92 ABNORMAL CONDITIONS OF and similarly infiltrated border of mucous membrane which surrounds the callous tuberculous ulcer of the intestine. The mouth of the bron- chial tube opens in exactly the plane of the wall of the cavern, and never projects beyond it. The blood-vessels present, as it were, the very reverse condition. The bronchial vessels are usually obliterated and thrust aside, and run along the walls of the cavern as ligamentous, projecting, yellowish-white, rami- fying cords, and those of an arterial nature, even when in this condition, for a long time resist the destructive processes which are here in opera- tion. A partially or entirely obliterated vessel, enveloped in atrophied lung-substance, is usually found in the bridges which run across the cavity of the abscess. It often, hoAvever, happens that, before the ves- sels are obliterated, they are laterally denuded of the surrounding tissue and of their cellular sheath; the two inner coats then soon give way, and occasion the pulmonary hemorrhages which, as is well known, occur in the coursfe of phthisis. There are two circumstances under which the caverns may reach the pulmonary pleura; either when they are originally formed in the peri- pheral portion of the lung, or when they were originally deep-seated, but have attained a considerable size in an outward direction. The first is very rarely dependent on the softening of tuberculous granulations, but, as we shall presently shoAv, is much more frequently a consequence of the softening and breaking down of tuberculous infiltration. In either case the pulmonary pleura may finally be destroyed, and this may occur in different ways and with different consequences. If there are no adhe- sions at the point where the cavern reaches the pleura, this membrane, after being denuded on its pulmonary surface, will be converted into a yellowish-white eschar, which extends over a greater or smaller portion of the cavern, and either becomes torn or else loosened along its circum- ference and falls out in an entire piece; in this Avay tuberculous pus and atmospheric air find their way from the bronchial passages into the pleural cavity, and give rise to pleurisy with pneumothorax, and usually to speedy death. Mere cellular adhesions cannot prevent this termina- tion ; they are, in part, mechanically loosened by the effusion from the cavern, and being involved in the pleuritic process, they are, in part, likewise destroyed in the exudation. If, on the other hand, there are thick adhesions, that is to say if the lung is bound down by dense, thick, callous, cellulo-fibrous, and fibro-cartilaginous pseudo-membranes, such as occur especially about the upper lobes and their apices in consequence of previous pleurisies, then the pulmonary pleura which has coalesced and become identified with these false membranes may sometimes be laid bare to a considerable extent without perforation and the above-named consequences ensuing. But the tuberculous destruction is usually limited by these callous bands; cases occasionally occur in which even these are perforated; irritation is set up in them at one or more spots ; they soften, become tuberculous, and suppurate, layer after layer; in this way they finally become perforated, and the tuberculous process attacks the wall of the thorax, insidiously advances to the ribs and soft parts, and at length reaches the outer surface of the chest, or even of the neck (Cru- veilhier), in the form of a tuberculous sinus variously combined with caries of the ribs, the sternum, and the vertebrae. THE RESPIRATORY ORGANS. 93 Tuberculous Infiltration, when associated with the above-described metamorphosis of interstitial tubercle, usually softens with very great rapidity, and by hastening the progress of the disease, constitutes what is termed florid, or, by English Avriters, galloping consumption. It causes the most frightful destruction of the pulmonary tissue, and gives rise to caverns of irregular form, which are surrounded by rotten, and as it were corroded parenchyma, infiltrated with tubercle and breaking down into pus. Tuberculous infiltration is most commonly deposited in the superficial portions of the lungs, and hence it is the caverns arising from this variety which most frequently open into the cavity of the pleura. There are several ways in which this may take place. (a.) The pulmonary pleura may be puffed up by the air rushing into the cavern, and may be violently peeled off the tuberculously-infiltrated parenchyma for some distance beyond the extent of the cavern, so as to form a flattish, round bulla, which finally bursts. (b.) It may be converted, as we have already shown, into a yellowish- white eschar, which either tears or becomes detached unbroken. (e.) Both the pleura and the infiltrated parenchyma surrounding the cavern may be attacked with gangrene, and become changed into a dirty- brownish, or greenish, pulpy, shreddy, fetid mass. This last-named termination is especially worthy of notice, as it may occur not only near the surface, but also in the deep-seated portions of the tuberculous infiltration, especially around a pre-existing cavern. Moreover, in consequence of the frequency with which intense tubercu- losis of the bronchial glands is combined with tuberculous infiltration, it may occasionally happen that a communication may thus be established between a deep-seated pulmonary cavern and a cavern in a bronchial gland. The contents of tuberculous caverns present many differences. Some- times, and especially when the infiltrated tubercles begin to soften, these caverns contain a yellow and somewhat thickish pus; more frequently, however, they contain a thin, whey-like fluid (tuberculous ichor), in which may be observed numerous grayish and yellowish, friable, cheesy, puru- lent flocculi and particles, whose quantity, however, is not in itself suffi- cient to explain the profuse expectoration which so often occurs in phthisis. This fluid is often of a grayish-red, or reddish-brown, or cho- colate color, from the admixture of blood; or of an ash or blackish-gray color, from the pigment which it takes up during the softening of the tissue. Moreover, the caverns sometimes contain smaller or larger fragments of lung, resembling the parenchyma contained in their walls, and chalky concretions are occasionally found in them. In other cases they contain coagulated or fluid blood in various stages of discoloration. This metamorphosis of pulmonary tubercle, in its twofold form, con- stitutes, as has been already observed, tuberculous pulmonary phthisis. If we now direct our inquiry to the state of the lung-substance around the tubercles and their abscesses, and from thence to the other organs and systems, in a distinct and uncomplicated case of this nature, we shall arrive at the following conclusions, in addition to what has been already stated, as the result of an anatomical examination when considered in reference to the living organism. 94 ABNORMAL CONDITIONS OF In the upper lobes, and especially in their upper third, there is usually a large cavern, surrounded inferiorly by several smaller ones, sopie of which communicate with it; between these are yellow tubercles in the act of softening, and gray tubercles just becoming opaque and discolored, whilst in the loAver portions, as well as in the inferior lobes, there is a comparatively small sprinkling of gray, crude, tuberculous granulations. The lung-substance between the tubercles is found in various states, according to the progress made by the disease. It may be normal, but generally there is a vicarious emphysema developed in its superficial portions, while the deep-seated parts are not unfrequently hyperaemic, or in a state of oedema. It is, however, sometimes atrophied, and this is a more important change, owing in part to interstitial inflammation, in part to the obliteration of the bronchial tubes and air-cells, in conse- quence of the pressure exerted on them by the accumulated tubercles, and in part to the occlusion of the bronchi by the blennorrhceal mucous secretion when bronchial catarrh is simultaneously present. Inflammation (croupous pneumonia), which sometimes attacks the greatest portion of the non-tuberculous parenchyma, is also an important change ; it appears partly as a brownish-red, and partly as a grayish-red hepatization, Avhich is everywhere converted into yellow tuberculous infiltration, which becomes dissolved, and collects in vomicae ; or the pneumonia may cause the deposition of a gelatino-glutinous product. (See p. 73.) In well- marked cases of this nature, the lung appears very bulky, and is coated with a grayish-yellow and generally thin pleuritic exudation, through which and the pulmonary pleura may be seen the peripheral tuberculous infiltrations, and the emphysematous patches amongst them. In the larynx we find tuberculous ulcers, which vary in number and extent; and, associated with them, we find aphthous erosions, especially on the tracheal, and sometimes also on the pharyngeal mucous mem- brane. The bronchial tubes proceeding to and from the caverns, exhibit streaks of mucous membrane in a condition of tuberculous infiltration, and are themselves filled with tuberculous matter; moreover, they are always in a state of catarrh, with reddening and softening of their mucous mem- brane, and with a muco-purulent secretion, which constitutes the greatest part of the sputa which are expectorated in the course of phthisis. The bronchial glands are enlarged, and more or less tuberculous. Externally we find pleurisies which present great variety in their extent, and in the character, mode of organization, and consequences of the exudation. They are the causes of the very acute pains in the chest to which phthisical patients are subject. Unless when they arise from superficial pneumonia, they are generally developed during the softening of the tubercles and the formation of the caverns, and are associated with the inflammatory reaction that is established in the adjacent inter- stitial pulmonary tissue. The most constant seat of these pleurisies is the conical apex of the pleura and the surface of the upper lobes generally ; they thus correspond to the starting-point of tubercle and of its meta- morphosis. They deposit an exudation which becomes organized into fibro-cellular cords, or into a thick, compact, fibrous investment, which covers the upper lobes from the apices doAvnwards, in the form of a hood, THE RESPIRATORY ORGANS. 95 and diminishes in thickness from above downwards, causing the lungs to adhere firmly to the costal walls, and thus affording a protection against the perforation that might otherwise be caused by large caverns. With rare exceptions, we find tuberculous intestinal phthisis associated with pulmonary phthisis, and although the former is usually only a secondary affection, dependent upon the pulmonary phthisis, it sometimes exceeds it in the rapidity of its progress, and rapidly occasions very great and exhausting ravages. As a general rule, the loAver portion of the ileum is the part originally attacked, and from thence the ulcers extend upwards along this division of the intestine, and downwards over the colon ; in their progress upwards the ulcers sometimes reach as far as the stomach. Frequently, however, and especially at certain times, the tuberculosis not only predominates in the colon, but is almost exclusively confined to it, the ileum entirely escaping ; and sometimes we may readily perceive that the ulcers Avhich are simultaneously present in the ileum are of a more recent date than those in the colon. In addition to the tuberculous ulcers on the intestinal mucous membrane, we also find that the corresponding mesenteric glands are more or less tuberculous. The mucous membrane of the alimentary tract, especially of the stomach and large intestines, is also in a state of more or less developed blennorrhoea; and, towards the end of phthisis, an acute softening of the mucous membrane of the great cul de sac of the stomach is not of un- common occurrence. The liver is very frequently affected ; the condition known as nutmeg liver, and depending on a morbid separation of the yellow and reddish- brown substances, with a preponderance, and more or less fatty degene- ration of the former, is extremely common, and so, also, is the true fatty liver. These changes in this organ are not peculiar to phthisis,—that is to say, to the softening of the tubercles and the tuberculous ulceration of the pulmonary tissue,—but are associated with tuberculous disease generally. The spleen exhibits no constant change which stands in any essential connection with tuberculous ulceration of the lungs. The right side of the heart appears sometimes to be dilated, in conse- quence of the impermeability of the lungs, induced by tubercle and its consecutive diseases; it is, however, much more frequently remarkably small, pale, and devoid of fat, in consequence of the anaemia which ac- companies phthisis in its progress. In the former case we find stasis and accumulation of blood in the right side of the heart, and from thence, in the whole venous system; in the latter, there is a general deficiency of blood, and a contracted aortic system. The central organs of the nervous system exhibit no essential anomaly, although, as a consequence of acute phthisis, we not unfrequently observe hyperaemia of the brain and its membranes, and recent serous effusions into the ventricles, associated with white (hydrocephalic) softening of the cerebral substance. The muscles are all emaciated in an extreme degree; the fat is, in most cases, almost entirely consumed, and the cellular tissue, especially on the extremities, is very often in an infiltrated condition. Tuberculous pulmonary consumption is unquestionably curable, as we 96 ABNORMAL CONDITIONS OF may infer from the appearances not unfrequently observed in the dead bodies of persons who formerly had more or less suspicious thoracic affections, and subsequently recovered. It is only by the investigation of the conditions under which these natural cures take place, that we can hope to arrive at a truly rational mode of treatment, and the results will be the more beneficial when directed against the tuberculosis gene- rally, and not merely against the pulmonary abscesses. Pulmonary phthisis, or tuberculous ulceration of the lungs, can only be healed when the general disease, and consequently the local process on which the ulceration depends, is eradicated. There are incontrovertible facts to show that, under these conditions, pulmonary abscesses may actually heal in various ways. a. The reactive inflammation of the interstitial tissue in the vicinity of the caverns gives rise, as has been already mentioned, to a gelatinous infiltration which causes an obliteration of the air-cells. By this means the whole of the adjacent parenchyma is converted into a dense, fibro- cellular layer of varying thickness. While this is taking place, the exudation, which is deposited by the same inflammatory process on the walls of the cavern, becomes organized from this fibro-cellular tissue into a smooth serous membrane. The whole cavern is now converted into a cellulo-serous cavity, whose inner surface secretes a serous, viscid fluid resembling synovia. The bronchial tubes, which open into these cavities, present a peculiar character, for the serous membrane lining the cavern, and the subjacent fibro-cellular tissue project beyond the outer stratum of the bronchial tubes at their openings, and their mucous coat hangs forward with a wrinkled, somewhat inverted free edge into the cavity. More commonly, however, we find the caverns lined with a villous, cellulo-vascular, more or less deep red layer resembling mucous mem- brane, which is intimately connected with the subjacent tissues. It ap- pears in a constant state of irritation; and, as we generally find in caverns with which large bronchial tubes communicate, its conversion into a smooth serous membrane appears to be impeded by the irritation induced by the constant entrance of atmospheric air. An already formed serous investment may doubtless be again reduced to this cel- lulo-vascular mucous membrane-like state, in consequence of this con- tinuous influence. It secretes a torpid, muco-serous fluid, and it is not unfrequently observed to be covered with fresh exudations in consequence of higher degrees of irritation. It is extremely probable that these pro- cesses of irritation, associated with other causes presently to be described, effect the gradual diminution and finally the closure of the caverns. In cavities of this sort, the form of the bronchial openings is somewhat different from that which has been already described; for the bronchial mucous membrane coalesces with the lining"texture of the cavern, which is analogous to its own tissue, and they merge into one another without any apparent line of demarcation. Osseous laminae are sometimes developed under the serous invest- ment, in like manner as in the cellular tissue beneath normal serous membranes. In these caverns an event not unfrequently takes place, which very often proves fatal on its first occurrence; this is the hemorrhage Avhich THE RESPIRATORY ORGANS. 97 is met with in caverns of this construction, and Avhich always springs from the larger branches of the pulmonary artery traversing the walls ; these branches often remain permeable, and become opened for a con- siderable extent on the side towards the caATity. There are two dif- ferent conditions which may give rise to the opening of these arteries. (a.) They either undergo an aneurismal dilatation in consequence of the absence of support in the direction towards the cavern, and finally tear at this point, without any further change in the texture of their membranes; (ft.) Or the delicate cellular sheath of the vessel participates in the irritation of the adjacent investment of the cavern ; the process extends to the fibrous coat, which becomes relaxed and infiltrated with gelatin- ous matter; and the vessel finally gives way, a previous dilatation of its coats being sometimes but not always observed. A circumstance deserving of notice sometimes accompanies these hemorrhages. The extravasated blood in the cavern coagulates into a fibrinous clot, which completely fills it, and is attached to a pedicle, which is seated in the rent in the vessel, and is continuous in both direc- tions with the cylindrical clot in the artery. The cavern may cer- tainly contract around this clot of fibrin when, in the course of time, it has become shrivelled and finally cretified; but as the cavity in its previously described state must be regarded as innocuous, and may be closed in another and a simpler manner, this method of cure, except in cases where hemorrhage takes place into a cavern which does not com- municate with a bronchial tube, must always be regarded as dangerous, and only of actual use, insomuch as the fibrinous coagulum affords a support for the vessels in the walls, and prevents subsequent hemor- rhages, which might occur before the cavity had closed by the ordinary way. The above-described cavern must be regarded as a cured pulmonary abscess ; but the cure may progress further, till there is perfect cicatri- zation. b. This occurs in the following manner:—If the abscess be not too large, it closes by a gradual approximation of its walls, which finally come in contact and coalesce. We then find, in place of the previous cavern, a cellulo-fibrous stripe, in which the bronchi end in blind sacs. This is of most frequent occurrence in the apices of the lungs, where the coexistence of open caverns and the presence of obsolete and cretified tubercles indicate the nature of the processes that is here going on. The obliteration of a cavity of considerable size always occasions a corresponding depression of the surrounding parenchyma, and a cica- trix-like folding and puckering of the pulmonary pleura, which is most frequently and distinctly observed in the case of those cavities which are often superficially situated quite in the apices of the lungs. The tho- rax is also depressed to an extent corresponding with the size and num- ber of the closing vomicae, and is obvious from the flattening and slight depression so frequently observed in the clavicular region. This process is undoubtedly favored very essentially by certain cir- cumstances, amongst Avhich we may enumerate the local depression of vol. iv. 7 98 ABNORMAL CONDITIONS OF the thorax, the contraction of its cavity in consequence of the diaphragm being abnormally pressed upwards by the contents of the abdomen, the development of emphysema in the parenchyma surrounding the cavern, and bronchial dilatation. It has been proposed and attempted to produce these conditions artificially, by way of treatment^ in various and sometimes violent ways : we have already discussed (in • the first volume) the admissibility of these methods of treatment, their modes of action, and the consequences to which they may give rise. When the healing process is rapid and continuous, the cicatrix some- times encloses chalky concretions of various sizes, formed by the inspissa- tion of tuberculous pus in the cavity. (c.) The cavern, instead of cicatrizing in the above-described manner, may be filled up with a roundish or irregularly branched mass of fibro- cartilaginous structure, in which the bronchi terminate in blind sacs. This is effected by the conversion of its cellulo-fibrous walls into a fibro- cartilaginous callus, which continues to grow thicker. The cicatrix-like puckering of the surrounding parenchyma is generally in this case very inconsiderable. This fibro-cartilaginous mass may sooner or later be converted into a very compact osseous concretion of corresponding form and size. 2. The second metamorphosis which pulmonary tubercles undergo under favorable conditions, is their cretefaction. After their softening has began or is perfected, they gradually diminish in volume and become converted into a yellowish-white, or grayish, or blackish-gray, smeary, chalky paste, and finally into a calcareous concretion. This concretion is situated, according to the intensity and extent of the process of reac- tion which is set up in the neighborhood of the softened tubercle, either in obliterated pulmonary tissue, or in fibro-cellular, or callous, fibro-car- tilaginous capsule. Here also cicatrix-like puckerings of the parenchyma occur over the cretified tuberculous masses. Tuberculous infiltration may also undoubtedly undergo this metamor- phosis, for we not unfrequently meet with paste-like masses of chalk, to- gether with cretified tuberculous granulations in the apices of the lungs, and corresponding in size and form to a pulmonary lobule; they are surrounded by a very delicate sero-cellular capsule, formed of condensed interlobular cellular tissue, and most probably are cretified lobular, tuber- culous infiltrations. 3. Finally, pulmonary tubercle, when in the form of crude gray gra- nulations, may become obsolete, shrivelled up, and abortive. It is then changed into opaque, bluish-gray nodules, having the resistent power of cartilage, which are incapable of any further metamorphosis. This de- struction of the tubercle is either general, or it is combined with the process of cretefaction, the central portion or nucleus being converted into a chalky concretion encysted in the obsolete peripheral layer of tuberculous matter. From what has been already stated, it follows that pulmonary tuber- culosis may be cured by phthisis with the elimination of the tubercle; but the two last-described metamorphoses, opposite as they are to one another, constitute more direct healing processes. Any one of them may take place under favorable conditions, and as a general rule, they THE RESPIRATORY ORGANS. 99 are all found in one and the same individual, for we find associated to- gether cellulo-fibrous caverns, their cicatrices, and cretified and obsolete tubercle. They are generally all found imbedded together in obsolete parenchyma, infiltrated with black pigment. Tuberculosis is either an acute or a chronic disease. In acute cases it attacks both lungs simultaneously, and frequently other parenchyma- tous organs and membranes, giving rise to peculiar symptoms resembling those of typhus; the tubercle is the product of tuberculous dyscrasia of the blood developed in a very high degree. The tuberculous mass is, in some cases, deposited at once, and in others at different intervals, which rapidly succeed one another, and are indicated by paroxysmal exacerbations : it is formed of gray, crude granulations, which are either very minute, vesicular, and transparent, or in some cases, as large as millet-seeds. The tubercles are always very numerous, discrete, and uniformly scattered through the lung-substance ; it is only rarely that we find them accumulated and confluent at individual spots, and in these cases they are all in the same stage, namely, that of crudity. Moreover the lung is in a state of hyperaemia, oedema, and emphysematous textu- ral relaxation; the hyperaemia occasionally passes into pneumonia and hepatization. In most cases it only attacks the lungs after tuberculous disease has advanced in them to the stages of softening and ulceration (vomica), and after it has existed for a longer or shorter period in its favorite locality, —the apices of the lungs—in the state of more or less circumscribed, insidious tuberculosis. A pre-existing chronic tuberculosis of the lungs is generally the predisposing cause of the acute production of tubercles in those organs. It proves fatal in consequence of the hyperaemia and of the subsequent oedema to which it giAres rise, in consequence of the violent production of emphysema, or from paralysis of the lungs. Chronic tuberculosis either deposits its product imperceptibly, or else as crises of a mild general disease, with symptoms of moderate vascular excitement, and recurring at intervals. In accordance with this view we find tubercles of various ages and stages ; and at the extreme points of the diseased lung-substance we have the two extreme stages of tuber- cle ; at the apices, where the tubercles are first developed, we have ca- verns ; and at the lowest portion we have recent, crude, tuberculous gra- nulations ; between these we have dissolved tubercles next to the caverns, and lower down such as are just beginning to soften. It either proves fatal in the form of phthisis through exhaustion and tabes, or through some of those accidents which we have already de- scribed as liable to occur in the course of phthisis, as for instance the supervention of pneumonia with a tendency to tuberculous infiltration (hepatization), hyperaemia or oedema of the lungs, hyperaemia of the brain and serous effusion into its ventricles (hydrocephalus, serous apo- plexy), tuberculous meningitis, exudative processes in the neighboring mucous canals, as the trachea or oesophagus, purulent metastases, or the supervention of acute pulmonary or general tuberculosis. The tuberculous habitus in general, and more especially the irritable scrofulous habitus, are the stamp indicating a predisposition to pulmo- nary tuberculosis; the torpid scrofulous habitus more commonly gives 100 ABNORMAL CONDITIONS OF rise to bronchial tuberculosis. The well-known (phthisical) conformation of the chest which predisposes to pulmonary tubercles, is by no means invariably present; its peculiar relation to tuberculosis is unknown, and any connection between the smallness of the respiratory organs in a con- tracted thorax, and the development of pulmonary consumption, is only hypothetical. Tubercles are often developed in the lungs of individuals, independently of any marked external influences, and then form consti- tutional pulmonary tuberculosis and pulmonary phthisis. On the other hand, they may arise independently of this constitutional dyscrasia, in consequence of appreciable noxious influences, Avhich induce either a purely tuberculous condition of the juices, or a modification, that is to say, a combination of this state with some other. This is acquired tu- berculosis, which is either pure, or more or less modified and combined, such as folloAvs the exanthemata and impetigo, gonorrhoea, syphilis, and anomalous gout, and occurs in drunkards, after the suppression of nor- mal or habitual discharges, as, for instance, of the menses, after the cure of inveterate ulcers, &c. The inveterate forms of dyscrasia deposit different varieties of tuber- cle, which have not hitherto been fully described ; they occasionally ter- minate in hemorrhagic tubercle. The tuberculosis is distinguished from the ordinary forms by commencing at an uncommon part, by its unequally attacking the most different parts of the lungs, by the deposit being ac- cumulated in circumscribed or grape-like branches, by its very conside- rable amount, and by its peculiar, dirty-gray or leaden color with a greenish sparkling appearance. (See Vol. I.) Cancer of the lungs is sometimes deposited in a form resembling tu- bercle ; Ave must carefully avoid confounding these morbid growths. Pulmonary tuberculosis, like tuberculosis in general, is excluded by all the conditions enumerated in the first volume, especially by diseases of the lungs, attended with atrophy, emphysema, bronchial dilatation, excessive condensation, compression, obsolescence or obliteration of the tissue. 6. Cancer of the Lungs.—Cancer occurs in the lungs both in the form of carcinoma medullare and carcinoma fasciculatum, seu hyalinum. The latter is extremely rare, but the former is comparatively common, and it is to it that the following observations apply. a. It most commonly occurs in the form of roundish, separate masses, varying from the size of a hemp-seed to that of the fist, and occasionally being even larger, and enclosed in a very delicate cellular capsule ; they are composed of gelatino-lardaceous or lardaceo-encephaloid or true en- cephaloid parenchyma, and hence they vary considerably in consistence; they are usually white, but are sometimes of a grayish-red, or dirty yel- loAvish-gray color. They are generally scattered in very considerable numbers throughout the lungs, both near the surface and deep in the texture, and when they are contiguous to the pulmonary pleura, they undergo a flattening or depression. The injury of the surrounding pa- renchyma is limited to its being displaced and compressed in the imme- diate vicinity of the adventitious product. It is only very seldom that it undergoes ichorous disorganization, in which case the accumulated cancerous ichor makes its escape by communicating with the bronchi. THE RESPIRATORY ORGANS. 101 It usually proves fatal by the exhaustion induced by its excessive growth, and by the high degree of general cancerous cachexia from which the growth originates. Pulmonary oedema and hydrothorax commonly supervene, either with or without simultaneous cancer of the pleura. It very rarely occurs in the lungs as primary cancer, that is to say, as the first in a series of successive local cancers; it almost always exists in association with other, and generally many cancerous deposits of older date, distributed over several organs; and is often developed with great rapidity after the extirpation of large cancers. It is chiefly combined with cancer of the pleura, with which it is usually simultane- ously developed, or with cancer of the mediastinum, or of the mammary gland, the liver, the kidneys, or the osseous system. b. The occurrence of pulmonary cancer as a special form of tubercle is very rare, and is never met with unless when there is cancer in some other organ. It presents itself in the form of tubercles or nodules of the size of a millet or hemp-seed, which, as far as we yet know, may be distinguished from other tubercles by their bluish Avhite color, their softer consistence, their aggregation in groups, and a difference in their elementary structure and composition. They sometimes exist in associa- tion with a retrograde genuine pulmonary tuberculosis. c. Cancerous matter is very rarely infiltrated or effused into the air- cells. When it occurs in this form it is the product of a pneumonic pro- cess, which, under the influence of a dyscrasis excited by the extirpation of cancer, assumes the external characters, and the elementary structure of carcinoma; the lung in this case appears hepatized with cancerous matter. Medullary cancer of, the lungs is sometimes more or less blackened by a pigment which enters into its composition; the medullary nodules are marked with broAvn, blackish-blue, violet, or black spots or stripes, or are completely and thoroughly black, constituting melanotic cancer— cancer melanodes—of the lungs. We have never met with it except in association with general and, in fact, with very acute medullary cancer. SUPPLEMENT. 1. Diseases of the Thyroid Gland.—As a general rule, the thyroid gland is liable to few diseases, and of these diseases we are almost as ignorant as we are regarding the structure and the function of this organ. It very frequently presents anomalies of size, being often very much enlarged. The augmentation of size is sometimes transitory and rapid, as, for instance, when it depends upon congestion or inflammation, and sometimes in the case of lymphatic goitre; or there may be a persistent gradual increase, as is observed in the more advanced stages of goitre. It either attacks the whole gland uniformly, which then retains its ori- ginal shape, or one lobe only, or a small part of one may be the only portion affected, so that the pressure which the gland naturally exerts on the trachea and larynx is variously increased in extent, and may affect 102 ABNORMAL CONDITIONS OF not only the pharynx and oesophagus, but also the great vascular and nervous trunks on both sides of the neck, and even the trachea and bronchi, and the blood-vessel within the thorax. Those forms of enlarge- ment are rarer, but at the same time more important, in which the thy- roid gland tends to surround the oesophagus like a ring, and in which the isthmus grows downwards so as to form a middle lobe, which descends along the trachea behind the manubrium sterni into the thoracic cavity; in the latter case it becomes transversely contracted when opposite the semilunar notch, but expands immediately below it (asthma^ thyroideum). The diminution of size or atrophy of the thyroid gland is an affection of little interest. Hyperosmia of the thyroid gland is not unfrequently observed, and most commonly occurs when there is some mechanical impediment to the emptying of the vena cava descendens and of the right side of the heart. Under these circumstances it may be either transitory or persistent. It may be recognized by the dark color of the gland, its abundance of blood, its looseness of texture, and its swollen condition (hyperaemia, congestive turgescence). Apoplexy of this gland, when its texture ia normal, is extremely rare. Inflammation of the thyroid gland, as a primary affection, is of very rare occurrence, at least as an object of anatomical observation. But we sometimes find what are termed metastatic abscesses in it, especially when there are numerous similar deposits in other organs, consequent on puerperal uterine phlebitis. Abscesses of the thyroid gland may give rise to a deposition of pus in the mediastina, or they may open into the trachea, or, which is most commonly the case, they may enter into the oesophagus on its left side. The most common disease of the thyroid body is that to which we apply the word struma (using the term in its strict signification), and its most striking characteristic is, as we have already mentioned, an aug- mentation of size. In the slighter degrees in which it usually occurs, it presents a very simple change of texture depending on a more decided development of the cellular structure of the organ. This occurs either equally through the whole gland, which then everywhere contains cells of equal size, or else we observe one, several, or very many isolated or agglomerated cells larger than the others, which are converted into roundish elongated cysts, with delicate membranous walls, and contain a gummy or glue-like, yellow, brownish or greenish matter (colloid). If this matter has attained a certain consistence, the cut surface of the gland presents a lardaceous appearance, and communicates a peculiar waxy and doughy feeling; the organ is at the same time pale and anaemic, and presents a marked increase of size without any disproportion of form. There are certain unknown conditions under which, on the one hand, the secretion contained in the dilated cells undergoes modification either from the beginning or during the progress of the disease, or, on the other, the walls undergo a striking change. In the former case we find gela- tinous or albuminous substances, of a whitish, gray, or flesh-red color, deposited in the form of concretions, whose coat may be peeled off, or they fill the interstices of an extremely delicate cellular network of new THE RESPIRATORY ORGANS. 103 formation. In the latter case the walls of the cells increase in thickness, and the cells become developed (hypertrophied) into sero-fibrous cysts, which may contain various matters besides those already named, and which often attain an astonishing size. These changes constitute those forms of struma, which are known as struma lymphatica and struma cystica. There can be hardly any doubt that these processes are essentially based on irritation, for repeated inflammations attack the walls of the dilated cells, and especially of the above-named cysts, during the ordi- nary progress of the disease, although they doubtless often pass unno- ticed. Here, as on normal serous, and fibro-serous membranes, they deposit the most varied exudations, and in consequence of the newness of the tissues, these are often hemorrhagic, and accompanied by the separation of large clots of fibrin. These, together with the walls of the cyst, undergo all the same metamorphoses as occur in the exudations and the walls of normal serous sacs (see Vol. III.), even to chalky trans- formation and ossification. The cysts in this manner not unfrequently become perfectly obliterated by contracting around the exudation, and we then find tough, somewhat voluminous, nodular, osseo-cartilaginous, chalky concretions imbedded in the gland. True effusion of blood not unfrequently takes place into the cavities of the dilated cells and of the cyst. The tendency to cyst formation, exhibited by the parenchyma of the thyroid gland, extends in a remarkable manner to the adjacent cellular tissue, for in no situation do we so frequently meet with small or large cysts with serous, gelatinous, or glue-like contents, as in the neighbor- hood of this organ. All other adventitious growths, excepting the above-named serous, fibrous, cartilaginous, and bony productions, are extremely rare in the thyroid gland; thus tubercles are scarcely ever found in it, and medul- lary cancer only very rarely. 2. Diseases of the Thymus Gland.—Anomalies of the thymus gland are even rarer than those of the thyroid body; the only abnormal con- ditions with which we are at present acquainted are a more or less con- siderable increase of its size in new-born children, and its persistence to the fifth, sixth, or seventh year, or even to or beyond the age of puberty. Its abnormal enlargement is almost entirely restricted to children in whom we simultaneously observe a great predominance of the whole lymphatic glandular system, rachitis, and hypertrophy of the brain. It presents either two lateral, flattish, round, thick lobes, which descend on each side into the mediastinum posticum, or it forms a tongue-shaped mass which extends downwards on the pericardium, and rests on the right auricle. Whether the thymic asthma which has been recently described, and which occurs in delicate children, is actually dependent on the pressure of an enlarged thymus on the air-passages, or whether there is any essential connection between that disease and the thymus, are questions requiring additional observations and careful examination. PART II. DISEASES OF THE ORGANS OF CIRCULATION. PART II. ABNORMAL CONDITIONS OF THE ORGANS OF CIRCULATION. We may divide the above into Diseases of the Heart, including those of the Pericardium, and Diseases of the Arteries, the Veins, and the Lymphatics. Under the last head are included Diseases of the Lym- phatic Glands. I.—ABNORMAL CONDITIONS OF THE PERICARDIUM. § 1. Deficiency and Excess of Formation. The first-named species of malformation manifests itself as a deficiency of the pericardium, occurring generally when the heart lies outside the thorax, although it is also met with when this anomaly is not present; but is then of less frequent occurrence. This deficiency is in almost every instance merely partial, consisting in the congenital anomalous position of the heart outside the thorax in a fissure of the pericardium, although it is not uncommon in some cases to meet with less marked traces of the same condition in the region of the larger arterial trunks and along the right layer of the mediastinum. The heart and the left lung lie, as a general rule, in one common large serous sac, which gives rise, at the place from whence the arterial trunks emanate, to the above- mentioned rudiments or traces, in the form of fatty mesentery-like folds. The apparent deficiency of structure, induced by the firm adhesion of the pericardium to the heart, seems to have been mistaken by some older observers, for true deficiency of structure. An Excess of Formation occurs in double monsters, where the peri- cardium is found to contain a double heart. § 2. Deviations in Size and Form. The size and form,of the pericardium depend originally upon the size and form of the heart; and likewise, although in a less degree, upon the calibre, number, and arrangement of the vascular trunks springing from the heart. An acquired dilatation of the pericardium frequently occurs in con- sequence of an increase of the heart's volume, or of dilatation of the vascular trunks, especially of the aorta, and very commonly from morbid effusions, as for instance, the formation of inflammatory products in its cavity. In these cases the dilatation of the pericardium is uniform, and frequently, as in exudations, and more especially in enlargement of the heart, it is so considerable that the pericardium may extend in a 108 ABNORMAL CONDITIONS OF diagonal direction from the anterior extremity of the second or first rib on the right side to that of the eighth rib on the left side, having its anterior surface pressed againt the sternum and the costal cartilages, reaching on both sides to the lateral Avails of the thorax, and compressing the lungs, especially their lower lobes, in the posterior part of the thoracic cavity. Moreover, in some feAv cases, a partial dilatation^ of the pericardium also occurs as a Diverticulum or Hernia Pericardii. This is in fact a hernial dilatation, occasioned by the penetration of the serous surface of the pericardium through different non-resisting or ill-protected parts of the fibrous layer, or through apertures in this layer, expanding into an appendage, which is attached to the pericardium by a pedicle or neck, and communicates with it by means of a narrow opening or canal. Our museum contains two very instructive cases of the development of Hernia Pericardii; in these the diverticula are seated on the lateral parts of the pericardium. Hart's case affords an important example of the attachment of a large appendage to the anterior portion of the peri- cardium. § 3. Interruptions of Continuity. To these appertain injuries inflicted by various penetrating instruments, and by the impaction of fragments of the sternum or the ribs ; lacerations from severe concussions or contusions of the body; ulcers perforating from without inwards, &c. § 4. Diseases of Texture. a. Inflammation is the most common form of disease of the pericar- dium, and is of the greatest importance, not only in itself, but also from the subsequent results to which it may give rise. Inflammation may either be primary or secondary, being in the latter case metastatic or derived from the inflammation of neighboring struc- tures. It may be either general or partial. It may be acute in its course, or, and such is more frequently the case, of a chronic form. The greatest variety is found to exist both in the quantity and the character of the exudation. The following remarks on the inflamma- tion of the pericardium will be found to be in accordance with Avhat has been already stated regarding inflammation of serous membranes in general. 1. From the importance of the subject, we will, in the first place, con- sider primary inflammation of the pericardium ; next, its general and partial forms, the character of the peripheral coagula of the exudation, with the mode of their organization generally ; acute and chronic inflam- mation with purulent exudation; chronic inflammation recurring in the false membranes ; inflammation with hemorrhagic effusion ; and lastly, and specially, inflammation with an exudation of a tuberculous nature. Primary general inflammation of the pericardium, in accordance with what has been already stated, affects the parietal as well as the vis- ceral surface, that is to say, the external serous investment of the heart and vascular trunks; it is more developed on the former than the latter, excepting in a few cases, and its peripheral coagula are more copious THE ORGANS OF CIRCULATION. 109 and abundant. Among the anatomical indications of inflammation most worthy of notice, we may especially mention injection, because it may here often be distinctly observed and investigated. The serous surface of the pericardium assumes in that case the appearance of soft, red velvet, having obliquely erect piles, and looking pale and turbid, as if infiltrated. Partial Inflammation may affect any part of the pericardium, as will be seen when we have occasion to refer to the circumscribed organized inflammatory products,—the so-called milk-spots. The peripheral coagula appear very fully developed and distinct upon the pericardium, in the forms that have already been generally described. Their free surface commonly appears as if covered with villous threads, which are either soft and lax, or stiff, and vary in character. Laennec has compared them to the inequalities remaining on two plates, which, after having been covered with a layer of butter, and laid against one another, have been quickly separated, and it is probable that this ap- pearance gave rise to the terms made use of by the ancients, when they described the heart as cor villosum, tomentosum, hirsutum, hispidum, &c. Sometimes these shaggy masses are more or less accumulated at different spots, or ranged side by side, which is doubtlessly owing to the direction of the undulations produced in the serous effusion by the heart's motion. In many cases they may be aptly compared to the appearance presented by the dorsal surface of a bullock's tongue, whilst in others, the coagulum exhibits an areolar free surface, similar to that of the mu- cous membrane of the gall-bladder. When the coagulable matter occurs in larger quantities in the serous portion of the effusion, it is found in some few cases in the form of round- ish and somewhat flattened free bodies, about the size of a bean or hazel- nut, and generally constituting a network between the heart and pericar- dium, to both of which it adheres. The plastic coagula become converted into a cellular or cellulo-fibrous dense tissue, with a permanent thickening of the pericardium, corres- ponding to the intensity of the process; and the different loose filamen- tous adhesions, or close fusions of the heart and pericardium, which are so frequently observed, either partially or totally (according to the ex- tension of the process) are formed by this tissue. Amongst the partial adhesions, we may specially draw attention to those of a circumscribed nature occurring at the apex of the heart, those occurring at different parts along the sulcus transversalis, and the adhesions of the pericardium in the vicinity of the arterial trunks. In the first of these spots, the connecting medium is often drawn into long threads or strings by the movement of the heart's apex, and the adhesion is thus at length broken through, in consequence of which we usually find an accumulation of long, shaggy, cellular tissue at that part, and on the opposite portion of the pericardium; the second class of adhesions derive importance from their ordinary combination with diseases of the valves, especially towards their margin of insertion; and the last from the evidence which their common occurrence affords of the frequency of pericarditis, which may prove of serious moment at the origin of the large vessels, as we shall subsequently have occasion to consider. 110 ABNORMAL CONDITIONS OF The milk spots, or maculos albidos, are appearances of frequent occur- rence on the heart. They are occasionally met with on the inner surface of the pericardium, but most frequently on the serous investment of the heart. There can scarcely be a question but that they are products of a partial or circumscribed process of inflammation. They are pale, bluish-white, tendinous-looking spots or plaques, appearing, when closely investigated, to be glued or soldered to the subjacent tissue; on being torn or de- tached, the pericardium is brought into view, and is almost normal in its character,—not perfectly smooth, but having a dense and sometimes even an opaque tissue. They must be distinguished from many other diffuse opacities of common occurrence on the pericardium, which con- sist in an inconsiderable excess of structure,—hypertrophy, a slight thick- ening and condensation of the serous investment of the heart. They further manifest many different characteristics with respect to their size and distribution, the number in which they occur, their form and limita- tion, the surface and mode of attachment; finally, they occur more fre- quently on some portions of the heart's surface than on others. The size of these spots varies from that of a silver groschen or a narrow stripe, or that of a silver thaler or more, so that one spot often spreads over a great portion of the heart's surface. A number of these spots are often found together, and they then blend into one another. Their form varies very much, and is extremely irregular; they commonly occur as narrow stripes along the coronary vessels in the sulcus longitudinalis. They usually expand into linear projections at their periphery, and are either sharply defined, or gradually attenuated into.a very delicate membrane, as may be seen in moist preparations. Their surface is either smooth, even, serous and shining, or wrinkled, folded, pale, felt-like, and shaggy; the whole presenting a layer of newly- formed cellular tissue. These milk-spots occur on every portion of the heart, but they are certainly more frequent on the right than on the left ventricle; they usually appear on the auricles in the form of stripes, and finally are met with at the origins of the arterial trunks, and more especially at that of the aorta. In connection with the subject of milk-spots, we may notice the meta- morphosis of a partial exudation into fibroid granulations, occurring about the size of a millet-seed. These are especially to be met with on the auricles, and on the corresponding portion of the parietal surface of the pericardium. Granulations of this nature are frequently situated on these spots. Inflammations with purulent exudation are distinguished by the quan- tity of the effusion, and are important on many accounts, which will be subsequently considered. Scattered accumulations of pus are of very frequent occurrence in the subserous layers of the pericardium. It is only in very rare cases that the purulent exudation leads to sup- puration of the pericardium. Our museum presents an instance of an originally sero-purulent ex- udation, which appears to have gradually undergone the following re- THE ORGANS OF CIRCULATION. Ill markable metamorphosis. At the circumference of the left side of the heart, the pericardium is closely adherent, whilst a whitish, very turbid fluid resembling milk of lime is accumulated around the right side of the heart. The inner surface of the pericardium, and more particularly the outer investment of the heart, appear partially encrusted as with a sandy mortar, and partly covered with a white, smooth, gypsum-like coating. Among the chronic inflammations those attacking the pseudo-mem- branes are especially frequent and important; here we find peripheral coagula of very considerable thickness, density and power of resistance, and of a fibroid texture ; the pericardium itself acquires a considerable degree of thickness, and in cases where there is a resorption of the fluid, the two lamellae of the peripheral coagula adhere together, and the heart becomes enclosed in a thick, tough, unyielding casing. Hemorrhage very generally accompanies the secondary exudations in this process. Finally, when the necessary conditions are present, the exudation may be tuberculous ; but this subject will be noticed when we proceed to the consideration of tuberculosis of the pericardium. In every form of pericarditis the pericardium may become very much distended, in consequence of the great quantity of the exudation, and especially of its serous portion. Osseous concretions are not unfrequently developed in the dense fibroid exudations occasioned by the process of chronic inflammation recurring in the pseudo-membranes. We shall have occasion to return to this sub- ject in a future page. 2. In reference to the secondary effects produced in the organism by general pericarditis, among which we must especially place extensive inflammations of the large serous sacs, it is worthy of notice that several, as for instance cachexia and dropsy, usually occur at an early stage and in a high degree of development* These conditions are occasioned by the injurious influence exerted by the pericarditic process on the heart, in consequence of which the muscular substance of that organ is paralyzed, its color changed to a dirty brown or yellow, and a flabby condition induced, which admits of the texture being easily torn, and which speedily leads to (passive) dilatation of the heart. These phenomena are col- lectively the more striking in proportion as the pericarditis is chronic, and the exudation is purulent, haemorrhagic, or tuberculous ; the dilata- tion becomes more permanent, the more completely the coagula have been metamorphosed into a thick dense resisting tissue surrounding the heart. Pericarditis, more especially when of a chronic form, is important in reference to the origins of the large vessels. It would seem, according to our view, that this disease, as far as it affects the cellular sheath of the vessels in the sub-serous cellular tissue, must induce paralysis of the elastic coat, dilatation of the aorta, and that form of spontaneous lacera- tion of the vessels within the pericardium, which is so often found to occur. 3. Pericarditis frequently occurs in original combination with inflam- mation of other serous sacs, as for instance with pleuritis, inflammation of the synovial membranes of the large joints (Bouillaud), and very fre- 112 ABNORMAL CONDITIONS OF quently Avith pneumonia. It is, moreover, in like manner associated with endocarditis, and occasionally with carditis: during the later stages it is often accompanied with the first-named inflammatory processes, and also with meningitis. * Pericarditis is often a secondary affection associated in various degrees of intensity with other processes of exudation, and very frequently a slight reddening, injection, and an inconsiderable degree of effusion, are found to attack the pericardium at periods of complete exhaustion, and in consequence of extensive exudations. Acute pleurisies extend, from the mediastinum to the pericardium, and centres of inflammation in the muscular tissue of the heart sometimes occasion general and sometimes partial inflammation of the pericardium. Pericarditis, contrary to the results of the investigations of many observers, is frequently met with beyond the middle periods of life and even in advanced age. b. Secondary Formations. 1. Adiposity of the Pericardium.—We not unfrequently observe an excessive accumulation of fat on the pericardium. This occurs in gene- ral not only in conjunction Avith an excess of fat in the heart itself, but also together with fatty accumulations in the abdomen, that is to say in the great omentum and its appendages, in the mesentery, under the cos- tal pleura, &c, constituting a general condition of corpulence. 2. Fibroid Tissue occurs in the milk-spots and in the fibroid granu- lations, assuming the form of a thick exudation, having the property of resistance, and being of a very dense texture. 3. Anomalous Osseous Substance is scarcely ever developed, excepting in the above-named fibroid exudation, after the lamellae have become fused together, and the pericardium has thus been made to adhere to the heart by this dense and resisting fibroid medium. This adhesive stratum is now covered by a deposit of tuberous uneven laminae and bands, or thick, roundish, nodular masses. The space occupied by the deposits varies considerably, but the first-named of these forms of deposition occasionally extends so far as to cover the greater portion of one ven- tricle. The projections occupying the side next the heart frequently extend to the texture of the heart itself, displacing the muscular bundles, and appearing as if developed within them. The thick, round, nodular masses are generally observed in the neighborhood of the sulcus transver- salis on the left side of the heart, being connected with an osseous con- cretion which usually has its seat at the margin of insertion of the mitral valve. They are consequences of a former state of endocarditis combined with pericarditis. 4. Tuberculosis of the Pericardium.—Tuberculosis rarely manifests itself in the pericardium in any other form than as a product of inflam- mation. Pericarditis gives rise to an exudation, whose peripheral coagula, after passing, wholly or in part, through various metamorphoses, merge into tubercle. It frequently happens in chronic inflammations of the exudation-deposits that the deeper or older strata have become tuber- culous, while the more recent coagulum, which is becoming tuberculous, is covered by a secondary, villous, and shaggy deposit from the fluid effusion. THE ORGANS OF CIRCULATION. 113 This form of tuberculosis of the pericardium, in accordance with what has been already stated regarding tuberculosis of the serous membranes generally, is not of a primary character, being usually associated with and dependent upon an earlier tuberculous condition, which has formed as it were the focus or starting-point of the disease, and has been mani- fested as tuberculosis of the lungs and bronchial glands, or as a chronic tuberculosis of some of the great serous membranes, especially of the peritoneum. In this form of pericarditis there is always much serous effusion, which is undoubtedly increased by the inflammation being paroxysmally deve- loped in the tuberculizing coagulum. This effusion frequently becomes haemorrhagic, in consequence of such secondary exudations. The tubercles, which are often of considerable size, and fused together into one aggregate mass, are occasionally seated close to the muscular tissue, into Avhose fibres they occasionally penetrate so far as to lead to much doubt regarding their original position. This form of tubercle very rarely passes into the metamorphosis of complete softening, since death, when it ensues, is generally occasioned by the pericarditis, or the subsequent tuberculous secretions, or even by general cachexia. Occasionally one or more tubercles, or tuberculous masses, may certainly be observed to become disintegrated, but the pro- cess is seldom sufficiently prolonged to produce an abscess, or a corro- sion,—tuberculous suppuration of the pseudo-membrane and of the peri- cardium itself. As we have already observed, the tuberculous exudation soon manifests its influence on the tissue of the heart, which, however rapidly the disease may prove fatal, is always found to be strikingly discolored, having generally acquired a dirty-brown color, and is moreover flabby and easily torn. 5. Cancer only affects the pericardium in a secondary manner; and, in most cases, only where secondary cancerous formations have been developed in the mediastinum. This secondary mass either spreads itself in the form of an infiltration of the fibrous layer of the pericardium over a large portion of its.surface, or presses upon and into the tissue itself, where it becomes developed into roundish or flattened, teat-like nodules. In the very rare cases in which cancer occurs in the pericardium, independently of the above conditions, it presents itself in the form of numerous, flattened, and roundish nodules. It then ahvays occurs in combination with cancer of other serous membranes, especially of the contiguous pleurae, and depends upon an excessive dyscrasia, developed by previous cancerous degeneration of different parenchymatous structures, and frequently exasperated by the eradication of large carcinomatous masses. We have never met with any other form of cancer of "the pericardium but the medullary. § 5. Anomalies of the Contents of the Pericardium. Besides the anomalies already treated of, it remains for us to notice, among those which exhibit special points of interest: Blood in a fluid or coagulated condition. It is almost always an arterial VOL. iv. 8 114 ABNORMAL CONDITIONS OF extravasation, and has been deposited by the spontaneous rupture of the left ventricle, or by a laceration of the origin of the aorta, occasionally also as the termination of an aneurism. The quantity extravasated seldom amounts, under these circumstances, to more than from 2 to 2£ lbs. Serum is frequently accumulated in greater excess than the normal quantity, which varies from J oz. to 1 oz.; and it then constitutes Hydrops Pericardii. This accumulation becomes serious in proportion to its amount, and possesses greater importance where the other coexisting anomalies, by which dropsy is influenced, are inconsiderable. It is generally combined with dropsy of other serous sacs, anasarca, and oedema of the lungs, and usually has a common origin with them. Occa- sionally it predominates over these affections, and is especially the case in pulmonary phthisis. The period of its duration may be estimated by the extent to which the fat has disappeared from the heart, and its place been occupied by a serous infiltration of the cellular tissue, and in pro- portion to the extent of turbidity and swelling from imbibition, observed in the pericardium, and especially its outer surface, and to the decolora- tion and paleness of the substance of the heart. The quantity of the Liquor Pericardii is often strikingly small, amounting to no more than what is barely sufficient to moisten the peri- cardium and the heart itself. The pericardium may even in some parts appear perfectly dry, of a yellowish color, and resembling parchment. We have remarked this appearance, which is devoid of importance, on the lateral portions of the pericardium, principally on its left side, where it had been brought in contact with the anterior parts of a lung in which emphysema has been developed. We have never met with an accumulation of Air in the pericardium, Pneumatosis Pericardii. Most of the cases recorded, like the pneu- matosis of other serous sacs, leave room for many doubts regarding their existence during life. Free Bodies are of very rare occurrence in the pericardium. In a very remarkable case of pericarditis we discovered, in the serous effu- sion, numerous fibrinous, soft, yellow concretions of the size of beans or almonds, and similar to the latter in shape, which would no doubt have eventually been converted into elastic, tough bodies of fibroid tissue. II.—ANOMALIES AND DISEASES OF THE HEART. We will now proceed to consider the Anomalies and Diseases of the Heart, including those of the Valves; but wherever it may prove of great practical interest to acquire a more correct knowledge, both gene- rally and specially, of the anomalies of the valves treated of in the different sections, we purpose, at the close of each, entering more fully into the details of the subject. We will, moreover, consider simultaneously all original malformations of the heart and of the vascular trunks, not only on account of the un- natural connection existing between them, but also Avith a view of fur- nishing the premises necessary for the better comprehension of the ap- pendix on cyanosis, which is subjoined to our remarks on the anomalies THE ORGANS OF CIRCULATION. 115 of the heart. In order, as far as possible, to facilitate a reference to the most important original malformations, we have arranged the follow- ing sections somewhat differently from those by which they are preceded. § 1. Deficiency and Excess of Formation. Absence of the Heart—Acardia—is generally of very rare occurrence, but is a common phenomenon in Acephalia (absence of the brain), espe- cially where there is an absence of the upper half of the trunk. It has only been observed in very rare cases where the nervous system is perfect and complete. In the consideration of deficiency of the heart we include a series of deficient formations (arrested developments) which may be arranged as follows. a. The lowest type of formation is that in which a single cavity with- out valves represents a ventricle in which a dilatation of the vena cava appears as the rudiment of an auricle. The latter is membranous, and the former has only thin muscular walls and weak trabeculae. b. Next we have a heart consisting of one ventricle and one auricle, with simple vascular trunks, into the former of which opens an aorta, and into the latter a vena cava. In many cases this formation approximates to the succeeding one in which there are two auricles with a single ven- tricle. c. In this form there is a single ventricle and one auricle, which is either partially or wholly divided into two cavities by means of a parti- tion wall. The arterial and venous trunks may be either single or sepa- rated. d. Here a capacious ventricle presents the rudiment of a septum ven- triculorum, which becomes so far developed as finally to exhibit only an aperture which is usually situated at its upper extremity. The most common anomaly of the vascular system combined with this form is the origin of the aorta from both ventricles, and the displacement of the pulmonary artery. The foramen ovale in the partition between the au- ricles remains open. In other cases the septum is perfect, but so situated as considerably to diminish the size of one or other of the ventricles, in- terfering with its valvular apparatus, and giving the auriculo-ventricular opening a very contracted and even closed appearance,—a condition of things that involves the patency of the foramen ovale and of the ductus arteriosus. e. Here we have a form of the heart in which the partition between the auricles is defective, although there is a perfect separation of the ventricles. The degree and form of this defective structure are very variable. The septum is sometimes entirely absent, its line of direction being simply indicated by several soft membranous filaments which pass from the posterior to the anterior wall of the common cavity of the auricles. In other cases the rudiment of a septum atriorum developes itself in the form of a crescentic band, either from the arch of the auricle, or below the septum ventriculorum. The wide aperture of communica- tion between the two auricles is round or oval, and has its major axis inclined from before backwards. In other cases, the rudimentary struc- ture is sometimes so far developed round the septum that this deficiency 116 ABNORMAL CONDITIONS OF is often represented by a smaller and obtuse triangular aperture; and in other cases, again, the septum seems so far developed from above that it may easily contain a foramen ovale. There are, in this case, two aper- tures in the partition betAveen the auricles, the former, which depends on defective formation, is not closed, and the latter (the foramen ovale) remains open. Cases of this nature are generally characterized by a congenital con- traction or insufficiency of the aorta, by extraordinary dilatation of the pulmonary artery, and by eccentric hypertrophy of the right side of the heart. /. In this form the foetal passages,—the foramen ovale, and the ductus arteriosus,—remain open. The degree of the patency of the foramen ovale varies considerably, its valve being very nearly or entirely absent in some cases, but more commonly the upper third or fourth portion of it is wanting, and most frequently of all there is a mere deficiency of attachment at the upper part of the isthmus, by which means a fissure rather than a foramen is formed, Avhich communicates in a very oblique direction from below and behind upwards and forwards from the right into the left auricle. This foetal condition is sometimes persistent to a greater or less degree, and consists in this—that under a marginal pro- jecting rudiment of the Eustachian valve, which penetrates into the ante- rior columna isthmi fossae ovalis, there is a communication with this fissure-like aperture, or with the still patent foramen ovale. The open- ing at the upper boundary of the isthmus is either formed as a simple fissure, or consists of several small and roundish apertures. The cause of the patency of the foramen ovale frequently depends on the different malformations of the heart already enumerated, and on the different anomalies of the arterial vascular trunks and of the ductus arteriosus, Avhich still remain to be noticed. The patency of the foramen ovale most frequently corresponds with an incidental arrest of development. In some cases it is associated with smallness of the heart, and retraction of the apex (the foetal condition). It is of very frequent occurrence in its lesser degrees. The patency of the ductus arteriosus will be more fully noticed in a future page. The following are the most important of these Anomalies of the Vas- cular Trunks: 1. Those affecting the Aorta. a. There may be a single arterial trunk, which may be regarded as an aorta sending off branches from different points to the lungs. b. The aorta may be a vessel from which only the branches of the upper half of the body (and not all of these) are given off, whilst the pulmonary artery, through the ductus arteriosus, constitutes the descend- ing aorta. c. There may be different degrees of obstruction of the aorta, which may be either very narrow or quite closed from its origin to its point of junction with the ductus arteriosus, in which case it is supplied by the latter with blood from the pulmonary artery. The whole arterial trunk with its ramifications,—in short the whole arterial system,—is in this case frequently disproportionally narrow. THE ORGANS OF CIRCULATION. 117 d. The aorta may originate from both ventricles, owing to a deficiency in the partition-wall between them, in which case it is deflected some- what to the right. The pulmonary artery is in this case, either normal, or, as is frequently observed, it is obstructed, narrow, and even closed. The ductus arteriosus, if it be present, then remains open, and carries the aortic blood to the pulmonary artery. 2. Those affecting the Pulmonary Artery. a. The trunk of the pulmonary artery is not only absent where the lungs are wanting, but even where these are present and are furnished with vessels from the aorta. b. Obstruction of the pulmonary artery, which may be either too narrow or wholly closed, in which case the blood is conveyed to it through the ductus arteriosus from the aorta. This occurs when the right ventricle is imperfect, when the conus arteriosus ends in a cul de sac, and very commonly when the aorta originates from both ventricles. To the above we may add— 3. Anomalies of the Ductus Arteriosus. a. It is sometimes wholly absent. b. Besides sending several vessels to the head and upper extremities, as do also the branches of the pulmonary artery, it supplies the aorta descendens, or rather merges into it. In this case the aorta diminishes in calibre after giving off its branches, and merges as a thin vessel into the large ductus arteriosus after the latter has been curved into an aorta descendens (Kilian). This anomaly occurs either separately and in- dependently, or conjointly with other anomalies of the vascular trunks and of the heart. c. The most common anomaly is a defective involution of the ductus arteriosus after birth; it either remains open or even in some cases ex- periences a dilatation. It is, however, much more rarely open than the foramen ovale, whose patency is in general a necessary consequence of different anomalies of the heart and vascular trunks, although even here many exceptions present themselves. On the one hand, it may remain open without any palpable anomaly of the heart and vascular trunks, and on the other it may be contracted, and even closed, where such anomalies exist. Its involution may be hindered either by the pulmonary artery or the aorta; thus it may either be entirely patent, or may exist as a mere opening closed in the direction of the pulmonary artery, but patent to- wards the aorta. To this class belong those cases in adults, where the ductus arteriosus forms a sac-like appendage to the aorta, and where the obliterated ostium arteriae pulmonalis has the appearance of having been reopened by violence. When the ductus arteriosus remains patent, many causes combine to keep the foramen ovale open. Finally, we also observe a deficiency in the formation of the valves. The auriculo-ventricular valves present various obstructions and malfor- mations, generally in connection with a simultaneous malformation of the corresponding ventricle, or associated with a contraction or occlusion of the opening, and principally on the right side. In reference to the arterial valves those of the pulmonary artery are occasionally absent, while malformation and closure of the latter artery, a blind termination of 118 ABNORMAL CONDITIONS OF the conus arteriosus, and an abnormal condition of the whole of the right ventricle, are simultaneously present. These valves not unfrequently assume an abnormally inflated annular form, and in some cases only two instead of three valves are observed in the pulmonary artery or in the aorta. The valve of the foramen ovale is either wholly absent or, as we have already remarked, is imperfect in various ways. In rare cases the Eusta- chian valve has been found wanting. Its defective involution after birth is interesting, inasmuch as it gives rise to the imperfect closure of the foramen ovale. The Thebesian valve has been found wanting in a few cases. Malformations per excessum affect the heart and vascular trunks in various modes and degrees, and may be referred either to a duplication, or to an arrest of development. To the former belong— Complete duplication of the heart, or the occurrence of two separate hearts in two distinct pericardia, or in one common pericardium, which is not unfrequent in double monsters, especially where there is duplica- tion of the upper half of the body, while the observations on record regarding a double heart in a single body, are very few in number, and of doubtful character. Duplication of one or more portions of the heart, or the presence of supernumerary, more or less perfectly separated cavities from which numerous vessels proceed, as if of very rare occurrence when there is only a single body. We observe, however, occasionally, in normally formed individuals, a rudimentary partition projecting, in the form of a band or amorphous mass of muscle, into one of the cavities of the heart. A large heart, from which proceed double vessels, is found in double monsters. To the latter belong— The persistence of a double aorta ascendens, a cleft condition of that vessel, the persistence of a ductus arteriosus on the right side (Breschet), and the duplication of the upper as well as the lower vena cava. The valves also occasionally exhibit an excess of formation; we have either an increase of the apices of the auriculo-ventricular valve of the right side, or supernumerary valves, or a multiplication of their apices, with perforation of the ventricular partition ; or there may be four semi- lunar valves in the aorta or the pulmonary artery, or duplication of the Thebesian valve, &c. § 2. Anomalies of Form. These are of comparatively common occurrence, and may affect either the external form of the heart, or its internal arrangement; occasionally both varieties are simultaneously present, in which case the deviation from the normal type in the external form is dependent on the anomaly in the internal structure. These anomalies are, moreover, either conge- nital or acquired, the former comprising, more especially, original mal- formations depending upon arrest of development; and the latter, the numerous and various deviations of form developed at different periods of life, and even in the foetus, as consecutive anomalies, arising more particularly from hypertrophy and dilatation. THE ORGANS OF CIRCULATION. 119 The most important original anomalies in the external form of the heart, are combined with and dependent on the already described impor- tant anomalies of the internal structure and of the vessels ; the more un- important may be present, associated with very trifling internal anoma- lies, as for instance, the patency of the foramen ovale, or even, where none of these exist, and where the internal structure is perfectly normal. To this class belong the retraction of the heart's apex—apex cordis bifi- dus, an arrest at an early stage of development—and the rounding of the apex of the heart, associated with predominant width of the whole heart, an arrest at a very advanced period of development. This last-named form, which depends on an equality in the size and thickness of both ventricles, is often continued to late periods of extra- uterine existence, and is maintained, together with the simultaneous patency of the foetal passages, by the defective development of the lungs, whose proper functions may be mechanically obstructed by the form of the sternum, as is observed in rachitis. Among the unimportant and incidental anomalies depending, very frequently, on various degrees of contraction and rigor, we must reckon different forms of the heart which aproximate to the round type, and are either long, slender, wedge-shaped, pad-like, spirally curved, broad and obtuse, &c. In order to avoid repetition, we would refer our readers to the sections on hypertrophies, dilatations, and textural diseases, for further and special notice of the acquired anomalies of the heart. § 3. Anomalies of Position. These are either congenital and original, or acquired. The former are very numerous, and admit, in part, of being referred to an arrest of development. Many depend on different adhesions of the heart resulting from inflammation in the foetus, and some again on different anomalies of neighboring organs, as, for instance, on the deficient development of a lung, the partial deficiency of the diaphragm, and the position of the abdominal viscera in the thorax. These anomalies are very various in their character, and the most important, together with the vascular ano- malies included in this case, are as follows: Position of the Heart exterior to the Body.—This anomaly occurs associated with a partial absence of the diaphragm and the abdominal and thoracic walls. Where the former of these is absent, the heart is generally situated with all or several of the viscera externally to the body, in a closed or open sac occasionally contained in the sheath of the umbilical vessels. Position of the Heart within the Body, but external to the Thoracic Cavity.—According to the direction in which the heart is placed, it as- sumes either a cervical position (ectopie cephalique), or an abdominal one (Breschet). Anomalous Positions of the Heart in the Thoracic Cavity.—These possess various points of interest from their presenting considerable analogy with many acquired anomalous positions of the heart, and also on account of their apparently arising from similar conditions. To these belong the position of the heart on the right side, without the simultane- 120 ABNORMAL CONDITIONS OF ous transposition of other viscera, its perpendicular position in the centre of the thoracic cavity, its horizontal, oblique positions, &c. Anomalous Origin of the Vascular trunks.—To this class belong : The displacement of the aorta towards the right side, and its origin from both ventricles, associated with a defect in the ventricular septum ; or the aorta may take its origin, conjointly with the pulmonary artery, from the right ventricle, where no such anomaly exists. We sometimes find a similar relation of the pulmonary artery, that is to say, it takes its origin from both ventricles, or conjointly with the aorta from the left ventricle. This vessel has also been observed to spring from abnormal positions in the right ventricle. Many anomalies of the systemic and pulmonary veins, as, for instance, the opening of a left descending vena cava into the auricle, an opening of the pulmonary veins of the right side into the right auricle, into the upper vena cava, &c, also belong to this class. Actual transposition may exist with reference to the heart alone, or conjointly with the thoracic and abdominal viscera generally. A more important transposition is, however, that affecting the vascular trunks, which often present the anomaly of the aorta, springing from the right, and the pulmonary artery from the left ventricle, while the veins open normally. Otto found, in the case of a double monster, that the venae cavae opened into the left, and the pulmonary veins into the right auricle, while the arterial trunks presented the normal mode of origin. The acquired changes of position of the heart are very numerous, but as they are merely secondary phenomena, they generally possess a very subordinate interest. An exception occurs, however, in the case of those anomalies of position of the heart, which arise from empyema, pneumo- thorax, pulmonary emphysema, atrophy of the lungs, &c, and which are of great importance with regard to diagnosis. The majority of these consist in a displacement of the heart from its normal position. It may occur in the most opposite inclinations either to one or the other side, or downwards, upwards, forwards, or backwards. The most common causes of these displacements are, on the one hand, excessive dilatation of one or other of the pleural sacs from exudations into its cavity, from pneumothorax, or pulmonary em- physema; and on the other, the formation of a vacuum in it by the cure of chronic pleurisies, by wasting and atrophy of the lungs conse- quent on indurated pneumonia, by bronchial dilatation, &c. The dis- placements of the heart towards one or the other side resemble similar congenital and original anomalies of the heart's position. A change in the position of the heart is but rarely occasioned by pneumonic and tuberculous enlargements of a lung, and still more unfrequently by an acquired position of the abdominal viscera in one side of the thorax, arising from laceration of the diaphragm, &c. The heart may likewise be differently displaced from its position by aneurisms of the aorta, the contiguity of voluminous adventitious products, &c. Flatu- lence, extreme ascites, and large adventitious products in the abdomen, may also displace the heart in an upward direction ; whilst a correspond- ing anomaly in the position of the heart is likewise induced by curva- ture of the spine, irregularity in the form of the thorax, &c. THE ORGANS OF CIRCULATION. 121 In contrast with the above-named anomalies, this change of position may sometimes be spontaneous, in consequence of the heart assuming an anomalous position and anomalous relations of contact with the diaphragm and ribs, arising from an uniform or a varying enlargement, and from its simultaneous increase in weight. § 4. Anomalies of Size. These anomalies manifest themselves either by an abnormal excess or deficiency of size. Both conditions may be either congenital or ac- quired, and are of great importance from their frequent occurrence and the serious and numerous consecutive disturbances to which they give rise. In order to arrive at a correct opinion regarding an individual case, it is especially necessary for the student to acquire a knowledge of the normal size of the heart and of its individual portions. Many measure- ments have been made in recent times, and from these a mean or average standard has been deduced. The results yielded by Bizot's measurements appear to us to be most correct. We will limit ourselves to the dimensions in adults, between the ages of 30 and 49 years. The following are the mean measurements : the The length of the heart, The breadth " The thickness " The length of the left ventricle, The breadth " " The length of the right ventricle, The breadth " " . The thickness of the walls of the left ventricle : " " " at the base, . " " " in the middle, . " " " near the apex,. The thickness of the interventricular septum in centre,........ The thickness of the walls of the right ventricle: " " " at the base, . " " " in the middle, . " " " near the apex,. The width of the auriculo-ventricular openings: " " " of the left, " " " of the right, . The width of the aorta (above the valves), " " origin of the pulmonary artery, We purpose, in the sequel, making further use of the other results of the labors of Bizot, which possess any degree of interest, and are not opposed to our own observations. According to Bizot, the heart increases in volume from birth to ex- treme age; this increase being most considerable to the age of 29, after which it is only appreciable by measurement. Augmentation of volume depends especially on the continuous dilatation of the openings, and on the increase of thickness of the walls of the ventricles, which is IN MEN. IN WOMEN Paris lines. Paris lines. 43& «A 47if 44^V IVjV 14^ 29H 31jf 53A 46r¥ 37^ 33£f 83*$ 76^ Hi H 5tV m m 3A m m m m ia m it H 48A 40« 54A 47^ 30f§ 28A 31±§ 29* 122 ABNORMAL CONDITIONS OF always most strongly marked in the case of the left, and is indeed scarcely perceptible in that of the right ventricle. The dilatation of the auriculo-ventricular openings is tolerably uniform, and that of the arterial equally so until middle life, but after that period the opening of the aorta is more rapidly dilated than that of the pulmonary artery, the latter becoming even narrower than the aorta. In children both the arterial openings remain equally wide, till from the sixth to the tenth year. The cavities of the right side of the heart have a greater capacity, and their openings are wider. Bizot's opinions regarding the influence of sex and bodily frame are, that the dimensions of all the parts collectively are smaller in women than in men; that the auriculo-ventricular openings in particular are narrower whilst the opening of the pulmonary artery is relatively Avider in them than in men. In tall persons of either sex, the heart, accord- ing to the same authority, is relatively smaller than in persons of shorter stature, while it is larger in broad than in narrow-shouldered persons. We adopt Bouillaud's data for the walls of the auricles, with a remark, however, that his estimate is too high; according to him, the thickness of the wall of the left auricle is one Paris line and a half, while that of the right auricle is one line. Laennec proposed to establish a scale for the relative measurement of the size of the heart, and rejected as inefficient all data of the weight and size of the heart that had been obtained without regard to individual bulk. The basis on which he founded his conclusions was, that the heart, including the auricular appendages, should be of a volume equal to that of the fist of the individual, or only in a slight degree either larger or smaller. The walls of the left ventricle should be somewhat more than twice as thick as those of the right one; the left ventricle, when cut open, should remain unclosed, while the somewhat wider right ven- tricle, which, notwithstanding the thinness of its walls, is furnished with more considerable trabeculae, should collapse. If in the consideration of these data (which are, however, in many respects defective), regarding the relative thickness of the walls of the right and left ventricles, we bear in mind that this relation is not only very commonly, according to Andral's observation, as 1: 3, but still more frequently (see Bizot's data), as 1: 4,1 and that these measurements refer only to middle life, we shall find that Laennec's comparison of the size of the heart with that of the fist deserves considerable attention, remem- bering that it must be received as simply approximative, and limits itself to cases where there is no apparent disproportion in the size of the fist. We have, therefore, as a general rule, regarded the heart as of a relatively normal size, when it was equal to that of the fist, and when there was an absence, both during life and after death, of any indications of cardiac disease. The weight of the heart, in its normal condition, has been variously estimated, and may be from eight to ten ounces. (Compare Lobstein, Bouillaud, and Cruveilhier.) 1 In all these statements the columnse carnse are not taken into consideration. THE ORGANS OF CIRCULATION. 123 A. Abnormal Size. Deviations in the size of the heart depend either on hypertrophy of its muscular substance (augmentation of its mass) or on dilatation of its cavities; while both conditions, with a preponderance of the one or the other, very commonly constitute the basis of the higher degrees of en- largement of the heart, as we shall presently have occasion to show. Here, as has already been indicated, we will merely consider hyper- trophy of the muscular substance. There is, however, a form of disease, for which we know no better denomination than hypertrophy of the endo- cardium, and of which, however much it may seem to belong to the sub- ject under consideration, we will treat subsequently in connection with endocarditis, a disease with whose products it may easily be confounded, and for which it undoubtedly is frequently mistaken. We will also defer the consideration of hypertrophy of the valves to a subsequent portion of our work. a. Hypertrophy of the muscular substance of the heart (hypertrophia cordis) constitutes either total or partial hypertrophy, as it affects the whole, or only some portions of the heart, and is characterized by various degrees of intensity. Total hypertrophy is, in most cases, so far unequal that it usually preponderates in one section of the heart,—commonly, although not in- variably, in the left portion,—where it forms the starting-point of a morbid development of bulk. Partial hypertrophy affects either the whole of one of the larger sec- tions of the heart, as for instance the walls of one of the cavities, or it attacks only certain parts of that section. Thus it is very frequently limited to the true muscular wall of one ventricle, thickening it in various degrees, while the papillary muscles and the trabeculae retain their normal volume, or even where they have become perceptibly thinner and fainter simultaneously with the dilatation of the affected cavity. In other cases hypertrophy principally attacks the papillary muscles and the tra- beculae, whilst the true fleshy wall is only moderately increased in thick- ness. The former of these conditions occurs generally in the left; and the latter, that is to say, an excessive development of the trabeculae, in the right ventricle. Hypertrophy of the muscular wall of a ventricle may present great variations ; it may, in one case, affect the whole, in another it may be limited to one portion of the ventricle, as, for instance the base, the middle part or the septum, or again it may predominate in one or other of those sections. Hypertrophy of the auricles is generally uniformly diffused over the wall, but it occasionally preponderates in the atrium towards the appen- dage. The degrees of hypertrophy present still more numerous differences. If we follow Bizot's data we must assume that ventricular hypertrophy is present when the thickness of the muscular wall of the left ventricle in men is about 6"' (Paris measure), and in women is about 5'", and when the right ventricle in men is about 3'" in thickness, and that in women 2£'" in thickness. From this point hypertrophy may pass 124 ABNORMAL CONDITIONS OF through every varying degree, till it induces so enormous an increase of bulk, that the walls of the left ventricle attain a thickness, varying from an inch to an inch and a half; that the Avails of the right ventricle vary from 6 to 9 lines, that the walls of the left auricle vary from 2 to 3 lines, or even more, and that the walls of the right auricle vary from 1J to 2 lines. The weight of an hypertrophied heart may range from one to two pounds, and even higher. The most important and serviceable classification of hypertrophies of the heart is that which is based on a reference to the condition of the cavities of the heart, more especially in regard to their capacity (Bertin, Bouillaud). 1. The capacity of the hypertrophied portion of the heart may remain normal, constituting simple hypertrophy, in which the dimensions of the heart are increased. 2. The cavity of the heart may be dilated, constituting eccentric hy- pertrophy (hypertrophia excentrica, centrifuga); here also the dimensions of the heart are increased. 3. The cavity of the heart may be contracted, constituting concen- tric hypertrophy (hypertrophia concentrica, centripeta). The dimensions of the heart may here be increased, normal or diminished. We shall treat more fully of these different forms when we take into consideration the most essential points relating to dilatation of the cavities of the heart. b. The dimensions of the heart are more increased by the dilatation of its cavities than by hypertrophy. This dilatation (dilatatio cordis, also aneurysma cordis in the old writers), may, like hypertrophy, be total, affecting all the cavities of the heart, or partial, attacking only one of these portions. The excessive degree which dilatation may attain led the early anatomists to compare the human heart to that of a bullock. Here also the most useful classification is that which is founded on the relation of the walls of the diseased portions of the heart. 1. Dilatation of the cavities of the heart may occur conjointly with hypertrophy of their walls, constituting aneurysma cordis activum (Cor- visart), and with eccentric hypertrophy. 2. Dilatation of the cavities of the heart may exist, associated with walls of normal thickness. This condition of simple dilatation— aneurysma cordis simplex—deserves equal attention Avith the above- named form of dilatation with hypertrophy, in as far as the normal thickness of the walls of the heart in dilatation of the cavities must ne- cessarily depend on hypertrophy; it may therefore be regarded as an active dilatation—aneurysma cordis activum. 3. Dilatation of the cavities of the heart may occur in combination with attenuation and relaxation of the walls, constituting passive dila- tation—aneurysma cordis passivum (Corvisart). Besides these forms of dilatation, there are others connected with and dependent on alterations of texture, limited on one portion of a single cavity, and which we will pass over in the present case, reserving their consideration for a more suitable occasion, under the head of inflamma- tions of the heart. We would here merely observe, that these forms of THE ORGANS OF CIRCULATION. 125 dilatation are known as partial dilatation and partial aneurism of the heart. As, however, we have applied the former of these terms to dila- tation of a single division of the heart, and as, on the one hand, the term aneurism is unsuitable to the forms of dilatation under consideration, while, on the other, dilatation, combined with and dependent on altera- tions of texture, and such as attack only one portion of a cavity of the heart, exhibit great affinity with aneurisms of the arteries, we would de- signate these last named, which we pass over for the present, as true aneurism of the heart. On considering the above-named forms of hypertrophy and dilatation, we find five, or perhaps more correctly speaking, four different condi- tions, and these will constitute the subject of the following remarks. Simple hypertrophy, which is in general of rare occurrence, affects the ventricles, attacking the left one more frequently than the right. It probably continues to exist only for a certain period of indefinite dura- tion, and then gradually merges into eccentric hypertrophy, that is to say, hypertrophy with dilatation. Although scarcely a doubt can be entertained of its existence, the attempt to confirm it is not devoid of difficulty. The existence of concentric hypertrophy has been doubted by many who have made observations on the human subject after death, and pro- secuted experiments on animals. In those Avho die from loss of blood, and occasionally after sudden and violent modes of death, the heart is indeed often in a condition of contraction, which might easily be mis- taken for concentric hypertrophy. We cannot, however, agree with those who doubt the existence of concentric hypertrophy, which occurs, al- though rarely, in both ventricles, and, according to our observations, more frequently in the left. The cavity of this portion of the heart ap- pears contracted in consequence of the thickening of the muscular wall, and of the papillary muscles, and the trabeculae. Disease of the heart is manifested during life, and the symptoms exhibited correspond to the appearances observed after death. Eccentric hypertrophy, active dilatation, including simple dilatation, is incomparably the most frequent condition. It attacks the ventricles as well as the auricles, and most frequently the cavities of the left side. Active dilatations originate in one portion of the heart, and, beginning at the left ventricle, gradually extend Over the whole organ. This con- dition gives rise to the highest degrees of cardiac enlargement, which were known to the ancients under the terms enormitas cordis, cor tauri- num, &c. The enlargement is most strikingly manifested at the conus arteriosus of the right ventricle, whilst the space of the actual ventricle is generally contracted by the intrusion of the arch of the septum. The auricles are occasionally the special seat of active dilatation, and in these cases the disease commonly depends on contraction of the auriculo- ventricular opening on the same side. The wall of the auricle is stiff and rigid, and the cavity is not unfrequently filled with coagulated blood, or occasionally with stratified coagula of fibrin. These forms of dilata- tion have, however, been observed unassociated with this form of con- traction. Passive dilatation, in its lesser degrees, is of frequent occurrence. It 126 ABNORMAL CONDITIONS OF attacks the ventricles as well as the auricles, especially the cavities on the right side of the heart, and the right auricle most frequently. When it affects the left ventricle it is most commonly and most decidedly seen at its apex, where it first manifests itself. Intense degrees of this form of disease are unusual, although the auricles in particular are capable of remarkable dilatation. These different forms may be variously combined. Where disease has attacked the whole of the cavities of the heart, one cavity is usually dis- proportionally affected beyond the others, and heterogeneous forms are observed to arise and exist in conjunction with one another, as for instance hypertrophy and active dilatation on the left side, together with passive dilatation of the right. In most cases the disease predominates in that portion of the heart's cavity which was first and, from some obvious cause, most intensely affected. Such is, however, not invariably the case, since consecutive disease occasionally supervenes, which fully equals or even exceeds that in the cavity originally attacked. Dilatation of the openings usually exists in conjunction with dilata- tions of the heart generally, corresponding in intensity with the various degrees of the latter, and depending most probably on one common cause. In active dilatations, the arterial openings are more prominently affected, whilst in passive dilatation the auriculo-ventricular openings more frequently participate in the disease. In this form of dilatation the valvular apparatus very commonly remains sufficient, in consequence of an enlargement of the valves, attended by a striking attenuation and an elongation of the tendons of the papillary muscles.—We must, how- ever, be careful not to confound these forms of dilatation with dilatation of the commencement of the aorta, which is of very frequent occurrence, and depends on a diseased condition of its coats, for the latter will occa- sion dilatation of the left side of the heart, with a frequency proportional to the association of dilatation of the vessel with insufficiency of its valves. It is important to notice that there is a relaxed condition of the heart after death, which is very similar to passive dilatation. In the rapidly decomposing bodies of those who have died of acute dyscrasiae, the heart is very commonly collapsed, visibly dilated, easily torn, and characterized by thinness of the walls, various discolorations of the muscular substance, and imbibition of haematin in the endocardium and along the coronary veins. It is very probable that a similar condition of the heart mani- fests itself in every case at a certain period after death. The above- named requirements of its occurrence enable us to recognize this pheno- menon as the result of decomposition, but the difficulty attending its diagnosis in the dead body reminds us of that which attaches to the question of the existence of concentric hypertrophy in so far as this con- dition is undoubtedly very frequently to be referred to the agonia mortis. In simple dilatation we also occasionally meet with a condition of the muscular substance of the heart, which gives it a passive character. In cases of active dilatation (eccentric hypertrophy) the trabeculae are frequently so completely atrophied as not only to be attenuated by elongation, but even entirely severed, their existence being indicated THE ORGANS OF CIRCULATION. 127 along the greater and middle part merely by the inner cardiac investment surrounding them, and by the muscular substance of which their termi- nations are composed. We are not yet able to explain why, under analogous or very similar conditions, dilatation of the heart will be developed in one case in a passive, and in another in an active form. We will append to our enumeration of the causes of these diseases of the heart the form of dis- ease that is usually dependent on each, merely remarking here, in general terms, that, in our opinion, considerable mechanical obstructions generally, and sometimes with great rapidity, induce an excessive degree of dilatation, whilst, on the other hand, lesser and more slowly developed obstructions give rise to hypertrophy. The form of the heart undergoes various alterations in consequence of these enlargements. Its malformation is the more important in propor- tion to the enlargement, and the more it is confined to, or preponderates in one single cavity of the heart. It affects the external as well as the internal form. In simple, and still more manifestly in eccentric hyper- trophy (active dilatation) of the left ventricle, where the chief seat of disease is at the base and the middle portion, the heart assumes a round wedge-like form, while in the more advanced stages of the disease, the whole ventricle is swelled into a pad-like shape. The malformation which especially consists in dilatations of the left ventricle, expands towards the right ventricle, into which the septum is bent in an arched form; its space being so considerably contracted, that it appears like a mere appendix to the heart, while its conus arteriosus appears dilated and hypertrophied. Dilatations of the right ventricle widen the heart at its base, and from thence down to the apex. Where there is simultaneous dilatation of the left ventricle, the heart acquires the form of an obtuse triangular pyramid, or a discoidal mass. Active dilatations of the conus arteriosus of the right ventricle, which are of frequent occurrence, lead to malformation of the heart by enlarging its circumference near the base, &c. The position of the diseased heart becomes the more anomalous in proportion to the volume and weight which it acquires. In a slight degree of enlargement, the heart inclines less to the left side of the thorax, while in excessive forms of enlargement and dilatation, it has its base almost diagonally inclined to the right and its apex to the left side, whilst its right half rests on the anterior thoracic wall, contracting both thoracic cavities in the region of the lower lobes of the lungs, and causing them to press in one large surface on the diaphragm, which is thus more or less pushed downwards on the epigastrium. The color, consistence, and texture of the muscular substance of the diseased heart, present numerous differences. The color of the hypertrophied heart is most frequently dark, and of a brownish-red hue ; the consistence is generally greatly increased, and the texture apparently normal. It must here be remarked that the con- sistence of the right ventricle presents a striking anomaly in the more highly developed forms of hypertrophy, the texture acquiring a tough- ness which is never observed under any condition in the left ventricle. The walls which become rigid and retract on being cut, exhibit extreme 128 ABNORMAL CONDITIONS OF resistance and hardness, and yield, when struck, a sound which, according to Laennec, resembles the tone emitted from hard leather. A similar relation is observed in active dilatation of the auricles, when excessively hypertrophied. This increase of consistence seems to depend on the deposition of a great quantity of organic matter in the form of a finely granular substance, and in the production of new flat muscular fibres without transverse striae. In other, and very frequent cases, the hypertrophied tissue of the left ventricle presents another character. Its color appears to be faded, and of a dirty brown or yellow tint, either in separate points in the form of foci, or over a layer, generally an internal one, whose thickness varies, or finally throughout the whole thickness of this portion of the heart. The consistence then becomes modified in a peculiar manner, the walls of the heart become rigid, tough, and capable of resistance, while their tissue loses its proper firmness, is fragile, and easily broken down. The texture is perceptibly altered, although in what manner the change is effected is not known. According to our investigations, this disease of texture must be regarded as a form of morbid fatty degeneration of the heart, similar to that treated of under Form 2 of Diseases of the Muscles; and we will therefore consider the subject' more at large under the head of Anomalies of Texture. We are moreover of opinion, that it associates itself with hypertrophy as a consecutive disease; that is to say, that after being once developed in the hypertrophied tissue, it favors the dilatation of the hypertrophied portion of the heart, and very frequently gives rise to those spontaneous ruptures which occur in this organ. Traces of inflammation not unfrequently occur, either Avith or with- out the above-named alterations of texture in the muscular substances of the left ventricle, when it is the seat of active dilatation. One or more points or foci of limited extent, either on the surface or lying deep in the tex- ture, occasionally exhibit a redness and injection of the bleached and flabby tissue, which is infiltrated with gelatinous, fibrinous or purulent matter. More frequently these are the residua of a former inflammation,—spots at which we find the muscular substance replaced by a white ligamentous (fibroid) texture. (See the section on " Inflammation of the Muscular Substance of the Heart.") These latent and recurring processes of in- flammation are in some instances connected with the residua and secon- dary effects of pericarditis and endocarditis, and undoubtedly would appear to promote the origin and further development of cardiac disease. In passive dilatations, the color of the tissue of the heart is occasion- ally purplish-red, but more frequently it is darker and bluish-red, owing to the imbibition of the haematin, which is greatly favored by the dis- solved condition of the blood, and the relaxation of the Avhole tissue. The muscular substance of the heart is in these cases extremely flabby and easily torn, while its walls collapse when they are cut open. In the higher stages of dilatation the muscular bundles in the auricles are forced asunder, so that the wall of the heart appears between them as a mere membrane. In dilatations arising in pericarditis, the muscular substance has a dirty rusty broAvn, or yellow leather-like color, is easily torn, and appears as if half boiled; in other cases, it is pale, flabby, and abnormally fat, THE ORGANS OF CIRCULATION. 129 the surface of the heart being frequently covered by an accumulation of adipose matter. The knowledge of the causes of the origin of these diseases of the heart is of the highest interest. Many admit of being discovered and made apparent without any great difficulty, but many others are partly problematical and partly uninvestigated. We will consider them in such an order as to proceed from those which are obvious to those which are less apparent, and finally to the problematical and hypothetical, giving special attention to the practically important ones comprised under each category. These causes are as follow: 1. Mechanical Obstructions, which give rise, according to circum- stances, either to preponderance of dilatation or preponderance of hyper- trophy. a. Mechanical Obstructions in the Ostia of the Heart.—The number of diseases produced by these causes is probably the greatest. They are consequent on various diseases of the arterial and auriculo-ventri- cular valves, more especially on the secondary effects of endocarditis (Bouillaud's chronic endocarditis), and admit of being generally referred to contraction (stenosis) of the ostium, and to insufficiency of its valves. Whether the latter has a tendency to give rise more frequently to dilata- tion, and the former to hypertrophy, has not yet been determined. As these diseases of the valves are far more frequent in the left than in the right side of the heart, so also are the diseases of the heart to which they give rise. The auricle or the ventricle becomes the more acutely affected according to the seat of the valvular disease, while both are simultaneously attacked where the arterial and auriculo-ventricular valves are alike diseased. Owing to the impediment presented to the emptying of the heart's cavities on the left side, and the consequent obstruction of the capillary circulation through the lungs, disease extends to the right ventricle, and from thence to the right auricle, commonly manifesting itself as hypertrophy with excessive dilatation, and occasion- ally—more especially in the auricle—as passive dilatation. b. Mechanical Obstructions in the^Arterial Trunks, occurring at dif- ferent distances from the heart, promote the development of cardiac dis- ease in proportion to their greater vicinity to that organ. These obstructions are of various kinds. Congenital contraction of one or other of the vascular trunks is not unfrequent, and is generally manifested in the aortic trunk by an insuffi- ciency of calibre which extends to the branches, and probably also to the more delicate ramifications. This condition induces very considerable dilatation with more or less hypertrophy in the left ventricle, and subse- quently leads to similar dilatations of the left auricle, and of the cavities on the right side of the heart. To this class belong acquired contractions of the vascular trunks and their main branches, together with their final obliteration, dependent on alterations of texture. Further, the contractions caused by compression or expansion, and the obstructions presented to the current of the blood by the elongation, angular curvature, twisting, &c, of the large arteries. vol. iv. 9 130 ABNORMAL CONDITIONS OF Lastly, there are also dilatations of these arterial trunks, which, as is well known, appear frequently, and in the most excessive degrees, in the trunk of the aorta and its main branches, under the various forms of aneurism. These conditions generally induce active dilatation of the left ventricle, with a rapidity and intensity proportional to their vicinity to the heart and to their importance. It must be observed, that although insufficiency of the valves of the diseased trunk may simultaneously occur, its existence is not necessary to the formation of cardiac disease, which is then owing to the obstacle opposed to the advance of each succes- sive blood-wave by the mass of blood accumulated in the dilated and paralyzed trunk. c. Similar (mechanical) Obstructions in the Capillaries.—Obstruc- tions in the capillaries of the pulmonary artery are tolerably evident, inducing active dilatations of the right ventricle, and, subsequently, dilatation of the right auricle, having in some cases a more active and in others a more passive character. To these belong: a. The obstruction presented to the circulation through the capillary system of the lungs by contraction of the thoracic cavity, and the con- sequent excessive thickness of the pulmonary texture. This condition presents a great degree of intensity and a character of constancy in malformations of the thorax and contractions of its cavities consequent on curvature of the spine, more especially extreme scoliosis and kyphosis, and in cases of rachitic chicken breast. When the above-named diseases of the right side of the heart attain a great degree of intensity, they commonly give rise to highly developed hypertrophy. ft. Next, we must notice an increased condensation and atrophy in a more or less considerable portion of the lung, in consequence of com- pression from pleuritic exudation and of its healing, and of indurated pneumonia. The development of the heart will be proportional to the actual atrophy of the pulmonary texture, to the extent of the surface atrophied, and to the degree in which the capillaries have been destroyed by obliteration. y. Atrophy of the pulmonary texture associated with extended and considerable bronchial dilatation. 8. The obstruction presented to the circulation through the capillaries of the lungs by their emphysema (emphysema vesiculare). This condi- tion depends at first on the continued excessive expansion of the pulmo- nary cells, and in the more advanced stages on the obliteration of the capillaries which occurs in an uniform degree with the atrophy of the texture of the lung. The importance of the heart-disease depends on the extent, degree, and period of duration of the emphysema; occasion- ally the disease is very intense. e. The obstruction opposed to the injection of the lungs by the pul- monary artery, owing to the insufficient emptying of the pulmonary veins in consequence of disease of the left side of the heart, and of the habitual over-filled condition of the capillaries of the lungs. Hence arise the greatest number of diseases of the right side of the heart, and all the numerous consecutively developed dilatations of the right ventricle and auricle, which originate in the left cavities, and are extended by means of the capillaries of the pulmonary system. The most important THE ORGANS OF CIRCULATION. 131 of these forms of dilatation are those which, in the manner already in- dicated, depend upon a contraction of the auriculo-ventricular opening on the left side of the heart. It is only in comparatively rare cases that tuberculosis of the lungs and tuberculous pulmonary phthisis give rise to even a very moderate degree of active dilatation of the right side of the heart. A certain degree of diminution in the size of the heart is more frequent, and is then manifested in the form of simple or even concentric atrophy, which corresponds with the general tabes and the wasting of the mass of the blood. On the other hand, similar obstructions in the capillaries of the aortic system are either wholly unknown, or are so obscure, that although a priori conjectures may be hazarded regarding their persistent or tran- sient existence, no physical (anatomical) demonstrable facts can be es- tablished in reference to the subject. 2. Diseases of the Texture of the Heart.—To these belong : a. First, and most prominently, inflammations, as for instance of the pericardium, the muscular substance of the heart and the endocardium, both in their primary and secondary character. By paralyzing the sub- stance of the heart, inflammations occasion dilatations, which are main- tained by their own secondary conditions, which mechanically augment them, and gradually superinduce hypertrophy. An important place must be assigned to dilatations arising from chro- nic pericarditis, especially when associated with purulent exudation, or when investing the heart with a pseudo-membrane incapable of contrac- tion, or lastly, when there is firm adhesion of the heart to the pericardium consequent on these new structures. Inflammation, in proportion to its intensity, and the quantity and purulent character of its effusion, tends to promote paralysis of the muscular substance of the heart, ac- companied by decoloration and diminished cohesion, and hence furthers the development of passive dilatation. The longer the inflammation has continued, the more permanent will be the character of the cardiac af- fection, and if at length the heart adheres to the pericardium, a mecha- nical obstruction is opposed to the contraction of the former by the pseudo-membrane, which agglutinates the pericardium to the heart. This form of dilatation commonly affects the whole heart. The dilatations induced in the same way by the endocarditic process, are similar to the former, but are usually less important; and when it gives rise to anomalies of the valves, they may gradually assume the active form by the association of hypertrophy. The left side of the heart, especially the left ventricle, is incomparably the most frequent seat of these affections. It must be evident that the importance of the dilatation induced by the inflammation of the muscular tissue of the heart, will be in propor- tion to the frequency of inflammation, and the number and extent of its starting-points. This form of dilatation, excepting in very rare cases, invariably affects the left ventricle. b. Adiposity of the Heart.—An excessive accumulation and formation of adipose tissue in the heart promotes dilatation of a passive character, in consequence of the simultaneous attenuation of the muscular walls of the heart. 132 ABNORMAL CONDITIONS OF The form which we regarded as consecutive, in speaking of the condi- tion of the texture of the hypertrophred and dilated heart, appears to favor further dilatation. 3. Finally, in all those cases in which cardiac diseasecannot be re- ferred to any of the above-enumerated causes, it may originate in exces- sive innervation of the heart. Under this head we may include a consi- derable number of cases of hypertrophy and dilatation of the left side^ of the heart, which Bouillaud has termed primary, in order to distinguish them from consecutive forms arising from the causes already indicated. Many of these causes, more especially endocarditis and its secondary conditions, are occasionally observed in the foetus, and the diseases to which they give rise under these circumstances are then congenital. Other cardiac diseases belonging to this category depend on original malformation of the heart, its ostia and vascular trunks, and constitute a special series, of Avhich we purpose treating subsequently under the head of cyanosis. Independently of these causes, the consecutive diseases, arising from affections of the heart, are alike important and numerous. The follow- ing are the most worthy of notice: Excessive Fulness and Dilatation. Stasis in the whole Venous Sys- tem.—This condition is most strikingly manifested in the great venous trunks, the venae cavae, and the trunk of the portal vein,—from whence it extends along their branches into the capillaries, and is then charac- terized by distension and cyanosis. Hemorrhages, resulting from the excessive fulness of the capillary system, manifested in discharges of blood from the mucous membrane of the nose, excessive menstrual uterine discharge, bleeding from the bron- chial and pulmonary mucous membrane (haemoptysis and haemoptoic in- farctus), hemorrhage from the intestinal mucous membrane, from the liver (apoplexy of the liver), and into the brain. The most frequent and important of these, are bleeding from the bronchial and pulmonary mu- cous membrane, and cerebral hemorrhage; and we will, therefore, treat of them specially, together with other subjects, in a future page. Hypertrophies, more especially affecting the parenchymatous abdo- minal viscera, as the liver, spleen, and kidneys, although more particu- larly the two former. These affections are frequently marked by a visi- ble increase in the volume of the organs, by a persistent tumor, and more commonly—either with or without the former,—by a striking increase of consistence depending on a compression of the elementary structure induced by hypertrophy. To these we must add hypertrophies of the mucous membranes and the chronic catarrhal inflammatory conditions—the forms of blennor- rhoea—to which they give rise. Those which are most remarkable for their intensity and extent are bronchial catarrh, and a catarrhal condi- tion of the whole of the intestinal mucous membrane. Dropsy which usually manifests itself first as anasarca of the lower extremities, and is then converted into general dropsy by the addition of serous effusions into the large serous sacs, is the result of the above- named venosity and mechanical hyperaemia. GMema of the lungs is highly important, whether it be slowly established, and as a result of THE ORGANS OF CIRCULATION. 133 dropsy in other parts, or whether it show itself among the earliest symp- toms of dropsy, and speedily attains a high degree of intensity, when it not unfrequently proves rapidly fatal. Besides these secondary conditions, there are others which, from their importance, merit special consideration : these are certain diseases of the liver. The diseases of the liver, of which we are about to speak, have fre- quently been regarded as causes of disease of the heart, but it is not very clear in what manner they can be supposed capable of bringing about such a result. Facts as well as theory tend rather to show, that the morbid condition of the liver is a consequence of heart-diseases, and is developed by the constant mechanical hyperaemia induced by the latter. To this class belong, besides the hypertrophy already described, the con- dition known as nutmeg liver, which is generally developed in a very in- tense form, that is to say, as a sharply-defined saturated yellow substance, very rich in blood, and marked with well-defined red patches; and, finally, that granular condition of the liver which is gradually developed from the latter, either with or without inflammation. In our observations on hemorrhages, we spoke of those of the bron- chial and pulmonary mucous membranes, and of cerebral hemorrhage as among the most important results of the cardiac diseases under consideration. Cerebral hemorrhage (apoplexia gravis) occurs in so large a majority of cases in conjunction with disease of the heart, that the latter has, with much reason, been regarded as a predisposing cause of cerebral apoplexy. The disease of the heart consists here in simple hypertrophy of the left ventricle, or what is much more frequently the case, in its dilatation, associated with highly developed hypertrophy. Cerebral apoplexy is undoubtedly induced by laceration of the cerebral vessels, occasioned by the augmented impulse propagated from the left ventricle; and this is the more easily effected the more the arterial coats in advanced life have lost their normal texture and cohesion, their power of resistance, and elasticity, or have become ossified, &c. A similar or even identical relation has been supposed to exist between hemorrhages of the bronchial and pulmonary mucous membrane and active dilatation of the right side of the heart. It must, however, be observed in refe- rence to this point, that hemorrhages of this kind very frequently occur in dilatation and hypertrophies of the most different portions of the heart, in the form of haemoptysis and haemoptoic infarctus (pulmonary apoplexy). The cases in which they are found to exist, are very rare in comparison with the frequency of active dilatation of the right ventricle, and their coincidence bears a very secondary relation to the frequency of the coexistence of active dilatation of the left ventricle and cerebral apo- plexy. Whether this depends on the absence of that diseased condition of the coats of the vessels in the branches of the pulmonary artery which is found to exist in the cerebral vessels, is a point that has not been deter- mined, since, on the one hand, cerebral apoplexy, when associated with the above-named heart-disease (viz., hypertrophy of the left ventricle), is found to occur without any recognizable anomaly of the cerebral ves- sels ; and on the other, because bronchial and pulmonary hemorrhage, are frequent in the cardiac diseases referred to. It follows, therefore, 134 ABNORMAL CONDITIONS OF that these affections are only in very rare cases to be referred to an increased impulse propagated from the hypertrophied right ventricle, and that in the most numerous cases they are the result of an excessive ful- ness of the whole vascular apparatus of the lungs, induced by the obstruc- tion opposed to the emptying of the pulmonary veins into the left side of the heart. These diseases of the heart attack individuals of every age, not even excepting the foetus, but they occur more frequently in advanced life than in childhood and adolescence, simply because the different causes favorable to their active development have been for a longer time in operation, and the system is no longer equally able to resist disease. They frequently prove fatal in consequence of the secondary diseases to which they give rise, and often produce sudden death, especially by paralysis of the hypertrophied organ, hyperaemia of the lungs, rapidly developed pulmonary oedema, or cerebral hemorrhage. They are further worthy of notice on account of the immunity from tuberculosis, which they insure to those affected by them; and it may be generally remarked, that the immunity which is yielded by the most various anomalies is always dependent on this class of diseases of the heart. b. Abnormal Smallness. Anomalous smallness of the heart appears under two essentially diffe- rent forms, being either congenital and original, or the result of atrophy —atrophied. Abnormal smallness from either of these causes is of in- comparably less frequent occurrence than excessive size. The former of these conditions is occasionally associated with a foetal conformation of the heart, patency of the foramen ovale, and even with more considerable malformations; but many cases present exceptions to this rule. The degree of abnormal smallness varies, the heart of the adult being in some well-marked cases no larger than that of a child of six or seven years of age. This condition appears to be most common in the female sex, and is not unfrequently connected with retarded develop- ment of the sexual organs, especially where this arrested development affects the whole system. The opinion expressed by Laennec, that fre- quent syncope is dependent on a heart too small in relation to the body of the individual, is worthy of observation. Atrophy of the heart accompanies, to a certain extent, all general wastings of the body, being commonly observed after typhus, and espe- cially in marasmus, in consequence of tuberculous and cancerous secon- dary formations and their disintegration. An atrophied condition of the heart is also occasionally produced by pressure and want of space, as for instance by bulky secondary products in the mediastinum, and is, moreover, also the result of pericarditis, accumulations of fat on the heart, &c. Contractions of the openings of the coronary arteries is an important and influential cause. The heart itself differs under these circumstances, the tissue being either tough, and in that case usually of a reddish-brown color, or re- laxed, easily torn, of a rusty faAvn-color, and a faded appearance. Ac- THE ORGANS OF CIRCULATION. 135 cording to Bouillaud, three different forms may be established in refer- ence to the cavities of the heart, viz. : a. Simple atrophy, wasting (attenuation) of the walls, with a normal condition of the capacity of the cavities. b. Eccentric atrophy, attenuation of the walls with dilatation of the cavities. c. Concentric atrophy, a normal or even an increased thickness of the walls, with contraction of the cavities; this is the most common form. In the first form the volume of the heart is contracted ; in the second it may be contracted, normal, or augmented; in the third it is con- stantly and generally strikingly contracted. This last form approaches most nearly to original smallness, with which it may even be con- founded. Besides the above named-characteristics of the muscular substance of the heart, other signs of atrophy may be mentioned, as, for instance, disappearance of the fat of the heart, serous infiltration of the adipose cellular tissue at the apex, the base, &c, in consequence of shrivelling of the opaque pericardium and of the milk-spots that may be present; and, lastly, an unusually winding course of the coronary artery. Morbid attenuation, atrophy of the endocardium, and of the valves, will be considered in the sequel. § 5. Anomalies of Consistence. We have already acquired some knowledge of several of these anoma- lies, to which belong: An increase of consistence in the muscular substance of the heart in hypertrophies, which is occasionally very considerable, especially in the right ventricle; A diminution of consistence in passive dilatations and in some forms of atrophy: A peculiar diminution of the consistence of the muscular substance of the heart, associated with decoloration, and as the result of pericar- ditis, and more especially hemorrhagic, purulent, and tuberculous exuda- tions, which impart to it something of the character of half-boiled meat. (See p. 111.) Another form of diminished consistence, of which we have only spoken cursorily, and which will be considered more fully in a future page, is that which accompanies adiposity of the heart. The cases that have been regarded by many observers as softening of the heart's substance, most probably belong to one or other of these forms of extreme diminution of consistence. It is not unlikely that many of these may have originated in an inflammatory centre in the tissue of the heart. The diminution of consistence, or a relaxed condition in which the tissues can be easily torn, and which is occasionally observed as the re- sult of typhus, is a mere symptomatic and simple diminution of consist- ence not depending upon any disturbance of texture. Softening of the valves will be considered when we speak of the dis- eases of these structures. 136 ABNORMAL CONDITIONS OF § 6. Separations of Continuity. To this class belong : a. Wounds of the heart produced by sharp thrusting instruments, as Avell as by the penetration of fragments of the ribs, sternum, &c. Such wounds, whether superficial or sufficiently deep to penetrate into the cavities, may injure the heart from different directions and at one or more points. b. Ruptures of the heart induced by violent shocks implicate, ac- cording to circumstances, different portions of the heart, very frequently to a great extent. c. Spontaneous Ruptures or lacerations of the heart. (Cardiorhexis, Ruptura cordis spontanea.) These are the most important of this class of lesions. Such spontaneous ruptures affect either the walls of a cavity of the heart, a papillary muscle, or its tendinous portion only, a trabecula carnea, or a valve,—the first of these being, however, by far the most common. The left ventricle is the most frequently lacerated, the right only comparatively rarely, and the auricles most rarely of all. When there is laceration of the left ventricle, the lesion almost invariably affects the convex or anterior wall, and generally its middle portion near the septum, the cases being very rare in Avhich the plane or posterior wall is lacerated. The laceration may generally be observed on the external surface of the heart in the form of a fissure, varying in length, and inclining inwards in the direction of the septum. This lesion presents a different appearance in the interior, for here we observe that the mus- cular substance is, as it were, bruised and crushed over a large extent, near the inner surface, the rent exhibiting either a straight or an oblique course, or in some cases a deep ramified cleft. A coagulum is very commonly found interspersed in the interior among the trabeculae, or it occasionally fills up the whole cavity. There is usually only one rent present, but there are occasionally two or even more rents, which are either wholly separate or connected under the surface, and appear at different distances from one another, even in wholly different compartments, as, for instance, simultaneously in the left and the right ventricles. The investigation of the causes that give rise to these lacerations is a subject of great importance. However much we might be disposed to believe that a heart having thin, relaxed walls, which can be easily torn, would be pre-eminently liable to rupture, or that this lesion would be more common in those portions of the heart in which the walls are thinnest, such is by no means the case, for laceration takes place, as we have already seen, precisely in the thickest and strongest portions of the heart, and is usually found to occur where the organ is in a hypertro- phied condition. On submitting such cases to a more careful investi- gation, we find, however, as has been already in part shown, that the portion referred to, viz., the left ventricle, in consequence of the dis- eased condition in which it is often found, especially when combined with hypertrophy, may be so intensely predisposed to spontaneous lace- ration that this lesion of the heart may occur during a condition of com- plete bodily and mental repose, and not merely under circumstances of increased action from various exciting causes. THE ORGANS OF CIRCULATION. 137 Among the morbid conditions predisposing to rupture, Ave must place the various fatty conditions of the heart, more especially those which we have mentioned under the head of hypertrophies and dilatations, as a frequent form of textural lesion, in Avhich the muscular substance of the heart assumes a dirty yellowish discoloration, may be easily torn, and becomes loose and flabby. Laceration of the heart is also frequently occasioned by centres of inflammation in the earlier stages, seated in the muscular substance. Contractions of the opening of the aorta may also be included among the remote causes, whilst advanced age affords a specially predisposing cause. These lacerations, as well as penetrating heart-wounds, generally terminate speedily in death. It has been asked where we are to seek the cause of the speedy occurrence of death in those cases where the quantity of blood extravasated in the cavity of the pericardium is not sufficient to account for the fatal termination of the disease. Some have referred the cause to the implication of the function of the heart itself, in consequence of the extravasation and of the separation of numerous muscular fibres in extensive wounds of this organ. Besides these causes, Bouillaud has advanced an opinion deserving of attention, that death results from syncope,—anaemia of the brain—owing to the sudden abstraction of blood induced by extravasation from the left ventricle. Penetrating heart-wounds are not, however, invariably rapidly fatal; life being in some cases considerably prolonged, while it would even appear, in accordance with some observations selected from a large number of cases, that wounds of the heart may be occasionally followed by recovery. The fact that death does not immediately ensue has been explained on the ground of the narrow and oblique course of the wound, and by the different position and crossing of the various wounded layers of the muscular substance. In many cases the wound has been closed by some portion or the whole of the instrument, or even a fragment of a rib, remaining imbedded in it. It is difficult to answer the question whether the rent occurs in sponta- neous ruptures, during the systole or the diastole. Many (Pigeaux, amongst others) are of opinion, although without sufficient ground, that it generally takes place during the diastole. Judging by analogy with lacerations of the voluntary muscles, it must take place during the systole. In proof, however, of the frequency of its occurrence during the diastole, the fact might be advanced that the course of the rent in the heart, when contracting after the haemorrhage, is not straight, but angular or zigzag, in consequence of the disturbed position of the different muscular layers. It is equally difficult to determine, generally or in any individual case, whether the rent has affected the whole thickness of the heart at once, or whether it has proceeded gradually, till it finally penetrated the whole thickness of the Avail, and whether it began at the exterior or in the interior. According to our observations on this subject, the rent begins, in most cases, in the inner muscular layers. The laceration of a papil- lary muscle, or of a trabecula carnea, is of very rare occurrence, and the conditions on which it depends are probably the same as those of fissure of the heart's wall. 138 ABNORMAL CONDITIONS OF Laceration of the tendons of the papillary muscles and of the valves probably always depends on the relaxation and lacerability of the tissue, associated with inflammation of the lining membrane of the heart (endo- carditis). It not unfrequently acquires importance by the valvular insufficiency to which it gives rise. Laesiones continui of the valves will be more fully considered in a future page. § 7. Diseases of Texture. a. Hyperosmia, Anosmia.—We are not acquainted with any special condition characteristic of hyperosmia of the heart. Occasionally how- ever, hyperaemia, as it manifests itself in the hypertrophies and dilatations which arise especially from stenosis, and in asphyxia in new-born infants and adults, is marked by the dark color of the muscular substance of the heart, and by a fulness of the vessels, more particularly of the veins, and in its more highly developed stages, by slight extravasation in the form of ecchymoses, about the size of millet-seeds or lentils, especially in the external strata and near the base of the heart, at the auricles, and in the vicinity of the origin of the arterial trunks. Apoplexy of the Heart, manifested by an extravasation of blood into the muscular substance,—a suffusion of the muscular tissue,—is a symptom of no importance in the various degrees of laceration of the heart. Anosmia of the Heart is probably often overlooked on account of the indistinct signs by which it is characterized. Such a state constitutes, however, a very important (but as it would appear, a hitherto disregarded) morbid condition, as we may learn from the contractions and final obliterations of the openings of the coronary arteries occurring in diseases of the aorta. b. Inflammations.—After having spoken of inflammation of the external investment of the heart—pericarditis,—it still remains for us to notice inflammation of the lining membrane, and of the muscular sub- stance of the heart. 1. Inflammation of the Lining Membrane of the Heart, Endocar- ditis.—It is only in modern times, and from the observations of Bouil- laud, that this species of inflammation, under the name of endocarditis, has been shown to be the special basis of numerous consecutive heart-dis- eases. The importance of the subject, both ' intrinsically and with reference to the different opinions advanced regarding the frequency of the disease, the absence of any well-founded data for its correct diagnosis after death (notwithstanding the many attempts made for their esta- blishment), and, lastly, our still inaccurate knowledge of its course, its termination, and sequelae, &c, have determined us to precede our general notice by a few explanatory observations; and at the same time we would simply remark, as will be seen in this section, that we have arrived, with reference to some points, at a totally different conclusion from the opinions usually expressed regarding endocarditis. The endocardium corresponds with the inner coat of the vessels, and consists essentially, besides the epithelium, of a longitudinal fibrous coat (Henle), under which there is a very considerable layer of elastic and cellular tissue, which is most distinct in the auricles, and especially in their atria, and on which rests the muscular substance of the heart. In THE ORGANS OF CIRCULATION. 139 the left side of the heart, more especially in the left auricle, a layer similar to that of the circular fibres of the arteries is occasionally found under the longitudinal fibrous coat. This compound investment covers the trabeculae carneae, the papillary muscles, and their tendons, while the true endocardium invests the valves also, which, however, can only be regarded as duplications of that membrane, if we consider them as essentially composed of a fibrous tissue supplied with vessels. Besides this fibrous tissue, which is composed of a cellular-fibre-like substance, and delicate nucleated fibres, we also find unstriped muscular fibres in the auriculo-ventricular valves in individuals having a robust and mus- cular frame. The internal layers of this integument (the epithelium and longitudinal fibrous coat, which constitute the true endocardium) are devoid of vessels ; but such is by no means the case with respect to the subjacent cellular tissue, which is permeated with numerous elastic fibres, or with the muscular substance of the heart. The endocardium, as we find in dilatations of the cavities of the heart, and in enlargements of the vahres, arising from dilatations of the ostia, is capable of undergoing considerable expansion and attenuation. It is much thicker in the left side, and especially in the left auricle, than in the right side of the heart. The relation of the true endocardium (the epithelium and the longitu- dinal fibrous coat) to the subjacent layer furnished with vessels, corre- sponds with that existing between the inner coat of the veins and their external coats. This condition affords a priori evidence of the possibility of inflammation of both coats, considering it, in its usual sense, with exudation of the free surface, whilst there is no inflammation, properly so called, in the inner coat of the arteries, at least not in the larger vessels, having a thick, yellow, muscular coat of circular fibres. The actual seat of these inflammations is the cellular substance lying under the endocardium and the inner coat of the vessel; we must, therefore, suppose, that in cases where products of inflammation are deposited on the inner surface of the heart or of the vein, the exudation must have penetrated through the permeable texture of the endocardium or through the inner coat of the vessel, or that the latter has been removed, either by solution or fusion, by means of the process of exudation. The latter condition will naturally be found to be of most common occurrence in inflammations having a purulent ichorous exudation. Such alterations manifest themselves by opacity, lacerability, and a felt-like porosity of the endocardium, excoriation of the subjacent layers, &c. We learn from the foregoing observations how far the designation endocarditis is applicable to inflammation of the lining membrane of the heart. Thus, for instance, it is evident that since the endocardium, like the inner coat of the vessels, is non-vascular, it cannot be the seat of inflammation, Avhich affects merely the tissue lying immediately below it, which is furnished with vessels. We purpose retaining the term endo- carditis in this sense, discarding its use in reference to the valves, for which we shall simply retain the designation of inflammation of the valves. Although endocarditis is a disease of very frequent occurrence, it must not be supposed that the term is applicable to all the diseases 140 ABNORMAL CONDITIONS OF ascribed to it, its products, and sequelae,, for, as we shall soon learn, many morbid conditions of the valves of the left side of the heart, espe- cially of those of the aorta, are the products of the same process which manifests itself in the arteries as a morbid deposit on the inner coat. Endocarditis attacks different portions of the lining membrane of the heart, affecting in some cases the endocardium covering the inner surface of a cavity, the papillary muscles, and the trabeculae, in others that of the valves, while in others again it affects both. Endocarditis of the valves is the most frequent and the most important, from the^ consecutive heart-diseases to which it gives rise. We will consider the signs of both under one head, referring specially to the peculiar characters of endocar- ditis of the valves. 1. Redness and injection.—In order that these conditions may be re- garded as the manifestation of inflammation, it is necessary that the former should be the result of the latter (inflammatory injection or sta- sis), or that it should depend on an exudation containing haematin into the tissue. This latter form of redness is always found together with other signs of inflammation, and usually presents a mottled appearance. Where the redness cannot be referred, at least in part, to the above cause, it cannot be regarded as a sign of inflammation. Now, in point of fact, all the different forms of redness of the endocardium, which have been generally described as characteristic of endocarditis, belong to the latter class, and the descriptions given of these various forms evi- dently show that they are mere modifications of that redness which de- pends on infiltration of the tissue with haematin. There are, however, so few opportunities of detecting the peculiar redness of the endocar- dium arising from an injection, as our own numerous observations can testify, that it would not be surprising if anatomists, instead of commit- ting an error of this nature, had wholly denied the existence of inflam- matory redness in endocarditis. It is only in the first stage of the dis- ease that a true redness and injection can be observed through the endocar- dium ; it is only, therefore, in the very rare cases in which death occurs in the earliest stage, either from this or some other disease, that this condition of redness can be perceived. In most cases a redness from imbibition, resulting from the diseased condition of the blood, is actually present, and renders it extremely difficult and almost impossible to discover the redness from injection, which differs wholly from the above-named red colo- rations, and is constantly of a pale, rose-red color, whose tint is subdued by the endocardium covering it. Its appearance is never that of a satu- ration of the tissue, and its stripe-like, ramifying course, corresponding to that of the vessels, may the more easily escape detection, when it is concealed by the presence of a simultaneous red coloration, arising from infiltration. In most cases we are unable to perceive this redness from the circumstance of its being wholly masked by the conditions we are about to consider, viz.: 2. Opacity and thickening of the Endocardium.—In consequence of the extension of the process, the endocardium at various differently-sized spots is rendered opaque, whitish, and milky, whilst at the same time it becomes more or less thickened and swollen. This opacity and thicken- ing depend on the deposition of the product of inflammation in the THE ORGANS OF CIRCULATION. 141 tissue of the endocardium and the subjacent stratum, where it either solidifies or exerts a relaxing, macerating, solvent action on that tissue. The opaque and thickened parts are not clearly defined, but appear gradually to lose themselves in the adjacent portions of the endocardium. Valves affected by endocarditis exhibit a remarkable degree of thicken- ing, because the substratum of infiltration—the tissue occurring between the two lamellae of the endocardium—is here accumulated in large quan- tity. The shining smooth appearance of the endocardium vanishes with the increase of the opacity and thickening, and it then acquires a dull, velvet or felt-like and rough surface. 3. The whole of the lining membrane of the heart acquires a looseness of texture, and then readily admits of being torn, while the true endo- cardium is easily detached. In inflammation of the valves, their fibrous tissue very frequently appears to be in an extreme state of looseness and relaxation. 4. Products of Inflammation.—To this class belongs the above-named infiltration of the endocardium and of the subjacent tissue, but the ques- tion here arises, whether there is also exudation on the free surface of the endocardium, and how far such a condition is necessary to establish the existence of endocarditis. The fact of such an exudation being deposited on the free surface of the endocardium in most cases of endocarditis, is rendered highly pro- bable, not only from the results of pathological investigations, and the analogy presented by inflammations of other similar structures, especially the serous membranes, but still more so from the symptoms manifested during life. This exudation at the moment of its production merges into, and is taken up by the mass of the blood, where, in accordance with its character and intensity, it gives rise to the different general symptoms manifested during life, and to the characteristic secondary processes observed in the capillary system in endocarditis. In many cases, however, this exudation, doubtless in consequence of a very high degree of coagulability, remains on the inner surface of the endocardium in the form of a membranous coagulum, having a delicate felt-like, or shaggy free surface, which we have rarely an opportunity of seeing in its original condition, but which may very frequently be subsequently observed under different forms, but most distinctly in the form of milk-spots on the endocardium'. In endocarditis of the valves it com- monly manifests itself in the form of felt-like or granular masses, under which the valve appears rough, loose in its texture, and excoriated, and it then, in part, constitutes the so-called vegetations of the valves of the heart. We shall subsequently speak of purulent exudation on the endo- cardium. 5. The so-called Vegetations or Fibrinous Coagula which occur under the most various forms, more especially when they appear on the valves of the heart, are generally, and without exception, regarded as charac- teristics of endocarditis. As, however, they are not invariably direct products of an exudative process, but, on the contrary, in some cases wholly, but more frequently only in part, indirect effects of endocarditis, since they undoubtedly also appear independently of that disease, we cannot regard them as signs of endocarditis without some limitation in 142 ABNORMAL CONDITIONS OF accordance with what we have already stated, and with that which we purpose advancing in a subsequent part of this work, when we proceed to treat specially of vegetations in the heart. It follows from the above considerations that the anatomical charac- teristics of endocarditis are very inconsiderable in number, when com- pared with those of other inflammatory affections; redness and injection are only seldom to be observed, an inflammatory product on the free surface of the endocardium is not always to be detected, and the vege- tations are only conditionally a sign of endocarditis. There remain, therefore, as the only constant signs, opacity and thickening of the en- docardium, with the disappearance of the smoothness and polish of its surface. But as these conditions of opacity and thickening of the endo- cardium may, as we have already remarked, be produced by a process wholly different from that of endocarditis, it will be readily understood how difficult is its diagnosis, and how easily its products may be con- founded with those of some wholly different process. In the above delineation we have purposely limited ourselves to the most important points, in order to give a general sketch of the endo- carditic process ; and with the further view of not disturbing our readers by any superficial details, we have described only the characters pre- sented in the most numerous and common cases of endocarditis. We purpose considering this subject with the completeness which its import- ance demands, and we will then treat of all those points that have been neglected in the present portion of our work. The following observations will contain a notice of many of the more uncommon events occurring in the course of endocarditis, and of many appear- ances and processes which have merely been briefly indicated in the preceding delineation, together with the terminations, sequelae, &c, of the disease. a. In intense forms of endocarditis, a separation of continuity of the structure affected by the inflammation not unfrequently manifests itself as a highly important occurrence. It may occur in different ways, either as laceration of a valve, or of one or more of the tendons of the papil- lary muscles, or of the endocardium on the wall of the heart. This separation of continuity is.the final result of a maximum degree of inflammatory loosening of the tissue. The margins of the fissure are generally jagged, and serve as the places of deposit for a large number of vegetations. The tissue of the torn structure, as for instance of a tendon, is usually considerably reddened, infiltrated by inflammatory products, and easily torn. Laceration at the wall may give rise to the formation of aneurism of the heart, whilst, if it affect the valve, it may, under certain circumstances, occasion valvular aneurism. b. Endocarditis with purulent exudation is not of very uncommon occurrence; and 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 these lacerations frequently occur. In these cases a purulent product mixed with blood is generally found infiltrated into THE ORGANS OF CIRCULATION. 143 the tissue, if not at the surface of the endocardium, whilst abscesses are occasionally found to have spread themselves over a various extent of surface below the endocardium, in the cellular and adjoining muscular strata, deep in the tendons, and in the tissue of the valves. Finally, the process of suppuration being established, an ulcerous separation of continuity will be effected in various ways, in the endocardium of the walls of the heart, in a tendon, or in a valve. The vegetations deposited on the ulcerated surface and its margins are remarkable for their exces- sive number, their inconsiderable consistence, bad color, and their ten- dency to purulent disintegration. The secondary processes in the capil- lary system terminate in purulent solution, whilst the intensity and ma- lignant character of the general symptoms during life lead us to conjec- ture that some deleterious substance has been taken up into the blood. c. Endocarditis is probably always an acute disease; it may, how- ever, frequently recur, and at the same spots ; but we cannot admit the existence of a chronic form of the disease, unless, according to Bouil- laud's incorrect view, we regard as such the symptoms manifested during life by its products, and the further development and metamorphosis of those products, that is to say, the terminations and sequelae of endocar- ditis as given below. 1. Exudations on the free surface of the Endocardium in the form of agglutinated, whitish, or bluish-white laminae of different size and form, resembling in appearance a serous or fibro-serous membrane, under which the endocardium appears normal, or scarcely at all opaque. They at one time appear in the form of narrow stripes, at another in that of more considerable, irregular plaques or patches, varying from the size of a silver groschen to that of a zwanzigerstiick [a coin rather larger than a shilling], and admitting of being easily removed from the endocardium, over which they are in general smoothly drawn or occasionally compressed together in folds. They are most frequently observed in the left side of the heart, at the upper part of the septum towards the aortic opening, where they are puckered and drawn aside into plaits by the blood flowing over them. Their texture resembles that of the longitudinal fibrous coat, and they consist in some cases of thick stiff fibres, and in others of soft fibres of areolar tissue. The facility with which the agglutination of the inner milk-spots are severed, and the laceration of texture occa- sioned by their separation, cause them to differ very widely from other structures. The milk-spots are, however, almost always sharply defined in these cases. 2. Permanent Thickening of the Endocardium and of the Subjacent Tissue becomes the more considerable in proportion to the intensity of the endocarditis, and the frequency of its occurrence at the same spot. It is generally occasioned either by infiltration into the tissue, or by exudation that has solidified and become organized on the free surface of the endocardium ; the former of these exerts, however, a preponder- ating influence, as is especially observed in the valves. Thickening is manifested in the walls of the heart in the form of patches of various extent, in some of the trabeculae as a tendinous ring or sheath, in the papillary muscles as a tendinous covering over their extremities, in the tendons themselves as a wad-like or spindle-shaped thickening, and in 144 ABNORMAL CONDITIONS OF the valves as a more or less uniform thickening of their free margins, extending from thence to various distances, and even across the valve towards their margin of insertion. The diseased tissue appears opaque, thick, tough, and of a white color, inclining to yellow; and it is with difficulty that the free exudation and the tissue infiltrated by solidified products of inflammation, which constitute the principal elements of the morbid mass, can be torn or split asunder, both having coalesced, and presenting a single fibroid and compressed texture. The thickening of the tissue of the wall of the heart is often made more apparent in endocarditis by the association of inflammation of the contiguous stratum of muscle to various depths, which gradually passes into induration, and leaves a fibroid callus in the place of the mus- cular fibres. 3. Coalescence is frequently associated with this thickening of the tissue. As the thickened tissues coalesce with the free exudation, so also the latter may occasion a fusion of various tissues. In this manner the trabeculae enclosed in tendinous sheaths unite with one another or with the walls of the heart, while the same process may be observed amongst the separate points of a papillary muscle, or the tendons of a papillary muscle may merge into either one or several strings, or the dif- ferent valves may coalesce Avith one another, or with the wall of the heart or of the vessel. 4. This fibroid mass of exudation exhibits here, as in other places, a marked tendency to shrivel, by which means^-a shrivelling or shortening of the thickened structure takes place. To this class belong shortening of the papillary tendons, and a shrivelling of the valves associated with various malformations. The wall of the heart is either very indistinctly or not at all shrivelled, since it is raised by the substratum of muscle in those cases where the latter has retained its normal texture and func- tion ; the adventitious product is expanded rather than shrunk, owing to the great influx of blood in those cases in which the muscular sub- stance of the heart has been reduced to a state of paralysis by the action of inflammation, or has suffered a change of texture. 5. Calcareous Concretions become developed sooner or later in the fibroid secondary product, and appear in rare cases in the form of nodu- lar uneven laminae in the thickened endocardium of the wall of the heart, and more frequently as simple nodular or ramified strings or rows, or even as amorphous masses of various thickness in the tissue of the thickened valves, and of the thickened papillary tendons which are gene- rally fused and blended together. 6. We have already fully considered the subject of endocarditis termi- nating in Suppuration. d. Although endocarditis is generally characterized by the termina- tions and sequelae already indicated, the cases in which it terminates by a perfect cure are not of very rare occurrence, as we learn from careful observations on the living subject, and by a correct interpretation of the appearances presented after death. This favorable termination de- pends occasionally on a complete resolution; or, in other words, on the absorption of the products of inflammation deposited in the tissue, and on the fact that the portion of the free exudation which is solidified on the THE ORGANS OF CIRCULATION. 145 endocardium, and the vegetations that may be present, are gradually taken up and mixed with the mass of the blood in the form of finely- divided molecules. In some cases fragments which, from their size and position, do not constitute an impediment to the circulation, may remain; or, again, in other cases partial thickening of the valves is counteracted and rendered inoccuous by their becoming attenuated at one or more points, by a shortening of one or more of the papillary tendons, or an elongation of the muscle or of the extremity of the diseased valve. e. The Vegetations on the Valves above referred to undergo different metamorphoses, as we have already seen, and as will be made more apparent in the sequel. We will here specially notice : 1. Their gradual Diminution and Final Disappearance.—According to numerous highly interesting analogies, it would appear that these con- ditions depend on an actual waste of the fibrinous coagulum. They un- doubtedly occur very commonly, and from a comparison of the frequent or almost invariable appearance of very numerous and extensive vegeta- tions on the valves in recent endocarditis, and their insignificant cha- racter and occasional absence in obsolete cases, it appears evident that in the course of time, they become considerably diminished, and at length entirely disappear. 2. Ossification and Calcification of these vegetations are metamorphoses, which, although of frequent occurrence, have not hitherto been duly con- sidered. They constitute a special form of valvular ossification, which has never yet been duly considered. /. The secondary Coagulation of Blood in the capillary system, toge- ther with its metamorphosis, which presents a highly important indica- tion of the endocarditic process,1 has also been disregarded by observers. It indicates the most important phenomenon manifested during endocar- ditis, namely, the formation of a product on the free surface of the endo- cardium and its absorption into the mass of the blood, and consequently shows the equal importance of endocarditis and inflammation of the ves- sels (namely, of the veins), while it moreover tends to elucidate the symp- toms of disease during life. It is more constant than in phlebitis, inas- much as, from the absorption of the inflammatory product, no coagulum can be formed in the heart of a similar nature to those which occur in the veins, and hence there can be no immunity afforded against a poisoning of the whole mass of the blood. This process probably, on this account, constitutes an important means of diagnosing between obsolete endo- carditis and a form of hypertrophy of the endocardium, and more espe- cially of the valves, -which is induced by depositions from the blood ; but this subject we will presently consider more at large. It is of common occurrence in the spleen and kidneys, but is seldom found in the lungs, excepting in the very rare cases of endocarditis of the right side of the heart. The secondary processes which result from endocarditis depositing a purulent exudation, and terminating in suppu- ration, are less limited to these organs of haematosis, and manifest them- selves as metastases in the subcutaneous cellular tissue, in the mucous membranes, &c. The process commonly called Phlebitis (but more appropriately termed 1 Oesterr. med. Jahrbiicher, B. xix. St. 3. VOL. IV. 10 146 ABNORMAL CONDITIONS OF Angioitis capillaris) consists, as far as we know, like that observed in a larger vessel (namely, a vein), in a coagulation of the blood in the capil- laries, and a metamorphosis of the coagulated fibrin, varying in accord- ance with the quality of the absorbed product. Since endocarditis, in ordinary cases, yields no deleterious product (pus or ichor), the metamor- phosis consists in a conversion of the fibrinous coagulum into a fibroid mass, with obliteration of the vessels, and so great a degree of obsoles- cence of the affected tissue of the diseased organ, that the whole resem- bles a cellulo-fibrous callus which shrivels to a callous, whitish or black cicatrix, containing pigment. It is not improbable that the process may terminate in resolution, or, in other words, in the solution of the coagulum, and thus leave no trace of its existence. In the very rare cases in which endocarditis deposits a purulent product, the coagulum in the capillaries becomes decomposed into a fluid, which is more or less purulent, according to its elementary composition, while there is consecutive fusion of the walls of the vessels and the diseased tissue, the result of which is the formation of an abscess, or so-called purulent metastasis. This form of endocar- ditis may result in a true process of exudation in the serous and syno- vial membranes, and even in the parenchyma, in consequence of the diseased condition of th blood induced by the morbid product. g. Endocarditis by its proximate, no less than its secondary results, and therefore by a twofold local cause, may give rise to Dilatations of the Heart. As we have already observed in treating of these diseases, the form of dilatation thus occasioned is of a passive character, and de- pends on paralysis of the muscular substance of the heart, which is impli- cated in the inflammation. The dilatation is moreover mechanically increased in the more remote sequelae of extensive endocarditis by the continuance of a morbid condition of the valves, which are almost inva- riably implicated; and in these cases a moderate degree of hypertro- phy is gradually associated with the dilatation. The dilatation must also, as is evident, be more considerable from its very origin, and must be of a more decided passive character, where endocarditis has been combined with pericarditis and carditis ; and where the latter affection is of a very intense and deep-seated character, endocarditis may give rise to true aneurism of the heart. Endocarditis occurs with a preponderating degree of frequency in the left side of the heart, where it is also generally present in the very rare cases in which it attacks the right side. In the case of the former, both the ventricle and the auricle are affected, while in the case of the right side of the heart, the ventricle is the special seat of the disease. The auriculo-ventricular valves of the left side are more frequently diseased than those of the right, whilst many morbid conditions of the aortic valves cannot be actually referred to an endocarditic origin. An interesting exception to these relations is presented in the foetus, where endocarditis is much more frequent in the right side ; and many of the cases of contraction of the openings of the right side, which are met with in childhood and youth, are undoubtedly congenital and of foetal origin. There are, moreover, many anomalies of the arterial open- ing, especially of the right side of the heart and of its valves, which are THE ORGANS OF CIRCULATION. 147 commonly regarded as malformations (as, for instance, contraction and occlusion of this opening, and an abnormal condition of the trunk of the pulmonary artery), which are most probably the results of endocarditis already existing in an early period of foetal life, and which give rise to many arrests of structure within the heart. We may undoubtedly ex- plain in a similar manner the many endocarditic metamorphoses observed in the hearts of persons suffering from cyanosis. From what has been already stated, it will appear, that endocarditis occurs in the foetal condition as well as after birth. Youth and adoles- cence are the periods in which this affection is most frequently mani- fested. The most important diseases with which it is associated, are its pri- mary combination with pericarditis, and, whether this be present or not, with inflammations of serous membranes, namely, those of the synovial membranes—rheumatic inflammations of the joints. Valvular endocar- ditis, implicating tendinous insertion of the mitral valve, when combined with pericarditis, is extremely important, owing to the peculiar formation of the consecutive metamorphoses. Thus, for instance, we observe that the calcareous band developed at the tumefied point of insertion, not unfrequently expands into an osseous mass seated in the pseudo-mem- branous agglutinating medium between the pericardium and the heart. Endocarditis is also occasionally combined with carditis—inflammation of the muscular substance,—and this combination is then the common occasion inducing aneurism of the heart; while in some cases endocar- ditis may be merely an incidental combination, arising from some centre of inflammation in the muscular substance adjoining the endocardium. To this class belong the combinations with croupous pneumonia, acute inflammation of the periosteum, acute ostitis, &c. Endocarditis and its sequelae are not unfrequently met with in combi- nation with Bright's disease, which is probably to be explained by the fact that this heart-disease becomes associated with disease of the kidneys in consequence of the abnormal condition of the blood. Many of the anomalies already partially considered occur as the re- mote and indirect sequelae of endocarditis. Foetal endocarditis, at an early period, obstructs the completion of the inner structure of the heart, by means of the results to which it gives rise, and especially by contracting the openings of the heart; when it occurs at a later period and after birth, it obstructs the involution (closure) of the foetal passages. In sub- sequent periods of extra-uterine existence, many of the diseases of the different systems and organs considered under the head of dilatation and hypertrophy, may still be traced to the dilatations of the cavities of the heart and the anomalies of the valves (contraction and insufficiency), which have their origin in foetal endocarditis. Hypertrophy and Atrophy of the Endocardium.—By these conditions we purpose indicating a thickening of the true endocardium (which, in respect to the main character of its composition, corresponds to the inner coat of the vessels), by a morbid deposition from the blood of a sub- stance which becomes metamorphosed into the layers of the epithelium and longitudinal fibres composing the endocardium. This excessive de- position of new layers of the endocardium is a process which occurs in 148 ABNORMAL CONDITIONS OF its most fully developed form in the arteries, and more especially in their main trunks, and will be duly considered in the appropriate place. Its proximate result is a thickening of the endocardium. This morbid condition acquires additional importance from the facility with which it may be, and no doubt very frequently is, confounded Avith endocarditis and its products, which it greatly resembles, and with which it is often found associated. We have, on this account, thought it best to devote the closing part of the present section on endocarditis, to the consideration of this subject, hoAvever unusual such an order of arrange- ment may appear. (See p. 123.) The folloAving remarks on the peculiar characteristics of this affection will clearly exhibit the differences which distinguish it from the endocarditic process and its products. In the lower degrees it is only by a careful investigation that we can discover any undue thickening of the endocardium. The color of the muscular substance is less clearly discernible, while more strata than usual must be removed before we reach the layer of cellular tissues inter- spersed with elastic fibres, which is situated under the endocardium; moreover we clearly observe that the innermost layers are lighter and softer, and that the tissue which constitutes the longitudinal fibrous coat is less developed and more moist. In this manner new depositions of layers of endocardium, either with or without an epithelial investment, are frequently found to cover one or more of the cavities of the heart (the ventricle or auricle of the left or both sides), together with the corresponding valves. When this process of deposition has been frequently repeated, and the thickening of the lining membrane of the heart is correspondingly in- creased, this condition will be easily recognized. In these higher de- grees of intensity we very frequently observe, as in the arteries, that the endocardium exhibits, at more or less well-defined spots, portions of thicker surface in the form of islands or patches, while we at the same time remark that the valves, more especially those of the aorta, have been considerably thickened and enlarged by the deposit. The opalescent translucence and stratification of the deposit and the uniform texture of the combined lamellae, distinguish it from the products of endocarditis, from the loosely-attached, bluish-white, opaque milk- spots, and from the fibroid thickening of the endocardium, which cannot, without extreme difficulty and effort, be separated into strata, and which exhibits greater density and dryness of its tissue, and evidently consists of fibrous or areolar tissue. The absence of redness and injection in every stage and of vegetations and secondary processes (metastases) in the capillary system, distinguishes it from the endocarditic process. The existence of the process of deposition in the trunk of the aorta affords us further diagnostic aid in determining hypertrophy of the en- docardium. A correct diagnosis, which has for its object to determine both pro- cesses generally, and to distinguish the special share taken by each in the anomalies under consideration, is rendered more difficult in those cases in which, as we have already observed, the products of endocarditis oc- cur simultaneously with the condition we term " excess of endocardiac formation," and which is indeed very commonly favored or even occa- THE ORGANS OF CIRCULATION. 149 sioned by the residua of endocarditis. A peculiar difficulty presents itself, when the deeper or older deposits lose their transparency, and become completely opaque, white or faded, in consequence of an athero- matous process, or of a metamorphosis tending to ossification. They may be distinguished from endocarditic products on a closer inspection, by the occurrence of a large quantity of molecules, consisting of albumen, fat, and calcareous salts, deposited in the different strata. This metamorphosis never, so far as we know, proceeds on the walls of the heart, beyond the incipient stage above indicated; we have never found it developed in the true atheromatous process, nor have we ever been able to ascertain that this process formed the basis of any of the numerous cases of aneurism of the heart which we have examined. The valves, however, occasionally present the appearance of an incipient atheromatous disintegration of the deposit, while ossification of the de- posit on the valves, more especially on those of the aorta, is very fre- quently a final result. It is highly probable, moreover, that all the forms of ossification of the valves which become developed in the advanced periods of life, belong to this class. Hypertrophy of the endocardium is limited almost exclusively to the left side of the heart, and of the two arterial trunks it only attacks the aorta. The aortic valves and the left ventricle are more frequently and more intensely affected than the auriculo-ventricular valves and the auricle. The aorta is at the same time diseased in like manner, but gene- rally in a very preponderating degree. The endocardium of the left auricle is, however, excessively thickened in some few cases where there is contraction of the mitral valve. Endocarditic hypertrophy, like that of the aorta and its ramifications, especially occurs in advanced periods of life, and undoubtedly consti- tutes the source from whence arise a great number of those diseases of the aortic valves,—as, for instance, thickening, shrivelling, ossification, and insufficiency,—which are slowly developed in maturity and old age, without the pre-existence of endocarditis. This fact presents many points of great interest, when considered in relation to diseases of the mitral valves, which usually occur in young persons as a result of well- marked endocarditis. This affection is frequently occasioned and favored by pre-existing dilatation of the heart and contraction of the openings, in consequence of which the blood is detained in the different cavities, and its further cir- culation impeded. Atrophy or Attenuation of the Lining Membrane of the Heart is very seldom sufficiently manifested to come under notice. This membrane is certainly found to be uncommonly thin and transparent in some cases of dilatation of the heart; while we have remarked the same appearance in excessively fat hearts. 2. Inflammations of the Muscular Substance of the Heart, Carditis (in the strict sense of the word), Myocarditis.—Although inflammation of the Muscular Substance of the Heart is less frequent than endocar- ditis, it is much more frequent than is usually supposed. Its anatomical characters and its terminations are the same as those exhibited in inflam- mation of the muscular substance generally, but there are, nevertheless, 150 ABNORMAL CONDITIONS OF many points connected Avith this subject which demand special notice, both on account of their importance and peculiarity. It occurs independently in the middle layers of the muscular sub- stance most remote from the pericardium on the one hand and from the endocardium on the other, and in original or consecutive combination with pericarditis and endocarditis. The pericardium and the endocardium are ahvays implicated in inflammation of the adjacent layer of muscle and conversely intense pericarditis, and more especially intense endocar- ditis influence the adjacent structure to various depths. It moreover most frequently affects the true fleshy walls of the heart, but sometimes its trabeculae, and in some cases both simultaneously. It also commonly occurs in the form of larger or smaller centres which are in some cases spread over a large portion of one cavity of the heart (as, for instance, the left ventricle), in which case, the wall of the heart is found to be affected throughout more or less of its thickness, when the disease is associated either with pericarditis or endocarditis singly or Avith both conjointly. In some rare cases one portion of the heart is found to be so thoroughly affected, that there are only a few layers of the muscular wall which are not implicated. The seat of the affection is almost exclusively the left ventricle, which it attacks at every point, although less frequently at the septum; the apex is commonly attacked when the disease is very extensive. The right ventricle is very rarely affected, although we have observed the disease in an intense degree of development in the anterior wall of the conus arteriosus. It is of very rare occurrence, as far as we know, in the auricles. (See our remarks, in a future page, on Aneurism of the Heart.) Inflammation of the substance of the heart always gives rise to dila- tation of the cavity implicated, and this dilatation is proportional to the extent of the inflammation and to the number of its centres. When combined in an early stage with endocarditis it occasionally results in the formation of an acute aneurism of the heart (of which we shall subse- quently speak), in consequence of a laceration of the tissue which has been loosened by the process of inflammation. Finally, as we have already remarked, centres of inflammation are not unfrequently the cause of spontaneous ruptures of the heart. This affection commonly results in induration and in suppuration, although it much more frequently assumes the former than the latter mode of termination. In the former we find, in place of the muscular substance, a white fibroid (cellulo-fibrous) tissue, either in the form of small stripes, or spread over a more extended surface, according to the size of the centres of inflammation and the mass of the inflammatory product; or we may observe, where the indurated product of inflammation is accumulated in larger quantities at definite points and forms a tissue of this nature, nodular, roundish or irregularly shaped, ramified tumors, having the toughness of callus, which protrude either externally, or internally into the cavity of the heart. This form of striped indurations is frequently found to be deposited in the same subject in great quantity on the most different strata of the muscular substance of the heart, especially where THE ORGANS OF CIRCULATION. 151 &n accurate investigation shows us the residua of pre-existing endocar- ditis, combined with consecutive dilatations and hypertrophy. Professor Bochdalek has drawn attention to this fact and to the frequency of carditis, which has hitherto been overlooked and generally denied. The more widely extended inflammations of the muscular substance of the heart exhibiting this termination are of especial importance. They affect either the inner layers of the walls of the heart, together with the trabeculae and the base of the papillary muscles, including the endocar- dium ; or the external layers, together with the pericardium ; or, lastly, the wall of the heart throughout its whole thickness, including both the pericardium and the endocardium. Occasionally we find that contiguous portions of the innermost, the middle, and the external layers of the muscular substance of the heart, are in turn attacked. The muscular substance is here found to be replaced by a fibroid tissue, while the walls of the heart, the trabeculae, and papillary muscles, appear to be con- verted into a white callous tissue ;—a process in which the endocardium so far participates, that it not only enters to a corresponding extent into the same metamorphosis, and becomes identified with this tissue; but it even generally exhibits a gradually decreasing fibroid thickening beyond the limits of the metamorphosis in the muscular substance. We also observe at the pericardium exudations, which are either well defined, or spread over the whole heart, and have been converted into cellular or fibrous tissues; and these give rise to adhesions. These generally-diffused metamorphoses, which affect the wall of the heart throughout its whole thickness, not only exert an influence, in a general sense, on the increase of the dilatation of the respective cavities of the heart by means of the inflammatory process, but also specially on the origin of defined saccular dilatations—true chronic aneurism of the heart—which we shall subsequently consider more at large. The fibroid tissue in the wall of the heart, in the trabeculae, and in the papillary muscles, becomes, not unfrequently, in the course of time, the seat of calcareous deposit, constituting what is termed ossification of the walls of the heart, which invariably depends on the pre-existing altera- tions of texture of the muscular substance of the heart, which we just described. The termination of carditis in Suppuration, which is much less frequent, gives rise to Abscess of the Heart. In accordance with what has been already stated, abscess of the heart is almost entirely confined to the wall of the left ventricle, where one or more accumulations of pus may be present. They are generally of inconsiderable size, being about equal in cir- cumference to a pea, a bean, or a hazel-nut. A more considerable size, if it does not consist in an extension of surface, is indeed incompatible with the continued existence of a recent abscess, since it would speedily be associated with a rupture of the walls. These abscesses are usually of an irregular form, exhibiting various sinuosities, running in different directions. The muscular substance of the heart immediately adjoining them, is in a condition of purulent infiltration and disintegration; at a somewhat greater distance, it is pale, permeated by a serous or sero-purulent 152 ABNORMAL CONDITIONS OF exudation, soft, and admits of being easily torn; while still further from the abscess it is livid, and not unfrequently interspersed with varicose vessels; it is also relaxed. Occasionally, the contiguous muscular sub- stance, in consequence of being infiltrated with a solidified fibrinous exudation, presents a lardaceous or lardaceo-callous appearance. Under the last-named conditions, the abscess may_ be encysted, in which case it may exist for a longer period, while its contents may moreover become either in part absorbed, or in part condensed and cretified, and the abscess may in consequence be obliterated. Its usual termination, however, Avhere paralysis of the heart does not supervene, will be its opening either internally or externally, and, in consequence, or independently of these causes, there will be complete perforation of the wall of the heart from laceration of the strata of the muscular sub- stance, which are incapable of further resistance. It frequently happens in internal openings, that the endocardium not only suppurates, but is torn to an extent corresponding with the size of the abscess. Such an opening is followed by a discharge of pus into the cavity of the heart and its absorption into the blood ; and very commonly, even before the symptoms of pyaemia have been fully developed, by a swelling of the muscular substance of the heart, oAving to the penetration of blood, into the cavity of the abscess, and by laceration of the remaining external layers of muscle, that is to say, by perforation. Some very rare instances of superficial abscesses opening internally may be unattended by perforation, in which case the cavity of the abscess will constitute an acute form of aneurism of the heart, till the pyaemia induced by the discharge of pus into the cavity of the heart ultimately proves fatal. We are not acquainted with any well-attested case in which the discharge of pus has been restrained by the mass of the blood flowing into the opened cavity of the abscess, and by the deposition of fibrinous coagula, or where aneurism of the heart had, in this manner, become established for any length of time. In the preceding remarks on endocarditis and carditis, and the sequelae of these processes, we have frequently alluded to Aneurism of the Heart. The importance of this secondary heart-disease demands, however, that we should treat the subject specially; and we, therefore, purpose devoting the following section to its consideration. Aneurism of the Heart, known also as partial (Aneurisme du coeur faux), or, according to Breschet, as consecutive aneurism, is a circum- scribed dilatation of one of the cavities of the heart, depending specially on a diseased condition of the texture of the endocardium and of the muscular substance of the heart. We retain the designation of aneurism, with its inappropriate accompaniments of "partial," and ufalse,u because the terms have been universally adopted, and because this con- dition exhibits in its pathological relations a certain resemblance to that which we designate Aneurism of the Arteries. We would, however, at once definitively explain, that we do not consider that there exists any close affinity between these two conditions. In fact, according to our views, this resemblance depends mainly on the circumstance that both conditions are based on an alteration of texture; we will, however, leave it to our readers to compare the tAvo, and to analyze for themselves the THE ORGANS OF CIRCULATION. 153 special similarities and differences they may be found to present. We are utterly unable to concur in Thurnam's views on aneurism of the heart; nor can we adopt, as the sequel will show, the classification by which he divides aneurism of the heart into numerous species, corre- sponding to the different forms of aneurism of the arteries. At the present day we are acquainted with only two essentially differ- ing species of aneurism of the heart, one of Avhich represents an acute, and the other a chronic form ; the former corresponding generally to false and the latter to true aneurism of the arteries. We are led, from the numerous observations we have ourselves made, either wholly to dis- card all other forms, or at any rate to regard those as doubtful which are based on the unsatisfactory researches of other inquirers. 1. One, and certainly a rarer form of aneurism of the heart, is a proximate result of a recent inflammatory process of the endocardium, and probably, also, in great measure of the contiguous muscular substance of the heart, and depends on a laceration of the diseased tissue, which is itself the immediate consequence of its inflammatory relaxation. The blood rushes violently through the rent, which is either limited to the endocardium, or involves with it a portion of the adjacent layers of the muscular substance, and thus disturbs the still uninjured muscular tissue of the heart to various depths. A cavity is thus formed, whose walls consist of the upheaved, lacerated muscular substance, and which is surrounded at its mouth by a torn and fringed margin of endocardium. The blood poured into this cavity deposits its fibrin in the form of soft coagula, infiltrating the lacerated muscular substance, and occurring on the fringed membranous margin in the different forms of vegetations observed in the valves. This aneurism is developed in an acute manner, as may be seen from what has been already stated, and is accompanied by the appearances of recent endocarditis. We have never seen a case in which the walls of an aneurism of this nature had become consolidated into a fibroid, callous tissue; for, in all the cases we have examined, the aneurismal formation was only of recent date, having existed only for a very inconsiderable period after the endocarditis, during the continuance of Avhich it had originated. None of the cases in which an aneurism with solid, callous walls, existed for any length of time after the endocarditis, afford the slightest evidence that it had originated in this acute manner from laceration. The investigations of foreign observers have so far influenced pathologists, that they have begun their inquiries regarding aneurism of the heart with callous walls with the preconceived opinion that a lossio continui occurs in the endocardium, as in the so-called mixed aneurism (A. spurium of Scarpa) of the arteries; and the difficulties attending the investigation of this form of aneurism of the heart, have greatly contributed to the maintenance of this error, notwithstanding the numerous proofs we have advanced to the contrary. 2. The second form of aneurism of the heart is either the remote conse- quence of the combined inflammation of the endocardium and of a some- what thick layer of the muscular substance, or more frequently of inflam- mation of the Avail of the heart throughout the whole of its thickness, ac- companied with endocarditis and pericarditis. The inflammation of the muscular substance, by its tendency to induration, promotes the develop- 154 ABNORMAL CONDITIONS OF ment of a Avhite fibroid tissue, which occupies the place of the muscular fibre in the trabeculae, as well as in the actual muscular substance of the heart, and coalesces, as it Avere, on its inner surface, with the endocardium, which is thickened into a similar tissue, and tOAvards the exterior, Avith cel- lular or fibroid formations,—the products of endocarditis and pericarditis. This tissue, with its inherent tendency to shrivelling, is unable to resist the pressure and flow of the current of the blood, and by its yielding and expanding gives rise to circumscribed dilatation of the cavity of the heart. Tie limits of this dilatation generally correspond with those of the metamorphosis of the muscular substance, extending as far as the point where the muscular fibre has remained undestroyed throughout the whole, or a considerable depth, of the thickness of the wall of the heart. The course of the development of this aneurism of the heart is therefore chronic, when considered as a remote result of the above-named com- bined inflammations. It follows from the above observations, that this form of aneurism of the heart is a circumscribed dilatation of one of the cavities, whose walls consist wholly or for the most part of a fibroid (tendinous, ligamentous, cellulo-fibrous, callous) tissue. This circumscribed dilatation exhibits a shallow sinus in the muscular wall of the heart, or an ordinary roundish sac, or even a mere appendage to the heart, which communicates Avith the cavity, by means of an opening, corresponding in size to the cavity itself, or in some cases by a narrow aperture, or even by a short canal. This appendage either rises above the cavity of the heart from a broad basis, or rests upon it by means of a neck-like constriction. The size of the aneurism varies from that of a pea, a bean, or a nut, to that of a hen's-egg, or of the fist, or may be even larger. The form and size of these structures no doubt mainly depend on the extent and depth to which the metamorphosis of the muscular substance affects the walls of the heart, on their duration and locality, on the patency of the openings of the cavity of the heart, and on the original degree of tense- ness and capacity for resistance in the walls of the aneurism. It is pro- bable that the size of the aneurism will be the greater, and that it will the more nearly approximate to the form of a true sac or appendage, in proportion to the extent and penetration of the inflammation of the mus- cular substance, to its duration, its exposure to the action of the blood flowing into the heart and entering its own cavity through the action of the still uninjured muscular substance, to the degree of contraction affect- ing the openings in the respective cavities of the heart, and to the yield- ing of the adventitious tissue constituting the walls of the aneurism. Instead of coalescing with the pericardium, as is usually the case, large aneurisms have occasionally been met with, adhering directly to the tho- racic wall and the lung. The walls of this form of aneurism of the heart consist, as has been already remarked, of a fibroid tissue, which having taken the place of the muscular substance, coalesces internally with the thickened endocar- dium. The walls of this form of aneurism never present the slightest trace of a separation of continuity, either in the endocardium alone, or simultaneously in it and in one of the contiguous layers of the muscular substance; for the thickened investment of the aneurism occupying the THE ORGANS OF CIRCULATION. 155 place of the endocardium always extends beyond the boundaries of the aneurism to the normal wall of the heart, where it is gradually lost in the normal endocardium. The assumption that there is a lossio continui in the endocardium may have originated in the circumstance that the endocardium of the cavity in question is frequently found to be hyper- trophied, that is to say, that it presents several newly-deposited layers, the most recent of which extend to the limits of the aneurism, which is filled with fibrinous coagula. The occurrence of an excessive morbid forma- tion of the endocardium on the lining membrane of the vessels, from the blood, as shown in diseases of the arteries, must necessarily, from its great extent and importance, lead to future investigations. This form of aneurism of the heart corresponds to true aneurism of the arteries. The walls of these aneurisms vary in thickness, although they are always thinner than the neighboring uninjured wall of the heart. They probably become so attenuated, in proportion to the increasing size of the aneurism, as to appear as if they were merely formed by the contact of the endocardium or pericardium, or of a doubled endocardium, in con- sequence of the aneurism having been developed towards another cavity of the heart. Osseous concretions, especially in the form of laminae, are frequently developed in the tissue constituting the walls of the sac, whence the aneurism acquires a partially osseous character. (See p. 151.) The cavity in this species of aneurism is very frequently filled with tough stratified fibrinous coagula, as in aneurism of the arteries. This, however, is usually the case only in larger aneurisms, and in fact the mass of fibrinous layers will, in general, be proportional to the size of the aneurism and to the extent to which the muscular fibres are de- stroyed. The inner surface of these aneurisms of the heart occasionally exhibit the ordinary villous, shaggy, and warty, or even the so-called globular vegetations. It is, moreover, worthy of remark, that new layers of endocardium are frequently found to be deposited in great numbers, and to a consider- able thickness, upon the inner surface of the aneurism. It is only on a close inspection that they can be detected lying upon the subjacent fibroid tissue. The atheromatous disintegration they occasionally ex- hibit, imparts a certain degree of importance to their presence, since this atheromatous process is, in some instances, the cause of the origin of aneurism of the heart. These two species, comprising an acute and chronic form, both of which depend on inflammation, embrace the numerous observations we ourselves have made, and will very probably, on an unbiassed inquiry, be found to include all cases on record. That inflammation is the original controlling process in this affection is proved not only by the history of inflammation of the muscular tissue generally, and by that of the muscular substance of the heart in parti- cular, but receives additional confirmation from the concurrence of the aneurism with endocarditis and its products, both as to their position and situation, even beyond the limits of the aneurism, generally even as far as the valves,—from the almost universal and simultaneous occur- rence of the products of pericarditis,—from the nearly exclusive occur- 156 ABNORMAL CONDITIONS OF rence of aneurisms in those portions of the heart, which are in like man- ner the exclusive seat of carditis and endocarditis, viz., the left ventricle, —and from the residua of the secondary metastatic processes in the ca- pillary system, which are frequently of simultaneous date Avith the endo- carditis. We see no grounds for concurring in the opinion of many observers who regard the alteration of texture of the endocardium and the sub- stance of the heart on which the second form of aneurism depends as a peculiar or unintelligible alteration. The question here arises, whether an abscess of the heart (cardite ulcerative of Bouillaud,) after opening into one of the cavities, can give rise to the formation of an aneurism. We are of opinion that aneurism of the heart does undoubtedly supervene, but the question is whether such an aneurism is of a persistent character. We have ourselves observed no case corroborative of such a view, and we doubt whether the pyaemia induced by the opening of the abscess could lead to the consolidation of its walls ; that is to say, could heal the abscess by converting it into an aneurism. (Compare pp. 151, 152, on abscess of the heart, and the ob- servations referring to the first form of aneurism of the heart.) Moreover, we cannot suppose the so-called atheromatous process—as it occurs in the arteries—to be the primary condition giving rise to aneu- rism of the heart. We have already remarked, under the head of hyper- trophy of the endocardium, that the newly-deposited layers of endocar- dium upon the wall of the heart have never, in any case that we have observed, been the seat of any but the earliest stages of that metamor- phosis which terminates in atheromatous disintegration, while it is only in some instances that it is observed in a more advanced form in the valves. It is, however, worthy of remark, that we have certainly seen this atheromatous disintegration affect some portions of the depositions lining the inner wall of the aneurism, although in a form which proved that it could not, as a primary disease, have given rise to the formation of the aneurism, but must apparently have been subsequently developed in the already existing aneurism. Aneurism of the heart occurs almost exclusively in the left side, and is incomparably more frequent in the left ventricle. There is only one undoubted case on record of this form of aneurism of the left auricle,— namely, that of Chassaignac, to which, however, we must add a prepa- ration in our pathological museum of an aneurism of the acute form in the auricular septum. Hence these formations chiefly occur in the arte- rial half of the heart, which is known to be the almost exclusive seat of endocarditis and carditis. Like the above-named processes, aneu- rism rarely affects the right side of the heart; and the few cases on record of aneurism of the right ventricle, and those described as situ- ated in the right auricle, prove (like those affecting the left auricle) not to be, strictly speaking, true aneurisms of the heart. These cases usually consist in a general dilatation of the auricle whose walls have been transformed by inflammation into a fibroid, callous, and even ossi- fying tissue of considerable thickness, and which itself adheres to the pericardium, having its cavity more or less completely filled up with fibrinous coagula. In the left ventricle the apex is the ordinary seat of aneurism, and THE ORGANS OF CIRCULATION. 157 here it also attains its greatest size. It is less frequently observed towards the base of the ventricle, and is of very rare occurrence at the septum, which, however, is commonly more or less implicated in those cases where the apex is the main seat of the disease. It is only in rare instances that we meet with more than one aneurism, and where two or even three exist simultaneously, they are generally in close proximity to one another, and not unfrequently present the appear- ance of one single aneurism, which has been more or less perfectly sepa- rated into two cavities by the marginal elevation of its walls. That portion of the heart which is affected by aneurism is found, in almost all cases, to be also the seat of an active dilatation, occasioned by the cardo-endocarditic process and its sequelae, by the aneurism itself, and simultaneous valvular affections. The spontaneous rupture of an aneurism of the heart may be men- tioned as an extremely rare termination of the disease. It may open into the cavity of the pericardium, into the pleura, or into the arterial trunk of the opposite cavity of the heart. Such an opening may occur in a chronic form of the disease as the final result of the increasing attenuation of the walls of the aneurismal sac in consequence of its own enlargement, as in a case we have observed where an aneu- rism in the ventricular septum, and near the apex of the heart, opened into the cavity of the right ventricle (the varicose aneurism of Thurnam). Acute aneurism of the heart more frequently terminates in laceration, which, in most cases, is very probably induced by the same cause which gave rise to the aneurism itself, namely, inflammation and inflammatory loosening of the tissue, and suppuration in the muscular substance of the heart.—In the case of a boy aged nine years, who presented extensive dilatation and hypertrophy of the left ventricle, and thickening of the endocardium at the septum, we observed immediately below the aortic valves, at the uppermost part of the septum, a laceration about the size of a pea, which led to a sac as large as a nut in the auricular septum, that had been formed by the upheaval of the muscular substance, and after penetrating into the right auricle, opened into its posterior side through an aperture about as large as a hemp-seed. Most of the cases of aneurism of the heart have been observed in per- sons of mature age and of more advanced life. When, however, we bear in mind that by far the greater number of cases on record belong to the chronic form of aneurism, we are led to conclude that the disease of the tissue, which is the precursor of the aneurism, must have originated many years before the fatal termination of the disease, and therefore in an earlier period of life, the more so from the circumstance that an appre- ciable number of cases occur before the age of thirty, while we have ob- served the acute form in early childhood. c. Metastasis in the Muscular Substance of the Heart.—Metastatic, purulent, and ichorous abscesses in the muscular substance of the heart may be reckoned among the ordinary conditions giving rise to metastasis, more especially when occurring in consequence of pus or ichor being taken up into the mass of the blood. There are usually several of these abscesses present, and they may result in laceration or ulcerous perforation of the heart. Metastatic processes are always simultaneously present, to a con- siderable extent, in other organs. 158 ABNORMAL CONDITIONS OF d. Gangrene of the Heart.—There is nothing, a priori, at variance with the possibility of the occurrence of gangrene in the muscular sub- stance of the heart. Ulcerations accompanied with malignant products are not of rare occurrence, but the correctness of the observations pur- porting to refer to gangrene of the heart, have nevertheless been called in question by several writers, and we must remark that no case of the kind has fallen under our notice. e. Adventitious Products.—Although adventitious products, with the exception of the adventitious tissue developed from inflammation, are generally of rare occurrence in the heart, yet some forms are not unfre- quently met with ; as, for instance, the varieties of adiposity of the heart, which we now proceed to notice. 1. Adiposity of the Heart.1—The occurrence of fat in the heart pre- sents various anomalies, and exhibits different degrees and forms. (Com- pare the observations made on fatty degeneration of the Muscles, in Vol. III. pp. 239-241.) a. The first form consists in the accumulation of an unusual quantity of fat on the surface of the heart. Fat is generally first abnormally deposited in those parts which, in their normal state, are covered by a certain quantity of fat, even in general emaciation; as the base of the heart, the sulcus transversalis, around the point of origin of both the arterial trunks, the sulcus longitudinalis and the course of the coronary vessels, the margin and anterior surface of the right ventricle, and the apex of the heart. The right side of the heart is always covered with large quantities of fat whenever there is any considerable tendency to the production of this tissue. In some cases this forma- tion of fat is so excessive as to enclose the Avhole heart in a thick irre- gularly lobed mass of adipose matter, giving it the appearance of being enlarged. This accumulation of fat in the heart is usually associated with a simi- lar accumulation in the pericardium, in the mediastina, and in the abdo- men (that is to say, in the omentum and mesentery, and on the gall- bladder), with fatty liver, and with general corpulence. The muscular wall of the heart, in young men of great muscular strength, is found to be in a normal condition, but in persons of advanced age, and in females, in conformity with the general character of the muscular substance, it is in general, relatively thinner, more flaccid, discolored, and paler. The latter condition, which constitutes the transition to a second form of adiposity, and in like manner varies in degree, represents— b. Actual Fatty Degeneration of the Heart,—Fatty Metamorphosis of the Muscular Substance.—The fat surrounding the heart penetrates inwards, and by gradually insinuating itself between the muscular fibres, tends in this way to displace the muscular substance. The apex of the heart and the right ventricle are especially subject to this form of degene- ration, which, according to Laennec's observations, originates at the first of these points. When the left ventricle is implicated, the disease is usually limited to the apex, from whence it advances towards the right ventricle. It is only in its more intense stages that it affects the main part of the left ventricle. The muscular substance at the apex of each 1 Oesterr. Med. Jahrbiicher, B. xxiv., St. 1. THE ORGANS OF CIRCULATION. 159 side of the heart, and consequently in the right ventricle, is frequently observed to be reduced to a layer, which, from its extreme thinness, scarcely admits of being measured, and appears like a mere muscular investment covering the fat. In cases of intense degeneration, the mus- cular wall of the left ventricle has even been found only from 2-1 \ lines in thickness. The muscular substance is flabby and much relaxed, of a faded color, capable of being easily torn, and infiltrated with free fat. This displacement and disappearance of the muscular fibres is similar to the alterations observed in the muscular coat of the intestine when the mesentery is intensely fatty, and in the corresponding coat of the gall- bladder. The valves of the heart are at the same time thin and trans- parent, while the papillary tendons are softened. This fatty metamorphosis does not only occur in the form of the above- mentioned transition stage, and in consequence of the excessive produc- tion of fat, and simultaneously with other accumulations of fat, but likewise independently of any such connection, and accompanied with general emaciation, as the result of tuberculosis and tuberculous phthisis, and lastly under circumstances that have not yet been explained. It is of frequent occurrence in conjunction with fatty liver. It is rarely met with before the age of 30-35 years, and is incomparably more frequent afterwards; it is also much more common in women than in men. Considerable interest attaches itself to a not unfrequent combination of these two forms of adiposity of the heart, in which there is atheroma- tous disintegration and ossification of the morbidly deposited layers of the inner coat of the arteries, and especially of the trunk of the aorta, associated with aneurismal formation in the trunk of the aorta. These fatty degenerations are, however, very frequently associated with ossification of the coronary arteries,—a circumstance which will be fur- ther considered when we treat of these fatty accumulations on the trunk and extremities, attended with atrophy of the muscular substance, and with ossification of the arteries, which remind us of other analogous com- binations of fatty accumulation with formation of bone, as in lipoma, fatty cysts in the ovaries, accumulation of cholesterin in ossifying cysts, &c. However, we might be disposed to imagine that fatty metamorphosis would frequently terminate in spontaneous laceration of the heart, such is very rarely the case, even where the fatty degeneration extends to the left ventricle, which, as the ordinary seat of spontaneous lacerations, would seem predisposed to this lesion. c. There is a third and very important, although hitherto unnoticed form (see vol. iii. p. 242) of this disease peculiar to the muscular sub- stance of the heart, and differing entirely from the two previous forms of adiposity. This form occurs more especially in hypertrophied and dilated hearts, in combination with the residua of endocarditis and carditis, or indepen- dently of these. The extent, seat, and duration of the disease present numerous remarkable diversities. In some cases, we observe scattered and distinct centres of inconsiderable extent, where the muscular sub- stance is pale, flaccid, of a dirty yellow color, and soft and friable, rather than admitting of being easily torn, as is usual in relaxation. In other 160 ABNORMAL CONDITIONS OF cases these centres are very numerous, and are found scattered over the true substance of the heart, in tuberculae, and in the papillary muscles. They are ill defined, their margins being indistinct or obliterated. The discoloration presents a striped appearance as it follows the course of separate muscular fibres, decreasing in intensity from the centre outwards, and being finally lost in the normal color of the substance of the heart. This anomalous condition frequently extends over the whole inner layer of the muscular substance, which, when seen through the endocardium, after it has become thin and even transparent, presents the discoloration to which we have already referred, showing on a closer inspection, that this change of tint depends on the presence of fine _ yellow granules or globules, which are deposited in great numbers, in close contact, as if strung together on strings, in and upon the muscular substance, and variously entwined among the muscular fibres. The trabeculae and the papillary muscles are usually diseased throughout their whole extent, as is also the muscular wall of the heart through its entire thickness, al- though not uniformly in all parts. This granular formation on and be- tween the muscular fibres marks the intensity of the disease, which fur- ther corresponds with the degree of discoloration and softening of the muscular substance. A microscopic examination shows an accumulation of black and dark-outlined globules, which prove to be fat, while the mus- cular fibres are found to have lost their striated appearance, and the fibrilli are soft, and readily break down into delicate molecules. This form of adiposity most commonly occurs in the muscular sub- stance of the left ventricle, and, in cases of hypertrophy, also in the right ventricle. This affection is, according to our observations, the most frequent cause of the spontaneous laceration of the hypertrophied left ventricle. It may, moreover, probably be regarded as a consecutive disease of hypertrophy of the heart, since it is developed in consequence of the state of paralysis or inertness of certain portions of the muscular sub- stance, induced by the disproportion between the mass of the tissues and the powers of innervation. The conditions of this disease are therefore similar to those experienced by the voluntary muscles in fatty metamor- phosis (the second form of adiposity). We have occasionally observed this form in hypertrophied muscular membranes, when the paralytic habitus is established, as, for instance, in the hypertrophied muscular coats of the intestine and the bladder. We have, however, occasionally met with this form of disease in non- hypertrophied hearts in young persons. Dilatation had probably been induced here by the adiposity, and the muscular substance relaxed in consequence. It is highly worthy of notice, that the papillary muscles are sometimes especially, and very extensively, diseased, as they may give rise to endocarditic murmurs and insufficiency of the valves, incon- sequence of inefficient action and tension. 2. Cysts.—These formations are very uncommon in the muscular sub- stance of the heart, especially if we refer to cysts containing entozoa. In treating of them, we will limit ourselves to acephalocysts, deferring all notice of the cysticercus till we consider entozoa. A sac containing acephalocysts is very rarely met with in the muscu- THE ORGANS OF CIRCULATION. 161 lar substance of the heart, there being only a few cases on record, to which, however, we must subjoin two derived from our own observation. The parent sac contains either one or many acephalocysts. In one of the cases, we observed only one acephalocyst, which almost entirely filled up the cavity of the parent sac; while in the other, the parent sac, as far as the injured condition of its contents enabled us to judge, was filled with many of these cysts. We are induced, from the rarity of their oc- currence, to give a short report of these cases, the former of Avhich was rendered peculiarly interesting from the circumstance, that the presence of these acephalocysts occasioned sudden death. A short notice of the second case, in one of the medical journals, is the only account that has yet been published of either of these two cases.1 1st Case.—This case refers to a young woman, aged 23 years, whose sudden death led to a judicial inquiry. The heart was somewhat en- larged and hypertrophied. The uppermost part of the ventricular septum presented a fibro-serous cyst with delicate walls, and larger than a hen's egg, which protruded into both ventricles, but more especially into the right and the conus arteriosus, and had so thoroughly displaced the muscu- lar substance, as to be almost exposed. It had burst over an extent of \\n towards the right ventricle. From this opening an acephalocyst, nearly equal in volume to the parent sac, had been thrown with the blood into the conus arteriosus and the pulmonary artery, where it was found tightly wedged, and so far within the trunk of the artery as nearly to reach to its left branch. The liver in this case was very large, and the right lobe contained one acephalocyst of the size of a child's head, and two of about the size of a hen's egg. 2d Case.—The heart of a soldier, aged 35 years, was examined; his sudden death being made the subject of judicial inquiry, as in the former case. The posterior and uppermost part of the ventricular septum, and the contiguous portion of the posterior wall of the left ventricle, were occupied by a round sac of the size of a duck's egg, having callous walls of a line in thickness, which projected into the cavities of the right ven- tricle and auricle. Towards the back of the sac the muscular substance of the heart had disappeared while the heart itself was attached at that point to the pericardium by a dense cellular tissue. On making a sec- tion through the wall of the sac, a rust-colored stripe was observed be- tween an outer and inner layer of white fibroid tissue, this stripe being the remains of the peripheral coagulum of a hemorrhagic exudation. The sac contained a pulpy brown fluid intermixed with crumbling and shaggy fibrinous coagula and the soft gelatinous remains of acephalo- cysts. 3. Fibroid Tissue.—Fibroid tissue very frequently occurs in the form of a fibroid thickening of the endocardium on the inner surface of the heart, as a fibroid thickening of the valves and their tendons, in the heart's Avails, and in the tissue of the papillary muscles and the trabeculae, where it is accumulated in different quantities and forms. We have always found that this product was based on some inflammatory process —endocarditis, carditis, or their combination. 1 Oesterr. med. Jahrbucher. Jahrg., 1841. Juni. VOL. IV. 11 162 ABNORMAL CONDITIONS OF It appears in the muscular substance of the heart, either in the form of white stripes, of diffused strata of various thickness, or finally of large, roundish nodules, or irregularly branching masses. This sub- stance, moreover, constitutes the greatest portion or the Avhole of the walls of aneurism of the heart, when of a chronic form. We have never observed fibroid tissue in the heart under the form of an independent fibrous tumor. 4. Anomalous Osseous Substance.—Osseous structures are frequently found within and upon the heart in the form of bony concretions. They invariably originate in the fibroid tissue which is produced, as we have already mentioned, by inflammation, and in the deposition of new layers ' of endocardium. In this manner bony concretions are occasionally developed in the fleshy wall of the heart, and in the tissue of the papillary muscles and of the trabeculae, in the form of nodular uneven plates, of nodular bands, or of irregular ramifying osseous masses. In the valves where these formations are of frequent occurrence, they are often in the form of nodular, ramifying bands and rings of different thickness. The whole fibroid mass sometimes ossifies, and may then be seen lying free and uncovered in the cavity of the heart, both in the valves and on the wall of the heart, when the muscular fibres are completely destroyed. Bony concretions in the valves are not unfrequently connected with others in the tissue of the heart, and (as we sometimes remark in diseases of the pericardium) with osseous formations in pericarditic exudations of fibroid texture; or lastly they form a bony mass, branching out in various directions. Smaller cylindrically-shaped concretions are often met with in the thickened tendons of the papillary muscles. In ossification of the valves these cylinders are larger and more connected. The valves of the left side of the heart, especially the aortic valves, also exhibit osseous formations, which are developed in the morbidly deposited hypertrophied endocardium. In the auriculo-ventricular valves they form plates of inconsiderable size, and in the aortic valves string- like or nodularly rounded concretions. They are distinguished from the bony formations produced from the fibroid inflammatory callus by their yellow color and their similarity to ossifications of the arteries. We have never been able fully to satisfy ourselves in reference to this last-named osseous formation upon the endocardium of the wall of the heart. Fibroid tissue and the bony concretions into which it is developed, when they are the remote consequence of inflammation of the endocardium or the tissue of the heart, are limited, like this process itself, almost exclusively to the left side of the heart. The few cases in which they are observed on the right side of the heart are probably those in which there is ossification of the valves. The occurrence of this osseous forma- tion in the left side is moreover limited to the valves and the ventricle, and never extends, according to our observations, to the left auricle. When bony formations occur in an endocardium which presents a morbid deposit, they are almost exclusively limited to the left side of the heart. 5. Tubercles.—If we except those cases of tuberculosis which have originated in the neighboring tissues and have extended to the organic muscular coats of other structures, as the intestine, &c, tubercles occur THE ORGANS OF CIRCULATION. 163 in the substance of the heart with the same rarity as in muscle generally. It is only in extreme degrees of tuberculosis that we have discovered one or more tuberculous masses in the muscular substance of the heart in addition to a tuberculous exudation on the pericardium. We must, however, here except those cases in which large tuberculous masses, exuded on the external investment of the heart, have gradually imbedded themselves in the outer layer of the muscular substance. It is remarkable, considering the similarity of the process of exudation on the endocardium and on the inner coat of the vessels with that on serous membranes, that tuberculosis should not occur on the two first- named structures. 6. Cancer.—Cancer of the heart is an extremely rare disease, and its occurrence is, probably, invariably owing to a highly developed cancerous dyscrasia, or to the proximity of a cancerous formation, as for instance in the mediastinum. The form of cancer affecting the heart appears, as far as we know, to be limited to medullary cancer in its genuine type, or in the form of melanosis. It is developed under and in the external investment of the heart, in any portion of the fleshy walls, or immediately below the endocardium, protruding, according to its size, more or less extensively either inwards or outwards, or even in both directions, in the form of nodules and clumps. We have observed a case of acute medullary cancer of the heart accompanied by very general acute cancerous formation, in the form of numerous, small, roundish nodules, seated in the innermost layers of the substance of the heart beneath the endocardium, and even upon it, somewhat in the manner of globular vegetations. The above general observations will show that this mode of formation of cancer must be regarded as a highly interesting form of disease of the fibrin. Cruveilhier (Livr. 29) has described the case of a ragged cancerous tumor seated on the inner surface of the right auricle, and projecting into the cava descendens and the right ventricle. This cancer probably resembled primary cancer of the veins. 7. Entozoa.—In addition to acephalocysts, to which we have already referred, the Cysticercus is by no means of rare occurrence in the heart, being then also simultaneously present in some of the voluntary muscles. There are seldom more than one or a very few of these worms to be found together in the substance of the heart; and in these cases they are also commonly present in the brain. The Trichina, unlike the cysticercus, does not occur in the heart, although it exists in the voluntary muscles. In addition to the above-named secondary formations we will here notice certain morbid structures which appear in the cavities of the heart, either free or adhering. These are not products of the endocardium, but essentially fibrinous concretions from the blood, and differing, therefore, from the above secondary formations, both in this and other respects. They constitute a series of formations which we will consider under the following title: 8. Coagula, Polypi, Vegetations in the Cavities of the Heart.1—The above terms have, at different times, been applied to this class of con- 1 Oesterr. med. Jahrbttcher, B. xxiv. St. 1. 164 ABNORMAL CONDITIONS OF cretions. We refer our readers to the general remarks on the diseases of the blood and its fibrin for all that relates to the pathology, nature, and metamorphosis of these structures. We purpose here treating speci- ally of their form, and shall only touch upon their other relations as far as is necessary towards the right comprehension of a subject which has been much beset with errors in the present day. The structures now under consideration occur in many forms. The question here arises as to these structures generally, and ^ each form specially, whether they are produced after death or before it, and how long they had subsisted during life. It has long been customary to distinguish certain fibrinous coagula from others by the designation of death-polypi. The fact that the blood", in consequence of the _ arrest of the heart's action, coagulates more or less perfectly in the cavities, into a loose soft clot, or a more compact mass, from which the fibrin is more or less thoroughly separated into a concretion, which, in its turn, exhibits the most various degrees of consistence or plasticity, has long been regarded as entirely in unison with the phenomena observed in drawn blood that has been left to stand and cool. The symptoms presented in the course of disease, the peculiar character of the phenomena exhibited in the death-struggle, the form of certain fibrinous structures in the heart, their relation to its inner surface, and their adhesion to the endocardium, have long since been advanced in support of the vieAV that there may exist, during life, an independent self-persistent polypus of the heart. This view has continued, to our own day, to be so entirely misunderstood and misapplied that even ordinary death-polypi have very commonly been mistaken for true polypi of the heart. No doubt can be entertained in the present day that fibrinous concre- tions are formed in the heart from the blood during life. It would appear certain that they form an organic (textural) connection with the inner wall of the heart; and further, that they experience various meta- morphoses in their elementary composition. We purpose considering these in the sequel; but we would, in the first place, make a few general remarks on the conditions under which fibrin is separated during life from the blood, and coagulates into different forms of concretion. We will also consider, under the head of these respective forms, all that relates to their formation after death or during life. These conditions exist partly in the heart and partly in the blood, and both are not unfrequently coexistent: the latter, however, are the more important, while the former are to be regarded as merely affording favor- able momenta. 1. The first condition involves an abnormally prolonged continuance of the blood in the cavities of the heart in consequence of a decrease in the actiA7ity of the heart's action, as in hypertrophies of considerable in- tensity, passive dilatations, aneurisms of the heart, and in every death- struggle depending on general paralysis, or in consequence of pre-exist- ing contractions (stenoses) of the ostia; or, lastly, there may exist vari- ous mechanical conditions in the form of inequalities and roughness on the inner surface of the wall of the heart and on the valves, in its pas- sage over which the blood deposits its fibrin in a corresponding form. 2. The other and most essential condition consists in the tendency of the THE ORGANS OF CIRCULATION. 165 blood to coagulate or to part with its fibrin in various forms of coagulation, either in consequence of spontaneous disease, or of the absorption in various Avays, of some heterogeneous matter. Under this head Ave must especially class the so-called inflammatory (croupous) crasis, as it occurs in a primary or secondary form, associated with inflammations, pneu- monia, rheumatism, &c.; the poisoning of the blood by the absorption of the multifarious products of the inflammation of normal or abnormal tissue, which have been produced within the vascular system on the endo- cardium, on the lining coat of the vessels, or externally to the vascular system, having in the latter case reached the blood by the most various channels. The coagula in the heart may be classed in the following order in reference to their form. Many have only recently been recognized and duly characterized as fibrinous concretions, and these have received de- signations corresponding to their forms. a. Clotty, roundish, membranous, ramifying coagula, when occurring in the cavities of the heart, commonly receive the designation of polypi or polypous coagula. These are variously sized clots, presenting diffe- rences in the number and length of the ramifying appendices by which their rounded forms are modified. They consist of a dark or blackish- red clot, from which fibrin is separated at some portions of the periphery, but seldom from the interior; or they consist, for the most part, of fibrin which has absorbed a certain quantity of cruor and serum, and appears colored with various tinges of red, or, when free from these, it exhibits a pale and somewhat dense coagulation. These concretions are especially common in the right side of the heart, Avhere they are found in large quantities, generally associated with a loose coagulum and fluid blood, and exhibiting coagula which have been formed during the last moments of life and after death. This form of coagulum does, however, un- doubtedly occur at various periods before death. Without entering into a description of these coagula, the limits of which it is difficult to sepa- rate, from those of the first-named variety, we would merely remark that the following conditions favor their development during life: 1. When they are situated in the left half of the heart, especially when extending into the aorta and its branches. 2. When their ramifications extend into the ventricles, and their branches are entwined among the trabeculae and the tendons of the pa- pillary muscles. 3. When they exhibit the impression of the contiguous surface of the heart, as is especially manifested in the auricular appendage (the auricle proper). 4. When they adhere or coalesce with the inner surface of the heart —the endocardium. 5. When they consist of pure fibrin, and are at the same time tough and tenacious. 6. When they exhibit a dirty yellowish and greenish color, and are, moreover, opaque. 7. When they present small purulent foci or tuberculous concretions. 8. When any one of the associated diseases of the blood is developed. These coagula cannot in themselves be regarded as symptoms of endo- 166 ABNORMAL CONDITIONS OF carditis where other essential evidences of the presence of this disease are wanting ; and even where the latter are present, they cannot be con- sidered as affording any direct proof of the existence of the endocar- ditic process, but simply of a pre-existing and spontaneous disease of the blood, depending, probably, on the absorption of endocarditic pro- ducts. It is incontestible, that these coagula not only adhere to the endocar- dium, as has been observed, but that they are also capable of entering into an organic or textural connection with the lining membrane of the heart, and thus vegetate independently and without the aid of a vascular system, as they are directly surrounded by the liquor sanguinis. On submitting the observations hitherto made on this subject to the severest criticism, we meet, amid a mass of erroneous and hasty conclusions, with some few cases which unquestionably belong to this class of coagula. These tumors are of various size; of a roundish, oval, cylindrical form, which appear attached to a broad or narrow base, as by a pedicle ; they are of a sponge-like, or elastic and tough, consistence ; they generally consist of a fibroid structure, but in some cases exhibit a soft texture, composed of membranes, covered with elementary granules and cellular nuclei, of delicate fibrilli, and of thick and even tubular fibres and amorphous coagula. Their color is red, yellowish-red, or white. When they are gradually receiving one or more coverings of newly-formed endocardium, which extends from them to the inner surface of the heart, they pre- sent the appearance of having been developed below the original endocardium, or, at all events, in the innermost layers of the muscular substance of the heart. Osseous and cretaceous concretions may be successively developed in them; and the free stony concretions which former observers have recorded as occurring in the cavities of the heart, were, doubtless, nothing more than loosened, liberated, fibrinous coagula, which have become ossified or cretified. We have never hitherto been able to detect vessels in them. (See Faber, Thomson, Vernois.) It is probable, that these coagula are somewhat diminished by a pro- cess of solution upon their surface, before they acquire any decided tex- ture and are coA^ered by layers of endocardium, and that they thus lose their original form, which is probably an irregular one, and become round. Such a supposition seems to derive support from analogy with the disap- pearance of vegetation on the valves of the heart, the gradual rounding of the globular vegetations, and the diminution and disappearance of the plug in an artery after the application of a ligature. b. Globular vegetations (vegetations globuleuses of Laennec) in the cavities of the heart constitute a second form. The formations distin- guished by this designation are generally round concretions, varying from the size of a pin's head to that of a nut, attached by means of ramifying, cylindrical, or flat appendages or bands which entwine them- selves among the trabeculae of the heart; and are of a more or less uniformly dirty, grayish-red, or white color. They are hollow in the interior, but contain, within a wall of irregular thickness, a dirty gray- ish-red, or even chocolate colored thickish fluid, resembling cream or pus, and which is occasionally of a dirty whitish or yellow color. One or more of these concretions very frequently burst, when the fluid may be THE ORGANS OF CIRCULATION. 167 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; or it is found mixed with the fluid blood contained in the cavity. The band-like appendages which they throw out, are either solid, or softened and liquefied in their interior. Besides the structures of this form, there are others belonging to the same class which exhibit different relations, being of an oval shape, somewhat like a wedge, and presenting a shaggy or villous appearance. They differ from those already named, by adhering directly and firmly to the endocardium. Although we very commonly meet with these structures in the condi- tion above described, this state is not the primary one in which they occur, but merely the result of a metamorphosis to which the fibrinous coagulum has been subjected, not only in its elementary character, but also in its external form. Cases may be occasionally met with in the course of a long-protracted series of observations, in which this metamorphosis may be followed through all its gradations. The globular vegetation is originally a solid fibrinous coagulum of irregular form, which varies in color according to the number of blood- corpuscles it contains, from different shades of red to a reddish-white color. This coagulum gradually assumes a roundish form, probably in consequence of the outer portion being taken up in the blood in a finely comminuted state. The metamorphosis which it undergoes is very im- portant, and begins as a softening disintegration or solution in the inte- rior of the nucleus, from whence it extends towards the surface. This process is so far developed in the globular vegetations above described, that there only remains a peripheral layer, which encloses the dissolved part as in a capsule. The soft and diffluent mass consists, as has been already remarked, of a pulpy, cream-like fluid, very often resembling pus, and of a chocolate, or dirty brownish-red, reddish-gray, pale yellow, or whitish color. A similar metamorphosis affects the ramifying band- like coagula, proceeding from the vegetations when they become hollow. The same process is occasionally discernible in the central layers of those coagula of the first form which have arisen during life; we sometimes observe in these coagula a tendency to decomposition, both by their tur- bidity and opacity, their dirty yellow color, their extreme lacerability, and by the appearance of a turbid cream-like moisture when they are compressed and torn. This metamorphosis of the fibrinous coagulum is, moreover, highly in- teresting, from the numerous and important analogies it presents. It is here undoubtedly dependent on disease of the fibrin, from which the coagulum itself is formed, as we have invariably observed in these glo- bular vegetations only in cases in which the blood is in a state of dys- crasia, as in croupous processes, after typhus, in the pyaemia of phlebitis, in a similar condition of the blood in the course of tuberculous or cancer- ous disorganization, &c. It is a remarkable circumstance that globular vegetations are almost always limited to the left ventricle, where they are attached in the man- ner already described to the apex and the contiguous parts. We have, hoAvever, observed a few exceptional cases in which globular vegetations 168 ABNORMAL CONDITIONS OF were situated in the left auricle as Avell as in the right ventricle and auricle. A proof of the part contributed to their formation and attachment by mechanical conditions is afforded by the fact of their being deposited in the apex of the left ventricle, and in the appendages of the auricles— in short in those parts of the cavities of the heart which are most favor- able to stagnation of the blood. We have seen these formations in the cavity of an aneurism seated at the apex of the left ventricle, and also, together with the ordinary valvular vegetations, on the mitral and the aortic valves in endocarditis. While, on the one hand, every fibrinous coagulum, when ^ considered in reference to its most essential feature—its metamorphosis—may be transformed into a globular vegetation, and coagula of the first form may thus be converted into these globular structures, there can, on the other hand, scarcely be said to be any true limits between the globular vegetations and those on the valves of the heart. The latter not only very frequently assume the globular form, as will be seen from the fol- lowing remarks, but valvular excrescences pass through the metamor- phosis of globular vegetations without assuming this form. c. The third form comprises all those coagula that have in recent times been distinguished under the collective designation of vegetations of the valves of the heart. These were formerly knoAvn as sarcomatous, fungous, condylomatous excrescences of the valves of the heart, and have derived especial importance in our own day in consequence of being commonly regarded as an infallible criterion of endocarditis. This form, which is more frequent than either of the others, also presents the greatest variety in reference to number, bulk, shape, mode of attachment, color, consistence, and internal composition. The form of these vegetations is partly influenced by their mass or size. Smaller vegetations occasionally exhibit a superficial roughness, only appreciable to the sight and touch on a close investigation, and Avhich is produced by the presence of fine granular or extremely delicate villous structures on the endocardium of the valves. When these structures are deposited upon one another in a finely gra- nular form, they are more prominently visible on the surface of the valves. They commonly present a coarsely granular or villous and finally a shaggy appearance, measure several lines in length, and are arranged either in rows of rigid, pointed, unyielding, excrescences, or soft, re- laxed, and pendent villi. They form shaggy appendages, having a thick, club-like, free extre- mity ; or, when of a more considerable size, they form round, oval, or pyriform pedicled excrescences. Lastly, when of considerable dimensions, they somewhat resemble con- dylomata, having a cock's comb or mulberry-like appearance, or they are irregularly nodular, and either broad or pedicled. Partial reference has already been made to the dimensions of these vegetations, which vary from the size of a hemp-seed to that of a hazel- nut. As we have already remarked, these structures may occur in very small or in very large numbers. In the latter case different forms and THE ORGANS OF CIRCULATION. 169 sizes are usually found associated together; at the same time, they are commonly spread over a considerable extent of surface. Their color, consistence, and composition vary according to their age, and the quality of the fibrin from which they are formed. We shall, however, revert to this subject in the proper place. Their principal seat is in the valvular apparatus; they attack the mitral as well as the aortic valves of the left side of the heart, and are generally remarkable for the number and size in which they are exhibited in all the different forms of this affection, to which we have already re- ferred. They are, moreover, observed on the tendons of the papillary muscles—in any part of the inner surface of the heart (the endocardium of which is, in consequence, thickened and rendered opaque, while its surface presents an absence of smoothness),—in and upon the margins of any fissure of the endocardium or of the subjacent tissue—on the margin of a fissure in the valve—on the edge of acute aneurism of the heart— on the torn extremities of a papillary tendon—on the inner wall of chronic aneurism of the heart—and, lastly, even without the heart, on rough, ragged, and uneven spots on the inner surface of the arterial trunks. They occur especially on the valves in small numbers, in the form of minute granular or villous depositions at the separate segments of the auriculo-ventricular valves, or on the nodules of the semilunar valves, and in their vicinity. They, moreover, in some cases form a granular, villous, or shaggy margin of varying breadth, near the free edge of the valve, which, inclining in a crescent-like form along the semilunar valves, follows the fibrous coat in the parenchyma of the valves. When occur- ring in great numbers, they occupy a considerable portion of the free margin of the valve, and, assuming every possible form, extend upAvards over the whole valve to the endocardium of the auricle, and downwards to the tendons of the papillary muscles. At other portions of the endocardium they commonly form granular or delicate villous deposits at the margin and in the vicinity of fissures, and most frequently near some exuberant quantity of large villous masses. It is worthy of remark, that all these forms of vegetations follow the course of the blood-current in every direction. Where they exhibit a broader margin on the auriculo-ventricular valve, this margin forms a projecting angle, from whence it is rapidly deflected. When they form villous or larger masses, they incline at the auriculo-ventricular valve towards the ventricle, and at the semilunar valves towards the direction of the vessel. We must also observe, that they are always situated on the side of the valve which is turned towards the calibre of the implicated opening. In reference to their color, they are, when newly formed, and at the commencement of their existence, usually of a pale blue or yellowish red color, less frequently dark red, and are either uniformly colored, or speckled and seamed. They gradually become pale, resembling faint yellow, faded, and thoroughly washed fibrin ; frequently, however, they do not part with their haematin, which in its further metamorphoses gra- dually loses its color, assuming a brownish-red, rusty yeast-like tinge, by which the vegetation is permanently characterized. These structures usually exhibit the consistence of a fibrinous coagulum, varying in their 170 ABNORMAL CONDITIONS OF degree of softness or hardness; thus they usually become harder in pro- portion to the increased paleness of their color, although in some rarer cases they are soft, dissolving like the globular vegetations. On lifting or tearing off the vegetation, there immediately appears, if it be recent, a loosened, excoriated, and rough portion of the endocar- dium, which, in structures of older formation, is also raised and swelled up. As they become older, they at the same time become more firmly attached to the endocardium. The following facts may be noticed in reference to their metamor- phoses subsequent to the process from which they originate : a. Vegetations once formed, in most cases, remain stationary fo'r a long time, or even through the whole period of life, more especially when they have acquired any considerable dimensions ; but it is certainly unde- niable that they may, in the course of time, shrink and diminish, and exhibit an increase of condensation and consistence (excroissances cornSes, cartilagineuses, Bouillaud), as we see in other fibrinous coagula. b. There is no doubt that they diminish in a different manner, and that at times their presence is scarcely perceptible, since they often de- generate into fine, whitish, brush-like fibrinous villi, and in some cases even wholly disappear, without leaving any trace of their existence. The latter is proved by the circumstance (see p. 144) that, while in obso- lete cases of endocarditis, the valves exhibit very insignificant or even no traces of vegetations, notwithstanding that they bear the impression of former intense disease, recent endocarditis very commonly presents a large number of these structures, characterized, in many cases, by the size and quantity in which they occur. These vegetations present an analogy with other fibrinous coagula within the vascular system, by be- ing worn out, as it were, superficially, that is to say, they are taken up into the blood in fine particles, and are thus gradually diminished. This remark especially refers to such vegetations or portions of them as are separated from the fibrin of the blood of the heart in the form of coagula, whilst those which have been deposited by exudation remain and shrivel up. (See our subsequent remarks on the origin and nature of these vegetations.) c. These vegetations on the valves—in perfect analogy with other fibrinous coagula—undergo, although less directly, a bony and chalky metamorphosis, constituting a special form of valvular ossification, to which we will revert in the sequel. d. These vegetations seldom, and indeed never, unless when of consi- derable dimensions, experience that metamorphosis of softening, by which a fibrinous coagulum is converted into a hollow globular vegetation. This metamorphosis, which occurs in the early stages of recent vegeta- tion, is undoubtedly the result of extensive diseases of the fibrin. In conformity with their elementary character they consist, according to their respective ages, of elementary granules, cell-nuclei, and cells— of a homogeneous base, intersected by nucleated fibres, in the manner of the longitudinal fibrous coat—of fibres and fibrillae resembling cellular tissue, and of thick tubular fibres. The corresponding opening is more or less closed, in proportion to their number and volume. THE ORGANS OF CIRCULATION. 171 In all considerations that relate to the origin of these vegetations we ought, in the first place, to notice their relation to the endocarditic process. In the greater number of cases these structures are accompanied with the phenomena of endocarditis—the alterations of texture to which it gives rise; their appearance so far coinciding with these phenomena, that recent vegetations are found simultaneously to occur with recent derangements of texture, and obsolete vegetations with inveterate dis- turbances of texture—the residua of endocarditis. The question here arises in relation to these cases, are these vegetations endocarditic exu- dations ? and if not, how can their origin depend upon the process of endocarditis ? In some rare cases they are observed unaccompanied with any pheno- mena of endocarditis ; and here it may be asked, how is their origin to be explained, and on what does it mainly depend ? The result yielded by very numerous and widely differing cases are as follows: a. That these vegetations, when considered collectively, are in some cases, direct products of inflammation—that is to say, exudations. b. That in the great majority of cases they are only in part to be re- garded as inflammatory products, since it is only the lowest layer, directly adhering to the excoriated valve, that can be considered in the light of an exudation, whilst the greater number have been produced in another indirect and secondary manner from the endocarditis. c. That they also occasionally occur without the existence of endocar- ditis. In the two latter cases, the vegetations occur as fibrinous coagula de- posited by the blood, and their formation is effected in the following indirect and secondary manner: Endocarditis induces a diseased condition of the blood, in consequence of the latter taking up its exudations. This morbid state is manifested by the readiness with which its fibrin coagulates and separates. As such coagula occur in different parts of the capillary system (as secon- dary processes in the spleen and kidneys), so also is the fibrin separated from the blood in the heart with a readiness proportional to the vegeta- tions produced by'the endocarditic process in the form of exudations, or the number of loose, rough, felt-like excoriated spots on the endocardium, either of which may exert a mechanical action. The number and dimensions of these secondary vegetations accord with the intensity of this disease of the blood, and more especially with its character; and we find that they occur in the most exuberant masses when there is intense endocarditis, manifested by simultaneous distur- bances of texture, and still more so where the disease is characterized by suppuration. This correspondence is further manifested in a remark- able manner by the great number of secondary processes in the diffe- rent parenchymatous structures to which we have referred. The mecha- nical influence is more developed in proportion to the greater intensity of the endocarditic process. The number of vegetations is, however, most remarkable on the margins of a fissure in the endocardium and in the subjacent tissues, occasioned by inflammatory loosening of the tex- 172 ABNORMAL CONDITIONS OF ture, or still more, perhaps, by suppuration. It is obvious that the num- ber of these vegetations increases with the extension of the endocarditis, and of the space over which the mechanical influence has diffused itself. The metamorphosis of all these vegetations generally, and of those of the second form especially, depends upon an internal cause (namely the blood). Where, as is usually the case, the product deposited is of a be- nignant nature, the fibrin constituting these ATegetations experiences the above-named favorable modifications, that is to say, the vegetations be- come condensed, gradually diminish, and even wholly disappear, or cre- tify. This is in accordance with such terminations as shrivelling, obli- teration, and atrophy, which usually characterize the secondary process accompanying such an endocarditis. In some less frequent cases the vegetations undergo a softening process, and become diffluent in their interior, yielding a variously colored purulent fluid. This is observed in intense endocarditis, and when it occurs with purulent exudation, and in this respect it also agrees with those secondary processes of a less be- nignant character which terminate in purulent fusion. These metamor- phoses are more commonly manifested in vegetations consisting of a large club-like villi or roundish masses, which, as Ave have already observed, accompany intense endocarditis, characterized by purulent exudations. The vegetations that begin to dissolve at the centre approach more nearly to the character of the globular kind in proportion to the roundness of their form. The size and the metamorphosis of the vegetations afford evidence of the intensity of the endocarditis, and more especially of the quality of its products, when, besides these, other essential phenomena of endocar- ditis are present, and when the diseased condition of the blood can alone be referred to endocarditis. In some rare cases where these vegetations are unaccompanied by any other important phenomena of endocarditis, they are usually incon- siderable in number and dimensions; and the question might arise, whe- ther they may not even here originate in some very slight degree of en- docarditis, which might produce scarcely perceptible disturbances of texture, that had been masked and hidden by the presence of the vege- tations. We must, however, bear in mind that the origin of these fibrinous coagula is, in general, mainly dependent on some peculiar cha- racter in the blood, that it admits not unfrequently of being referred to some process remote from the heart, and that in some cases even it may be said to be spontaneously developed ; that in addition to benignant and inconsiderable vegetations, there are other extensively diffused secon- dary processes in the different parenchymatous structures, which have a wholly heterogeneous character, and terminate in purulent fusion ; that there is no trace of endocarditis to be detected, or, at all events, no new endocarditis corresponding to the recent condition of the vegetations; that a mechanical influence is especially important in the deposition of these vegetations which are formed not only on every rough part of the endocardium and the valves, but even on the lining membrane of the vas- cular trunks; and lastly, that the normal valvular apparatus, by means of its tendons, affords a highly favoring requirement for the separation of the fibrin. The above observations leave no doubt that, like other THE ORGANS OF CIRCULATION. 173 fibrinous coagula, these vegetations may be formed and deposited inde- pendently of simultaneous endocarditis, and in consequence of some other disease of the blood, upon any favorable portion of the inner sur- face of the heart, as, for instance, the free margin of the valves, which has become suited to its reception by incidental roughness or inequality of surface. These vegetations cannot, therefore, be regarded as constituting an absolute indication of endocarditis, whose existence requires to be con- firmed by the presence of more essential disturbances of texture, but must be considered simply as evidences of a diseased condition of the blood. If, however, such disturbances are present, these vegetations enable us, in the manner already described, to form an opinion in refe- rence to the intensity of the endocarditic process, and the nature of its products. ABNORMAL CONDITIONS OF THE VALVES, AND ESPECIALLY OF THEIR OSTIA. § 1. Deficient and excessive formation. We have already considered this subject at p. 117, where we treated of the most important anomalies. § 2. Anomalies of size,—Hypertrophy and Atrophy of the Valves. Anomalies of size in the valves, that is to say, their superficial en- largement or diminution, usually correspond to an altered thickness of the valves, the former being commonly associated with attenuation, and the latter with thickening of the valves. Exceptions do, however, occa- sionally present themselves. Hypertrophy of the valves is found to be almost constantly asso- ciated with dilatation of the ostia of the heart, and here we see a heal- ing tendency in nature which endeavors to maintain the valves in a state of sufficiency. We observe this in the auriculo-ventricular, as well as the arterial valves, and more especially in those upon the left side of the heart, which, as is well known, is more frequently affected with dilata- tion of the cavities and ostia. The valves, as we have already re- marked, are in these cases usually thin, delicate, and transparent, and so attenuated as occasionally to exhibit actual perforations (atrophy); in like manner the papillary tendons are found to be thinner and more slender in proportion to the extent of the dilatation, while there is a striking thinness and transparency of the whole of the inner lining of the heart.—Exceptions are, however, occasionally observed; the en- larged valve appearing tolerably thick in comparison with the degree of its hypertrophy, which shows that the fibrous tissue of which it is com- posed must have increased in bulk. This is especially shown in hyper- trophied aortic valves by the corresponding enlargement in size and thickness of their nodules, and the fibres passing from them. If we except the shrivelling of the valves induced by the inflamma- tory process and its products, atrophy of the valves is of rare occur- rence, although it may, indeed, very frequently be overlooked. It occurs in diminution (concentric atrophy) of the heart, and is manifested 174 ABNORMAL CONDITIONS OF in the form of a shrivelling of the valves, more especially at their free margin, whence the whole valve, including the margin, is found to be thicker and less transparent.—Kingston has observed a case of shorten- ing of the auriculo-ventricular valves, with unaltered thickness, flexi- bility, and transparency, and with normal width of the ostium, and has described it as a form of atrophy of the valves. Shortening may affect one, or more, or all the apices of the valves, and its immediate conse- quence is insufficiency. It has hitherto only been observed in the auri- culo-ventricular valves. Hypertrophy of the valves affects either their fibrous texture or their investment of endocardium. We have already observed that hyper- trophy of the fibrous basis of the valves is occasionally associated with their general hypertrophied condition. We, moreover, frequently notice in the auriculo-ventricular valves, and especially the mitral, both in indi- viduals of advanced life and in young persons, a pale white, yellowish- white bulging, or thickening of the valve towards its free edge, or a series of bulgings at the insertions of the papillary tendons, which, however, do not interfere with the function of the valve. No osseous concretions are ever developed in this hypertrophied tissue of the valves. In young persons, we occasionally meet with a condition of this portion of the valvular structure, which very probably indicates incipient hyper- trophy of the fibrous texture, the free edge appearing swollen, more especially at the insertions of the papillary tendons. This bulging is produced by a pale red, translucent, more or less gelatinous substance, effused into the texture of the valves, from which, as from a blastema, the fibrous tissue is developed. This substance is very commonly found to consist of a translucent, partly homogeneous, and partly indistinctly fibrous mass, in which are imbedded numerous cell-nuclei, and the so- called nucleated fibres. It may be observed in reference to the arterial valves, that hypertrophy of the aortic valves, more especially of their nodules, is not of very rare occurrence. This last-named condition is, however, less frequently observed. Hypertrophy of the Endocardium is, on the other hand, both more frequent and more intense in the arterial valves, where it more especially affects the aortic valves, as might be expected, from the greater ten- dency of the left side of the heart and of the trunk of the aorta, to a similar condition of excess of growth in the endocardium and the lining arterial membrane. The valves become thicker in consequence of the deposition of new layers, and the aortic valves more especially at their nodules and free margin present an appearance of bulging; the protuberance being roundish or cylindrical in form, uneven and nodular, and having occasionally a somewhat prismatic or facetted character from the pressure which they mutually exert on one another. The valves thus coalesce with one another, and with the walls of the arteries, by means of prolonged depositions from their lateral insertions. This in- crease of bulk, which is intrinsically important, is rendered more so in consequence of its secondary effects. A shrivelling process, similar to that by which the arteries are analogously diseased, now affects the valves, which become thicker, full and rigid, and degenerate into a cylindrically formed swelling, and by this means on the one hand con- THE ORGANS OF CIRCULATION. 175 tract the ostium, and on the other become insufficient. A bony substance may also be developed in the deposited strata in the form of nodular, round, or band-like ossifications, equally important with those affecting the arteries; or, lastly, this deposit may exhibit (as when it affects the arteries) an atheromatous disintegration and loss of substance resem- bling an ulcerous process, which, in the same manner as the ossifica- tions, may produce fibrous coagula in the form of granular, villous vegetations. This form of hypertrophy of the valves and its so-called consecutive phenomena, occur only in their greatest intensity in the aortic valves, for the disease invariably exhibits an inferior degree of intensity when it affects the auriculo-ventricular valve on the left side of the heart. This disease is always associated with hypertrophy of the endocardium, and more especially with the deposition of new arterial membrane in the aorta. Although it is most common in advanced life, it does occasionally occur at the age of thirty, or even earlier, and gives rise to the insuffi- ciency of the aortic valves, which is very often gradually and almost imperceptibly developed in persons of advanced life. It is not of endo- carditic origin, although it is very often erroneously regarded as a con- sequence and residuum of endocarditis.1 Atrophy of the Valves.—This disease is manifested by attenuation, unusual delicacy and transparency of the valves, and in its more intense forms by the formation of apertures within them. We have already instanced a condition of attenuation of the valves, as the consequence of their hypertrophied state. We, moreover, observe attenuation of the auriculo-ventricular valves associated with excentric atrophies and adi- posity of the heart. The more highly developed forms of atrophy, in which there are perforations in the valve, are only found in the arterial valves, and more especially in those of the aorta; we do not remember to have observed any case affecting the auriculo-ventricular valves, and we should indeed be disposed to regard this disease as exclusively belong- ing to the valves of the arteries, if Kingston had not seen a few (three) cases occurring in the former, two of which were in the tricuspid, and the other in the mitral valve. This perforated condition of the valves occurs almost invariably, associated with hypertrophy, in consequence of the dilatation of the corresponding ostium. These perforations are almost always situated near the free margin of the valves, and more especially near their insertion, where they originate, increasing in numbers as they spread towards the nodules of the valve. They are, at first, about the size of a scarcely appreciable pin-hole or of a poppy seed, but after gradually enlarging by the confluence of several into one, they finally attain the size of a grain of millet or a hemp-seed, or even of a pea. When several are present together, they impart a reticular broken ap- pearance to the valve. The perforations are, moreover, surrounded by a smooth margin, and are never round, but oval, elliptical, or fissure-like, and their long axis is at right angles to the free margin of the valve. They are also generally bounded by the fibrous bundles of the valves, so that the atrophy, at least at first, attacks only the thinnest portions. 1 Dr. Ldbl has been led, by clinical observations, to adopt the opinion, that a disease of the valves of the aorta, differing from endocarditis, does actually exist. 176 ABNORMAL CONDITIONS OF Besides considerable and appreciable attenuation of the valve, and in some cases even perforation, we occasionally find some portions, as, for instance, the free margin, the nodule, and the fibrous bundles passing from it, thickened or hypertrophied. Perforation of the valves is not of importance unless the apertures are very large, or some among them are deep and seated in the middle of the valve, and cannot be closed by the approximation of the valves; very generally, too, the symptoms are influenced during life by the simultaneous occurrence of heart-disease, as, for instance, dilatation of the left ventricle, and occasionally by the insufficiency of the atrophied valves, that is to say, by their inconsiderable magnitude compared with the dilatation of the ostium. It is, moreover, very probable that attenu- ated valves, independently of all other conditions, give rise to a change in the sounds of the heart in consequence of diminished resistance, and modifications in the capacity for yielding sounds. It is in the middle and advanced periods of life, more frequently than in any other, that we meet with atrophy of the valves, in the more in- tense form associated with perforation; there is thus, in this respect, a perfect harmony with the periods most prone to dilatation of the ostia, of which the aortic opening is the one more frequently diseased. These periods further correspond with the age at which we most frequently observe excessive depositions of new membrane in the trunk of the aorta, the so-called atheromatous process, and ossification with dilatation; and atrophy of the valves is not uncommonly associated with these dis- eased conditions of the aorta. § 3. Anomalies of Form. Malformations of the valves are alike frequent and varied; but as they are not possessed of any intrinsic importance we do not deem it necessary to enter upon any classification of them. They will be found under their respective sections, and it will therefore suffice to observe, that the malformations affecting the valves in consequence of endo- carditis and of hypertrophy of the endocardium, are the most frequent and the most important. The vahres of the left side of the heart would appear, from the observations hitherto made, to be the more especial seat of these malformations, more particularly when affecting the endo- cardium. § 4. Anomalies of Consistence. We need do no more than simply refer to the anomalous toughness and hardness of thickened or shrivelled valves, and to the decrease of consistence which accompanies inflammation of the tissue of the valves in the form of relaxation and lacerability, as this subject has already been treated of in a different form under the head of atrophy of the valves. We would here, however, enter more fully into the consideration of a morbid condition of the valves hitherto but little observed, as we know no other place to which we could more appropriately refer the subject, when regarded in a scientific point of view. We allude to a diminution of consistence in the form of an abnormal softness and tendency to THE ORGANS OF CIRCULATION. 177 laceration of the valves,—an appearance of the greatest practical im- portance. This disease, when considered in a practical point of view, might be termed a gelatinous condition of the valve. The cases in which we have seen it have not been rare, but they were always limited to the valves of the left side of the heart. We find that the valve, either throughout its Avhole extent, or at individual portions is more yielding, softer, and more readily torn ; the faint whitish color, and the gloss of the fibrous texture disappear, and are changed to a pale yellowish tinge, approaching here and there to a reddish hue, while the whole becomes translucent. The latter condition probably depends upon the gelatinous non-adhesive substance effused into the tissue of the valve ; but yet it is difficult to comprehend how the other anomalies can be produced which we find in this condition of the valve. The tissue of the valve was always found to have disappeared wherever this gelatinous substance was present, and the valve itself, after the removal of this extraneous matter, was observed to be in a state of extreme attenuation or atrophy. The question here arises, is this gelatinous substance a new formation, —a blastema effused here in order to be metamorphosed into fibrous valvular tissue, and for the purpose of strengthening the atrophied valve, —or is it the softened, disintegrated fibrous tissue of the valve itself? The former view appears to us incomparably the more probable, and we are of opinion that this gelatinous substance is the same which, as we have already observed, presents itself in a more dense and tough state, and in the act of undergoing a metamorphosis into tissue, in hyper- trophies of the valves. The valve which is rendered soft and lacerable by attenuation becomes still more so from the deposition of this gela- tinous substance by which the remaining textural elements are forced asunder. The softness and tendency to laceration of the valve would thus appear to admit of explanation on a mechanical principle, and not on any actual softening process of the tissue. This gelatinous condition occasionally produces lacerations, more especially of the valves of the aorta. These can be easily distinguished from the perforations already described as produced by atrophy, ap- pearing either as true fringed rents passing lengthways through the valve from its free margin, as fissures in the middle of the valve, or as a laceration or detachment of the valve from its insertional margin.— The gelatinous condition of the valves must, therefore, be classed amongst the more important diseases affecting these structures. The diminished power of tension and resistance must necessarily occasion some modifi- cation of the heart's sounds. This gelatinous condition of the valves undoubtedly admits of cure, since the gelatinous substance may be gradually converted into a fibrous tissue, and thus condensed, by which means the attenuated valve in- creases in bulk, and is enabled, if necessary, to enlarge and adapt itself to the size of the dilated ostium. This condition occurs, at the same periods of life, and under the same circumstances, as atrophy of the valves, either with or without simulta- neous hypertrophy. VOL. iv. 12 178 ABNORMAL CONDITIONS OF § 5. Separations of Continuity. Separations of continuity occur under the forms of laceration of vary- ing depth at any part of the valve, from the margin towards its insertion —as perforation of the valve at different parts more or less remote^from the margin—and as a loosening of the valve at the margin of its inser- tion ; and affect the auriculo-ventricular as well as the arterial valves. Commonly only one or other of these forms occurs ; occasionally, how- ever, several are present either in one or more of the valves. One very important form of lossio continui, which does not affect the valve through- out its whole thickness, but only one of the layers of endocardium and a certain portion of its fibrous tissue, is especially Avorthy of notice, since it constitutes the basis of aneurism of the valves, to which we shall refer more fully in the sequel. These lacerations of the valves are occasioned by disease of the val- vular tissues, arising chiefly from their gelatinous condition; next in frequency, by inflammation (endocarditis); and, lastly, by the loosening of the tissue which accompanies inflammation of the valves. Lacerations of the valves are not only highly important, from the circumstance that their existence presupposes a high degree of the diseases we have already named, but also from their giving rise to valvular insufficiency. § 6. Diseases of Texture. To these belong: a. Inflammation (endocarditis) of the valves, which is by far the most frequently observed. This disease is especially important from its re- sults, that is to say, from the morbid changes of the valves to which it gives rise, and the various heart-diseases depending upon the latter alterations. Endocarditis, as we have already observed, especially affects the val- vular system, which in many cases is alone diseased, while in others, it participates in the endocarditis attacking other parts. The valves of the left side of the heart are especially subject to this disease, as we have already seen; and even where the valves on both sides are diseased, those on the right side are always affected in a very much less intense degree. Inflammation of the valves, in very many cases, is limited to the free margin, whilst, in others, it extends from thence to a various extent towards the insertion of the valve, and not unfrequently attacks the insertion itself, extending to the endocardium of the cavities of the heart and to the tendons of the papillary muscles. In addition to what has been stated in reference to endocarditis, the following short notice may suffice to explain the characteristics of this disease. 1. Redness and Injection—Vascularity of the Fibrous Tissue of the Valves—can only be observed in rare cases of recent endocarditis, for this condition has generally passed into exudation, and cannot be recognized in consequence of the products deposited in the tissue of the valve. Considerable difficulty, moreover, attends the discovery of vascularity, even in recent cases, since it is most frequently masked by the redness of the valves occasioned by imbibition. THE ORGANS OF CIRCULATION. 179 2. Opacity and Bulging of the Valve are among the most prominent appearances, and depend upon the deposition of inflammatory products in the tissue of the valve. They attain considerable intensity, and are either limited to the free margin of the valve, or extend over a greater portion of it; in some cases the whole valve with its attached margin, or in others with the papillary tendon, is implicated. The endocardium of the valve at several spots loses its usual smoothness and lustre, and the whole has a rough pilous appearance. 3. There may he Loosening of the Tissue of the Valve, which, in intense inflammation, predisposes to laceration. 4. An Inflammatory Product, which, in addition to the exudation infiltrated into the tissue of the valve and effused and solidified upon its free surface, appears in recent cases as a pilous and granular coagulum in the form of vegetations, or as a membranous exudation having a free finely villous surface, beneath which the valve appears rough, felt-like, and excoriated. In cases of long standing, these products may often be more readily recognized in the form of a more or less stratified pseudo- membrane, on which depend the thickening and the various forms of adhesions and coalescence of the valves. 5. Vegetations, as we have already seen, are deserving of attention, although they cannot be regarded as absolute characteristics of endo- carditis. In the course and as consequences of inflammation of the valves, we obsenre : a. Occasional Laceration of the Valves in one or other of the above- named forms, or laceration of one or more of the papillary tendons; the margins of the rent here generally exhibit an exuberant quantity of vegetations. Laceration is an invariable evidence of the existence of a high degree of the inflammatory process. b. Inflammation, giving rise to a purulent product and to purulent fusion (suppuration) of the tissue of the valve, is also not very rare. It may under certain conditions give rise to aneurism of the valves ; and is distinguished by an exuberant production of vegetations, which may be considerably diffused, and very frequently undergo purulent disinte- gration. c. The most common termination of inflammation of the valves is : 1. Permanent thickening of the valve, arising from the product which is deposited in the tissue and on the free surface, and becomes converted into fibroid tissue. The degree of rigidity attained either by the valve and the papillary tendons, or by the former alone, depends upon the extent of the inflammatory process. Contraction of the ostium, and insufficiency of the valve, are frequent results of this condition. 2. This anomaly is rendered more striking when the thickened valve is finally shrivelled. This shrivelling may occur either in the direction of the perpendicular diameter of the valve, or concentrically with the axis of the ostium. The former produces shortening of the valve, and at the same time insufficiency, and the latter contraction of the contiguous ostium. Both acquire importance in proportion to the extent to which the valve is inflamed, and the contraction is most considerable in the auriculo-ventricular valves, Avhen the inflammation has extended to their margin of insertion. 180 ABNORMAL CONDITIONS OF Hence arise numerous Malformations of the Valves and of the^ corre- sponding Ostia. Thus the auriculo-ventricular valves, Avhen their free margin and the papillary tendons have been thickened and shortened, present the appearance of a rigid funnel penetrating into the cavity of the ventricle, and exhibiting an elliptic fissure-like opening at the mitral valve and a triangular opening at the tricuspid valve. When the Avhole or the greater portion of the valve has been thickened and shrivelled, the auriculo-ventricular opening of the left side degenerates into a fissure or button-hole-like aperture surrounded by a rigid string-like ring, while that on the right side appears like a somewhat rounded triangular open- ing. The arterial valves degenerate into an annular protuberance around the ostium, being of regular height and thickness when the disease is of uniform extent, or irregular in consequence of inequalities in the subjacent surface. In some extreme cases they form a diaphragm inclining Avith the concavity of its sinus towards the heart and perforated in the centre by a small opening. These are often associated with— 3. Adhesion, coalescence or fusion of the different apices of the valve and of the tendons of the papillary muscles to a greater or less extent. These papillary tendons are often found to be fused together into one single or several thick, smoothly roundish rigid strings or bands; but it is only in rare cases that one or more of these apices adhere to the con- tiguous wall of the heart or of the vessel. It is obvious that such a con- dition must contribute to produce contraction of the valve on the one hand, and insufficiency of the ostium on the other. The contractions of the ostia produced by these consecutive anomalies of the valves are, moreover, heightened by the vegetations which so commonly occur. 4. Osseous concretions are frequently and variously developed as a secondary disease in the newly-formed fibroid tissue of the valves. These are occasionally small, scattered, nodular and roundish, or larger nodular rough band-like formations, and at other times complete osseous rings surrounding the ostium. From these rings the formations diverge in various directions towards the inner part of the valve, passing out- wards from the attached margin, where they come in contact with other concretions developed in a simultaneously occurring pericarditic fibroid exudation. They may also be occasionally connected with concretions in the contiguous wall of the heart, when, together with its endocardium, it had been the seat of inflammation. These morbid metamorphoses of the valves are, as we have already observed, by far the most frequent originating causes of dilatations and hypertrophies of the heart. Inflammation of the valves and its results must not be confounded with hypertrophy of the valves,—with excessive endocarditic deposition on them and its metamorphoses. By way of supplement to this subject we will now treat of the so-called Aneurism of the Valves. Aneurism of the Valves.—Some writers (Thurnam) have applied this designation to a morbid condition of the valves, which has indeed some affinity with aneurism, more especially if we adopt Scarpa's theory of spurious Aneurism (the mixed Aneurism of others). From our own observations, we should be led to divide aneurism of the THE ORGANS OF CIRCULATION. 181 valves into two forms, and to compare them with the two forms of aneurism of the heart we have already described, although they do not indeed strictly correspond to one another, since only one (namely the acute) form of the disease in the valves corresponds with acute aneurism of the wall of the heart, while we have observed no form of aneurism of the valves corresponding to chronic aneurism of the heart. We would, however, include under this head consolidated (cured) aneurism of the acute form, affecting a valve, whose continuity is still undestroyed, although it may present unimportant sinuosities, such as are sometimes observed at the mitral valve near the free edge. We have found these structures in only one case, together with the residua of endocarditis, at the aortic valves, and, if they were not consolidated aneurisms of the acute form, they must have been produced by a hernia of one of the lamellae of endocardium, through the fibrous layer of the valve.—This class would necessarily include the three cases described by Thurnam (one of which affected the mitral, one the tricuspid, and the third one of the aortic valves), since he regards them as dependent on gradual extension of the valves. The following is the mode of origin of acute aneurism of the valves, according to the observations made by ourselves and others. In the course of intense inflammation of the valves, a lossio continui is produced in the valve, affecting only one of the laminae of endocardium, and a layer of the contiguous fibrous tissue. 1. This lossio continui appears either as a separation or fissure of the structure, and may occur, a. As the consequence of the condition of loosening and lacerability induced by inflammation, b. Or it may arise from the loosened condition of the tissue, observed in the neighborhood of an abscess, in the parenchyma of the valve. 2. A lossio continui may also be the result of an abscess proceeding from the lowest part of the valve, and penetrating towards or even through its endocardium, or in other words it may be owing to a final suppura- tion of the endocardium. (In one specimen in our collection, a sinus even passes from an abscess in the substance of the heart towards the aortic portion of the mitral valve; above this the valve is torn from the ventricle, and the whole sinus thus converted into an aneurismal sac.) It is however very questionable whether the endocardium is actually in a state of suppuration in such cases, or whether it may not rather be lace- rated above the adjoining abscess, in which case the whole process would essentially belong to that which has been considered under b. When there is a tendency to laceration of the valve, this will occur with a frequency proportional to the extension of the aneurism in the direction towards which the blood flows to the valve,—the auriculo- ventricular valves being lacerated in the direction of the auricle and the arterial valves in that of the ventricle,—and especially when the lossio continui affects the surface of the valve against which the blood is propelled. Thus where the valve has been perforated to a greater or less extent, the blood which impinges on it, penetrates into its parenchyma, and causes more or less extensive infiltration. By this means the yet uninjured 182 ABNORMAL CONDITIONS OF portion of the valve assumes the appearance of a projecting tumor on the corresponding surface; and becoming, as it were, inflated, constitutes valvular aneurism, in the form in which we have observed it, and to which the following remarks apply. This tumor is usually about the size of a pea or a bean, although,_ after continued attenuation of the layer of the vahmlar tissue of Avhich it consists, it becomes as large as a hazel-nut, or even a pigeon's egg. The tumor is especially capable of such an enlargement at the auriculo-ven- tricular valves, in consequence of the more abundant mass of the fibrous tissue occurring in them. Its form is round and hemispherical, or frequently so far irregular that it presents various sinuosities in the circumference of its base, as well as in its arched portion. It generally extends over a considerable space, in consequence of the widely diffused infiltration of the blood into the paren- chyma of the valve. Its aperture although originally a fissure-like rent, is generally round, and has fringed margins, which, together with the circumference of the valve, are covered with luxuriant vegetations. Its cavity is filled with a variously discolored bluish-red, reddish- gray, yellow-reddish, dirty white, solid, or more frequently loose, soft coagulum, which very often becomes disintegrated like the globular vegetations. Aneurism of the valves is, therefore, as may be seen from what has been already stated, an acute formation occasioned by a considerable degree of inflammation of the valves. These tumors in general terminate somewhat speedily in lacerations. This usually occurs in the more intense aneurisms of the auriculo-ventri- cular valve at the highest point of the aneurism, or at the summit of one of its various pouches, in the form of a small fissure-like rent, inclining from its circumference towards the opening, and having its margins speedily covered Avith vegetations. Death does not follow from this mode of termination of the disease, but results from the endocarditic process and the corresponding disease, to which the latter gives rise in the blood.—In the rare cases in which this aneurism is consolidated (that is to say, where it has its opening and the walls of the cavity covered with membrane), it constitutes a chronic aneurism, and, like simple or hernial sinuosities, continues longer (see the cases recorded by Thurnam and others), and may become fatal through consecutive diseases in connection with other coexisting heart-affections. It may be observed, in reference to the size of such aneurismal pouches of the valves, that in one case seen by Thurnam the tumor had attained the unusual dimensions of a large walnut. Our own experience coincides with that of most foreign observers, in having discovered this aneurism on the valves of the left side only,— a circumstance that corresponds with the relation of endocarditis to the same side of the heart. It is probably always more extensive at the auriculo-ventricular valve, on account of the greater development of the parenchyma in that structure whilst it is lacerated in the arterial valves soon after its formation, and may thus terminate in a large fissure.— Thurnam, as has been already observed, found aneurism of the tricus- THE ORGANS OF CIRCULATION. 183 pid valve in a heart in which there was a communication between both ventricles. In this case there were four aneurismal pouches on the valve. ^ From the above observations it will easily be seen, that although aneu- rism of the valves possesses a scientific interest, it is not of much prac- tical importance when considered either on its own account or in refe- rence to the intense disease from Avhich it arises. b. Adventitious Structures.—These are almost entirely limited to the occurrence of fibroid tissue and anomalous osseous substance (ossification), both of which are of very frequent occurrence. 1. The fibroid tissue presents various anomalies in reference to the elements of which it is composed. Thus, for instance, as will be seen under their respective heads: a. It is found to be abnormally developed in hypertrophy of the valves. I" b. It occurs in excess in those products (exudations) of inflamma- tion of the valve which are developed in the tissue as well as on its surface. c. The endocardium, deposited in excess on the valve, usually under- goes some metamorphosis of this nature. d. A similar metamorphic process is observed in reference to the vege- tations of the valves. 2. Osseous formation occurs in various essentially different forms, to which little attention has hitherto been paid : a. The fibroid tissue produced by the process of inflammation, occurs in the above-mentioned form of protuberant, roundish, and band-like concretions. They are originally developed in the inner part of the thickened and shrivelled valve, from Avhence they increase in circumfe- rence, owing to the continued ossification of the fibroid tissue, and at length come to vieAV uncovered in different portions of the cavity of the heart. They are closely analogous to the ossifications of fibroid exuda- tions found in serous membranes. b. The endocardium abnormally deposited upon the valve becomes ossified. These concretions are very frequent at the aortic valves, and of rarer occurrence at the mitral valve. In the former case, they frequently attain considerable bulk ; but, in the latter, they are merely small plates. They correspond with the ossifications of the inner lining membrane which is deposited in excess in the arteries, and are originally developed, like these, in the lowest and earliest strata, being denuded and coming to view Avhen all have been ossified. Such are the ossifi- cations frequently observed in advanced life which have no connection with pre-existing endocarditis, however they may be associated with endo- carditic products. c. In addition to these concretions there is a third variety,1 which is highly interesting from the many analogies with which it is associated. It presents itself most frequently (more especially at the aortic valves) as an osseous concretion in a stalactitic form, or as a rough granular agglo- meration. These calcareous formations constitute a metamorphosis or conversion of the vegetations on the valve into bony and chalky matter. 1 Oesterr. Jahr. B. xxiv., St. 1. 184 ABNORMAL CONDITIONS OF As might be expected, and in accordance with experience, they are fre- quently found to be associated with one or more of the two above-named forms (more especially, however, with the ossifications considered under a), which are developed in the valve after it has been thickened by inflam- mation. These stalactitic osseous masses occasion and promote the con- tinued formation of new vegetations, and are consequently very commonly surrounded by them. Even the normal tissue of the valve becomes of a dirty yelloAV, faded color in advanced life, and exhibits a layer of fat and calcareous salts in a finely comminuted form. Besides these secondary processes, we will consider: 3. The atheromatous disintegration of newly-deposited endocardium as it commonly occurs in a low degree on the valves. 4. Finally, in rare cases, where the necessary constitutional conditions are present, the vegetations on the valves of the heart exhibit a carcino- matous character, the cancer being usually of the medullary kind. Review of the Anomalies of the Valves, and more especially those pro- ducing Contraction of the Ostia and Insufficiency. We have endeavored, in the foregoing observations, to indicate those cases in which an anomaly of the valve produces contraction of the cor- responding ostium, or the causes by which the valve itself becomes in- sufficient. The causes on which contraction of an ostium depends, the mode in which it is variously developed through thickening or rigidity of the valvular apparatus, vegetations, &c, and the manner in which it may finally give rise to consecutive heart-diseases, in the form of hypertrophy and dilatation, are alike self-evident. This contraction is frequently so considerable, that the diameter of the auriculo-ventricular opening, more especially on the left side, scarcely equals that of the nail of the little finger, or even of a goose-quill, while the arterial opening would not admit of the passage of anything larger than a crow-quill. The condition of the valves known as insufficiency, has only been ade- quately considered by modern observers. By the term insufficiency, we understand that condition of the valves in which they are unable to close the ostium, and thus allow the blood to return or regurgitate into a cavity of the heart which would be isolated if the ostium were completely closed. In this way, the insufficiency of the auriculo-ventricular valves allows a portion of the blood to return from the ventricles into the auri- cles during the systole of the former, while the insufficiency of the arte- rial valves allows the blood to return into the ventricle during its diastole. As might be expected, we frequently find that one and the same ano- maly of the valves produces contraction of the ostium and insufficiency. The latter is especially owing to the following anomalies. 1. A relative diminution in the size of the Valves with dilatation of the Ostia, the degree of the former depending on the intensity of the latter. As we have observed, the valves in these cases are commonly enlarged at the expense of their thickness and power of resistance, and they may continue to remain sufficient when the ostia are very consi- derably dilated. THE ORGANS OF CIRCULATION. 185 2. Perforation of the Valve, in consequence of atrophy. It must be very well marked before it can give rise to any considerable degree of insufficiency. 3. Laceration of the Valve, under various forms, in consequence of the gelatinous condition of the valve, or perhaps, still more from its inflam- matory state. The degree of insufficiency is increased in proportion to the extent of the laceration. In like manner, laceration of one or more of the papillary tendons produces insufficiency of the valves. 4. Shrivelling and Shortening of the Valve and its Tendons:—the valve does not close the ostium, in consequence of its rigidity or its insuffi- cient length. This insufficiency in the case of the mitral valve is in general owing to well-marked endocarditis ; in the aortic valves it is often very slowly developed, and in advanced life, it is generally owing to an exces- sive deposit on the endocardium. This is the most frequent form of in- sufficiency, and the one which attains the most considerable degree of intensity; it is usually attended with contraction of the ostium, owing to the rigid, thickened, and shrivelled state of the valve. It will be seen from what we have already stated, at p. 173, that it is only in very rare cases that insufficiency ensues in consequence of shortening of the valve depending on atrophy. 5. Fusion of the Valves with one another, or their Coalescence with the wall of the Heart or Vessel, generally induces a high degree of in- sufficiency in combination with the above-named conditions. It will be easily understood, that not only carditis and its metamor- phoses, but also fatty degeneration of the muscular substance of the heart, especially when seated in the papillary muscles, may induce insufficiency of the valves. Insufficiency of the valves gives rise to the same heart-diseases as con- traction of the ostia; but, as has been already observed in p. 129, it has not been clearly demonstrated whether it specially induces dilatation, and on the other hand whether the stenosis specially gives rise to hyper- trophy. SUPPLEMENT. Cyanosis has so long constituted a special subject of anatomical in- quiry, that our work would be incomplete were we to omit stating our vieAvs in reference to this affection, and the relation it bears to heart- diseases. We must however observe, that our opinions are not derived from a careful consideration of all the known cases of cyanosis of the heart, but are, properly speaking, the mere expression of the views we have adopted from personal observation, and from the study of a limited number of the cases reported by others (Morgagni, Ferrus, Louis, &c.) A distinction is commonly made betAveen cyanosis, arising from organic heart-disease, acquired in advanced periods of life, or from diseases of the lungs, and cyanosis depending upon congenital malformations of the heart. The latter form is specially designated cardiac cyanosis ; but we shall see in the sequel that both forms are identical in origin and cha- racter. 186 ABNORMAL CONDITIONS OF The cause of cyanosis, when depending upon original malformation of the heart, has usually been sought in the admixture of the venous Avith the arterial blood, either in the ventricles, the auricles, or the trunks of the vessels; and this admixture, together with the cyanosis, has been supposed to arise from a deficiency in the septa between the cavities of the heart. According to our view, cyanosis does not arise from an admixture of the venous and arterial blood, which is in many cases very problematical, and not unfrequently altogether impossible, but depends rather upon an ob- struction in the passage of the venous blood into the heart, and upon an overcharging of the venous system, which is either transient or habitual, according to the circumstances of the case, and induces a corresponding repletion of the capillaries. We moreover consider that all cyanoses generally admit of being classed under one head, however the causes from which they immediately arise may differ in depending on original and congenital, or acquired anomalies of the heart and lungs. We are led to conjecture from our own experience, confirmed by the observations of others, that cyanosis never arises from malformations of the heart, consisting in deficiency of the septa, unless there exists at the same time some special anomaly of the arterial trunks, as narrowness or insufficiency of calibre, or contraction of the ostia of the heart. We will limit ourselves in the following notice to the most remarkable forms of this affection, and to cases which admit of being observed during a pro- longed period after birth. Patency of the Foramen ovale, although not uncommonly observed after death, is very generally not manifested by any symptoms during life, unless it occur in connection with some anomaly of the arterial trunks. This circumstance is the less remarkable when we remember that, under similar conditions, there may be an entire absence of the auricular septum, unaccompanied by the presence of cyanosis. This patency cannot, in ordinary cases, be referred to any definite cause, and is, as far as we know, purely accidental; but in some com- paratively rare instances, it certainly depends upon an anomaly of the arterial trunks, the patency of the ductus arteriosus, the presence of apertures in the ventricular septum, endocarditic metamorphosis of the valves, giving rise to contraction of the ostia in the foetus, or upon pul- monary diseases, as catarrh, atelectasis, &c. It must be observed, in reference to the question of a mixture of the venous and arterial blood, in patency of the foramen ovale, that in ordi- nary cases it is most probable that no such admixture actually occurs, inasmuch as the masses of the blood accumulated in the auricles equi- poise one another, and the valve is pressed against the septum by the blood in the left auricle. Symptoms of cyanosis do not occur even in cases of considerable defi- ciency of the valve of the Foramen ovale, without or even with the per- sistence of the foetal condition of the Eustachian valve, which carries a portion of the blood of the Vena cava to the Foramen ovale, although in the latter case there is necessarily an admixture of venous and arte- rial blood. In those cases, however, in which the patency exists conjointly with THE ORGANS OF CIRCULATION. 187 or is dependent upon the above-named anomalies, the symptoms of cya- nosis are necessarily present, although this admixture of both kinds of blood is not invariably effected, as is commonly assumed, by the afflux of A'enous to arterial blood. The mode of admixture depends upon the nature of the accompanying anomaly in the vessels or heart. If for in- stance there is abnormal narrowness or obstruction of the pulmonary artery, the blood of the right auricle will be mixed with that of the left auricle in consequence of the obstruction to the escape of the blood from the right ventricle of the heart; but if, on the other hand, the aorta be the seat of the anomaly in question, the arterial will be carried to the venous blood. Either of these conditions will be induced in alterations of the ostia, occasioned by foetal endocarditis, according as the right or the left side of the heart has been the seat of this process. The patency of the Ductus arteriosus involves patency of the Fora- men ovale from the right auricle, although not always in the manner usually assumed. It is supposed that the quantity of the blood in the left auricle diminishes with the width of the latter, as it flows into the aorta, and that a continued current of blood from the right auricle pre- vents the closure of the Foramen ovale. There are cases, however, in which the form of the open Ductus Botelli, and its two mouths, as, for instance, its expansion from the direction of the aorta, render it highly probable that the blood flows from the aorta towards the pulmonary artery, and, in such cases, the transmission of the blood of the right auricle, and the patency of the Foramen ovale, are the result of the ex- cessive fulness of the former, arising from the passage of the aortic blood into the pulmonary artery, and the consequent obstruction to a free discharge of blood from the right side of the heart. In either case, whether the venous blood passes into the arterial, or the arterial blood into the venous, the presence of cyanosis will occasionally be manifested, in consequence of the inability of the blood in the Venae cavae to pass into the diseased heart when already in a state of dilatation. Very considerable deficiency, or even the entire absence of the auri- cular septum, although necessarily accompanied with the admixture of the venous and arterial blood, does not give rise to cyanosis where the arterial trunks are normal. Numerous observations testify, however, that this deficiency very probably seldom exists unaccompanied by an anomaly of the vascular trunks, although its presence may frequently be overlooked. This consists in an obvious narrowness of the trunk of the aorta, which gives rise to a remarkable degree of cyanosis, although the arterial blood obviously passes into the venous. Narrowness of the trunk of the aorta, like contraction of the aortic opening, occasions active dilatation of the left ventricle, extending to the left auricle, and lastly, to the right side of the heart, through the capillary system of the lungs. The immediate consequence of the obstruction to the pas- sage of the blood from the left ventricle and the auricle, occasioned by the narrowness of the trunk of the aorta, is undoubtedly to carry a por- tion of the arterial blood of the left toAvards the right auricle. A more remote consequence of the obstruction to the discharge of the blood from the left side of the heart, is to impede the passage of the blood of the Venae cavae into the right side of the heart, and we then have 188 ABNORMAL CONDITIONS OF cyanosis as the result of the overloading of the capillaries from the Venae cavae. It is evident that in these cases there will generally be a considerable degree of active dilatation of the right ventricle, especially of the Conus arteriosus and the trunk of the pulmonary artery. Bouillaud is unable to explain this circumstance, otherwise than by assuming that the right ventricle becomes arterialized from contact with the arterial blood, which enters it from the left auricle. It would appear, from numerous obsenrations, that a deficiency of the ventricular septum—as its perforation—and the communication conse- quently established between the two ventricles do not, in all probability, give rise to cyanosis, unless there exists a simultaneous anomaly of the arterial trunks. For, in the absence of this predisposing cause, and only under certain conditions, such as mental emotion, bodily exertion, or disease of the lungs, cyanotic symptoms are of rare occurrence and of a transient character. It must, however, be observed, that important anomalies of the vascular trunks are of such common occurrence with deficiency of the ventricular septum, that the latter condition is almost constantly associated with excessive cyanosis. The anomalies of the vascular trunks most commonly associated with absence of the ventricular septum, are a more or less striking narrow- ness and obstruction, or even the complete closure of one or other of the arterial trunks, more especially the pulmonary artery, so that the aorta springing from both ventricles supplies the circulating system generally, and the lesser circulation especially, by means of anomalous pulmonary branches. The aorta here shows itself inadequate to the discharge of the blood from both ventricles, and the cyanosis must, therefore, undoubtedly arise from the obstruction opposed to the entrance of blood from the venous system, for we find in numerous cases of defi- ciency of the septum, where the vascular trunks are normal as well as where they are displaced, that cyanosis is either wholly absent, or that it occurs only on certain occasions, as, for instance, in pulmonary disease; that is to say, it arises in consequence of the retention of the blood in the venous system, by which the passage of the blood from the right side of the heart to the lungs is impeded; there can, however, be no doubt that an admixture of the venous and arterial blood is constantly taking place. In like manner, where the entire ventricle is not properly developed, it and the vascular trunks to which it gives rise are rendered insufficient for the discharge of the mass of the blood. The heart, in all these cases, exhibits dilatation and hypertrophy, which either affect both ventricles uniformly, or one more than the other, especially the right one, so that the heart retains its foetal character, more especially in reference to the mutual relation of the ventricles. Cyanosis is either continuous, although commonly remittent, or results from certain definite causes, among which we may reckon all those which influence the free passage of the blood through the lungs and heart,—as mental emotions, violent bodily exercise, &c. Pulmonary diseases may, perhaps, be regarded as the most powerful of any; and among these, the pulmonary catarrh which affects children and young persons is more THE ORGANS OF CIRCULATION. 189 especially influential in giving rise to symptoms of cyanosis; the more so, perhaps, because habitual bronchial catarrh is very commonly found to be associated with the above-named malformations, in consequence of the insufficient emptying of the pulmonary vessels into the heart. Cyanosis occasionally appears in childhood and puberty, when it is un- doubtedly to be ascribed to a want of relation originating at this period of life, between one or other of the arterial trunks and the heart. The appearances presented after death correspond with the character of the cyanosis, whether it be constant or transitory, and whether it have arisen from different known and obvious causes, or be owino- to influences either unknown or unexplained; and we thus find that some persons suffering from cyanosis manifest retarded development, deficient nutrition and animal heat, and general debility, and die prematurely, while others exhibit merely a very slight depression of the functions of organic life. In some cases, in which the heart presented conditions admitting of the admixture of venous and arterial blood, all the func- tions were fully performed;—a circumstance that it has been attempted to explain by the assnmption that no admixture of the two kinds of blood occurs, in consequence of the equal development of both sides of the heart. A morbid form of growth frequently associated with cardiac cyanosis, is_ the drumstick-like or club-shaped form of the ends of the fingers, with a corresponding convexity of the nails. This phenomenon has not been explained, and if, as has been asserted by different observers, a similar malformation is acquired in pulmonary phthisis, it may serve, from its association with pulmonary cyanosis, to confirm our view of the mode of origin of cardiac cyanosis. An important observation militating against the ordinary view of the mode of origin of cyanosis has been made by Breschet, who found, in one case, that the subclavian artery of the left side sprung from the pulmonary artery, while the extremities presented no anomalous color. We find, however, that there exists a species of local cyanosis in those cases in which the return of the venous blood has been obstructed by the afflux of arterial blood into a vein, as in varicose aneurism. Finally, in the foetus there is no cyanotic color, although there is a constant ad- mixture of the arterial and venous blood (Fouquier). Capillary haemorrhages of the most various organs constitute pheno- mena in every way important in cardiac cyanosis. They most com- monly occur as bleedings from the lungs, and are undoubtedly occasioned by the rupture of the overcharged capillaries. They afford as strong a confirmation of our views* as a case which fell under our notice of a cyanotic boy, aged 8 years, who died from laceration of the trunk of an insufficient aorta beyond its arch, and in whom there was an opening in the ventricular septum, closure of the pulmonary artery, and an origin of the aorta from both ventricles. Cyanosis, or the abnormal formation of the heart on which it depends, may terminate in death, either suddenly and rapidly, or slowly, in the same manner as in acquired heart-diseases. There is an anomalous form of cyanosis depending on original narrow- ness of the arterial trunks, associated with a normal formation of the 190 ABNORMAL CONDITIONS OF heart, which constitutes a transition stage from the cyanosis, arising from malformations of the heart and of the arterial trunks to that form of cyanosis which is a symptom of acquired heart-disease. This anoma- lous narrowness, associated with a normal formation of the heart, ex- tends in various degrees to the aortic trunk; and, like many other phe- nomena of cachexia, occurs most commonly during childhood and in puberty. Finally, cyanosis is a common symptom of many heart-diseases, such as dilatations and hypertrophies of a higher degree, together with the anomalies of the valves, from which they originate. These diseases also commonly give rise to acquired anomalies of the vascular trunks, such as contraction and obliteration, acquired communications of the aorta with the pulmonary artery and with the Venae cavae, and the conse- quent entrance of arterial blood into the two last-named vessels. These forms of cyanosis very frequently do not appear decidedly until advanced periods of life, although the heart-disease may have been acquired in early childhood, if it be not even congenital. It is still problematical whether this form of cardiac cyanosis can be acquired by the reopen- ing of the closed Foramen ovale and by a morbid perforation of the sep- tum, owing either to inflammation and suppuration, or to a fissure. This view of the possibility of the reopening of the Foramen ovale originated at a period when too much importance was attached to its patency, and would appear to be especially designed to serve for the completion of the whole theory. The cases recorded of acquired mor- bid perforation of the septa are certainly not wholly improbable, but the previous history of these cases affords us no convincing grounds for the assumption of the process of inflammation and suppuration or the existence of a fissure. These cases are also incapable of solving the questions Avhether these processes may not date from the period of foetal life, and whether, therefore, the morbid perforation may not be a congeni- tal heart-disease ; nor do they show whether the case may not be one in which the products and residua of inflammation belonged to a process subsequent to the perforation rather than to one by which this process was effected. This perforation deserves the more consideration, since traces of old or recent endocarditis have not unfrequently been found in hearts presenting such anomalies of formation. Cyanosis may not only be derived from the heart (where it most com- monly originates in the right side), but it may also depend on the most various congenital and acquired diseases of the lungs, which impede the circulation of the blood in the capillaries. The insufficiency of the pulmonary capillaries to carry the blood from the right side of the heart, causes an impediment in the discharge of the venous system into the right cavities of the heart, and thus gives rise to cyanosis; and it, moreover, as is clearly observed when of long continuance, in- duces active dilatation of the right side of the heart, the intensity of which corresponds to the degree of the impermeability of the pulmo- nary capillaries. We purpose in a future page to treat this subject more in detail. Diseases of the left side of the heart, such as dilatation and hyper- trophy of the ventricle, but more particularly contraction of the auriculo- ventricular opening, occasion the right side of the heart to be over-filled, THE ORGANS OF CIRCULATION. 191 in consequence of the obstruction opposed to the discharge of the blood from the capillaries of the lungs ; and hence we have the phenomena of cyanosis, usually with extension of disease (dilatation and hypertrophy) to the right side of the heart. Cyanotic phenomena of various degrees of intensity may also depend on conditions of excessive density, and on continued compression of the lung (as for instance from exudations), on atelectasis of the lung, on catarrh and bronchial dilatation, emphysema of the lung, extensive pneu- monia and pneumonic induration, pulmonary tuberculosis, &c, in like manner as on narrowness and closing of the arterial trunk, and admit of an equally easy mode of explanation. These phenomena of cyanosis may, moreover, either when congenital or acquired soon after birth, ob- struct or wholly prevent the involution (closure) of the foetal passages. All cyanoses, or rather all forms of disease of the heart, vessels, or lungs, inducing cyanosis of various kinds and degrees, are incompatible with tuberculosis, against which cyanosis offers a complete protection, and herein we find a key for the solution of the immunity against tuber- culosis afforded by many conditions which at first sight appear to differ so widely from one another. III.—ABNORMAL CONDITIONS OF THE ARTERIES. § 1. Deficiency and Excess of Formation. We have already treated, in their connection with anomalies of the heart, of all anomalies or other defects of structure of the tAvo arte- rial trunks, in so far as they present any true pathological interest. We would here only notice the following facts. It is extremely doubtful whether there is a complete absence of a vas- cular system even in the most imperfect monsters, although extreme de- ficiency and a very imperfect indication of the two systems, is common in these cases. Where there is a deficiency of individual portions of the body there naturally exists some anomaly in the corresponding por- tions of the vascular system, which will present deficiencies correspond- ing in intensity to the degree of arrest of development. Supernumerary parts present a corresponding excess of formation in the vessels, although it must be observed that as a multiplication of organs is not uncommonly merely apparent, the multiplication of the arteries and veins implicated in the anomaly is only apparent, indicating the mere cleavage or subdivision of a trunk. We have already spoken, and purpose treating more fully, of the excess of vessels supplying diffe- rent new formations. To these anomalies in the number of the indivi- dual vessels belong: § 2. Anomalies in the Origin, Course, $c, of the arteries. These, which are known as varieties, are very numerous, and are in part produced by anomalies of position and form in the corresponding organs. Several are highly important in reference to operative sur- gery ; but as we are unable, from personal experience, to add any new facts in relation to this subject, we would refer our readers to the Mono- 192 ABNORMAL CONDITIONS OF graphs in which it has been treated, and to the ordinary Systems of Surgery. § 3. Anomalies and Diseases of Texture. We commence with the consideration of these anomalies, because they are both intrinsically important, and constitute the foundation of the principal consecutive anomalies and diseases, and because a knowledge of them is absolutely necessary for the right comprehension of the great majority and the most important of the alterations affecting the calibre and thickness of the walls of the arteries, their separations of conti- nuity, and the subsequent phenomena to which they give rise. We shall institute various comparisons with the corresponding textural diseases of the veins, and we would here specially refer, on all these points, to the remarks we shall have to make subsequently on the diseases of the veins. a. Inflammation of the Arteries—Arteritis.—In the first place it will be necessary clearly to comprehend whether there actually exists a spontaneous arteritis, and whether that special form of arteritis ever occurs which is commonly supposed to be met with in our hospitals and dead-houses. If under the term arteritis we understand an acute inflammation, in which the inflammatory products are deposited or exude, as in phlebitis (inflammation of the serous membranes, &c), on the free surface of the lining membrane of the vessel—that form of inflammation which is sup- posed to give rise to those appearances of redness commonly observed after death in the inner coat of the arteries—it will be necessary to no- tice the following points in reference to this subject: 1. The absence of vessels in the (yelloAv) circular fibrous coat, and more especially in the inner coat of the vessels, forbids our assuming the possibility of inflammation in these layers. This is also fully con- firmed by experience, and we find that the redness observed in these coats, more especially in the lining membrane of the vessels, is obviously owing to imbibition, which is developed after death, and possibly even during life, with a rapidity proportional to the state of decomposition of the blood. The coloration always proceeds from the inner surface of the vessel without a trace of vascularity, and penetrates to different depths in the yellow membrane ; whilst there is no product of inflammation to be discovered either on the inner surface of the vessel or in the tissue of either of these arterial coats. The phenomena manifested during life by the supposed arteritis, are in such cases always dependent on pri- mary or secondary disease of the blood. 2. The cellular sheath of the vessel is alone capable of inflammation, and we are here led to inquire, whether this inflammation can deposit its products on the inner surface of the artery, under what conditions this may be done, and, what experience teaches us in reference to this subject. The circular fibrous coat in the larger arteries, as, for instance, in the trunk of the aorta, exhibits so great a thickness, together with such density of texture, that we are unable to comprehend how it can be per- meated by an exudation, unless by the agency of an acute process. This is fully confirmed by experience; for, at all events, we have never THE ORGANS OF CIRCULATION. 193 detected any such process in the trunk of the aorta, or, in other words, never observed arteries in the sense in question; and we are, therefore, led to deny, or at all events to doubt the correctness of the observations recorded in reference to this subject. According to our vieAv, the sup- posed pseudo-membranes on the inner surface of the aorta, and its redness, together with the fibrinous plug obstructing its canal, are sepa- rated and coagulated from the diseased blood. We, moreover, regard it as very doubtful whether pus is ever pro- duced in the inner coat of the arteries or between this and the middle one, nor do we attach any great weight to the observations of Andral, in which, as he asserts, he found some half dozen abscesses of the size of hazel-nuts under the inner coat of the aorta. Experience alone is able satisfactorily to determine the limits at which the thickness and density of the texture of the circular fibrous coat cease to oppose an absolute obstacle to the imbibition and permeation of an exudation produced in the cellular sheath of the artery, or to its appear- ance on the inner surface of the vessel. We find, indeed, from observa- tion, that such inflammation frequently exists in the femoral arteries, especially in women, and likewise in the umbilical arteries of neiv-born infants; and Ave are hence led to conclude, that it may occur in all those arteries generally which possess a like organization. The anatomical appearances of acute arteritis, considered within the limits Ave have assigned to its occurrence, are: 1. Injection, Redness of the cellular sheath of the vessel.—This is commonly no longer distinctly apparent after the establishment of those products which we are about to name. 2. Infiltration of the cellular sheath, with a serous, sero-fibrinous, partially solidifying moisture, causing puffiness; in some feAv cases the tissue exhibits purulent exudations, Avhich are either diffused, or limited to individual points, or grouped into circumscribed foci. 3. Extreme lacerability—the facility ivith ivhieh the cellular sheath may be removed from the circular fibrous coat. Hitherto we have only enumerated the appearances attending inflam- mation of the cellular tissue. (See vol. iii. p. 18.) 4. The circular fibrous coat appears loosened and succulent; admits readily of being drawn into fibres and separated from the elastic coat; is commonly blanched, and sometimes colored in different shades of red from the inner surface of the vessel through imbibition, although without any apparent injection. The lining membrane of the vessel is loosened, and may easily be detached or torn; its free surface is dull, and occa- sionally exhibits a felt-like or Avrinkled appearance; it is either pale or reddened through imbibition. 5. The vessel is frequently, although not ahvays perceptibly dilated, which is OAving to the paralysis of the elastic layer of the cellular sheath and the circular fibrous coat. A coagulum of blood acting as a plug is lodged in the canal of the vessel, whose bore is thus more or less com- pletely filled and obstructed. 6. The presence of a free product (exudation) covering the inner surface of the vessel in the form of a pseudo-membrane is, in most cases, problematical. It occasionally occurs in the form of a soft, pale yellowish, vol. iv. 13 194 ABNORMAL CONDITIONS OF or yellow-reddish layer, differing from the inner lining membrane of the vessel, as well as from the peripheral stratum of the plug. _ In more frequent cases, that which may be regarded as a free product, is merely the outer layer of the plug in the act of being metamorphosed into a structure analogous to the inner coat of the vessel. In these cases, the exudation throAvn out on the inner surface of the vessel is taken up into the blood before it has been consolidated and has thus given rise to the formation of an obstructing coagulum. In many cases a portion of the exudation is solidified under one of the strata forming the inner coat of the vessel—below the epithelium and the longitudinal fibrous coat—and these strata being thus loosened are thrown off. They form a covering to the plug Avhich projects into the canal of the vessel. These appearances constitute the so-called adhesive arteritis. 7. In rare cases arteritis gives rise to a partially or wholly purulent exudation, which may be recognized by the following appearances : „ a. The inner surface of the vessel sometimes distinctly exhibits a thin layer of purulent exudation, which is partially attached to the plug. b. This exudation, which is discolored and loosened, undergoes a pro- cess of softening, both in its interior and at different points of its circum- ference, and is reduced into a puriform semi-fluid mass, or into a fluid exhibiting a corresponding degree of decoloration. c. The inner and the circular fibrous coats are SAVollen, unusually succulent, of a somewhat yellowish color, loosened and stratified, and are distinctly infiltrated and permeated with the purulent exudation. d. The whole of the lining membrane of the umbilical arteries of new- born infants is frequently found to be detached from the yellow mem- brane, which again is separated from the elastic coat by means of the exudation which is produced from the cellular sheath, and is, for the most part, accumulated between these coats. e. The cellular sheath exhibits the above-named signs of inflammation in a highly developed form, having purulent exudation diffused over the tissue or accumulated in circumscribed foci. This form of arteritis deposits, therefore, as appears from the above observations, a product which is either capable of coagulation and solidi- fication, and of being metamorphosed into tissue, or is of a purulent cha- racter. The first of these forms is commonly termed adhesive, on account of the obliteration of the vessel to which it very usually gives rise; it is of much greater frequency than the other form. In reference to the modes of termination and the metamorphoses of the products of this form, we must notice the following particulars: 1. Adhesive arteritis occasionally passes into resolution, as does more frequently adhesive phlebitis; the products of inflammation in the tissue of the coats of the artery are resorbed, while the plug is gradually dissolved, and taken up into the blood in a finely comminuted condition. 2. The ordinary termination is permanent and more or less complete obliteration, which, in its turn, gives rise to atrophy of the vessel.—The plug in the vessel gradually shrivels, being decolorized and converted into a fibroid string. When the plug has entirely filled the vessel, and is attached to the inner wall by means of one of the above-named struc- tures, the coats of the vessel will be found to adapt themselves to its THE ORGANS OF CIRCULATION. 195 shrivelling, while the vessel closes around it into a solid cylinder. But where the plug has not completely filled the artery, and is only attached at some points to the wall of the vessel, or where the shrivelling and metamorphosis have been effected too rapidly to allow of the walls of the artery following the process uniformly, and the adhesions have there- fore been drawn aside and partially loosened by the flow of blood, the obliteration will be incomplete. In these cases the artery is occupied by a fibroid cord or string, which closely adheres at certain points to the wall of the vessel, although free at all other parts, or is, at the same time, attached in different places by means of string-like structures or pseudo-membranous plates, so that the calibre is very much contracted, and the circulation, more especially in the smaller vessels, correspond- ingly impeded. In consequence of complete closure, the specific tissue of the artery, more especially the circular fibrous coat, very rapidly dis- appears, and the vessel becomes converted into a hard fibroid cord en- veloped in cellular tissue. Bony substance may be developed in this fibroid cord, which may be ossified over various extents of its surface. 3. Arteritis with purulent exudation leads, in some few cases, to com- plete or partial suppuration—ulcerous destruction of the vessel. This occasions hemorrhage, which, according to circumstances, is either external or directed into the tissue—a result which very rarely occurs in spontaneous arteritis, although frequent in the suppuration arising in an artery after it had been tied. Arteritis is very rarely fatal through the fever by which it is accom- panied, or the various inflammations to which it gives rise in important organs- Inflammation of the umbilical arteries, when it extends to the peritoneum, often proves fatal through peritonitis. Spontaneous gan- grene in the form of mummification, commonly known as gangrena senilis, is often produced during arteritis or occurs as one of its sequelae, when it attacks the trunk of a vessel belonging to a part of the body, Avhich cannot be supplied by any collateral circulation. This result of arteritis, which is dependent on the closure and obliteration of the vessel, has been most frequently observed in the lower extremities in inflammation of the femoral arteries. It is a common cause of the fatal result of spontaneous arteritis. General infection of the mass of the blood, as the consequence of the absorption of the products of arteritis into the blood, and of the secon- dary metastatic processes in the capillary system with which it is inti- mately connected, is, according to our experience, a very unusual phe- nomenon, and hence a very uncommon cause of the fatal termination of arteritis. Our own opinion is confirmed in reference to this point, by the concurrent testimony of other observers. (Hasse.) We have already endeavored to explain this rarity of the secondary processes, as compared with their frequency in phlebitis. We will here briefly observe, that this rarity must be referred to the greater suscepti- bility of the arterial blood for taking up inflammatory products which speedily give rise to coagulation and to obturationof the vessel, and to the circumstance that their reaction in the arterial current, being ex- hausted towards the capillaries in ordinary cases, hinders the general 196 ABNORMAL CONDITIONS OF infection of the blood beyond the limits of those vessels. The inflam- mation of the veins accompanying an inflamed artery, which we have had very frequent opportunities of observing, does not appear to us always to possess the character of secondary phlebitis, occasioned by coagulation of the blood from its absorption of the products of arteritis, but rather to depend on the transmission of the inflammation from one vessel to another. This arteritis is of very rare occurrence when compared with phlebitis. It is occasionally an idiopathic affection, but more frequently it ap- pears to be secondary (metastatic), as it occurs after different acute dis- eases. The causes on which it depends are frequently very obscure, but in some cases it may be referred to traumatic influences. The form of arteritis which is occasioned by operative agencies, such as ligature, torsion, &c, will, by the process of healing by which it is followed, con- stitute the subject of future remarks. General arteritis, like general phlebitis, has no existence. The above remarks apply to the inflammation of the arteries of the aortic system. In the system of the pulmonary artery appearances in- dicating inflammation of the larger branches are very rare, and probably are merely secondary processes arising from spontaneous coagulation of blood, and resembling secondary phlebitis. The occlusion of these vessels in most cases results in death, before the development of an excessive inflammation in their coats. The smaller the arterial vessels are, the more dependent are they on the condition of the surrounding tissue. They likewise participate in this inflammatory process, which either penetrates directly into the A'essels of their cellular sheath, or affects them indirectly, in consequence of the inflammatory products penetrating through and saturating the delicate, permeable coat of the vessel. Hence arise the occlusion of the arteries of an inflamed parenchyma, and the obliterations arising from inflammation terminating in induration, as we see in the AATalls of healing caA'ities of the lungs. Although there exists no true chronic arteritis of the form here indi- cated, acute arteritis having products of an adhesive nature may persist for a prolonged period; the textural metamorphosis of its products may be effected sloAvly, and the terminations Ave have already indicated may be only very gradually brought about; Avhile arteritis with purulent exu- dation may terminate in protracted ulceration. That which is com- monly regarded as chronic arteritis or as one of its sequelae, is not origi- nally or essentially inflammation, although it constitutes one of the most frequent and most important diseases of the arteries, as we shall pre- sently have occasion to show. There is, however, a chronic inflammation of the arteries, manifested as inflammation of the cellular sheath of the arteries (which consists of a layer of elastic, and a layer of cellular tissue), to which its products are limited, and which merely exerts a secondary disturbing action on the normal relation of the inner arterial coats of arteries, viz., the circular fibrous, and the true lining membrane. This constitutes a very frequent, and, at the same time, a highly important phenomenon in arteries of large calibre, as, for instance, the trunk of the aorta and its branches. THE ORGANS OF CIRCULATION. 197 It is occasionally a primary, but more frequently a secondary disease, and as such constantly accompanies the morbid deposition on the inner coat of the vessels and its metamorphoses. Its anatomical appearances are in general those of chronic inflammation of the cellular tissue, as, for instance, unusual vascularity of the cellular sheath, with dilatation of the injected vessels, and, corresponding to the degree of its injection, a more or less uniform, saturated coloration, varying from a dark red to a purple, while the cellular sheath is infiltrated with a grayish, or grayish-red, watery or adhesive and gelatinous fluid. This disease terminates in hypertrophy, thickening, and condensation of the cellular sheath, which is converted into a tough, apparently lar- daceo-fibrous, and callous, white stratum, varying in thickness from 3 to 6 lines. (Sclerosis.) It induces paralysis of the diseased tissue, more especially of the elastic layer of the vessel, and consequently dilatationi which appears, according to its degree, either diffused, local, or partial. The circular fibrous coat, which is loosened in texture by the dilatation of the vessel, exhibits a morbid brittleness in cases of callous condensation of the cellular sheath, is stratified in appearance, and is of a dirty yelloAvish, faded color, Avhich indicates a tendency to spontaneous lacerations, owing very probably to the deranged nutrition of the coat of the vessel. Dila- tation of the vessel moreover induces the excessive formation of an anomalous inner coat, and its further consequences. This inflammatory process and the modes of its termination that we have already indicated, are accompanied by two different conditions of the cellular sheath. In the one case, the vascularized, infiltrated, cellular coat of the artery, together Avith the elastic layer, admits of being detached Avith unusual readiness from the circular fibrous coat—a condition which may degene- rate into spontaneous detachment, and give rise to spontaneous lacera- tion of the lining membrane (dissecting aneurism.) In the other and more commonly obsen^ed case, the callous and thick- ened cellular sheath has coalesced Avith the circular fibrous coat. This most commonly occurs in dilated aneurismal arteries. Special reference must be made to the inflammation of the cellular sheath at the origin of the two arterial trunks, which depends on peri- carditis. It would appear from the milk-spots and adhesions found at this point, that inflammation of this portion of the pericardium occurs very frequently, either partially or associated with general pericarditis. By affecting the subserous cellular substance, it also implicates the cellular coat of these arterial trunks. This inflammatory condition very fre- quently extends beyond the period of the acute pericarditis, and in the form of chronic inflammation of the cellular sheath gives rise to dilata- tion, more particularly of the aorta. In reference to the pulmonary artery, this chronic inflammation some- times attacks the trunk and its two branches, and it is commonly present in an inferior degree associated with a similar condition of the cellular sheath of the aorta. « b. Ulcerous Processes or destructive ulcerations occur under different conditions in the arteries. They are somewhat frequent, considering 198 ABNORMAL CONDITIONS OF the very striking integrity exhibited by the arteries in the midst of ex- tensive abscesses. They invariably originate in the cellular sheath or its vicinity, and in no case do we meet with an ulcerous process either in or upon the inner coat of the vessel. The so-called atheromatous process, which is frequently regarded as ulceration of the inner coat of the artery, is not of an ulcerous character. To this class belong: 1.. The already described suppuration of an artery (see page 95) re- sulting from arteritis producing purulent exudation—the suppuration arising from arteritis occurring after the application of a ligature, and which will be considered in a future page. 2. Small arterial vessels, together with the capillaries, frequently suppurate when there is suppuration of the different tissues, and we then generally find them in a state of obturation (see p. 196). In less fre- quent cases, a very violent suppuration of a low character affects vessels in which there is no occlusion, and occasions hemorrhage into the abscess. 3. Ulcerous destruction of the larger arteries in the form of circum- scribed corrosion and perforation of the arterial wall from surrounding and contiguous abscesses, constitutes a very important and remarkable phenomenon. The wall of the artery is so much destroyed at a cir- cumscribed spot, that it generally presents a round or oval opening, sur- rounded either by a smooth, as if cut, edge, or a jagged and fringed margin, and contracted in some instances towards the interior in a funnel- like shape; it is attached by means of this aperture to the abscess, or to the base of the ulcer. This form of ulcerous destruction is the origin of many very dangerous external and internal hemorrhages. Among the most important of these we may instance ulcerous openings of the larger arteries in many different parts of the body. We have ourselves fre- quently observed perforation of the femoral artery from a suppurating syphilitic bubo, and Hasse noticed such a perforation of the vertebral artery of the right side from an ichorous abscess arising from syphilitic caries of the cervical vertebrae; and to these examples we may add the opening of different arteries on the base of perforating ulcers of the sto- mach, and the opening of branches of the pulmonary artery by tubercu- lous caverns. These ulcerous processes, as we may sometimes notice in the ramifica- tion of the pulmonary artery in the walls of tuberculous cavities of the lungs, also give rise to a laceration of the artery. This is owing to the removal of the surrounding protecting parenchyma, and to a loosening and softening of the coats of the vessel, resulting from imbibition of the ulcerous fluid. In some cases this is preceded by a lateral dilatation of the artery towards the cavern. c. Excessive Deposition of the Lining Membrane of the Vessels.— We rank with the above anomalies a process which, although it does not originally exhibit a diseased textural condition of the arterial coats, at all events results in such, and moreover stands in a near relation to chro- nic inflammation of the cellular sheath of the artery, the latter being either associated with it, or in rarer instances the indirect cause of its origin, in consequence of previous dilatation of the vessel. It further constitutes the basis of aneurismal formations and of numerous sponta- THE ORGANS OF CIRCULATION. 199 neous obliterations. It is the most frequent form of disease affecting the arteries, and is on that account of the greatest importance. It consists in an excessive formation and deposition of the lining mem- brane of the artery derived from the mass of the blood, and at the same time constitutes hypertrophy of this membrane.—We purpose devoting the following remarks to the consideration of this subject, in which we will endeavor briefly to notice all its most important bearings. 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 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 Avrinkled. 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 Avhich it is usually com- pared, and for which it is still occasionally mistaken. In the latter con- dition it adheres internally to the circular fibrous coat. This substance admits of being split into lamellae, and drawn away in the form of strata. If this is done at those spots Avhere the deposition forms isolated plates or islands, we discover that one or more of the lamellae thus drawn away, generally the innermost (superficial) ones, ter- minate beyond the limits of the plates in a delicate membrane, which is prolonged to the contiguous, and apparently normal lining membrane of the vessel. The thickness and extent of this deposition correspond to the degree of the anomalous condition. It varies in thickness from a quarter of a line to two lines and upwards ; and extends in extreme cases over the whole trunk and main branches of the aorta, implicating the entire arterial system. The deposition is generally the thickest directly over the division of a trunk, or at the bifurcation of a vessel. At these points the deposit is frequently so thick, that the mouths of the divergent vessels are much contracted, and even wholly closed.—The spot at the trunk of the aorta, which next to those we have already mentioned, deserves a special refe- rence as a common locality for this deposition, is the loAver Avail of the aortic arch adjoining the left bronchus. This deposition, which is in itself highly interesting, is rendered still more so when it undergoes ossification. For as we shall have occasion to show, the osseous concre- tion gives rise here to an angular curvature, and a consequent contrac- tion of the tube of the aorta. We find on close examination of the deposit, that it has nothing in common Avith cartilage or fibro-cartilage, Avith which it is ordinarily com- pared and even confounded (cartilaginescence of the arteries), and that it actually consists of structures analogous to the layers which constitute the lining membrane of the vessel (the epithelium, fenestrated membrane, and longitudinal fibrous coat). 200 ABNORMAL CONDITIONS OF The circular fibrous coat is found, Avhen compared with the other arte- rial coats, to be soft, brittle, cleft, and of a faded, dirty brownish color. The cellular sheath exhibits considerable vascularity and puffiness, or is in a state of sclerosis. It will be seen from this description of the appearances observed in the more highly developed stages of the disease, that our attention should, on the one hand, be directed to its incipient stages, and on the other to its further progress. At its commencement, this deposition cannot be detected without a previous familiarity Avith its appearance. It is then a delicate, soft, suc- culent membrane, exhibiting a vitreous "transparency, and appears in some cases, where it is thrown into small folds by the preponderating contraction of the circular fibrous coat, to be exceedingly thin, and co- vered Avith Avhite dots or stripes. The circular fibrous coat is normal, when not altered in consequence of pre-existing inflammation of the cellular sheath. The deposition continuously increases in thickness by the addition of neAv strata, and thus gradually passes from the condition of transparency and succulence, characteristic of recent formations, to that state in Avhich it appears opaque, resembling coagulated albumen, and finally presents a ligamentous appearance, having a dull, wrinkled surface. Before Ave enter upon the consideration of the metamorphoses which further occur in this deposit, it will be necessary to direct attention to some points which, although of extraordinary interest, have hitherto been wholly OArerlooked. On attentively examining the inner surface of a highly diseased artery, we perceive that the deposit is interspersed with openings or foramina, varying in size from a pin's head to that of a poppy-seed. These open- ings occasionally attract attention by a small drop of blood oozing from them on pressure. In some cases these openings are very numerous, whilst in others it is difficult to detect them. They might, at first sight, be mistaken for the contracted mouths of vessels; but the error of this view is readily made apparent by a closer examination, and by the cir- cumstance that they occur at spots where no such vessels are given off, as, for instance, on the ascending arch of the aorta. These openings lead to canals, which penetrate to various depths in the deposit, where they either terminate Avithout changing their form, or again divide, and turning, with their branches, in an oblique direction, enter the circular fibrous coat, where they finally ramify. They con- stitute a system of canals to convey the blood into the deposit and the cleft circular fibrous membrane, which is filled by the blood of the dis- eased vesel, and may frequently be seen through the deposit. As far as we are aware, these canals are not connected with the vas- cular system of the cellular coat, and do not anastomose with its vessels, although they penetrate as far as its elastic layer. The manner in which these openings and canals originate is a question of the greatest interest. They are undoubtedly the result of partial re- sorption in the deposit, by means of which openings are formed, Avhich enlarge into canals by coming in contact with each other in the dif- ferent strata of the deposit. Their mode of origin is very probably THE ORGANS OF CIRCULATION. 201 similar to that of the apertures of the fenestrated or striated arterial coat, and is closely connected with it; it is very likely, also, the same process which Stilling observed in the thrombus of tied arteries, and which we have also noticed in a fibrinous coagulum in the heart (in the so-called polypus of the heart), where it rendered the coagula porous, and caused them to acquire a cavernous structure, erroneously regarded as a condition of vascularity. This channelling of the deposit undoubtedly constitutes the basis of that degeneration of the arterial walls which Lobstein considers under the head of softening of the arteries (arteVio-malacie). The wall of the artery, in some few cases, degenerates into a spongy tissue, resembling the corpus cavernosum, or occasionally into the form of a tumor, from which, when it is cut, blood pours forth from an innumerable quantity of openings, as from a sponge. The metamorphoses through which the aboATe described deposit passes, after it has become completely opaque, are the so-called atheromatous process, and ossification of the arteries. 1. The atheromatous process consists in the metamorphosis (disinte- gration) of the deposit into a pulpy mass, compared by the French to a pure'e of peas, consisting of a large number of crystals of cholesterin, fatty globules, and of molecules exhibiting various degrees of consis- tence, from coarseness to extreme fineness, and consisting of albumen and calcareous salts. The metamorphosis begins with a finely punctuated opacity and de- coloration of the deposit, and it is not limited to any definite duration, occurring sometimes at an early stage, and at other times at a more advanced period, although, as has been already observed, generally Avhen the deposit has become opaque. It, moreover, commonly begins in the deeper, older strata of the deposit, and advances from thence towards the surface. It usually affects a space varying in circumference from the size of a lentil to that of a crown or a shilling piece. There is, at the same time, an increase of volume, and a swelling of the deposit; the uninjured lamellae rising above the surface towards the interior in proportion to the depth to which the process has affected the deposit, and then frequently exhibiting a perceptible fluctuation. After this process has penetrated to the innermost layers, or Avhen they have burst above the pulpy mass, and been torn asunder by the force of the blood pressing into the cavity, the mass itself appears un- covered on the inner surface of the artery, and in contact with the blood, in which case fibrinous vegetations]of different forms are deposited on the fringed margins, after the occurrence of the bursting or rent. The pulpy mass, both immediately after it has been laid bare and also subsequently, is taken up in different quantities into the blood, although another and the more consistent part of it is infiltrated by the blood, and permeated by its fibrin, and is thus rendered firmer, and, at the same time, colored by haematin, in various degrees of intensity, being first of a dark red, then of a dirty brown or purplish, and lastly, of a yeast-like color. In addition to these discolorations, the mass acquires a very peculiar appearance, when its surface is covered with large crystals and accumulations of cholesterin, for it then looks as if it were interspersed with spangles, or silver-like and shining scales. 202 ABNORMAL CONDITIONS OF These spots are even at the present day regarded as ulcers—fungous ulcers of the arteries. But the atheromatous process presents no essen- tial analogy Avith an ulcerous process, nor is the deposit itself an inflam- matory product. We discover no trace of an ulcerous product in the atheromatous mass, and its admixture with the blood is not characterized by any marked subsequent symptoms, as Ave learn from the experience of hundreds of cases. The atheromatous mass is very often gradually thickened, and con- verted into a moist, soft, plaster-like substance; and finally appears in the form of a coarsely granular stalactitic calcareous concretion. This loss of substance is occasionally replaced by a fresh deposit, when the atheromatous mass has either been wholly, or for the most part, taken up into the blood, in which case these spots remain below the level of the inner surface of the vessel, and thus acquire a cicatrix- like and wrinkled appearance, in consequence of the amount of shrivel- ling of the callous cellular sheath. They also very often acquire a slate- gray or greenish-gray, or black color from the haematin by which the tissue is saturated, and which remains on the margins and on the base. They are regarded as cicatrices of the supposed ulcers of the arteries. 2. Ossification is the second form of metamorphosis of the deposit. This includes the well-known ossification of the arteries. It presents many essential points in common with the atheromatous process, and occurs only in a deposit of comparatively extensive thickness, beginning in the lowest strata, where it is first manifested by the pale turbidity of the deposit, which has then become opaque. When the process of ossification has been completed, and the meta- morphosis has extended throughout the whole thickness of the deposit, the osseous concretion lies exposed. Its form is that of a concavo-con- vex plate, having a tolerably smooth, even, and concave inner surface, and a rough, nodularly uneven, convex external surface, with irregular and jagged margins. The bony plate is bored through at the point where a branch of the ossified artery is given off, unless the mouth has already been previously closed by the deposit. In arteries of large calibre, as the femoral arteries, the concretions present the form of rings which enclose more or less of the circumference of the vessel. The number and size of these concretions are subject to great varia- tions ; in some cases they only appear at detached points, whilst in others, the artery appears to be converted into a more or less solid osseous tube. In large arteries, the exposed bony plates are often partially detached by the current of the blood, when they remain in the vessel at different angles of inclination. Their rough margins readily become the seat of fibrinous vegetations. This form of arterial ossification exhibits a yellow color, and, in general, considerable density and hardness of texture. It is deficient in the delicately lamellated structure of bone, and has no medullary canals or bone-corpuscles. (See Miescher, Valentin.) The seat of arterial ossification is the lining membrane of the vessel, which is itself produced in anomalous excess. The bony plate does not, according to the general view, remain stationary between the inner and THE ORGANS OF CIRCULATION. 203 the circular fibrous coat; nor does it press these layers asunder, and induce atrophy in the former of the two by pressure, but it is developed in the parenchyma, and in the numerous thick superimposed strata com- posing the recently formed inner coat of the vessel. It at length becomes exposed in the artery, in consequence of the final ossification of the innermost lamellae, and not simply from their atrophy. Besides these, other concretions are occasionally observed in the arte- ries. Thus, for instance, granular or stalactitic calcareous masses are occasionally found upon the inner surface, or the raised margin of these bony plates. These are either thickened, cretified, atheromatous sub- stances (see p. 202), or cretified fibrinous vegetations. According to our view, although in opposition to that of many good pathologists, these two processes or metamorphoses very commonly co- exist ; but, it must be admitted, without any marked preponderance in either of them. Having given the above description of this deposit and its metamor- phoses, and having observed that all the different conditions of this de- position very frequently exist in the same vessel, we purpose, in the folloAving remarks, to consider the relation simultaneously exhibited by the other coats of the arteries. 1. At the commencement of the deposition, and till it attains some degree of thickness, there is no perceptible alteration in the circular fibrous coat. But such alterations become the more apparent in propor- tion to the increasing thickness of the deposit; for this coat gradually acquires a dirty yellowish color, its texture becomes looser, and it admits, with uncommon readiness, of being separated into fibres and layers; at the same time it loses its elasticity, and yields to the pressure of the column of the blood, Avhence dilatation of the vessel supervenes to a degree that corresponds to the extent of inflammation already set up in its cellular sheath. It loses its power of resistance, and becomes thinner in consequence of this dilatation. In the more highly developed stages of this deposit, and when the atheromatous and ossifying processes have become fully established, and even made considerable progress, the circular fibrous coat presents a dirty brown, yeast-like color, and is soft, lacerable, and cleft. As the dilatation of the vessel increases, the fibres gradually separate, and the deposit sinks into the interstices thus produced, where it comes in con- tact and finally coalesces with the cellular sheath, which has in the mean time been converted into a callous tissue. According to our observations, this disease of the circular fibrous coat depends on the development of fat—fatty degeneration, by which, analogously with the process observed in the so-called fatty metamor- phosis of the muscular tissue, its peculiar ramifying fibres and its elasti- city are destroyed. This coat is directly implicated in the atheromatous process, which extends to it from the deposit, and destroys it. 2. The cellular sheath of the vessel, in the majority of cases, is found to be in a state of chronic inflammation—that is to say, in a state of vascularity, redness, infiltration, and puffiness, or has been converted, in consequence of this process, into a layer of white, very dense, callous 204 ABNORMAL CONDITIONS OF tissue of considerable thickness, coalescing with the circular fibrous coat, or with the deposit within its interstices. The following points are of the greatest importance in reference to this condition of the cellular sheath : a. The intensity of this condition bears no relation Avhatever to the degree of the deposition, since, in the higher stages of this process, it is occasionally, and in the less developed stages very frequently absent, whilst it never exists in the incipient form of the deposit. b. This condition must, therefore, be of a secondary character, and associated with a certain stage of the deposit. This fact does not, how- ever, exclude the possibility of the converse relation, for as we shall have occasion to show, a primary and substantive chronic inflammation of the arterial sheath may give rise to a local deposit, in consequence of dilatation of the vessel. The deposit is either local, limited to one or more spots of the vessel, or it extends over a large portion of an artery, or over a separate part or the whole of the arterial system. In the former case it depends on local dilatations of the vessel, and on the slowness or partial stagnation of the current of the blood; in the latter, the controlling influence must be a general state of disease, which Ave Avould designate as a constitutional condition. The deposit, when appearing as a constitutional disease, occurs almost exclusively in the arteries, and only in the aortic system. This agrees with the consecutive anomalies, especially the occurrence of ossification of the vessels, aneurismal formation, and obliteration. Very little relative importance can be attached to any scales purport- ing to give the frequency of the occurrence of this constitutional affec- tion in the different portions of the aortic system, for whenever the disease appears especially developed in any definite part, the rest of the system—as, for instance, the aortic trunk—will also be implicated. The trunk of the aorta is most frequently the seat of the disease ; and here we find that the ascending aorta, and the arch, are most commonly affected, next the abdominal, and lastly the thoracic portion. Next in order follow the splenic, the femoral, the internal iliac, the coronary arteries of the heart, the trunks of the arteries of the brain— that is to say, the carotids within the cranium and the vertebral arteries, with their branches,—the uterine, the brachial and subclavian, the sper- matic, the common carotid, and the hypogastric arteries. It is Avorthy of notice, that certain arteries are only very rarely, and in exceptional cases, subject to even a subordinate degree of this disease ; among these we may reckon the mesenteric arteries, and yet more, the coeliac, the gastric, the hepatic, and the epiploic. This scale corresponds generally to the frequency of the occurrence of metamorphoses in the deposit, such as its ossification, as well as aneuris- mal formations. We have not been able to determine, Avith the requisite accuracy, whether there actually exists such a symmetrical occurrence of the con- ditions already described (viz.: crude deposition, ossification, and the atheromatous process) in the corresponding arteries of the two sides of THE ORGANS OF CIRCULATION. 205 the body, as Bizot maintains that he has observed, and regarding which he has established a laAV; and indeed our views of the constitutional cha- racter of the disease prevent our attaching any great importance to the subject. This disease is of very rare occurrence in the pulmonary artery and its branches ; but if it be present here, it is ahvays likewise considerably developed in the aortic sytem. This affection scarcely ever occurs as a constitutional one in the veins, for here it always exists as a secondary phenomenon, depending on a sluggishness of the current of the blood, produced by ordinary causes. (See Diseases of the Veins.) On the other hand, the veins are frequently affected by a morbid formation, which, although it may not be purely constitutional, yet presents a very remarkable analogy with the disease of the arteries under consideration : Ave refer to the so-called phlebolites or vein-stones. It is, moreover, worthy of special notice, that the deposit in the veins commonly attains a high degree of development when arterial blood makes its Avay into them. (Varicose Aneurism.) Sex exercises no special influence on the occurrence of the deposit and its different consecutive conditions; but Hasse appears, on the whole, to be correct in his vieAv, when he states that disease of the abdo- minal aorta is more frequent, and more highly developed, in women than in men. Age, on the other hand, gives rise to important differences; but although the disease is most frequent betAveen the fortieth and the sixtieth year, the assertion that it increases in frequency in proportion to the age, and that it occurs in advanced life almost as a normal condi- tion, is not well grounded; for although it may undoubtedly date in many aged persons from a comparatively early period of life, there are many others in whom it is entirely absent. Old age presents, indeed, a mechanical disposition to this affection, from the dilatation of the arteries common to that period. Before the above-mentioned age, the disease is undoubtedly more rare, although frequent even between the thirtieth and fortieth year. Before that period it is very much rarer ; and Avhen it occurs prior to the age of twenty years, it is mostly only a local disease, depending on congenital or early acquired anomalies of the trunks of the vessels and of the heart. This observation refers especially to its occurrence during the periods of puberty and childhood. If, after considering the above remarks, we proceed to the question— In what consists the nature of the disease ? Ave gather the following facts from our examination of all the important points bearing on the subject: 1. The deposit cannot be regarded as the product (exudation) of an inflammation of the arteries. The chronic inflammation of the cellular sheath of the diseased vessel is almost always a secondary consecutive appearance Avhich associates itself with the already established deposit. 2. The deposit is an endogenous product derived from the blood, and for the most part from the fibrin of the arterial blood. 3. Its formation demonstrates the pre-existence of a peculiar crasis of the blood, A\*hich is intrinsically arterial, although at the present time we are wholly ignorant of the character of the peculiarity on which 206 ABNORMAL CONDITIONS OF this depends. We must regard the old dogmatic view, which sought the cause of the affection in arthritis, as an opinion deficient^ in proof. 4. In proportion to the extent of the disease of the arteries, so much the less likely is it to be combined with tuberculosis ; and this disease undoubtedly is in part the cause of that immunity against tuberculosis which we constantly notice in large aneurisms of the trunk of the aorta. The grounds of this relation are not known ; but it is not wholly impro- bable that this immunity may arise from a similarity between the process of deposition (which occurs in the form of separation of fibrin), and the tuberculous process, by exhausting the arterial character and the mate- rials of the blood. On the other hand, Ave very frequently observe an excessive production of fat associated with the deposition and ossification in the arteries. This abnormal formation occurs—independently of the fatty degeneration of the circular fibrous coat, and of the atheromatous process,—more especially in the neighborhood of the ossified arteries with atrophy of the muscular tissue, in the vicinity of aneurisms, and, in addition, as excessive accumulations of fat in the blood, of cholesterin in gall-stones, &c. 5. The deposit and its metamorphoses present numerous, highly im- portant analogies, that have hitherto been wholly neglected. For the sake of brevity we will here notice only the most important; viz.: the deposit also occurring under certain conditions in the veins, the phlebo- lites (which we will consider under Diseases of the Veins), the capsules investing different fibrinous coagula in the Avascular system, and causing them to adhere to the walls of the vessels and of the heart, and the metamorphosis which these fibrinous coagula undergo within the vascular system, and which may even affect fibrinous coagula externally to that system. The effects produced by this disease in its reaction on the whole organ- ism are still unknown. In respect to the vessel itself, the disease gives rise to different forms of dilatation, Avith contraction of its branches and complete closure of their mouths, constituting a highly important, although little known, secondary condition. When arteries of lesser calibre have been ossified, and the deposit continues to exist, they finally become closed and obliterated. It is, moreover, probable that the capillary arteries at the seat of the deposit become diseased, in conse- quence of the diminution and cessation of nutrition arising from the obstruction and arrest of their permeability. Either may, moreover, give origin to the formation of spontaneous gangrene—the so-called dry gangrene—mummification of the tissues. Finally, this disease is often found to terminate in spontaneous laceration of the large arteries, and especially of the small trunks. It still remains for us to add the following remarks to the observations already made in reference to the diseases of the valves of the heart at p. 174. The valves of the aorta exhibit a thickening and an adhesion to the Avail of the vessel, and appear fused together with consecutive shrivelling, malformation, and ossification. We have already remarked, in the same page, that this disease which generally forms the basis of that insufficiency of the aortic valves which is slowly and almost imper- ceptibly developed in advanced life, is not of endocarditic origin, but THE ORGANS OF CIRCULATION. 207 depends upon an excessive formation of a tissue analogous to the inner coat of the vessel, and deposited from the blood upon these valves. It is commonly associated Avith a diffused deposition in the trunk of the aorta and a dilatation of the latter with aneurismal formation. d. Adventitious products.—A very few of these forms occur in the vascular system generally, and especially in the arteries. 1. Among the productions of fibroid tissue we may include sclerosis of the cellular sheath in consequence of its chronic inflammation, and perhaps also that metamorphosis of the deposit in which it becomes con- verted, in many cases, into such a tissue: 2. An anomalous production of bone occurs in the folloAving forms : a. The well-known ossification of the arteries—a metamorphosis of the deposit—to which we have already sufficiently alluded. The fre- quency of its occurrence in the different portions of the system, corre- sponds with that of the morbid deposition in the arteries on which it de- pends. A similar relation exists in reference to the periods of life and the sex in which it most frequently occurs. b. Chalky, mortar-like concretions, formed by the thickening of the atheromatous mass, or by the metamorphoses of the fibrinous vegetations deposited on the above-named bony plates, &c. c. Ossification of the occluding plug, which owes its origin to inflam- mation with exudation on the inner coat of the vessel, after the previous conA'ersion of the plug into a fibroid string. 3. The numerous forms in which the anomalous "production of fat occurs are extremely important. The cholesterin which is contained in the so-called atheroma of the arteries, is the only fatty product that has been hitherto noticed (Gluge, Gulliver). Yet the fatty degeneration of the circular fibrous coat (see p. 203), which may be compared to stea- tosis of the muscles, is, in our opinion, more important in its results, whilst the excessive formation of fat that is combined with ossification of the arteries, present numerous points of interest, both on its own account and in consequence of many analogous conditions (see p. 206). 4. Cysts are of very rare occurrence in the arteries, and probably only appear in the cellular sheath and the neighboring tissue. We have never yet observed a case of this nature. Corvisart attempted to build up a theory of the formation of aneurism on two cases which he had observed, but his views were long since refuted, and never met with sup- port. 5. Tuberculosis neither occurs here nor in any part of the vascular system. The deposit does indeed, as we saw at p. 206, give indications of an analogous process, which gives interest to the fact that this disease does not occur in the venous system as a constitutional one. 6. The larger arteries with thick walls steadily resist the invasion of Cancerous Degeneration, and in this respect present a striking contrast to the veins. Whilst the veins traversing a cancerous tumor exhibit cancerous degeneration of their walls, and are often completely filled up by cancerous excrescences, the arteries are found to be undestroyed. While the spontaneous coagulation of the blood in the arteries is rare, we find that the tissue developed from it is still more rarely of a cancer- ous nature. Velpeau and others have observed the very rare occur- 208 ABNORMAL CONDITIONS OF rence of an obstruction of the aorta and iliac arteries by a plug of a cancerous nature, in an individual exhibiting a general cancerous dys- crasia. The # rarity of cancer of this form—primary cancer of the arte- ries—\s worthy of notice, when contrasted Avith its more frequent occur- rence in the veins. § 4. Anomalies of Calibre. A. Dilatation of the Arteries (Aneurism). As we purpose limiting ourselves, in the following pages, to the con- sideration of the conditions of actual dilatation of the artery, we will postpone to another chapter the consideration of false, varicose, and dissecting aneurisms, as subjects which do not appropriately belong to the present place. After simply referring to the development of the arteries in reference to their calibre and the thickness of their walls, as observed in organs having become hypertrophied (in the gravid uterus and in morbid aug- mentations of size in the most different organs), we will pass on to dila- tation of the arteries based on disease of the arterial coats. It seems, however, especially necessary to notice, in the first place, the conditions under which dilatation of an artery is established. These are as follow : 1. Some dilatations arise without any visible alteration of texture in consequence of a loss of elasticity and contractility of the coats of the artery, that is to say, of the circular fibrous coat and of the elastic sheath, or in consequence of a mechanically induced continuous and excessive filling of an artery or even of one entire section of the arterial system. Such dilatations are very commonly observed, particularly in advanced life, in the trunk of the aorta, and especially in the ascending arch, in consequence of the first above-named causes. If, as we think, not im- probable, Cloquet's two cases of circoid aneurism (or arterial varix), belong to the class in which the aneurism is not the result of exten- sive chronic inflammation or of deposition, such a dilatation might be extended over the larger portion, or even the Avhole of the arterial sys- tem. In such dilatations the Avails of the arteries are thinner, softer, and more yielding, and the circular fibrous coat is paler than usual. The dilatation, especially at the trunk of the aorta, excepting where it exhibits a more or less strongly marked protrusion of the convex por- tion at the ascending aorta, presents a regularly cylindrical form: in the so-called circoid aneurism, hoAvever, it appears so far irregular that it preponderates in one or other portion of the surface, and thus gives rise to the interlaced twisted course of the artery (which seems as if it were coiled round an imaginary axis), and to the bulgings occurring at certain points, as Avell as to the lengthening of the diseased vessel. Dilatations arising from mechanical obstructions are observed in the aorta; but more especially in the pulmonary artery and its branches, in consequence of the Ararious diseases of the parenchyma of the lungs Avhich impede the normal injection of the capillaries, in cases of stenosis of the left side of the heart, &c. THE ORGANS OF CIRCULATION. 209 2. Chronic Inflammation of the cellular sheath of the arteries gives rise, as has been already remarked, to dilatation of the vessel, in conse- quence of its paralyzing the elastic coat. This is especially observ- able in the trunk of the aorta, and it may, moreover, have laid the foun- dation of some or other of the recorded cases of cirsoid aneurism. Dilatations of the point of origin of the trunks of the pulmonary artery and the aorta, depending upon inflammation of the cellular sheath, com- bined with pericarditis, deserve notice on account of their locality (see p. 122). These dilatations are generally of a cylindrical form. The forms of dilatation based upon the two causes above described, constitute (more particularly in reference to the arterial wall enclosing the dilatation) true Aneurism (Aneurisma verum), which has been dis- tinguished by the designation Arteriectasis from those aneurisms which are regarded as depending for their origin on a more essentially anato- mical disturbance. 3. Most forms of dilatation commonly included under Aneurism (spon- taneous aneurism), and at the same time the most important of all, are owing, as we have already shown (p. 199), to the deposition of a tissue, analogous to the lining membrane of the vessel, derived from the blood, and occurring upon the inner surface of the artery, and to consecutive disease of the circular fibrous coat and the cellular sheath. Attempts based on an examination of the mode of construction of their walls, have been made to separate these dilatations into true and false or spurious aneurisms; or in accordance with a principle at variance with Scarpa's view of the cellular sheath of the vessel, into true and mixed aneurism, the latter being subdivided into external mixed and internal mixed or hernial aneurism. This class, moreover, comprises the dilatations which Cruveilhier and others, distrustful of the results of anatomical examina- tion, divided merely in accordance with their external forms, into diffuse, fusiform, cylindroid and sacciform aneurisms. The last class were divided by Cruveilhier into "A. sous Vaspect d'ampoules" with subdivi- sions into "A. peripheriques, semiperiphSriques," and " d bosselures," and "A. sous l'aspect de poches d collet." These dilatations considered under the common term of aneurism— spontaneous aneurism—will form the subject of the following remarks. We must, however, begin by observing that a classification of aneu- risms, simply based on the anatomical conditions of the coats of the artery, can only have reference to gradual disturbances, and cannot, therefore, afford a representation of essentially different and well-defined species, where the grounds that give rise to the formation of aneurism are the same. Although, indeed, a division derived from external form may have some practical utility, it cannot afford a sound classification, inasmuch as it has no reference to the anatomical disturbance on which the form depends, nor can it separate well-defined species, owing to the numerous transitions of form which they undergo.—We do not purpose giving any special description of the arrangements made by different ob- servers of these forms, since the references made to them in the appro- priate parts of our work will be sufficient for their correct apprehension. Spontaneous Aneurism appears in its simplest type as a diffused di- latation of a vessel towards all points of its surface in a cylindrical form, vol. iv. 14 210 ABNORMAL CONDITIONS OF or when, as is usual, it gradually decreases towards both its extremities, till they assume the normal calibre, it is fusiform (the A. diffusum cylin- droideum of some writers, Cruveilhier's A. sous I'aspect d'ampoules periphiriques). Where the diseased condition of the coats of the vessel affects a more or less sharply-defined and considerable portion of the surface, the vessel dilates at that point in the form of an originally shallow pouch, which is gradually converted into a sac, flattened at its edges, where it is in con- tact with the interior of the artery, constituting saccular Aneurism, Cruveilhier's A. sous I'aspect d'ampoules semiperipheriques. The same is the case when, in diffused disease of the vessel, the morbid condition pre- ponderates at any one point of the surface ; the vessel being then gene- rally dilated, but more especially at this point, whereas in the former case it is dilated into the form of a sac with ill-defined margins, and flattened at the spot where it branches off from the vessel. It will be readily understood that a cylindrical or fusiform aneurism may very commonly be converted into a saccular aneurism, in conse- quence of the preponderance of disease at one or other point of its walls ; or, even in the absence of disease, this change of form may arise at any point especially exposed to the force of the blood-wave, as for in- stance at the convexity of the ascending aorta. These aneurisms are not only remarkable for their frequency, but more especially for the extraordinary size which they very commonly attain. The most important among them are those in which the saccular expansion affecting a portion of the periphery of the vessel is so situated that the wall opposite to the sac retains its normal form and direction. These approach to the pedicled aneurisms. Saccular Aneurisms are commonly of a round form, although they are occasionally oval or conical in shape, even from their commencement; more frequently the form loses its roundness in consequence of excessive disease of the coats of the vessel at different points, when the dilatation preponderates more or less in one direction. Finally, secondary pouches in the form of roundish or conical eleva- tions, or protuberances—Cruveilhier's A. sous I'aspect d'ampoules a bosse- lures—not uncommonly occur in the aneurisms already described (viz., in cylindroid, fusiform, and sacciform aneurisms), when the disease of the coats of the vessel preponderates at several generally inconsider- able, although somewhat sharply-defined points. These protuberances may in their turn give rise to excrescences of a secondary form (a tertiary / aneurismal formation), which project in various ways over each other, giving the vessel the appearance of an irregularly lobulated sac. When a cylindrical or fusiform dilatation attacks a vessel irregularly over a considerable portion of its surface, and preponderates at different alternate points of the periphery, causing the vessel to extend in a longi- tudinal direction, by which its course becomes twisted, and as it were distorted round its axis, we again have the form of aneurism termed cirsoid. A study of the development of the above forms yields the following facts in relation to the construction of the walls of these aneurisms. When the dilatation has not exceeded a certain degree, the walls of THE ORGANS OF CIRCULATION. 211 all these aneurisms consist of the whole of the diseased coats, and hence constitute true aneurism. The internal stratum is formed by the depo- sition in its different conditions of opacity, fibroid metamorphosis, athero- matous process or ossification, and in a state of actual channelling. It represents the lining membrane of the vessel. Next follows the decolor- ized and cleft circular fibrous coat in the act of being metamorphosed into fat; and, lastly, the elastic and cellular coat—the cellular sheath— whose fibres are entwined with one another, and with those of the circu- lar fibrous coat in a hyperaemic and vascular condition, and which ex- hibits either a bluish red coloration, or pallor and sclerosis. When the dilatation is very considerable, the tissue of the circular fibrous coat is found to be much separated, while the stratum seen through it is thinner than usual. When the dilatation has extended be- yond a certain limit, the fibres of the circular fibrous coat are not only completely separated, and even wanting at several inconsiderable portions of the aneurism, but this coat gradually disappears at the borders of the highest elevation of the fusiform or saccular aneurism, and at the margins of the superposed secondary pouches; the wall of the aneurism consisting here only of the diseased lining membrane of the vessel and of the cel- lular sheath. At these pouches the dilatation constitutes the so-called internal mixed or hernial aneurism, which we purpose considering more in detail. There is a form of aneurism presenting considerable interest in many points of view, which Cruveilhier has designated A. sous I'aspect de poches d collet, and which may be termed pedicled aneurism. It dif- fers very decidedly in its marked external form from the saccular variety already described, and is separated from it by many stages of transition. This aneurism resembles a round sac, which is in general attached to the diseased vessel by means of a neck-like base or contraction. This base corresponds to an opening into the vessel, which is equal in circumference to the contraction, and is either round or oval in form, and surrounded by a projecting margin. It constitutes the channel of communication between the vessel and the aneurism. No form of aneurism presents such striking variations in magnitude as this ; since, without reference to the calibre of the vessel, it may ex- hibit every possible size, from that of a pea to that of the fist, or even of a man's head. The most common size is from that of a walnut to that of a middling-sized apple. These aneurisms are, moreover, dis- tinguished by their tendency to burst when still of very inconsiderable dimensions, as for instance, when they are not larger than a pea or a bean. An examination of the walls of these aneurisms yields the following facts: 1. In most cases, the wall of the sac at its base near the opening into the artery, consists of the wall of the artery that has been everted by the aneurism and of all the diseased coats of the artery, whilst the circular margin surrounding the opening is formed by a duplication, as it were, of the entire wall of the vessel. At different distances from this point, however, the circular fibrous coat, after having become gradually thinner, entirely ceases, and the wall of the aneurism then consists almost wholly of the deposition (the inner coat of the vessel) and the cellular 212 ABNORMAL CONDITIONS OF sheath. The margins of the opening are smooth and covered by the deposit; the aperture is roundish.—These appearances present them- selves in very small as well as in large aneurisms of this nature. This form of aneurism almost invariably occurs as a secondary formation, being seated on a cylindroid or fusiform aneurism. 2. In some few cases the circular fibrous coat terminates sharply at the margin of the aperture in the artery. The aperture is generally irregular and angularly contracted, whilst the wall of the saccular pouch above it consists of the cellular sheath and of a deposit, which projects from the contiguous inner surface of the vessel over the margin of the circular fibrous coat in the form of bridge-like plates and strings, and adheres loosely to the cellular sheath in the cavity of the expanded por- tion of the vessel. This appearance is observed only in small aneurisms before they exceed the size of a bean or a hazel-nut, and they then com- monly prove fatal by bursting. They usually occur as primary aneu- risms, and in general in arteries that are only slightly and locally dis- eased. The aperture in the circular fibrous coat is obviously the result of loss of substance. 3. In cases of similarly rare occurrence, we meet with a sharply- defined bulging of the artery, filled with the atheromatous mass resulting from the disintegration of the deposit and the circular fibrous coat. The wall is here composed of the cellular sheath. On considering the above relations, we arrive at the following con- clusions in reference to the origin and form of these aneurisms. Although nothing positive can be determined in reference to the question, whether the appearances considered under the first head are the result of the further development of the appearances included under the second head, it is however very probable that such is not the case. The aneurism considered under the first head appears to be the result of excessive disease of the coats of the artery at a circumscribed spot. The artery bulges, and its wall then bends at the margin of the diseased tissue towards the tube of the vessel, with which it forms, as it were, a duplicature of the wall of the artery. Finally, the circular fibrous coat gradually separates at the top of the bulging, when the deposit, con- sisting of the diseased lining membrane of the vessel, is brought in con- tact with the cellular sheath with which it coalesces within this cavity. The further enlargement is now especially exhibited at this point, until the wall of the aneurism finally consists, for the most part, merely of the deposit and the cellular sheath. This is undoubtedly the form that'has been named external mixed aneurism (Scarpa's Aneurysma spurium), and is believed by some observers to consist merely of the cellular sheath of the artery, in con- sequence of their having regarded its investment as unessential and as a recent formation, and from their inability to trace the whole of the layers passing into the aneurism. Since we are disposed from our view of the subject to regard the investment as originally formed by the diseased lining coat of the vessel (although certainly in a condition of expansion and attenuation) which has coalesced with the cellular sheath in the aperture formed in the circular fibrous coat, we may regard this aneurism as the same which has been named by other observers hernial aneurism. THE ORGANS OF CIRCULATION. 213 The appearances considered under the second head, have undoubtedly been developed from those noticed under the third head ; at all events we are unable to discover in what manner this loss of substance has taken place within the wall of the vessel, unless by the atheromatous process described under the third head. We find that the deposit and the circular fibrous coat are affected throughout and destroyed. The atheromatous mass is gradually lost by being absorbed into the blood, and hence the bulging at this point consists of the cellular sheath.—This aneurism, when considered in accordance with the above-described mode of origin, is, strictly speaking, an external mixed aneurism ; but in this form it pro- bably never constitutes the subject of anatomical investigation. Thus, for instance, an inner coat of the vessel is produced in the form of a recent deposit, which renders it difficult, or indeed almost impossible, to recognize and distinguish this aneurism from others, especially when it has existed for a prolonged period. This aneurism does not appear, however, to be of long continuance, but generally bursts while of incon- siderable size. It is, moreover, of very rare occurrence when compared with other aneurisms, and cannot therefore have been the sole means of giving rise to the theory in reference to external mixed aneurism, or of originating the opinion of the frequency of its occurrence. We take the present opportunity of answering the question, Whether a rent in both the inner coats of the artery can give rise to the formation of an aneurism of this class f The belief in this mode of origin has met with almost universal accordance, although, as far as we know, the correctness of the opinion has never been proved by any one. The cavity in the neck or pedicle of these last-named aneurisms has commonly been regarded as a fissure. Yet, as far as we are aware, no such rent has ever been detected, nor have we ever found that a fissure in the inner coats of the artery afforded a basis for the formation of an aneurism. (Compare Laceration of the Arteries.) We believe that the above observations comprise all the most important points in reference to the form of spontaneous aneurisms and the con- struction of their walls, however much they may seem at variance with a sharply-defined classification of aneurisms in accordance with any fixed principle. By way of completing our observations, we will only remark, that the deposit covering the inner surface of the last described aneurism which is attached by a neck, is also found to be affected by the different conditions of opacity, atheromatous disintegration, and ossification. There still remain several other appearances in the aneurism which demand our attention. 1. The cavity of the aneurism very_ frequently contains fibrinous coagula, which usually form very distinctly stratified masses. The external and older layers consist of a whitish fibrinous substance, gene- rally more or less deprived of color, and of a faded appearance. They are dense, compact, tough like leather, and dry. The inner layers con- stantly become looser, more moist, and colored, until at length the innermost—those of most recent formation—resemble a recent coagulum of blood. The fibrinous layers frequently exhibit many other conditions of great interest. Thus, for instance, the external, denser layers become, in some cases, converted into a whitish, callous texture, which coalesces 214 ABNORMAL CONDITIONS OF with the wall of the aneurism, and very considerably strengthens it. In some cases they present an ossification similar to that which appears in the fibroid exudations, as, for instance, on the serous membranes ; while, at other times, they are observed to be softening into a yeast-like yellow or whitish pulp, or a cream-like fluid. As an important phenomenon Avhich is often presented, we may notice that a recently formed layer of the lining coat of the vessel is inserted at different points between the strata of the fibrinous coagulum, giving the Avhole mass the appearance of being invested with such a membrane, which is then prolonged into the deposit investing the interior of the vessel. We here discover the means employed for restoring and main- taining the continuity of the vessel by closing the cavity of the aneurism with a new layer of the lining membrane of the vessel. The fibrinous layers in the aneurism fulfil, therefore, no other purpose than that of assisting mechanically to maintain the coagulation of the blood and of its fibrin. They are not the product of an inflammatory process in the wall of the aneurism, nor do they exhibit the character of a malignant growth. These coagula are not present in every aneurism. As a general rule it may be assumed that, without reference to the size of the aneurism, they will be present in large quantities, in proportion to its distance from the axis of the blood-current, and to the smallness of the communication between the cavity and the calibre in the vessel, when compared with the size of the aneurism. Hence we see the reason why fibrinous coagula are so much more readily and extensively deposited in aneurism of the pedicled form, which presents these two requirements in the most highly developed degree, and why their formation becomes the less easy when the aneurism differs from the above and approximates to the spindle- shaped or cylindrical variety. In these and saccular aneurisms, the formation of the coagula depends only on the extent to which the wall of the pouch recedes from the axis of the blood-current. It is, moreover, natural that fibrinous coagula should occur in larger quantity in large than in small aneurisms of the same form. These fibrinous coagula derive importance from the obstruction they oppose to the rapid increase of the aneurism and to its early bursting, and in consequence of their causing a wasting of the aneurism, and thus inducing its spontaneous healing. 2. These aneurisms differ very considerably in their dimensions, as has been already observed, varying from the size of a pea or bean to that of a man's head, and thus occasionally filling up the greater part of one of the large cavities of the body. In general, the largest aneurisms occur on the large arteries, more especially on the trunk of the aorta; but there is no invariable proportion observed between the size of the aneurism and the calibre of the vessel, for aneurisms fully equal in size to those which occur on the trunk of the aorta, are occasionally met with in vessels of inferior calibre, as, for instance, the femoral and popliteal arteries. Large aneurisms experience a very extensive alteration in the con- struction of their walls, to which sufficient attention has not been paid. Until the aneurism has acquired a certain degree of enlargement, it THE ORGANS OF CIRCULATION. 215 retains its primary wall, whose composition we have already described; but when the aneurism exceeds these limits, and the wall is no longer equal to the expansion, its place becomes supplied by adventitious tis- sues and structures, either over the whole extent, or at more or less sharply-defined spots, corresponding to the direction of the increase in volume. These are the structures with which the aneurism is in contact during its increase, and with which it gradually coalesces. This circum- stance explains the reason why aneurisms, which only increase very sloAvly in volume, and therefore are only gradually brought in contact with structures able to compensate for the loss of substance of their walls, may attain so great a size, whilst those aneurisms which are rapidly formed and enlarged, and are, therefore, not brought in contact with many of these structures, speedily burst. These adventitious pro- ducts are accumulations of cellular substance, serous and fibrous mem- branes, muscular expansions, &c, together Avith parenchyma, as, for instance, that of the lungs. We must distinguish between the manner in which aneurisms of great size lose their primary wall, and the loss arising from the result of detritus—the absorption occasioned by pressure where the aneurism is in contact with bone. Thus we find, that where aneurisms, even of very inconsiderable dimensions, are in contact with bone, the aneurismal wall, together with the periosteum, is partly destroyed and the bone exposed. 3. We have already considered all the essential points in reference to the form of these aneurisms. It will be evident that the vicinity of re- sisting structures may, in various ways, modify the form of the aneurism during its growth. Thus aneurisms on the descending aorta occasionally assume a bilobar form posteriorly, in consequence of the resistance offered by the vertebral column, which causes it to separate into two sacs lying on either side. 4. We find great diversity in the number of aneurisms which may be simultaneously present. In some cases, several aneurisms are present together, either on different arteries or in close vicinity to each other on the same artery, so that the tube of the vessel exhibits a row of adjoin- ing and even confluent aneurisms. Large aortic aneurisms are usually isolated, which may be explained, at least in part, by the weakening of the mechanical force through the carrying off of a large quantity of blood towards the aneurismal sac. 5. The greatest interest and the most important results arise from the relations exhibited by the branches passing from an artery affected with aneurism ; they consist in narrowing or entire closing and displacement of the mouths, and the consequent atrophy of the vessel. These results are produced by various and often intimately connected means. a. A highly developed degree of deposition (see p. 206), very com- monly gives rise to the important conditions of contraction, and, finally, complete closure of the mouths of vessels opening into the artery affected with aneurism. It more especially affects the mouths of small vessels branching off from the diseased trunk, either at a right or an obtuse angle, as, for instance, the mouths of the intercostal arteries, and of other vessels branching off from the diseased thoracic aorta; although it also not unfrequently implicates the mouths of vessels of larger calibre, as, for instance, those of the carotids, the subclavians, &c. 216 ABNORMAL CONDITIONS OF b. Secondly, the mouths of the branches of the vessels are also ren- dered insufficient and are displaced by means of the fibrinous coagida deposited on the wall of the aneurism. They have commonly been already contracted by the deposition, or have been rendered insufficient by means of the fissure-like opening, which we shall shortly notice. This imperviousness of the mouths is more especially limited to those vessels which branch off from the diseased trunk, either at right or obtuse angles. In consequence of the displacement and closure of the mouth, the blood which reaches the branch of the vessel through the collateral cir- culation coagulates, and the vessel is then obliterated from above the plug to the point where the next branch is given off. c. Thirdly, the branches passing off from a diseased trunk are ren- dered insufficient by the round form of the mouth being contracted and altered into a cleft-like opening, which is frequently rendered still more impervious by the projection of a valve-like margin which inclines back- wards in the direction of the heart. This is more especially found to occur in the branches of the arch of the aorta, when the latter is the seat of large saccular dilatations. d. Finally, there is a mode of obliteration that occurs in the vessels branching off from an aneurism, either independently, or complicated with the above-described forms. This mode of obliteration is the result of inflammation with exudation upon the inner surface of the vessel, and of the subsequent coagulation of the blood. It appears only in ves- sels having thin walls, and which are, therefore, liable to this form of inflammation. The effect of the aneurism on neighboring parts is to displace and press upon them, in proportion to their inability to offer any resistance to this pressure. By these means the functions of the injured organs are either partially or entirely obstructed. Thus aneurisms of consider- able size may variously contract the space of the cavities of the body, and either diminish the apertures of different passages, such as the trachea, the bronchial tubes, the oesophagus, the arteries and veins, &c, or compress them so powerfully as to render them entirely impervious. Pressure gives rise in different structures to various alterations which are proportional to the degree of pressure and the capacity for resistance presented by the tissue. Moderate pressure generally occasions inflam- mation in the contiguous structures, which gives rise to condensation and thickening—increase of bulk. When the pressure exceeds a certain limit, it results in atrophy. Both of these results are, however, fre- quently combined, being found simultaneously present in different parts of the tissue; thus, for instance, the parts in the immediate vicinity of the aneurism may be atrophied, whilst the more remote tissue exhibits a new formation of cellular substance and of fibroid tissue. We very frequently observe that bones which have been exposed to the action of an aneurism exhibit atrophy (detritus), whilst various osseous formations —osteophytes—occur at detached points surrounding the aneurism, and even sclerosis may be present in the contiguous bony layers. Yielding membranous expansions in part give way to strong pressure, while their fibres admit of being separated; and in part they become THE ORGANS OF CIRCULATION. 217 gradually atrophied like cellular tissue, serous and fibrous membranes, muscular coats, &c. Large masses of muscle become pale and thin, and even wholly disappear. Highly vascular and nervous structures, such as the external invest- ment and the mucous membranes, have their texture so much loosened by inflammation, that they readily tear; or where this is not the case, they become gangrenous. Parenchymatous structures waste away in consequence of the exuda- tion produced by inflammation, and finally become atrophied. Vessels are obliterated either in consequence of coalescence, induced simply by perfect compression, or in consequence of inflammation, that is to say, by means of adhesion to a coagulum of blood produced by the inflammatory process. Nerves undergo atrophy through pressure and tension. ^ Rigid structures become atrophied in proportion to their deficiency of elasticity. Detritus of the bones is therefore very commonly induced by aneurism, whilst cartilage and fibro-cartilage, as, for instance, the intervertebral cartilages, are longer able to resist this action. This detritus is most frequently observed in the bodies of the vertebrae, in the ribs and the sternum, the clavicle, and also in the scapula in aortic aneurisms, and is often present in so highly developed a degree, that these bones are entirely destroyed, and the osseous wall of the thorax perforated. The vertebral canal has even been seen opened. The process of resorption induced by the deposition and pressure of an aneurism on the bones, destroys not only the osseous substance itself, but, sooner or later, the aneurismal wall also, which becomes fused as it were with the periosteum and the other fibrous structures that usually invest the bones. The bone is then either very commonly laid bare, or is only covered by a layer of the deposition investing the aneurism, or by the fibrinous coagula in the aneurismal sac. The exposed vertebral column thus very frequently constitutes a portion of the aneurismal wall. In aortic aneurisms which perforate the anterior or lateral wall of the thorax, the roughened and nodular extremities of the ribs, the clavicle, and the sternum, are almost entirely denuded on their inner surface, and project into the sac of the aneurism. The effects of the aneurism are diffused beyond its own immediate locality to distant organs, and even over the whole organism. These effects are as varied in their nature as the influences from which they arise; but in general they occur more rapidly, are more violent, and are more extensively diffused in proportion to the size of the aneurism, its relation to a main artery, and its vicinity to the heart. The pressure on the nerves and their tension occasion variously developed symptoms of neuralgia and paralysis. The pressure of the aneurism gives rise to a varicose condition of the veins below the aneurism, venosity, cyanosis, dropsy, and inflammations, which frequently terminate in gangrene. Large aneurisms on the trunk of the aorta have a tendency to produce active dilatation of the heart, and this tendency is the more marked in proportion to their vicinity of that organ. They give rise to this disease either in association with insufficiency of the aortic valves, which is, how- 218 ABNORMAL CONDITIONS OF ever, generally the case, or independently of this affection. They also induce general venosity, diffused, as it were, from this point, as from a centre. . . . The pressure on the arteries, and the occlusion resulting from it in the region of the aneurism, may possibly be unattended by injurious results, in consequence of the establishment of a collateral circulation. The stasis and coagulation of a considerable quantity of blood within a large aneurism, have the effect of withdrawing so large a quantity from the organism, as to occasion symptoms of anaemia, tabes, a watery condition of the blood, general dropsy, and cachexia. The pressure of the aneurism on parenchymatous structures, and the obstruction of their functions, contribute without doubt to the presence of cachexia, and to the development of its special character. The following must be noticed in reference to the modes of termina- tion of aneurism: Aneurism very commonly terminates fatally. This fatal termination is very frequently induced by the results already mentioned, amongst which we may specially place diffused inflammations terminating in gangrene, dropsy of the cavities of the body, hyperaemia and acute oedema, more especially of the lungs, cachexia, and general marasmus. Spontaneous opening or laceration, rupture and extravasation of blood from the rent constitute a very frequent, always extremely unfavorable, and indeed very often rapidly fatal termination of aneurism. We would direct attention to the following particulars in reference to this subject. The tendency to spontaneous opening does not bear a direct relation to the size of the aneurism, for we find that small aneurisms burst more frequently than larger ones. The direction in which the aneurism opens, and in which the blood emerges, varies considerably. Aneurisms in the limbs open into the surrounding cellular tissue, in consequence of which a large quantity of blood is extravasated into the intermuscular, subcutaneous cellulatftissue, below and between the aponeuroses, the muscular sheaths, &c. Aneu- risms of the trunk, and of some of the branches of the aorta, as, for instance, the splenic, open into the large cavities of the body, as the peritoneal sac, one or other of the pleural sacs, or the pericardium, occa- sioning hemorrhage into the corresponding cavity and the sub-serous cellular substance. Aneurisms of the cerebral arteries open in a similar manner into the sac of the Arachnoid, and into the tissue of the Pia Mater. Aneurisms very frequently open into canals, as the trachea, the bron- chial tubes and their large branches, and oesophagus, and more rarely into the intestinal canal and the cavities of the urinary passages. They however very commonly open into other bloodvessels, either arteries or veins, and even into the cavities of the heart, more especially the auricles. Such openings very frequently occur in aortic aneurisms into the trunk of the pulmonary artery and its branches, and into the ascending or descending Vena cava. Aneurisms that are imbedded in parenchymatous structures do not often open; the hemorrhage here takes place into the parenchyma, and THE ORGANS OF CIRCULATION. 219 after the latter has been extensively displaced or perforated in the form of a canal, the blood flows freely into the adjacent serous cavity. We have seen one instance in which an aneurism of the aorta opened into a tuberculous pulmonary cavity having healed, consolidated walls. Finally, aneurisms may sooner or later penetrate to the general invest- ments, and open externally. The manner in which aneurisms open is not the same in all. Aneurisms which project into a serous cavity burst at that part which, having coalesced with the serous membrane, and become extremely thin from a deficiency of the surrounding tissue adapted to strengthen and protect it, offers* the slightest degree of resistance in consequence of the excessive attenuation of its walls. The opening generally occurs at one of the most saccular portions of this wall, and is either in the form of a fissure, or more frequently of a roundish aperture having a fringed margin. The latter appearance induced Hasse to believe that the open- ing was preceded by a pre-existing and self-induced process of softening, but we have never been able to detect its presence in the numerous observations in which we have been engaged. In those cases in which the aneurism bursts through the walls of the canals on which it is seated, and opens into their caA-ities, the process is more complicated. Thus aneurisms open into the trachea, the bronchus, and the oesophagus, when the fibro-cartilaginous and muscular elements, together with the adhering wall of the aneurism, are destroyed by detritus, in consequence of the mucous membrane becoming the seat of inflammation, and tearing in that condition with the aneurismal wall. In other cases, as for instance at the oesophagus, a gangrenous eschar is developed in the mucous membrane over the encroaching aneurism, and, by extending over the whole of the aneurismal wall, usually gives rise to extensive opening of the aneurism. The opening of the aneurism into the cavity of the neighboring blood- vessels is brought about in various ways. In some cases the aneurismal wall coalesces with the cellular sheath of the adjacent artery in such a manner as to deprive the circular fibrous coat of the latter of its proper support. As the aneurism exerts a stronger impulse on the vessel, the cellular sheath becomes completely separated from the artery, and, con- sequently, the aneurism and its circular fibrous coat at length burst. The rent is in general large, and presents an angular form in this coat of the artery; it is usually complicated with detachment of the cellular sheath over varying extents of surface from the fissure. (See Dissecting Aneurism.) In other cases, the cellular sheath of an adjacent artery coalesces not only with the aneurismal wall, but also with the circular fibrous membrane of the affected artery, in consequence of a very chronic process of inflammation, and the slow development of the aneurism. The circular fibrous coat directly coalescing with the aneurism is thus rendered thinner, whilst its fibres separate from one another, and at last wholly disappear at different points. At the point which corresponds with the most marked protrusion of the aneurism into the artery, the aneurism bursts together with the layers of the lining membrane of the artery coalescing Avith its wall. The rent, as in aneurisms that open towards a serous cavity, is small, fissure-like, or resembles a roundish hole.—The 220 ABNORMAL CONDITIONS OF opening of aneurisms into a contiguous vein is effected in the same man- ner. (Spontaneous varicose aneurism.) We occasionally find in aneurisms imbedded in parenchymatous organs and cellular accumulations, that there is an acute inflammatory process, which hinders the development of a protecting and strengthening callus, and by predisposing the tissue to softening and laceration above the pulsating spot, occasions laceration. In other cases the tissues are sepa- rated by the pressure, without the concurrence of any such inflammatory process, and thus give rise to the rupture of the aneurism. When an aneurism opens outwards on the surface of the body the process depends, as in aneurisms that open into the mucous canals, on a nigh degree of inflammation in the true skin, occasioning a separation or laceration of the tissue, or on a gangrenous eschar implicating the general investments. Such openings are very often rapidly formed and single, although occasionally we observe several small perforations, so that there is at first only a gradual and recurring oozing of blood, until the opening acquires a very considerable size. Finally, the wall of a cylindrical, spindle-formed, or saccular (true) aneurism, frequently exhibits perforations which are owing to a lacera- tion and detachment of the diseased inner coats from the cellular sheath of the vessel. But this is a subject to which we shall revert when we pass to the consideration of the spontaneous lacerations of arteries. The above forms of aneurismal ruptures in ordinary cases produge death by hemorrhage, externally, or into one of the large serous cavities, or into the trachea, the alimentary canal, &c. When the aneurism opens into other vessels, such, for instance, as the arteries in the vicinity of the heart, or into any of the cavities of the heart, the result is in general speedy death, in consequence of the obstruction in the circulation. There are, however, exceptions to this rule; and we find that in some instances, small perforations of the latter kind may exist for a prolonged time without causing death, in which case the aperture through which the communication is maintained, acquires a smoothed, healed appear- ance, from its margin being invested with a recently formed lining mem- brane. This is more especially the case when the aneurism opens into a vein, and thus constitutes a basis for the formation of a so-called spon- taneous varicose aneurism (Thurnam). However unfavorable the ordinary termination of an aneurism may be, instances are occasionally observed in which the disease takes a more favorable turn, and nature brings about a spontaneous cure of the aneu- rism. This result is effected in many different ways, which have4 been especially considered by Hodgson. 1. The aneurism may compress the artery on which it is seated in such a manner, either above or below, that it gradually becomes impervious, and is then obliterated with the aneurism. We attempt to imitate this healing process artificially, by passing a ligature either above or below the aneurism. Such a result can only affect saccular aneurisms, and such as are attached by a neck. 2. The aneurism may be completely filled with fibrinous coagula above which a deposit is formed, which represents the lining coat of the vessel) THE ORGANS OF CIRCULATION. 221 and stops the communication between the cavity of the aneurism and the tube of the vessel. Aneurisms attached by means of a neck, and having only a narrow passage of communication, present the most favorable conditions for this mode of termination. We even observe, in some rare cases, that where saccular or spindle-shaped aneurisms have been com- pletely filled with fibrinous coagula, new formations continue to be depo- sited upon the former, until at length the whole diseased vessel becomes obstructed. Decrease in the general quantity of the blood and a diminu- tion of the heart's action must be regarded as the most favoring influ- ences. In both these conditions the aneurism shrivels and contracts over the coagula, either in the form of a fibroid capsule or of a spindle-shaped cylindrical roll, and is then atrophied. 3. In aneurisms in the extremities the gangrenous process to which they give rise attacks the aneurism itself, and by exciting arteritis, causes the artery to be stopped up by a coagulum. The aneurismal sac is thrown off and removed, and the artery obliterated at various parts. In the same manner, abscesses and inflammatory foci in the vicinity of an aneu- rism may occasion arteritis, accompanied by occlusion, and subsequent obliteration of the artery, by which the aneurismal sac is destroyed, and removed by suppuration. Spontaneous aneurism generally occurs with the same proportional frequency in the two arterial systems, and in the different portions of the aortic system as the disease of the coats of the vessel on which they are based (see p. 204). The relative scales of frequency established by diffe- rent observers are indeed tolerably accurate; but still many of the re- sults which have been given are incorrect ;/thus, for instance, the assump- tion of the great frequency of aneurism of the popliteal artery, is un- doubtedly so far incorrect that it includes in the same class with sponta- neous aneurisms of the lower limbs, which are certainly not of rare occurrence, many others which very probably were of traumatic origin. In general, aneurisms are incomparably more frequent in the larger than in the smaller arteries, and their occurrence on the trunk of the aorta is characterized by remarkable frequency. Aneurisms are, on the contrary, very rarely observed in the pulmo- nary arterial system, where, as far as we know, they are limited to the trunk. Fusiform and saccular dilatations do certainly sometimes occur in the ramifications of the pulmonary artery, within the parenchyma of the lung, as we have observed near tuberculous caverns; but as they originate from entirely different causes, they do not belong to this class (compare p. 198). Aneurism of the trunk of the pulmonary artery is scarcely ever pre- sent, unless there is at the same time aneurism of the aorta, or, at all events, a tendency to that disease. Although it may be said in reference to the sex most frequently affected that there is a preponderance in men, it is by no means so considerable as is usually supposed. The age at which aneurisms are most common is between the 30th and 60th year; they are of much rarer occurrence between the 20th and 30th year, and must be regarded as extremely unfrequent, and as exceptional cases, when they are present before the 9<>2 ABNORMAL CONDITIONS OF age of 20 years. We must, however, exclude from this calculation all the aneurisms of traumatic origin which have hitherto not been separated with sufficient care. , It has long been supposed that aneurisms are based on a special aneu- rismal diathesis, in consequence of the frequency with which they have been observed to appear spontaneously and independently of external influences, and from the fact that several occur simultaneously or in quick succession to each other in the same individual. Thus incidental and individual cases have led to the idea that these predisposing condi- tions were to be sought in gout, syphilis, or mercurial cachexia; and this opinion was supposed to derive support from the more frequent occur- rence of aneurisms in men, as well as from the period of life at which they are most commonly observed. It was conjectured that this diathesis gave origin to the diseased condition of the texture of the coats of the vessel, and to their loss of elasticity and their softening and brittleness. We have sufficiently considered the anatomical bearings of the disease affecting the coat of the vessel on which the formation of spontaneous aneurism depends (see p. 199), and have drawn attention to an anomaly of the blood-crasis, which may give origin to an aneurism (see p. 206). Nothing positive is known in reference to this blood-crasis ; but the con- currence of the above-named diseases with aneurism appears to us to be purely accidental, nor do we think that such individual cases afford suffi- cient scientific grounds for the connection that has been supposed to exist between these diseases and the aneurism. It is a very important fact that spontaneous aneurism never exists in combination with tuberculosis. This immunity is based on the following grounds: a. The diseased condition of the coats of the vessel on which aneurisms depend, constitutes a cause of immunity against tuberculosis (see p. 206). b. Large aneurisms of the aorta give rise to consecutive disease of the heart in the form of dilatation, with a readiness proportional to their vicinity to the heart. It is, therefore, in consequence of the venosity and cyanosis occasioned by the latter disease, that aneurisms of the aorta afford a decided immunity against tuberculosis. Aneurisms, as we have already seen, have nothing in common with cancer. It still remains for us specially to notice several particular forms of aneurism. Aneurism of the Aorta.—The aorta is more frequently the seat of aneurism than any other Aressel, and the parts most commonly affected by aneurismal formations, are the ascending aorta, and the arch. The aneurisms most common on the trunk of the aorta are the cylin- drical and spindle-shaped aneurism, the saccular form affecting only one side of the vessel, the pedicled, and even the cirsoid aneurism, Avhich is occasionally observed along the entire length of the tube of the aorta. Saccular expansions very frequently occur in the ascending aorta at the sinuses, and especially at those two which correspond to the convex wall of this portion of the aorta. These aneurisms very frequently burst at an early stage into the cavity of the pericardium, and occa- sionally into the right auricle.—Pericarditis in some instances gives THE ORGANS OF CIRCULATION. 223 rise to the rupture of aneurisms projecting into the cavity of the peri- cardium. Aneurisms are incomparably more frequent on the convex than on the concave side of the ascending aorta. The same is the case in reference to aneurism of the arch of the aorta. On the aorta descendens, aneurisms within the thorax appear most fre- quently to proceed from the posterior wall and the sides of the vessel, so that they very commonly implicate the vertebral column and the adjacent thoracic wall. Aneurisms of the abdominal aorta are usually spindle-shaped and sac- cular, and are most frequently developed from the anterior and lateral portions. An extensive series of observations has afforded the following particu- lars in reference to the remarkable peculiarities presented by these aneu- risms. 1. Those aneurisms which arise from the convexity of the ascending aorta, and from the anterior and upper wall of the arch of the aorta in general attain a very considerable size, inclining in such a direction that they touch the right half of the sternum, the costal cartilages, and the ribs of the right side from the first to the fifth or sixth, or even extend to the sterno-clavicular articulation and the right clavicle, finally destroying the parts by detritus, and coming to view externally in the corresponding region of the thorax. It is important to remem- ber that such is their course, from which there are very few exceptions, because an aortic aneurism occurring at the sterno-clavicular articulation and at the right clavicle is very commonly mistaken by the bedside for a subclavian aneurism, which is in general erroneously supposed to be of great frequency. 2. Aneurisms, proceeding from the concavity of the ascending aorta, extend in the direction of the pulmonary artery, or are seated in front of it, towards the wall of the left auricle, and open into one or other of these parts. Those aneurisms which proceed from the concavity and posterior por- tion of the arch of the aorta, abut upon the trachea and the bronchi, and in general open into them at an early period, and long before they have attained any considerable volume. 3. Aneurisms of the thoracic aorta commonly first implicate the ver- tebral column at the part corresponding to the above-described points of origin, and destroy it to various extents, and in rare cases, to such a degree that they come in contact with the dura mater of the spinal chord, and even burst into the canal. They moreover diffuse them- selves over the posterior wall of the left side of the thorax, and occa- sionally open freely into its cavity, or, in some rare cases, so completely destroy the thoracic wall as to come to view externally on the back. They very often implicate the left bronchus, make their way into the pulmonary parenchyma, and open into it, or into one of the larger bron- chial tubes within the lung.—When they occur on the right side of the vessel, they are situated in the mediastinum and on the oesophagus into which they open. 4. In the very rare cases in which aneurisms of the abdominal aorta 224 ABNORMAL CONDITIONS OF burst, their contents are usually effused into the cavity of the perito- neal sac. On Dilatations of the Ductus Botalli.—The dilatations which in rare cases are observed in the Ductus arteriosus, in every period of life, from the earliest infancy, are simple, and not dependent upon any altera- tion of texture in the coats of the vessel. They are occasioned by a deficient involution of the duct after birth. If we except that degree of patency of the Ductus arteriosus, in which, in consequence of a uniformly deficient involution (closure), it remains similar in calibre to a branch of the pulmonary artery in new- born infants, and forms a very secondary cylindrical vessel, we find the following different forms of dilatations, which admit of being referred to an unequally deficient closure of its mouths. 1. In one case, when the occlusion of both mouths has once commenced, the process goes on more slowly in one—probably the aortic mouth, whose calibre continues permeable after the other mouth has become considerably contracted. Blood now collects here, dilating the vessel, and gradually coagulating within it, forming a spindle-shaped or round, spherical capsule (aneurism), after which this mouth also is finally closed. This anomaly is unquestionably devoid of importance, and does not lead to any secondary consequences, as the coagulum, and the coats of the vessel over it, gradually shrivel together. 2. In other cases the Ductus arteriosus is found to present a funnel- like dilatation from the aorta, and the opening into the pulmonary artery is then surrounded by a torn and fringed margin. That this anomaly is not a true patency,—a persistence of the Ductus Botalli in its original form and significance,—is made evident by the above-mentioned relation of the duct, and more especially of its mouths; by its violent reopen- ing from the aorta, towards the pulmonary artery, as indicated by the character of the mouth; by the occlusion of the Foramen ovale, which is observed in such cases; and the existence of a current opposed to the foetal circulation, and inclined from the aorta towards the pulmonary artery. This condition is owing to the relation of the duct and its openings, that is to say, to the violent reopening of the closed ostium of the pulmonary artery from the dilated aortic portion of the duct; and also to the active dilatation present in these cases in the right side of the heart, which is one of the results of the obstacles produced by the en- trance of arterial blood into the current of the pulmonary artery. On Traumatic Aneurisms.—These are aneurisms which patients refer to some traumatic influence, such as a contusion, shock, or some unusual muscular effort, &c, and which the physician, in the absence of all dis- ease in the coats of the vessel, must regard as having such an origin. Aneurisms of this character especially occur in the arteries of the ex- tremities, and, as we have already observed, they are too commonly included without further inquiry under spontaneous aneurism, when they are undoubtedly of traumatic origin. To this class belong a certain number of aneurisms of the femoral, popliteal, and brachial arteries. We are here led to inquire what disturbance is set up in the wall of the vessel by the traumatic influence, which can give origin to the for- mation of the aneurism. THE ORGANS OF CIRCULATION. 225 This question is very difficult of solution; for on the one hand, we rarely or never have an opportunity of examining the artery immediately after the accident, while on the other an examination of an aneurism, when already developed, does not afford absolutely valid grounds for judging of the original disturbance. It is, however, very probable that this disturbance may be based upon some traumatic influence inducing paralysis of the circular fibrous coat at the affected spot ; destroying its contractility, and causing a separation of its fibres; and occasioning a partial laceration of the coat, not affecting either the integrity of the lin- ing membrane or of the cellular sheath of the vessel. We are led to this opinion from a consideration of the folloAving facts : 1. We cannot believe that traumatic aneurism can be produced by spontaneous laceration of the lining and of the circular fibrous coat of the artery, and therefore be owing to the dilatation of the cellular sheath at the spot where the rent occurs. We have never, for instance, seen an aneurism arise from a separation of the continuity of the lining and circular fibrous coats when it appears either as a spontaneous or a me- chanically induced rent; but, on the other hand, there is always, in these cases, a more or less violent and extended detachment of the cellular sheath, whether the arterial coats be healthy or diseased, constituting a secondary laceration of the sheath, and effusion of blood over the vessel. (See Dissecting Aneurism.) 2. In consequence of the great toughness and power of resistance of the cellular sheath of the artery, a separation of continuity can only be effected in all the coats of the vessel when the shock or contusion has been such as necessarily to produce extensive and repeated laceration of both coats. The consequence of this would at all events be to produce effusion of blood from the vessel over a considerable extent, giving rise to an evident false diffused aneurism which would also be subsequently apparent in the consecutive condition of false circumscribed aneurism. 3. The dilatation developed at the affected spot manifests itself origi- nally as a circumscribed and gradually enlarging tumor which is slowly developed, and shows both by its form and construction the probability of the view we have advanced in reference to the disturbance on Avhich traumatic aneurism is based. This dilatation exhibits either the form of a saccular expansion, or of a pedicled aneurism according to the de- gree of depression of vitality and loosening of continuity produced by external influences in the circular fibrous coat. Its walls principally con- sist of the lining membrane of the vessel and of the cellular sheath; in the first form we find remains of the circular fibrous coat between the other membranes, while in the second form the fibres of this coat are separated through external agencies; the lining coat of the vessel adhering within the interstices to the cellular sheath, and gradually protruding through it. The attenuation which the lining membrane of the vessel must ne- cessarily undergo, cannot be directly observed, in consequence of the new membrane which has been simultaneously formed in the aneurism. This second form of traumatic aneurism appears therefore to be a hernial aneurism, according to the signification we shall attach to it in the fol- lowing remarks. On Hernial Aneurism.—The existence of a hernial aneurism, or of vol. iv. 15 226 ABNORMAL CONDITIONS OF an internal mixed aneurism, has formed the subject of numerous inves- tigations, from the time of Haller to our own day. We have already become acquainted with aneurisms, which, as we in- cidentally observed, must be regarded as hernial aneurisms, in conse- quence of the anatomical disturbance to which they owe their origin, and in consequence also of the construction of their walls. It now re- mains for us more closely to define the sense in which we are led from experience to admit the existence of a hernial aneurism. If it be requisite for the establishment of a hernial aneurism that it should exhibit a dilatation of the lining membrane of the vessel in the form of a hernia through an opening in the middle and outer coat of the artery, we must wholly deny the existence of such a form of aneurism. 1. The direct experiments of J. Hunter and E. Home showed that the removal of the external coat of an artery did not give rise to the pro- trusion of the lining membrane in the form of an aneurism. Whether the external coat alone, or that and the middle one, Avere both loosened and detached, the result was simply inflammation and cure without any alteration in the calibre of the injured artery. However limited may be the application to be extended for various reasons to the results of these experiments, they are still highly interest- ing, and must excite our surprise from the opposition in which they stand to the result we should have been led to expect. We are not astonished merely at the circumstances that, after the removal of the outer and the middle coat, the lining membrane did not protrude, but still more that, considering its slight power of resistance, it did not at once give way. The circumstance that the middle and lining membranes were not lacerated after the removal of the outer coat, is very probably owing to the elastic sheath having been left on the vessel, and not removed with the outer coat. 2. To the results of these experiments we must add those yielded by observations on human arteries. Detachment of the sheath of an artery, which consists of an elastic and a cellular layer, is not attended, as we learn from observations of the so-called dissecting aneurism, by a saccular expansion of the exposed yellow and lining membranes, but by its immediate laceration, both in those cases in which it is owing to external influences, and those in which it has resulted spontaneously from a morbid process. When, moreover, this occurrence is met with in cases where the middle and lining mem- branes were observed to be healthy, we are the more led to conclude that it would exist where there is disease of these membranes. In such ulcerous perforations of the arterial wall from without inwards, as we noticed in the femoral arteries (see p. 198), notwithstanding the probably gradual and stratified separation of the different layers of the tube of the artery, we perceive no trace of aneurismal formation at the affected spot. ^ There is, on the other hand, a form of aneurism very frequently met with, which, when considered in the following sense, represents hernial aneurism. a. In spontaneous, spindle-shaped, saccular aneurism, the diseased circular fibrous coat gradually yields at spots which vary in number THE ORGANS OF CIRCULATION. 227 according to the size of the aneurism. The lining membrane of the vessel (the deposition) coalesces in the interstices thus produced with the cellular sheath, and wherever these portions are excessively dilated, the secondary aneurismal formation deposited on a cylindroid, fusiform, or sacciform aneurism, gives rise to aneurisms of a secondary form, com- monly known as hernial aneurism. b. Aneurisms that are attached by a neck, and that are composed for the most part merely of lining membrane and cellular sheath, essentially constitute hernial aneurism, in as far as they are produced in the same manner as the above-named secondary dilatations. c. Finally, traumatic aneurism, in accordance with the process from which it arises, and which has already been described, is a hernial aneurism. Dubois, Dupuytren, Breschet, and others have undoubtedly taken a similar vieAv of the question, when they maintained the existence of a hernial aneurism. We would, moreover, specially remark, although the circumstance seems sufficiently evident from the foregoing observations, that the inner coat of our hernial aneurism is by no means composed of the original lining membrane of the vessel, but consists almost entirely of newly-deposited strata. We do not, for obvious reasons, regard the establishment of hernial aneurism as a separate class to be essential, nor do we think it possible, in all cases, to separate it strictly from spontaneous aneurism. B. Abnormal Narrowness—Contraction—Obliteration of the Arteries. The arterial system presents numerous varieties of irregular narrow- ness, and, moreover, exhibits many differences in respect to its extent and degree. To this class belong congenital anomalies. 1. A Congenital Abnormal Narrowness of the Aortic System, which is strikingly apparent in the large arteries, and more especially in the trunk of the aorta. This is found in some cases, in adults, to be con- tracted, particularly in its descending arch, to the calibre of an iliac or even of a carotid artery. This anomalous condition, which is very gene- rally associated with deficient development of the system, and with a striking thinness and softness of the arterial walls, is often overlooked in childhood, and very commonly does not exhibit any distinct symptoms until the period of puberty, when it manifests itself by insufficiency in the calibre of the artery compared to the quantity of the blood, and by dilatation of the heart, more especially of the left ventricle. It most frequently occurs in females, and is combined with retarded develop- ment generally, and more especially with smallness of the sexual organs. Anomalies of various extent, amounting even to entire occlusion, are occasionally exhibited in the trunk and branches of the pulmonary artery, occurring as congenital conditions, combined with, and depending on obstructions in the interior of the heart. 2. A Congenital deficient Development of separate Portions of the Arterial System, more especially in relation to the calibre and elabora- 228 ABNORMAL CONDITIONS OF tion of the coats of the vessels supplying undeveloped, stinted parts and organs of the body. Acquired Abnormal Narrowness appears under many forms, and frequently attains so great a degree as to present complete occlusion of the artery. All the various contractions, and the atrophies in Avhich they result, may be principally referred to a simple involution of the artery, to contraction and obliteration in consequence of disease of the coats of the vessel, to occlusion of the artery, and to contraction and obliteration depending on pressure on the artery. 1. Contractions and Obliterations in the Form of simple Involution of the Artery. To this class belong the following: a. The contraction and subsequent atrophy which affect the arteries of organs that are becoming atrophied through accidental or intentional (operative) injuries inflicted on portions of the body which have been previously arrested in their growth. b. An obliteration which is very similar to the atrophy of the fostal passages, as for instance, that of the Ductus arteriosus. Such an oblite- ration of an artery is occasioned by the establishment of a collateral cir- culation, which is especially induced by a congenital narrowness (obstruc- tion) of the artery in question. The vessel becomes narrower in pro- portion to the progressive development of this collateral circulation, and is entirely closed when the latter is completed. To this class undoubtedly belong many cases of obliteration of the different arteries, the causes of which have not been sufficiently explained, and most certainly those cases of obliteration of the aorta at its arch beyond the part where the Ramus brachiocephalics is given off, corresponding to the depression of the Ductus Botalli. These cases, which embrace the majority of the observations made on obliteration of the aorta, have hitherto been unexplained, both in refer- ence to the malformations on which they depend and the process giving rise to final obliteration. They have been repeatedly collected and arranged (Barth, Craigie). From the interest which attaches to these obliterations of the aorta we are induced to add the following remarks, which are derived from the observations above referred to, as well as from my own experience. 1. An inconsiderable portion of the arch of the aorta, generally at the part already referred to, becomes sooner or later obliterated. The aorta, that is to say its descending portion, is generally abnormally narrow before the establishment of complete obliteration. 2. The aorta before this point, and the branches given off from its arch exhibit considerable dilatation, which extends from these branches over all their ramifications and anastomoses. 3. The heart is in a state of general dilatation, although the left ven- tricle is the special and original seat of the affection, which also extends to the trunk of the pulmonary artery and its branches. A careful consideration of all the circumstances leaves little doubt that the following theory is correct. 1. This anomaly is based upon a deficient formation, consisting in the permanence of the aorta in that early foetal condition in which it THE OROANS OF CIRCULATION. 229 constitutes a trunk which merely supplies branches to the head and upper extremities, whilst the pulmonary artery bends round towards the descending aorta in the form of the future Ductus arteriosus, and sup- plies branches to the rest of the body. The ascending aorta, after giving off its three branches, merges as a thinner vessel into the pulmo- nary artery. If the branch of the pulmonary artery which bends down to the descending aorta, and represents the Ductus arteriosus, be closed, —which, singularly enough, happens in all cases,—the descending aorta cut off from the pulmonary artery, approaches the ascending aorta so closely as to leave only a very narrow connecting link between them, viz., the thin vessel already described, merging into the pulmonary artery which represents the descending aorta. 2. This portion of the vessel, from its narrowness, presents the con- ditions requisite for its obliteration and atrophy. It becomes narrower, with increasing years, in relation to the ascending aorta and to the quantity of blood passing through that vessel, while, at the same time, not only the ascending aorta, but the branches given off from it are pro- portionally dilated. This dilatation soon extends over all the ramifica- tions and their anastomoses, as, for instance, those of the internal mam- mary and the first intercostal with the remaining intercostal and the epigastric arteries. In proportion as the collateral circulation draws the blood more freely from the left side of the heart and from the isthmus between the arch and the descending aorta, the former becomes narrower, and is at length rendered useless, completely closed,'and finally atrophied. The heart is, in all these cases, more or less distinctly affected with active dilatation. This dilatation obviously depends at first on the narrow isthmus between the ascending and descending branches of the aorta, and, after the latter has become atrophied, on the inefficiency of the col- lateral circulation. This contraction and closure of the aorta has been observed from the fourteenth to the ninety-second year. It occurs far more frequently in men than in women. There are fifteen or sixteen such cases on record.1 1 These cases, as already remarked, were collected by Barth (Presse Medicale, 1837), and by Craigie (Edinburgh Med. and Surg. Jour., Oct. 1841). Craigie enumerates ten cases, among which, according to Hasse's statement (Path. Anatomie, Bd. i. p. 91), one of the cases collected by Barth must be wanting. I unfortunately have not Barth's memoir by me at the present moment. He collected nine cases, which include Otto's case (which Hasse must have missed in Barth's collection, as he specially enumerates it, although it is not given in Craigie's list), ROmer's case (Oest. Jahrb., Bd. xx. St. 2), and the case observed by Craigie, and described in the above-named memoir. These, together, make twelve cases, to which four others have been recently added—one case observed by M. Aug. Mercer in the year 1838 (which Craigie has overlooked), a case observed by Muriel in 1842, one described by Hamernjk in 1843, and one case, also occurring in 1843, which is preserved in our Patholo- gical Museum. We think that a more detailed notice of the last-named cases may contribute to the com- pletion and elucidation of Barth's and Craigie's series. The thirteenth case, observed by M. Aug. Mercer (Bulletin de la Soci6te* Anatomique de Paris, xiv. ann^e, p. 158): Contraction, with almost complete Oliteration, of the Thoracic Aorta.—Potier, a shoemaker, aged 38 years, was received into La Charite' on the 29th of March, 1838. He had been seized, in the October of the preceding year, with violent bleeding from the nose, which continued for three hours. This occurrence of epistaxis relieved him from attacks of giddi- 230 ABNORMAL CONDITIONS OF Death is generally occasioned by the heart-disease and the anomalies to which it gives rise; in four cases it was owing to rupture tAvice of the ness to which he had been previously subject. Towards the month of January he suddenly experienced a sensation of cold and weakness (paralysis) in the right hand, which disabled him from using his knife. This sensation disappeared in about a week. Frorri the 27th of February he had had an occasional cough; but it was not until the 27th of March that blood was expectorated, which increased very considerably on the 28th and 29th. The patient experienced pain in the region of the apex of the heart, and forwards and backwards at about the same elevation, which prevented him from lying on his side. The beats of the heart were frequent, but without any peculiar sound; but at the summit of the arch of the aorta, a strong bellows-sound, continued into the carotids, was heard in unison with the arterial pulse. The sound was almost equally loud at the lower angle of both scapula?, where two or three of the intercostal arteries were observed to pulsate with violence. The pulse at the wrist was 140, very large and hard, but otherwise regular. There was no sound along the femoral arteries, which beat so faintly that they could scarcely be felt. An obstruction to the current of blood in the descending thoracic aorta was diagnosed. On the 31st there was a violent pain at the top of the ninth dorsal vertebra, between the spinal column and the scapula. The symptoms of pleuro-pneumonia increased, notwith- standing energetic treatment; and the patient died on the 9th of April. Autopsy.—The left pleural sac contained a coagulated and fluid exudation; the lung was in a state nearly approximating to pneumonia in its third stage. The heart was large, and invested with pseudo-membranous coagula; the aorta, together with the arteries branching off from it, was dilated from its commencement to about a few lines below the origin of the left subclavian. In the middle of the free margin of one of the aortic valves, there was seated a whitish-red, and apparently old coagulum. About five lines below the point of origin of the left subclavian, the aorta appeared to be almost entirely obliterated. The opening, which would only admit a blunt probe, was closed up with coagulated blood. It was linear in form, and surrounded by a posterior and an anterior lip, the latter of which projected far less than the other, causing the opening to approach nearer to the anterior than the posterior wall of the aorta. The tissues appeared to be normal at the contracted spot. The Ductus arteriosus was obliterated, terminating in the concave portion of the aorta, about three-fourths of a line above its contraction. The contraction extended over a very inconsiderable space, and was sharply defined both at its commencement and its termination. Immediately below it, the calibre of the aorta scarcely varied perceptibly from its normal dimensions. The abnormal aorta, and the iliac and femoral arteries, were also only slightly smaller than usual. The pair of intercostal arteries, branching off above the contraction, were 2'" in diameter; the remainder gradually decreased in calibre to the fourth, which appeared to be normal. Fourteenth case, described by William Muriel in the seventh volume of " Guy's Hospital Reports" for 1842. James Bert, a laborer, aged 25 years, of small stature, died on the 27th of July, 1842. Nine years previously, he had suffered from symptoms resembling those of an aneurism of one of the larger vessels of the chest. The symptoms gradually abated under the proper treatment, and, after a few months, he had so far recovered as to be able to work again; and was employed as a farm-servant uninterruptedly till the 20th of June, 1842. On that day, however, on lifting a heavy weight, he sprained himself. This accident gave rise to pain in the back and spasms, which were alleviated by opiates and counter-irritants applied over the spine. He lingered, however, until the 27th of July, when he died in a comatose state, which had been preceded with severe pain in the head. On a post-mortem examination, the body was found to be somewhat emaciated, the chest deformed by the projection of the sternum, more especially towards the ensiform cartilage, and there was an inclination of the spine in the upper dorsal region towards the right side; the pericardium contained about three ounces of fluid ; the heart was somewhat hypertro- phied, with some dilatation of the ascending aorta, and of the vessels branching off from the aortic arch. At the point of union of the Ductus arteriosus, the aorta was extremely con- tracted and almost obliterated, whilst the superior intercostal arteries, more especially on the left side, were much dilated. There was no malformation of the heart. Opposite the con- tracted portion there was a hard tumor, about the size of a hen's egg, which was intimately connected with the aorta and the trachea, and formed by the bronchial glands. The left sides of the bodies of the third, fourth, and fifth dorsal vertebra; were partially destroyed in the region of the tumor; the lungs and the other viscera were healthy; the head and spine were not examined. THE ORGANS OF CIRCULATION. 231 ascending aorta, once of the right ventricle, and once of the right auricle. Here, as is generally the case Avith those heart-diseases which frequently Fifteenth case, described by Dr. Jos. Hamernjk, of Prague (Oesterr. Wochenschrift, 1843, No. 10). N. N. Maurer, aged 42 years, who had always enjoyed good health, had been injured eighteen years previously by the upsetting of a carriage, which occasioned contusion and a dislocation of the scapular end of the clavicle. He was seized with pains in the feet and cedema; and stated that, although these symptoms disappeared in a few days, he suffered ever since the accident from palpitation of the heart and headache, which were always removed by spontaneous epistaxis. About ten days before his death, he was attacked with pneumonia of the right side, and died on the 13th of February, 1843. Dr. Hamernjk saw him two days before death, and found the temperature of body higher than usual, the pulse at the wrist 120, and tolerably large. The pulsations of the heart might be seen and felt between the sixth and seventh ribs, while at the same time the next two upper intercostal spaces sank inwards; the same happened with the first-named intercostal space at the diastole, whilst the two intercostal spaces above bulged out. The resonance in the region of the heart was not strikingly diminished, but the sounds of the heart, and along the greater arterial trunks, were not distinct, excepting perhaps the second sound in the pulmonary artery and the aorta, which were strong and very clear. A clear blowing sound was perceptible over the whole surface of the cardiac region, somewhat after the cystole. This sound was strongest at the left border of the sternum, from whence it diminished in clearness, although it might be heard at a considerable distance (from the dilated internal mammary artery, which was rough). There was pneumonia of nearly the whole of the right lung, of which only the upper part seemed free. A somewhat rough bellows-sound was perceptible in the carotids and the subclavians, as well as in the other large arteries. This sound was rather clear, and loud and protracted at the back, to the left of the vertebral column, at the "posterior extremity of the second rib, and might be heard over the whole length of the vertebral column. Bulgings of the compressed and pulsating arteries were to be seen over the whole surface of the back, running in a twisted manner, and more espe- cially diffused on both sides of the vertebral column in the direction of the axilla. There was no cedema. On opening the body, pneumonia of the right lung was discovered. The heart was some- what large; the cavity of the left side, however, was small, although its walls were upwards of an inch in thickness; the valves were normal, as was also the pericardium. The above- described rolls of pulsating bulgings along the vertebral column, were the dilated and attenuated branches of the transverse arteries of the neck and scapula, as well as of the sub- scapular artery. Dr. Hamernjk himself only saw two separate portions of the body, which he describes: 1. On the walls of the chest the two internal mammary arteries were laid open; their calibre was enlarged to the thickness of the little finger; their coats were interspersed at various points, with some few uneven cartilaginous plates, more especially at the upper portion of the vessel. 2. The portion of the Aorta.—The arch of the aorta, as far as the left subclavian, was only about an inch and a half in length; it measured 1'" in diameter, and its walls exhibited their normal thickness and elasticity. The left subclavian artery was 6£w in diameter, and was therefore nearly as large as the remaining portion of the arch of the aorta. There were scarcely 2'" of the subclavian artery remaining in the preparation, and the outer wall was invested with some thin plates of bone, as was also the posterior wall of the descending portion of the aorta. About one inch below the point of origin of the subclavian from the aorta, the latter was suddenly contracted circularly, but more especially at the back, by a deep furrow, so that, with its walls included, it did not exceed 5W in diameter when measured from right to left. The contracted portion scarcely measured 4"' from before backwards, and was therefore somewhat flattened. Above the confined or contracted por- tion, the aorta was swollen to about the size of a middling-sized hazel-nut, and ossified. At the point of contraction, a transverse wall was observed, having the form of a bi-concave lens, and about 1-1 %" in thickness, which entirely closed the tube. Below the contracted portion, and about 2"' deeper, the aorta began suddenly to dilate, and measured 12J'" in diameter. This dilatation extended over a length of about an inch and a half. The aorta then again assumed its normal diameter; and about 1 inch above the diaphragm it was very slightly dilated. The intercostal arteries of the right side, more especially the second and seventh, were dilated; the former was at least double its normal width. Its walls were thin and collapsed. The remains of two small shrivelled vessels, with contracted tubes, lay close together on the concave wall of the contracted spot, where each ended in a cul de sac They corre- 232 ABNORMAL CONDITIONS OF continue unnoticed for a long time, and do not give rise to disturbances in the system until they have attained a certain limit, the patients con- tinued perfectly well up to a certain period, when the symptoms of heart- disease were either gradually or suddenly manifested. sponded to the opening of the Ductus Botalli. Dr. Hamernjk was not able, from the restric- tions imposed on his use of the preparations, to discover whether this character depended on original division (duplicity) of the arterial passage, or whether it could be regarded as owing to acquired shrinking or puckering. There was no roughness or cartilagescence to be seen below the obliteration. Dr. Hamernjk is of opinion that these appearances were due to original formation. Sixteenth case, in our pathologico-anatomical Collection. Dr. Dlauhy, who conducted the post-mortem examination, has given me the following particulars: Harzmann Ignaz, aged 27 years, a day laborer, suffered for some years before his death, from slight erysipelas of the face, during one winter and a succeeding autumn. For more than a twelvemonth he had experienced considerable palpitation of the heart at night, after hard work. During the last three months, this had been frequently associated with cough and expectoration of tongh mucus, and with oppressed respiration. This condition grew rapidly worse; and for two months before his death, which occurred in the beginning of March, 1843, he had cedema of the feet. Autopsy.—The body was of a robust make; there was osdema, more especially of the lower extremities; the abdomen was much distended and fluctuating. The sinuses of the dura mater were distended ; the pia mater, together with the brain, abounded in blood. The abdominal cavity contained about 201bs. of clear serum, intermixed with scattered fibrinous flocculi. The liver was not much enlarged ; its substance was distinctly separated into a yellow and a dark reddish tissue (nutmeg liver) ; its peritoneal investment was thickened, and in some spots had a tendinous appearance. The gall-bladder contained tough, dark brown bile. The spleen was dense, of a dark reddish-brown color, and tolerably large. The kidneys large, and very tough. Ramifications of veins, much filled with blood, were observed on the ileum. Both lungs were, for the most part, attached by cellular adhesions to the costal wall; the cavities of the pleural sacs contained about a pound of serum; both lungs were puffy, and oedematous; in each of the lower lobes there was a spot of the size of a pomegranate, in addition to several smaller ones, of a blackish-red color and fragile,—a hemorrhagic infarctus. The mucous membrane of the trachea and the bronchi was bluish-red, and loosened; and the bronchial ramifications were filled with a thick, yellowish, puriform mucus. There were about two ounces of clear serum in the pericardium. The heart was more than twice the normal size, and invested with numerous milk-spots; the muscular substance was tough throughout, and of a reddish-brown color. The left ventricle was much dilated, and its wall was about an inch in thickness; and the right ventricle and the left auricle were dilated and hypertrophied. The valves were normal; the Foramen ovale was closed; the Venae cavse, the intercostal veins, the jugular veins, &c, were dilated and swelled. The Aorta.—The preparation consisting of a part of the ascending aorta, the arch, and a portion of the descending aorta, presented the following appearances: The ascending arch of the aorta (regarded as the vascular trunk designed to supply the head and the upper extremities) was unusually extended downwards; after giving off the arteria innominata, it diminished so much that its diameter did not exceed 5'" at the point where the left subclavian was given off, which formed, as it were, a continuance of it, and was of equal calibre with it. Above the valves its diameter was ll'". From this point it was deflected rapidly, and almost angularly, as a vessel of about 11'" in length, and not more than 3'" in diameter; its lower extremity corresponding to the depression of the obliterated Ductus arteriosus, was contracted and already undergoing obliteration, and was cut off from the descending aorta by a deep furrow. At this spot, the calibre of the artery scarcely measured one line; the passage, which only admitted a thin probe, was obstructed in the direction of the descending aorta by a small plate of white, opaque deposit. The descending aorta varied from 8 to 9 lines in diameter.—The deposit was very considerable, opaque, and partially ossified, in the ascend- ing aorta; the walls were rigid. The descending portion exhibited only a few plates of an opaque deposit. The arteria innominata was about 5 or 6 lines, the left carotid about 2 inches, and the leA subclavian, as we have already remarked, about 5'" in diameter. The ends of the intercostal arteries branching off from the descending aorta, more especially the uppermost ones, were considerably dilated. THE ORGANS OF CIRCULATION. 233 2. Contraction and Obliteration in consequence of Disease of the Coats of the Vessel.—To this class belong : a. Obliteration of the mouths of a vessel, occasioned by the excessive formation of a tissue, analogous to the lining membrane, within a trunk. —This condition, which is followed by atrophy of the vessel itself, is a mode of obliteration of the arteries which has not been much regarded, and one whose nature is not known. It is the result of the excessive process of deposition in one of the trunks of the vessel, and in the vicinity of the mouth, as has already been described at p. 199. The mouth continues to become narrower, until it is finally closed by the last layer deposited around it, whilst it diminishes by the fusion of the mass around the circumference. After this the mouth very frequently appears as if it were closed by a membrane stretched across it. When the vessel has become shrivelled and wasted, the closed mouth presents a cicatrix-like puckered appearance, or has wholly disappeared. Above the closed mouth, the blood carried by the collateral circulation into the vessel coagulates over various extents of surface, until its coagulation is prevented by the circulation established by an anastomosing process. The artery shrivels and becomes atrophied above this clot or plug. As this process of deposition must be very highly developed in order to produce such occlusions, and as it results in dilatation of the diseased artery, we are able to explain the appearance of these contractions and final obliterations of the mouths of the vessels, more especially upon the branches going off from aneurismal vessels. (See p. 215.) We have already alluded generally to the importance of this obliteration, which is, indeed, self-evident; but it exhibits special interest in some individual cases, among which we may notice the following : 1. The contractions and obliterations of the branches of vessels pass- ing from the arch of the aorta. 2. The contractions and obliterations of the coronary arteries of the heart. Neither of these is by any means a phenomenon of rare occurrence. b. The contraction and final impermeability of an artery in conse- quence of excessive deposition—of its ossification—or of the deposition of fibrinous vegetations on the rough inner surface of the vessel, and their cretefaction.—This may be especially observed where the process of ossification is much diffused on the smaller branches of the femoral arteries; many cases of senile gangrene are based on this impermea- bility of the arteries, which, however, is seldom observed in vessels of considerable calibre. 3. Occlusion of the Arteries. To this class belongs the occlusion of the vessel arising from different varieties of coagulation of blood. a. Occlusion of an inflamed artery.—According to our definition of arteritis, this condition can only affect arteries in which the circular fibrous coat is only subordinately developed. (See p. 193.) b. Occlusion of an artery arising from a coagulation of the blood, de- pending upon an internal cause, such as a blood-disease.—To this class belong Velpeau's case of closure of the aorta, from the third lumbar vertebra downwards, with a part of the iliac artery, owing to a coagula- tion of a cancerous character in an individual exhibiting cancerous 234 ABNORMAL CONDITIONS OF cachexia, and undoubtedly also the cases of occlusion of the thoracic and abdominal aorta'observed by Schlesinger and Barth. Occlusion arising from arteritis, and especially the form above described, is very rare when compared with the frequency of occlusion of the veins. 4. Contraction and obliteration arising from persistent pressure on the artery.—Such a continued pressure may be exerted by different tumors, as goitres, encysted tumors, cancerous products, and aneurisms of neighboring arteries. Complete obliteration is very rarely induced by these causes; at any rate, in the larger arteries. The vessel becomes obliterated at the spot exposed to pressure in consequence of the coales- cence of the lining membrane of the vessel; above this point the occlu- sion is affected by means of a plug reaching to the nearest branch, and beyond this the vessel is finally obliterated in the same manner as after tying the artery, as we shall have occasion to revert to in the sequel. Besides these different modes of contraction, occlusion, and oblitera- tion, we further noticed the following conditions when treating of aneu- risms. (See p. 216.) a. An impermeability of the mouths of the branches passing from an aneurismal vessel in consequence of their contraction into fissure-like openings. b. An impermeability of the mouths of these vessels, induced under certain conditions already indicated at the above page, by the fibrinous layers filling the aneurismal sac, and the shrinking and obliteration of the vessel consequent upon it. We shall consider the establishment of the circulation consequent on the obliteration of an artery when we treat of the healing of cut arte- ries, and the process of obliteration that follows the tying of an artery. § 5. Mechanical Separations of Continuity.—To these belong lacera- tions and wounds of the arteries produced by cuts, thrusts, or gun-shot wounds. Spontaneous lacerations are the most important of any, especially those of the trunk of the aorta. To this class belong lacerations of the large arteries arising from violent concussions or shocks, viz., in conse- quence of a contusion (as, for instance, by a spent ball), striking a cir- cumscribed portion of the vessel. No special interest attaches itself to those lacerations of the arteries which arise from excessive extension; such as, for instance, in the arteries of the extremities from dislocations, and which may be associated with extensive lacerations of the soft parts, and destruction of the bones. Wounds of the arteries inflicted by cuts, thrusts, and shots, derive importance from the conditions oi false and varicose aneurism, in which they frequently result. A. On the lacerations of the larger Arteries.—Dissecting Aneurism. Lacerations of the larger arteries, arising from traumatic influences, as from concussions and contusions of the body, are only interesting in a scientific point of view, Avhen the different mechanical modes of lacera- tion affect indifferently the separate arterial coats, and when they re- THE ORGANS OF CIRCULATION. 235 semble certain spontaneous lacerations. Such is the case when the lace- ration implicates the two inner coats of the vessel (the lining and yellow membrane), while the cellular sheath of the vessel is in a state of inte- grity, or when the separation of its continuity does not correspond in extent, form, and direction with this laceration. In this respect we must regard with special interest the lossiones con- tinui, which are owing to some influence limited to a circumscribed portion of an artery, or to a loosening of the cellular sheath and a laceration of both its inner membranes owing to the same influence. They present the greatest similarity with that spontaneous laceration which is termed dissecting aneurism. Spontaneous lacerations* may be classified under the following heads. 1. The laceration depends upon a delicacy of construction of the whole arterial wall, and on the generally simultaneous narrowness (insuf- ficiency of calibre) of the vessel; or on congestion, or excessive expansion of the mass of the blood. We have observed several cases belonging to this class. 2. The laceration depends upon a diseased condition of the texture of the coats of the arteries. The cases belonging to this class form two distinct series. a. In those of the first series, the lossio continui consists in a detach- ment of the cellular sheath from the tube of the vessel, and of a lacera- tion of the middle and lining coats of the vessel within the detached cel- lular sheath. The question here arises, which of the two is the primary and at the same time the controlling cause ? Experiments prove that it is by means of the cellular sheath, more especially of its elastic longitudinal stratum, that the artery is able to resist any violent lacerating action, and to sustain the force of the blood- wave when the texture of the inner layers, particularly of the yellow coat, is in a state of integrity. In the above cases, the alteration of texture consists essentially in a chronic inflammation of the cellular sheath, which causes it to be more easily detached. The cellular sheath is here loosened, over various extents of surface, from the tube of the vessel, either alone or with an adhering layer of the yellow membrane, which is generally torn trans- versely, and only very seldom longitudinally to the vessel. The yellow coat is very brittle in the cases to which we refer, and where this condi- tion was certainly the result of advanced age, this membrane admitted readily of being separated. The lining membrane was for the most part diseased,jilthough only in a moderate degree, exhibiting a deposit which was partially ossified.—By way of elucidation we will give a case bor- rowed from the memoir before referred to. A. G-. v. P—, aged 52 years, a widow, fell to the ground in the street, on taking a quiet walk after dinner, towards evening, on the 18th of February, 1833. After being bled, she was carried to the hospital. She vomited twice, and after momentary recurrences of consciousness, died on the following morning, after long-continued and profound syncope. Autopsy.—The body was of moderate size and thin. The walls of the cranium were 3-4'" in thickness and compact; on 1 Oesterr. med. Jahrb., Bd. xvi. St. 1. 236 ABNORMAL CONDITIONS OF the left parietal bone, above the semi-circular line, a compact exostosis was discovered, about the size of half a walnut; the inner cerebral mem- branes were infiltrated. Some of the arteries on the base of the brain were partially ossified. The lungs, with the exception of the swollen anterior margins of their upper lobes, were of a dark red color, rich in blood, and oedematous at different points. The left pleural cavity contained 1 lb., and the right cavity about 4 oz. of pale reddish sanguineo-serous fluid. There was considerable extravasation of coagulated blood in the pos- terior mediastinum round the aorta and the oesophagus, more especially, however, round the pulmonary vessels and the branches of the trachea, towards the roots of the lungs ; the pericardium contained upwards of a pound of coagulated and fluid blood. The heart was somewhat larger than usual, nearly of a round form ; the left ventricle and the Conus arteriosus were very large, and the walls of all the cavities were of normal thickness. The right side of the heart was covered with a considerable layer of fat; the ramifications of both the coronary arteries were, for the most part, ossified. The substance of the heart was pale and friable. Aorta.—The ascending aorta, like the pulmonary artery, was very wide; the valves of the former were thickened at their insertion and their nodules, and were partially ossified. The cellular sheath (the elastic and cellular coats) of the aorta was loosened throughout its entire length round the ascending portion, at its arch and on the whole of the thoracic and abdominal aorta, over full a third of its circumference, where there adhered to it either a thin layer or partially exfoliated thicker portions of the yellow coat. This condition extended upwards over the arteria innominata to the common carotid, the right subclavian and its larger branches, and downwards over a portion of both the iliac arteries; in the former the cellular sheath was entirely separated over the whole circumference of the artery, while in the latter it was only partially loosened, or admitted of being easily detached all round, to- gether with the external layer of the middle coat. The same condition was observed in most of the small and large branches of the thoracic and abdominal aorta for a considerable extent of surface from their points of departure. The cellular sheath was of a bluish-red color, infiltrated with blood at many parts of its detachment, and very thick; at those points, however, at which a layer of the yellow coat still ad- hered to it, and where the two were not entirely separated, it was paler and less thick from a deficiency in the suffused blood, and was inter- sected by a highly developed network of vessels. The free space be- tween this and the yellow coat of the vessel was filled with a consider- able quantity of coagulated and fluid blood. Within the cellular sheath, which was detached, as we have already seen, from the ascending aorta, the yellow and lining membranes were torn transversely over an extent of an inch and three-quarters above the valves, so that there remained only a spiral strip of their posterior wall (about two lines and a half in breadth, and equal in length to about half the circumference of the aorta), which connected together the two extremities of the rent, and was raised along the concavity of the trunk THE ORGANS OF CIRCULATION. 237 of the aorta from its original horizontal position, in consequence of the displacement of the upper extremity of the rent, which we shall now proceed to notice. While the lower extremity of the rent was turned upwards with an almost circular opening, in consequence of the exposed transversal rent, the upper one was almost entirely enclosed by the convex wall and driven into the cavity of the arch of the aorta as far as the left subclavian, the entrance of which was even obstructed by a conically rolled portion of the tube of the aorta, so that a communication was opened from the sub- clavian into the inserted vessel, and through this into the cavity of the cellular sheath. In this manner, both the extremities of the rent were from about an inch and a half to an inch and three-quarters from each other, while within the almost saccularly expanded cellular sheath at this spot, as well as over the whole extent of the aorta and the branches already re- ferred to, the space between it and the yellow coat of the artery was completely filled with coagulated and fluid blood. This accumulation of blood had compressed the aorta and the coeliac axis at different points, and completely detached from their origin several small branches of the aorta and a large branch of the renal artery on the left side. The blood had been further extravasated from this space into the peri- cardium and the mediastinum, in the following manner. The cellular sheath of the ascending portion of the aorta was torn outwards and backwards along the descending Vena cava, near its opening into the auricle, in a longitudinal direction, together with the portion of the peri- cardium by which it was invested. This sheath was also considerably attenuated at several points along the descending aorta, where it readily admitted of being torn. The yellow coat of the artery could be easily peeled off in all parts, but more particularly at the aorta itself; it was also very brittle. Several small bony plates were observed in the lining membrane of the arch of the aorta. The intestines were pale throughout, although this pallor was especially perceptible at some circumscribed portions of the ileum"where the mucous membrane was perceptibly attenuated, and had even wholly disap- peared. When we consider the appearances here presented, with a view of ascertaining the relation of the different coats of the artery in their physiological and pathological condition, we arrive at the following theory, viz., that a detachment of the cellular sheath occurs spontaneously at a certain stage of its disease, giving rise at the same time to laceration of the two inner coats. These coats are usually torn transversely along the course of the yellow fibres, in consequence of the artery being deprived, at the moment when the cellular sheath is detached, of the support which had limited its further expansion and stretching. Such a laceration is also the more readily effected, when the two inner coats, notwithstanding the integrity of their texture, are unable to resist this expansion and tension from having become soft and brittle, owing, as is commonly the case, to advanced age, or to the dilatation of the vessel which is observed in all such cases. 238 ABNORMAL CONDITIONS OF The detachment of the cellular sheath must, therefore, constitute the primary agent or cause, while the laceration of the inner coats is the con- secutive effect of this condition. It is, however, probable that this may admit of a different explanation. Thus, for instance, we are unable to apply tfiis theory when, in addition to the cellular sheath, an adhering layer of the yellow coat is loosened with it at the spot of the laceration, and when, therefore, the rent itself affects only the inner layer of this coat (with the lining membrane of the vessel). Another theory suggests itself when we consider that dilatation of the vessel is present in all cases. This dilatation depends, in all probability, upon the paralysis of the elastic layer, owing to a chronic inflammation of the cellular sheath ; and the laceration of the yellow coat of the artery might therefore be the final result of the greatest dilatation it was capable of resisting without any considerable disturbance of texture of the whole arterial wall. Laceration will, moreover, be the more readily effected in proportion to the brittleness of the yellow coat dependent on the advanced age of the patient. In accordance with this view, the rent in the lining and yellow coats must be the primary occurrence, and the loosening of the cellular sheath, either with or without an adhering layer of the yellow coat, must be re- garded as a secondary result owing to the forcible escape of blood from the rent. The following conditions appear from our observations to be worthy of notice as controlling causes : The heart is hypertrophied in all cases, and its left ventricle is in a state of active dilatation. In most cases the laceration is effected without any special excitement of the heart's action, so that the occurrence must be regarded as the final result of the diseased condition of the vessel. The integrity of the detached cellular sheath, that is to say, the hinderance thus opposed to the free extravasation of the blood, occasion- ally postpones the fatal termination for a few hours; in Laennec's case death was delayed for four days. The cellular sheath is. generally lacerated in consequence of its dis- tension by extravasated blood, usually in the vicinity of the lining mem- brane of the artery, but occasionally, however, at one or more spots remote from that rent. These lacerations are generally transverse, and only rarely take a longitudinal direction. Lacerations are much more frequent in the ascending aorta, at a short distance above the valves, than in the thoracic aorta. They generally occur in persons of advanced age. This form of lacerations belongs to the class which has been repeatedly investigated by English pathologists, who have applied to them the in- appropriate designations of dissecting aneurisms, or of anomalous or interstitial aneurisms. These observers have not hitherto given a feasible explanation of this process, and they appear to have overlooked the con- ditions that induce such diseases of texture. b. The cases belonging to the second series differ in every respect from those of the first. These are lacerations of an artery exhibiting a pro- foundly diseased condition of the texture of the whole wall—somewhat in the manner of the so-called dissecting aneurism, that is to say, with THE ORGANS OF CIRCULATION. 239 detachment of the cellular sheath, but this is here always effected by the violent action of the blood extravasated from the rent, and therefore con- stitutes a secondary occurrence. A cause predisposing to these lacerations is afforded by a high degree of the disease which we have described at p. 199, and to which we have referred as the cause of origin of aneurism. The cellular sheath of the vessel here firmly coalesces with the yellow coat of the artery, in conse- quence of a process of chronic inflammation by which its tissue becomes thickened, callous, and condensed. The inner coats of the dilated artery are lacerated in consequence of their morbid brittleness within the closely adhering, thickened, callous, resistant, cellular sheath, which is here violently detached by the blood, but never over an extended surface, as in the cases belonging to the first series. The cases belonging to this class are generally longitudinal lacerations, in which the fibres of the yellow coat of the artery are actually torn asunder. Transverse lacerations occur only as exceptions to the rule. When laceration takes place after a very considerable degeneration, with unequal disease of the arterial coats, the rents are irregular and curved. The following case may serve as an illustration of these appearances. On the 6th of March, 1834, a post-mortem examination was made of the body of a woman, aged 50 years, who had died suddenly two nights before. The autopsy shoAved the body to be robust, and in tolerably good condition. Both arms bore marks of repeated venesection. There was a grayish white foam, collected in the trachea. The lungs were of a dark-red color, very full of blood, and oedematous, excepting in the right lower lobe. There were two pounds of coagulated and fluid blood in the pericar- dium. The heart was half as large again as usual, fat, and flabby in the left ventricle, and the Conus arteriosus of the right ventricle was dilated. The auricles and trunks of the vessels contained coagulated and fluid blood. The ascending aorta and its arch were considerably dilated; their inner surface was uneven, and covered at some parts with a white, opaque, cartilaginous, and smooth deposit, and at other parts with a light-colored, wrinkled deposit of considerable thickness; the mouths of the three branches of the arch of the aorta were contracted. About an inch and a half above the semilunar valves on the concave wall of the ascending aorta there was a jagged, rectangular rent in the diseased inner and middle (yellow) coats of the artery. The longest direction of the rent measured one inch and five lines, and ascended into the arch'of the aorta, while its other side (which was only half the length of the former) extended along the posterior wall of the aorta. A rectangular lobule, composed of a portion of the inner and of half the thickness of the middle coat, had been exfoliated from the above-described right angle, and from this point the ascending aorta had lost the cellular sheath, together with the external layer of the middle coat, except at a mere narrow strip on its concave surface. The space between these two laminae was filled with coagulated blood. The external lamina had burst into the pericardial cavity backwards, behind the descending Vena cava, 240 ABNORMAL CONDITIONS OF longitudinally and downwards, over a surface extending more than half an inch, together with the contiguous lamina of the pericardium. The cellular sheath of the aorta was unusually thick, althoughat the same time of a callous condensation, and intimately connected with the yellow coat. It was of unusual thickness, nearly V" at the arteria inno- minata, and more especially at the right subclavian, and was converted into a whitish, very dense and tough, lardaceo-fibrous stratum, and fused as it were into the yellow coat. It was less thick at the left carotid and the subclavian, although it presented a similar character. On examining the abdominal cavity, the gall-bladder Avas found to contain a concretion, about the size of a nutmeg; and the fundus uteri was filled with a fibroid growth, equal in size to a child's head, and attached by a thick pedicle. These Lacerations, like the diseases in which they originate, generally occur in advanced periods of life. They also usually affect the ascending aorta, Avhich may be explained by the circumstance, that this vessel is, in most cases, especially diseased, Avhile it is at the same time exposed to the force of the blood-wave propelled from the heart. The heart, as may be conjectured from the observations already made, is subject, in these cases, to dilatation and hypertrophy, more especially of the left ventricle. Among the aneurismal forms, especially allied to these cases of the second class, Ave must reckon lacerations of the smaller, diseased arte- ries, having rigid membranes and having become brittle, which are either frequently spontaneous, or the result of wholly inexplicable conditions, such for instance as ive especially see in apoplexy (cerebral hemorrhage). 3. Finally, this laceration may depend upon the removal of the supports of an artery, in consequence of an ulcerous process, and upon a loosen- ing and softening of its texture, arising from its coats becoming infil- trated with the ulcerous secretion surrounding them. This form of laceration more particularly affects delicately constructed arteries of in- ferior calibre, as, for instance, the branches of the pulmonary artery in the walls of tuberculous pulmonary caverns. In some few cases the laceration is preceded by a lateral (aneurismal) enlargement of the vessel towards the cavern (see p. 198). B. On Incised, Penetrating, and Gunshot Wounds of the Arteries. Such injuries of the artery as are inflicted by sharp-pointed instru- ments, even Avhere it is only opened at the side, and shot-wounds which merely remove a small portion of the wall of an artery, are, as is well- known, extremely dangerous ; for they usually give rise to the so-called false aneurism, and, under certain conditions, to varicose aneurism, which we shall soon consider in detail. It is true that penetrating and incised wounds of an artery may heal under favorable conditions, as we see in cases where the temporal artery has been opened, and, as Amusat has recently shown, by observations at the bedside and by experiments on animals, in the same manner as similarly injured veins. But as in man, injuries are often inflicted on the arteries under circumstances which exclude the concurrence of these favorable conditions, such wounds THE ORGANS OF CIRCULATION. 241 do not commonly heal; in gunshot-wounds of the artery more especially, a cure is never effected by the adhesion of the margin of the wound, but, as an ordinary consequence, we generally have the so-called false aneu- rism. On False Aneurism.—When an artery of one of the extremities has been injured in any of the above ways, the blood is effused into the sur- rounding cellular tissue, forming an extravasation, if unable to escape from the outer wound. The blood is then accumulated in a cavity formed by the laceration of the tissue, the structures around it being suffused and infiltrated Avith blood. This constitutes diffuse false aneurism, or, according to Foubert, primary false aneurism. When considerably diffused it in general terminates fatally in inflammation degenerating into gangrenous disintegration, associated with symptoms of paralysis, and in continuous external hemorrhage. It is only in rarer cases, and when the aneurism is less diffused, that it can heal by the artery becom- ing obliterated during the ichorous process, through arteritis, and by the drying up of the ulcerous process, after expulsion of the extravasation and of the tissue destroyed by it. When the neighborhood of the extravasation becomes the seat of an inflammatory process (reaction), tending to condensation (sclerosis) and hypertrophy of the tissue, the cavity containing the extravasation ac- quires a true wall and definite limits, and becomes converted into a sac, seated upon and surrounding the artery, and into which the arterial wound opens. A lining membrane may be formed upon its inner surface, and the sac may then present such similarity with a mixed aneurism as to render its anatomical diagnosis extremely difficult. In this condi- tion, the collective appearances represent what is commonly known as false circumscribed, or Foubert's consecutive false aneurism. It is obvious that these conditions do not originally merit the designa- tion of aneurism, whilst the consecutive condition of a false circumscribed aneurism presents appearances which give it in every respect the signi- ficance of an aneurism. This form of aneurism, which commonly attains a very large size, as, for instance, in the popliteal space generally, as is the case with large aneurisms, terminates fatally when left to run its course. On varicose aneurism, Aneurysma spurium varicosum, Varix aneu- rysmaticus, A. per anastomosin (W. Hunter), A. per transfusionem (Dupuytren). This aneurism consists in the communication of an artery with a neighboring vein, effected by means of an aperture in the artery corres- ponding to one in the vein. This communication may be direct or in- direct, and further may be the result of injury, or may occur spontane- ously. . . Varicose aneurism is most commonly produced by some injury which simultaneously affects the contiguous walls of an artery and of a vein ; such, especially, as penetrating wounds or injuries from small shot, and when it arises from incised wounds, it is in general owing to venesection in which both walls of the vein have been cut through, and the lancet has penetrated through the wall of the artery below it. The latter mode of injury is, moreover the most frequent cause of varicose aneu- vol. iv. 16 242 ABNORMAL CONDITIONS OF rism, and consequently the bend of the elbow is the most common seat of this aneurismal formation. Moreover, neighboring arteries and veins may be so much injured by splinters of bone that the arterial blood may enter a vein. The same result has also been effected by violent contu- sions. The most common form of traumatic varicose aneurism is that occur- ring after venesection, and seated between the brachial artery and the median vein, or when the brachial artery divides higher up, between the radial or ulnar artery and the median, cephalic, or basilic vein. The same form of aneurism has also been observed in the brachial artery in the upper arm, in the subclavian, in the carotid with the jugular vein, in the femoral, popliteal, temporal, and other arteries. Spontaneous varicose aneurism is the opening or rupture of an aneu- rism into a vein that has coalesced with it. Cases of this kind have been noticed by myself and many foreign observers in the femoral artery, in the abdominal aorta with the Vena cava inferior, and in the ascending aorta with the Vena cava superior. The communication established between the artery and the vein is, as we have already remarked, either direct or indirect. The former is fre- quently observed at the elbow, as a consequence of venesection; thus, for instance, whilst the outer wound of the vein is cicatrizing under a bandage and compress, which prevent the formation of an extravasation into the cellular tissue, the two vessels coalesce together, more especially in the immediate vicinity of the openings of the wounds, by which means a direct communication is formed between them. The vein at the spot presents the appearance of a swelling or roundish expansion, which com- monly increases to about the size of a hazel-nut or half a walnut, but, in some rare cases, attains an extraordinary volume (Hodgson, Larrey). The direct communication of the two vessels, and the dilatation of the vein at the corresponding point constitute what is known as aneurysmal varix. Such a communication between the artery and the vein is always present in spontaneous varicose aneurism. The indirect mode of communication is effected in the following man- ner by the presence of a false aneurism. In those cases in which a sufficiently strong compress has not been applied immediately after the injury, and where two vessels have been injured, which are not in imme- diate contact, or are not fixed in one common layer of cellular substance, or where finally the wounds in each do not originally correspond together, or where, after the injury has been inflicted, the vessels have been dis- placed or separated,—an extravasation into the cellular tissue is formed, which, in the last-named cases, pushes the vein aside from the artery, and thus prevents the establishment of a direct communication between the two. This extravasation,—a false diffused aneurism,—is now reduced to a false circumscribed aneurism, the cavity of which forms the medium of communication between the artery and the vein. This false aneurism varies in size, but it commonly is not larger than a walnut or a hen's egg. It generally forms a more considerable and a tougher swelling than that which occurs in a direct communication, and hence Scarpa was THE ORGANS OF CIRCULATION. 243 led to distinguish this condition from aneurismal varix by the designation of varicose aneurism. The aneurismal sac presents many differences in reference to the extent to which it lies on the artery, and especially in relation to the opening. The size of the openings into the two vessels also varies very con- siderably, and depends, like their form, on the size of the original wound, on the instruments by which the injury was inflicted, &c. The opening in the artery in general permanently retains its original size and form, whilst that in the vein undoubtedly experiences many alterations like the aneurismal sac itself. The openings in the vessels, as well as the inner surface of the aneu- rismal sac, are invested with a lining membrane of recent formation, which continuing into the two vessels, gradually loses itself, and merges, more especially in the case of the vein, into the deposit formed upon the inner surface of that vessel. In consequence of this, the openings in the vessels have a smooth and healed appearance. In the so-called aneurismal varix and in spontaneous varicose aneurism, the communication is effected by means of a simple opening, through the coalescing adjacent walls of both vessels, which acquires a smooth and healed appearance in consequence of being invested with a membrane of recent formation, and thus loses its original character of a rent or rupture. All observers are unanimously of opinion that the arterial blood prin- cipally, if not exclusively, passes into the vein, in both these modes of communication, the direct as well as the indirect. Breschet thinks, that in an operation for a varicose aneurism he also saw the venous blood pass into the artery through the aneurismal sac, during the diastole of the latter. To this circumstance, which may indeed occur in some cases, he refers the dilatation of the arteries below the aneurism, together with the attenuation of the arterial walls, in consequence of their contact with venous blood,—an explanation that has been given by no other observer. The character of the vessels above and below the place of communi- cation, as indicated by all observers, and as I have repeatedly had occa- sion to notice, corroborates the existence of a very preponderating cur- rent of arterial blood towards the vein. The vein becomes first dilated below the point of communication, and then finally spreads beyond and above it. This dilatation is associated with an enlargement of the valves. The walls of the veins become thicker and more rigid, principally in con- sequence of the formation of new layers of lining membrane (see p. 205); they at length acquire an appearance similar to that of the arteries. Below the communication the artery is contracted in consequence of the blood being drawn away towards the vein; and its walls then become thinner, relaxed, and more similar to the veins in consequence of the diminished energy of their function, corresponding to the extent to which the blood is drawn away from it. The artery becomes dilated above the communication, in consequence of the obstacle which the venous blood opposes to the entrance of arterial blood into the vein. The limb below a varicose aneurism is frequently swollen; it also pre- 244 ABNORMAL CONDITIONS OF sents a cyanotic color, its cellular tissue is infiltrated and hypertrophied, and the general investment is the seat of repeated erysipelatous inflam- mations, excessive epidermal formation, &c. The sequelae of spontaneous varicose aneurism between the trunks of the aorta and of the Vena cava are obvious, but they are often indis- tinctly manifested in consequence of their being masked by the results of the aneurismal affection of the trunk of the artery, and by the simul- taneous presence of heart-disease. The process of healing and obliteration after arteries have been cut through or tied.—An artery, on being cut through, is immediately retracted in its sheath,—at any rate, as far as the next lateral branch, if of considerable size, while it at the same time becomes gradually con- tracted. The blood pours outwards in a greater or less quantity, accord- ing to the extent and position of the external wound, or it is effused into the cellular tissue. Independently of the aid afforded by art, the exhaus- tion itself exerts a favorable action on the coagulation of the blood effused around the artery. The coagulum within the canal of the arterial sheath, which is produced by the retraction of the vessel, forms the outer plug,— the most essential and the actual means of arresting the hemorrhage. In addition to this plug, another—the inner plug, is gradually formed within the artery itself, by the coagulation of the blood which is arrested in the stump by the first plug, unless a considerable lateral branch is given off in the immediate neighborhood. By these means the necessary conditions are obtained for arresting the hemorrhage; and the cure—closure—is then effected by the adhe- sive inflammation of the cellular sheath of the vessel on the margin of the wound and by the obliteration and final atrophy of the whole stump of the artery, as far as the next collateral branch, in the same manner as we observe after ligature, torsion, &c, and which we will now proceed to consider. The whole healing process of arteries that have been cut through, has been fully elucidated by the invention of the ligature, and by the numer- ous investigations in reference to this process, as shown by experiments on animals. The labors of Stilling have thrown the greatest light on this subject in modern times; and we purpose in the following remarks to borrow from them the most important facts, which we will incor- porate with our own views regarding individual points of the whole process, as obtained from investigations on the human subject. We would here briefly remark that the alterations resulting from ligature, &c, more especially the formation of thrombus, are more evident at the cardiac than at the peripheral end of the affected artery, and that the following remarks more especially apply to the alterations effected at the former of these points. After the application of the ligature or torsion, the terminations of the cut artery, as has been already observed, retract. This gradual con- traction, which affects the artery as far as the next lateral branch, pro- bably depends, at first, upon the irritation set up by the ligature, and subsequently, on the decrease in the quantity of blood entering this portion of the artery, in consequence of its abstraction tOAvards the dilated branches, and on the diminished impulse. By this contraction THE ORGANS OF CIRCULATION. 245 of the fibres of the yellow coat the lining membrane of the vessel is wrinkled into delicate longitudinal folds; whilst the whole of the wall of the vessel- is puckered into more considerable plaits at the spot where the ligature has been placed. The ligature or torsion takes the place of the external plug, causing a stoppage of the blood in the vessel between it and the first lateral branch. By being arrested, it forms a conical coagulum, that is to say, in the words of Stilling, " the arrested blood forms a conical mass, whose apex is near the first lateral branch, and whose base is seated on the extremity of the vessel, and is contained within a funnel of blood in partial motion. The larger opening of the funnel, where its walls are sharply cut and very thin, is in the neighborhood of the base of this cone, or just above the extremity of the vessel, whilst its smaller (blind) opening, whose walls are constantly increasing in thickness, until they finally unite, lies near the first lateral branch, in the axis of the vessel or the middle of its cavity." This conical coagulum constitutes an inner plug, which is com- monly designated a Thrombus. The thrombus begins to be formed at the termination of the vessel, and from thence extends onwards in its axis to the point where the first lateral branch is given off; it possesses a conical shape from its com- mencement, and not being very thick, it does not entirely fill up the tube of the stump of the vessel, but simply projects into it with its base or middle, at which parts it is usually of a dark, blackish-red color, and of very inconsiderable consistence. The apex, however, is white, more dense and hard, and resembles coagulated fibrin. It occasionally acquires a more fusiform shape by the addition of supplementary new layers, consisting in such cases of concentric superficial strata in addition to the original coagulum in the centre. It occasionally lies free in the stump of the artery, but more commonly it adheres, although at first loosely, by its base. It is subsequently invested with an albuminous moisture, by means of which it adheres loosely to the wall of the artery, although its apex remains free. This adhesion is frequently effected by means of filamentous bridge-like attachments. The inflammation, which is set up around the injured vessel, also implicates its cellular sheath. Plastic lymph exudes into the tissue of all the structures and into the cellular sheath of the vessel. We find also that a process of adhesive inflammation affects the spot at which the ligature is applied, and where the different folds of the lining membrane of the vessel come in contact with each other; and that there is an exudation of coagulable lymph, which causes a slight adhesion of the walls of the vessel, and of the thrombus at its base. The inflammation in the terminal part of the vessel is owing, not only to the irritation established by the operation, but also to the thrombus, which acts here as a foreign body; exudation being effused between the coats of the vessel as well as also on the free surface of the lining membrane. The thrombus is always formed gradually; but in some cases it is found to be forming within half an hour or an hour after the operation, while, in other cases, there is no trace of it at the end of several hours. It is generally completely developed within twelve or eighteen hours after the closure of the vessel; it is more rapidly formed in small than in large vessels. 246 ABNORMAL CONDITIONS OF The further alterations include the metamorphosis of the developed thrombus, its coalescence with the wall of the vessel, and the final oblite- ration and atrophy of the artery. The thrombus occasionally exhibits light-colored spots, both on its surface and in its interior towards its apex. Stilling observed fibrous or thread-like stripes on these spots, which he convinced himself by a lens were vessels. In the course of time the thrombus acquires a porous structure, and becomes spongy and cavernous. Stilling found, in several experiments, that in addition to the numerous canals which he injected, and which traversed the thrombus in different directions, there was a central lon- gitudinal canal opening into the cavity of the vessel. The periphery was especially injected in the more recent thrombi, whilst in those of older formation, the injection advanced more towards the centre or the axis. Where this so-called vascularization was present, the thrombus was always of a paler, flesh-like, faint rose-red color, turning to yellow, and finally to white, whilst the consistence was proportionally more con- siderable.—This metamorphosis of the thrombus is succeeded by its regressive formation. In the meanwhile the thrombus becomes intimately adherent by its base, and very frequently by the whole of its body to the wall of the vessel,—in smaller vessels on the second or third day, and in larger ones on the fifth or sixth day; the former adhesion has now been converted into a firm coalescence. The greater part of the apex of the thrombus commonly, however, remains free during the period of its greatest vascularity. The regressive formation of the thrombus consists in the diminution of the number of the so-called vessels within it, in its increased pallor and density, and in the fact, that " the whole mass of the thrombus still remaining at this period, merges, as it were, into the mass of the stump of the artery, forming with it one body." (Stilling.) This portion of the vessel gradually loses its proper texture; the exudation effused into the coats of the vessel becomes in part resorbed, and is in part metamorphosed into a cellular or fibroid tissue; the walls of the vessel gradually close around the shrivelling thrombus, and be- come obliterated into a cellulo-fibrous, ligamentous string, which in the course of time disappears still more, until it can no longer be recog- nized. This alteration is effected in smaller vessels in from about twenty to twenty-two days, and in larger ones in from thirty to forty- five days. The ligatures by which the middle circular fibrous coat and the lining membrane have been originally divided, are loosened, and come away, in consequence of the suppuration of the cellular sheath at the spot where they have been applied, during the above-mentioned process.— This suppurative process not unfrequently gives rise to destruction of the coats of the vessel above the ligature, and of the thrombus, and hence induces hemorrhage. The circulation is established, after the application of the ligature, in the same manner as in obliteration of an artery generally, by the dila- tation of the lateral branches and their anastomoses,—the so-called THE ORGANS OF CIRCULATION. 247 collateral circulation, which is developed, in cases of spontaneous and gradual obliterations, with a rapidity proportional to the increasing con- traction of the vessel, so that its final occlusion is imperceptibly effected. When a main artery has been tied, the circulation is at first carried on by means of all the innumerable communications of the small rami- fications ; subsequently, however, some of these vessels and anastomoses dilate in a preponderating manner, while the others gradually return to their normal calibre. This dilatation is especially remarkable in,„the small branches, whilst the trunks and larger branches are relatively dilated to a very inconsiderable degree (Hodgson.) We would only add to this description the materials derived from a review of the facts and opinions which have been deduced from an inves- tigation of tied arteries in man, and from the simultaneous consideration of highly important conditions analogous to thrombus. We must, however, at once premise, that we do not regard this ques- tion as wholly settled, since this process in man presents numerous ano- malies, independently of those cases in which the thrombus is not duly formed, in consequence of debility, cachexia, &c. Our views in reference to the process, and the individual conditions on which it depends, are as follows: 1. We are of opinion, that the occlusion of a tied vessel may take place without the occurrence of thrombus (the inner plug), and that this is a mere incidental formation, and not by any means an inevitable and neces- sary condition of obliteration. There is very frequently no thrombus present, and occasionally its place is supplied by an adhering red gelatin- ous, in general irregularly thick, wrinkled, gland-like, shaggy coagulum, whose color is subsequently changed to a yellowish-red tinge; or the thrombus is inadequate to fill up the whole of the vessel, and hangs loosely in the stump of the artery, without actually adhering at any one point; although, notwithstanding this arrest of growth in the thrombus, it yet closes the extremity and a neighboring portion of the vessel. No trace of the previous existence of a thrombus can, however, be detected on cutting through this coalescence. 2. Although we would not wholly deny the point in reference to every case, we are yet of opinion that a true arteritis, with exudation on the inner surface of the vessel—constituting the so-called adhesive exudation, by which the thrombus is fixed and made to adhere to the wall of the vessel—is not an essentially necessary condition; since we have found it absent in numerous cases, in which all the requirements for occlusion were present,—that is to say where neither a change, induced by exuda- tion in the tissue of the circular fibrous coat and in the lining membrane of the vessel, nor a free exudation on the latter could be distinctly re- cognized. We do not regard the albuminous or gelatinous layer, which invests the thrombus and the lining membrane of the vessel, and attaches the thrombus to the arterial wall, and which at first is transparent, but subsequently becomes white and opaque, as the product of arteritis, or as an exudation, but as a product of the blood—as a structure analo- gous to the lining membrane (see p. 204), which is produced in the stump of the vessel with a readiness proportional to the necessary mechanical conditions which are present. We may very often distinctly perceive 248 ABNORMAL CONDITIONS OF how it encloses the thrombus, and extends, sometimes in a bridge-like form, from its basis towards the wall of the vessel. In other more advanced cases, these two lamellae are everywhere, or at some spots fused together; and, in the latter case, as the thrombus does not com- pletely fill the vessel, it adheres by threadlike structures or bridges. The wrinkled, velvety coagulum investing the inner wall of the vessel, and which we have already described, has a similar significance; in like manner we believe, that the degeneration Avhich attacks the circular fibrous coat, and gives rise to loosening, bleaching, and lacerability, is not to be regarded as the consequence of an exudation, and to be re- ferred to its action on the tissue, but must be considered in the light of a regressive metamorphosis—an involution,—such as we meet with in atrophies of arteries, as, for instance, the obliteration of the foetal passages, &c, which are effected without the agency of any inflammatory process. 3. We hold that the occlusion and obliteration of tied arteries are essentially dependent on the same process that occurs in vessels which no longer receive an energetic current of blood, in consequence of the circu- lating fluid taking another course, and become unserviceable, as for in- stance, the umbilical arteries and the Ductus arteriosus. After the end of the tied artery next the ligature has become closed by the fusion of the opposite surfaces of the inner wall of the vessel, the further obliteration follows from the decrease of the vessel as the blood is turned into another course, and a collateral circulation established; and from its walls finally coalescing, either by means of the original lining membrane, or of a newly-deposited layer of that structure. The white mass, which we find as a central substance in the stump of the vessel, seems therefore to con- sist of this newly-deposited stratum. When a thrombus is formed, which is far more commonly the case, the same process takes place—that is to say, the vessel contracts, and becomes occluded above it; it undergoes a metamorphosis into a fibroid string—a white fibrous mass. 4. Whether the thrombus, in certain cases, disappears by resorption into the mass of the blood in a state of minute disintegration or (as Remak expresses it) by solution, is a point which is certainly not at present established. There are, however, no facts positively opposed to this view, and it would be an occurrence in whose favor there are many analogies,—as, for instance, the fusion or resolution of coagula of blood in inflamed veins, the diminution and the final disappearance of vegeta- tions on the valves of the heart, the disappearance of the ends of phlebo- lites, &c. 5. We have never observed the formation of vessels in a thrombus (its so-called vascularization). We do not, however, in the least doubt the accuracy of Stirling's observations,—that is to say, that the mass of the thrombus was porous, and capable of being injected; we cannot, how- ever, participate in his view, that this condition depends on a true formation of vessels, and represents an organization of the thrombus. We prefer believing that this condition is the same as that with which we have become acquainted as channelling of the deposit (of the structure analogous to the lining membrane of the vessel, and formed in great excess, see p. 200), and which we regard as a very remarkable pheno- THE ORGANS OF CIRCULATION. 249 mena ; that eAren this channelling sometimes occurs in other structures similar to thrombus, as, for instance, in the fibrinous coagula in the heart; and that it is of this, and nothing else, which observers speak, when they fancy they have injected polypi of the heart (Alex. Thomson, Vernois, see p. 166). We have recently had opportunities of observing this porosity, and the cavernous structure to which it gives rise, in vegetations within the cavities of the heart. Holding this view of the case, we cannot regard the diminution and shrivelling of the thrombus, whereby its vessels—that is to say these canals—becoming obliterated, as a regressive formation in Stirling's sense. 6. Neither have we had an opportunity of observing a long central bloodvessel, either single or ramifying at its extremity, running through the stump of the obliterated vessel, as described by Lobstein and Blandin; nor have we ever observed the arborescent sprouting of vessels from a stump, as seen by Jones, Ebel, and others. According to our view, this phenomenon is intimately connected with the channelling of the thrombus, and the presence of these central vessels in the stump is exclusively owing to the persistence of longitudinal canals in the thrombus, such as have been frequently noticed by Stilling; and these arborescent vessels are nothing more than such persistent canals of the thrombus, which may perhaps, in the course of time, become longer and broader within the atrophying stump of the vessel. They most assuredly have no affinity with true vessels, however generally they may be regarded in that light. We think it highly probable that Mayer's case of two arch-like lateral vessels, which connected the two extremities of the carotids after they had been tied, belongs to this class, although we are unable to give a definite opinion on the subject. The formation of central canals in the coagula which obstruct inflamed veins—under which head we must include the case observed by Barth, of a central canal through an old plug obstructing the abdominal aorta, —may depend upon the same process of channelling, or upon another process, to which we shall refer, when we proceed to the consideration of the veins. IV.—ABNORMAL CONDITIONS OF THE VEINS. § 1. Deficiency and Excess of Formation. We have already noticed, under the head of Anomalies of the Heart, the most important anomalies and other deficiencies of structure affecting the trunks of the venous system. Moreover our remarks, in the corre- sponding chapter on the Arteries, apply likewise to the Veins. § 2. Anomalies in their Origin and Course. Various anomalies of this nature are of frequent occurrence in the venous system, although they do not, according to Meckel, preponderate over those of the arteries to so extensive a degree as is generally supposed. We refer our readers to the more circumstantial anatomical works for a detailed notice of these anomalies. There is, however, one form of anomaly belonging to this class which 250 ABNORMAL CONDITIONS OF deserves especial mention, notwithstanding the notice which "will be given of it under Dilatations of the Veins. This form consists in an anasto- mosis of the epigastric cutaneous veins with the umbilical vein at the navel, on which depend the persistence and patency of the latter vessel. § 3. Diseases of Texture. We purpose, for the better comprehension of the subject, prefacing our consideration of other anomalies, as, for instance, those of calibre, by a notice of these diseases. a. Inflammation.—The study of inflammation of the veins (Phlebitis) constitutes one of the most important departments of pathology. It is entirely the result of anatomical research; yet, however complete may appear to be the development which this subject has attained in our day, it still presents many important deficiencies, which have either been dis- regarded by observers designedly or from a deficiency of materials, or have been supplied by irrational conclusions an4 hypotheses. Inflammation of the veins is a very frequent disease, and is highly important, both on its own account, and also more especially from the absorption of its products into the blood. It is, under all circumstances, incomparably more frequent than inflammation of the arteries. Its seat is the cellular coat of the vein, and likewise the cellular fibrous coat, in as far as the latter exhibits a certain degree of vascularity; and its products are deposited alike in the tissue of both these coats, and in the non-vascular strata of the lining membrane of the vessel from whence they extend to the canal of the vein. It more frequently exhibits an acute than a chronic character, and it is then distinguished by the deposition of exudation on the inner surface of the vessel. The following remarks refer to this form of the disease, the chronic form of which will be considered in a future page. It is especially necessary to distinguish two forms of phlebitis : 1. Phlebitis (inflammation of the coats of the veins) is the primary disease, although it may be owing to various causes, while every anomaly of the blood within the inflamed tube of the vessel, and still more, per- haps, beyond that spot, such, for instance, as the coagulation of the blood within the inflamed vessel, is a secondary phenomenon, depending upon the product of the inflammation. This phlebitis is very frequent as a primary disease, and arises from the most various injuries, as cuts or thrusts, affecting either the vein alone, or, conjointly with it, other soft and firm parts; from contusions and displacements of different soft parts including the vein; or from many forms of surgical or medical maltreatment of wounds of the veins. This disease so far depends upon the epidemic constitution, that it is of extremely frequent occurrence at certain periods, with or without the concurrence of these favoring circumstances. This disease may also be of a secondary character, and in that case it is derived either from in- flamed contiguous structures—as, for instance, the inflammation of the veins in the neighborhood of abscesses, phlebitis from inflamed carious bones, &c,—or is of a metastatic nature, as the phlebitis which occurs in the course of many different acute febrile affections, and as one of their sequelae. THE ORGANS OF CIRCULATION. 251 2.At other times the coagulation of the diseased mass of the blood within the tube of some one vein is the primary, and indeed the special occurrence, which gives rise, from reaction as it were, to inflammation of the coats of the veins—phlebitis. This disease is then a dependent, secondary affection, of subordinate importance. Such a form of phle- bitis always consists in the establishment of a disease of the blood, which is either of a spontaneous character, or depending upon the absorption of different^ deleterious substances, such as inflammatory products origi- nating either within or external to the vascular system. It constitutes the most frequent of what are termed metastases, especially if we include the process of the coagulation of blood in the capillaries—the so-called capillary phlebitis. This distinction of character, which has hitherto not been sufficiently regarded or properly understood, is of the greatest practical importance and interest, since it affords a clue to the right comprehension of the significance of phlebitis in individual cases, and thus contributes to throw light on many points in the history of phlebitis which had either remained entirely obscure, or had been explained in a wholly irrational manner. We shall always indicate this latter form of phlebitis as that which depends upon coagulation of the blood. A. The following are the anatomical indications of (acute) phlebitis: 1. Injection and Redness of the Cellular Coat of the Vein, in different degrees and shades of color. The cellular coat is very commonly inter- sected by varicose vessels, and is at the same time of a bluish-red color, which, however, experiences various modifications by the infiltration of inflammatory products into its tissue. The latter membrane very fre- quently presents a darkish-red, mottled or streaked appearance, in con- sequence of slight extravasations. 2. Infiltration of the Cellular Coat, with a serous, sero-fibrinous, partially solidifying, grayish, gray or yellowish-red moisture, and bulging of the coat; the infiltration is very commonly associated with a thin sero- purulent, or thick purulent moisture and with bulging, whilst more or less circumscribed abscesses occur in the interior of the vessel. The neighboring cellular tissue participates, in various degrees, in the process, although, generally speaking, in proportion to its vicinity to the seat of the disease; the tissue becomes vascularized, infiltrated, and swollen, and the vein becomes then fixed or imbedded in it. We also very often observe circumscribed abscesses, together with diffused puru- lent infiltration at some distance from the vein. 3. Injection and Redness, as well as the other discolorations produced by the infiltration of various products, extend into the circular fibrous coat of the vein. The latter coat appears to be vascularized; but more frequently the injection and redness of the tissue are already obliterated. It then presents a grayish-yellow faded appearance, and is discolored at different points by imbibition from within, or from the contiguous extra- vasations in the cellular coat, or is mottled red by small extravasations within its own tissue; it is, moreover, unusually succulent, and is swollen. In phlebitis with purulent exudation, it is most distinctly infiltrated with the purulent or sero-purulent fluid. 4. The inner coat of the vessel presents a dirty-white appearance, or 252 ABNORMAL CONDITIONS OF is colored red, violet, brown, or even green, by the imbibition of haematin from its interior, or from haemorrhagic exudations into its tissue. It is swollen; the inner surface is devoid of lustre, is dull, felt-like, and wrinkled. When purulent exudation is present, it is more especially of a pale yellowish color, succulent and lustreless. 5. In addition to these alterations, all the coats of the vein are relaxed in their texture, and admit very readily of being torn, and separated from one another. In some cases the strata composing the inner coat (together with the valves) are detached from the circular fibrous coat, and even cast off in the form of a tube; and this is of very general occurrence in the more intense forms of phlebitis with purulent exudation.—In these cases, the inner coat, which is thrown off in the form of a tube, may be the more readily mistaken on a superficial exami- nation for a tubular exudation, when its tissue admits of being readily torn, and it has been colored yellow by the imbibition of pus. 6. The vein appears to be dilated and paralyzed; its tube is gene- rally either filled by a plug of blood, which either resembles a recent coagulum, or has entered into different metamorphoses, or is filled with the product of the process (the exudation), more especially pus. The formation and significance of the above-named coagulum are intimately connected with the actual process of exudation, as will be seen by the following remarks: 7. Exudation.—The exudations deposited in the texture of the venous coats, and in the contiguous tissues surrounding the vein (its cellular bed), have already been in part considered, both in reference to their bulk and nature. A far more important class of exudations are those which are deposited on the inner free surface of the vein (within the vein), and which, owing to their absorption into the blood, and the infection to which they may give rise, impart to phlebitis the dangerous character that renders it so formidable a disease. The general disease arising from these conditions, together with its intensity and character, depends upon the nature of the exudation, and also upon certain accidental circum- stances, Avhich we now proceed to consider. a. The exudation may vary very considerably, both in reference to its physical properties and its internal composition. A direct anatomical demonstration of the exudation itself, either in reference to the original- ly inconsiderable quantity in which it appears, to its absorption into the blood, or still more in regard to the evidence of its original and special quality, is very difficult or even impossible. We would especially no- tice: The so-called plastic exudation, capable of undergoing a metamor- phosis of tissue, which, in rare cases, occurs in an appreciable quantity as a flocculent, soft, or consistent membranous coagulum on the inner surface of the vessel, or adhering to the fibrinous plug which fills the vein. The quantity of exuded serum originally contained within it never admits of being detected, as it is absorbed by the blood at the moment of its exudation, together with the greater portion of its coagulable matter. The purulent and ichorous exudation, which is a very frequent pro- duct of phlebitis, is generally secreted in such abundance, that it may THE ORGANS OF CIRCULATION. 253 be easily recognized, even in those cases in which the blood has coagu- lated within the vessel. It very commonly expels the blood entirely from the vein, which is then completely filled with pure pus or ichor, the product of the process of exudation. We, moreover, here meet with exudations of a fibrinous, purulent product deposited under the lining membrane of the vessel, in the form of islands or large patches, exhibit- ing diffused, purulent, ichorous infiltration of the venous coats, together with discoloration, loosening, and a high degree of lacerability and de- tachment of the strata composing the lining membrane, in the form of a lax, lacerable, disintegrating fusing cylinder, which might easily be mistaken for a tubular exudation. Are any of these exudations of a hemorrhagic or a tuberculous character ? In many instances, indeed, we observe a red, brownish or violet-red, or chocolate-brown coloration of the exudation on the in- ner surface of the vessel, together with a haemorrhagic suffusion of the coats of the vein, and centres of haemorrhagic exudations in the neigh- borhood of the vessel. We have never observed a tuberculizing exudation, or even one whose nature led us to suspect a tuberculous character, on the inner surface of the vein. ~(See our subsequent remarks on Tuberculosis.) b. The coagulation of the blood in the inflamed vessel, or the forma- tion of a fibrinous plug, which is most intimately connected with the depositfon of an exudation upon the inner surface of the vein, and with its absorption into the blood, is a phenomenon of the greatest and most varied interest. It arises from the contact of the blood with the pro- ducts of inflammation. The subject has been already generally con- sidered under Diseases of the Blood, and will therefore be noticed here only in as far as is indispensably necessary towards the right comprehen- sion of phlebitis. Phlebitis, if we may judge from appearances after death, very rarely occurs without a simultaneous coagulation of the blood in the inflamed vein. The inflamed vein is very commonly filled by a cylindrical fibrinous plug, which, according to circumstances, is either single or ramified, and terminates conically at both extremities. In phlebitis having a purulent exudation, the coagulum is either pre- sent in the above-described form, or is disintegrated, and blended with the purulent product in the form of loose, friable detritus ; or, finally, there may be no trace of its presence, in which case the vein is entirely filled by copiously exuded pure pus. 8. Further evidence of the phlebitic process, both in reference to its own nature and that of its products, and to its highly important charac- ter, is afforded by numerous secondary conditions, which we shall briefly notice in the following remarks, referring our readers to our previous observations on the subject in Diseases of the Blood. a. The immediate consequence of the phlebitic process is a diseased condition of the blood, arising from the absorption of the morbid pro- ducts, which constitutes the basis of all the subsequent secondary phe- nomena. This disease generally induces degeneration of the blood, ac- cording to the character of the product, either into a so-called phlogis- tic condition (haemitis, hyperinosis), or into pyaemia. Hence arise : 254 ABNORMAL CONDITIONS OF b.. The processes of stasis and coagulation of the blood in various por- tions of the capillary system (lobular processes, deposits, metastases, ca- pillary phlebitis), with the different metamorphoses of such a coagula- tion ; namely, shrivelling to a fibroid callus with atrophy of the tissue, or purulent, ichorous fusion with similar destruction, necrosis of the tissue; processes of coagulation in larger vessels, more especially the veins ; and finally in the heart itself, under the form of different vege- tations. c. The allied processes of stasis and of exudation into the parenchy- matous structures, as well as upon the membranous, serous, and mucous surfaces, with the fusion of the substratum, which is especially percep- tible on the mucous membranes, and with suppuration and necrosis of the tissue. This general infection of the blood by the product of phlebitis, together with the further phenomena depending upon that process, does not, how- ever, invariably take place,—a circumstance that some observers attempt to explain, in imitation of Cruveilhier, by the so-called sequestration of the vein. Thus, for instance, the coagulation of the blood on the limits of the inflammation, and the exudation into the vein, are supposed to isolate the inflammatory product—the pus—and prevent its absorption into the blood. We have been led, by extensive experience, to adopt the following views in reference to the solution of these two intimately associated questions regarding the cause of the non-occurrence of a general infec- tion, and the significance of the so-called sequestration, as a special means of arresting the process. The non-occurrence of a general infection of the blood in phlebitis would appear to be frequent, if we judge from observations on the living subject; but, on the other hand, it is rarely noticed after death, where the phlebitis which is brought under our observation is generally charac- terized by purulent exudation. In the latter cases, therefore, the exudation must be absorbed into the blood, and carried away with it from the seat of its formation. The reason of the non-occurrence of a general infection depends, in our opinion, upon the fact of the blood coagulating at the place of the exudation, and upon the rapidity with which the whole of the blood, or one of its strata, is coagulated in consequence of the absorption of the inflammatory product; whence the course of the recently deposited or still exuding product is at once arrested. As, however, this coagulation in the ordinary and more frequent cases is not effected immediately, but requires (as we see exemplified in the frequent development of coagula in a section of the vascular system re- mote from the infected portion of the blood) that the heterogeneous sub- stance must remain for some time in contact with the blood, we are able to explain why a portion of the exudation is in general carried onwards by the circulation, and the blood is then infected before the coagulation can be established in the vessel. A sequestrating fibrinous plug must be distinguished from the coagulum originally filling the vessel, and induced in the blood-current by the ab- sorption of the exudation. THE ORGANS OF CIRCULATION. 255 It is certainly true, that in every case of phlebitis the coagulation of the blood extends beyond the limits of the inflammatory centre, along the vessel, and the coagulum filling it. In order to comprehend the sig- nificance of this coagulation as a means of sequestration, it will be neces- sary for us to form a clear idea of the conditions requisite for its forma- tion. The coagulation is effected in a simple manner, above and below the inflamed vein, and around the coagulum which originally filled it. The blood is coagulated below the inflamed vein (at its circumference) in all the branches where it is retained by the coagulum obstructing the vessel; above this point, towards the centre, the blood is arrested as far as the next considerable-sized venous branch that opens into the diseased vein. The coagulation is thus dependent on the coagulum originally obstructing the inflamed vein, and is essentially a thrombus. Seeing that this form of coagulation can only be effected after the formation of the original coagulum, there are two points to be considered in reference to its significance. a. A general infection usually occurs, as has been already stated, before the development of the coagulum which originates in the absorp- tion of the exudation, and consequently still longer before the formation of the sequestrating clot. b. The original coagulum is rapidly formed after the deposition of the exudation, and it hinders the general infection by entirely filling up the tube of the vessel, and absorbing the whole of the exudation. The se- questrating plug does not appear, in either case, to be of any essential service. We here, however, draw the following inferences in reference to the possibility of infection arising from the metamorphosis of the original coagulum: 1. If the phlebitis had deposited a so-called plastic exudation, and belonged to the form which terminates in disintegration or obliteration (see the modes of termination of Phlebitis), the sequestrating plug would be of no obvious utility in either of the cases considered under a and b. 2. If the phlebitis had deposited a purulent ichorous exudation, there would necessarily have existed one or other of the following conditions : a. A general infection of the blood must have been induced previously to the development of the original coagulum, which may either have filled the diseased vessel throughout its entire length, or may have been limited to the margins of an accumulation of pus in the vein, if that fluid were exuded in large quantity. The sequestrating plug cannot, in such a case, hinder the pyaemia, in the course of whose existence it has, in fact, been developed; while it is itself, moreover, subject to purulent fusion from a prolonged continuance of the disease. b. Or the original coagulum may have been rapidly formed by coming in contact with the pus, in which case general infection of the blood could not possibly have been effected at that moment, but inasmuch as this coagulum undergoes a more or less rapid purulent fusion, there is a possibility of the blood becoming secondarily infected by the disinte- grated admixture of the coagulum. This coagulum may be permanently 256 ABNORMAL CONDITIONS OF retained through a subsequent coagulation of the blood that has continued unaffected. It is only under these conditions that the coagulation which occurs at the limits of the inflamed vein is of essential use—that is to say, it is only the pus proceeding from the metamorphosis of a coagulum established in the vein by the absorption of a purulent exudation pro- duced at the spot, that can in the true sense of the word^ be sequestrated. In addition to the signs and consequences of phlebitis to which we have already referred, there are certain associated and consecutive phe- nomena, which still require notice ; namely, accumulation of blood in the small veins and capillaries beneath the inflamed vein, a cyanotic tint, and oedema around this portion of the vascular system; these are conse- quences of the occlusion of the inflamed vein. As the inflammatory pro- cess extends, we have inflammation of the cellular sheath of the vein and of the surrounding cellular tissue, with sero-fibrinous, sero-purulent, he- morrhagic exudations; we further have inflammation of the skin in the form of erysipelatous redness, which, from the beginning, accompanies the inflammation of the subcutaneous veins in the form of red streaks along the course of these veins; and, as a final result, we have moist gangrene, caused by the stasis established in the capillaries by the exten- sive occlusion of the inflamed vein. The following are the terminations of phlebitis: it may end in resolu- tion ; in chronic inflammation, with persistent thickening; in coalescence of the vein with contiguous structures ; and in dilatation, in persistent obliteration, or in suppuration of the vein. 1. The termination in resolution (or perfect recovery) is by no means rare in slight cases of phlebitis, even where there has been a general in- fection, like that occurring in endocarditis, which, independently of the local residua, very frequently assumes a similar favorable character, not- Avithstanding the pre-existence of general infection. The coagulum ob- structing the inflamed vein is gradually absorbed into the blood in a finely comminuted state, and being dissolved like the originally absorbed exuded substance, the diseased vein becomes again free. 2. In some cases there remains a condition of chronic vascularity of the coats of the vein, with bulging, which is not unfrequently accom- panied with a rusty-brown or slate-gray discoloration, with paralysis and dilatation of the vein. In this condition there are often acute relapses, more especially in the veins of the lower extremities. It finally leads to hypertrophy of the coats of the vein, in consequence of the continued accumulation of the exudation in their tissue ; to rigidity of these coats; to permanent dilatation, and by means of the sclerosis of the surround- ing cellular tissue, to permanent immobility of the vein, and coalescence with the neighboring structures—as, for instance, aponeuroses, muscular sheaths, the general investments, the periosteum, &c. The latter condi- tion further predisposes to the formation of new layers of lining mem- brane from the blood, in consequence of the retarded flow of the blood- current. 3. Termination in obliteration is induced by means of the coagulum, which obstructs the inflamed vein. This coagulum, which is formed by the absorption of a so-called plastic exudation (that is to say, an exuda- THE ORGANS OF CIRCULATION. 257 tion capable of being metamorphosed into tissue), undergoes a gradual decoloration and is converted into a whitish fibroid band, which is very commonly interspersed with rusty-brown or black pigment. After this metamorphosis, the coagulum becomes shrivelled. This string or band is attached to the wall of the vein, either at all parts of the circumference, or only at separate points, by means of a cellular structure, formed by the metamorphosis of a portion of the exu- dation on the inner surface of the vein. If the wall of the vein par- ticipate, in the former case, in the shrivelling of the coagulum, the vessel is rendered impermeable, and becomes finally atrophied, and completely obliterated. But if, on the other hand, the wall of the vein does not generally participate in the shrivelling of the coagulum, in consequence of the latter being attached merely by partial adhesions, or if the blood forces its way into the obstructed vein notwithstanding the total adhe- sion of the coagulum, the structure by which the shrivelling coagulum is attached to the wall of the vein becomes torn into threads and laminae, which gradually acquire an investment of recently formed lining mem- brane from the blood; and the vein being in consequence only partially obliterated exhibits the following appearances : The vein is either occupied by a fibroid, roundish string, which adher- ing only to a portion of the wall of the vessel leaves the latter free and permeable in other parts. Or, in addition to this connection of the fibroid string with the vessel, thread-like bridges, or membranous partitions, which are more or less perforated—the torn adhesions above referred to—are also attached to the free portion of the wall of the vein, while its tube is broken up into numerous straight or oblique canals or divisions. Or the fibroid string is attached at various parts to the interior of the vessel, by means of adhesions, arranged in the most irregular manner. ^ The coats of the vein are thickened, the vessel itself being more or less firmly imbedded in a cellular stratum in a state of sclerosis; the free portion of the wall is dilated and elongated, so that the vessel de- scribes intestine-like coils round the resistant fibroid string, or twists itself around it as around an axis, as the former changes the points of its adhesion. This condition gives rise to a special form of varicosity. The vessel at the same time presents some analogy in its calibre with the structure of the sinuses of the dura mater, more especially Avith the supe- rior longitudinal sinus. This fibroid string within the vein may ossify in the progress of time, constituting a form of central ossification. This condition has been more especially observed in the cutaneous veins of the lower extremities—on the trunk and ramifications of the saphena veins. We noticed it in one case, together with the products of intense peritoneal inflammation, on the whole system of the mesenteric veins ; and on account of its rarity, we will give a brief history of it. The body of a girl, aged 13 years, exhibited the following appear- ances, in addition to an excessive degree of emaciation, and a pale de- coloration of the general investments. The abdomen was swollen, and felt hard and board-like to the touch; the linea alba presented the VOL. IV. 1? 258 ABNORMAL CONDITIONS OF resistance and the appearance of a cartilaginous layer, and was a line and a half in thickness ; the same character was generally exhibited by the aponeurotic portions of the abdominal wall. The peritoneum of the abdominal wall was invested by a pale slate-gray, cartilaginously tough pseudo-membrane, a quarter of a line in thickness, Avhich extended to the intestinal canal and the stomach, which it covered. It contained a yellowish-white purulent fluid. The mesenteric vein, with its ramifica- tions, was partly thickened and callous, while its canal was divided by numerous bridge-like partitions, which were perforated at different spots, and whose margins were torn, and was partly contracted by detached structures of this kind. The walls of the portal vein were uniformly thickened. The coats of the hepatic, cystic, and common bile-ducts were swollen, whilst their mucous membrane was covered with numerous, and generally suppurating, villous growths; the ducts contained an ichorous, brownish fluid. A similarly colored dark fluid was also found in the stomach and the intestinal canal. The patient, in addition to general indisposition, had suffered from chocolate-colored discharges, both by stool and vomiting, and had also, throughout her illness, vomited light- red, pure blood, Avhich proceeded from the gall-ducts. Cheesy matter, and a substance resembling moist chalk or mortar, are, moreover, occasionally found in veins that have been obliterated, and are either the disintegrated remains of the coagulum which had ob- structed the vessel, or inspissated pus. 4. The termination in suppuration, and in an acute purulent fusion and necrosis of the coats of the veins, corresponding to the previous (acute) course of the disease, is, on the whole, somewhat rare. The dilated vein is filled with a large quantity of purulent exudation, mixed with blood, and all its coats, besides presenting a dirty-red tint from im- bibition, are infiltrated with pus, and tear with great facility and almost like tinder; while the inner coats peel off from the cellular sheath in the form of a crumbling pipe or tube, and the cellular tissue surrounding the vein is in a state of suppuration. This process sometimes occurs at individual spots, so that, after the solution of the venous wall, circum- scribed abscesses are occasioned in the adjacent cellular tissue. This acute suppuration of a vein usually only occurs when the highest degree of pyaemia has been developed. A more frequent occurrence is a pro- tracted suppuration in sequestrated varicose veins, which had originally suffered from chronic inflammation, a subject to which we shall again recur. The phlebitis induced by the coagulation of blood often termi- nates in gangrenous suppuration and fusion. \ From what has been already stated, both in reference to the exu- dation and the last two modes of termination, it follows that the phle- bitis of which we have already treated is sometimes adhesive and some- times suppurative. b. The phlebitis depending on coagulation of the blood differs from the form of acute phlebitis hitherto treated of, inasmuch as the coagu- lation within the vessel is the primary phenomenon, whilst the inflam- mation of the coats of the veins—phlebitis—is associated with it merely as a secondary affection. The coagulation is therefore not occasioned by the inflammatory product of the coats of the veins—that is to say, THE ORGANS OF CIRCULATION. 259 by the absorption of the exudation into the blood from the inner sur- face of the vein, but is the result of a disease of the blood, Avhich is either spontaneous or occasioned by the absorption of different products of stasis or inflammation, deposited either within or external to the vascular system. This disease reaches so high a degree of development at differ- ent points, and in the second case at different distances from the centres of infection, that the column of the blood coagulates more or less rapidly, with a more or less complete separation of the fibrin. When the coagulum is once formed, inflammation of the coats of the veins, if not invariably and very rapidly developed, is at all events of very common occurrence. The existence of this process, when developed in the manner above described, proves the undoubted occurrence of coagulation of the blood in the various portions of the vascular system, from the centre to the capillaries, even where there is no trace of inflammation in the vessel; but it does not prove that where inflammation of the vein is present, its intensity and development have been sufficient to cause the coagulation by the deposition of exudation on the inner surface of the vessel. The indications of this phlebitis are, in general, identical Avith those observed in the inflammation of the veins which we have already con- sidered, but it is nevertheless of the greatest importance to notice the following special points: 1. We very frequently observe the above indicated want of relation between the nature and metamorphosis of the coagulation and the degree of intensity we should expect to meet with at the beginning of true inflammation of the coats of the veins. The disease generally, how- ever, exhibits a very slight intensity, while the lining membrane of the vessel is not in a condition which would seem to indicate the immediate pre-occurrence of an exudation into its tissue, extending by means of the latter to the inner surface of the vessel. This is the most re- markable, since, as we shall see by the following facts, it is usually owing to a purulent exudation that the process is developed in its sub- sequent course. 2. In general it is an ordinary pyaemia which occasions the coagulation of the blood in vessels of considerable calibre. In accordance with this view, the coagulum commonly undergoes a purulent metamorphosis, a fusion into a more or less organized pus or ichor. According to the cir- cumstances of the case, the vein finally contains a chocolate-brown, gray- ish-red, or yeast-yellow purulent fluid, mixed with partially dissolved fragments of the plug; or a dirty-brown, brownish-green, foetid, ichorous fluid, or even a very discolored, stinking, gangrenous ichor (Phlebitis septica). The contents are here not the product of the inflamed venous wall, but proceed from the metamorphosis of the coagulum. 3. In consequence of this metamorphosis—that is to say, of the con- tact of the inner coat of the vessel with the deleterious substance and its subsequent imbibition, the inflammation of the coats of the veins rapidly attains a high degree of development, and gives rise to corre- sponding purulent and ichorous exudations, which are added to the above described contents of the vein. 4. The diseased condition of the blood is in a high degree the con- 260 ABNORMAL CONDITIONS OF trolling cause, while the so-called metastatic processes, to which it gives rise, are distinguished by their number and intensity. 5. An isolating or sequestrating coagulation cannot, as is obvious, be in any way conducive to this process. It must be remarked, in reference to the terminations of this phlebitis, that— 1. The ordinary termination, in case death be not sooner induced by the general disease, is an acute ulcerous fusion, a gangrenous and ichor- ous destruction of the vein, arising from the process already considered under 2. 2. It is very rare, in accordance with the facts above referred to, for the disease to terminate in permanent occlusion, or in complete or incom- plete obliteration. When the pre-existing inflammation of the coats of the veins has attained so high a degree of development as to cause a plastic exudation to be deposited on the inner surface, it will give rise to the adhesion of the obstructing plug; this may also be effected by the direct coalescence of the lining coat of the vessel with the plug. To this form of phlebitis belong also those processes in the capillary system of the different tissues which have been commonly designated lobular processes, metastasis, and capillary phlebitis by the French. They are, in fact, the same process which we have already considered as that form of phlebitis which is induced by coagulation of the blood. We shall revert to this subject when we enter upon the consideration of the diseases of the smaller vessels, and of the true capillaries. Although we think we need hardly enter upon any special discussion of the differential diagnosis of these two forms of acute phlebitis, after having considered them with every possible attention under the heads A and B, we would yet draw attention to the following additional remarks: The division of phlebitis into an adhesive and a suppurative form is well known, and has been generally followed. The two forms we have established may participate in either of the above characters. We would, however, expressly notice the error into which French observers have fallen, in regarding the purulent mass, which is in the centre of the coagulum, as the product of the inflamed coats of the veins. Cruveilhier attempts to show that the pus reaches the coagulum from without, by the capillary action of the coagulum ; but this very unnatural hypothesis is quite inadequate to the solution of the question. We know, from many highly important analogies, that in ordinary cases the metamor- phosis of the coagulum begins at its central nucleus, and that the puru- lent matter in the midst of the plug obstructing the vein cannot be regarded as the product of the inflamed coats of the vein. c. Chronic Phlebitis, as already observed at p. 256, is occasionally a consequence of the acute form of the disease; it may, however, likewise occur independently of the latter. In the latter case it consists in chronic inflammation of the cellular coat, into whose tissue, and the contiguous layers of the circular fibrous coat, it deposits its products. The cellular substratum of the vein must obviously participate in this process. Its anatomical indications are chronic inflammation of the cellular tissue. THE ORGANS OF CIRCULATION. 261 It gives rise to dilatation, varicosity, and thickening, through the hy- pertrophy and sclerosis of the cellular coat of the vein; and, seconda- rily, through the new layers of lining membrane that are formed from the impeded blood-current, to the gluing of the vein into its cellular bed, to rigidity of the venous coats, and to gaping of the cut tubes ; in short, it makes the veins approximate in character to arteries. It has a great tendency, on very slight provocation, to pass into acute phlebitis. Its most obvious causes are persistent distension and dilatation of the veins, in consequence of the impediments presented to the passage of the blood through them, besides which, it very often arises from the inflammation of the contiguous cellular tissue by an extension of the process. In accordance with what has been already stated, this condi- tion is especially frequent in varicose veins, and in the veins of the lower extremities, where it very frequently originates in the subcutaneous tissue, which is then the seat of chronic inflammation, arising from habi- tual eczema. Phlebitis very generally follows the course of the blood-current to- wards the heart, at all events during the early stages of its development; but yet exceptional cases are not unfrequently noticed, in which the inflammation follows a different course, and extends, during its more advanced stages, in an opposite direction. It still remains for us to notice the phlebitis which attacks some spe- cial portions of the venous system. 1. Inflammation of the sinuses of the dura mater arises from injuries of the cranium, in consequence of a concussion of the dura mater near the sinus, or of a direct injury of the latter from fragments of bones, &c. It is frequently observed to arise from inflammation of the dura mater in the neighborhood of a sinus, and from inflammation and sup- puration of the bone. A tolerably frequent example of the latter mode of derivation presents itself in the inflammation of the sigmoid sinus,1 arising from caries of the petrous portion of the temporal bone, whence it commonly spreads, with considerable rapidity, to the internal jugular vein. In some rare cases, this form of phlebitis is owing to coagulation of the blood (metastasis); and as it is almost invariably accompanied, under these conditions, by a purulent exudation, we not unfrequently find that the walls of the sinus exhibit incipient suppuration. We have repeatedly seen cases in which the inflammation, after attacking the cavernous sinus, had extended by