a :*x.-' ■"'i** ;£* h:3 :r\ -.mm - ^ **'.# $& :'l?v 1 ■ ■ ■ &' 'US'' - ; * < '^.'-^R^; ■*v /if'- * ~?{ tA^t?1 NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland "^ I the PATHOLOGICAL ANATOMY OF THE HUMAN BODY- * Of *■■•- * Vp [1047 i i ■ ■ J. JiiUt^^z'cJeJ^z,. THE PATHOLOGICAL ANATOMY THE HUMAN BODY. BY JULIUS VOGEL, M.D. PROFESSOR OF CLINICAL MEDICINE AT THE UNIVERSITY OF GIESSEX. TRANSLATED FROM THE GERIMAN WITH ADDITIONS, BY GEORGE E. DAY, M.A. & L.M. CANTAB. MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS; PHYSICIAN TO THE WESTERN- GENERAL DISPENSARY ; LECTURER ON HISTOLOGY AND ANIMAL CHEMISTRY AT THE MIDDLESEX HOSPITAL MEDICAL SCHOOL; MEMBER OF THE PATHOLOGICAL SOCIETY OF LONDON, AND FORMERLY SENIOR PRESIDENT OF THE ROYAL MEDICAL SOCIETY 0F EDINBURGH. MAY 26 1897 :-u,,. if HYGIENE, .Jc^jfe. ILLUSTRATED BY UPWARDS OF ONE HUNDRED PLAIN AND COLOURED ENGRAVINGS. PHILADELPHIA: LEA & BLANC HARD. 1847. Griggs & Co., Printers. TO C. J. B. WILLIAMS, M.D. F.R.S. THE PRESIDENT ; B. GUY BABINGTON, M.D. F.R.S. RICHARD BRIGHT, M.D. F.R.S. JOHN CLENDINNING, M.D. F.R.S. JOHN FORBES, M.D. F.R.S. J. MONCRIEFF ARNOTT, M.D. F.R. CAESAR HAWKINS, ESQ. C. ASTON KEY,ESQ. ROBERT LISTON, ESQ. F.R.S, THE VICE-PRESIDENTS J JAMES COPLAND, M.D. F.R.S. THE TREASURER THE PATHOLOGICAL SOCIETY OF LONDON, WHOSE LABOURS IN MORBID ANATOMY AND PATHOLOGY HAVE ACQUIRED FOR THEM UNDYING NAMES IN THE RECORDS OF MEDICAL SCIENCE, THIS VOLUME IS DEDICATED WITH EVERY FEELING OF RESPECT BY THE EDITOR. A* TO THE BEADED The entire absence of any English work on Morbid Anatomy,. embracing the recent discoveries effected by Chemistry and the Microscope, affords a sufficient reason for the appearance, in the present form,, of Vogel's Pathological Anatomy on the Human Body. This volume forms in itself a complete Treatise on general Morbid Anatomy. It will very shortly be followed by a second, devoted to the consideration of Pathological changes affecting special organs. The additions that I have made to this volume are trivial and un- important, with the exception of the Plates and their explanations. These are almost entirely selected from the Author's "Icones His- tologiae Pathologicse," and will, I trust, be found valuable aids to the clear understanding of the subjects they are intended to illus- trate. I gladly avail myself of this opportunity of expressing my obliga- tions to Dr. Vogel, who has not only promised me a considerable! amount of additional matter bearing on general Morbid Anatoaay vni TO THE READER. (which will appear in an Appendix on the completion of the Work,) but has carefully examined a considerable portion of this volume, and expressed his satisfaction at the manner in which I have exe- cuted my task. I am likewise much indebted to my brother, Mr. E. Welby Day, for important assistance in preparing this volume for the press. George E. Day. 3, southwick street, hyde park. TABLE OF CONTENTS. Page Introduction. . . . . . 13 The relations of pathological anatomy to the other depart- ments of medical science. . . . 13—29 CHAPTER I. Abnormal development of gaseous matters—pneuma- toses. . . . ..... 31 Causes of pneumatoses ...... 32 From the external pressure of the atmospheric air . . 32 From gases developed in the body . . . .35 Development of gas from the decomposition of food in the intes- tinal canal ....... 36 Development of gas from the decomposition of the constituents of the body . . . . . • .38 The actual secretion of gas by different parts of the body . 39 CHAPTER II. Abnormal collections of aqueous fluids—dropsies. . 42 1. Serous dropsy. . . . . 44 Properties and chemical composition of the fluids occurring in serous dropsy . . . . . . .41 Causes and mode of origin . . . . .49 X table of contents. Further progress of the dropsical fluid after its effusion Its diagnosis and anatomical relations 2. Fibrinous dropsy. . Properties and chemical composition of this fluid Causes, mode of origin and further progress Its diagnosis and relation to the surrounding parts ;L False dropsy. ........ CHAPTER III. Pathological relations of the blood 1. Physical and chemical changes. Changes in colour Alterations in the colour of the serum Changes in its consistence Deviations in the coagulation The buffy coat Changes in odour and taste Changes in the blood-corpuscles Increase or diminution of fibrin . Increase or diminution of blood-corpnsck Increase or diminution of water . Increase or diminution of albumen Increase or diminution of salts . Increase of urea . . . Foreign matters in the blood Free lactic acid . Carbonate of ammonia Pyin, sugar,*bile-pigment, pus-corpuseles, and entozoa The geaeral ehanges of the blood 2. Changes in its quantity. . General hyperemia General anaemia . Local hyperemia Venous hyperemia Hyperaernia of the capillaries Congestion—Stasis Local anaemia 3. Extravasation of blood. . 4. Solution of hsematin and saturation of the tissues with table of contents. XI CHAPTER IV. THE GENERAL RELATIONS OF PATHOLOGICAL EPIGENESES. Distinction between organized and unorganized epigeneses Unorganized formations . Organized pathological formations The cytoblastema The law of analogous formation The cell theory . Formation of cells Persistent cells . Transitory cells . Exceptions to the cell theory Classification of morbid epigeneses Page 100 CHAPTER \\ Special relations of pathological epigeneses. Pus. . . .. ... 1. True genuine pus, . . . Pus-corpuscles .... Molecules in pus Serum of pus or liquor puris Chemical composition of pus Formation of pus Diagnosis of normal pus Abnormal pus . 2. Spurious pus. .... Compound inflammatory globules—Granular cell Suppuration .... Malignant suppuration Cause of the formation of granular cells Resorption of pUs—Metastatic abscesses Solid pathological epigeneses. Epigeneses of imperfectly organized structures Epigenesis of areolar (or cellular) tissue. . Epigenesis of the blood and vessels. xii TABLE OF CONTENTS. Epigenesis of epithelium and epidermis. Granulations. .... Epigenesis of fat and adipose tissue. Epigenesis of muscular tissue. a. Striated muscle . b. Nomstriated muscle . Epigenesis of elastic tissue. . Epigenesis of granular pigment—^melanosis. Epigenesis of nervous tissue. Epigenesis of cartilaginous and osseous tissues. Tumours. . * . . » Their classification and general relations. Non-malignant tumours analogous to the normal elements of the body. - » . < First Group-"—Vascular Tumours Second Group—Fatty Tumours . Third Group—Fibrous Tumours Fourth—Cartilaginous Tumours Fifth Group—Osseous Tumours Sixth Group—Melanotic Tumours Seventh Group—Gelatinous Tumours Eighth Group—Encysted Tumours Malignant heterologous tumours—'Pseudoplasmata. First Class.—Pseudoplasmata slightly or not at all organized Typhous deposits ..... Scrofulous deposits « Tubercle ...•».. Second Class.-—Epigeneses of a more highly organized cha- racter. . ... Cancer « Forms and varieties of cancer * First Form—Cellular cancer. Encephaloid Second Form—Fibrous cancer. Scirrhus Third Form—Melanotic cancer » . Fourth Form—Gelatinous cancen Colloid Polypi and fungoid growths Special relations of unorganized pathological epigeneses 1. Precipitates of protein-compounds . , 2.---------- of the fats . 3.----------of uric acid and the urates 1.----------of the salts of lime Page 168 169 170 173 173 175 177 178 184 185 188 189 192 192 195 199 207 213 215 218 220 240 248 249 252 253 265 266 288 289 295 300 301 302 303 307 308 311 312 table of contents. xiii 5.----------of ammoniaco-magnesian phosphate 6.----------of sulphuret of iron 7. —---------of bile-pigment . 8.----------of silica . 9.----------of various other substances Concretions. ..... First Class.—Concretions in the fluid secretions. i. Urinary calculi. Calculi of uric acid and the urates ------of uric oxide ------ofcystin. ------of oxalate of lime ------of the earthy phosphates . ------of organic matter Alternating calculi Calculi formed in the generative organs ii. Salivary concretions. in. Lachrymal calculi. iv. Concretions in the nostrils, throat, tonsils and bronchi. v. Pancreatic calculi. . . vi. Gall-stones. ...... vii. Intestinal concretions. .... vm. Concretions in the cutaneous glands. Second Class.—Concretions in the parenchyma of organs. Page 313 314 314 315 315 316 316 317 318 323 323 324 325 326 327 328 330 333 334 335 336 340 346 348 CHAPTER VI. Pathological changes in the physical properties of the tissues and organs of the body . . 355 1. Change of colour. ...... 355 Abnormal paleness ...... 356 Abnormal redness . . . . . . 358 Dark colouration ...... 359 Yellow colouration ...... 359 Green colouration ...... 360 Blue colouration ...... 361 2. Changes of form and size. ..... 362 3. Changes in the consistence of the various organs. . 366 Hardening or induration. * . . . . 367 XIV table of contents. Softening Gangrene Pai»e 368 371 CHAPTER VII. Combinations of morbid elementary changes. . 373 First Group—Venous hyperemia and serous dropsy . . 374 Second Group—Capillary hyperemia a«d fibrinous dropsy . 375 Inflammation . . . . . . 378 CHAPTER VIII. Independent organisms in the human body—parasites Nature of parasites . Equivocal generation ........ Relations of parasites to disease Parasites derived from the vegetable kingdom—epiphytes. l. Fungi in human fluids. . . . . The yeast plant . The sarcina ventriculi ..... ii. Fungi on the human integument and its appendages. Fungi in the- scrofulous scald-head, (Tinea favosa) Fungi in the sheath of the hair fn mentagra Fungi in the interior of the hair-roots in herpes tonsurans and in plica polonica in. Fungi on mucous membranes. Parasitic animals. . . i. Parasitic infusoria. .... n. Parasitic insects. .... Fleas ...... Lice ...... Bugs ...... in. Parasitic arachnida. .... The itch-mite . The acarus of the human hair-sac iv. Parasitic worms. . .... 380 381 382 384 385 389 389 391 392 393 394 394 395 396 398 400 400 401 403 404 405 410 411 table of contents. XV Page First Order.—Nematoidea. The guinea-worm The filaria oculi humani The filaria bronchialis The trichina spiralis The trichocephalus dispar The tricocephalus affinis The spiroptera hominis The strongylus gigas The ascaris lumbricoides The ascaris alata The ascaris vermicularis . . Second Order.—Trematoda. The liver-fluke (distoma hepaticum) The distoma oculi humani The polystoma pinguicola Third Order.—Cestoidea. The common tape worm (taenia solium) The broad tape worm (bothriocephalue Iatus) Fourth Order.—Cystica. . The cysticercus cellulose The echinococcus hominis Acepholocysts—hydatids Pseudoparasites. . . CHAPTER IX. Congenital modifications of the human body.—mal- formations. . . . . . . . 434 Their causes ....... 436 Their classification ...... 440 First Class.—Malformation in which certain parts are entirely absent, or are too small. ..... 441 First Order—Deficiencies, in the strict sense of the word . 441 Second Order—Abnormal diminutiveness of parts—dwarfish structure ....... 448 Second Class.—Malformations from coalescence of organs. 449 Third Class.—Malformations in which parts normally united are separated from each other—Fissures. . . 453 411 411 413 415 415 417 417 417 418 418 419 420 420 420 422 422 422 422 423 426 426 427 430 432 XVI table of contents. Page Fourth Class.—Malformations in which normal openings are closed—-Atresia. ...... 459 Fifth Class.—.Malformations of excess, or in which certain parts have a disproportionate size. . . . 459 First Order—One or more parts disproportionately large . -459 Second Order—One or several supernumerary organs . . 460 Sixth Class.—Malformations in which one or'many parts have an abnormal situation. ..... 471 Seventh Class.—Malformations of the generative organs— Hermaphroditism. ...... 471 Eighth Class.—Malformations arising from morbid changes affecting the foetus, the placenta, and the membranes . 475 CHAPTER X. Changes occurring in the body after death—post mortem changes. ...... 477 Explanation of the Plates. . . . . ... 483 INTRODUCTION- The great object of works on the Anatomy of the Human Body in a state of health, is the description of the elementary tissues and their properties, and of the manner in which these tissues are ar- ranged and distributed so as to form the different organs; further, to explain their mode of formation, and the manner in which the whole body is developed from them. The whole of these elemen- tary textures, tissues, and organs are in each individual body essentially the same, although occasional differences present them- selves, which if very striking, are described as varieties. The case, however, is different when a'body, or a portion of it, which has suffered from disease is submitted to anatomical exa- mination. Here deviations from the appearances presented by the healthy body are frequently observed. These deviations are very numerous in character; sometimes the elementary textures are changed; sometimes new formations foreign to the normal condition are introduced ; in some cases the position or form of some of the organs is changed; whilst in others the deviation has reference merely to particular portions or elements of one or more organs. The knowledge and description of these changes, and the inves- tigation of their origin and development constitute Pathological Anatomy, which, therefore, depends upon healthy anatomy as its natural basis; the former embraces as its peculiar study precisely that which the latter rejects. From the nature of the boundary be- tween these two departments of anatomy, the question often arises—to which of the two certain cases belong. Each draws its materials from the examination of the dead body and its various organs; one 9 14 INTRODUCTION. investigates healthy, the other diseased conditions. But the ideas pf health and disease are very relative, and since no human organ presents the ideal of health in absolute perfection, it frequently be- comes questionable whether certain appearances ought to be regarded as appertaining to pathological or to healthy anatomy. When these dubious changes influence whole organs, or large parts of them, a precise decision is possible, but the farther the investigation is carried out in all minute details, so much the more difficult becomes the decision; and it must be granted that there is a neutral ground, the indisputable property of neither department. The influence of our science on pathology is frequently misunder- stood, being sometimes too lowly, sometimes too highly estimated ; it consists essentially in the information which it communicates respecting the material changes in the different parts of the body which accompany or produce morbid symptoms. In showing how these morbid products are formed and gradually perfected, it assists pathology; and in elucidating the processes by which the affected part returns to its normal condition, it is subservient to therapeutics. To both of these departments of medicine, it yields an important part of the materials absolutely requisite for their firm establishment. They may be in- complete, and consequently susceptible of augmentation ; but if based on correct observations, and free from hasty and incorrect conclu- sions, they will remain permanently valid. They have continued and will always continue the same, independently of the confirmation or subversion of any medical theory. Having thus shown the intimate connexion between pathological anatomy and the medical sciences in general, we will now notice its bearings in relation to the individual branches. Medicine has a double signification ; it is at once a science and an art. Medicine, as an art, has a practical value in relation to life, and is therefore regarded by the mass of its disciples as of the highest importance. But it is an error, and an indication of little intelligence to regard the practical as the only important part of medicine, and the scientific as a mere superfluous decoration, as a brilliant but useless ornament. There are crafts in which the manual dexterity acquired by long practice seems to suffice for practical purposes independently of all scientific inquiry; yet even in these cases, the immeasurable strides with which these arts have recently progressed, afford the most convincing proof that the ap- INTRODUCTION. 15 plication of scientific principles to even the simplest operations, which were supposed to be incapable of improvement, has been productive of the happiest results. In medicine such harrow views must be rejected, for they would tend to produce the blind self-es- teem which regards ancient formulae and mechanically learned pro- cesses as sufficient to heal all diseases; or else they would excite doubts regarding the whole science of medicine and deny its power in toto, because there are. difficulties and obscurities which exceed its power of solution. Each of these views regarding the healing art is equally erroneous; the directions for medical treatment given to us by the various schools are yet far from sufficient, and every conscientious physician will confess that those unworthy disciples of Esculapius, who with self-sufficient confidence, publish their own methods of cure as alone true and infallible, are richly de- serving of the scorn and contempt which satire from the earliest ag^es has heaped upon them. Equally mischievous and deplorable is medical scepticism. It is true that the science is yet far from being in a condition to answer all the intricate questions which the varied character of disease may suggest; that time is still far dis- tant, indeed it may never arise ; yet the science still remains, and confidence in its results is the sole prop on which the practice of the physician can rest. The consciousness that he has scrupu- lously followed its indications, and so discharged his duty, is his only comfort, when in sadness he is constrained to confess the inu- tility of all his efforts. Above all, we must not be led away by such phrases as "practical views" and "medical experience"— terms of common use, and too often conveying an erroneous im- pression. The practical views of the physician are the result of a series of accurate observations elucidating the treatment of disease. The true physician may be distinguished from the empiric by this, that the latter is more or less unconscious of the grounds on which he acts-; and if the experienca of the empiric seems in some few cases to be more successful than science, it can only be referred to a fortunate chance directing to the right point, and probably not based on the conscious experience of a single case. But science itself consists of the accumulated experience of individuals ; and in proportion as that experience is limited (and especially when it is confined to a single individual) it follows from the very nature of the case that it cannot rest on a sufficiently broad scientific basis. 16 INTRODUCTION. In proportion as the science, advances, and its cultivation is zeal- ously carried on, so much the more will practical views and expe- rience become the common property of all physicians who combine theory and practice ; and that which was formerly regarded as the exclusive property of the medical pioneer will be open to all—will be almost the common stock of all who strive to obtain it. It has been shown by long experience that scepticism in medicine leads, as it does in religion, to bigotry and superstition. It often leads its votaries to become the converts of one-sided unscientific systems, which having some semblance of truth, have at different periods been brought forward and supported, such as Humoratism, Solidism, Brunonianism, Iatrochemistry, Homcepathy, Hydropathy, and the like, which after a short meteoric brilliancy have utterly disappeared ; or, in better cases, after withdrawing their vaunting pretensions, have contributed the germs of truth which they con- tained to the great stock of medical knowledge. Confidence in true science is the best defence against this medical bigotry. He w7ho takes a calm survey of the whole science is not likely to take up a one-sided system ; he who feels the incompleteness of the science will be ill little danger of glorifying in the perfection of his know- ledge, or of proclaiming the infallibility of his practice. The above observations apply equally to every part of medical science. The, relation in which,- pathological anatomy stands to the sister science is still more striking. The human organism is wonderfully constructed, being infinitely more complicated and delicate than the most perfect mechanism ever designed by the human intellect. It consists of an infinite number of parts, fluid as well as solid, connected with each other in a wondrous manner. The branches of medicine elucidating this structure are histology, anatomy, and animal chemistry. The va- rious parts of the human organism are in a state of continuous ac- tivity, and stand in various relations both to each other and to the external world. Hence are developed those mysterious vital phe- nomena which physiology has in vain attempted to unravel. But these vital phenomena are by no means uniform in their character; they present the most striking contrasts in different individuals, and even in the same individual at different periods, and the relative proportions of the various parts and systems of the organism are, even in the normal condition, for ever fluctuating. INTRODUCTION. 17 The idea of normal life is, therefore, extremely indefinite, and it is only by a forced abstraction that the normal can be separated from the abnormal. Hence also the idea of disease is very indefinite; it cannot be separated by any well-defined boundary from the idea of normal life, and the two conditions are connected by a species of debatea- ble border land; It is not a mere deviation from the normal condi- tion which constitutes disease, for that condition is of itself variable; but it must be productive of injury to the organism before it can be ranked as disease. The extent and degree of this injury is again most variable. From those grave injuries which rapidly terminate in death, down to the slightest form of disturbance, hardly worthy of the term disease, howr infinitely multiplied are the varieties. Hence in this point of view, disease is not strictly distinguishable from the normal state. The idea of disease must also be considered in a different point of view. A disease is not, as many believe, a self-existing entity ; it consists rather in a change in the vital phenomena of an organ- ism ; it is no more an independant organism, or even pseudo-or- ganism, than are the separate states or vital indications of an or- ganism, such as walking, sleeping, eating, or speaking. Diseases may in different cases present the greatest varieties ; each vital in- dication of an organism, every process connected with life may, in various ways, either alone or in combination with other processes, assume a morbid condition. Hence diseases will not admit of the same species of classification as if they were peculiar organisms, such as animals or plants: organism like diseases, are generally com- plex in their character, but in every animal and vegetable species all the individuals are, with very trifling deviations, composed of the same parts, while there are hardly two cases of disease in which the symptoms are precisely identical. And when, for convenience in teaching, such a classification is adopted, we must bear in mind that it is, and ever must be, an imperfect and arbitrary one, and not based on any natural system. As the normal condition of the vital processes is dependant on the normal condition of the individual parts of the body, and on the proper discharge of their various functions, so disease arises when portions of the body deviate from their normal character, and either cease to discharge their functions at all, or discharge them in an 2* 18 INTRODUCTION. abnormal manner. These morbid changes, affecting the functions of the body, are very frequently dependant on material changes, perceptible to the eye, and recognised by the feelings. These ma- terial changes (in the widest sense of the term) form the domain of pathological anatomy. It is not, however, in all diseases that we can, at least in the present state of our knowledge, recognise such material changes. Hence there are diseases to which pathological anatomy seem to have no application. There are many transitory morbid changes in the vital phenomena, dependent on the nervous system, which ap- pear and vanish without leaving a material change capable of detec- tion by the most zealous investigator. Certain changes probably have occurred, but were unsuspected at the time, and hence, in a scientific point of view, yielded no result. In other cases, diseases seem to produce appreciable changes, not on the solid organized parts, but on the fluids, impressing, upon them certain chemical changes either of a qualitative or quantitative character: whether these are to be regarded as appertaining to pathological anatomy, must be a matter of opinion. As anatomy is usually considered to embrace the theory of the constituent parts of the human body in re- lation to form and composition,^ so pathological anatomy ought to include deviations in chemical composition: there seems, however, to have been a tendency lately to regard this class of changes as be- longing to a separate science to which the term Pathological Che- mistry has been given. In addition to observing the material changes accompanying va- rious diseases, it is likewise the object of pathological anatomy to investigate the causes which give rise to them, their development and gradual formation, and their consequences; but this can only be done as far as is consistent with certainty. This condition, there- fore, is especially important in all that concerns pathological anatomy. Pathology, from its very nature, must often frame hypotheses, and must frequently be content with probabilities when cerfain truth is unattainable ; for the physician cannot suspend his practice in cases where he does not distinctly see his way. But it is otherwise with pathological anatomy, in which the imme- diate object in view is not the same as in practical medicine ; it must, therefore, restrict itself to positive knowledge, and must be always conscious of the degree of certainty w7hich its conclusions INTRODUCTION. 19 ■warrant. And then, let the systems of medicine change as they may, the doctrines of pathological anatomy will stand unaffected. Almost every disease is made up of various disturbances, w7hich often, to the detriment of science, as well as of the patient, are re- ferred to a single morbid origin, and receive one common name. Pathological anatomy must not adopt this course ; its object must be, on the contrary, to separate each material change from all the rest; to isolate it, follow it in its minutest details, and trace its causes and effects. It is not till this is accomplished that the relation of these changes to others is to be considered. By these means, and by these alone, can pathological anatomy arrive at certain truth, and gradually attain a position to assist in the construction of the medical sciences on a broad and sure foundation. Pathological anatomy is, therefore, a useful section of pathology, contributing to practical medicine, as it were, the solid materials from which to con- struct a basement, without having the power to erect a perfect edi- fice. And here is the point in which it differs from pathology—a point respecting which there are two common errors. Some have overstretched the true limits of pathological anatomy, and have in- cluded w7ithin them disturbances in the functions of the^nervous sys- tem, and other morbid symptoms altogether foreign to its jurisdic- tion, and have endeavoured to elevate it to pathology. Others, on the contrary, have attempted to reduce pathology to pathological anatomy, and to explain all morbid phenomena by recognised ma- terial changes, debasing the science of medicine into one-sided pa- thological solidism. The importance of pathological anatomy to the different branches of pathology varies considerably. It has always been of the great- est importance to surgery, principally in reference to visible changes in the position, size, and connexion of the different organs : hence the origin of the surgical department of pathological anatomy. The changes accompanying internal disease are less obvious to the eye. They require the finest dissection and microscopic observation, and then often evade detection ; their causes and consequences are like- wise very obscure. Hence the influence of pathological anatomy on this department of pathology is of, comparatively speaking, re- cent origin. We may here again repeat what has been already mentioned, that the pathology of the solids is that which will receive the greatest benefit from pathological anatomy, whilst in diseases of 20 INTRODUCTION. the nervous system, and in disordered conditions of the fluids, it will be of less service. Although at first sight it might appear that our subject was of small importance in relation to therapeutics, this is not in reality the case. Scientific treatment necessarily demands an extensive knowledge of the material changes which lie at the foundation of the various morbid symptoms. Hence pathological anatomy neces- sarily forms a portion of the positive basis of therapeutics ; and, far- ther than this, it points out the processes by which the different altered parts may be gradually restored to their normal condition. It not merely points out what requires healing, but in many cases, also, the course that must be adopted in order to aid the curative ten- dency of nature. It serves likewise as a check on therapeutics, exposing, in a most conclusive manner, the absurdity of many pre- tended methods of cure. It points out, for example, that in a cer- tain stage of inflammation of the lungs, a fibrinous fluid separates from the blood, and by its coagulation renders a portion of the parenchyma of the lungs impermeable to air; and further, that it requires several days for this coagulated matter to reassume the fluid condition, and be removed. Now, if any one should assert, that, in this stage of the disease, he could apply a remedy which would cure the patient in a few hours, a very superficial know- ledge of pathological anatomy would show the folly of such an assertion. Let us now turn to the means by which a knowledge of patho- logical anatomy may be attained. The study of those morbid changes to w7hich the various parts of the body are liable, depends on a thorough previous knowledge of their normal relations; hence pathological anatomy requires a per- fect knowledge of the structure of the healthy body, and of a spe- cial department of physiology (de usu partium) in order to be able to estimate the influence which any morbid alteration of an organ impresses on its function. Our science must not merely study the coarser changes, such as are visible to the unaided eye ; but also those finer modifications affecting elementary tissues, visible only by the microscope; hence the necessity for an accurate knowledge of general anatomy or histology. Histology and descriptive anatomy are most intimately connected with pathological anatomy; they unite to form the necessary data for its successful cultivation; and INTRODUCTION. 21 further, there exists a boundary in common to all three, which they simultaneously occupy and cultivate. Thus, for example, certain varieties in the form and position of different parts of the body, as of the vessel, may be ranged under either normal or pathological anatomy; moreover, the theory of the development of most of the tissues is the same in pathological as in normal histology. In order to understand those deviations from the normal type which occur in the foetal condition, pathological anatomy demands an accurate pre- vious knowledge of the law of development; indeed there are many points in w7hich these two sciences closely approach each other. In the establishment of its own observations, pathological anatomy requires not merely the theoretical knowledge already alluded to, but also the same manual dexterity which is needed in the practi- cal exercise of normal anatomy, namely, skill in dissection, which can be much more readily acquired by practice than by any verbal, or written instructions. The absence of any regularly adopted sys- tem of investigation—of that savoir faire which diminishes and shortens every difficulty—is not so indispensable, but that by appli- cation and careful investigation it may be retrieved : and this very savoir faire, without such qualities, would only lead to charlatan- ism, dazzling the eyes of ignorant spectators, but evolving no results useful to science. In the investigation of delicate points connected with pathological histology, the microscope is indispensable, and the application of chemical re-agents must be observed under it. Chemical analysis is, indeed, of the greatest importance to patho- logical anatomy, being the only means by which we can on several points obtain the desired information. At present, much to the detriment of the science, chemical investigation is little pursued in conjunction with pathological anatomy ; but assuredly the time will soon arrive, when chemical analysis will be deemed just as indis- pensable to the prosecution of pathologico-anatomical investigations as the microscope is at present, and when every follower of this sci- ence will consider chemical analysis so essentially requisite, that if his own time and opportunities prevent him from carrying it out, he will employ a chemist, under his immediate guidance and direc- tion, to undertake it for him. Pathological anatomy derives the materials of its knowledge from two separate sources. First, from observation, which in- 22 INTRODUCTION. eludes the examination of portions of the living body altered by ^disease, and removed either by the knife of the surgeon, or thrown off as excreta (in the widest sense of the word) together with the examination of the dead body, which is often sufficient of itself alone to explain to the practised observer the whole course of the disease. In most cases, it is, however, of importance that the examination of the dead body should be supported and perfected by observa- tions made during the progress of the disease. It is also essentially important to therapeutics, that pathological anatomy should be pur- sued by scientific, unbiassed pathologists, rather than by mere ana- tomists ; but' we must be very careful in tracing the connexion which subsists between the symptoms observed during life, and the changes noticed after death. Hypotheses, which can be as little avoided in pathological anatomy as in medicine generally, must be most carefully checked, and their actual value borne in mind ; they must not be ranked with ascertained facts and theories, if wTe wish to see our science preserve its positive character and its objective position high above the troubled flood of medical systems; and if we would protect it from the contempt with w7hieh certain physicians are inclined to regard it. The other mode by which pathological anatomy gains new facts is by experiment. Experiments instituted on animals, and, in cer- tain cases, on man, with the view of artificially producing a morbid condition, and then carefully studying it, afford most valuable aid ; for here the quality and quantity of the causes in action are much more under control than in ordinary cases of disease. By these means, the actual causes and consequences of individual pathological changes can be much better studied than in cases when they arise of themselves, and where their causes are frequently either entirely,concealed, or can only be followed in doubt and obscurity through a multitude of influences, whose origin cannot be traced with certainty, or even probability. We sometimes hear it objected, that from pathological changes observed in the lower animals, no certain conclusions can be drawn as applicable to man. This objection has, however^ long been re- futed by experience, which shows that, bearing in mind the differ- ences necessarily consequent on variety of structure, such conclu- sions are not only admissible, but that comparative pathology and INTRODUCTION. 23 pathological anatomy afford as much assistance in the prosecution of this science in relation to man, as comparative anatomy does for the thorough comprehension of human anatomy and physiology. It is, therefore, much to be desired that experiments producing morbid changes in animals should be more frequently instituted; for it is only from a large number of similar experiments, not from isolated cases, that conclusions can be safely drawn. The adoption of the experimental method in pathological anatomy promises far- ther advantages;' for, by its application, the fruitful labours of that science will cease to remain the exclusive property of the practical physician, who, from his usual occupations, or possibly from his ig- norance of the means of carrying out microscopic and chemical in- vestigation, frequently fails to draw from the cases that come under his eye such useful observations as might have profited himself and his science. The materials thus gained by observation and experiment must be used with the greatest care, if science is in reality to be ad- vanced by thern. This care must, in the first place, extend to de- scription ; the object of which is to give to others a correct and in- tuitive conception of the changes that have been observed ; hence definite terms must be used, whose interpretation can admit of no mistake. Care must also be taken to describe in like manner all the relations which admit of an exact notice, as number, size, and weight. This must only be omitted in cases where it is obviously unnecessary, and general information will suffice. What these cases are, must be left to the judgment.of the describer, who must, there- fore, always clearly understand, in every case that he examines and describes, what are the essential points requiring an exact descrip- tion, and what on the contrary, do not require, or even admit of par- ticular notice.* In the next place, it is the object of pathological anatomy-to ex- amine the various changes occurring in the different parts of the body ; to follow each individually tlirough its minutest details; and to set forth, as clearly as possible, its causes, gradual development, and consequences. It is only by strictly pursuing this course of complete separation and isolation that useful results can be obtained, * On these points the reader may consult with advantage the recent Treatise by Engel; Propiideutik der pathologischen Anatomic Wien. 1845. 24 INTRODUCTION. and confusion—that bane of all science—be avoided. A compara- tive examination of the various changes shows that there is much in common between many of them, and that the same, or similar processes frequently occur in very different parts of the body. Thus it becomes another' department of our science to examine into the community of the various changes, and to regard them from one general point of view. Hence pathological anatomy is naturally separated into a special and a gerieral part. Of these the latter, although of the later origin in the development of the sci- ence, must yet, for the sake of a scientific arrangement, be first con- sidered. In order to obtain general results in pathological anatomy, two different methods may be pursued, similar to those already men- tioned, in relation to obtaining material for our science ; namely, the method of observation and the method of experiment. Observations instituted on the dead body, teach us what are the changes that most commonly occur together ; and from the frequency or rarity of their simultaneous occurrence, enable us to draw con- clusions, respecting the relative connexion of these changes. Expe- riment seeks to investigate the actions induced by artificial causes; and, consequently, to discover the causes and consequences of cer- tain pathological conditions in the most direct manner. If we wish to attach a scientific value to observations grounded on experiment respecting the simultaneous occurrence of certain changes in the human body, and the relation in which they stand to each other, such observations must be made with the greatest care. Cases imperfectly recorded, respecting the frequency or rarity of simultaneous phenomena, must be rigidly excluded, as unfit to form the basis for any sound conclusions. The comparison must be made on an exact mathematical basis; and conclusions must only be deduced in accordance with the rules of probabilities and the laws of high numbers. The numerical or statistical method must be carried out as fully as possible.* In.applying this method to pathological anatomy, we must clearly understood what it is actually capable of effecting, and neither em- ploy false data, nor overrate the results yielded by it. The certainty * Consult Gavarret: Principes Generaux de Statistique Medicale Paris, 1840. INTRODUCTION. 25 of its results is dependant on two conditions ; Firstly, on the number of the observations; and, secondly, on the accuracy with which each observation is described. The more closely these conditions are fulfilled, so much the more sure and accurate will be the results yielded. A few illustrations will elucidate our meaning. Let us assume that, from the Creation to the present time, at least one billion of men have lived, and, after a longer or shorter life, have died. Of this whole number none have lived beyond a certain age; for instance, no one is now alive who was born in the fourteenth century. Hence, the probability that any man now alive will die, is to the probability that he will not die, as a billion to one. The number is here so large, that no rational being can doubt that death must earlier or later ensue. In this case, the number of observations is the greatest that can possibly occur, and the conditions respecting the nature of the observation are clearly defined. Hence, the probability is so very great, that it may be deemed an absolute certainty. There are likewise other questions respecting which, if the nu- merical method cannot reply with the same degree of certainty, it may yet yield an answer for the correctness of which there will be the highest degree of probability. For example, suppose it be.asked what per centage of mankind die before their thirtieth year ? Here the object of the question—the occurrence of death before or after the thirtieth year—may be determined with tolerable certainty. In a well ordered country, there are few cases in which the age at death is not recorded. The official registration of births and deaths places a large number of observations at our command ; and from these data the question may be answered, not only with very considerable ac- curacy, but we can even approximate to the greatest error that can possibly occur in the calculation. In pathological anatomy the case is, however, different; for the number of observations is much smaller, while the objects to be ob- served are frequently of a very indefinite nature. Suppose it were determined to prove, by statistical records, that scirrhus and tuber- culosis exclude each other. In the first place, the meaning of the terms scirrhus and tuberculosis must be accurately determined; for although physicians are not likely to dispute whether or not a man is really dead, there are few points on which there is more difference of opinion than whether a tumour is to be regarded as of a scirrhous 3 26 INTRODUCTION. nature or not. But, even if this difficulty were overcome, and it were agreed that a number of observations on the presence of scirrhus in undoubted cases were actually made, still the number must be comparatively small. Suppose thirty cases of scirrhus have occurred without the presence of tubercle in any of them; then the probability that the next (thirty-first) case of scirrhus will not be associated with tuberculosis will be as thirty to one. But in addition to these cases of scirrhus in which there have been found to be no indication of tuberculosis, probably 300,000 other cases have occurred, yielding no evidence for or against its co-ex- istence. Now, if from these thirty observed cases, we were, to con- clude that scirrhus always excludes tuberculosis, that is to say, that amongst the 300,000 cases there had not been a single one in which tubercles wTere present, such a conclusion would, according to the laws of. probability, be very uncertain, and such an application of the calculations, founded on that law, would be misplaced. It would be a still more dubious matter to attempt to establish, on statistical grounds, not merely the simultaneous occurrence, or non- occurrence of certain morbid changes, but likewise the mutual rela- tions, and the connexion of cause and effect existing between them. Suppose it were attempted to be proved by statistical records from the dead-house, that hydrocephalus in children is the cause of tu- berculosis; or, vice versa, that hydrocephalus arises from tuberculosis. Our first object would-be to obtain statistical information respecting the simultaneous occurrence of these two diseases, or of the invaria- ble disappearance of the one before the appearance of the other; and the conclusions would be very doubtful unless drawn from a large number of cases. It would further have to be proved that other morbid changes frequently occurring with hydrocephalus, but inde- pendent altogether of tuberculosis, were not the actual cause; or, to penetrate still deeper, that other changes, invisible in the dead body, may not have produced the hydrocephalus. For such reasons as these, the statistical information we at present possess, in relation to pathological anatomy, must be used with the greatest caution. I do not, however, desire to underrate the importance of the applica- tion of the statistical method to our science; on the contrary, I hold it of essential importance that in all serious forms of disease, statis- tical information respecting the morbid changes found in the dead body should be carefully drawn up and laid publicly before the pro- INTRODUCTION. 27 fession. But these examinations must be made writh the greatest care ; the nature of the changes must always be communicated in the most definite and special manner; and, above all, the observer must avoid drawing general conclusions from too small a number of cases, or from cases badly observed and badly described. In our science, we must follow the examples set us by the astronomers, rnagnetists, and meteorologists, who continue for years to carry on the most careful general observations, and to make them public property, in the hope that, the general laws which they fail to establish will be developed by their successors. The other method by which pathological anatomy can and will extend its limits, seeks to penetrate directly into the connexion of symptoms; far from excluding the statistical method, it is rather an essential completion of it, whilst its results, when sure, act as a test for those obtained by the numerical method. A few examples will serve to illustrate my meaning. Common observation teaches us that venous hyperemia is fre- quently accompanied by a collection of dropsical fluid in the sur- rounding parts. Our knowledge of the functions of the blood-vessels renders it probable that the dropsical fluid, in these cases, proceeds from the veins, and that their hyperemia is the cause of its collection. Carefully instituted experiments, which by ligature, or in some other way, have caused venous hyperemia, and thus actually produced dropsical effusion, confirm this opinion; and it becomes more sure in proportion to the number of experiments, and the different con- ditions under which they were performed, with the view of removing every possible source of error. The following may serve as another illustration : Experience shows us that certain changes in the substance of the kidneys are accom- panied by the secretion of albuminous urine. A close examination of the diseased kidney shows that blood-plasma has escaped from the vessels into the substance of that organ, and that the fibrin has coagulated there. Physiological theory leads us to assume that the fluid portion of the blood-plasma becomes mixed with the urine, and that the albumen is at least in part obtained from that source. In order to fulfil its office, and efficiently to serve general and special pathology and therapeutics, pathological anatomy must adopt and scrupulously carry out both these methods. 28 INTRODUCTION. If pathological anatomy lays claim to the rank of a science, it must arrange the results which ithas obtained, and exhibit them connected in one comprehensive scheme. This can, at present, only be effected in a very imperfect manner. One of the most difficult tasks in the science of pathology, is to classify the different diseases, and to ar- range them in accordance with a scientific system. The great cause of the difficulty consists, as we have already mentioned, in their being neither organisms nor pseudo-organisms, but merely deviations from the normal condition. In pathological anatomy, the difficulty is still greater; for, frum its very nature, it must investigate isolated facts ; and its general department if we retain that which is positive, and do not adopt too many hypotheses, is at present in a very aphoristic condition. Hence, I regard a systematic arrangement in patholo- gical anatomy—at least at the present time—as of small importance, and I shall only add afew words regarding the system I have adopted, not so much with the view of justifying it, as to assist the reader in .he perusal of the following pages. The special department treats of the pathological changes in dif- ferent parts of the body. The arrangement is entirely arbitrary, and I have adopted it simply with the view of avoiding repetition. The general part, which proceeds as it were from the special, em- braces the changes of a more general nature, which may occur in different tissues and organs in the same, or in a very similar manner, noticing also their general relations, causes, and consequences, so far as they are at present known. The following sketch of the order in which the different morbid changes follow each other, will serve as a summary of the contents. We commence with- abnormal col- lections of fluids in the body—of the gaseous (pneumatoses,) of the aqueous (dropsies.) The latter are divided in a manner that seems natural and practically important, although not hitherto adopted: namely, into serous, fibrinous, and false dropsies. Then comes a sketch of the morbid changes of the blood as far as they are at pre- sent understood. This is succeeded by a chapter on pathological epigeneses,* which from their nature occupy a very considerable space, and by a brief sketch of the changes which the tissues undergo in thei^ physical properties, together with some remarks on the * NeuhiLdungen ; literally, new formations. INTRODUCTION. 29 manner in which morbid changes in the elementary tissues are con- nected with each other. The next chapter treats of the indepen- dent organisms which occur in the human body, as causes or conse- quences of morbid changes (parasites.) Then there is a chapter devoted to congenital pathological changes (malformations, and we conclude with a notice of the changes occurring in the body after death. 3* PATHOLOGICAL ANATOMY. CHAPTER I. ABNORMAL DEVELOPMENT OF GASEOUS MATTERS.-- PNEUMATOSES. Abnormal collections of gaseous matter are by no means rare,. either in the living or the dead body. They are included in the general term pneumatoses,* and occur in the tissue of organs (con- stituting emphysema,) between the fibres of cellular tissue, as in the parenchyma of the lungs or liver; and in the natural cavities of the body, as in the intestinal canal, the peritoneum (constituting tym- panites,) the pleura (constituting pneumothorax,) the pericardium, between the membranes of the brain, or in the cerebral ventricles ; in the urinary bladder, the uterus, the heart, arid blood-vessels, f They are most common in the, intestinal canal, and comparatively rare in the other cavities. As we shall have occasion to notice most of these pneumatoses in relation to the special organs in which they occur, we shall here merely offer a few general remarks on their causes and mode of origin. These accumulations of gas may be dependant on very dif- ferent causes. • J. P. Frank, De Cur. Horn. Morb. lib. vi. § 701—730 ; Andral, Path, Anat. vol.;. i. p. 394 ; Lobstcin, Path. Anat. vol. i. p. 13 i; Canstatt, Spec. Path. u. Ther. k>1. :<. p. 17,-. t Otto, Path. Anat. vol. i. p. 42, 32 PNEUMATOSES. 1. They may arise from the external pressure of the atmospheric air The mechanism of this form of origin is most strikingly seen in those cases of general emphysema which arise from an injury to the lungs, dependant on a penetrating wound of the thorax: If the intercostal opening of the wound be not parallel with that in the external skin, emphysema almost invariably results, since the air is forced through the wound at every expiration; and instead of escaping externally, is propelled into the cellulartissue beneath the skin. If, on the other hand, the external opening of the wound is parallel with the inter- nal,, and the course of the wound is thus kept open,, no emphysema results, since there is no impediment to the progress of the air out- wards. The air admitted into the-cellular tissue of the thorax gradually works its way over the body, and the emphysema thus becomes more or less general. The orbits become closed up ; the eyes and mouth remain shut, in consequence of the swollen condi- tion of the eye-lids and lips; the nose is hidden between the tumid cheeks; the skin of the neck is so monstrously distended that all distinction between the head and the trunk disappears. The skin is most distended at those points where it is connected with the sternum and the spinous process of the vertebral column. The scrotum swells to such a size as to conceal the penis. The limbs enlarge and as- sume a cylindrical form ; the palms of the hands and the soles of the f;-et (in consequence , of thehvfirm connexion with' the subjacent tissues) being the only parts not. affected. The swollen parts feel tense, crepitate when pressed by the fingers, and on removing the pressure no pitting is visible. In unfavourable cases, the patient dies from impeded respiration and apoplexy, in consequence of the compression exercised on. the air-tubes and jugular veins by the swelling. Larrey* has described two cases of this nature, and has given a representation of one of them. Some very similar instances are mentioned by P. Frank, after penetrating wounds of the larynx or trachiea, and in cases of fractured ribs; and, indeed, without any external lesion in severe cases of pertussis and in phthisis; in raising heavy weights, and duringthe pains of labour .-f In all these cases ther.e was, doubtless, an internal laceration through which the air pene- trated from the respiratory organs into, the cellular tissue. The case * Larrey, Clinique ehruirgicalte, tome.n. p. 188,. pknchc 4. t J. P. Frank, Epitome, cap. vi. § 707.. PNEUMATOSES. 33 is precisely the same in local, or circumscribed emphysema; thus, according to Dr. Frank^* persons in the habit of playing,on wind- instruments, frequently suffer from a painful inflation of the cheeks, arising from the air entering the cellulartissue of these parts, through laceration of the buccal mucous membrane. It likewise happens that in applying the air-douche, with a view to open and enlarge the Eustachian tube in cases of deafness, local emphysema is sometimes produced in a similar manner. In this w7ay the various forms of pulmonary emphysema are produced, of which we shall here only explain briefly the mode of origin; since they, will be fully discussed when we treat of the pathological conditions of the lungs. When a portion of lung is so clogged up with fluid or solid de- positions that no air can enter it, or when it is bound down by un- yielding false membranes, it is impossible that it can follow and correspond with the movements of the thorax at each inspiration, as in the normal state. A vacuum is formed between the lungs and the parieties of the thorax, which the air, entering through the tra- chcea, endeavours by the ordinary laws of mechanics to fill; conse- quently, the expansive portions of the lungs are enlarged to a greater degree than in the normal state, and the result is vesicular emphy- sema, in which the pulmonary cells of the expansible portion of lung become distended, and contain a larger amount of air than in a state of health. If, however, in consequence of the pressure of the air, or the delicacy in the cell-walls, any laceration occurs, the air enters the parenchyma of the lung, and interlobular emphysema is the con- sequence. Air may likewise enter the cavities of the body in this mechanical way, either from the respiratory organs or directly from the atmos- phere. When vomicae in the lungs, communicating with the bronchi, perforate the cavity of the pleura, air is forced inwards and pneumo- thorax is the consequence. After wounds of the large superficial veins, especially in the vicinity of the heart, where the diaStole of the right auricle and the enlargement of the thorax during inspiration, exert a certain suction- force on the blood, the external air may enter the vein and thus be conveyed with the blood to the heart. Finally, it appears that many accumulations of gas take place me- * Op. cit. 34 PNEUMATOSES. chanically in the course of the intestinal canal (especially in the stomach) by the entrance of atmospheric air. Pneumatoses of the oesophagus and of the stomach are by no means rare, and most com- monly occur in hysterical and hypochondriacal persons, especially when the stomach has been long empty, as two or three hours after meal-time. In some of these cases, there is an excess of acid de- veloped in the stomach; in others, on the contrary, there is a defi- ciency. Their most frequent cause is a mental one.* The stomach becomes swollen, and forms an elevated, .elastic tumour beneath the sternum, yielding a clear sound on percussion. Various nervous symptoms, palpitations, dyspnoea, angina, pain in the gastric region, &C-, accompany the phenomenon, which usually disappears with eructations.f Many authors (P. Frank, Lobstein, &c.) are of opi- nion that in these cases the gas is secreted, by the walls of the sto- mach. BudgeJ.has, however, shown that in the eructations which precede vomiting, and, therefore, probably also in many other cases, atmospheric air enters the stomach through the oesophagus. I con- fess, how'ever, that to me the mechanism by which the air is driven into the stomach is not perfectly clear. According to Budge, the stomach enlarges its. cavity by an active tension, and then the air is driven in by the, ordinary laws of physics. How the stomach can, by a contraction of its muscular fibres, dilate itself, and thus produce a vacuum, I do not understand. If the fact is placed beyond doubt, some further explanation is at least requisite. It is possible that some of the cases in which gas is discharged from the generative^ organs of the male, from the uterus, and the urinary bladder, § may be explained in this way : namely, by a me- chanical pressure of the air into these parts in consequence of a peculiar antiperistaltic motion, or dilatation of the organs. In the same manner, in all probability, the air passes from the stomach into the other parts of the intestinal canal; howrever, most of these col- lections of gas iri the intestinal canal admit of another explanation, as we shall immediately see. On making a chemical analysis of these gases, it is found that in * Sir Francis Smith, Dublin Med. Journal. Jan. 1841, p. 454. t P. Frank, op. cit. § 714. \ Die Lehre vom Erbrechen, 1st Part. § P. Frank, op. cit. p. 724-T-726. PNEUMATOSES. 35 their composition they are identical with common air; but that in consequence, probably, of their prolonged contact with the blood and other organised fluids, they undergo changes similar to those which occur in the lungs in the act of respiration : viz., the oxygen is, in part, replaced by carbonic acid, and is saturated with hy- drogen." 2. Gases are developed in the body in consequence of decomposition, fermentation, and putrefaction. It is well known that most organic matters undergo decomposition at the temperature of the human body and in the presence of water, even when air is excluded. This decomposition occurs under the forms of fermentation and putrefaction ; and, in many cases, is ac- companied with the development of gaseous products. That such decompositions, accompanied with the development of gas, also occur to the human body, and that some pneumatoses are produced in this way cannot be doubted by any one who is in the slightest degree acquainted with the recent progress of zoo-chemistry. But if these general facts are established, our special knowledge of the subject is very imperfect; and it is at present impossible to explain theoretically, in any given case, the nature of the decomposition, and the properties of the developed gases. The following attempt to determine this point with a greater degree of certainty must only be regarded as provisional. The decompositions of organic matters, which have been hitherto studied, have received different names in consequence of their dif- ferent natures. We distinguish : firstly, alcoholic fermentation, in which sugar is converted into alcohol and free carbonic acid gas. Secondly, acetic fermentation, in Which alcohol absorbs oxygen, and is converted into acetic acid and water, or sugar is converted into lactic acid ; in this case no gaseous products are formed. Thirdly, putrefactive fermentation, which, according to the nature of the putrifying body, presents very different modifications-, but in which gaseous products are usually evolved. The alcoholic fermentation is of very rare occurrence in the human body, unless when ferment- ing drinks, unfermented beer, &c. have been taken in large quan- tities. It appears that in such cases this fermentation may occur in the stomach, and give rise to the development of an accumulation of carbonic acid. Acetic fermentation cannot give origin to any pneumatosis, since no gaseous products are developed. Hence, 36 PNEUMATOSES. there is only left the putrefactive fermentation to be carefully studied. As a general rule, it occurs very rapidly when portions of vegetable or animal organisms are exposed in the presence of water to a tem- perature corresponding with that of the human body. The gases that are developed vary in accordance with the putrefying substances that give origin to them. Non-nitrogenous substances yield carbonic acid, carburetted hydrogen, and hydrogen; nitrogenous matters yield ammonia in addition to carbonic acid: if sulphur and phosphorous are present, sulphuretted and phosphoretted hydrogen, and hydro- sulphate of ammonia are also developed.* Gas may be developed in this manner in the human body, partly from food in the act of decomposition in the intestinal canal, and partly from the decomposition of the constituents of the body itself. a. Development of gas from the decomposition of food in the in- testinal canal.—Accumulations of gas in the intestinal canal, at least in its lower portion, and the discharge of wind by the anus, are of such common occurrence, that they can hardly be. regarded as pathological indications. Indeed they occur in perfectly healthy persons. That the gas arises from the decomposition of food is much more probable than that it is secreted by the mucous membrane of the intestines, as the older writers (P. Frank and Lobstein) believed. For: firstly, food moistened with water, and exposed to a tempera- ture of 95°-—104° for a space of twenty-four or thirty-six hours ac- tually becomes putrid. Secondly, human fasces present all the signs of putrifying matter; they have a putrid odour, and infusoria are developed .in them. And, thirdly, the gases in the intestinal canal are identical wTith those which are formed out of the human organism during the putrefaction of animal or vegetable bodies ; they consist of carbonic acid, hydrogen, carburetted hydrogen, sulphuretted ^hydrogen, hydrosulphate of ammonia, and nitrogen.f The nitrogen probably arises from the air that is swallowed, the corresponding oxygen being contained in the carbonic acid. In support of the view that these gases originate from the food, it may * Compare Weinlich, Lehrbuch der theoret. Chemie, p. 344; Hunefeld, Chemie fcnd Medicin. vol. i. p. 258; Liebig, die organische Chemie in ihrer Anw. auf Agri- kultur, 1st Edition, p. 200. f Compare Befzelius, Thierchemie, 4th Edition, p. 338. PNEUMATOSES. 37 be urged that certain species of food give rise to an abundance of gas in the intestinal canal, and that sulphur taken medicinally gives rise to a copious development of sulphuretted hydrogen.* In a state of health, these accumulations of gas in the intestinal canal are, however, very trifling, or may be altogether absent, whilst in certain pathological conditions they are very abundant, and may even produce fatal effects. The caecum, or colon, will occasionally swell to the thickness of the arm or of the thigh, and may even burst.f The explanation of these cases is pretty clear on taking a close view of the chemical relations of the process of digestion. During healthy digestion, as soon as the food has entered the stomach a secretion of acid gastric juice is excited, which checks any decomposition and evolution of gas. The food, after its con- version into chyme, retains its acidity, which is not at once neu- tralized by the addition of the bile, but gradually disappears towards the extremity of the small intestine. Consequently, in a normal condition, there can be no evolution of gas in the small intestine. But nature has farther afforded means of restraining the decomposi- tion of food in the caecum and colon ; for when, after having ad- vanced so far, it still contains undecomposed sugar, this constituent becomes changed into lactic acid, and consequently it happens, according to Blondlot,f that the chyme which has gradually become neutral towards the extremity of the small intestine, not unfrequently again becomes acid in the caecum. Hence, in the normal state, the decomposition of food, accompanied with the development of gas, is restricted to the lower extremity of the intestinal canal. But when, in a diseased condition of the digestive organs, the secretion of gastric juice is either entirely absent or not sufficiently abundant, the decomposition of the food takes place sooner, and a considera- ble volume of gas may be generated. Blondlot has shown, by ex- periments on animals, that the absence, or accumulation of gas is in some degree dependant on the nature of the food. When ru- minating animals take turnips, beans or peas, which being rich in sugar, readily yield lactic acid, there is no development of gas in the first stomach. Gas is, however, formed when they have eaten * Berzelius, op. cit. t P. Frank, op. cit. p. 715—720. t Blondlot, Traite Anal, de la Digestion, § 103. 4 38 PNEUMATOSES. hay or clover, which yield no lactic acid, and are, therefore, prone to decomposition.* The occurrence of these gases is, as a general rule, restricted to the intestinal canal, and gives origin to the conditions known as meteorism and flatulence. They may, however, find their way from the intestinal canal into the cavity of the peritoneum,^either by an actual lesion, (as in cases of perforation,) or by permeating the unwounded intestinal walls. That this may happen, is obvious from the slate-gray colour of the surface of the spleen and liver fre- quently observed in post-mortem examinations, and due to the ac- tion of sulphuretted hydrogen or hydrosulphate of ammonia, which must have permeated the walls of the intestinal canal before it could reach those organs. Further particulars on this subject will be found in our observa- tions on Melanosis. b. Development of gas from the decomposition of the constituents of the body.—Gas may likewise be developed by the putrefaction of the constituents of the animal body, either during life or after death. Its occurrence during life is not very rare ; it takes place in putrid fevers, in typhus, and gangrene. Gas is most commonly evolved from the animal fluids, especially from the blood, when, before undergoing any chemical decomposition, it is arrested in dif- ferent parts of the body, and its purification by respiration and se- cretion is thus impeded, when certain secretions, as the biliary and urinary, are checked, and their constituents remain in the blood. Gaseous products are then developed, which collect in the paren- chyma of organs, and in the cellulartissue, constituting emphysema, and find their way into the cavities, or finally are discharged exter- nally. These gases are usually accompanied by a volatile odorous matter, and consequently evolve a penetrating putrid odour.f Morbid fluids effused into the cavities of the body may likewise un- dergo decomposition and evolve gases. Thus, pneumothorax may arise from the decomposition of fluid effused into the cavity of the pleura, and air may collect in the cavity of the peritoneum after gangrenous peritonitis. Likewise excretions, as urine or fasces, may * Blondlot, op cit. p. 95. t For further particulars, see Gangrene. PNEUMATOSES. 39 develop gas when they escape through wounds, lacerations, fistulee, &c, into the parts adjacent to their natural passages, and there un- dergo decomposition. Many of the. accumulations of air, arising from putrefaction, which are found in the body after death, are formed after the cessation of vitality.f This putrefaction after death takes place, however, the more rapidly under similar external conditions (temperature of the surrounding medium, and the greater or less facility with which the dead body gives off its warmth to surrounding objects; the period that has elapsed between death and the examination, &c.,) in pro- portion as the constituents of the body—at least its fluids—were predisposed towards putrefaction during the final period of life. There may, consequently, be an abundant secretion of gas in the dead body,, when, from external conditions, it would not have been expected, if during life, there has been a tendency towards decom- position. Hence, in individual cases, it is not always easy to de- terrnine whether gas found in the body existed there during life, or has been developed after death. Many cases of pneumatosis in which authors have stated that no signs of putrefaction were presented by the body,f belong probably to the latter category. Thus the vesicles of air in the vessels of the arachnoid, if they actually existed during life, and whilst the circu- lation was still proceeding, would, in accordance with the ordinary laws of physics, be conveyed with the blood to the heart. We have thus shown, that very many of the accumulations of air that have been described as occurring in the body, may be ex- plained on physical and chemical grounds. There remain, how- ever, other cases that do not admit of explanation on these grounds, and we are almost led to add, that 3. Gases may be actually secreted by different parts of the body. Thus, Magendie and Girardin assert that, on confining a portion of the intestine of a live dog between two ligatures, in the course of some hours the included portion was found full of air, which escaped with a hissing sound on making an incision.^ In the * Sec the chapter on the changes of the body after death. t Otto, op. cit. p. 42. X M;igendic et Girardin, Recherches physiolog. sur les gaz intestin. Paris, 1824, p. 24.; Lobstein, Path. Anat. vol, i. p. 138. 40 PNEUMATOSES. intestinal canal of swine we sometimes meet with considerable accumulations of gas between the layers forming the walls of the bowels. Sir Francis Smith* has described an interesting case of the development of gas in man, which deserves a full notice. He states—" On the 12th of May, 1840, I was consulted by a gentle- man, who told me that he often suffered from an enormous develop- ment of gas in the stomach, which he discharged by eructation : that he likewise, occasionally, experienced a development of gas from^the bladder, and that his skin acted in a similar manner, as he had observed in the bath. On the morning of the 15th, I found my patient in a bath at 79° F. His breast, shoulders, abdomen, and hands were literally Covered with minute bubbles of gas. On being questioned, the attendant at the bath stated that he had never previously witnessed any thing of the kind. On removing the hands and arms from the water, the air-bubbles disappeared, but gradually returned.on again immersing those organs. The bubbles were of the size of a pin's head. On wiping them off] they disappeared, but gradually formed again." In opposition to the above observations of Magendie and Girardin, it may, be urged that the gas which was developed might probably have arisen from the decomposition of remnants of food in the enclosed portion of intestine, or that the portion of gut becoming distended by peristaltic, motion, had imbibed air from the peritoneal cavity, or from the adjacent portions of the intestinal canal; and, similarly, the escape of air from the stomach and urinary bladder, in Smith's case, admits of the same mechani- cal explanation as has been given in a previous page. Not so, however, the escape of air from the skin : the fact that all bodies, when immersed in water, give off a little entangled air, affords no explanation of the continuous evolution of gas from the skin : neither does the accumulation of air occasionally noticed in the intestinal canal of swine seem to admit either of a mechanical or chemical solution. If we are asked for the particular causes of these developments of gas, I confess I can give no satisfactory reply. No secretion of gases occurs in the human body in a normal condition ; for the development of gas in respiration is a purely physico-chemical proceeding, and is in exact accordance * Dublin Med. Journal, January, 1841, p. 454. PNEUMATOSES. 41 with the laws of displacement and diffusion of gases, as has been recently proved by Valentin and Brunner;* and, probably, the same law holds good for the development of gas through the skin. We can only refer to the analogical proceeding in fishes, where we find an actual secretion of gas in the swim- ming-bladder, and must, for the present, defer all further questions respecting their causes or pathological indications. * Valentin, Lchrb. d. Physiolog. d. Menschen, vol. i, p. 55D. • 4*-": 42 DROPSIES. CHAPTER II. ABNORMAL COLLECTION OF AQUEOUS FLUID.—DROPSIES. Morbid collections of aqueous fluids in the body are designated by the general terms, hydrops, or dropsy. Dropsies are of very fre- quent occurrence, and in an anatomico-pathological point of view, present many varieties dependant on the region of the body in which the fluid has collected, on its action on the adjacent parts, and, finally, on the chemical properties and mode of origin of the fluid. 1. The dropsical fluid may be situated in one of the serous cavities of the body, and in such cases it often amounts to a very considerable quantity.—This class of dropsies has been further divided into dropsy of the pleura (hydrothoraXj) dropsy of the pericardium (hydrops pericardii,) dropsy *)f the peritoneal sac (hydrops ascites,) dropsy of the tunica vaginalis testis (hydrocele,) dropsy in the cavity of the cranium (hydrocephalus,) dropsy of the spinal canal (hydrorhachis,) and of the eye (hydrophthalmus.) In these cases the fluid usually occurs free, and, in accordance with the laws of gravity, settles in the most dependant part of the serous sac. It is, however, occasionally enclosed in recently formed membranous sacs. It is then termed encysted dropsy (hydrops saccatus.) 2. The fluid may be effused within the parenchyma of certain organs. This condition is known as oedema; its ordinary position is the cellular tissue beneath the skin, between the muscles, &c. The disease is then known as dropsy of the cellular tissue (anasarca, hy- drops telae cellularis.) It is, however, by no means rare to find the DROPSIES. 43 parenchyma of internal organs affected in-this manner, as in oedema of the lungs. Moreover, certain forms of dropsy of the cellular tissue have received special names, as oedema of the cellular tissue of the upper part of the larynx (oedema glottidis,) and oedema of the scrotum. Some writers* have denied that oedema occurs in internal organs of dense texture, as for instance, the liver, spleen, kidneys and brain. They are undoubtedly wrong, for collections of dropsical fluids occur in these structures, as will be shown when we come to speak of the organs spe- cially ; but this condition may be easily overlooked, or ascribed to other causes. Moreover, dropsical fluids are sometimes found enclosed in re- cently formed membranous sacs, both in the cellular tissue and in the parenchyma of organs. These sacs, with their contents, are termed hydatids. They are closely connected, in part, with en- cysted dropsy, and in part with other formations that will be subse- quently noticed. On examining the properties and chemical characters of dropsical fluids, we may divide them into: 1. Serous dropsy, in which the fluid is identical in its qualitative chemical composition with the serum of the blood. 2. Fibrinous dropsy, in which the fluid contains dissolved fibrin, and in its chemical composition resembles the plasma of the blood. 3. False dropsy (hydrops spurius,) in which the fluid differs es- sentially in its chemical composition from either of the preceding forms. These three forms of dropsy differ, not merely in the physical and chemical characters of their fluids, but likewise very essentially in their causes. Dropsical fluids are not always pure; they frequently contain ex- traneous substances, as, blood, pus, ichor, &c. We shall not in this place enter fully into the various points connected with these fluids. The various forms of dropsy occurring in different parts of the body, will be fully discussed in the chapters on the individual * Lobstein, op. cit. vol. i. p. 156. 44 DROPSIES. organs. Here we shall merely treat of their general relations, and the causes of their formation; in this point of view, the chemical arrangement is the most suitable. The above chemical differences in dropsical fluids have only very recently been accurately determined. 1. SEROUS DROPSY. Dropsy in which the effused fluid corresponds with the serum of the blood is by far the most common, and constitutes true dropsy in the restricted sense of the word. Most cases of ascites, hydro- thorax, hydrocele, anasarca, and oedema, belong to this category, as likewise do the fluids of pemphigus, blisters, &c. Properties and chemical composition of the fluids occurring in serous dropsy.—It is only the dropsical fluids effused in serous cavities^ or enclosed in cysts, that can be collected in large quantity and in a state of purity, and be submitted to analysis; although the fluid of oedema does not admit of being collected in so large a quantity, or in the same degree of purity, it cannot be doubted that in its che- mical and physical properties it is perfectly similar. • A pure dropsical fluid is generally nearly clear, limpid, or colour- less ; or, it may be, of a yellowish green tint, more or less turbid, opalescent, and whey-like. Its reaction is most commonly alkaline, rarely neutral, and still more rarely acid. Sometimes it is as fluid as water, but is frequently thick, viscid and tenacious. Under the microscope it appears as a pure fluid; it frequently, however, contains a small amount of corpuscles w7hich, on standing, form a more or less abundant sediment. This sediment may possess various properties, and be dependant on very different modes of origin. It may contain fragments of epithelium from the serous sur- face, accidentally mixed with .the fluid, pus-corpuscles from second- ary suppuration, blood-corpuscles accidentally present, or finally, but rarely, an actual deposition of inorganic matter. The fluid of hydrocele frequently contains a crystalline deposit of cholesterin. The many differences observed in.the physical properties of dropsical fluids are dependant, for the most part, on the presence of extraneous matter. In a perfectly pure condition, the fluid of dropsy is either colour- less, or of a yellow or yellowish green tint from the presence of bile-pig- DROPSIES. 45 ment. On the addition of nitric acid, it then yields the series of colours indicative of bile-pigment; that is to say, a little nitric acid renders it green; on the addition of more acid, it becomes blue, then violet-coloured, a hya- cynthine tint, and finally of a pale yellowish red colour. A red colour is dependant on haematin ; a milk-white turbidity, on the admixture of fat or epithelium scales, or of albumen, if the fluid is very aqUeous,* The con- sistence varies with the chemical composition; the more water is present, the thinner it is. A large quantity of albumen renders it viscid; a very large quantity (above 12°£) renders it thick, tenacious, and capable of being drawn out in threads, like albumen itself. Its alkaline reaction ap- pears to be due, like that of the blood, to alkaline carbonates (?) or basic phosphates. An acid reaction is rare, but sometimes occurs in dropsy after miliary fever and acute rheumatism: the acid on which the reaction is dependant is probably lactic acid. I have on several occasions attempted to isolate it, but always without success, in consequence of the small quan- tity present. The chemical constituents of the dropsical fluid are identical with those of the serum of the blood; water, organic substances, especially < dissolved albumen, fat, and extractive matters, (sometimes, also, small quantities of urea, bile-pigment, and haematin) and various salts, (chiefly alkaline and earthy carbonates, (?) and phosphates, and chlorides.) The amount of these constituents is somewhat variable ; sometimes the dropsical fluid is identical in its quantitative composi- tion with the serum of the blood ; but, most commonly, there is more water and less organic matter to thesame amount of salts. It is only very rarely that wre find it more concentrated, and richer in organic constituents than the serum. Dropsical fluids, especially those that have collected in large quantity in the serous cavities, have been often submitted to analyses. Of these analyses, I will only quote so many as are essential to the clear under- standing of their chemical relations,! and for their better comparison with the normal serum of the blood. * Sclicrer, Untersuch. p. 113; or Simon's Animal Chemistry, London, 1846, vol. u. p. 491. t The most important chemical analyses of dropsical fluids may be found in the following works and Memoirs:—Berzelius' Thierchemic, 4th Edit. p. 198; Leop. Gmelin's Chemie, vol. u. 2nd Part, p. 1388, &c.; D. Wagner, mediz. Jabrbuch d. osterr. Staates, 1833, vol. v. p. 2; Marchand and Bouchardat, in Valentin's Repert. 46 DROPSIES. 1 2 3 4 5 6 7 Serum of the Hydrocele. Hydrocele. Ascites. Ascites. Ascites. Ascites. blood. Water 905.0 920.0 927 946 956 988.0 704 Albumen 78.0" ) . 48 33 29 0.9 290 Extractive I 71.5 matter 4.2 I 10> 13 9 2 Fat 3.8' 9S 7\ 10.0 — Salts 9.0 8.5 6 8 83 ~~7o6'9 —993 9" 4 1000,0 999.0 1000. "boo" 1000 1. Healthy serum of the blood, the mean of two analyses by Lecanu, (Etud. Chim. sur le Sang, p. 57.) , 2. By Marcet. (Leop. Gmelin, vol. n. 2nd Part, p. 1392. 3. By v. Bibra, (Chem. Untersuch. versch. Eiterarten, p. 160.) 4. Analysed by myself. 5. By v. Bibra, (op. cit. p. 170.) 6. Analysed by myself; the fluid was turbid and of a milky appear- ance. 7. By Dublanc. (Leop. Gmelin, voj. n. 2nd Part, p. 1391.) These analyses, conducted in different ways, and therefore not admit- ting of close comparison, clearly show the great similarity between the serum of the blood and these dropsical'fluids. In analysis 2, the dropsi- cal fluid is almost identical quantitatively with the serum; in the follow- ing analyses, the amount of water increases, and of albumen diminishes, till in analysis 6, the latter has reached its minimum. The amount of salts, on the other hand, remains very nearly the same. The fat and ex- tractive matters are extremely variable, and we cannot very well com- pare them in the two fluids. Analysis 7 shows that dropsical fluids may be more concentrated than the serum of the blood; and it would not be difficult to refer to other cases illustrative of the same point; for instance, several are given by Scherer;* they are, however, comparatively rare, and only occur when the effusion is of some standing, and a portion of the water has been gradually removed by absorption. In most of these cases, where the fluid is very thick and pultaceous, peculiar terms are applied, as, for instance, cysts, hygromata, &c. The causes of these va- vol. n. p. 198; Babington and Becker, in Valentin's Repert. vol.,v. p. 359 ; Marquart in Albers' Atlas d. path. Anat. 14th Part; Valentin's Repert. vol. vi. p. 300; v. Bibra, chem. Untersuch. verschied. Eiterarten. Berlin, 1842, p. 155, fee.; Scherer, chem. u. rnikrosk. Unters. z. Pathologie, p. 112, 119, 125; Simons' Animal Chemis- try, vol. n. p. 490, &c. * Chem. und mikr. Unters. p. 125, 130. DROPSIES. 47 rieties are, for the most part, enveloped in mystery ; we shally however, notice them in our observations on the causes of dropsy generally. If, in its general characters, the dropsical fluid resembles pure or diluted serum, there still may exist in many cases chemical differences between them, which can only be detected by a careful analysis. The essential organic constituent of the serum, as likewise of dropsical fluids, is dis- solved albumen, which, in the majority of cases, has all the properties of pure albumen or of albuminate of soda : it either coagulates immediately on the application of heat, or, in the latter case, after the albuminate of soda, has been decomposed by an acid. On submitting this albumen to ultimate analysis, it is found to be identical with the ordinary protein- compounds (Scherer.)*. Sometimes the fluid does not coagulate thorough- ly on boiling, even after the previous addition of an acid, although a large quantity of albuminous matter is present: the albumen appears, therefore, to be modified; it separates on evaporation in the form of a membrane, and in that respect, although not in its behaviour towards reagents, it re- sembles casein; this was observed in some of the cases analysed by my- self. Scherer found a substance of this nature, similar in many respects to mucus, in the fluid of ovarian dropsy, which likewise contained albu- men and albuminate of soda. Elementary analysis proved that in its composition, it differed from protein (2Pr-f NH^—04).t Moreover, Collard de Martigny found, in the contents of a long standing cystic tu- mor between the uterus and rectum an albuminoid matter, differing how- ever from actual albumen:% but it appears to be questionable whether the case should be regarded as one of dropsy. In many cases a por- tion of the protein-compounds is thrown down by the mere addition of water, but on adding a neutral salt, the precipitate dissolves, as is fre- quently observed in the albumen of the egg. From these observations, it follows that the protein-compounds occurring in dropsical fluids, present various chemical modifications—modifications which, in the present defi- cient state of our knowledge regarding the protein-compounds, it is im- possible clearly to elucidate. Urea has been frequently noticed in dropsi- cal fluids ; thus in three, cases, Marchand found 4.2, 6.8 and 5 in 1000 parts of fluid.5 In other cases, again, this substance, is either entirely absent, or is present in so very small an amount as to render its quanti- * v. Bibra, op. cit. p. 217. i Scherer, op. cit. p. 129; or Simon's Animal Chemistry, vol. ii..p. 487. t L. Gmelin, op. cit. vol. n. 2nd Part, p. 1393 ; or Simon's Animal Chemistry, vol. u. p. 4-:5. § Valentin's Repert. vol. n. p. 198, and vol. in, p. 212. 48 DROPSIES. tative determination -impossible (Scherer's* and my own observations.) The salts in dropsical fluids are in general the same as occur in the serum of the blood. Chloride of sodium is usually the predominating ingredi- ent : the other salts—phosphate and carbonate (1) of soda, sulphate of potash, phosphates of lime and magnesia, and lactates—occur in smaller and very variable quantities.f Under the term dropsical fluids, we include some which, from their pathology, are distinguished by special names ; but which in respect to their chemical composition, as likewise to their mode of origin, are identical with the fluids we have been considering. These are the fluids of the bullous exanthemata (erysipelas bullosum, pemphigus, pompholyx,) the vesicles resulting from burns, or from the application of cantharides, and those occurring in gangrene. The formation of bullae differs in this respect alone from true dropsy, that the fluid is not enclosed within a shut sac, or effused in the tis- sue of an organ, but is confined beneath the cuticle, which is thus elevated, so as to constitute a blister. Some of these fluids form, as it were, the transition from serous to fibrinous dropsy. More- over, dropsical fluids may be mixed with the secretions; for in- stance, with the urine, which, in such cases, is -albuminous ; with the sputa in oedema of^the lungs, &c. Some of these fluids have not yet been fully analysed. The fluid in blisters produced by burns, or the ordinary vesicants, (independently of minute flocculi, consisting of coagulated fibrin, pus-corpuscles, and epithe- lium cells,) is clear, and sometimes of a yellowish-green colour, commu- nicates a blue tint to reddened litmus paper, and in addition to its princi- pal constituent albumen, contains a little fat, extractive matters, and the ordinary salts of the'serum of the blood. In the fluid from a blister raised by cantharides, which on heating coagulated into a solid mass, Bostock found: water 928.6 ; albumen 60; extractive matters 1.4 ; salts 10.J The fluid of the vesicles that are found^ on the body, in cases of gangrene, is red (from dissolved haematin.) but clear, resembling port wine cjiluted with water, and contains so large an amount of albumen, that on boiling it coagulates into a firm mass. The fluid of sudamina, containing no albumen, is not included in this category. * Op. cit. p. 116 ; or Simon's Animal Chemistry, vol. 11. p. 491. t Compare v. Bibra, op. cit. p. 159, fee; Scherer, op. cit. p. 121, 124 ; or Simon, op. cit, vol. 11. p. 490, &c. X Leop. Gmelin, op. cit. vol. 11. 2nd. Part, p. 1394. DROPSIES. 49 Causes and mode of origin of serous dropsy.—The close coinci- dence between the chemical composition of the fluiti of dropsy, and the serum of the blood, seems to suggest that the former takes its source from the latter. Pathologico-anatomical observations and ex- periments on animals confirm this view; showing that any impediment to the venous circulation, in whatever part of the body it may occur, is accompanied by an effusion of dropsical fluid from the veins affect- ed into the adjacent parts. Here we are induced to believe that serous dropsy always proceeds from the venous system, and that it takes place as soon as there is a want of balance between the poro- sity of the venous walls and the specific gravity of the blood con- tained therein; that is to say, when the venous walls become more porous, or the blood lighter and more" aqueous than in the normal condition. In either case there is an increased transudation of serum through the walls of the vessels* This is the manner in which local dropsy invariably occurs where individual veins are compressed, or, either for a time or permanently obstructed, as in cases of pressure from a tumour, or of complete obliteration. In this manner, the pressure of the impregnated uterus causes oedema of the feet; and pressure on the vena portce and vena cava ascendens, arising from degeneration of the liver, or some other tumour, pro- duce ascites and oedema of the lower part of the body. Instances of this nature are so numerous, and occur so frequently to every observant physician, that it is unnecessary to refer to special exam- ples. In all these cases, if there are no anastomoses to carry off the venous blood, the hydrostatic pressure of the blood in the affected veins increases, and their walls become distended and attenuated. An in- creased flow of arterial blood to a particular part produces a similar re- sult. If the aorta of the animal is compressed or tied below the spot at which the renal arteries are given off, dropsical effusion takes place from the renal veins; for the veins, as the most )Tielding part of the vascular system, become first distended by the increased quantity of blood.f From these experiments we are led to the belief that the blood, under the influence of strong pressure, causes and gives origin to the formation • Compare Hcnle in Hufeland's Journal, May, 1840, p- 13. t Compare the investigations of Meyer in Roser und Wunderlich's Archiv. fur Physiolog. Heilk. 1844. Part 1, p. 119 ; and those of G. Robinson in the Medico. Chirurg. Trans. 1843, p. 51—79. 5 50 DROPSIES. of dropsical fluids, by permeating the attenuated vein-walls, so that the whole proceeding,might at first sight be regarded as purely mechanical. This, however, is not the case, and the phenomena still present much that is obscure. In the first place, it is remarkable why the fibrin dissolved in the plasma does not enter into the dropsical fluid ; arid secondly, why, as a general rule, dropsical fluids should contain as large an amount of salts, and more water, but less albumen than the serum of the blood. This shows that the process is more complicated than at first sight it ap- pears to be. A more accurate acquaintance with the relations of endos- mosis than we at present possess is required to explain these points in a satisfactory manner. As a local action on individual veins gives rise to local dropsy, so general dropsy is produced by causes acting on the venous sys- tem collectively; such as organic diseases of the heart and lungs, which hinder the return of the venous blood to the right side of the heart, and consequently give rise to an increased hydrostatic pres- sure throughout the whole venous system. We shall enter at length into this subject, when treating of the patho- logical anatomy of the lungs and heart. Dilatation of the veins, and subsequent dropsy may be depend- ant not merely on external causes acting mechanically on those ves- sels, but may arise from dynamic causes, such as nervous influence alone. In this way, dropsy occurs in paralysed limbs in very de- bilitated constitutions.* Under this head we may also place (what is termed) inflammatory dropsy, which is either a complication of Jropsy with inflammatory exudation, or mere dropsy caused by an esoteric dilatation of the veins dependant on the nervous system, and accompanied by symptoms of irritation, (Fuchs's hydrochysis.) Dropsies of this sort are very frequent, but the phenomena accompa- nying them are generally complicated, and consequently their causes are not so immediately obvious as when the dropsy is dependant on mere mechanical conditions. To this class belong the blisters, arising from bqrns or ordinary vesicants, erysipelas bullosum, anasarca after scarlatina and acute rheumatism, inflammatory hydrothorax, and acute hydrocepha- lus. These subjects, however, fall under the head of the pathology of the * Compare Henle in Hufeland's Journal. DROPSIES. 51 nerves, rather than of pathological anatomy. The difference befween dropsy and inflammation will be found in our next section—on fibrinous dropsy. Serous dropsy, in my opinion, appertains to the venous system ; and fibrinous dropsy to the capillary vessels. The forms of dropsy already considered, take their origin in an attenuation (and increased porosity) of the. venous walls1; another cause of dropsy is probably to be sought for in an attenuation of the blood. Even at a very early period, the causes of most dropsies were referred to a modified condition of the blood, including those which we now know to arise from distension of the venous walls. Recent experiments have, at least, in isolated cases, confirmed this view ; thus, Magendie found that dropsical effusions occurred after defibrination of the blood, and the same has been observed by Valentin, myself, and others, after the injection of a large quantity of water into the vessels. (In rabbits'dropsy was easily induced ; in dogs with more difficulty.) Moreover, dropsy occurs when the blood has been rendered very aqueousby repeated venesection. More- over, it is probable that the retention of the aqueous secretions, (as in cases of suppression of the cutaneous perspiration and urine,) may give rise to an excess of water in the blood, and thus cause dropsy.* Our knowledge on these points is, however, still very imperfects A large number of quantitative analyses of the blood in cases of dropsy may serve to fill up some of these deficiencies. It is not every temporary overloading of the blood with water that causes dropsy, otherwise the abundant use of Water, if not at once carried off by the kidneys, would always produce it;, hence other relations, at present unknown to us, are in action. Henle's explanation of the causes of dropsy have obtained for him a deservedly high reputation. The laws which he has laid down appear to me only in so far to require limitation, that instead of referring the source of dropsical fluids to the vascular system generally, it should be limited, as we have already stated, to the venous system alone. Further progress of the dropsical fluid after its effusion. A dropsical fluid may be either resorbed1 or remain unchanged. As * Henle, op. cit. p. 16. 52 DROPSIES. only the acqueous portion admits of resorption, the fluid may be- come thickened. It admits of no organization, and cannot act as a cytoblastema for organic formations. Whether, and to what degree dropsical fluids become resorbed de- pends on various causes. The veins resorb the aqueous portion by en- dosmosis, with a facility proportionate to the tenuity and dilution of the fluid. Hence it is clear that venous resorption cannot occur when dropsy is dependant on a mechanical impediment to the venous circulation. It takes place, however, when dropsy arises from a dynamic dilatation of the veins, as soon as there is a remission of the noxious agency. In ad- dition to the veins, the lymphatics, also, exert a power of resorption ; and if for any reason, the functions of both classes of vessels are destroyed, there can obviously be no resorption. On the. other hand, resorption by the lymphatics may proceed with such activity that the effused fluid is at once removed; and, therefore, cannot collect in any quantity. In this point of view, the old opinion, that dropsy was dependant on increased exhalation and diminished resorption, has a certain degree of truth. Re- sorption is, however, dependant on local relations and circumstances. (Edema, in portions of the body abundantly supplied with lymphatics, disappears much more readily than dropsy in cavities where the only ab- sorbents are situated on the surface. By the absorption of the water and salts, in accordance with the laws of endosmosis, the fluid becomes thicker, and ultimately forms a viscid mass, containing comparatively little water, but much albumen (see p. 46, anal. 7.) That the dropsical fluid never forms a cytoblastema in which pus-corpuscles or other cells can be de- veloped, I have convinced myself by numerous experiments. When pus-corpuscles and other organic forms occur in dropsical fluids, they al- ways arise from other plastic processes accidentally combined with the dropsy. But by chemical influences some of its own constituents may be separated, as, for instance, cholesterin, or albumen, on diluting the fluid with water (see page 48.) Diagnosis of the dropsical fluid, and its anatomical relations.— Dropsical fluids may be recognised by the physical and chemical characters already described. They are distinguishable from the spurious dropsical fluids (subsequently to be described,) by their containing fluid albumen, which coagulates on the application of heat, or the addition of nitric acid. A precipitate is caused by the addition of nitric acid, when (as we have already mentioned,) the albumen is modified, and no longer coagulates on boiling. It is DROPSIES. 5-3 only in those cases in which the dropsical fluid contains so little al- bumen that no coagulation occurs, either on boiling, or on the addi- tion of nitric acid, that the diagnosis becomes difficult or doubtful • then, however, a quantitative analysis usually gives the required in- formation. It is distinguished by negative characters from other morbid fluids, as fibrinous dropsy, pus, &c. ; it does not coagulate spontaneously, and contains no essential corpuscles, such as occur in blood and pus. By means of a quantitative analysis we can some- times, but not generally, ascertain whether these substances are mingled with the dropsical fluids. On this subject, see the remarks on the following fluids, If the dropsical fluid is contained in a serous cavity, the sac be- comes distended, and compresses the adjacent organs.- The serous membranes enclosing the fluid are usually (and always when the disease is of any duration) loosened {aufgelockert,) pale, dull, and opaque. In cavities with yielding walls, fluctuation may be detect- ed by percussion. In infiltration of the tissues, there is a soft, pasty, shining tumidity, which pits on pressure of the finger. On making a puncture or incision, the fluid escapes either by drops, or in a stream, in proportion to the quantity present. The fluid occurs in the first place in the interstices between the elementary parts of the tissues, which imbibe it and assume a less compact and more flaccid appearance than in the normal condition. In recent cases, that is to say, when the venous dilatation that has caused the dropsy has only occurred shortly before death, the dropsical organs appear to be reddened (as is frequently noticed in pulmo- nary oedema); usually, however, they arc pale, and only the larger veins appear to contain-much blood. More on this subject will be found in the second part when speaking, of the separate organs. 2. FIBRINOUS DRQPSY. This species of dropsy, distinguished by the circumstance" of the effusion containing dissolved fibrin, is not rare, being of more frequent occurrence than the preceding,, although hitherto . 5* 54 DROPSIES. it has seldom been described,* and its signification has not been properly interpreted. It has never hitherto been correctly dis- tinguished from serous dropsy, and has consequently never had a special name assigned to it. Like serous dropsy, it may occur either in serous cavities (as in the pleura, arachnoid, peritoneum, or pericardium,) or may collect in the parenchyma of organs, either by infiltration, or by filling recently formed cavities in them, as, for instance,, in the substance of the brain. Hitherto, this occurrence has received the general name of dropsy ; effused into the peritoneum, it is known as ascites; into the pleura, as hydrotho- rax or empyema; into the parenchyma of organs, as oedema. This morbid process is, however, distinguishable by the circum- stance, that the fluid does not, like that of serous dropsy, present any constancy in its behaviour towards different re-agents, but under varying circumstances occurs in varying forms, as will be fully shown in its proper place. Properties and chemical composition of this fluid.—The fluid is essentially the same, whether obtained from the parenchyma of an organ, or from a serous cavity. In the latter case, however, it may be obtained in larger quantity, and purer, and consequently its different properties are more obvious. Examined immediately on. its discharge, the .fluid resembles in all points that of serous dropsy. It is either perfectly clear and colourless, or else more or less turbid, opalescent, and of a green- ish yellow colour; and, examined microscopically in its recent condition, exhibits either no solid particles, or only such as may be accidently present, as occasionally minute amorphous coagula of fibrin, pus-corpuscles, &c. Some time after its discharge, the whole fluid generally coagulates in consequence of holding fibrin in solution,'and forms a homogeneous, tremulous jelly, which, after standing for some time, separates into a partially consistent, colourless, or yellowish-red clot of coagulated fibrin, and a clear yellow fluid analogous to the serum of the blood. On washing * Cases in which this form is described are given by : Schwann and Magnus, in Muller's Archiv. 1838, p. 95, &c.; Delaharpe, in archives gener. de Med. Juin, 1842; Scherer, Unters. z. Patholog. p. 106—110; or Simon, op. cit. v. n. p. 491, &c.: Ginge, Anat. mik. Unters. It138. p. 74; Quevenne, Journal de Pharmacie, Nov. 1637. I have myself observed a very large number. DROPSIES. 55 the clot with water, and pressing it between folds of fine linen, we obtain a small quantity of tolerably firm, stringy fibrin, precise- ly similar to that which may be obtained from fresh blood by stirring and thoroughly washing. The coagulation of the fibrin sometimes takes place in the body during life, as we shall presently show. The coagulation out of the body, to which we have already referred, varies considerably in the time of its oc- currence ; sometimes taking place in an hour, in other cases, not until the lapse of twelve, or even twenty-four hours. Moreover, Delaharpe (op. cit.) has occasionally observed the fibrinous clot re-dissolve in the fluid. The coagulated fibrin appears under the microscope as a perfectly amor- phous mass, and devoid of any traces of cellular structure. In its chemical composition, this fluid is identical with the plasma of the blood ; that is to say, with the blood independently of its corpuscles; it is serum, or the fluid of serous dropsy with dissolved fibrin. By chemical analysis, we find that it contains: water, dis- solved fibrin and albumen, fat, extractive matters, and salts (chlo- ride of sodium, carbonate (?) and phosphate of soda, sulphate of potash, phosphates of lime and magnesia, carbonate (?) of lime, and lactates.) The similarity of the fluid to the plasma of the blood occasionally extends even to their quantitative composition : usually, however, the dropsical fluid is the richer in water, and contains a less amount of organic constituents—albumen and fibrin. It is very seldom that this rule is reversed. In this ppint, therefore, there is the same relation as between the fluid of serous dropsy and the serum of the blood. In order to give a clear view of these relations, I shall communicate a few analyses, preceded by a formula representing the mean composition of the plasma of the blood. 1000 parts ot fluid contain: 12 3 4 5 Plasma of Empyema. Empyema. Empyema. Ascites a. b. c. a. b. 906 003,5 945.6 f53 941 935,5 936 881 3.4 17 1,09 0,91 — 0,62- 0,60 83 Water Fibrin Albumen . Extractive mat Fats Salts 47,3 32 42,2 49,8 52,8 27 3 I 17 l 6 5 ° 5 7'2 2',1 1,4 ( 9 8 S _ >__________8 8,1 8________7.4 S_______ 1000 4 999,7 1000,0 1000 9Uf,5 999,4 999,8 1000 56 DROPSIES. 1. The mean composition of the plasma of the blood, according to Lecanu. 2. The fluid of empyema removed by paracentesis, analysed by Q,ue- venne.* 3. The fluid of empyema consequent on pleuritis, analysed after para- centesis by Dr. Merklein and myself. a. Discharged at the first operation, on the 18th of January, 1841. b. Discharged at the second operation, on the 25th of January. On both these occasions the fluid coagulated after some hours. c. Discharged at the third operation, on the 27th of January, shortly before the patient's death. It did not coagulate* and contained no fibrin; that constituent seemed to be supplanted by pus-cor- puscles, which formed a white, creamy sediment at the bottom of the fluid. 4. Fluid of empyema, analysed by Scherer.f j a. The fluid yielded at the first operation. b. The fluid yielded at the second operation, eight days subse- quently. 5. Fluid of ascites, analysed by Schwann.f The form of the analysis is slightly modified, in order that it may admit of comparison with those that precede it. The amount of fibrin is so large, that a doubt arises whether the amount stated was actual fibrin. These analyses are sufficient to show the close similarity, in a quantita- tive point of view, that exists between the fibrinous form of dropsy and the plasma of the blood. The differences are slighter than between serous dropsy and the serum of the blood. Analyses 3. and 4. are especially in- teresting, as showing that there may be very considerable differences in the secretion of the same organ of the same individual under similar cir- cumstances. It seems impossible to make analysis 5. (by Schwann) harmonize with the others; probably the amount of fibrin is much over- stated. It is very possible that Schwann neglected to wash the clot be- fore drying it, and that it contained pus-corpuscles, &c. At any rate, this seems to be the case when we consider that the amount of fibrin in the dropsical fluid (according to this analysis,) exceeds by twenty-four times the amount in the normal plasma. With respect to the other constituents of fibrinous dropsy, the same observations apply as to serous dropsy. The-albumen occurs either as pure albumen, or albuminate of soda. Of the fixed salts, Scherer§ found chloride of sodium 7.5, carbonate of * Journal de Pharmacie, Nov. 1837. f Op. cit. p. 106 t Muller's Archiv., 1838, p. 95. § Op. cit., p. 111. DROPSIES. 57 soda 0.8, phosphate of soda 0.4, sulphate of potash 0.9, phosphate of lime 0.3, carbonate of lime 0.3, total 10.2 in 1000 parts of fluid. In analysis 3 b instituted by Dr. Merklein and myself, the salts in 1000 parts of fluid amounted to 8, of which 0.4 was phosphate of lime; there was also much carbonic and a little sulphuric acid, chlorine, and a trace of phosphoric acid; of bases there' was much soda, and traces of potash, magnesia and lime. In 3 a there was much chlorine, a little phosphoric acid, much carbonic and no sulphuric acid. The fluid of fibrinous dropsy may be effused on the surface of the body in vesicles and pustules, in the same manner as the fluid of serous dropsy : it always occurs in the pustules of variola and vari- cella, at least in the early stages; frequently in the blisters from the ordinary vesicants, and burns before they have proceeded to sup- puration, and in many other similar cases. It may also be mixed with the secretions, in which case they possess the property of spon- taneous coagulation; this has sometimes been observed in the urine.* I may mention, as a case of this sort, a secretion containing dissolved fibrin, from the udder of a goat; it is interesting as showing that the same process takes place in animals. In the summer of 1842,1 received from a veterinary surgeon a glass with the following note. " It contains a fluid from the udder of a goat suffering from inflammation of that organ, it is originally of a pale green colour, and issues only from one teat, the others yielding normal milk." The fluid amounted to about an ounce, was of a greenish yellow colour, and rather turbid. There was floating on it a coagulum somewhat larger than a walnut, which did not make its appear- ance till after it had been despatched to me. It was larger than the ori- fice of the glass, so that there was some trouble in removing it. The fluid appeared homogenous; but when examined under the microscope was seen to contain innumerable normal pus-corpuscles about the 400th of a line in diameter, which gave rise to its turbidity. The clot was composed of coagulated fibrin, which when examined under a microscope* appeared to be amorphous ; it enclosed numerous pus-corpuscles, and a section ex- hibited a radiating appearance. Not a trace of milk-globules could be seen either in the fluid or in the coagulum. Causes, mode of origin, and further development of fhinous dropsy.—If there are good reasons for believing that the fluid of serous dropsy is derived from the blood, the reasons in favour of * Compare H. Nasse, Unters. z. Physiolog. und Pathol. 2nd Part, p. 209. * 58 DROPSIES. the fibrinous fluid arising from the same source are even stronger ; for it so very closely resembles the plasma of the blood, that in many cases no difference whatever can be detected, and, indeed, we can imitate the fibrinous fluid by quickly filtering frog's blood through fine tissue paper. Hence, we are led to the view that, in this case, even more decidedly than in the serous form, there is a purely mechanical permeation of the plasma through the walls of the vessels. We must not, however, forget that the fluid some- times appears more dilute, and, as a general rule, contains rather less fibrin and albumen than the plasma of the blood. Hence, in such cases, as we have already seen, endosmodic action is called into play, only to a less degree than in serous dropsy. Since the serous, and also the fibrinous fluids, take their origin from the blood, and are produced by the permeation of its fluid constituents through the walls of the vessels, how is it that in some cases we have one, and in others, the other form of effusion ? In the present state of our knowledge, this question cannot be satisfactorily answered ; there is, however, every probability that it admits of this solution: namely, that serous dropsy, as we have already stated, owes its origin to a permeation of the fluid of the blood through the walls of the veins, \vhile fibrinous dropsy arises from a similar per- meation through the walls of the capillary system. In favour of this view may be urged : firstly, the different pro- perties of the walls of these two divisions of the vascular system. The veins have thick walls, consisting of several layers of cells and fibres, while the waljs of the capillaries are very thin and delicate. It is true, that we cannot accurately estimate the differences in their endosmotic properties, but from analogy (from all the experiments that have been made in this department,) we may conclude that the product of endosmosis, in the former case, is more dilute and poorer in solid constituents; and that in the latter, it is more concentrated and abundant in them. Secondly, as we have already shown that serous dropsy is associated with dilatation of the veins and attenua- tion of their walls, so we learn from microscopic examination of the capillary system, that a dilatation of those vessels and an attenu- ated condition of their walls, precedes, and is associated with the occurrence of the fibrinous fluid, either in the parenchyma of an organ, or in a cavity. v The simultaneous occurrence of the effusion, and the modified condition of the vessels is, however, so constant P DROPSIES. 59 that we may conclude with all the certainty possible in such cases, that the dilatation of the capillaries is the cause of the effusion. It naturally follows, that in the gradual transition of the capillaries into veins, there is no rigid limit between fibrinous and serous dropsy, and that one may easily merge into the other. Further, many causes producing a dilatation of the capillaries can likewise act in a similar manner on the veins ; hence the two processes are very frequently associated together; and thus, in the fluid of serous dropsy, we very often meet with small quantities of fibrin. In serous dropsy, the causes of venous dilatation are frequently mechanical, and are, consequently, included in the department of pathological anatomy. Not so with fibrinous dropsy. Here the di- latation is dependant on dynamic causes, whose investigation would, of necessity, lead us far into the department of nervous pathology. We should, moreover, be led to the consideration of many other phenomena, as for instance, the stoppage of the blood in the dilated capillaries, which will be considered in another place. I restrict myself, therefore, at present, to the mere statement that fibrinous dropsy is essentially dependant on the capillary system ; that it is associated with, and for the most part arises from a dilatation of those vessels, and a tension and attenuation of their walls. The consequence of this process, in relation to the pathology, as well as to the physiology of nutrition is so great that, in point of importance, there is scarcely any other that can be compared with it. All nutrition depends on an effusion of fibrinous fluid into the parenchyma of organs, and the transition from the normal state into a morbid condition is so imperceptible, as to render any line of rigid demarcation an impossibility. And as the process admits of being associated with many others, it has received a variety of appella- tions. Many portions of the process of inflammation, may be re- ferred to it. The so termed exudation, and the effusion of plastic lymph are nothing more than the result of this same process, and the general nutritive fluid which we term, " exudation, or plastic lymph," is nothing more than the fibrinous fluid now under conside- ration. I have made this brief statement with the view of avoiding unnecessary repetition ; I shall subsequently have occasion in many places to take up the thread, which I for the present drop, and pur- sue it further. The subsequent fate of the fibrinous fluid may be much varied ; 60 DROPSIES. andthe course it may take is of high pathological significance. It is mainly dependant on two principal conditions; firstly, the fibrin- ous fluid being coagulable, coagulation may occur while the fluid is still in the body; and, secondly, as it admits of plasticity, and it may act as a cytoblastema for organic formations. Both these points require a full consideration. The fibrinous fluid may remain unchanged in the body for days, or even weeks; and then coagulate on its discharge and behave in the manner already mentioned. In other cases, however, the fibrin coagulates in the body itself. It then forms a coagulum of more or less firmness; which, under the microscope, appears either perfectly amorphous, or exhibits a confused fibrous, or radiating appearance ; and is sometimes covered with a finely granular, or pulverulent matter.* If the fluid is effused in the parenchyma of an organ, these coagula fill all the interstices between the elementary parts of the tissue surrounding them, just as solidified mortar does the stones of a wall, and forming with them a compact, apparently ho- mogenous mass, in which the original elements of the tissue can only be rendered visible by the action of acetic acid or ammonia, which dissolve the coagulated fibrin. In the cavities, on the other hand, these coagula occur as flocculent, or filamentous masses, either attached to the walls of the cavity, or occasionally, swimming unat- tached in the,fluid; or the fibrin may be deposited in layers on the walls'of the cavity, forming membranous patches. These membranes occasionally form a perfectly closed sac within the cavity ; indeed, there may be several such sacs of coagulated fibrin lying one within the other. This is the origin of encysted, dropsy, and of many forrns of hydatids. When all the fibrin dissolved in the fluid has assumed the coagulated condition, and has become perfectly isolated, then the remaining fluid in every respect corresponds with that of serous dropsy, and, consequently, the older observers regarded all these as cases of ^ hydrops serosus." The question, why the fibrin in many cases remains for a long time fluid, whilst in others it rapidly coagulates, and on what its coagulation in the latter cases is dependant, cannot at present be satisfactorily an- swered, any more than we can state with certainty, why the blood coag- ulates after its removal from the body. The most satisfactory reason is * See pi. ii. figs. 2. and 3; and pi. in. fig. 5. DROPSIES. 61 doubtless a chemical one, although at the same time certain influences of the organism seem also to be in play. Just as difficult is the explanation how and why fibrin in its coagulation assumes such very different forms.* On allowing a fibrinous fluid to remain in a state of repose, the whole mass at first assumes the consistence of a tremulous jelly; the fibrin then collects together and forms a species of clot, whereby a portion of the fluid contained in it is mechanically pressed out, and separates as serum. If, on the dther hand, the fibrinous fluid during its coagulation is stirred with a rod, or is shaken with solid bodies, as fragmentsof glass &c. in a stoppered bottle, the fibrin then assumes a filamentous or membra- nous form on the solid bodies. From these acknowleged facts, and with the aid of experiments on the dead body, we may draw many conclu- sions respecting the mode in which fibrin coagulates in the living-body. A perfect coagulation of the fibrin (such for instance as to form a jelly,) never or very rarely occurs within the body. The comparatively frequent cases Where an apparently gelatinous exudation occurs, as for instance, on the surface of the pleura, do not fall under this head : they consist merely of serum, with which the fibres of the serous membrane are infiltrated. Experience teaches us that the coagulation of the fibrin takes place more slowly within than without the body, and hence it is probable that the or- ganic parts exert a certain attractive power on the fibrin, such as the glass rod seems to do during the process of stirring. Further, the organs of the body are seldom in a state of absolute repose, but in a manner imi- tating the action of stirring, which we adopt in the artificial separation of the fibrin. Thus, in the cavities we find stratified depositions of coagula- ted fibrin. As coagulation within the body takes place very slowly, these layers are extremely thin ; a layer, a line in thickness, of coagulated fibrin may be divided into twenty or more separate and distinct strata. From the regularity and similar thickness of these layers, it cannot be doubted that they have been successively deposited by the fluid, so that the outer layer (that namely in apposition with the serous membrane) is the oldest. As a further argument in favour of this view, it may be added that the external layer is the first that becomes organized. If, moreover, we bear in mind that in many cases the separation of the fibrinous fluid from the capillaries is very gradual, and further, that it does not occur equally at all points of a serous membrane, (as for instance, the pleura or peritoneum) we can easily understand why some parts of these membranes are covered with layers of coagulated fibrin, while others are * A very instructive account of the various relations influencing the coagulation of fibrin, i9 given in Henle's Report: Zeitschr. fur rationelle Medic, vol 11. p. 168, &c, 6 62 DROPSIES. not. In such cases, the fibrin coagulates at the points at which it exuded, depositing itself on the serous membrane, and forming slight elevations on it. The subsequent exudation seems to be chiefly deposited on these elevations, which, like foreign bodies, act as points of attraction, and in this way there arfe formed tufts, flocculi, &c. This affords us an easy ex- planation of the formation of the cor villosum, and other singular forms of coagulated fibrinous exudations, without any necessity for having re- course to electricity, &c, as has been done by Eisenmann, who fancies that in these forms he can detect electric figures.* As long as the fibrinous fluid is not coagulated, it may, like the serous fluid, be resorbed, and either entirely or in part disappear, or become more concentrated; and the resorption proceeds with a greater facility than in the former case, there being commonly no hindrance to the activity of the venous system. But if the fibrin has once coagulated, then the resorption can only extend to the serum ; hence, in consequence of their loosing a por- tion of the fluid enclosed in them, the fibrinous coagula become tougher and firmer. The coagulated fibrin can only disappear by undergoing an organic change, as will be shown in the following section. Whether it cannot be rendered fluid, and then gradually resorbed by chemical means, as for instance, by the use of iodine, and other similar remedies, must for the present, remain unanswered questions. The dropsicalfluid, enclosed in a sac of coagulated fibrin, is in a manner cut off from the resorbent vessels—the veins and lympha- tics; and its resorption is a more difficult and tedious process than if it were not thus enclosed. This explains the unyielding character of encysted dropsy. The fibrinous fluid is Capable of organization, which is always effected at the expense of the fibrin contained in it. It constitutes the peculiar cytoblastema; hence there is no developmental capacity in the fluid of serous dropsy in consequence of the absence of fibrin. As far as development is concerned, it is indifferent whether the fibrin is in a fluid or coagulated state, as in either case it acts equally well as a cytoblastema, and its capacity is unlimited, that is to say, there may be evolved from the fibrin the most different forms of tissue, either normal, as cellular tissue, simple muscular fibre, car- * Haser's Archiv. vol. i. Part in. p. 373. DROPSIES. 63 tilage, bone, vessel, nervous fibre; or pathological, as, pus, granular cells, cancer, tubercle, concretions, &c. The process of develop- ment invariably follows general laws, whose bearings I have at- tempted to* investigate in the.following section on pathological epi- geneses. Through this capacity for organisation, fibrinous dropsy becomes the common source of a great variety of morbid growths, as will be shown in the subsequent chapters. - , The first indication of the developmental process in the coagulated fibrin. is the formation of cells: till then it is amorphous. Sometimes the fibrinous coagula attached to the serous membranes contain cells of an earlier for- mation ; these, however, are not developed from the fibrin, but appertain to the epithelium of the serous membrane, and having been thrown off during the process of exudation, have, thus become entangled in the coagu- lating fibrin. This is especially frequent in recent exudations into the pericardium, and in all probability the case described and illustrated in pi. n. fig. 4, belongs to this class. The fibrin appears to undergo no essential change in its elementary composition by the act of coagulation; subsequently,* however, certain chemical changes do Occur in it. I postpone their consideration to one of the following sections. Diagnosis of fibrinous dropsy, and anatomical relations of the sur- rounding parts.—The fluid is sufficiently characterised by its con- taining dissolved fibrin, and by its spontaneous coagulation after removal from the body. The diagnosis can only be doubtful when a serous fluid contains a considerable quantity of blood, as sometimes happens from the operation of paracentesis; for a serous fluid, mixed with one third or one fourth its quantity of blood, after a time like- wise gelatinizes. If, however, the amount of blood is not. so con- siderable (and this may be decided by the colour and the quantity of the blood-corpuscles,) then the coagulation Of the fluid is a certain sign that the dropsical effusion contained dissolved fibrin. If the fibrin has coagulated within the body, the diagnosis is rendered certain by the following tests: by the appearance of the coagulum * Von Fellenberg, (Fragments de recherches comparees sur la nature constit. de differ, sortes de fibrine du cheval. Berne, 1841,) believes, however, that he has proved by his ultimate analyses, that it loses the elements of hydrogen, or of oxygen and hydrogen in the proportion to form water; a view which being opposed to the expe- riments of Scherer and others, at all events requires further confirmation. 64 DROPSIES. under the microscope ; by its becoming transparent on the addition of acetic acid or ammonia; by its dissolving in caustic potash, and by the liquid in which it floats resembling that of serous dropsy. The surrounding parts are usually reddened, and when examined under the microscope, their capillaries appear to be distended and filled with blood.* When the parenchyma becomes infiltrated by the fluid, there is at first a soft, doughy swelling, such tas occurs in serous dropsy ; when, however, the fibrin coagulates, the tumour becomes hard, and, on making a section through it, appears firm and lardaceous. Since, however, inflammatory affection's of the external organs, the fibrinous fluid is usually poured forth very gradually from the capillaries, the first portion coagulates before the second is effused; hence, the tumour is commonly firm and resistent from the time it is first ob- served.. ' When effusion takes place in a serous cavity, it gives rise to dis- tention of the enclosing membrane; and, hence, to compression of the surrounding parts. The fibrinous effusion is of most common occurrence after pleu- ritis, or pericarditis; it is more rare after peritonitis succeeding para- centesis. In the dead body it is usually found in a coagulated state. 3; FALSE DROPSY. In the early systems of pathology, many cases were regarded as dropsies, in which fluids collected in the secreting organs, or in their discharging passages, in consequence of some impediment to their exit. Thus, we read of dropsy of the kidneys (hydrops renum,) of the uterus (hydrometra,)'of the fallopian tubes, of the gall-bladder, of the appendix vermiformis of the caecum, and of the lachrymal sac. These dropsies belong neither to serous nor to fibrinous dropsy. They arise from the duet of the secreting organ being, in some part of its course, either temporarily or permanently closed. In conse- quence of this impediment, the fluid accumulates in the secreting organ, and in its discharging duct as far as the obstruction, distend- ing those parts., The fluid in this form of dropsy, is, therefore, * See. pi. ii. fig. 1. DROPSIES. 65f originally identical with the secretions which has thus given rise to the tumour; in the kidneys it is urine; in the intestines, uterus, and fallopian tubes, it is a product of the secretion of the mucous mem- brane, &c. If the obstacle continues for any length of time, the secretion undergoes certain changes, becoming modified by the endosmotic action that is set up between it and the surrounding fluids. Hence, for instance, the fluid of dropsy of Ihe kidneys (hy- drops renum) is not always identical with normal urine. The particulars respecting the different forms of these false dropsies may be found in the special part of our treatise, under the individual organs. 6* 66 PATHOLOGICAL RELATIONS OF THE BLOOD. CHAPTER III. PATHOLOGICAL RELATIONS OF THE BLOOD. The blood of the human body may in various ways deviate from its normal condition. The following may be regarded as the most important deviations : 1. Its physical and chemical characters may undergo alteration. It may be either thinner or thicker than usual, and its colour may be affected. The blood-corpuscles may appear changed. The proportion of its constituents to each other may be altered, and it may contain matter not normally existing in it, as sugar, free lactic acid, &c. i 2„ Its quantity may be increased (hypersemia or polyhasmia) or diminished (anaemia or hypaemia.) This increase or diminution may either be general, extending to the whole organism, or local and re- stricted to particular parts of the body. 3. It may be effused in consequence of laceration of the blood- vessels, into the interstices of the parenchyrna of certain organs, or into some of the cavities of the body, constituting extravasation. 4. The haematin may, by a process of decomposition, become dissolved, and then be imbibed by the tissues. 1. PHYSICAL AND CHEMICAL CHANGES OF THE BLOOD. Deviations in the physical and chemical characters of the blood are of very frequent occurrence. We find them in the body after death, just as they are observed during life when blood has been taken by venesection or other means; and yet, until recently, the statements of most authors respecting these changes are extremely indefinite and unsatisfactory, rendering it alike difficult to attach any certain meaning to their facts, or to discover their causes or signifi- cation. Moreover, there is hardly another department in the whole PATHOLOGICAL RELATIONS OF THE BLOOD. 67 range of medical science which has been so frequently used as a foundation for false hypotheses and theories relating to pathology and therapeutics—hardly another on which the majority of the pro- fession entertain such obscure views and vague ideas as on the pa- thological changes of the blood. Hence, on this subject, the neces- sity for thoroughly determining the rigid and exact truth is doubly necessary. The above changes may be arranged under two divisions, in ac- cordance with the means requisite for their detection ; firstly, such as are directly obvious to the senses, and are especially noticed in pathologico-anatomical researches on the dead body. These are principally modifications in its physical characters, as in the colour, consistence, or nature of the coagulation. Secondly, such as for their detection require certain processes, often of a complicated nature— as most of the deviations of a chemical character. In accordance with the plan stated in my Introduction, I shall say no- thing of the physiological or vital phenomena of the blood. But the changes in the blood which are recognizable by the senses, belong strictly to pathological anatomy, and with respect to the chemical changes, I cer- tainly think that the most important, if they are sufficiently confirmed, should not be excluded, even if they appertain less to pathological anatomy than to chemistry. But it is the task, and fortunately also the tendency of the present day, to unite these two sciences. DEVIATIONS IN THE PHYSICAL CHARACTERS OF THE BLOOD. Change in colour.—Arterial blood in a normal state is, as is well known of a bright red, while venous blood is of a dark red colour, with a shade of blackish brown. Any attempt at an accurate esti- mation of these shades of colour, and of the associated pathologi- cal conditions, by mere description, must of necessity be vague and unsatisfactory. To obtain accurate results of this sort, we should draw up certain colour-tables, such as are used in the cynometer for the purpose of estimating the blue tint of the sky. Hence, the statements hitherto made respecting the changes of colour noticed in the blood are very unsatisfactory. The following are the most im- portant of these changes. Variations in the colour of arterial blood have been seldom noticed, and little is known regarding them, in consequence of the few opportunities that present themselves of 68 PATHOLOGICAL RELATIONS OF THE BLOOD. examining that form of blood. In cases of cyanosis, where the venous and arterial current's become partially mixed, in consequence of a portion of the former not passing through the lungs, but going through the patent ductus botalli, for amen ovale, or a perforation of the wall separating the ventricles, it is commonly darker than intihe normal condition. A similar condition is probably established in those pul- monary diseases in which, although the passage of the blood through the lungs is not impeded, the free contact of the blood and atmosphe- ric air is disturbed, as in oedema pulmonum. Here the cause is suffi- ciently obvious. It consists of a limitation of those shades of co- lour which the venous blood naturally acquires in its passage through the lungs. It is seldom clearer, but often of a darker colour than in the normal state; Venous blood is sometimes observed with a bright red tint in cases of scurvy ;* this is probably dependant on an increased amount of saline matter, which as is known, commu- nicates that tint to the blood. I have sometimes noticed venous blood of a bright red colour, with a shade of blue, much the tint that is developed on treating uric acid with nitric acid and ammonia : thus, in the dissection of an arthritic subject, the blood of the renal veins presented this tint. In other cases, the venous blood appears dark, of a brownish red or almost black colour, sometimes even re- sembling tar or ink. These variations in colour are often associated with other physical changes, as an abnormal increase or diminution of density, &c. They are, however, never so constant as to permit of pur always finding the same tint in the same disease, nor can we recognise their causes with any degree of certainty. In fact, the causes of the tints proper to healthy arterial and venous blood are not altogether established. ' Hence, no great importance should be attached to any peculiar colour presented by the blood, and still less should any conclusions be drawn from them at least, until we are in a better condition than we now are to recognise with certainty the cause of such a change in each individual case. With respect to the causes of the difference in the colour of arterial and venous blood, see H. Nasse's Article in Wagner's Handworterbuch der Physiologie, vol. i. p. 181, &c.,where all that we at present know on the subject is clearly described and criticised. The colour of the blood is modified by the action of many different substances, and we possess a * Lobstein, path. Anat. vol. n. p. 537. PATHOLOGICAL RELATIONS OF THE BLOOD. 69 great amount of information respecting these artificial changes:* but even the very-circumstance that so many causes produce a similar colour, ren- ders the determination of the cause in an individual case, a matter of much greater difficulty. The colour possessed by fresh blood remains after coagulation and the separation of the coagulated blood into the clot and expressed serum. The former retains the original colour, but, after a time, the surface usually assumes a brighter tint from the action of the oxygen of the atmosphere. - In the normal state, the serum is co- lourless, but it frequently exhibits a brownish green, or yellow tint. This yellow, yellowish green, or brown colour of the serum, may depend on two distinct causes. 1. On bile-pigment.—In this case on treating the serum with nitric acid, the well-known changes of colour are produced: a little acid renders the serum green ; a larger quantity, blue, purple, violet, and lastly of a-dull red or yellow colour. This reaction is, however, usually somewhat modified by the presence of the albumen of the serum, which is precipitated by the acid, and subsequently assumes a yellow tint, which conceals or modifies that of the altered bile-pigment. A large amount of this pigment is always present in cases of jaundice, when not merely the blood, but also the other fluids and secretions, and even the parenchyma of the different organs become of a yellow tint. This may, how- ever, occur without jaundice in persons apparently healthy. I have seen a large amount of bile-pigment in the serum of an old man, who was not jaundiced, in whose case venesection was ordered in consequence of apoplectic symptoms, and a smaller, but still very considerable quantity in the serum of a man with arachnitis. 2. The yellowish green or brown tint of the serum may be dependant on the brown colouring matter of healthy blood, which was first described by Simon, and received the name of hcema- phcein from that chemist, f Nitric acid will serve to prevent its being mistaken for bile-pigment. The serum, which in a normal state ought to be clear, is some- * Compare Berzelius, Thierchemie. 4ih Edit. p. 72, &c.; Simon's Animal Chemistrv, vol. i. p. 112; and especially Hiinefeld, der Chemismus in der their Or- ganisation^. 117. f For a description of hoemaphaein, see Simon's Animal Chemistry, vol. i. p. 42. 70 PATHOLOGICAL RELATIONS OF THE BLOOD. times opaque and of a milk-white appearance. This may depend on various causes. Firstly, on a large number of Microscopic fat-vesicles. Secondly, on the presence of a considerable quantity of minute granules of coagulated fibrin, as has been observed by Scherer and Simon.*" Thirdly, probably also on the formation of a free acid in the blood, whereby a portion of the albuminate of soda becomes decomposed, and albumen, in a finely granular form, becomes separated. The turbidity dependant on the pre- sence of fat is sometimes observed in perfectly healthy persons, shortly after partaking of an abundant meal, when the blood is receiving a large quantity of chyle. Turbidity, arising from coagu- lated fibrin, was observed by Scherer in a pregnant woman with bronchitis tuberculosa, in a leuco-phlegmatic person suffering from attacks of vertigo, and in a spirit-drinker with cerebral congestion ; Simon noticed it in a man with Bright's disease. It would appear as if this separation of the fibrin in a granular form, were owing to some peculiarity in its mode of coagulating. The causes of the turbidity in these cases may be readily detected by the micro- scope ; the fibrin-granules dissolve in acetic acid and in a solution of nitrate of potash; the fat-vesicles which may be recognised by their peculiar form, are not soluble in these fluids but dissolve in ether. The serum sometimes appears reddened in consequence of blood-corpuscles being suspended in it; this is chiefly noticed when the coagulation is imperfect; it occasionally, but more rarely, is dependant on a solution of the haematin, of which we shall speak presently. The changes in the consistence of the blood are likewise very imperfectly understood, and the statements on this subject are as indefinite as they are uncertain, since we have no proper means of determining with accuracy the degree of consistence of this fluid. Our information is limited to this, that we sometimes find the blood thinner than in.the normal condition, sometimes thicker and more viscid; a change of consistence is usually associated with a modi- fication in the colour of the blood. According to Lobstein,f the blood is thinner than usual in scurvy, in morbus maculosus Werl- * Untersuch, p. 85 "and 87. Simon, Beitrage z. physiolog. und patholog. Chemie, p. 287 ; Zimmerman zur Analysis u. Synthesis der psendo-plastischen Processe, p. 100, &c. t Path. Anat. vol. n. p. 539. PATHOLOGICAL RELATIONS OF THE BLOOD. 71 hofii, in typhus, in petechial fever, in malignant pustule, in scarla- tina, and in measles. It was likewise noticed by Scherer* in puerperal metritis. It appears thicker than usual in cholera, in consequence of the amount of water in the blood being much diminished. Generally speaking, our information respecting the variations in the consistence of the blood are of little value, be- cause their determination has not been based on accurate princi- ples; and they are even more unserviceable and deceptive when they refer, not to fluid blood escaping from the living body, but to the entirely or partially coagulated blood found on dissection, since the original degree of consistence existing during life is al- ready modified. This leads to the consideration of deviations in the coagulation of the blood. The blood coagulates out of the body in the same manner as in the body after death. In each case the process is es- sentially the same, although, in the latter there are so many modifying circumstances that it is better that we should consider each pheno- menon separately. Blood obtained from the living body, either by opening a vein, or by any other means, may present the following peculiarities in its coagulation. 1. The blood may coagulate very rapidly, or, on the other hand, not for some time after its discharge: in some cases it occurs in one and a half minutes; in other cases it only commences after the lapse of fifteen or twenty minutes. This acceleration and retardation of the coagulation cannot be well accounted for; and the causes in- fluencing the rapidity being apparently very complicated, no prac- tical conclusions can as yet be drawn from these phenomena. It appears that it is hastened, and, indeed, principally caused by the action of the atmospheric oxygen ;f on the other hand, it is well known that the artificial addition of many salts to fresh blood retards the coagulation. Hence we must conclude that a slow coagulation is frequently dependant on an increase of the salts. According to H. Nasse, the blood of the common hen and the goose, which is very slow in coagulating, contains from one third to one half more salts than human blood.J In every case the cause of the difference appears to be chemical, and not vital. * Op. cit. p. 160 and 163. + See Nasse's Article in Wagner's Handworterbuch, &c, vol. i. p. 112. % Op. cit. p. 114. 72 PATHOLOGICAL RELATIONS OF THE BLOOD. 2. Many deviations occur in the consistence and other properties of the clot, as well as in the proportion of its volume to that of the serum. The clot is sometimes very tough and firm, difficult to break up, and offering a resistance to the knife; in other cases, it is very soft and loose, forming a slightly consistent gelatinous mass, like currant jelly, breaking up on the slightest touch; in some cases it even happens that no true clot is formed, the blood remaining fluid, and, after standing for some time, merely forming a few soft, floccu- lent coagula. These are the two extremes, between which there may be many intermediate degrees. These differences are dependant on the condition of the fibrin, and in part, also, on its quantity. In proportion to the coagulating tendency possessed by the fibrin, and to its quantity, so much the firmer and more solid is the clot, which, in this way furnishes us with an approximation to the amount of fibrin present. These modifications of the fibrin may depend on various causes, all, however, of a chemical nature. The most fre- quent cause is the same that retards the coagulation, namely, an in- crease of the salts; in extreme cases, when, for instance, no coagu- lation takes place, it depends on an increase of the alkaline carbonates. The salts, when artificially added, lessen the tendency to coagula- tion, and the latter (the alkaline salts) altogether destroy it. Thus, in a case of putrid typhoid fever, Scherer* found carbonate of ammonia in the blood, which was black and pitchy, and did not coagulate into a solid clot, but merely formed a diffluent saline mass. The presence of the carbonate of ammonia was shown by the develop- ment of a white vapour on holding a glass rod moistened with non-fuming hydrochloric acid over the blood: and further by the circumstance, that the blood distilled on the water-bath yielded a fluid which had an alkaline reaction, and frothed on the addition of an acid. T/ie volume of the clot to that of the serum differs extremely in different cases; sometimes the clot is small, while above it there is a very considerable quantity of serum ; sometimes it is large, occupying nearly the whole volume of the blood, while only a very small quan- tity of serum is separated. These proportions, like those we have just considered, are also dependant on the coagulability of the fibrin, which stands in a direct ratio to the compactness of the clot, and to * Untersuch. p. 68. PATHOLOGICAL RELATIONS OF THE BLOOD. 73 the amount of serum expressed from its interstices. Hence the presence of a large amount of serum must not lead us to infer that the blood contained an excess of water; neither is a large clot to be regarded as a certain indication of the presence of an excess of fibrin. The coagulated fibrin of the blood, likewise exhibits differences in its chemical relations. Such differences occur in health between the fibrin of arterial and venous blood ; thus, venous fibrin gradually dissolves in an aqueous solution of nitrate of potash, while arterial fibrin is insoluble in that menstruum. In inflammatory affections, however, the coagulated fibrin of venous blood is frequently insolu- ble in that solution. This a point worthy of consideration. 3. Coagulated blood sometimes exhibits on its surface what is termed the buffy coat (crusta phlogistica seu pleuritica.) We may explain its formation in this way, that in this case the blood-cor- puscles began to sink before the occurrence of coagulation, so that the upper surface of the clot, enclosing no blood corpuscles, appears colourless, and consists of mere fibrin. Several causes may tend to produce this deposition of the blood-corpuscles previous to coagula- tion ; thus, sometimes, they sink more rapidly than usual from their arranging themselves in columns resembling rolls of coin, and thus overcoming'the resistance of the plasma, on the same principle that large bodies sink through a fluid more rapidly than small ones; sometimes the blood appears to coagulate more slowly than usual; and not unfrequently both causes are in operation. We frequently observe an increased quantity of fibrin in blood with the bufiy coat; but the increase of that constituent is not the cause of the buff, and the opinion that the formation of a buffy coat is always a sign of in- flammation, and that, consequently, further venesection is necessary, is utterly false, and has led to very disastrous practical conse- quences.* The variations occurring in the coagulation of the blood in the body after death cannot be easily explained, and the observations that have been recorded on this point are of little or np value, in con- sequence of the causes of their variation not being at the same time indicated. Generally speaking, on examining the body after death, we find the blood in the capillaries fluid ; while in the heart and veins, it is coagulated, the arteries being frequently empty. The * Compare Nasse, das Blut. p. 36 and p. 204, &c. 7 74 PATHOLOGICAL RELATIONS OF THE BLOOD. fluidity of the blood in the capillaries is not dependant on a defi- ciency of fibrin, for blood taken from the capillaries after death, fre- quently coagulates in the course of twenty-four hours, or even later. It is very possible, as has been suggested by Nasse,* that the exclu- sion of the atmospheric air tends to retain the fibrin in a state of fluidity. Although the coagulated blood in the heart and large ves- sels of different bodies presents different properties, it has been found impossible to deduce any general laws on the subject. Co- agulation within the vessels is never so perfect, nor the clot so firm as when the coagulation takes place out of the body. The condition of the blood, or at least of the fibrin, previous to death, obviously exerts a great influence on the condition of the subsequently formed coagulum. The heart not unfrequently contains white or yellow coagula o{ fibrin, with few or no enclosed blood corpuscles. These coagula sometimes extend from the heart into the large arteries; more rarely into the large venous trunks. It is not very easily seen, how so perfect a separation of the plasma from the blood-cor- puscles can take place after death, that the fibrin for the most part shall coagulate alone, without including blood-corpuscles ; and hence it is most probable that when the fibrin has a tendency to co- agulate, these white coagula are ready formed during life in the death- struggle. The contractions of the heart, and the pulsation of the arteries exert in these cases an influence on the blood, similar to that artificially produced by stirring with a glass rod, and thus the fibrin is separated and forms white coagula. I am confirmed in this opi- nion, from having repeatedly found tough white coagula in the heart, in cases where some days before death, syncope with disturbed car- diac action has supervened.f The blood in the heart and large vessels is either fluid or very imperfectly coagulated in cases of death from lightning, from various sorts of poison, in scurvy, in many cases of typhus, and in putrid fevers. Although this condi- tion is obviously dependant, (like the analogous relations of the blood out of the body, either on a diminution of the fibrin, or on that constituent having lost its power of coagulating, we are not at present in a condition to state with any degree of certainty the che- mical causes of these changes. Consequently we are not yet in a * Ilundworterbuch der Physiolog. vol. i. p. 113. t See the description of fig. 3 in pi. u. PATHOLOGICAL RELATIONS OF THE BLOOD. 75 condition to draw any valuable inferences from the changes under- gone by the blood in the dead body. Changes in the odour and taste of the blood have been noticed by different observers; thus the taste of the blood of syphilitic women has been observed to be saline ; of jaundiced persons, bitter; and in cases of rachitis, acid ;* in scurvy and putrid fever, it has a pu- trid odour; and Barruel even asserts, that from the odour developed on the addition of sulphuric acid, he can distinguish the blood of man from that- of woman, and recognise the blood of different ani- mals. Experiments of this nature in respect to the taste and odour of the blood are generally of trifling importance, although the for. mer might be serviceable in the detection of odorous matters, not easily recognised by tests, in the blood : as for instance, alchohol, phosphorus, hydrocyanic acid, &c. Changes in the blood-corpuscles.—It is well known that the blood- corpuscles undergo numerous changes, when brought in contact with various re-agents, as well as during the decomposition and pu- trefaction of the blood.f Numerous as these changes are, the causes producing them maybe referred to two distinct types. Firstly, they may be of a merely physical character, and dependant on endosmo- sis or exosmosis, as when the blood is diluted with water, or mixed with/a concentrated saline solution. In the former case, the blood- corpuscles become tumid, and the central depression disappearing, they cease to be biconcave and become spherical. In the latter case, they become contracted, irregular and indented at the edges, or pre- sent appearance of being surrounded with a festoon of minute gra- nules. Secondly, the changes maybe of a chemical nature, since many substances enter into combination with, or dissolve certain constituents of the blood-corpuscles. Thus water dissolves their colouring matter, causing them to become transparent, and ultimately to disappear; nothing but the nuclei (when these are present) re- maining. Moreover, acetic acid, ammonia, and the other alkalies dissolve the corpuscles. Changes of this nature rarely occur in the living body, but frequently after death. The most common change noticed in fresh blood, just drawn * Lobslien, Pail). Anat. vol. u. p. 540. f For thi> most perfect account of these changes, sec Hunefeld, der Chemismus in der tli'cr. Organisation, p. 43, itc. 76 PATHOLOGICAL RELATIONS OF THE BLOOD. from a vein, is this, that some of the corpuscles appear tumid and spherical, or else contracted, irregular or studded with granules. This appearance as we have already observed may be explained on the principles of endosmosis and exosmosis.* Even this change is of rare occurrence. In the dead body these changes are of more common occurrence. Thus Schererf found that the corpuscles of the blood, contained in the heart of a woman who died from puerperal metritis, Were swol- len and indented at the edges ; the blood contained free lactic acid, and-chemical decomposition had therefore already commenced. In gangrenous parts, I have frequently observed that the greater num- ber of the corpuscles were entirely dissolved, not a trace of them being left. In all these cases we may conclude that the modifica- tion of the blood corpuscles is dependant on the influence of a che- mical change in the blood ; the nature of this change must be de- termined by, chemical analysis, since very different re-agents pro- duce similar changes irf the corpuscles. Sometimes these chemical changes and the consequent alteration in the form of the corpuscles, do not commence till after death. Thus in typhus, the change in the blood-corpuscles frequently takes place in ten or twelve hours, in consequence of the rapidity with which putrefaction commences in this disease, as has been frequently observed by myself, and con- firmed by Gluge.J Dubois§ found that the blood-corpuscles of scrofulous persons were devoid of the proper colour, some having lost it at their edges, others entirely ; moreover some were more flattened than usual, while others presented a tumid and spherical appearance. Changes in the blood-corpuscles may easily be induced by dilu- ting the blood with water, or thin syrup, or by the evaporation of 'the liquid portion of the serum during the experiment; hence, the necessity for great care in such observations. In microscopic examinations of the corpuscles of defibrinated blood, we sometimes, but not always, observe that they indicate a * According to Andral, the raspberry-like appearance of the corpuscles is depend- ent on the adhesion of fibrinous grauules to them. t Untersueh, p. 160—16a t Sec the chapter on the changes occurring after death. § L'Experience, 1839, No. 87. PATHOLOGICAL RELATIONS OF THE BLOOD / / tendency to arrange themselves with their surfaces in contact, in forms resembling rolls of coin. This tendency is interesting, since it very probably plays a part in many pathological phenomena : thus it favours the formation of the buffy coat* since the corpus- cles, arranged in this form, sink more rapidly than in ordinary cases. Henlef remarks that this arrangement is closely connected with the occurrence of inflammation, being the cause of the stagna- tion of the blood in the capillary vessels. Hence it would be of much importance to ascertain the cause of their tendency to adhere to each other. Henle believes that it arises from an excess of albu- men, and at the same time a deficiency of salts in the serum of the blood. I have instituted several series of experiments with the view of elucidating this important question ; they did not, however, yield any definite results. I was unable to establish this tendency by the addition of an albuminous solution, devoid of salts ; while on the other hand, by the addition of a concentrated saline mixture to blood already exhibiting it, this tendency was sometimes, but not invariably increased. The point is one of sufficient importance to render a further investigation well worthy of being undertaken. CHANGES IN THE CHfcMICAL CONSTITUTION OF THE BLOOD. With a few exceptions, all our knowledge respecting the chemical changes of the blood has.been acquired during the last few years, and although it seems to explain several important points, it is still far from being in a complete and satisfactory state. In the following observations I shall therefore merely bring forward the most important points.J The blood in its chemical composition is a very intricate fluid, * Sec p. 73. t Hcnle und Pfeufer'a Zcitschr. vol. n. p. 120, &c. t Til' following are the mo-t important \v*>rks on this subject: Denis, Essai sur Papplicalion de la Chiinie a l'Etude physiolog. du Sang de 1'Homme, Paris, 1638. Lccanu, Etudes chimiques sur le Sang humain, Paris, 1837. Andral ttGavarrct, Rochcrchcs sur les ?>Iodific. de proportions de quelques princi- pes du Sang dans les Maladies, Paris, 1S40. Scliercr's Untcrsuchungcn z. Pathologic, 1813. Andral's Hematologic. Simon's Animal Chemistry ; to which may be added the Translator's Reports on the Progress of Animal Chemistry, in Ranking's half-yearly Abstract of the Medi. cal Sciences. 7* 78 PATHOLOGICAL RELATIONS OF THE BLOOD. containing a large number of different substances. As each of these substances entering into the composition of the blood may undergo either a qualitative or quantitative change ; and as, more- over, in certain pathological conditions, substances not occurring in normal blood may be present, it is manifest that the deviations in its composition must be very numerous. To make the subject clearer, we shall divide them into certain groups. 1. Any one constituent may be either relatively increased or de- creased. a. T/ie fibrin may be increased.—In 1000 parts of normal blood, there are from one to three parts of dried fibrin ; but jn certain pa- thological conditions, it may rise to 5-7, or even 10 parts, being more than treble the normal quantity. This is the case in most in- flammatory affections, and especially in most of the cases that give rise to fibrinous dropsy, in pneumonia, pleuritis, bronchitis, perito- nitis, acute rheumatism, severe erysipelas, and in many cases of pulmonary tuberculosis ; at the same time we frequently find that the qualities of the fibrin are also altered. After coagulation it is insoluble in a solution of nitrate of potash, differing in this respect from normal venous fibrin, and resembling that of arterial blood. The fact that the fibrin is thus increased is established beyond all doubt, but respecting the causes of this augmentation, and in part respecting its signification, there is still much to be explained. Si- mon, relying on the observation that the quantity of blood-corpus- cles is simultaneously diminished, conjectures that this increase takes place at their expense, and that the fibrin is formed from the haematoglobulin. On equal grounds it might be asserted that the fibrin is produced from the albumen of the plasma, since we possess no certain knowledge respecting the conditions under which one protein-compound is converted into another, and respecting the pro- duction of the fibrin in normal blood: Henle* has offered another explanation. He believes that the increase of the fibrin in all these cases is dependant on an exudation from the vessels (our fibrinous dropsy) containing less fibrin than the plasma, which thus after the exudation contains a relatively larger amount of fibrin than before. But this hypothesis fails to account for the great augmentation of the * ZcUschrifl fttr ration.elle IVIedicin v. Hcnle und Pfeufer,.vol. i. No. i. p. 119. PATHOLOGICAL RELATIONS OF THE BLOOD. 79 fibrin in inflammation, and for its relative increase in proportion to the quantity of blood-corpuscles. A diminution in the amount of fibrin (when for instance it falls below 1 in 1000 parts of blood) may either actually occur, or may be only apparent in consequence of its coagulation and separation being prevented by an excess of salts, or by the occurrence of car- bonate of ammonia. The amount of fibrin is determined by collecting the fresh blood in a weighed vessel, and stirring it with a glass rod of known weight, till all the fibrin has coagulated, and either separated in floccitles or attached itself in the form of membranous shreds to the rod. By weighing the whole, we know the weight of the blood. The blood is then strained through a cloth which retains the fibrin that has separated in flocculi. To this we must add the portion adherent to the rod, and wash the whole (retaining it in the cloth) till it becomes colourless. It must then be dried on the water-bath, its fat removed by boiling in ether, and finally weighed. b. The quantity of blood-corpuscles may be increased or diminish- ed.—Although we have not the means of determining the amount of the blood-corpuscles with the same accuracy as that of the fibrin, we have yet sufficient evidence, to show that, like the other consti- tuents of the blood, they admit of considerable variation. While every 1000 parts of normal blood, contain on an average 127 of dried corpuscles, in cases of fever the number may rise to 136, 160, or even to 185, while on the other hand, in cachectic conditions, and especially in chlorosis, it may fall to 100, 80 or even 38.* This diminution is associated with morbid processes which impede nutrition, but we do not at present possess any insight into those processes which cause this diminution, those cases being excepted in which it is obviously dependant on hasmorrhage, copious blood- letting, or, in short, any other direct removal of them from the sys- tem. In a therapeutic point of view, it is an interesting circum- stance that the internal use of iron, not merely gradually removes the bad consequences of this condition of the organism, but also effects a gradual augmentation in the amount of the corpuscles. Whether the augmentation of the corpuscles in cases of fever is, as Andral and Gavarret believe, essentially connected with the disease, * Andral and Gavarret. 80 PATHOLOGICAL RELATIONS OF THE BLOOD. or whether it is merely the result of an imperfect system of analysis, must be decided by future investigations. The quantitative determination of the blood-corpuscles requires a much more complicated process than that of the fibrin, and is much less accurate. It may be undertaken in different ways. Andral and Ga- verret adopt the following method: A portion of blood is allowed to co- agulate, and the serum and clot are then separated as completely as pos- sible. Both are weighed, dried on the water-bath and again weighed. By subtracting the latter from the former weight, we obtain the amount of water in the serum, and in the clot. The rest of the proceeding is merely numerical, being founded on the undemonstrated assumption that all the fluid contained in the clot was serum, and therefore contained as large an amount of solid constituents as actual serum. Hence we first calculate the amount of solid constituents of serum corresponding with the quantity t»f water separated from the clot, and subtract this and the fibrin (which is supposed to have been already determined) from the clot; the difference is the weight of the dried corpuscles. The following illustration may serve to elucidate the somewhat complicated calculations requisite in this process. An old man was bled in consequence of stran- gulated inguinal hernia, and a portion of the blood collected in a basin of known weight. The blood weighed 280 grains. In the course of twelve hours, thevseparation into clot and serum was perfect. A small quantity of serum was carefully taken up with a small pipette, so as to .include no corpuscles, and was placed in an evaporating basin of known weight. By deducting this weight from the given weight of the serum and the ba- sin, the serum was found to weigh- 95 grains. On drying it on the wa- ter-bath till it ceased to lose weight, the residue weighed 8 grains, conse- quently 87 grains of water had been expelled. The clot with the rest of the serum weighed 185 grains and after the most careful drying weighed 48 grains; hence 137 grains of water were lost. This water is, accord- ing to the above assumption, regarded as Serum, and is consequently as- sociated with a corresponding amount of solid constituents, which must be deducted1 from the clot. It follows from the above data, that 87 (the quantity of water in the serum): 8 (the quantity of solid residue in ditto) : : 137 (the quantity of water in the clot); x = 12.6. Subtracting thus from the dried clot, there remains, 48 — 12.6 = 33.4 grains as the weight of the dried corpuscles, or reducing to the scale 1000 parts (280 : 33.4 :: 1000 : x,) the dried globules amount to 119.3. This method of estimating the quantity of the blood-corpuscles is sim- ple and easily performed, but does not yield very accurate results. It is uncertain, on account of the undemonstrated assumption, that all the wa- PATHOLOGICAL RELATIONS OF THE BLOOD. 81 ter in the blood is associated with the same amount of solid constituents as the water of the serum—an assumption opposed to the idea that a por- tion of the water may be combined in some other form with the haema- toglobulin of the blood-corpuscles, in which case the above calrulations would no longer hold good. But besides this, it has disadvantages which influence the accuracy of the results. For it is difficult to remove the whole of the water from the portion of clot, which according to this pro- cess must always be tolerably large. The retained water increases the apparent weight of the blood-corpuscles in two ways, namely by its own weight, and further, by its amount of solid constituents regarding it as serum, which in this way escapes deduction from the clot. Hence in pro- portion to the abundance of corpuscles in the blood, is the uncertainty of this method of analysis, in consequence of the increased difficulty of dry- ing the clot. Another method has been proposed by Simon. He attempts a direct estimation of the haematoglobulin, which cannot be accomplished with any degree of accuracy except by an expert chemist. I, therefore, merely refer the reader to the description of Simon's method.* Instead of determining the blood-corpuscles collectively, we may esti- mate their individual constituents—the globulin, hnematin, and iron—and the ratio of each to the other. This, however, is laborious, difficult, and with our present resources yields only approximate results. Another method of determining the amount of blood-corpuscles in a direct manner has recently been proposed by Figuier.t It is founded on the circumstance, that on adding1 sulphate of soda to defibrirtated blood, the corpuscles can be collected by filtration. He directs that three or four ounces of defibrinated blood be mixed with about double its volume of a saturated solution of sulphate of soda, and that it be projected on a previously weighed filter, moistened with the same saline solution. The serum and the saline solution pass through, while the blood-corpuscles remain behind. They must then be washed with the saline mixture, which must be removed by dipping the filter with the corpuscles in boil- ing water, which coagulates the haematoglobulin while it extracts the sul- phate of soda. From repeated trials I can confirm this statement in all its essential points : I did not, however, always succeed in obtaining the corpuscles entirely colourless; a proof that the hasmatin is not entirely insoluble in a solution of sulphate of soda. 1 Animal Chemistry, vol. I. p. 175. f Comptcs Rendu.*, vol. n. p. 10] ; or Simon's Animal Chemistry, vol. i. p. ICO. 82 PATHOLOGICAL RELATIONS OF THE BLOOD. An accurate trial of these different methods of analysis instituted si- multaneously with the same blood, and a comparison of the results yield- ed by them would be highly important. For until we are better in- formed respecting the degree of accuracy that can be attained by each method, any application of their results to pathology must be open to various objections. c. The amount of water in the blood may be increased or diminish- ed.—The amount of water in the blood is liable to considerable va- riations, even in healthy persons, and Lecanu has endeavoured from numerous experiments, to deduce general laws on the subject. He found it less in men, more abundant in women ; less in vigour- ous persons in the bloom of life, large in children and in aged and debilitated persons ; less in the sanguineous, larger in the lymphatic temperament. In 1000 parts of blood the mean quantity is 790 ; it is, however, considerably augmented in ansemia, chlorosis and simi- lar conditions, in which it has been observed at 870, if not lower ; in cholera, on the other hand, the amount of water in the blood is diminished, in consequence of the copious liquid evacuations from the bowels. The estimation of the quantity of water is simple. A weighed quan- tity of blood must be reduced to a state of dryness on the water bath; the loss is equivalent to the amount of water. As the accuracy of the result depends on the completeness of the drying, it is advisable to.use a smaller \ quantity of blood than is recommended by Andral and Gavarret. d. The amount of albumen in the serum of the blood may vary.—- It appears to,be diminished in'Bright's disease, and probably in other cases in which there is a considerable secretion of serous fluid from the blood (serous and fibrinous dropsy.). In 1000 parts of healthy serum, there are 70—80 of dry albumen ; but in Bright's disease the amount falls, according to Andral and Gavarret, as low as 61—57. The amount of albumen may be determined in the following manner. A weighed quantity .of serum is neutralised with a little acetic acid, in order to decompose any albuminate of soda that may be present, and then diluted with water and boiled till the albumen coagulates into floc- culi. These are cpllected on a filter of known weight, washed with PATHOLOGICAL RELATIONS OF THE BLOOD. 83 water, and dried on the water-bath. The accuracy of the determination may be increased by boiling the dried albumen in ether, which takes up any fat that may be present. e. The salts of the blood may be either increased or diminished.— Variations in the amount of the fixed salts (those, namely-, left after incineration of the blood) are not only of common occurrence, but of considerable pathological importance. The salts are increased in scurvy, and it is very probable that this change influences the con- dition of the fibrin, hindering its coagulability, and perhaps check- ing its formation; that it affects the blood-corpuscles by with- drawing their water, rendering them granular, and collecting them in heaps ; and that it thus plays an essential part in the disease it- self. On the other hand a diminution of the salts is of considerable importance; it causes a tumidity of the corpuscles, favours their ad- herence to each other, and, according to Henle, tends to produce the retardation in the capillaries in inflammatory affections, of which we shall say more presently. Moreover, the relative proportions of the different salts may change. If these observations entitle us to conjecture that we may expect important developments in this de- partment of pathology, we are not yet in a condition to deduce gene- ral laws respecting these augmentations of diminutions. The mean amount of fixed salts in 1000 parts of normal blood has been variously estimated by different observers, some assigning it at 8—9, others 12—13 parts. The amount is estimated by incinerating the blood in a platinum crucible ; an operation requiring considerable time, but facilitated by frequently moistening the ashes with distilled water; it must be continued till the residue forms a white or faintly coloured saline mass. f. The amount of urea may be increased.—In healthy blood it oc- curs in such minute quantity as scarcely to admit of detection. In cases where its separation by the kidneys is prevented or impeded, as after extirpation of those organs, or in Bright's disease, it increases to such an extent as to admit of quantitative determination. 2. Substances may occur in the blood which do not exist there in a state of health. a. Free lactic acid.—If the blood has an acid reaction, it reddens litmus paper. The occurrence of free acid in the blood is a sign 84 PATHOLOGICAL RELATIONS OF THE BLOOD. that the fluid is undergoing decomposition, and occurs in diseased conditions in which a tendency to decomposition in the fluids is sus- pected—in miliary fever, in acute rheumatism, and in puerperal fever: it is therefore, of considerable pathological signification, al- though we are still not in a condition to see how the free acid acts on the blood, and, consequently, on the whole organism. Scherer found that the blood had an acid reaction in the bodies of persons dying from puerperal fever and phlebitis,* and declared that it contained free lactic acid. Thave on several occasions noticed this acid reaction in miliary fever and in rheumatism, but only in the dead body ; never in blood taken by venesection. If the quantity of the acid is only smalh the blood loses its alkaline reaction and becomes neutral ; this was observed by Scherer in the blood obtained by venesection, in a case of metritis.! In a practical point of view the acid reaction of the blood is a sufficient indication of the presence of the acid ; the separation of the lactic acid requires a difficult and complicated process. b. Carbonate of ammonia.—The occurrence of this substance in the blood is, also an indication of decomposition ; it hinders the co- agulation of the fibrin, and renders the blood unfit to discharge its ordinary functions. This change is sometimes observed in well- marked cases of typhus. Scherer| found carbonate of ammonia in blood taken from the arm of a typhus patient. The means of detecting this substance are given in p. 72. c. The blood may contain a substance precipitable by acetic acid, resembling pyin. Scherer§ found a substance of this nature, together with free lactic acid, in the blood of a woman who had died from metroperitonitis. This observation is important, because a similar, if not the identical matter, is of common occurrence in exu- dations, in pus, in scirrhous tumours, &c, as we shall presently see. To recognise this substance, the serum must be boiled in order to sepa- rate the albumen, and then treated with acetic acid, which throws down a precipitate insoluble in an excess of the re-agent. t Op. cit. p. 149. § Op. cit. p. 160. * Untersuch. p. 160, 163, l74, 230. i Op. cit. p. 69. PATHOLOGICAL RELATIONS OF THE BLOOD. 85 d. The blood may contain sugar in cases of diabetes mellitus. As the process for the recognition of this substance is intricate and difficult, I shall not attempt to describe it. e. The blood may contain bile-pigment which may be detected by the rules given in p. 69. In addition to these abnormal conditions, indicated by the art of the chemist, there are others which can only be detected by micro- scopic observations ; of these the most important are pus-corpuscles and entozoa. In morbid conditions of the system, pus-corpuscles in the blood are not of very rare occurrence. They are in some cases pro- duced within the vessels, in others they enter the vessels from without. Respecting the means of detecting them, their signification, and their mode of development, we shall have various occasions to speak. Entozoa have also been discovered in the blood, especially in the lower animals. This subject will be fully discussed in the chap- ter on parasites. We are indebted to J. Engel* for a meritorious essay which has been lately published on the theory of the changes which the blood undergoes generally, as far as they can be revealed by the different pathological conditions observable after death. The following are the most important of his conclusions: In suppurative fermentation [Eitergdhrung) the blood loses its tendency to coagulate ; it is of a dirty dark red colour, does not become brighter on exposure to the atmosphere, and is very fluid. The corpse appears swollen, and presents a dirty appearance, being marked with numerous death-spots, partly hypostases and partly sugillations. After inflammatory affections aud tuberculosis, numerous fibrinous coagula are found in the blood, the clot is large and hard, and the blood more consistent than in the normal state. The sugillations are fewer and not so diffused, and their colour is less deep. In typhus and miliary tuberculosis the blood has a dark violet tint, is viscid, and exhibits no tendency to form a consistent clot* * Ifcoser und Wund-rlich's Archiv. vol. i. p. 535, &c. 8 86 PATHOLOGICAL RELATIONS OF THE BLOOD. It is slow in reddening when exposed to the air, has no peculiar hypostatic tendency, but communicates to the organs, a dark violet, or reddish brown tint, by the firm adhesion of its colouring matter. In the cancerous dyscrasia, the blood is of a dark colour, very slight consistence, does not readily coagulate, reddens imperfectly or not at all on exposure to the air, and exhibits a hypostatic tendency. The colour of the dead body is of no diagnostic importance, in consequence of the slight viscidity of the blood, and the consequently slight adhesive power of the colouring matter. In dropsy the blood is not deeply coloured, and is very fluid, but yet exhibits a tendency to the formation of small clots. The hy- postatic appearances on the dead body are trifling. In marasmus (senilis vel prsecox) the blood is black and fluid, de- ficient in quantity, and forms no clot. It soon reddens oh exposure to the atmosphere, but, on account of its small quantity, forms no hypostases. r In scurvy the properties of the blood closely resemble those in suppurative fermentation. It has, however, a deeper colour, and gives rise during life to the formation of petechias, but pot to puru- lent dispositions. Moreover, the blood in scurvy readily induces liquefaction of the tissues (ulcerative destruction,) without any trace of reaction or inflammation. The blood of persons addicted to in- toxication belongs to the same category. It is very difficult, indeed impossible, from these statements, and those of other observers, to draw any certain conclusions respecting the changes of the separate constituents of the blood, or the causes of such changes. In fact our whole knowledge respecting the physical and chemical changes of the blood is in the highest degree unsatisfactory, and the statements of different observers vary so widely, that it is impossible to deduce any general laws from them. It is probable that many may regard the pre- ceding observations as unnecessary and aimless? I had a double view in arranging them in this form. In the first place, I was desirous of show- ing how little certain information we possess on this subject, and how dangerous it is to base theories for whole classes of diseases, and pro- posals for their treatment, merely on individual observations. Secondly, I trust that they will afford a convincing proof of the number of different acting forces to be kept in mind, in considering the various pathological changes of the blood. PATHOLOGICAL RELATIONS OF THE BLOOD. 87 2. CHANGES IN THE QUANTITY OF THE BLOOD. The amount of blood in the human body may undergo changes, and may either be increased or diminished. An abnormal abun- dance constitutes plethora or hyperemia ; a diminution, anaemia. Hyperaemia or anaemia may either be general (in which case the whole mass of blood in the body is increased or diminished) or it may be local. In the latter case, it is confined to a single organ, or to a larger or smaller portion of the body, while the remaining organs are either normal in relation to their amount of blood, or are in the opposite condition to the affected organ. Pathology has for a long time recognized the existence of gene- ral hyperaemia or plethora as an established fact, and has described the symptoms by which we may detect it. But all these symptoms (injected countenance, full pulse, tendency to congestion, &c.,) are not infallible. We have no certain means of determining whether the whole mass of the blood is actually increased, and still less are we in a condition to determine it with certainty in any particular instance. The mean quantity of blood in the human body cannot be determined with certainty. Valentin* has pointed out a very ingenious means of ascertaining the quantity of blood in animals, which, if certain necessary preliminaries are determined, might give tolerably accurate results ; but this method cannot be applied to man. In fact, all the means hitherto proposed for determining the amount of blood in the human body have been very unsatisfactory. We are usually contented with estimating the amount of blood from the degree of redness in the different parts of the dead body, from the contents of the large vessels, and from the blood that escapes on making,incisions on various parts. These means are import- ant, as showing comparatively the amount of blood in the different parts of the body, but they are of little or no value in enablirig us to ascertain even approximately the whole amount of blood in the body. To clear up this point, I propose another method, which although difficult and te- dious, would yet give far more accurate results. By carefully washing out the vessels of a body by injection with pure water, all the haematoglo- bulin contained in those vessels may be obtained, and after purification can be estimated quantitatively. Any conclusion respecting the whole * Repertorium, vol. ui. p. 281, &c; or, Physiologie, vol. l. p. 490. 88 PATHOLOGICAL RELATIONS OF THE BLOOD. quantity of blood deduced from the amount of haematoglobulin is doubt- less always uncertain, in consequence'of the varying proportions in which that constituent may be present in the blood. In cases, however, when it is possible to institute venesection shortly before death, we might ascer- tain by the processes already given, the proportion in which the corpuscles occur, and then after death calculate the whole amount of blood with tole- rable certainty. Laborious to an extreme degree as these investigations are, they are essential for the perfection of our knowledge of the blood. Until by such, or similar experiments, general plethora becomes better understood than it;novv is, all that has been stated regarding it must be considered as merely hypothetical. There is a close parallelism between anaemia and general pletho- ra. It is certainly an undoubted fact, that by loss of blood'the quantity of that fluid in the body is diminished, and that, for in- stance, a man directly after a copious venesection contains less blood than in the normal state. The loss is probably rapidly made up by the absorption of fresh matter especially of water, so that the amount of blood may become the same as before. It is true that the blood possesses a.different composition than if previously did, containing fewer corpuscles, and more water and albumen, but this condition should not be termed ancemia, but, as has been very properly sug- gested by Simon, spanaemia f and the symptoms in the dead body, dependant on this condition, are those commonly associated with the occurrence of anaemia. General paleness, deficiency of red clots in the vessels, and the escape of but little red blood, on making incisions into the different organs, are not always to be regarded as signs of anaemia, since they are equally likely to occur when spanae- mia is present. Local hyperaemia, as it occurs in the dead body, may have its seat in the veins or in the capillaries, sometimes occurring simulta- neously in both sets of vessels. Venous hyperaemia may be detected with the naked eye, or if only the smaller veins are affected, with a lens. The veins usually present a continuous ramifying appearance, are more distended than usual, and contain a blue, violet or reddish brown, or occasion- ally blackish blood, which escapes on making an incision. On cut- ting into the part affected, the section reveals numerous isolated From 97r.a.vo;, poor. PATHOLOGICAL RELATIONS OF THE BLOOD. 89 blood-spots. Venous hyperaemia is ' usually accompanied by an effusion of dropsical fluid from the distended veins; in the dead body, this may, however, be absent, or at any rate may escape ob- servation, since local hyperaemia is very limited, and exists only for a short time, and the effused serous fluid may have been resorb- ed by the lympatics. The causes of this hyperaemia are partly me- chanical—as obstruction of the venous trunks, stoppage of the heart's action, &c, and partly dynamic—as dilatation of the venous walls through the influence of the nerves.* Hyperemia of the capillaries.—The capillaries of different parts of the body frequently appear to be dilated to a greater or less degree, and to be over-filled with blood. In the lesser degrees of hyperae- mia, the diameter of the capillaries increases by one half; in the more highly developed cases, the diameter is sometimes double, or even treble the ordinary length, and then the vessels not unfre- quently become ruptured. The blood so completely fills up the whole lumen of the vessels, that the interstices at their border, which in the normal state are free from blood-corpuscles, disappear. The blood-corpuscles themselves are much more closely pressed,on each other than is usual, so as to prevent them from being recognized in- dividually, and the whole of the blood forms an apparently homo- geneous and coagulated mass ; but on removing the blood from the vessels by pressure, &c, the corpuscles again become separated, and the fluid assumes its normal appearance. The part affected by hyperaemia is redder than usual. This ab- normal redness may be either general or local, according to the ex- tent of the hyperaemia ; and decreases gradually as it approaches the unaffected parts. Under the microscope, it is observed that the red- ness is not uniformly distributed over the whole of the affected part, but that it follows the course of the capillaries, while the interstices remain colourless.f On cutting into the hypersemic organ, a more than ordinary quantity of blood escapes, in which the corpuscles are normal, or only slightly modified. The affected part is also denser than usual; the consistence is either normal or apparently softened ; it is never increased, unless, in addition to the hyperaemia, there is also a deposition of coagulated fibrin. The above relations are sufficient to render the diagnosis a matter * See p. 51. t See pi. n, fiay 1. b. 8* 90 PATHOLOGICAL RELATIONS OF THE BLOOD. of certainty. It can only be confounded with extravasation of blood, and with infiltration of dissolved haematin. The points serving to distinguish between them will be found in our remarks on these pa- thological conditions. Causes, mode of formation, and termination.—Hyperaemia of the capillary vessels is dependant on two forces (momenten)—on a dila- tation of the capillaries, and on the accumulation (and retardation) of the blood-corpuscles in them. The causes of these two forces, their mutual dependence, and the manner in which the whole pro- cess is conducted, belong to a department of pathology in which our knowledge is by no means accurate. To follow out this subject would lead us into the obscure domain of nervous pathology, and the physiology of tissues ; we shall confine our remarks at present to those points which more especially fall within the range of patho- logical anatomy. In many cases capillary hyperaemia is undoubtedly dependant on the nervous system; this, from whatever cause it is induced, gives rise to dilatation of the capillaries and relaxation of their walls : the dilated capillaries receive, on purely mechanical grounds, more blood than they previously did ; and a capillary which in its nor- mal condition could admit of the passage of only a single row of corpuscles, may now admit of two or three. At the same time an excess of plasma escapes through the attenuated walls of the capil- laries. The part affected contains an excess of blood-corpuscles, andhenee appears reddened. This is the condition which is known in pathology, as congestion ; it frequently occurs in the living body in external parts, as in the face, the eye, or the skin ; it is, however, more rarely observed in the dead body since it is seldom a cause of death. Here there is no stoppage of the blood corpuscles, the whole process being dependant simply on dilatation of the capil- laries. If the blood^corpuscles become impeded, the process ean- notbe referred to mere dilatation. Henle* has made a very ingenious attempt to refer the stagnation of the corpuscles to mechanical and che- mical causes. He supposes that in consequence of the exudation arising from the attenuation of the capillary walls,-the plasma becomes modified, containing proportionally more albumen and fibrin, but a * Henle u. Pfeufer, Zeitschrift fur rat. Medicin, vol. n. No. I. p. 130, &c. PATHOLOGICAL RELATIONS OF THE BLOOD. 91 smaller amount of salts than in the normal condition. This chemi- cal change in the plasma communicates to the corpuscles a tenden- cy to adhere, and this adherence mechanically induces stagnation. Plausible and ingenious as is this theory of the stagnation of the blood, it must only be regarded as a mere hypothesis against which weighty arguments may be adduced ; and we must confess that our knowledge is still uncertain respecting the true reasons of this phe- nomenon. As that form of capillary hyperaemia, in which there is no stag- nation of the corpuscles is termed congestion, so the higher degree —where they stagnate, and the local circulation is arrested—is term- ed stasis. On examining these conditions in the dead body, we find no difference between them. It is likewise perfectly indiffe- rent, whether the process is accompanied with symptoms of nervous irritation (true inflammation) or with depression of the central ner- vous system, (hypostatic inflammation, passive hyperaemia.) The phenomena of dilatation of the capillaries, of the aggregation of blood-corpuscles in them, and of the effusion of serous or fibrinous fluid from them, are in both cases the same, and the pathologist is unable to draw any certain distinction between them. The further course, and the combinations of local hyperaemia are very numerous, for it is usually associated with the effusion of serous or fibrinous fluid, and frequently with rupture of the vessels and extravasation of blood. Its terminations are: 1, dis- appearance of the hyperaemia by the dispersion of the impeded corpuscles, and the re-contraction of the vessels: 2, the occurrence of decomposition of the blood, in which case the haematin dissolves in the serum ; 3, or of gangrene, in which case the whole of the blood undergoes a chemical change. Of this we shall speak presently. As we have local hyperaemia, so likewise is there local anaemia. It may be recognized by the affected part being paler than usual, and by the effusion of very little blood on making an incision. Its causes are: 1, a constriction or occlusion of the arteries sup- plying the part: or 2, a contraction of the capillaries dependant on the nervous system, as, for instance, in sudden pallor of the cheeks, &c. 92 PATHOLOGICAL RELATIONS OF THE BLOOD. 3. EXTRAVASATION OF BLOOD. It frequently happens that in consequence of laceration of the vessels, the blood escapes from them and is effused in the cavities of the body or in the parenchyma of the organs, between the histo- logic elements. The process is termed hemorrhage, and the blood is said to be extravasated. ^ The effused blood may either coagulate or remain fluid. Gener- ally we only find it coagulated when it has been effused in large quantity,—as after wounds, in severe apoplectic attacks, and in pul- monary and bronchiaUhaemorrhage. The coagulation, as in ordinary cases, depends on the solidification of the fibrin, and the clot is composed of that constituent and the corpuscles enclosed in its meshes. Blood effused into the intestinal canal (in haeniatemesis and melaena) coagulates in a peculiar manner; the fibrin remains fluid while the albumen of the plasma becomes coagulated by the free acid of the gastric juice, and encloses the blood-corpuscles. Moreover, this acid converts the red colour of the blood into a blackish brown tint. The process may be imitated artificially by adding hydrochloric or sulphuric acid to defibrinated bjood. In other cases we find the extravasated blood remain fluid, especially when it is effused in small quantity. On removing this fluid blood from the body, it usually coagulates spontaneously after a short time ; and on examining it under the microscope, the corpuscles are found to be normal or only slightly modified ; hence in its essential characters it resembles normal blood. Extravasations of blood may be divided into : Firstly, those of the capillary system, in which the effused blood either forms small points scarcely visible to the'naked eye, or is uniformly distributed through the parenchyma of the affected part, which thus becomes either uniformly reddened, or is else merely covered with red specks. In diis case the blood proceeds from the smaller vessels, and this condition, or an alternation of it with capillary hyperaemia, is often noticed. Secondly, effusions of a large volume of blood." The effused blood then forms.large masses, which may be easily recoc- nized and distinguished from the surrounding parts. In capillary- extravasation, the blood, is most commonly fluid, in the other form it is generally coagulated. PATHOLOGICAL RELATIONS OF THE BLOOD. 93 The quantity of effused blood is extremely variable; it may be only a few drops or may amount to several pounds. Causes, formation, and ultimate fate of extravasated blood.— Extravasated blood always proceeds from the vessels, and results from their laceration. The view, that at least some of these effu- sions of blood may occur without any injury of the vessels, by a mere transudation of blood through the attenuated vascular walls (diapedesis) is altogether untenable, although some even of our recent authors (Carswell amongst others)* still support it. The walls of the blood-vessels—even of the smallest capillaries—are so impervious, that it is impossible for such large particles as the blood-corpuscles to pass through them in an uninjured condition. Moreover, the smaller vessels may be so readily lacerated by numerous internal causes without any outward injury, that there is no difficulty on thepoint,and the fact that those sanguineous effu- sions which occur in the normal state—as the menstrual discharge— are dependant on an injured condition of the vessels, is confirmatory of it. In many cases in which the blood is discharged from larger vessels we may easily detect the seat of the injury, and conse- quently the source of the hemorrhage; if we are not always so fortunate in hcemorrhage from the capillaries, it is owing to the imperfection of our diagnostic aids, not to the absence of a lace- rated vessel. The causes giving rise to laceration of the vessels, and conse- quent effusion of blood are very numerous; many of them are ex- ternal, and mechanical or chemical in their nature: as wounds with cutting or stabbing instruments, bruises, blows and concussions ; occasionally the vessels are injured by caustic applications, as for. instance, caustic potash. The manner in which these different in- fluences work is too obvious to demand any explanation ; but more- over, there are certain morbid processes within the body that fre- quently injure the vessels, and cause the extravasation of blood, as for instance, violent coughing or vomiting, mortification, suppura- tion, or softening of tumours, destroying the organic tissues, and hence injuring the continuity of the vessels in a manner presently to be described. Another very frequent internal cause of rupture of the vessels is a disturbed state of the circulation. When, in any * Patholog. Anatomy, fasc. 6. Hemorrhage. 94 PATHOLOGICAL RELATIONS OF THE BLOOD. part of the body or from any cause, the circulation is either tempo- rarily or permanently impeded, the pressure of the blood in the ves- sels of the adjacent parts is increased, and their laceration often re- sults. Hence all the forms of hyperaemia, described in the former section, are frequently associated with extravasation of blood. It is observed in obstruction of the veins, in stoppage of the heart's ac- tion, in stagnation in the capillaries, and, indeed, in almost every case'of inflammation. Hence it is that extravasation of blood is so frequently combined with hyperaemia, with the effusion of serous or fibrinous fluids, and with suppuration. Moreover, pathological changes in the waljs of the vessels themselves frequently give rise to laceration, and it has been especially noticed that the arteries are more easily lacerated than usual under the ordinary pressure of the blood, when their walls have become softened by atheroma- tous deposits, or have become brittle by the deposition of earthy matter. Amongsf the causes of extravasation, many writers place certain changes in the blood itself, especially those that occur in ordinary and land scurvy, and in the higher degrees of putrid fever and ty- phus. But we must clearly distinguish between the extravasation of actual blood containing corpuscles, and the infiltration of dis- solved haematin which transudes through the uninjured walls of the vessels, and will be considered in the next section. This dissolved condition of the haematin is entirely dependant on a decomposed state of the blood. In typhus, petechial and putrid fever, &c, the extravasation of true blood is, however, very frequent, but is always dependant on laceration of the vessels; and in producing this lace- ration a change in the composition of the blood can only act a very secondary part. It can at most only act through a series of means, by favouring congestion and stagnation of the blood. On these points, however, we know very little. The further course of extravasated blood resembles in all essen- tial points that of a fibrinous fluid. Firstly, it may either be resorb- ed and thus disappear; or secondly, it may act as a cytoblastema and become organized. A perfect resorption is probably only pos- sible while the blood remains fluid. This fluid undergoes various modifications in its properties, corresponding doubtless with chemi- cal changes with which we are at present only imperfectly acquaint- ed. When blood is extravasated in a part where its changes can PATHOLOGICAL RELATIONS OF THE BLOOD. 95 be traced with the eye, as for instance, under the epidermis, it gradu- ally undergoes progressive changes of colour; it passes from a dark red into a blue, then into a brown, and lastly into a yellow colour, before it entirely disappears. The causes of these changes are un- known. Sometimes they do not occur ; blood which was effused in the conjunctiva from straining during a severe cough, gradually disappeared without any change of colour, the last traces exhibiting the tint of normal blood. Scherer* has carefully examined the changes which blood, extravasated in consequence of a blow on the upper part of the thigh, Underwent as long as it remained in the body. After a few days, it lost its power of coagulating, and con- tained no more fibrin. The blood-corpuscles were still observable, but were, spherical and swollen ; and the blood itself contained more water, and less solid constituents than in the normal state. Three days later, the corpuscles disappeared, the blood was much more liquid, and contained a few pus-corpuscles, and in the course of a few days it was entirely converted into pus. When coagula of blood become organized, as in certain apoplectic cases, the changes are much more complicated. The clot is usually found after some time to consist of two distinct substances, an inner one, which is soft and forms a reddish brown mass (changed blood- corpusclesjand an outer one consisting of firmer layers, which are white, or at any rate less red than the inner, mass, and present a granular amorphous appearance under the microscope. This differ- ence between the outer and inner portions may be referred to, two distinct causes: either the cOagulum, in consequence of the irrita- tion which it produces, gives rise to inflammation of the surrounding parts, and to the exudation of fibrinous fluid which deposits itself in a coagulated form around the original clot; in which case the outer white layers are new formations, altogether independent of the ori- ginal clot: or the haematin in the outer layers of the coagulum, to which the fluids are readily accessible, may be for the most part ab- sorbed, and the difference in colour between the outer and inner layers thus accounted for. In many cases it is probable that both these causes are in operation; I think, however, that we may con- clude, from numerous observations, that every considerable extra- vasation of blood causes an effusion of fibrinous fluid around it. and * Unters. p. 194. 96 PATHOLOGICAL RELATIONS OF THE BLOOD. is> therefore, generally combined with fibrinous dropsy. In its further course of development, the clot appears to be influenced by the general laws, which form the subject of our next chapter. The most distinct products may be evolved from the blood ; patho- logically, pus, granular cells, melanosis, &c.; normally, cellular and fibrous tissues, vessels, &c. ; also concretions. Extravasated blood undergoes a peculiar change in gangrene. It becomes converted into blackish brown clots with a cadaverous odour, and frequently covered with black granules in which no blood-corpuscles can be recognised. Further information on this subject will be found in our section on gan- grene. See also pi. ix. Fig. x. Consequences of extravasated blood, anatomical relations of the surrounding parts, and frequency of its occurrence.—The conse- quences of extravasation of blood are partly general and partly local. The general are chiefly dependant on the amount of blood which is thus removed from the vascular system, and is consequently pre- vented from discharging its ordinary functions in the body ; when the amount is small, they are very trifling, but if it is large, there may be much debility, or even death induced. The local conse- quences are dependant on the action of the effused blood on the surrounding parts, (chiefly by the pressure and mechanical influences exerted by it;) also on the quantity of extravasation, and on the functions and importance of the organ in which it has taken place. Thus, considerable effusion of blood in the brain produces apoplexy, with its consequences; in the lungs and bronchi it fills the air cells, and checks respiration ; in the pleura it compresses the lungs, and in that way impedes respiration ; in the urinary bladder, by coagu- lating in the urethra, it gives rise to a mechanical stoppage, and re- tention of urine with its consequences ensues Finally, amongst the evils arising from extravasated blood, we may reckon softening, inflammation, suppuration, ulceration, and gangrenous destruction of the affected part. The anatomical relations of the surrounding parts differ extremely in different cases. When hyperaemia and stagnation are the causes of extravasation, the surrounding parts appear hyperaemia, even in the dead body ; in other cases where the effusion has been very copious, the whole body appears pale and bloodless. PATHOLOGICAL RELATIONS OF THE BLOOD. 97 The extravasation of blood is a very frequent occurrence, and may take place in almost any organ containing blood-vessels; in the lungs constituting haemoptysis, in the brain apoplexy, in the stomach and intestinal canal haematemesis and melaena; it is likewise not uncommon in the kidneys, urinary bladder, and uterus. The par- ticulars of these forms of haemorrhage are further noticed in the chapters on these different organs. Diagnosis of extravasated blood.—Effused blood may be generally detected with the naked eye ; if the quantity is very small, it may however, be requisite to have recourse to the microscope. The only appearances with which it can possibly be confounded are hy- peraemia of the capillaries and infiltration of haematin. The dis- tinction between extravasation of blood and hyperaemia of the ca- pillaries is not always, obvious, and the difficulty is increased by their frequently occurring together. We may be assured that ex- travasation has occurred when the redness of a part is not uniform, but distributed in patches, and further, when the specks of blood which we can detect, either with the microscope or unaided eye, have a larger diameter than the vessels of that part, even when dilated to the utmost. Sometimes other circumstances contribute to strengthen the diagnosis ; thus, for instance, there would be great probability in the assumption that blood was extravasated in the lungs, if during life the sputa were observed.to contain numerous blood-cor- puscles, as occurs in pneumonia, or when in the dead body the bronchi were found to contain^bloody mucus. Coagulated blood in the ureters, and bloody urine lead to the inference that there has been extravasation in the kidneys. Fortunately in these cases where the diagnosis between these two conditions is not easy, its accurate establishment is of no great value, for ea.ch is intimately combined with and keeps up the other, and the extravasation is most com^ monly produced by hyperaemia and stagnation of blood. The difference between the extravasation of blood and the infiltration of haematin is explained in the following section. Blood effused into the stomach and intestinal canal, and either found there on dissection, or discharged by the mouth or the rec* turn, has, however, a different character. Instead of being red it is of a brownish black colour, and of the consistence of tar, or else flocculent and resembling coffee grounds. Under the microscope 9 98 PATHOLOGICAL RELATIONS OF THE BLOOD. there are observed patches of an irregular form and size, but of a deep reddish brown colour, like the blood modified by gangrene,* and in which no blood-corpuscles can be observed. This appear- ance is caused by the blood coming in contact with the acid of the gastric juice, and other intestinal fluids, by which its albumen be- comes coagulated. When it is found in the stomach, or has been discharged by vomiting, it is liable to be mistaken for bile. The diagnosis is easily effected by the addition of nitric acid, which changes the colour of bile from a dark into a clear green, then into a blue, violet purple, and finally, a pale red ; while the blackish- brown blood, in the absence of bile, does not undergo these modi- fications. 4. SOLUTION OF HJEMATIN AND SATURATION OF THE TISSUES WITH IT. When on making a dissection we observe the various organs of a blood-red colour, we sometimes hastily conclude that there is either extravasation of blood, or hyperaemia, whereas a more careful ex- amination would show that the red colour was due to the saturation of the tissues with serum containing haematin in solution. Haematin seldom becomes dissolved during life, but often after death. We sometimes observe it during life in gangrene, and in putrid and petechial fevers. In these cases the blood obviously undergoes a chemical change, which causes the haematin to dissolve in the serum. The nature of these changes is not accurately known; they probably depend on various causes, such as the occurrence of free lactic acid, or of carbonate of ammonia in the blood, and possibly on a great diminution of the salts. In gangrene there is not unfrequently ob- served a clear red, or else- a turbid brownish fluid in vesicles under the epidermis, constituting gangrenous ichor. This is merely serum tinged with dissolved haematin; the brown colour occasionally noticed is probably dependant on a modification of the haematin, produced either by an acid or by ammonia, similar to that which occurs in melaena. In those cases in which the haematin becomes dissolved during life, the whole mass of the blood is probably not affected, but only a portion, which has either stagnated in or escaped from » See pi. ix. fig. 10. PATHOLOGICAL RELATIONS OF THE BLOOD. 99 the vessels.* This change is, however, of much more frequent occurrence after death than during life, and we may conclude that when it occurs very soon after death, the blood during life must have had a tendency towards decomposition. In due time it inva- riably occurs in the dead body, as a consequence of putrefaction; ammonia and other products being formed, which dissolve the haematin. This condition should be carefully studied, for the red colour dependant on it, (which is very frequently observed in the inner surface of the heart and larger arteries, and likewise occurs in the bronchi and other parts,) is very often mistaken in dissection for the red- ness of inflammation. This redness is for the most part less intense than that from hyperaemia or extravasated blood, and is more uniformly distributed, more subdued, and rather of a purple than a blood-red colour. The microscope will always settle the point; it will show that the capillaries in the affected part are not gorged with blood as in hyperaemia, and that there are no masses of blood-corpuscles as in extravasation. The latter are altogether absent, and, under the microscope, the part appears of an, uniformly red colour, but pale in proportion to the magnifying power. * See the description of fig. 10 in pi. ix,. I 100 PATHOLOGICAL EPIGENESES. CHAPTER IV. PATHOLOGICAL EPIGENESES,* In the primary formation of the body, and subsequently in its nutrition, new formations (elementary particles and tissues) arise, interpolated as it were between those already existing. A somewhat similar process is of frequent occurrence in pathological formations ; indeed, so frequent are these morbid epigeneses, that the greater number of the changes which pathological anatomy can demonstrate after death may be arranged under this head. At the same time, they are so various, and the relations of their formation, develop- ment, and termination in individual cases so different, (two or more epigeneses being frequently associated and combined,) that a satis- factory description of these conditions, including a clear arrangement and separation of the individual elementary phenomena is a task of the greatest difficulty. In order not to lose ourselves in the details connected with this extensive department of our science, and at the same time to acquire a clear view of these various relations, we shall attempt to work out, as far as possible, the general laws followed by pathological forma- tions in their development. These laws are very closely allied with those which direct the development and formation of tissues in the normal state; indeed, in many cases, no definite line can be drawn between normal and abnormal formations. It cannot be expected in pathological anatomy that the ultimate causes of all morbid changes in the organism should be noticed, any more than that all the symptoms should be described; which generally accompany those changes. On the other hand, it is a most important point to dis- Neubildungen, literally,, new formations. PATHOLOGICAL EPIGENESES, 101 tinguish, as far as our opportunity for observation will allow Us, the-origin, development and gradual formation of these changes; further, we should investigate the general laws of their formation and development as far as this can be done by cautious conclusions from undoubted observations, and we should compare these laws with those which apply to the normal development of the whole organism, and of its individual parts. Pathological epigeneses naturally divide themselves into two groups,. the organized and the unorganized. The distinction between these groups is a double one. 1. There is a morphologic difference.—Organized bodies exhibit the same perfect form and internal organization throughout as in their separate parts, and as soon as they become parts of the organism. Unorganized bodies are devoid of organization, the highest and most perfect form they can assume being that of a crystal. 2. There is a genetic difference.—Unorganized formations are al- ways produced in accordance with the laws of pure chemistry, while organized formations follow the developmental laws of organic life. If even in perfectly normal formations, the difficulty in defining the limit between vital organization and mere chemistry is consider- able, in pathological formations it is much increased, for each may be combined with, and indeed; merge into the other, so that in indi- vidual cases, it is not always easy to determine to which group a formation belongs. This does not, however, hinder us from regard- ing the two groups as representing opposite types. In their chemical compositions there are no essential differences, except that the orga- nized formations consist, for the most part, of the substances known in chemistry as compound radicals; while the unorganized consist in part of inorganic matters, although compound radicals frequently also enter into their composition, and hence the terms organic and organized are not altogether synonymous in relation to morbid for- mations. Like every thing else in nature, pathological growths require a material for their formation—a matter from which they may be pro- duced. To this which may be either fluid or solid, and may vary extremely in its chemical composition, we apply the general terms plasma, or formative matter. It is a necessary character of this plasma to be amorphous; it must neither be crystalline, nor have a definite organic form. An^ 9* 102 PATHOLOGICAL EPIGENESES. already formed structure can only assume that function by throwing off* its shape and becoming again structureless. A plasma may act as formative material either for organized or unorganized products, or for both at the same time. The plasma for unorganized formations, which is usually an aqueous solution, from which deposits are produced or crystals formed in accordance with chemical laws, we shall name a mother-liquid; the matter giving rise to organized formations which are ehiefTy produced by the formation of cells, we shall term a cytoblasiem,a* or, for brevity a blastema ; and lastly a plasma, from which organized and unor- ganized products are developed, will be designated as a mixed plasma. The manner in which pathological formations are produced from a mother-liquid is essentially different from that in which they are produced from a cytoblastema. The former being the most simple will be first considered. , Almost any fluid in the body may act as a mother-liquid for pa- thological formations, if a portion of the dissolved unorganized or organized matters assumes an insoluble condition and separates as a precipitate. The conditions under which this phenomenon en- sues are very numerous ; but, as far as yet known, are influenced simply by chemical laws. A deposition frequently occurs from too concentrated a condition of the mother-liquid; substances thus assuming a solid form, from, the absence of a sufficient quantity of water to retain them in solution. Such a concentration may occur when a thin fluid, almost saturated with substances difficult of solution, is placed in contact with an animal membrane, on the other side of which is a fluid deficient in water ; under these cir- cumstances, it follows from the laws of endosmosis that the original fluid will lose a portion of its water: or when a fluid parts with water by evaporation from a free surface, as for instance in the nasal cavities. There is also another very obvious cause for the production of deposits, depending on the circumstance of the sol- vent power of acids and alkalies. For instance, human urine in the normal state is acid. The free acid is here the condition by which the earthy phosphates are retained in solution. If for any Fromxt/Toc, a cell; and /Sp^o-th/m*, growth. PATHOLOGICAL EPIGENESES. 103 ■reason the urine, either in the bladder or in the pelvis of the kidney, becomes alkaline (from the alkaline serum of the blood entering it, or from the decomposition of urea into carbonate of ammonia) the earthy phosphates can no longer be retained in solution, and be- come deposited in an insoluble state. Again, an excess of free acid in the urine decomposes the urates, and if the secretion is very deficient in water, the liberated uric acid which is not so solu- ble as its salts, no longer remains in a state of solution. Most of the fluids of the human body contain phosphate of magnesia—a salt of considerable solubility: on coming in contact with ammo- nia, a very insoluble compound—ammoniaco-magnesian phosphate —is at once produced ; hence, when the body undergoes putrefac- tion, and ammonia is set free, almost all the tissues are bestrewed with crsytals of this salt. It is true that the causes for the formation of unorganized depositions are not always so simple and clear as in the above cases, as will be seen on referring to the section on the concretions, where the matter is more fully discussed. It is suffi- cient in the present place to have shown that all the pathological depositions of whose .formation we have any clear idea, are formed in strict accordance with the laws of chemistry, in a manner that cztn frequently be imitated in the laboratory. These products may vary in form ; sometimes they occur in a very minute granular state, sometimes in indefinite crystalline masses, and sometimes in perfect crystals, which are usually so small that their form cannot be recognized by the unaided eye. These varieties depend, as in ordinary chemical processes, on the rapidity or slowness of the separation, and on the crystallizing or non-crystallizing tendency of the substances. In chemical composition they vary in accordance with the place of their formation, and the properties of the fluid which acted as the mother-liquid. There are two classes of. morbid products which we must distinguish from each other, namely, those which are formed in fluid secretions, possessing specific chemical con- stituents, and such as occur in the parenchyma of organs^ in the cellular tissue, &c. The latter closely resemble each other in chemical composition, from whatever part of the body they are obtained; they usually consist for the most part of earthy phos- phates and carbonates, (lime and magnesia,) and their ordinary mother-liquid is the exuded plasma of the blood, which may be 104 PATHOLOGICAL EPIGENESES. regarded in the light of a mixed plasma, that is, it usually gives origin to unorganized as well as to organized morbid products, so that the process is only in part influenced by the laws of chem- istry. A few of the depositions occurring in the parenchyma form an exception to this general law; for instance, gouty concretions, which consist of urate of soda. The depositions on the other hand, which are formed in the fluid secretions, have a varied chemical composition corresponding with differences in the mother- liquid from which they are produced. Earthy phosphates and carbonates occur also here, but many other matters may likewise be present, as for instance, the fatty acids, cholesterin, margarin, pile-pigment, uric and oxalic acids, uric oxide, cystin, &c. The production of the above morbid products is not always ac- complished by means of a finely granular or crystalline precipitate : as a general rule, each simple primary form yields compound secondary forms: the particles of the deposit adhere together by new depositions—by mucus or some other means of connexion— and form larger masses visible to, the naked eye, and either soft or firm, according to the nature of their constituents. These are named concretions, concrements, or calculi; they occur for the most part in the fluid secretions, in cavities Or canals, and may be either free or connected with the adjacent walls. Their form is usually irregular, being sometimes dependant on that of the cavity in which the concretion was produced, and sometimes on the simultaneous presence of several concretions'rubbing against and so flattening each other, and thus often producing a shape almost as regular as that of a perfect crystal. They are frequently composed of concentric layers' deposited round a nucleus. Their fracture is occasionally crystalline, as in many urinary calculi, and in gall-stones consisting of cholesterin, and it is but rarely that a defi- nite external form determines the corresponding internal appearance, which, however, appears to be the case in prostatic concretions. In' other cases these concretions instead^of being free are con- nected with the surrounding'tissues, often so intimately as not to admit of separation by mechanical means: this is especially the case with concretions in the cellular.tissue, and in the parenchyma of organs. Inserting themselves between organized parts, the his- tological elements are compressed to the utmost, and their physical properties as well as those of the whole organ are changed. Such PATHOLOGICAL EPIGENESES. 105 depositions are termed ossifications, although hardness is the only character they have in common with bone, and, histologically, they differ most obviously from recently formed osseous tissue. Occasionally such depositions surround organized parts, forming incrustations and filling up their cavities, so as to exhibit a very regular and, at first sight, extremely surprising form. Thus the epithelium cells occasionally present in the urine become incrusted by urinary sediments, and probably the regular spherical concretions of lime found in the choroid plexus are formed in a similar way by incrustation of the cells.* Intimate as the connexion between these depositions and organized forms sometinies appears to be, the adhesion is never chemical, but merely mechanical, and on remov- ing the unorganized structures, either mechanically or chemically, the organized parts stand forth in their original normal form. It is deserving of especial mention, that the production of many unorganized formations is dependant on the development of a new secreting organ, previously created by a morbid process. In illus- tration, we may mention the deposition of crystallized cholesterin in encysted tumours, especially in that form termed by Cruveilhier the laminated nacreous tumour, where the deposition is so abundant, that the whole contents form a connected and often tolerably firm crystalline mass. ON THE DEVELOPMENT OF ORGANIZED PATHOLOGICAL FORMATIONS. The development of organized morbid tissues is dependant on laws differing essentially from the chemical laws already considered. The difference is obvious, even in the formative material. It is not every mother-liquid that can act as a cytoblastema for organized products. The cytoblastema is usually fluid ; it may, however, be solid, but in this case it must of necessity be amorphous, that is, it must not exhibit either a definite organized appearance, or crys- tallization. The only solid cytoblastema which has yet been no- ticed in relation to morbid products is coagulated fibrin in its amor- phous condition and permeated with water, in the state, for instance, in which it occurs in inflammatory exudations. But even this blas- tema was originally fluid, and only assumed the solid form on the * Compare Henle's Allgem. Anatomie, p. 10. 106 PATHOLOGICAL EPIGENESES. coagulation of the fibrin. It is possible, although it has not yet been observed, that other protein-compounds—albumen, casein, or globulin—may act when coagulated as cytoblastemata. In the pro- duction of morbid formations from mother-liquids, the plasma seems never to occur in a solid state: if in the department of unorganized nature, as in chemistry or mineralogy, a crystalline formation can take place in a partially or entirely solid amorphous substance, as for instance, in iron, sugar, silica, &c, nothing similar has yet been observed in the human body. As fibrin in the coagulated form appears to be the principal agent in solid cytoblastemata, so dissolved fibrin seems of similar impor- tance in those that are fluid ; indeed, its presence seems to be a ne-- cessary condition for such formations as we are considering. This point is, however, so important that it ought to be accurately deter- mined. It is possible in many cases to isolate, and consequently, when they occur in sufficiently large quantity, to analyse the fluid cytoblastemata of morbid products, as in exudations into the serous cavities, or in the formation of vesicles beneath the epidermis, where they are composed of water, fluid albumen and fibrin, fat, extrac- tive matters, and different salts. That aqueous solutions of salts and extractive matters are of themselves insufficient to act as blas- temata for organized products is placed beyond all doubt; they can act the part of mother-liquids, they can, in many cases, even enter into different structures, (as for instance, salts of lime into the bones, and chloride of sodium, according to Lehmann,* into cartilaginous tissue,) but organized formations can only be produced in them when at fibrinous fluid is also present, as for instance, when exuda- tion occurs jn the cavities of the uropoietic system, or of the diges- tive canal. The same is the case with the fats ; certain kinds admit of crystalline formations, (as cholesterin in gall-stones,) and can also enter as constituents into organized formations, but can never of themselves alone, or in combination with salts and extractive mat- ters, act as cytoblastemata ; at least, up to the present time nothing of the sort has been observed. Hence there remain, as the actual and potential constituents of the blastema, only the protein-com- pounds ; although these are never found alone in the body, being always associated with the above named substances. Further, all * Physiologische Chemie, vol. i. p. 133. PATHOLOGICAL EPIGENESES. 107 these protein-compounds are not susceptible of development. Fluids which merely contain dissolved albumen and the above sub- stances never appear to act as cytoblastemata. In the common dropsical effusions, which are always rich in albumen, we never ob- serve any organized products, unless fibrin be also present: this is at least the result of my own observations, which have been very numerous, and I am not acquainted with a single exception to the law.* Moreover, fluids in which casein is the only protein-com- pound, cannot as far as observation has yet shown us, act as blaste- mata. In the milk for instance, as long as it contains merely casein, we never observe any pathological formations, for the granular bo- dies belong to the normal process of development of the milk ; as soon, however, as any fibrin is present, morbid products, such as pus-cor- puscles, may be formed in it. On the other hand, in all fluids which we regard as cytoblastemata for morbid products, fibrin has always been found : hence we must regard it as the necessary and apparently the most essential ingredient in the cytoblastema. This law respecting the necessity for the occurrence of fibrin in the cyto- blastemata of morbid products, which I have seen tq hold good in several hundred cases, without a single exception, is not'at all in ac- cordance with the course of normal development: thus the egg, the prototype of all formative fluids, contains no fibrin ; its place being apparently supplied by albumen.f In the nutrition of the perfect organism, the general nutrient fluid,—the modified blood- plasma permeating the walls of the vessels,—acts as the general cytoblastema for all new formations. Whether the fibrin is the only essential formative material in this fluid, or whether the albumen likewise takes part in development, is a question which cannot be answered with the Same degree of certainty as in the case of morbid products, since the normal fluid, of nutrition can never be obtained free from extraneous constituents in sufficient quantity to. be accu- rately analysed. If it appears certain that the protein-compounds are the only substances capable of development in the human body, the question—which of them * See the section on serous dropsy. + There may possibly be some connexion between this fact and the observation of Mulder, that the albumen of the egg contains one atom less of sulphur than the al- bumen of the blood, and that consequently in its ultimate composition it is identical with fibrin. 108 PATHOLOGICAL EPIGENESES. can act as a cytoblastema 1—does not admit of a positive answer, since we at present possess but a moderatejy accurate knowledge of a few of the numerous, modifications of this substance. This answer must, however, only be regarded as provisional, and will probably require con- siderable modification when we know more of the nature of theprotein- compounds. When we have once established the principle that the blastema for morbid products must always be amorphous, the old idea is ob- viously overturned, namely, that a normal tissue may be directly converted into a pathological formation. Direct evidences will be subseqently adduced, when treating of individual morbid products.* Having now considered the chemical composition of the cyto- blastemata of morbid products, another question presents itself— whence do they arise, and from what part of the body are they pro- duced? In the present condition of our physical knowledge, I be- lieve that no one will dispute with me, that without further preamble we may establish the principle as a general law, that the*cytoblaste- ma of every morbid product, as also of the tissues in healthy nu- trition, is obtained from the vessels, and that its source is always the blood, or in some few cases the chyle or lymph. In normal nutri- tion the proposition cannot be determined by direct observation ; but the grounds on which the probability is founded, are so sound, as to prevent the possibility of denial, for all the nutriment which in the latter instance the formative material conveys to all parts of the body, passes at length-into the blood ; on the other hand, parts to which the supply of blood is checked or diminished are not at all, or only imperfectly nourished. • In pathological epigeneses, it may often be directly observed that in consequence of inflammation, the plasma exudes through the vessels and forms the cytoblastema; and in cases in which we observe no morbid secretion, it is more than probable that the ordinary nutrient fluid escapes through the vessels without inflammatory action, and thus forms a blastema for morbid products. Information on the processes by which this increased separation of plas- ma from the vessels is effected, has been already afforded in the section on * As examples of the amorphous solid cytoblastema, we may refer to pi. i. fig. 14, and pi. n. figs. 2 and 4, with the accompanying explanations. As a good illus- tration of the fluid cytoblastema, we may refer to the fluid of fibrinous dropsy. PATHOLOGICAL EPIGENESES. 109 fibrinous dropsy. I shall advert to the subject more fully in treating of inflammation. Organized morbid epigeneses are therefore produced in a blas- tema separated from the blood, and at the expense of the fibrin con- tained in it. Before we consider the processes which take place in development, we will take a glance at the question,—=:on what is the development of the cytoblastema dependant ? A purely che- mical precipitation like those by which unorganized forms are pro- duced, cannot in this case be regarded as sufficient, for while che- mistry serves to point out the chemical differences between these formations, we still cannot perceive how the various forms of the fibres and cells can proceed from it. By assuming a vital power, and referring all phenomena to it, we do not gain a single step ; since while we substitute these, as the foundation of all phenomena, we are even confessing that the latter is dependant on the entity of the organism, and is inexplicable to us: an insight into the primary causes of all formations is, however, the point that most concerns us at present. In order to obtain a starting point, let us proceecj from hypothe- ses. There are two different causes which may be supposed to effect the transition of the blastema in development; firstly, the cause may be grounded on the nature of the cytoblastema, and the formation may be developed with the same necessity, which, under favourable conditions, compels the separation of certain crystals from their mother-liquid : or secondly, the transition in the development may be dependant on external conditions, independent of the cyto- blastema, as for instance, on the influence of the surrounding parts *of the body, &c. In order to ascertain which of these two hypo- theses is deserving of preference, it is requisite that every one should have perfectly clear and distinct ideas on the following points. We must distinguish between the capacity of the cytoblastema in the progress of development (potentia,) and the actual transition (actus.) That the capacity for development essentially pertains to the cyto* blastema, no one will deny. If it depended merely on external in- fluences, then would any [substance placed in similar relations under*- o-o the same process of development—an assumption entirely at va- riance with experience. In this respect the cytoblastema of a mor- bid product resembles an egg or a seed ; it differs, however, in the circumstance of its actual development (the transition of the poten- 10 110 PATHOLOGICAL EPIGNESES. tia into the actus) being much more dependant in external condi- tions. Its development is not merely dependant on the same gene- ral conditions as those of the egg, which is developed out of its mother's body, (namely on the presence of warmth, moisture, and oxygen;) in the majority of cases, it is likewise requisite that it should be connected with the body of a living individual: a blas- tema for morbid products, can, as a rule, only be developed when it is in connexion with, and reacting on a vital part of the living body. After death no cytoblastema is developed in the body: moreover, in parts of the living organism, in which vitality has been destroyed by gangrene, there can be no further development. Of course this is not the case with rndependant organisms. Fungi and infusoria may be formed in the dead body. Moreover the coagulation of fibrinous fluids after death does not fall under this head, for the coagula- tion of fibrin is a process unconnected with development. We can at any rate include here the fibrinous flakes* (Fasersloffschollen,) described by H. Nasse, although I could not convince myself of their existence after a series of observations conducted with the greatest care. On the other hand there appear to be isolated exceptions to the above rule, and cases apparently occur in which we must assume that pathological elements, especially p'us-corpUscIes, can be produced without the,contact of organ- ized tissues, indeed, even externally to the body. Thus Helbertf has re- cently observed, that the fluid of a blister, produced by cantharides, which on its discharge contained no corpuscular particles, after standing five or six hours in a glass contained granular cells (imperfect pus-corpus- cles,) and he has even followed their progressive formation under the mi- croscope. (Figs. 1, 5, 6, and 7 of the plate attached to his Dissertation.) I shall again refer,to this subject in speaking of the formation of pus, when I shall give some other examples of independent cell-formations un- connected with organized parts. The development of a cytoblastema with- out either the influence of surrounding organized parts, or a previously exciting germ is, however, rare, and appears to be limited to very simple formations, such as pus-corpuscles. Moreover, the greatest caution is ne- cessary in carrying on such observations as those of Helbert. In the mi- croscopic examination of a fluid containing a few scattered particles in suspension, it frequently happens that those particles escape detection, till the fluid has stood for some time, and they have gravitated to the bottom * Mullet's Archiv. 1841. p. 437. t De Exanthematibus arte factis fragmenta, Gottingse, 1844, p. 16. PATHOLOGICAL EPIGENESES. Ill of the vessel. In such cases the observer might be readily deceived, and led to believe that these bodies were actually produced in the fluid in the vessel. If after the above observations it hardly can be doubted that the capacity for development is inherent in the cytoblastema, and that the actual development is modified by external influences ; the im- portant question still remains—what share the cytoblastema has in the development^ and what share is due to external influences ? Taking a general view of the question, we find considerable diffe- rences on this point. In the formation of the animal organism from the egg, the share of the cytoblastema is very predominating ; there is contained within it not merely the Capacity, but likewise the whole quality of the future formation : in fact, the whole of the fu- ture organism is included in the egg : external circumstances can hin- der, but cannot essentially change it. When speaking of the theory of malformations, we shall consider this subject more closely. In the nutrition of the perfect organism, the case is different; we here observe the various tissues of the different organs evolVed from the blood, or rather from the general nutritive fluid,—as cellular tissue, bone, muscle, and nerves. The element of this difference cannot therefore lie in the blastema; it must rather be sought in the ready-formed parts of the body, which influence the blastema to the development of parts similar to-themselves. We must accordingly conclude that the formative capacity, which being equally diffused through the egg is impressed on the whole blastema, now acts at special points, and on those individual tissues which have the capa- bility of exciting a development in a suitable blastema, leading to the formation of analogous compounds within its sphere of action, that is, in its immediate neighbourhood. This is a formative act similar to that by which an entire organism enables a cytoblastema to develop an individual similar to itself. The nature of the blas- tema is not, however, to be regarded as a matter of indifference in this process; it can generally only be traced in the development, when it possesses a definite chemical composition, and on this, as well as on the chemical changes which the blastema undergoes in its development, the chemical part of nutrition is dependant. Let us now apply this to morbid products. Numerous cases present themselves in which the epigenesis takes place in a manner 112 PATHOLOGICAL EPIGENESES. perfectly analogous to that which occurs in healthy nutrition. Thus, in the process of regeneration and in hypertrophy, where the in- fluence of the cytoblastema on the nature of the development is at its minimum, the development itself appears to be entirely depen- dant on the normal histological elements between which the blastema is effused. Thus, in regeneration and hypertrophy, the blastema between areolar tissue, becomes areolar tissue ; in the vi- cinity of bone, it becomes cartilage and bone; between muscular fibres, it is converted into similar tissue ; at the extremities of divided nervous fibrils, it forms nervous substance, &c. The circumstance that these and no other structures are formed, cannot in these instances be dependant on the blastema, which as far as chemical analysis goes seem to be the same; and it is entirely the influence of the surrounding parts that modifies the character of the development. Here then, if we may be allowed the expression, we are entering the department of solid pathology. But it may be further asked: it being granted that in the above cases, the nature of the development is essentially dependant on parts of the body already formed, what is the case with those patho- logical epigeneses in which the resulting morbid product is perfectly different from the surrounding parts, as in scirrhus, encephaloid, tubercle or pus ? Is not the abnormal character! of the product de- pendant on a: peculiar pre-existing blastema, so that there is always one kind of blastema for scirrhus, another for encephaloid, and so on ? "We are yet hardly in a condition to answer this question satis- factorily. It is quite possible that the elements of the peculiar structures of scirrhus and encephaloid may be traced to the blastema from which they spring, and that in accordance with the views of the humoral pathologists, the pseudo-plasma may be dependant on an abnormal chemical composition of the blood. Another explana- tion may be attempted which equally elucidates the appearance of these peculiar morbid products, namely, that the peculiarity of the epigenesis is not dependant on any property of the blastema, but on changes in the properties of the tissues influencing the blastema; and thus the explanation of these phenomena is again transferred from the department of humoral to that of solid pathology, or, since in many cases these changes are dependant on a change in the nervous influence, to that of nervous pathology. It is, however, in PATHOLOGICAL EPIGENESES. 113 the highest degree probable, that in the majority of cases neither the one nor the other of these views alone is strictly correct, that for the most part changes in the cytoblastema and changes in the physio- logical properties of the tissues are conjointly at work in producing an abnormal epigenesis. These brief observations on a much-disputed question must for the present suffice. The only possible method of thoroughly testing the subject is by an examination of individual pathological- epi- geneses. The nature of the, development of pathological epigeneses is; dependant on : 1. The cytoblastema, the quantity, quality, and mode of its pro- duction. The more rapidly and abundantly it is secreted, and in proportion a.s the chemical composition (which, however, is certain- ly hot accurately known) differs from the normal blood-plasma, so does the influence of the surrounding histological elements decrease^ and the formation proportionally deviate from the normal type. Thus small quantities of exudation become easily organized, and simple hypertrophy usually consists in small exudations repeatedly occurring after long intervals (weeks or months.) We can draw no very definite limit between this process and that of healthy nutrition. Abundant and rapidly formed exudations are rarely organized, usually proceeding to suppuration. Exudations undergoing incipient putrefaction—as, for instance, ichor—do not become organized ; and where the composition of the blood, (and consequently the ex- udation proceeding from it,) differs considerably from the normal type—as is probably the case in typhus and scrophulosis—either ho organization follows or else it occurs very imperfectly, as we shall: presently see when speaking of typhous matter, scrophulous depo- sitions, and similar products. 2. The nature of the development is influenced by the histological elements of the part in which the epigenesis occurs. If the influ- ence of these parts predominates, the newly formed material resem- bles the pre-existing normal tissue, and thus in morbid hypertrophy,, in regeneration of lost parts, &c, the. process is just the same as in, ordinary nutrition.* This important law which plays a very active * This law is clearly laid down by Meckel; he observes that morbid epigenesea resemble the adjacont normal structures. Path. Anat. vol. u. Part n. p. 213. 10* 114 PATHOLOGICAL EPIGENESES. part in pathological epigenesis, I will for brevity term " the law of analogous formation." The law of analogous formation, is, however, essentially modified by the nature and vital properties of the parts in question: a. The more complex in structure the tissue is in which the epi- genesis occurs, so much the less does it resemble the normal ele- ments. Areolar tissue, osseous tissue and simple (non-striated) muscular fibre are easily reproduced, nerves not so readily and more slowly, whilst complex organs, such as the tissue of the lungs, brain, &c, are either not reproduced at alitor only very imperfectly. The extent of this law varies considerably in different organisms; while in men and the higher animals, the regenerative power is very limited, or, if I may use the expression, the power of producing histological elements from the cytoblastema is at its minimum, in the lower animals where whole organs can be reproduced, this power is much more energetic. b. In proportion as the physiological properties of the parent-tissue deviate from the normal type, so much the more heterogeneous will be the epigenesis. Thus in gangrenous parts the exudation admits of no normal development; and the same is the case in parts in which the nerves have been divided. In structures which have been changed by chronic inflammation, or of which the physiological properties of the elementary parts differ for any reason from the normal type, pathological epigeneses , are produced distinct from those that occur in healthy parts. _ The cytoblastema on the one hand, and the pre-existing tissues on the other, are each factors influencing the formation of organized morbid products, and it is on their different properties that these epigeneses are dependant both for their mode of formation, and for their general characters. Having dismissed these questions, let us now advert to the pro- cesses that take place in these morbid developments. Schwann in confirmation of his cellular theory,* has made the remark, that he * Mikrosk. Untersuch. ilber die Ueberelnstimmung in der Structur der Thiere und Pflanzen, 1839. CELLULAR FORMATION. 115 has observed its application to a large number of morbid products. Since that date numerous observations have been published which support this view. Schwann's theory of cellular formation has, during the last few years, been attacked from many quarters, or at least adopted with modifications, as by Arnold, Henle, and Vogt,* while Reichertf has stood forth as its advocate. According to Schwann, development is always dependant on a formation of cells in an amorphous cytoblastema, and the formation proceeds in this manner. In the first place, one or more minute granules (nucleoli) appear, around which the cytoblast (nucleus) is formed, and this again becomes surrounded with a membrane (the cell-wall) which at first closely envelopes it, but subsequently in the course of its growth, becomes separated from the nucleus, thus leaving a cavity between it and the cell-wall. This is termed the cavity of the cell, and is filled with a substance differing essentially in character both from the nucleus and the cell-wall. In the cell thus produced, the nucleus is not in the central point, but is situated eccentrically at a point on the inner surface of the cell-wall. It is from these cells alone, by a,process of further development, that all organized pro- ducts arise. That this mode of development from cells occurs in pathological epigeneses may be readily shown in numerous cases. This process can be most obviously traced in the formation of pus-corpuscles, when they are produced from a fluid blastema on a free surface, or in a cavity connected with the exterior of. the body. In such a case, we first observe numerous isolated granules,! which become surrounded by a very delicate transparent cell-membrane,§ which subsequently forms so thick and opaque a wall, that the nucleus can no longer be seen through it;|| on the addition of acetic acid, which dissolves the cell-wall, or at any rate renders it transparent, the nuclei again become visible.U If it is impossible to trace the whole course of development in one and the same cell, we can yet make out the successive changes of the whole mass of cells with sufficient * Unters, fiber die Entwicklungsgeschichte der Geburtshelferkrote, 1842, p. 117, &c. t Muller's Archiv. 1842. Jahresbericht uber die Fortschr. der mikrosk. Ana- tomie. t Plate in. fig. 6, a, b. § Plate in. fig. 11, a. || Plate hi. fig. 6, a, a. * Plate m. fig. 9, b. 116 PATHOLOGICAL EPIGENESES. certainty. These and similar observations, such as for instance may be made on the formation of epithelium, confirm the opinion that in all essential points Schwann's theory is applicable to morbid forma- tions; but that in individual cases, many facts may be observed which do not coincide with this theory, or at least render some mo- dification imperative. With,respect to the early relations of the nucleus and the nucleolus, I cannot convince myself of the existence of the nucleolus prior to the nucleus, or at least that the nucleolus is, as it were, the means of forming the nucleus in the same way as the nucleus forms the cell. In some cases this may happen, but certainly not in all. I must agree with Henle in opposition to Reichert, in believing that Schwann's cellular theory represents only one of the various forms of development, of which the type in different eases may present very numerous differences. The nuclei of morbid formations present great differences both in form and size; they are round or oval,* or occasionally elongated and pointed, as in the formation of areolar tissue, and simple mus- cular fibre.f Nucleoli are sometimes clearly visible, usually one or two in number, but occasionally three or four; sometimes, however, no trace of a nucleolus can be detected. In many cases the nucleus has a well-defined, regular outline; in others, this appearance is absent, and it then. occurs as an aggregation of minute, indefinite granules, or as a soft mass without any well-defined limit. In this point of view, morbid products of the same kind present great dif- ferences, as for instance, pus-corpuscles, in which the nucleus con- sists of an aggregation of minute granules, sometimes quite uncon- nected with each other, and sometimes united by a connecting medium presenting perfectly distinct chemical properties, so that in this case great differences occur in the form of the whole nucleus, as well as in the mode of deposition and properties of the individual molecules. The size of the nucleus is always very minute, varying in diameter from the 600th to the 100th of a line, but seldom ex- ceeding the 200th: the only exception is in the case of elongated fusiform nuclei, which may exceed the 100th of a line. The nucleoli are, however, much smaller, their diameter seldom exceedinc the 1000th of a line. * See Plate i f Plate iv. fig. 4. CELLULAR FORMATION. 117 The chemical relations of the nucleus are very remarkable. It possesses the property of resisting the action of acetic acid, a reagent which attacks the solid cytoblastema in which the nucleus is situ- ated, as well as the cell-wall surrounding it, rendering the latter pale and sometimes causing its total disappearance. Hence acetic acid affords the means of rendering the nucleus visible when it is hidden by the cytoblastema or the cell-wall. In pus-corpuscles, where the relations of the nucleus are very peculiar, the addition of acetic acid usually causes it to break up into minute granules. By the prolonged action of a solution of borax, caustic ammonia, and more rapidly by caustic potash, we find that - the nucleus and the cell-wall disappear simultaneously, being dissolved by these re- agents. After this solution is effected, there usually remain minute granules apparently composed of fat, for on extraction with ether, previously to applying the alkalies, they did not appear. These are regarded by Messerschmidt and Lehmann* as the nucleoli of the pus-corpuscles; but I do not believe that they stand in any special relation to the nucleus, since they do not occur in all nuclei, and may further occur free in a fluid containing cells. Relations of the cell-wall generally, and especially towards the nucleus.—Observations on the development of morbid products teach us that sometimes the facts are precisely in accordance with the general law laid down by Schwann, but that there are likewise exceptions to this rule. Undoubted cells are sometimes observed in pus corpuscles, and generally in encephaloid and scirrhus. The form and magnitude of these cells are extremely variable; they are usually round or oval,f sometimes elongated and fusiform,J and occasionally quite irregular. § It is, however, only rarely that we can distinguish in them a decided membranous cell-wall, and a cavity distinct from it;|| the cell most commonly appears as an homogenous mass (with the exception of the nucleus) so that we can distinguish in it the substance of the nucleus and the substance of the cell, but no cavity. Even in pus-corpuscles the sharp external * Messerschmidt de pure et sanie, Lipsiro, 1842, p. 11. Lehmann u. Messerschmidt ilber Eiter und Geschwilre. Archiv. v. Roser und Wunderlich, vo' i. t Plate i. figs. 1—6, and 13. X Plate i. fig. 12. § Plate i. %. 11. || Plate i. fig. 2. 118 PATHOLOGICAL EPIGENESES. outline is sometimes absent, so that -here we have no definite and limited deposition around the nucleus. This opinion, first suggested by microscopic observation, is confirmed by the laws of endosmosis. For while on the addition of water to pus-corpuscles with an un- doubted cell-wall, the membrane constituting the wall becomes first dilated, and then bursts and liberates the nucleus, pus-corpuscles without a decided cell-wall merely become swollen, without rup- turing themselves. ' Hence, in addition to the kind of cellular for- mation described by Schwann, according to which the cell consists of a constricted membrane surrounding a nucleus, we must assume a second kind, in which a somewhat indefinite precipitation occurs around the nucleus. Moreover, the relation of the cell-wall to the nucleus in morbid products differs in many points from Schwann's theory. A species of cellular formation occurs in which there are no pre-existing nuclei; thus pus-corpuscles without nuclei are often observed ; they are usually of an irregular form, and after the application -of acetic acid leaye only a few (fatty) granules, and sometimes not even these.* These non-nucleated pus-corpuscles are always formed in large quantity in unhealthy suppuration, and apparenlly not singly amongst normal corpuscles ; hence, in these cases the whole pro- cess of development appears from some general cause to undergo an essential modification. Under this form of non-nucleated cel- lular formation, we must include the fibrinous flakes (Faserstqff- schollen) described by H. Nasse,f if their general occurrence be confirmed. I have never yet succeeded in detecting them, al- though I have repeatedly sought for them both in blood and in exudations, and other observers have been equally unsuccessful. J. Meyer| explains them as being merely epithelium rubbed from the walls of the vessels. The non-nucleated corpuscles, some- what resembling fibrinous flakes, which occur in encysted tumours, and in pus from glandular organs,§ I certainly regard as epithe- lium. Hence the absence of the nucleus may be easily referred to resorption, as certainly the older cells of the epidermis are non- nucleated. Colloid of the thymus presents another non-nucleated * Plate hi. fig. 7. t Muller's Archiv. 1841, p. 437. X Froriep's N. Notizen, 1843, No. 560. § Plate i. fig. 3, pi. in. fig. 9, c. d. CELLULAR FORMATION. 119 structure, which externally appears as if it were cellular. If we agree with Nasse in regarding these formations as not composed of cells, but constructed according to distinct laws, nothing is gained by such a supposition. The cellular theory, if a general law of development is to be founded on it, must take cognizance of all these phenomena, and must endeavour to explain them in accordance with its own doctrines. Sometimes the absence of the nucleus in a cell is only apparent, being concealed by the cell- wall, and coming in view after the addition of acetic acid : in other cases the nucleus is formed and becomes resorbed, as takes place with the cells of epidermis and various epithelia. Besides the cases in which cells are devoid of any nucleus, there are others to be considered, in which a cell contains more than a single nucleus. This phenomenon admits of a double explana- tion ; firstly, the composite nucleus might be first produced, and a simple cell formed around it; or secondly, another cytoblast may form within a cell containing a single nucleus. In fact, both these modes of formation actually occur. It has been al- ready stated that the nucleus of pus-corpuscles is not simple, but consists of several (2—4) portions. We frequently observe that these composite nuclei are present before the cell is formed. Sometimes I have seen, in a pus-corpuscle, several such nuclei consisting of minute nucleoli; once I noticed as many as four, so that the whole of the pus-corpuscle was filled with granular mat- ter, the individual portions of which were riot clearly defined. The second mode of formation, that namely in which the nuclei are formed subsequently to tfie production of the cell, is of ordi- nary occurrence in vegetable cells and in cartilage. Here the newly formed cytoblasts act as central points for a new forma- tion of cells, and then there arise cells within cells—parent cells and their offspring. Moreover, this process may be observed in morbid products, as in encephaloid, where we often find cells with many nuclei, and parent-cells with their offspring.* It has been already mentioned that Schwann's opinion, that every cell possesses a decided cell-wall between which and the nucleus there is a cell-cavity filled with a matter differing from the cell-wall, is incorrect. Numerous cases, however, occur in which * Plate i. figs. 6 and- 7. 120 PATHOLOGICAL EPIGENESES. these points strictly accord with the laws of the cellular theory. A decided wall with a double contour, sometimes occurs in can- cer-cells.* In all probability the cell-wall invariably consists of a protein- compound, and it is chemically distinguished from the nucleus by being rendered transparent by acetic acid, and frequently after prolonged action being altogether dissolved. A similar reaction occurs on the addition of solutions of borax, caustic ammonia, and (more powerfully) of caustic potash. Recent cells have usually a homogenous cell-wall, which subsequently becomes opaque, and, covered with a granular matter, usually insoluble in acetic acid and in alkalies, but soluble in ether, and therefore probably of a fatty nature. The contents of the cell, when they are distinct from the cell-wall, are usually fluid. They cannot be detected by the eye, and their presence can, therefore, only be inferred by the circumstance that the cell collapses when bursting under the compresser, and that its fluid contents escape. They form a tolerably concentrated solution of-matter soluble in water, as their relation in respect to endosmosis testifies, for on placing such cells in pure water, they swell till they burst, since their contents by endosmosis absorb water; in concen- trated saline solutions, on the other hand, they shrivel, since they lose water by exosmosis. Sometimes the cells contain fluid fat in the form of drops, which may be distinguished under the micro- scope from the surrounding fluid by their different refracting power, f The solid contents of cells are usually granular," and the granules are most commonly devoid of colour ;| but sometimes they are black, brown, or orange. The chemical properties of these con- tents are various; sometimes the granules consist of fat, and are then soluble in ether; sometimes of calcareous salts, in which case they dissolve in acids. As examples of eells with coloured con- tents, we may mention those containing black pigment,§ and yellow bile-pigment. || Moreover, crystalline deposits sometimes occur within cells, crystalline groups of margarin being occasionally no- ticed in fat-cells.H It is not always easy to distinguish whether * Plate i. fig. 2 ; pi. vm. fig. 9. t Plate i. fig. 9. t Plate i. fig. 2 ; pi. m. fig. 12 and 13* § Plate i. fig. 10. II Plate i fig. 8. f Plate x. fig. 3. CELLULAR FORMATION. 121 granular matter is actually within the cell, or only deposited on its walls. According to the theory of Schwann, who ascribes the formation of all structure to cells, the process of development is not completed by the above mentioned formation ; the cells undergo further changes, and do not follow the type in accordance with which they were first formed, but differ very considerably in different structures. These changes may be divided into two groups depending on the proper- ties of the product developed from the cells. It is the very same distinction as we meet with in the consideration of the elementary parts of the normal organism. In the first group we include those organs which, in their highest stage of development, retain their cel- lular formation, as for instance all epithelia, the blood-corpuscles, and the cellular constituents of the liver, kidney, and other glands. In the second group we include those parts in which the original cells undergo further modifications which destroy their cellular type. This is likewise the case with morbid products, and it may happen that either: firstly the organized product is completed by the forma- tion of cells ; or secondly, the cells altogether Jose their characters as cells, and become changed into different tissues, with whose formation and perfection the process of development is concluded, and its object thoroughly attained. Let us now proceed to consider these possible relations somewhat more closely. 1. The morbid development may remain as a cellular formation, and the original cells having attained tlieir highest degree of deve- lopment, may undergo no further metamorphosis into other tissues. In the morbid products belonging to this class there are yet fur- ther differences to be noticed, namely, a. whether the cellular for- mation is persistent, and in its perfect form constitutes a fixed con- stituent of the organism ; or, b. whether the cells are transitory, breaking up and being rejected or resorbed without being of any service to the organism, or contributing any permanent constituent to it. This distinction has reference not so much to the individual cells as to the tissues formed from them : moreover, in the persistent cellular formations the individual cells become gradually broken up in the process of metamor- phosis, but new individuals are developed with the same relations, so that the integrity of the tissue is maintained inviolate, while in the second division 11 122 PATHOLOGICAL EPIGENESES. the whole structure breaks up simultaneously with the destruction or re- moval of the individual cells. a. PERSISTENT CELLS. The chief parts of the human body which in their perfect condi- tion are composed of cells, either directly connected with one another, or united by a very minute quantity of intercellular sub- stance, are the epidermis, the epithelia of mucous and serous mem- branes and of vessels, the internal cellular investment of ducts in glandular Organs, and fatty tissue. Moreover, the cartilages (with the exception of fibrous cartilage) belong in some measure to this class, if we, regard their structureless intercellular substance. When by a morbid process, any of the above-mentioned struc- tures are produced anew, the process of epigenesis is exactly the same as that of the original formation in embryo; it follows that the cells formed from the cytoblastema gradually assume the form and properties which pertain to the normal cells of the newly formed tissue. Hence the whole change undergone by the original celjs consists in this, that they gradually become similar to the cells of the normal tissue which they are to repair. The changes thus oc- curring in the primary cells may in special cases be very different; they may become flattened and increase in breadth, as in pavement epithelium, or they may increase in length, and assume a conical form, as in cylindrical epithelium. This mode of formation of the persistent cells can be most readily ob- served in the restoration of destroyed epithelium, as after burns or blisters. We shall notice especial instances when speaking of the epigenesis of epi- dermis and epithelia. b. TRANSITORY CELLS. While the above-mentioned persistent cellular formations exist in the normal body and are subservient to organic life, and to certain de- finite objects—as protection from without, secretion or absorption—so also in morbid processes, we very frequently meet with a species of cellular formation, in which secondary cells which have proceeded from primary cells discharge no functions connected with the vital process. These do not remain connected with each other, but sepa- rate, and are either discharged as foreign matter from the organism, CELLULAR FORMATION. 123 or when this does not or cannot happen, being capable of no fur- ther development, gradually break up, until they are at last reduced to a nearly structureless, finely granular mass, which (like any other mass incapable of acting as a cytoblastema) gradually separates, as far as is possible, from the fluids of the body, and at last for the most part or entirely disappears. A large number of morbid products fall under this head ; for instance pus and what are termed malignant epigeneses, such as tubercle, ence- phaloid, and scirrhus, whose descriptions are subsequently given. 2. The cells may be converted into other forms.—Instead of being converted into secondary persistent cells or being altogether de- stroyed, the original cells may be converted into other structures, which in their perfect state have entirely lost the original cellular form. The processes by which this takes place are very different, depending on the properties of the tissue to be constructed from the cells ; they admit, however, of division into two fundamental types. a. Several cells may be fused together by the uniting of their walls. Thus according to Schwann are formed blood-Vessels, nerves and muscular fibre. b. The cells may become divided, each individual cell separating into different parts. This is observed in the development of cel- lular tissue. We shall enter with more minuteness into the genesis of these structures, when treating of the morbid formations occurring in the individual tissues. The above scheme enables us to take an easy review of the dif- ferent organized morbid formations, and further, as will be presently shown, it has its practical uses. It is founded on Schwann's theory of development. It pre-supposes that all organized forms are com- posed of primary cells,—a supposition which in relation to normal development has been opposed on many sides, and in relation to morbid products cannot be very strictly carried out. In our obser- vations on morbid cells, we have shown that their development does not in every point coincide with Schwann's theory ; there are numerous exceptions in the transitory formations, namely, in the tissues which in their perfect condition do not retain the cellular form. In these cases we frequently cannot detect any cellular for- mation throughout the whole process of development, or at most a 124 PATHOLOGICAL EPIGENESES. mere analogy—a faint tendency to the formation of cells, but no such actual production. This occurs in scrophulous and typhus ex- udations, and in a great part of the cases of tubercle. Here we first have an amorphous or finely granular exudation (blastema) forming a tenacious and tolerably firm mass, which by degrees breaks up into a more or less fluid magma, exhibiting under the microscope indefinite granular molecules of various forms and sizes, sometimes resembling cytoblasts and cells, but never indicating a decided cel- lular formation. Further, they are produced in many fluid cytoblastemata, partly together with regular cytoblasts and cells, and partly as isolated formations, minute indefinite granules (elementary or molecular granules) which sometimes appear to form constituent elements of future cells, but as frequently to remain for a long time unchanged, and finally without undergoing any further metamorphosis to disap- pear or be discharged. They are not invariably, (indeed not even for the most part,) fat-vesicles with a definite wall, as Henle* sup- poses, but solid granules which apparently consist sometimes of fat, and sometimes of the salts of lime, or of a modified protein-com- pound. These elementary granules are frequently arranged in some- what regular groups, clinging together and forming by their union large granular bodies (aggregate corpuscles) which sometimes so closely resemble cells that scarcely any difference can be observed. Indeed', it appears that such groups of molecular granules may even be invested with an actual cell-wall, and thus form true cells. In all these cases of morbid epigenesis, we find no decided cel- lular formation, such as should occur according to Schwann's theory; on the contrary, these cases approximate towards the mode of for- mation of unorganized depositions, (forming a sort of transition be- tween them and organized morbid epigeneses. The above mentioned elementary granules are of very frequent occur- rence, and we shall often have occasion to revert to them. They occur as very minute granules of an indefinite rounded form, and vary from the 800th of a line to a size too small to admit of measuring. Differing as we have shown in their chemical characters, they behave differently to- wards reagents. Those of most common occurrence seem to consist of * Allgemeine Anatomie, p. 163. CELLULAR FORMATION. 125 coagulated protein-compounds and resist the action of most reagents. Neither acetic nor nitric acid, nor yet caustic ammonia or potash, nor ether cause them to disappear. Those consisting of fat dissolve in ether with the aid of heat. Those finally which consist of calcareous salts (phosphate and carbonate of lime) disappear on the addition of nitric acid, in the latter instance with the development of air-bubbles. There can be no doubt that these elementary granules are always deposited in a fluid condition, and subsequently assume the granular form either by coagu- lation or chemical precipitation. In those completely organized morbid products which in their per- fect condition, no longer retain the cellular form, it is only rarely that any decided cellular formation can be detected during the pe- riod of development, as according to Schwann's theory must always be the case. Thus in the development of areolar tissue, and of fibrous tissue, we certainly sometimes find Cells which are prolonged into fibrils, but more frequently we meet with mere cytoblasts with- out decided cells (with a wall, cavity and contents,) and the blaste- ma appears to be converted directly into fibrils; indeed, sometimes we observe the formation of fibrils without even the pre-existence of a decided cytoblast. This and many similar observations which we shall notice when speaking of the different tissues confirm the opinion that Schwann's theory requires considerable modifications before it can be applied to morbid tissues, and further that all per- fectly formed tissues do not originally possess a decided cellular formation ; this Cellular structure in some cases existing only, for a short time, as during the formation of the cytoblast, and in other cases not at all. As, however, our knowledge respecting the de- velopment of the different morbid formations is still very deficient,, we must rest satisfied with the above statement, and refer individual observations to the departments under which they naturally fall. The processes we have hitherto considered have reference princi- pally to the morphology of development. It has been already stated that with this morphological change there is also a chemical change in the cytoblastema. We have seen that as in the cellular forma- tion of the blastema there are chemical differences, so the nucleus differs in its chemieal reactions from the surrounding cell-wall. This chemical change is still more important, when perfectly organ- ized forms, as areolar tissue, muscular fibre or nervous matter have- been produced from the original blastema, since all these siuV 11* 126 PATHOLOGICAL EPIGENESES. stances, as a general rule, differ considerably in their chemical com- position from their cytoblastema. Thus, for instance, from coagu- lated fibrin there may be formed areolar tissue consisting of gela- tigenous tissue, or cartilage which on boiling yields chondrin, or os- seous tissue which in addition to gelatin contains a large amount of calcareous salts. - We are. far from being in a position to lay down general chemical laws regulating these formations. We can cer- tainly compare the chemical formula for the cytoblastema with that for the product formed from it, and calculate, how many atoms of oxygen, carbon, hydrogen, or nitrogen must be deducted or added, in order to convert the one into the other, but such a proceeding is in most cases a mere sporting with formulas, which in some instances may give probable results, but here, when we are attempting to form general laws, is altogether out of place. I, therefore, reserve the consideration of this subject till the tissues individually are con- sidered. We have already stated sufficient to show the undeniable importance of Schwann's cellular theory in contributing to our knowledge of the de- velopment of morbid epigeneses. This theory gives us the key to the understanding of a large number of processes, by enabling us to take a general view of them. But in its original form it is not sufficient to ex- plain all the phenomena which occur in the development of morbid pro- ducts. Since, as has been already sjiown, it is impossible to include all the phenomena relating to morphological relations in our general laws, it is naturally far more difficult to indicate ihe general causes of develop- ment, or, in other words, to give a general theory of the development of organized epigeneses. This is the more difficult since the chemical bearings of the subject, which require as much attention as the mor- phological, have hitherto been much neglected; and for that reason I shall not attempt to establish any such theory. SPECIAL RELATIONS OF ORGANIZED PATHOLOGICAL EPIGENESES. The final results of the development of the pathological epigeneses already described are in special cases very different. Some of the products are of a fluid nature—emulsions, which like the blood, contain organized solid parts suspended in a liquid ; others are solid. The latter are tissues which are in all respects identical with those of the normal body, as areolar tissue, epithelia, vessels, car- tilage, bone, &c.; or on the Other hand, they may be of a peculiar REPARATION—CICATRICES—TUMOURS. 127 nature to which there is nothing analogous in the normal body, as for instance, tubercle, encephaloid, scirrhus, &c. In many cases the newly formed tissue is homogeneous.; in others, on the contrary, it is composed of very different elements. In another point of view, the newly formed tissue is either per- sistent, or in other words, forms a permanent part of the body, and is there nourished like any other'portion of the system : or else it is transitory, and after a time softens, breaks up, and is removed. This is the leading difference between non-malignant and malig- nant epigeneses. Further, morbid epigeneses may be classified: 1. Into such as form a reparation of a lost part (regeneration.) These regenerated parts are either : A. Perfectly formed, the newly constructed part being similar to that which was lost, both in its morphological, chemical, and func- tional characters (true reparation.) This true regeneration always follows the law of analogous formation, and in the human body is confined to simple tissues ; in the lower animals it exists on a much more extensive scale. b. Or they are imperfectly formed (cicatrices.) Cicatrices are sometimes transitory, existing only so long as the morbid product is continuing to be developed. When it is completed, the new tissue is perfectly similar to the old, and the cicatrix disappears. In other cases the cicatrix is persistent. The new parts then remain undeveloped and half-amorphous, or they are composed of elements of lower physiological importance, as of areolar tissue, while the complicated elements of the lost part, as it normally existed, (nerves, muscular fibres, glands, &c.) either do not occur at all, or at any rate much more sparingly than before ; hence the new part can only imperfectly fulfil the functions of its predecessor. 2. Into tissues whose elements are not reparative, but directly increase the bulk of previously normal organs. Hypertrophies— tumours. These may be distinguished by observing that in cases of hyper- trophy, the newly formed parts are continuous with those pre- viously existing, and cannot be anatomically distinguished from them. Hypertrophy may thus, in the same way as regeneration and on the same grounds, be divided into the true and perfect, or the false and imperfect. 128 PATHOLOGICAL EPIGENESES. In tumours (in a restricted sense) the newly formed parts are not as it were, fused into the older, as in hypertrophy, but are more or less separate and independent. This is, however, a mere artificial distinction between hypertrophy and tumour. All these distinctions are, however, of little service; we shall consequently leave them, and seek to resolve the individual epi- geneses into their elementary phenomena. A classification of the different pathological epigeneses is very difficult in consequence of the various relations in which they stand to each other, and of their frequent transitions from one form into another. In accord- ance with the point of view from which we establish our observation will either the one or the other mode of arrangement be preferred. The surest basement for pathological anatomy is a sound acquaintance with histology, and impressed with that feeling, I intend, in the following pages, to resolve the different morbid formations as completely as pos- sible into their elementary parts, to consider these first in relation to themselves alone, and then as occurring united in large masses (tumours) and thus from that which is simple, to proceed to that which is com- pound. The connexion between the different pathological epigeneses and the relations in which they stand to each other will be afterwards considered. pus. 129 CHAPTER V. SPECIAL RELATIONS OF PATHOLOGIGAL EPIGENESES. PUS.* The term pus, in the sense in which it is commonly used, con- veys with it no very definite idea. We apply it to almost every creamy, white or yellow fluid, occurring in almost any part of the body, the only necessary assumption being that its formation is de- pendant on a mqrbid process. On more closely examining this class of fluids, we find that they often present very considerable dif- ferences, partly as regards their mode of formation, and partly as regards their microscopical and chemical relations. Thus diffluent encephaloid and tubercle are frequently regarded as pus, indeed, even normal structures, such as epithelium cells which have been rubbed off and formed a sort of emulsion with a fluid, have often from their purulent appearance and from the omission of accurate observation been mistaken for pus. Hence the necessity for divi- ding fluids which appear purulent into true genuine pus, and into spurious or false pus. * The literature of pus is very abundant. The following are the most important recent works and memoirs on the subject: Th. Gluge, Observationes nonnullse microsc, fila. (quae primitiva dicunt in inflammat. spect. Berol. 1835 ; Gueterbock, de Pure et Granulatione, Berolini, 1837; Wood, de Puris Natura atque Formatione, Berolini, ] 837 ; J. Vogel, tiber, Eiter, Eiterung und die damit verwandten Vorgange, Erlangen, 1838 ; Henle, iiber Schleim- und Eiterbildung. Hufeland Journ. f. d. pract. Heilk. vol. lxxxvi. p. 5 ; Gluge, anatpm.-mikrosk. Unterschungen. Minden, 1838, p. 15. &c.; L. Mandl, Anatomic microsc. Livr. 2. Pus et Mucus, Paris, 1839 ; Gruby, Observa- tiones microscop. Vindob. 1840. F. E. Braun, der Eiter, &c, Kitzingen, 1841; Messerschmidt, de Pure et Sanie, Lipsiae, 1842; E. v. Bibra, Chemische Untersuchun- gen verschiedener Eiterarten, Berlin, 1842. Lehmann und Messerschmidt, tiber Eiter und Geschwiire; Archiv. f. physiol, Heilk. v. B. Roser u. C. A. Wunderlich, vol. i. p> 220, &c.; F. Biihlmann, Beitr. zur Kenntniss der kranken Schleimhaut der Respi- rationsorgane, Bern. 1843 ; Henle, Zeitschrift fur rationelle Medicin von Henle u. Pfeuffer, vol. n. p. 177, &c. 130 PATHOLOGICAL EPIGENESES. But even true pus presents many differences in the form and pro- perties of its Corpuscles, in the proportions of the corpuscles to the fluid portion, &c. Hence genuine pus must be divided into many varieties, which it is necessary that we should know and be able to distinguish, if we hope to have a clear understanding of the varia- tions presented by the process of suppuration in different cases. 1. TRUE GENUINE PUS. Normal pus (pus bonum et laudabile) is that which is yielded by healthy-looking wounds healing by suppuration, and by mature abscesses. This is the best adapted for showing the properties of perfectly formed pus as well as the mode in which it is pro- duced. Normal pus forms a creamy, thick, opaque and homogeneous fluid, containing no flocculent matter, depositing on standing no caseous, grumous precipitate, and communicating a soft and fatty feeling when rubbed between the fingers. It has a faint yellow, and some- times a white or faintly green, tint, and develops, as long as it re- mains warm, a peculiar, mawkish animal odour, which it loses on cooling. It is somewhat sweet, and insipid, and has a specific gravity of 1030—1033. Normal pus consists essentially of two distinct parts, of very mi- nute organized particles—the pus-corpuscles, and of a colourless aqueous fluid—the serum or liquor puris in which the pus-corpuscles are suspended as in an emulsion. The pus-corpuscles are quite invisible to the naked eye, and we can only begin to distinguish them by a magnifying linear power, of 50—100; but in order to study with accuracy their properties and structure, they should be magnified 200—400 diameters. Their form is in generaj spherical,* and is regular in proportion as the pus assumes a normal character. Sometimes they are irregular- ly rounded, elongated, oval, or rugged ; and generally speaking, they are irregular in proportion as the pus deviates from the normal type. Their diameter varies from the 200th to the 300th of a line ; it seldom exceeds the 150th or falls below the 400th. These fluc- tuations in size are" apparently dependant on the individual from * Plate in. fig. 1 and 2. PUS. 131 whom the pus is obtained, or on the nature of the disease ; some- times we find that all, or the greater number of pus-corpuscles from an abscess or wound are small; in other cases that they are all large. In some cases the pus-corpuscles are very delicate, pale and transparent, and their surface smooth and even ;* but more com- monly they are opaque, tough, uneven and granulated, that is to say, studded with very minute particles from the 1000th to the 1500th of a line in diameter.f When observed separately, they appear colourless ; in heaps, they exhibit a yellow tint. They are only slightly elastic, but very soft, and under the compressor are reduced to an amorphous magma. They are specifically denser than the serum, and gradually fall to the bottom. Many deviations of the corpuscles from the normal form will be de- scribed in our observations on abnormal pus. The corpuscles of genuine pus are organized forms, for the most part of a cellular nature, with a nucleus, cell-wall, and contents. The cellular structure with a decided nucleus, appears only in un- changed pus-corpuscles, when the cell-wall is very thin and transpa- rent.! In the majority of cases, the nucleus is covered by the gra- nulated opaque cell-wall,§ and does not become visible till the latter is dissolved or rendered transparent by acetic acid.|| In other cases, in which the development of the pus-corpuscle is imperfect, we see only the nucleus and no cell-wall.If The nucleus does not lie in the centre of the pus-corpuscle, but as is the case with all cellsj is situated eccentrically, and is usually attached to the inner surface of the cell-wall. We may convince ourselves of this by allowing pus-corpuscles to float and rotate in the field of the microscope.** It is only the larger nuclei that form an exception to this rule, for they are sometimes so large as to oc- cupy the whole space of the pus-cell. The nucleus of the pus-cor- puscle presents many peculiarities, and is so different from other nuclei as to require a somewhat careful consideration. * Plate in. fig. 11, a. t Plate hi. fig. 1. X Plate m. fig. 2, b, and fig. 11, a. § Plate in. fig. 1. || Plate in. fig. 3. T Plate in. fig. 7,a, b. »* Plate m. fig. 11, a. 132 PATHOLOGICAL EPIGENESES. In other cells the nucleus is a simple body, but in the pus-cor- puscle this is not always, or indeed generally the case ; it is usually composed of several (2—5) minute granules forming a composite multiple nucleus. Sometimes on treating fresh pus-corpuscles with acetic acid, or a solution of salt, a single nucleus becomes^apparent, indented like a trefoil leaf, or cloven into 2—4 smaller nuclei.* But it is not every nucleus that undergoes this change; in some cases it appears to resist the action of these reagents. The single large pus-corpuscles with a diameter of the 100th to the 80th of a line, exhibit several (two, three or four) such nuclei, each of which is composed of smaller bodies insoluble in acetic acid. The corpuscles which form the nucleus, when, by the addition of acetic acid, they are clearly brought before us, present various forms; sometimes (generally in good pus) they are elliptic, and pre- sent an excavated cup-like form, resembling fresh blood-corpus- cles ;f sometimes, however, they present a spherical or oval appear- ance.J In some cases they are distinct from each other, even lying in different parts of the cell-cavity ; but they are more frequently in apposition, and joined together, so as to present the figure of a tre- foil leaf, or some other form. This composite character of the nucleus in the majority of the corpuscles, as revealed by the action of acetic acid, is very charac- teristic of normal pus. The only other instances in which this oc- curs are in young gland-cells, and in the most recent layers of pave- ment epithelium, but.in these cases they are never so general as in pus. Hence it follows that the size of the nucleus is liable to great deviations ; from being entirely absent it may occupy the whole cell. Its usual limits are the 800th to the 400th of a line. Nucleoli are rarely found in the nuclei of pus-corpuscles. I shall show further on, that the granules which remain after treating pus-corpuscles with alkalies or borax, and which Messerschmidt^ consi- ders as nucleoli, cannot be regarded in that light, since they occur as much out of the nucleus as within it. If some writers altogether deny tie exist- ence of nuclei, or have seen them otherwise than as we have described, it must arise from imperfect observations, or from the circumstance that * H«nle, fig. 8—12. t Plate m. fig. 3 ; fig. 9, b. t Plate in. fig. 6, a. § Op. cit. p. 8—10. pus. 133 normal pus was not examined. The above differences in the nuclei are connected with their chemical composition, and with differences in the mode of formation of the pus-corpuscles. I shall again return to this sub- ject and attempt to elucidate it. The cell-wall of the pus-corpuscle varies in thickness, and sur- rounds the nucleus more or less closely. In delicate and young pus-corpuscles, it is very thin, smooth, membranous and transpa- rent ; in older and many peculiar sorts of pus, it is thick, tough, opaque, and studded with minute granules. In many cases, pus- corpuscles have no definite or distinct cell-wall, consisting merely of a nucleus, and an irregular deposition around it, without any clearly- definite outline, as may be shown not merely from microscopic in- vestigation, but by their relation towards endosmosis. This is espe- cially the case with young imperfectly formed pus-corpuscles. Moreover, there are many differences in the contents of the cell occurring between the cell-wall and the nucleus. In pus-corpus- cles with a single nucleus, a well-marked membranous cell-wall, and consequently a cavity between them,* we often find no solid body in the cell-cavity, excepting the nucleus. The contents must therefore be fluid, and doubtless identical with the serum of the pus, containing dissolved albumen ; for the corpuscles are rendered turbid and opaque by reagents which coagulate that substance. In other cases, in addition to the nucleus, granular contents are seen, with independent chemical reactions. Sometimes the contents seem as it were so thoroughly fused into the cell-wall, that the two form only a single substance, a solid but soft mass in which the nu- cleus is imbedded. Endosmotic and chemical relations of the pus-corpuscles. When either solid or fluid substances are allowed to react on pus-corpus- cles, numerous changes, dependant on two different causes, are ob- served to take place. One of these causes is the endosmotic acti- vity of the pus-corpuscle itself; the other is the chemical action of the reagents on the various materials entering into the composition of the pus-corpuscle. Generally speaking, both forces are simultane- ously in action; we shall, however, consider them separately, in order to determine with greater accuracy the effect of each individual reagent. * Plate in. fig. 11 a. 12 134 PATHOLOGICAL EPIGENESES. When pus-corpuscles are submitted to the action of fluids, very deficient in solid constituents, they imbibe water by endosmosis, and become tumid. Conversely very concentrated saline solutions, or dried hygroseopic substances, such as chloride of sodium, sugar, or chloride of calcium, have just the opposite effect; they with- draw water from the pus-corpuscles, and cause them to contract. The former of these processes being termed endosmosis ; the latter, which only differs in the opposite direction of the current, is for the sake of distinction named exosmosis. The changes produced in the pus-corpuscles by endosmosis are most obvious when they are placed in contact with distilled water : they then swell, become larger, and assume a spherical shape ; in most cases the distended cell-wall becomes more transparent, and the nucleus more obvious, the nuclei retaining for some time their cupped appearance. By prolonged action, those cells with a perfect wall increase until they ultimately burst, on which the regular form of the external contour disappears, and the corpuscles assume an irregular ragged appearance. By further prolonged action the nucleus imbibes moisture, and its individual portions lose their cupped form, and become spherical. Some corpuscles present ex- ceptions to the reaction ; they swell to a less degree, and the capsule is not distended to actual bursting. This is the case with those that possess no regular cell-wall, but consist merely of an irregular, badly defined precipitate around the nucleus. In this case, however, the nucleus becomes changed. To observe the phenomena of exosmosis, the pus-corpuscles must be placed in a concentrated solution of common salt, or else dried salt must be added to the pus: the corpuscles then assume a contracted appearance, and present a plicated and clear outline. Generally they become considerably smaller; pus-corpuscles whose diameter was the 200th of a line, afterwards do not measure more than from the 300th to the 400th of the same measure. Others are not so much affected, especially those which possess no regular cell; the addition of water, the pus-corpuseles reassume their original form and character. Many chemical reagents produce a modifying effect on pus-cor- puscles ; but when they are applied in a very dilute or very concen- trated state, they combine the action of endosmosis or exosmosis with their own peculiar chemical reactions. We shall here give PATHOLOGICAL EPIGENESES. 135 merely the most important reactions, those namely which elucidate the chemical composition of the pus-corpuscles.* Dilqte acids render the substance of the capsule transparent, and burst it by endosmosis, but do not even by prolonged action alto- gether dissolve it. They cause the nucleus to stand clearly out, and for that purpose, dilute acetic acid is the best reagent. Moderately dilute solutions of most of the neutral salts, as of hy- drochlorate of ammonia, chloride of sodium, or nitrate of potash gra- dually dissolve the substance of the capsule and the greater part of the contents, with the exception of the nucleus, and even this they render tumid, so that it loses its shape and outline, and forms an in- definite mass. Solutions of the alkaline carbonates and borax, convert the pus- corpuscles into a viscid mass, and the same effect is more rapidly induced by the caustic alkalies. Both capsules and nuclei dis- appear and there remain only very minute, dark molecules with a diameter less than the 1000th of a line. Lehmann and Messer- schmidt regard these molecules as nucleoli; I cannot, however, accept this opinion unconditionally, since they are scattered among the half- dissolved pus-corpuscles without any definite order ; and further, since they are sometimes absent in pus-corpuscles with undoubted nuclei, and are present in other abnormal pus-corpuscles in which no nuclei are apparent; and lastly, since they are found in the serum) altogether independent of the pus-corpuscles. Substances which coagulate fluid albumen, such as metallic salts, tincture of iodine, alcohol, &c, render the pus-corpuscles opaque, a sign that they are infiltrated with an albuminous fluid. Saliva, mucus, urine, blood, and other animal fluids, do not as a general rule produce any very essential change in the pus-cor- puscles ; bile, however, seems to break them up, possibly in con- sequence of its containing soda. Boiled with concentrated hydrochloric acid, pus-corpuscles react in the same manner as the protein-compounds, forming a violet coloured fluid. From these reactions we may conclude that pus-corpuscles con- sist of several substances differing in their chemical characters, and we can distinguish : * A full and very accurate account of these reactions is given by Lehmann and Messerschmidt. Op. cit. p. 22G. 136 PATHOLOGICAL EPIGENESES. 1. The substance of the capsule, which is soluble in solutions of the caustic alkalies and their carbonates, of borax, and for the greater part, in saline solutions, as those of hydrochlorate of am- monia, nitrate of potash, &c, and in part soluble in dilute acids, as acetic acid. It forms the wall and a portion of the contents of the cell, and is doubtless a portein-compound, very similar to, and probably identical with that modification of albumen which is pre- cipitable by water, and is again dissolved on the addition of neutral salts or acetic acid.* 2. The substance of the nucleus, insoluble in acetic acid, swel- ling in saline solutions, and dissolving in solutions of borax, the caustic alkalies and their carbonates. This likewise is a protein- compound, and is probably identical with the modified form of coagulated fibrin which swells in a saline solution.f 3. The substance of which the minute molecules consist, which remain undissolved on treating pus-corpuscles with solutions of the caustic alkalies and borax. They are regarded by Lehmann and Messerschmidt as nucleoli, and in some cases probably this may be the true explanation, but they certainly also occur within the cell, but at the same time externally to the nucleus. Lehmann and Messerschmidt regard this substance as a protein- compound analogous to keratin, and in many cases this is doubt- less true. Sometimes, however, these molecules consist of fat; they are then soluble in ether, and if the pus-corpuscles are boiled in that menstruum, before the addition of the alkali, they do not make their appearance. Many kinds of "pusbonum" contain nothing corpuscular besides pus-corpuscles; others, on the contrary, contain minute rounded molecules,^ often in very considerable quantity. They are always very minute, for the most part less than the 1000th of a line in diameter, and swim either alone or in heaps in the serum and be- tween the pus-corpuscles which are frequently studded with them- These molecules present great differences in their signification and chemical constitutions ; sometimes they are protein-compounds ana- logous to the substance of the capsule, of the nucleus, or of the *' Lehman and MessciSchmidt's a filirin. t Lehman and Messerschmidt's b fibrin. X Plate in. fi;r. 1, b. pus. 137 molecules insoluble in alkalies—elementary granules and partially- developed or abortive pus-corpuscles. In other cases they consist of fat. Finally, there are sometimes infusoria present, minute monades and vibriones, especially in pus from foul ulcers. As long as the animalcules are alive, we then observe an active motion, and I have sometimes been enabled, by feeding them with carmine, to bring into view the minute spots representing their stomachs. Moreover, we sometimes find accidental admixtures in healthy pus, some of which may be easily distinguished by the microscope, as epithelial cells or fragments of epidermis, crystals of cholesterin or of ammoniaco-magnesian phosphate, and flocculi of amorphous or semi-organized fibrinous exudations. The liquor puris, or, serous fluid, in which the corpuscles swim, maybe separated by allowing thin pus to stand for some time in a high and narrow glass ; the pus-corpuscles then gradually sink to the bottom, while in the upper part of the glass there is pure serum. This fluid is identical both in its physical and chemical charac- ters with the serum of the blood : it is an aqueous solution of albu- men, extractive matters, various salts, and fat. The qualitative composition of this serum is tolerably constant, but the quantities of the different ingredients vary considerably, as we have already seen to be the case with the dropsical effusions. It is upon these slight differences in the chemical composition of the serum that the varying action of pus on vegetable colouring matters is dependant. If the alkaline carbonates (?) or basic phosphates predominate, the pus has an alkaline reaction, as is usually the case with fresh and good pus. Subsequently an acid (lactic ?) is developed in it, which first renders its reaction neutral and then acid. The serum of pus occasionally contains a viscid matter > which may be distinguished by its being precipitated by acetic acid and by alum. It was first described by Guterbock, under the termpyin, and regarded by him as characteristic of pus. This is not the case ; pyin rarely occurs in good, and more frequently in abnormal pus ; it likewise occurs in other morbid products, as for instance, in car- cinoma ; and even at the present time too little is known regarding its properties and chemical composition to allow of its being known by a definite name. J 12* 138 PATHOLOGICAL EPIGENESES. • Taking a comprehensive view of the quantitative analyses of pus, it appears in essential points to coincide with the plasma of the blood, or fluid of fibrinous dropsy. There is only this difference, that a portion of the protein-compounds which are dissolved in the latter, exist in pus in a coagulated state, forming the pus-cor- puscles. I give below a few analyses of pus, selected at random,* and by their side, for the purpose of comparison, I likewise place the composition of the plasma of the blood. 1000 parts contained : . B oo 77 5 80.4 60 63 9f 180 Extractive matter 3 20 29 19 Salts Fat 8 3 13 25 (6) - 9 (9) 12 (9) 24 1000 1000 999 994 992 1. Was taken from a small-pox pustule and analysed by Lassaigne. 2. Was taken from an abscess in the neck and.analysed by v. Bibra, op. cit. p. 41. 3. Was taken from an abscess beneath the breast and analysed, by v. Bibra, op. cit. p. 96. 4. Was taken from an abscess in the cheek, v. Bibra, op. cit. p. 27. Hence it is obvious that the analyses of the blood-plasma, and of pUs may present great variations without destroying the analogy which subsists between them. The conversion of the blood plasma into pus always occu- pies a certain time, during which it is exposed to all the modifying influ- ences of metamorphosis and endosmOsis, to which must be added that a considerable evaporation of fluid takes place from suppurating surfaces. Hence pus is usually more concentrated, and contains less water than the plasma from which it is formed. Formation of pus* The formation of pus is dependant on two very distinct circumstances. In the first place a fluid must be secreted or separated to act as a cytoblastema; and secondly, the pus-cor- puscles must be formed in and from this cytoblastema. The latter follows the general laws regulating organic development. * Numerous analyses of pus will be found in the woks quoted in the note in p. 129; especially in ihe Treatise of v. Bibra. PUS. 139 The cytoblastema of pus is always the fibrinous fluid which has already been described in our observations on fibrinous dropsy. Consequently the formation of pus must invariably be preceded by the exudation of a modified blood-plasma. The opinion that healthy pus can be produced from the tissues of the body by their decomposition or solution, is at the present day un- worthy of a serious refutation. That broken up fragments of tissue may be contained in abnormal pus will be presently shown. It ap- pears certain that pus cannot be formed from a merely serous fluid containing no fibrin, like that of serous dropsy. Moreover extrava- sated blood can only act as a cytoblastema for pus, in so far as it contains plasma.1 The formation of pus-corpuscles from the cytoblastema does not take place in a very uniform manner; it occurs in one way when the plasma remains fluid, in another when the fibrin coagulates pre- viously to the formation of pus. The process of the formation of pus from a fluid cytoblastema can be best observed in fresh wounds cleansed from blood. In examining the fluid secretion from a wound, we first observe minute granules, less than the 1000th of a line in diameter, which are chemically identical with the molecules insoluble in the alkalies and in borax. There then appear, partly around these molecules, and partly independent of them, somewhat larger corpuscles, solu- ble in the alkalies, but not in acetic acid, identical with the nuclei of the pus-corpuscles. These nuclei appear sometimes isolated, sometimes in groups of twos or threes,* thus forming composite nuclei ; around these the cell-wall is subsequently developed, first appearing as a pale transparent membrane,! and subsequently be- coming thickened and granular; and thus the pus-corpuscle is formed. The production of pus-corpuscles in this manner is tole- rably rapid; in the course of three or four hours after the first ap- pearance of the nuclei perfect corpuscles may frequently be seen ; in other cases the process is slower. If the above observations describe the general type of the forma- tion of pus in a fluid blastema, there are in special cases many ex- ceptions which show that nature does not always strictly adhere to » Plate in. fig. 6, a. b. t Plate m fig. 11, a. 140 PATHOLOGICAL EPIGENESES. the same models, but induced, as it were, by new requirements, permits of many exceptions. The nucleus of the pus-corpuscle sometimes contains a molecule, which must be regarded as a nucle- olus ; in other cases this is absent. The nucleoli do not here, at any rate, play the part which has been assigned to them; they appear to serve merely as the most favourable points for the for- mation of the nucleus, in the same manner as an urinary calculus, for instance, is formed by deposition around a nucleus : they are, however, not essential to the formation of the nucleus. Nuclei are in- variably formed in healthy pus: hence they may be regarded as essen- tial to perfect pus-corpuscles ; but they are sometimes single, some- times double, treble, or even quadruple, and their individual parts present almost innumerable differences in relation to size, form and arrangement. The differences are perhaps the most marked in the formation of the cell-wall and contents. Sometimes the formation proceeds in entire accordance with the scheme laid down by Schwann: we observe a simple and apparently vesicular nucleus placed eccentrically in a transparent, elastic, and round cell-wall: with a well-defined external contour. The nucleus, contents, and cell-wall are all destined to undergo, at a subsequent period, fur- ther simultaneous metamorphoses. In other cases, as we have already observed, there is only a nucleus, and an indefinite, granu- lar, amorphous precipitate around it, without a clear outer circum- ference, and, as its behaviour in relation to endosmosis shows, with- out a surrounding cell-wall. I have sometimes found in an isolated, very large pusrcorpuscle (one sixtieth to one eightieth of a line in diameter) three of four separate nuclei, each of which, on the addition of acetic acid, falls into two or three distinct portions. Around these several nuclei only a single cell-wall is formed. In pus-corpuscles the nucleus is, however, always formed previously to the cell-wall. We are not at present in a condition to state with certainty what are the causes leading to these differences in the formation of the pus-corpuscle. Let us now throw a glance on the chemical process occurring in suppuration. Lehmann and Messerschmidt* have made an attempt to explain it. In the first place molecular granules become sepa- * Op. cit. p. 247. PUS. 141 rated from the fluid plasma. These may consist of a peculiar pro- tein-compound, or of fat, are of no very great importance in the nor- mal formation of pus (since in healthy pus they frequently do not amount to one hundredth of the mass of the corpuscles) and very often are not converted into true pus-corpuscles. The nuclei are then formed, which doubtless consist of coagulated fibrin. Whether the capsules of the pus-corpuscles are likewise composed of coagulated fibrin, or whether as Lehmann and Messerschmidt assume, they are formed from the albumen of the plasma, is a point which I shall leave undecided. With our present deficient knowledge of the pro- tein-compounds we can merely offer conjectures. At all events the two following points may be regarded as established. Firstly, pus- corpuscles cannot be formed from albumen alone. Secondly, after the full development of the pus-corpuscles, the amount of fibrin in the plasma is exhausted, and the remaining serum of the pus re- sembles the serum of the blood, or the fluid of serous dropsy. The latter point was placed beyond all doubt by a case of empyema, which I observed three years ago at Munich. It is the case referred to in p. 55, and the composition of the fluid is given in analysis 3. The fluid discharged by the first two operations of paracentesis contained fibrin in solution, and in a short time coagulated. On the third occasion it no longer contained fibrin, but, on the other hand, pus-corpuscles. A few days after the last operation the patient died. On dissection it was found that the pleural cavity was completely invested with a thick pseudo- membrane, which was already half-organized, and must therefore at all events have existed several days previous to death. The pus could there- fore only be formed in the fluid; but since the fluid which was first dis- charged contained fibrin, it is clear that this constituent was not origi- nally absent, but was doubtless consumed in the formation of pus. Pus formed in this manner from a fluid cytoblastema is of frequent occurrence in the human body. We observe it in the suppuration consequent on wounds, on the external skin after burns or the ap- plication of blisters, in fibrinous dropsy into serous cavities, in pleuritis and peritonitis with exudation, and on mucous membranes, as in catarrhs, bronchitis, gonorrhoea, and many other analogous cases. This mode of formation is frequently combined with that which is now to be described, when the fibrin has in part coagulated previous to suppuration. Pus discharged externally usually exhibits 142 PATHOLOGICAL EPIGENESES. in these cases, perfect corpuscles; there are frequently, however, seen amongst them, imperfect ones of an earlier development, and indeed in some cases, when the pus has been rapidly discharged be- fore its corpuscles can be completely developed, it contains little more than nuclei without any external capsule.* The mode in which pus-corpuscles are formed from a solid cyto- blastema of coagulated fibrin is somewhat different from the above. In this case, changes take place in the plasma identical with those de- scribed in the section on fibrinous dropsy, which accompany the Coagulation of the dissolved, fibrin. In the coagulated fibrin, and from it alone are the pus-corpuscles formed. The process of develop- ment is here much more difficult to observe than in the fluid cytoblas- tema. We seldom perceive the corpuscles till they are altogether formed; they then appear enclosed in a stroma of amorphous or in- definitely fibrous fibrin.f By acetic acid the stroma becomes trans- parent and invisible ; the capsules of the pus-corpuscles likewise dis- appear, and their nuclei become apparent. The mode of formation is very probably the same as that already described. At first the pus-corpuscles are scantily dispersed over the stroma ; subsequently, however, they become more abundant, and ultimately occupy the whole stroma, being separated from each other by intervening se- rum ; finally the solid portions of fibrin disappear, and the whole of that constituent is converted into fluid pus. In this manner pus is formed in all abscesses in which the soften- ing is dependant on the coagulated fibrin changing into fluid pus: in this manner it is formed in solid exudations from the pleura or peritoneum, in gray hepatization of the lung, and in a hundred similar cases. It frequently happens that this mode of formation is combined with the preceding, so that some of the corpuscles are formed from the coagulated, others from the fluid portion of the fibrin. In this or some other way, pus may be formed from exuded blood, as the daily experience of surgeons teaches, and the experi- ments of Gendrin and others demonstrate. It does not always happen that pus produced in the latter manner is perfectly formed when discharged from abscesses, &c.; it fre- quently contains flocculi of coagulated fibrin, which indicate no change, or merely an incipient conversion into pus. These have Plate in. fig. 6, and its explanation. t Plite in. fig. 5. PUS. 143 been termed " ventriculi puris" {Eiterpfrbpfe).* We sometimes observe them forming a viscid mass (pyin?) in which are imbedded perfect and distinct pus-corpuscles. It is scarcely necessary to observe that most of the opinions that have been promulgated regarding the formation of pus are undeserving of a serious refutation; as, for instance, the view maintained by Gendrin that pus-corpusclfes are nothing more than modified blood-corpuscles. In fact they have required no refutation since the works of Wood, Giiterbock, myself, Henle, Valentin, Gluge, &c, have opened a new path in the theory of the formation of pus. During the last few years Gendrin's ideas on the subject have been revived by Braun, v. Bibra, and Barry, but unsupported on any new grounds. I consider it unnecessary to state, in this place, all the points which are adverse to this opinion, for one is sufficiently convincing: namely, that the above described mode of forma- tion of pus-corpuscles from a fluid cytoblastema has been directly ob- served, whilst on the other hand, no one has ever yet succeeded in fol- lowing under the microscope the conversion of blood-into pus-corpuscles. Other objections to this view may be found in the above-named works on pus, and in Henle.f Another opinion to which I have already al- luded, namely, that pus-corpuscles are modified epithelium cells, was pro- mulgated at a time when we had no knowledge of the general laws of cell-formations, and knew very little even of the epithelium. This view, like the opinion of Gerber and Valentin, that pus-corpuscles are formed by the higher development or retrograde formation of the so-termed exu- dation-corpuscles, rests more on the interpretation than on the morpholo- gical development of the structure. We shall have occasion to revert to the exudation-corpuscles at the end of our section on pus. Diagnosis of normal pus. The recognition of this morbid fluid is apparently so easy that any one after orice seeing it, and observing the above physical properties, would trust himself to distinguish whether or not a fluid was actually pus: and yet there are numer- ous sources of deception.. Fluids containing fragments of epithe- lium-cells in suspension may readily be mistaken for pus, and in examining the body after death, we sometimes believe that we have discovered suppuration, where in fact no morbid process had been going on. The examination of the fluid by the microscope is the * See Ascherson in Casper's Wochenschr. 1837. No. 46. t Henle und Pfeufer, Zeitschrift fiir rationelle Mcdizin, vol. n. p. 202- 144 PATHOLOGICAL EPIGENESES. best, and, indeed, the only certain means of guarding against such deceptions. If this instrument reveals the presence of normal pus- corpuscles, and on the addition of acetic acid, the characteristic nuclei appear,* then we may be sure that we have been examining pus, and normal pus. As I have repeatedly witnessed the above deceptions, I will by way of warning, mention two cases. A woman died from pleuritis, with con- siderable purulent exudation into the pleural cavity. On examination I likewise found in the pelvis of the kidney, and in the ureter on each side a whitish-yellow, thick, creamy fluid, which had all the physical cha- racters of pus, and was mistaken for that fluid by the physicians who were present. As during life there were no symptoms of disease of the kidneys, and as dissection did not reveal any mOrbid change in these or- gans, the case was regarded as a demonstration of the resorption of pus, and of its subsequent removal by the kidneys. I examined tthis assumed pus microscopically, and found in it no trace of pus-corpuscles, but merely broken cylindrical and pavement epitheliumt from the pelvis of the kid- ney and the ureter. In another case in which the patient died from peri- tonitis with exudation, the stomach and upper part of the intestinal canal were perfectly free from remnants of food and chyle, but contained a large quantity of a thick yellow fluid, which was mistaken for pus. In this case also the microscope shovved that the fluid contained no pus-cor- puscles, but merely the cylindrical epithelium of the intestinal canal. Formerly great importance was attached to the distinctions between pus and mucus, and numerous pus-tests were published, which at present possess merely an historical value. They were based for the most part on the chemical relations of the pus-corpuscles towards various reagents. In addition to many which were founded on no sure principle,]: we may mention the following. Grasmeyer§ treated diluted pus with carbonate of potash. The mixture became converted by prolonged stirring into a thick viscid gelatinous mass, capable of being drawn out in threads. Caustic ammonia acts in a similar manner (Donne's test.) Both alkalies cause the pus-corpuscles to swell and gradually to dissolve into a viscid mass. These pus-tests explain a peculiar change which pus sometimes undergoes in the body, especially when mixed with urine. When, in disease of the bladder, * Plate in. fig. 1—3. t Plate m. fig. 4. t Compare J. Vogel, Untersuch. uber Eiter, &c. p. 96, &c. § Abhdlg. v. Eiter u. d. Mitteln ihn von ahnlichen Feuchtigkeiten zu unterscheideir, 1790. PUS. 145 alkaline urine containing a large quantity of carbonate of ammonia is mixed with pus, the pus-corpuscles undergo the same change in the bladder from the alkaline reaction of the fluid contained in it as they do in the preceding pus-tests; they become converted into a viscid mass which physicians often mistake for mucus, thus altogether losing sight of its true signification. Gruithuisen's* pus-test was founded onfalse premises; he supposed that pus and mucus during decomposition contained different forms of infusoria. Moreover, Giiterbock'st test, based on the circum- stance that pus being fatty burned with a clearer flame than mucus, is of no. practical use. The microscope renders all these chemical pus-tests superfluous; it enables us not merely to distinguish pus from mucus, broken epithelium, blood, &c, but likewise to determine approximately the amount of these different substances, which chemical analysis has never succeeded in doing. It is only in a few cases that no certain conclusions can be deduced from microscopic examination. We sometimes find in normal mucus, that is to say, in the product of the secretion of healthy mucous membranes, isolated corpuscles, similar to those of pus; they are termed mucus-corpuscles and are probably epithelium-cells in a very early stage of development. When we find these corpuscles in the secretion of a mucous membrane, it is difficult to distinguish them from a small number of pus-corpuscles; but in all these doubtful cases a very accurate diagnosis is of no importance, for if amongst millions of epithelium-ceHs, we do find a few pus-corpuscles, so slight a process of suppuration is un- important to the physician. By the help of the microscope we cannot only distinguish pus from the normal fluids of the body, but also good pus from that which presents an unhealthy appearance, from ichor, or from the detritus of encephaloid or tubercular masses, as will subsequently be shown. ABNORMAL PUS. We have hitherto described pus in its ordinary normal characters. The deviations from this type, are, however, so numerous and dis- tinct, that a whole series of slight, hardly appreciable changes might be given, at one extreme scarcely differing from normal pus, at the other there being a fluid so different in its characters from pus, as no longer to deserve its name. These deviations are dependant on various causes. » Naturhist. Unters. liber den Untersch. zw. Eiter und Schleim. 1809* t Op. cit 13 146 PATHOLOGICAL EPIGENESES. A. On the admixture of foreign ingredients. Blood may be mixed with pus. On opening an abscess some blood often gets mixed with it, forming red streaks or flocculi in which undoubted blood-corpuscles can be recognized. Or if the pus is formed in consequence of a contusion, or of extravasation, the mixture of blood with it is much more intimate. Here the effused blood acts as the cytoblastema for the formation of pus-corpuscles, and the blood-corpuscles are more or less injured or dissolved ; in- deed, they often entirely disappear. In addition to the more or less perfect pus-corpuscles we observe an indeterminate, grumous, and often reddish-brown mass. This pus is impure. Mucus is often mixed with pus in suppuration of the mucous membranes : it then contains mucin which renders it tenacious and capable of being drawn out in threads, in addition to epithelium-cells, and other substances of accidental occurrence. On the addition of acetic acid the mucus coagulates, entangling the nuclei of the dis- solving pus-corpuscles.* Moreover, pus from abscesses without containing any of the secreted products of the mucous membranes, sometimes appears tenacious and stringy, its serum containing a viscid substance in solution, which is coagulable by acetic acid and alum (pyin ?). f Moreover, the cells of the epidermis or of glands, flocculi, and crystals of cholesterin or of ammoniaco-magnesian phosphate, are not unfrequently mixed with pus.| b. On changes in the structural portion of the pus itself, malfor- mations of the pus-corpuscles, fyc. The pus-corpuseles sometimes differ more or less from their normal type, losing their regular rounded form, and becoming angular or club-shaped.§ The nuclei also frequently appear changed. || Sometimes, on the addition of acetic acid, no nuclei make their appearance, (being apparently en- tirely absent,) and we observe only the minute molecules which are noticed after treating pus with alkalies or a solution of borax.II In many cases the quantity of the granular molecules, which consist either of modified protein-compounds or of fat, appears to be in- creased in the pus, and sometimes, from the simultaneous deficiency of pus-corpuscles, it would seem as if these granules had taken their * Pltae in. fig 6, b. t Plate in. fig. 11, and its explanation. t Plate hi. fig. 8 and 9. K Plate m. fig. 10, d. § Plate in. fig. 7 and 10. V Plate in fig. 7, b. pus. 147 place, being either broken up or abortive corpuscles. These mo- dified conditions of pus appear in numberless forms; they occur in unhealthy suppuration, in abscesses, in gouty and scrofulous persons, &c. c. On tlie diminution of the corpuscles in relation to the serum. Formation of ichor. Pure ichor contains no corpuscles, but is a fluid of a reddish or brown-red colour and a more or less sickly odour. It is the serum of the blood coloured by the pigment of the dissolved corpuscles, but frequently contains, mixed with it, the detritus of various textures. A perfect formation of ichor entirely prevents suppuration, being a consequence of the decomposition of the blood, and the death ofa portion of the body (gangrene.) Both processes, however, frequently occur together and their products become mixed. These modifications of true pus form an uninterrupted series, ulti- mately extending to morbid fluids hardly deserving the name of pus. Of these we shall now speak. I select the following, by way of illustration, out of the large number of instances of abnormal pus and ichor which I have had the opportunity of examining. They may perhaps serve to show the mode of examining and describing such cases. For other cases see the explanation of Plate in. The abdominal cavity ofa woman who died from peritonitis with exuda- tion, contained several pounds of a thin yellowish white fluid, in which were soft flocculi, varying from the size of a lentil to that of plum-stone. It had a faintly alkaline reaction, and after standing for some hours sepa- rated into a yellow sediment, and a supernatant colourless serum. The reactions of this serum were precisely those of the fluid of serous dropsy. The sediment contained minute granules, which in the irregularity of their form and size differed essentially from normal pus-corpuscles. They were ofa somewhat indefinite roundish form with rough angular points, and in size they varied from the 400th to the f 50th of a line. On treating them with acetic acid, there were no decided indications of nuclei: under the prolonged action of that reagent they almost totally disappeared, nothing being left but very minute dark granules, about the 1000th of a line in diameter. These molecules were very unequally distributed amongst the corpuscles, some containing none, others three or four. An aqueous solu- tion of borax, allowed to act for some time, produced no material change in the corpuscles. The larger flocculi were very soft, ofa yellowish white colour, and consisted of an aggregation of the same corpuscles, sometimes arranged in a definite manner, sometimes in an amorphous mass. 148 PATHOLOGICAL EPIGENESES. Pure ichor from a vesicle on the gangrenous arm of a typhus-patient, was a perfectly clear fluid of a reddish colour, and to the eye resembled light red wine. It had an alkaline reaction, and under the microscope, no solid bodies—neither blood nor pus-corpuscles—could be detected in it. It coagulated on the application of heat. In 1000 parts there were obtained by evaporation 60 of solid residue, consisting of albumen with some saline constituents. This fluid was therefore the serum of the blood coloured by dissolved haematin. A woman with ascites frequently underwent the operation of paracen- tesis ; and finally the canula was allowed to remain, in hopes of exciting adhesive inflammation. The fluid which then escaped was brownish-gray turbid ichor, of a cadaverous odour. Under the microscope, no pus-cor- puscles could be detected, but there was an indefinite granular matter similar to that which is thrown down on the addition of corrosive subli- mate or an acid to a fluid containing albumen in solution. This granular matter was insoluble in acetic acid, ammonia, and potash, and was not even rendered gelatinous by the alkalies. It appeared to be a protein- compound, since it dissolved in' boiling concentrated hydrochloric acid, forming a.violet coloured liquid. 2. SPURIOUS PUS. The abnormal sorts of pus which we have described form a gra- dual transition-series to other morbid fluids which have usually been included under the general name of pus, but aire formed in a per- fectly different manner, namely by the breaking up and liquefaction of distinct morbid products, such as tubercle, encephaloid, scirrhus, &.c These products will be described in a future page, and their distinctions from pus clearly indicated. In the present section we must describe certain granular forms, which are sometimes found in-true,pus between the corpuscles, and sometimes occur alone in serum, forming an apparently purulent fluid. In form they present many differences, and their.mode of production, and their signification is by no means invariable. They were first described by Gluge, who termed them compound inflamma- tory globules; to me, the term granular cells appears more appropriate, since their connexion with the" inflammatory process is not more in- timate than that of various other organized formations occurring in ex- uded fluids, and they are formed under conditions in which there is very little probability of their resulting from inflammation, as for in- stance, in cysts in the thyroid gland. SPURIOUS PUS. 149 When these granular cells occur in a perfect condition, they vary in diameter from the 200th to the 80th of a line ; some of them are perfectly round, others oblong, irregular and even angular. At first sight they appear as an agglomeration of minute granules, vary- ing in diameter from the 800th to the 1000th of a line. By refract- ed light they appear dark, of a brown or blackish colour ;* by re- flected light, white. These granular cells are not affected by water; if exposed to the prolonged action of acetic acid or ammonia, they separate into the individual granules of which they are composed. Caustic potash and ether sometimes, but not always, dissolve these granules. From my own ■ observations I should say that the formation of these granular cells is best observed in inflamed lungs, where it ap- pears to occur in the following manner. Cells with a nucleus and a nucleolus, differing from pus-corpuscles in their larger size (the 200th to the 100th of a line) and in having a single nucleus, are formed in the fluid or coagulated exudation (fibrinous dropsy.) These become gradually filled with minute granules, which at first, when only few in number, readily admit of the nucleus being seen ; subsequently, however, they conceal it, and the originally smooth cell-membrane becomes rugged, the granular cell appearing as a spherical agglomeration of granules. Subsequently the cell-wall appears to vanish, the enclosed granules to separate from one another and to fall into irregular heaps, and each individual granu- lar cell to undergo, in a minute scale, the very same process which a mass of coagulated fibrin undergoes in its conversion into pus- corpuscles. This view of the formation of granular cells is confirmed by Bennett.t According to Gluge,J they are formed by the adherence of the nuclei of dissolved blood-corpuscles: but the nucleus of the human blood-corpus- cle is itself of doubtful existence, and I have sometimes observed the de- velopment of these cells, as distinctly as, considering the difficulties of the case, could be expected, * Plate in. figs. 13, 14 and 15. t Pathological and Histological Researches on Inflammation of the Nervous Cen- tres, in the Edinburgh Medical and Surgical Journal. Oct. 1842, and April 1843. X Anat. Mikrosk. Unters. p. 12, et seq. 13* 150 PATHOLOGICAL EPIGENESES. Prom their chemical relations the granules appear to consist partly of fat, soluble in ether, partly of a modification of protein similar to the molecular granules of normal pus, insoluble in the alkalies and in borax, and partly of salts of lime (the carbonate and phosphate.) I am con- vinced that the true granular cells are formed from cells which as a gene- ral rule first appear pale in colour, containing a nucleus, and with fluid homogeneous contents, which subsequently become granular. It is true, that this process cannot be directly observed : I have, however, seen in very many cases where these granular cells were present, that when the development was not very far advanced, there were undoubted cells with- out any or with only a few granules ;* that when the development was somewhat further advanced, the cells appeared for the most part, or en- tirely filled with granules:! and finally, that when the development was perfect, they formed irregular granular neaps and scattered granules.^ The whole course of events in that form of pulmonary hepatization which does not proceed to suppuration, but disappears by resolution, confirms the above view. It is true that in this case, we have only the opportunity of instituting microscopic observations, when the patient is carried off by some other disease during the stage of resolution; I have, however, met with several such cases. Here we observe in the first place, that so long as the mass remains firm, there are only a few granules, but numerous undoubted cells; as development progresses, the cells diminish and the granules increase in, number, and finally, after perfect softening, there are fewer cells and fewer granular heaps ; the latter being broken up into se- parate granules. Some observers, especially Henle and Bruch,§ have declared themselves against my view regarding the mode of formation of granular •cells, but still I cannot help firmly maintaining the "correctness of the above description, at least with reference to some of the forms. Their reasons are for the most part theoretical, and founded merely on analogy, and may be refuted by a similar mode of argument. Theoreti- cally, it is not more improbable that granules should be formed from a fluid in the cavity of a cell, than that they should be formed from a fluid not enclosed within a cell. We observe, however, similar processes in most vegetable cells. Moreover, in encephaloid and scirrhus, cells at first perfectly homogeneous become afterwards filled with granules. Hence, to this mode of formation also, there is no lack of analogies. On the other hand I will not deny that occasionally the mode of formation may * Plate in. fig. 12. t Plate in. fig. 13. X Plate in. fig. 14. § Das. kornige Pigment der Wirbelthiere,, p. ] 8. SUPPURATION. 151 be reversed, namely, that isolated elementary granules may be first pro. duced, which subsequently collect into groups, and finally become invested with a cell-membrane. Indeed, I believe that I have sometimes observed this process, that I have seen the accumulated granules gradually invested with a membrane, and granular cells or very similar forms produced. This I have witnessed in expectoration. There is also a third case of frequent occurrence. There arise in the solid or fluid cytoblastema, elementary granules, which either remain sin- gle or accumulate into irregular heaps without any cellular formation. They entirely resemble the molecular granules which have been already noticed as frequent constituents of normal pus. Cases also frequently occur where exudations, without any trace of cellular formation, break up directly into these elementary granules. Practically, it is often hard to distinguish whether this process or the formation of granular cells has existed. The difficulty arises when there has been no opportunity of ob- serving the development in its earlier stages, but when the final results alone are subjected to microscopic examination; these final results being the same in both cases. Yet as a sufficient number of cases have been observed, wherein on the one hand there is'a mere distribution of the elementary granules without any trace of granular cells, and on the other, there are distinct granular cells without any isolated granules, we may consider ourselves well entitled to separate, theoretically, the two processes from each other. The diagnosis of granular cells is easy in those cases where "they are perfectly formed and occur in large quantities. The granular bodies of the colostrum* have a close resemblance to them. But the constituent molecules here are of unequal size, and the entire corpuscles less regular than the true granular cells. In examining the fluid from an inflamed breast, the two may be confounded together, as I myself on one occasion saw; With practice they will, however, be easily distinguished. Where imperfectly formed granular cells occur together with the elementary gra- nules previously described, the diagnosis of the individual corpuscles be- comes almost impossible. Having thus described the morphological and chemical constitu- tion of the different fluids embraced uuder the somewhat general name of pus, we may now take a general view of the formative » Plate hi. fig.16. 152 PATHOLOGICAL EPIGENESES. relations, and the pathological importance of these morbid pro- ducts. Pathological anatomy has, in this respect, a much more difficult office than pathology, for the latter is able to follow the entire series of processes from their first appearance in the vascular system to the perfect formation of these products, and to consider them in their mutual relations; whilst' the former is often confined to the observation of results, which must be retraced with many interruptions and obscurities in the connecting links. I refer, therefore, for the completion of this fragmentary outline to my article on "Inflamma- tion and its Results,"* and to the rigidly critical development of inflammation and its results by Henle. f We shall return in a future page to the connexion of these processes. Suppuration consists essentially in the fact that the parts of the exuded plasma capable of such formation, undergo a peculiar or- ganization—an organization on fahich the character of pus is de- pendant, and which distinguishes it from other morbid products. When this capability of organization in the plasma is clearly manifested, true pus-corpuscles, or completely formed granular cells occur; when it is less strongly declared, we observe either pus- corpuscles, of simply accumulations of elementary granules. These elementary types—true pus-corpuscles, abnormal pus-corpuscles, granular cells and elementary granules—are, however, but the final results of a continuous morphological series, between which there exist an infinity of intermediate points. All these formations have a definite mode of development from which they never deviate; they are capable of no higher stage of completion, that is to say, they are not in a mere transition-stage to a more perfect organism. From a pus-corpuscle or a granular Cell nothing higher can be produced. Hence the importance of this formation to the organism. It is never permanent, but is re- moved either by internal resorption, or by external rejection. When pus arises from a fluid blastema, then its formation hinders the coagulation of the fluid. But when pus arises from a solid blaste- ma, that blastema itself-becomes dissolved and rendered fluid by the formation of the pus, and thus its external rejection becomes possible. * Wagner's Handworterbuch der Physiologie, vol. i. t Zeitschrift f. rationelle Medicin, vol. n. SUPPURATION. 153 The uses of the formation of pus to the organism consist in this, that by its means exudations which were originally fluid, and would have become solid, are prevented from coagulating; and those already coagulated again become fluid, and thus the conditions requisite for their removal are effected. The distinction between genuine suppuration and the formation of granular cells depends upon the way and manner in which the exudation is removed. In genuine suppuration there is an effort to reject the fluid products externally. In pus forming upon membranes in free connexion with the external surface of the body, this discharge is directly effected, as on the mucous membranes and the external skin. When it occurs in enclosed portions of the body, as in the paren- chyma of organs, this tendency to external rejection is not less remarkable. The pus collects in cavities, forming abscesses, and escapes either by seeking for itself an external outlet, or its evacua- tion is assisted by art. In the formation of granular cells the exudation is likewise ren- dered fluid. But the minute granules into which the granular cells at last break, are very much smaller than the pus-corpuscles and with them the tendency to external rejection is less strong: they are much more easily resorbed than pus-corpuscles. Hence genuine suppuration may be characterized as the lique- faction of an exudation with a tendency to external rejection ; the formation of granular cells, as liquefaction with a tendency to re- sorption. This is, however, but an elementary type-of either pro- cess. Both may occur together, or either may be converted into the other. Thus, in many cases pus enclosed within the parenchyma of an organ may disappear without having been rejected externally ; its corpuscles breaking up and gradually becoming resorbed. But these are exceptions ; in the majority of cases the enclosed pus finds for itself a way by which it reaches the external surface, though its course may be a slow one, as in deep-seated abcesses, psoas ab- cesses, &c. Conversely, the formation of granular cells may cause an abcess, especially in very tender and* delicate organs. A fre^ quent example of this is afforded in inflammatory softening of the brain. Hence it follows that the formation of granular cells is that form of suppurative process by which the organism is the most spared, and the same is the case with suppuration on free surfaces. When pus is formed in the parenchyma, especially when an abcess is pro- 154 PATHOLOGICAL EPIGENESES. duced, and pus forcibly seeks to obtain an external outlet, there must be some destruction or injury of the organized parts. This injury or destruction is in different cases of very varying intensity. Thus, there is the healthy abcess, where the loss of substance is soon replaced, and the part shortly after the rejection of the pus re- turns to its primitive, condition ; and there is the malignant phage- denic abcess or ulcer, where the loss of substance continually in- creases, and the ulcer gradually extends. In attempting to explain these processes we are led to investigate the causes which give rise to the formation of pus, and the reasons why in some cases normal pus, in others granular ce,lls, or abnormal pus are produced. Let us first consider the question—why does pus arise from ex- uded plasma? Does this arise naturally from the chemical proper- ties of the exuded plasma, or is it dependant on external in- fluences ? The exudation possesses in itself a certain tendency to the forma- tion of organized products; there are produced in it, independently of external influences, more or less perfect pus-corpuscles. In the case of empyema mentioned in page 141, pus was formed in a large quantity of fluid, which was excluded from all communication with the external parts of the body by a thick layer of fibrin. A very accurately performed experiment recently submitted by Dr. Helbertto our Physiological Institute, gave a singularly striking proof of this tendency.* Fresh plasma taken from beneath the cuticle raised by an ordinary blistering plaster, exhibited no corpuscles of any kind. After standing in a glass for five or six hours, minute corpuscles were formed exactly analogous to those which appear in wounds when the formation of pus commences. Repeated experiments in- variably gave the same results. Hence there was an incipient for- mation of pus even in plasma which was entirely separated from the body. On the other hand, it is a known fact that the formation of pus can be obstructed or promoted by the application of external means. The application of moist warmth promotes it; of cold, retards or even prevents it. Further, it is certain that large quantities of exu- * Helbert, de exanthematibus arte factis fragmenta. Getting. 1844, p. 16. See also the remarks in p. 87 of this volume^ SUPPURATION. 155 dation are most easily converted into pus, while small quantities are most liable to be converted into persistent tissues. Again, in indi- viduals of vigorous constitution, and possessing that peculiar dis- position of the nervous system in which the inflammatory process is especially intense and rapid, normal pus is easily formed, while in weak cachectic persons with feeble vital energy, and where there is a tendency to gangrene, and in persons with very torpid chronic diseases, there is a tendency to the formation of unhealthy pus. There is no doubt that in these cases certain chemical, physical, and vital inflnences, dependant upon the nervous system, and unknown to us, combine together; and through this multiplicity of conditions we are prevented from obtaining an exact and definite acquaintance with the acting causes. If a certain impulse is once given in di- recting the formative process, then the elaborated product tends to sustain it, for fully developed pus, in the same manner as neigh- bouring healthy structures, excites a local tendency to the forma- tion of a substance similar to itself. This explains the old obser- vation that pus makes pus, and that when an abcess is too early opened, perfect suppuration is delayed or prevented. The distinction between healthy and malignant suppuration ad- mits of the following explanation. In healthy suppuration the for- mation of pus proceeds very rapidly; in three or four hours after its effusion the exudation maybe converted into pus ; although in many cases, the process requires three or four days for its completion. When the elementary textures of an organ are surrounded, and,, as it were, enclosed by the coagulated exudation, so as to be excluded from the influence of the nerves, and to be deprived of the cir- culation of the blood, it is only by the conversion of the exudation into pus that their liberation is effected ; and, if this is accomplish- ed sufficiently early, no destruction of tissue results. Again, nor- mal pus is a bland substance, devoid of all deleterious properties, and its constituents are analogous to those of the blood-plasma. Hence normal suppuration is not destructive to tissue, which is only affected mechanically, as by the collection of pus in an abcess causing local compression, or by the surrounding parts ultimately giving way. It is otherwise with malignant suppuration, the course of which is usually chronic, lasting for weeks, and even months before the exu- dation liquefies. Through this prolonged exclusion of the nerves 156 PATHOLOGICAL EPIGENESES. and capillaries, the normal tissue becomes partially destroyed; it dies away, breaks up, and its remains are thrown off' with the pus which is at the same time formed.. Further, there are dynamic caiises which influence the formation of malignant pus, and simul- taneously act upon the constituents of the parenchyma : in unhealthy suppuration, and when there is a tendency to gangrene, the histo- logic elements of the tissues are much more easily destroyed than in their normal condition. Finally, unhealthy pus frequently exerts a chemical action on the surrounding parts, sometimes containing free acids, carbonate of ammonia, or other constituents which chemically exert an injurious effect.* In this way malignant suppuration be- comes immediately connected with those abnormal epigeneses, which under the names of tubercle, encephaloid/cancer, &c, form alike the terror of the physician and of the patient. We shall in a future page return to the consideration of these formations. But the process of suppuration stands also in the most intimate connexion with healthy epigeneses, with the process of regenera- tion, and the formation of granulations ; of this also subsequently. With regard to the cause of the formation of granular cells, even less is known. I can here only repeat what I have already else- where observed respecting it.f It is observed principally in very composite organs—in the brain, the lungs, the liver, the spleen, the thyroid gland, &c,—and it occurs in those cases where the result of the exudation is most favourable, namely, where resolution occurs. Sometimes, indeed, as in the brain, it leads to softening of the pa- renchyma. ' This formation appears to be carried on most favour- ably when the quantity of exudation is small, and its effusion is Very gradual. In conclusion, we must offer a few remarks on the resorption of pus and on what are termed metastatic abcesses. An actual re- sorption of pus can only occur when its corpuscles become liquefied and fluid. This process is, indeed, very rarely observed, and an extremely long time is requisite for it, since the fluids of the body in which the pus-corpuscles must be dissolved usually exert no great solvent power upon them. The resorption of pus often ap- * According to Dumas, even hydrocyanic acid may be formed in the process of suppuration, Comptes rend. 1841^ vol. xm. p. 144. t Wagner's Handvirorterbuch d. Physiologie, vol. i. p. 345, 355. SUPPURATION. 157 pears to occur in a comparatively short period, for the serum of a fluctuating abcess becomes suddenly resorbed, causing the fluctua- tion and all physical signs of the presence of an abcess to disappear while the pus-corpuscles, however, remain long uninjured, and are only very gradually resorbed. Frequently also the term " resorption of pus" is applied to the occurrence of pus in the circulating system. Pus, however, never occurs in the veins or lymphatics, in consequence of resorption through the uninjured vessels. It is either, generated in the veins themselves, or is admitted into them through openings caused by some injury. It is only the serum of pus which can be conveyed unchanged into the vessels by means of resorption ; this subject we shall again notice in the special part, when we treat of the vascular system. I have in the preceding part described four morphological elementary types of the corpuscles presented in pus—true pus-corpuscles, abnormal pus-corpuscles of irregular form, and without any, or with an irregular nucleus, granular cells, and elementary granules. All these structures are essentially distinct from those which occur in exudations developing per- manent structures, and which will be treated of in the next section. The structures described by Henle and Gluge as inflammatory globules, I re- gard partly as broken up granular cells, and partly as aggregated elemen- tary granules; and the name which they have adopted appears to me un- suitable, because all kinds of pus may be the product of inflammation just as much as these inflammatory globules, and further, because these sometimes occur under circumstances where no inflammation, at least in the common acceptation of the term, can have taken place. Valentin,* and with him some others, have distinguished the proper pus-corpuscles from the exudation-corpuscles, which latter are of a whiter colour, and lie upon each other in a tessellated manner; afterwards, however, according to them they assume a yellower tint, and are converted into pus-corpus- cles (through the absorption of fat ?.) To me it appears unsuitable to de- signate pus-corpuscles in their early stages by a separate name; but tha* other structures—cells already clearly characterized as ofa different sort __can be converted into pus-corpuscles, I do not believe. At an earlier period, when I had Chiefly considered the formation of pus upon mucous membranes, and at a time when the importance of Cellular formation in 14 * Repert. vol. in. p. 173. 158 PATHOLOGICAL EPIGENESES. its earliest stages was scarcely recognized, I did, indeed, believe in the possibility of the conversion of immature epithelium-cells into pus-corpus- cles. Now I regard the formation of pus, as a peculiar product of the ex- udation which occurs immediately on the appearance of the first forma- tive molecules; and this leads me to believe that structures intended for other objects cannot be converted into pus-corpuscles, and conversely, that pus-corpuscles can never be converted into the elements of a per- sistent tissue; of the latter I am decidedly convinced. Millions of pus- corpuscles have been brought under the microscope before my eyes, but never have I perceived the least indication of a transition towards another structure. On the other hand, I have very often examined the earlier stages of the development of persistent tissues, in which cells do indeed appear, which an unpracticed observer might confound with pus-corpus- cles, but due examination shows an essential difference between them. After being subjected to acetic acid, they never show the nucleus with two, three, or four granules characteristic of pus-corpuscles, but merely a simple nucleus. I do not believe that such a cell can, by a retrograde metamorphosis, be converted into a pus-corpuscle. I am not acquainted with any case wherein the nucleus ofa cell has experienced in its deve- lopment so important a transformation as that which is here assumed. One out of many similar examples that I might adduce will serve to prove this. Two dogs received at the same.time flesh wounds. After the lapse of twenty-four hours these were perfectly similar in appearance. There was little discharge, for the dogs as is usual, frequently licked the wounds. The fluid contained blood-corpuscles, and also very many round colourless corpuscles varying in size from the 400th to the 300th of a line. They were smaller than the ordinary pus-corpuscles in dogs, but when treated with acetic acid, they showed the same .composite nu- clear structure, (containing 2, 3, or 4 granules) as ordinary pus-corpus- cles. Hence there can be no doubt that these were young pus-corpus- cles. In addition to the flesh-wound, one of the dogs had received a small wound penetrating the abdominal cavity, into which a dilute solu- tion of hydrosulphate of ammonia was injected. The animal seemed to suffer violent pain from the injection, and was very ill for a quarter of an hour; he then began to amend, and in forty-eight hours, when he had ap- parently quite recovered, was killed. The intestine was covered in seve- ral places with coagulated fibrinous exudation, which being examined with the microscope appeared to be partly amorphous, and partly to con- tain cells which were either fusiform or tolerably large round primary cells (from the 200th to the 100th of a line) with a single nucleus which was not affected by acetic acid; they were, therefore, entirely different from the above described rudimentary pus-corpuscles. The wound in the SOLID EPIGENESES. 159 intestine was nearly closed, and exhibited thinly scattered granulations which contained pus-corpuscles with nuclei capable of being broken up by acetic acid, and perfectly similar to those above described. Since, how- ever, the cells occurring in exudations are distinct from their very first origin, and we can distinguish between those which become pus-corpus- cles and those which develope themselves into persistent tissues, it appears quite unnecessary to regard exudation-corpuscles as peculiar struc- tures ; especially since there is no certain mark by which they can be dis- tinguished from any other primary cells. If it were proposed to designate as exudation-corpuscles all those primary cellular forms which occur in exudations, and whose nature is not accurately determined, the proceeding would be illusory, and more than that, superficial observers would run the risk of applying the name of exudation-corpuscles to all cells occurring in exudations. On this last ground it appears to me that the name is par- ticularly objectionable. Such an objection might not be sufficiently strong to cause the disuse of a name already established, but it is weighty enough to have its effect when new ones are to be adopted. SOLID PATHOLOGICAL EPIGENESES. Although the variety of forms exhibited by fluid morbid products is very considerable, this is still more strikingly the case with the solid epigeneses ; in order to facilitate the consideration of our sub- ject we will divide it into two parts. The first of them embraces the elementary structures which occur in regeneration after the loss of tissue, and in hypertrophy. The second concerns the composite structures which are commonly designated by the name of tumours, and embraces partly the same elementary structures either singly os in combination, and partly also other distinct elements. EPIGENESES OF THE ELEMENTARY TISSUES, Imperfectly organized structures. In dissections, it very frequently happens that solid epigeneses are found, which without belonging to the class of concretions, yet ex- amined by the microscope offer no trace of organization. They are designated according to circumstances by various names, as solid exudation, coagulated lymph, fresh pseudo-membrane, and so forth. They are characterised by the fact, that under the microscope they 160 PATHOLOGICAL EPIGENESES. appear perfectly amorphous ;* and when treated with acetic acid, ammonia, or potash, they become paler and more transparent, until at length, in some cases, they entirely disappear.. In many cases they are mixed with granular elements—vesicles and granules of fat—which when treated with ether disappear ; or with protein-com- pounds in a granular state—elementary granules in which no de- cided cellular formation can be discerned.f This granular appear- ance usually remains unchanged after the application of the above- named reagents. Solid epigeneses of this kind sometimes cover the surfaces of internal organs, as for instance of those parts which are invested with serous membranes, and sometimes they are depo- sited in the parenchyma, thickening the elementary textures, and thus giving rise to imperfect,hypertrophies or tumours. They always exhibit a lardaceous appearance. Chemically they re-act like co- agulated protein-compounds (fibrin) with a certain amount of fat,, and more or less saturated with serum. They always arise from fibrinous dropsy, of which the fibrin has coagulated, and are to be regarded as solid cytoblastemata, whose further development was interrupted by the death of the organ which was attacked. Had the vitality of the organ been prolonged, they would, according to cir- cumstances, have been changed into the several kinds of epigeneses —into concretions, areolar tissue, fibrous tissue, pus, rion-malig- nant or malignant tumours ; or they would have been resorbed. It is unnecessary to multiply example's! of these imperfectly organ- ized epigeneses, since they are of extremely frequent occurrence, and are found without exception in all vascular parts of the body, in which fibrinous dropsy occurs. When they present themselves as isolated tu- mours, they are very frequently regarded as tubercle ; indeed, one half of the cases of supposed tubercle belong to this class. To this subject I shall have frequent occasion to refer in the special part of this work. These imperfectly organized epigeneses are of very frequent occurrence in the most dissimilar organs. With regard to the unprofitable question, whether they are always the product of inflammation, I must refer to the section which treats of the pathological anatomy of that morbid process. * Plate n. fig. 2. t Plate n. fig. 3 and 5. X See the description of fig. 2, 3 and 5, in Plate n. EPIGENESIS OF AREOLAR TISSUE. 161 EPIGENESIS OF AREOLAR TISSUE. The development of areolar tissue is one of the most common- pathological epigeneses. It occurs in regeneration succeeding loss of tissue, in cicatrices, and in hypertrophy of those parts which in the normal condition consist principally of areolar tissue; but also in independent tumours, and in short under the most variable con- ditions. Since areolar tissue enters into almost all organs, and is a' constituent of most parts of the body, the frequency of its patho- logical development is the more easily understood, in accordance with the law of analogous formation, when it happens that in any part or from any cause an increased secretion of blastema takes- place. The cytoblastema of this tissue is sometimes fluid; sometimes solid. It is formed from a fluid cytoblastema in the healing of wounds by suppuration, in granulations, in the gradual hypertrophy of parts consisting principally of areolar tissue, in warts, condylomata, &c. Here the formation is gradual, and is supported by a long 'continued increased secretion of blood-plasma (the nutrient fluid) kept up by inflammatory irritation. The epigenesis of areolar, tissue, and with it the increase of hypertrophy, continues so long as the secretion of the formative material continues augmented. It would appear, therefore, in its power to be unlimited, for such epigeneses as con- dylomata, warts, or the proud flesh of granulations often attain a very considerable size. Again, areolar tissue is very frequently formed from a solid cyto-- blastema. In these cases the formative material is always the coagu- lated fibrin of fibrinous, dropsy, as in false membranes on serous sur- faces, as for instance in the pericardium, the pleura, or the perito- neum, or after inflammatory induration of the subcutaneous cellular tissue. Hence this epigenesis is as a rule confined to the metamor- phosis of the exuded and subsequently coagulated fibrin, and ceases when this is perfectly converted into areolar tissue. Morphology of its development.—Normal areolar tissue consists^ as is well known, of fine transparent fibres, varying from the 2000th to the 1000th of a line in diameter ; and the same is the case when it is pathologically reproduced. But, as in pathological structures generally, the product is frequently less perfect than the normal; type. The individual fibres are not always so clearly separated; 14* 162 PATHOLOGICAL EPIGENESES. from one another, being more or less fused into an amorphous cyto- blastema ; the arrangement of the fibres in the mass, their division into fasciculi^ &c, is less regular than in the normal areolar tissue. This is most especially the case when the formation is recent: very old morbid formations of areolar tissue, as adhesions, pseudo-liga- ments, &c, usually consist of areolar tissue which in no respect dif- fers histologically from the normal type. Also the nucleated fibres described by Henle, which are distinguished by their resisting the solvent action of acetic acid, are frequently found in larger or smaller quantities in newly formed pathological areolar tissue. The process of development is the same for morbid as for normal areolar tissue ; the fibres proceed from a more or less distinct cellu- lar origin. In the former case, there are formed in the cytoblastema nucleated primary cells, which are lengthened at both their ends,- and assume a fusiform shape; the extremities of these unite with one another, aud there are thus formed long varicose fibres.* From these caudate cells arise the fibres of areolar tissue ; a cell being either converted into a single fibre! or else by assuming a grooved arrangement, and these grooves deepening, finally splitting into a bundle of fibres.J In other cases the process is less clearly indi- cated, and deviates more from the cellular type. We often observe in the cytoblastema very pale gelatinous nuclei arranged length- ways in regular order, sometimes mixed with elementary granules, but not surrounded with clearly defined cell walls.§ From the blastema thus imperfectly converted into cells, the fibres are di- rectly produced. . In other cases the cells are indeed clearly defined, but irregularly and for the most part laterally fused together.|| Sometimes there are seen very pale, irregular and apparently non-nucleated cells: the nu- clei are, however, not really absent,, for after the application of acetic acid, they become clearly visible. In the nuclei we can usually,, but not always observe nucleoli. From these statements it follows that, in idea, areolar tissue in its pathological epigenesis follows the cellular type, but that in some cases peculiar, influences seem to * Plate i. fig. 12 ; Plate iv. fig. 1, c, and 2, a; Plate vn. fig. 3, b, e, 4, d. t Plate vn. fig. 3, d, 4, d. X Plate iv. fig. 1, d, 2, b,,c ; Plate vn. fig. 4, c, § Plate iv. fig. 1. a ; Plate vn. fig. 3, c. || Plate iv. fig. 1, b. EPIGENESES OF AREOLAR TISSUE. 163 throw the type very much in the back ground, if not entirely to ob- literate it. This explains the variation in the statements of different observers, as for instance, Schwann and Henle, respecting the nor- mal development of areolar tissue.* Sometimes, indeed, the cel- lular formation is so obscure, that the most careful observer can dis- cern no trace of nuclei or cells, and the fibres of areolar tissue would appear to spring immediately from an amorphous solid cytoblastema. It is necessary here to guard against confounding the indefinite fibrillse and lines which the coagulated fibrin, while yet undeveloped, sometimes exhibits,! with the fibres of areolar tissue. Whether the nucleated fibres which here and there occur in morbidly formed areolar tissue, and which by their great thickness, their usually winding, or even spiral course, their occasional dichotomic separa- tion, and their insolubility in acetic acid, are distinguished! from true areolar tissue and range themselves with elastic tissue—whether these, as Henle believes, arise from a prolongation and fusion of the nuclei, or whether they are to be regarded as another structure alto- gether distinct from areolar tissue, between whose elements they in- sert themselves—I will not venture to decide. A perusal of the descriptions of the plates will throw considerable light on the above remarks. I have made a large number of examinations (upwards of 50) respecting the pathological development of areolar tis- sue, partly on the human body, and partly on animals, after wounds, subcutaneous division of tendons, &c. They yielded the results which have been above described, and sometimes even more varied ones ; I have never been able to establish a general law that would explain why the cellular formation that accompanies this development is sometimes clearly and sometimes only indistinctly apparent. Chemistry of the development.—Perfectly formed areolar tissue consists chemically of a gelatigenous substance (colla,) while the cytoblastema consists of fibrin, as may be clearly demonstrated in those cases where areolar tissue arises from an exudation of coagu- lated fibrin. Fibrin and colla differ, however, from each other not only in their chemical properties, but also in. their elementary * Bischoff has collected the different opinions on this point in his Entwicklungs. geseh. p. 452. t Plate in. fig. 5. . X Compare Henle,.Allgem. Anat. Plate n. fig. 6, 7, 8. 164 PATHOLOGICAL EPIGENESES. composition. In the development, the morphological change must be simultaneously accompanied by a chemical change of the blaste- ma ; this is first shown by the appearance of the nucleus, which dif- fers chemically from the cell-membrane. This chemical change is not a sudden but a gradual one. This is seen in the fact that im- mature areolar tissue when boiled yields no gelatin ; and the same is the case with that of the foetus (Schwann,) and with that of granu- lations and condylomata (G. Simon and Giiterbock.) On boiling this substance, both obtained a fluidswhich after filtration gave the same reaction as if pyin were present. In my own investigations of recently formed, or forming areolar tissue, I have frequently found a fluid which coagulated on the addi- tion of acetic acid, and therefore in this point of view resembled pyin; Hence we may presume that in the chemical changes which ensue, some of the elements of fibrin are thrown off and form pyin, whilst others are converted into colla. But the chemical properties of these substances are as yet too little known to admit of more than mere supposition on these points. The above description is equally applicable to the morbid forma- tion of fibrous tissue, qf the fibres of tendon, and of other tissues, which histologically accord with areolar tissue. The time requisite for the formation of areolar tissue cannot be pre- cisely determined. It is longer than that which is necessary for the formation of pus. , Yet if is short in comparison with that which ap- pears to be required for the formation of other'organized structures. I believe from repeated observations that I am justified in concluding that from four to five days after the formation of the cytoblastema, fibres of areolar tissue may occur in it; the formation, however, of large masses of this tissue appears to require -at least. one, and fre- quently several weeks. Gelatin, whose ultimate chemical composition is doubtless indentical with that of areolar tissue, eontains according to Mulder, 50.4°- C. 63.J|- H, 18.0" N? 25.3° O, while fibrin contains 54.6°r C, 6.9a H, 15.7° N, 22. lg 0 with0.7gS and P. Hence in the conversion of the latter into the former, carbon and hydrogen must be given off and oxygen added, while the nitrogen remains unchanged; or nitrogen and oxygen added, arid carbon and hydrogen removed. All attempts to determine.these changes accurately by calculation must fail, and lead only to a useless sporting with formulae with the semblance, but not the reality of exactness. We know far too EPIGENESIS OF THE BLOOD AND VESSELS. 165 little of the chemical composition, and especially the atomic weight of these organic substances to obtain from such attempts any certain results. These are the elementary relations of the above-mentioned epigenesis ; to enter more minutely into their varied modifications; would in the present place be superfluous, since they will be frequently brought forward in the following pages. EPIGENESIS OF THE BLOOD AND VESSELS. Blood-vessels occur very frequently as pathological epigeneses in the restoration of lost parts, in granulations, in pseudo-membranes, in various hypertrophies, and in tumours. But our knowledge of the process of this development is still defective, especially since the normal formation of the blood-vessels in the embryo is only imper- fectly understood. It has been much disputed whether new ves- sels occur simply, as a prolongation or further development of the old, or whether they may be formed independently and without con- nexion with the normal vessels.* From a large number of observations, I believe myself justified in concluding that new vessels arise directly in the blastema, and only at a later period connect themselves with the previously existing normal vessels, indeed, that this is usually the case ; further, that not only the vessels themselves, but also their contents—the blood—can be produced anew in this manner. In support of this formative pro- cess the condition in the embryo may be adduced, where the blood, as well as the vessels, is formed from the common cytoblastema; it is supported also by direct observation. In the midst of newly formed substance, (inflammatory exudation, &c.) accumulations of blood-corpuscles surrounded with more or less clearly indicated walls without any connexion with the normal vessels are observed. It is true that we might be easily deceived on this point, since ex- travasated blood, which might be mistaken for a new formation, is mixed with many exudations; there remain, however, plenty of cases in which the attentive observer need be in no danger of being misled. According to my own observations! the process seems to be as * Soc Hasse's Pathological Anatomy, English edition by Swaine, p. 192. t Plate v. fig. 1—4. 166 PATHOLOGICAL EPIGENESES. follows: in an amorphous blastema (coagulated fibrin) red points are formed, which are commonly of a size sufficient to enable the observer to discern them with the naked eye. Under the micro- scope each point appears as a group of blood-corpuscles of various sizes, in form roundish, and without the central depression observa- ble in perfect blood-corpuscles; they have usually a clearly defined out- line and a yellowish-red'eolour. Their diameter is generally some- thing smaller than that of normal blood-corpuscles, being from the 600th to 450th of a line. I have never observed that newly formed blood-corpuscles in any pathological structure were (as is the case with the formation of blood in the embryo) greater than normal ones. They dissolve in water and acetic acid, without yielding any indi- cation of nuclei: the groups of these blood-corpuscles have not at first a very distinct contour, but appear at the edges to merge into the surrounding exudation ; their form is indefinite, roundish, elon- gated, or annular. It is only after some time that these groups ap- pear clearly distinct from the parenchyma; they then throw off rays or branches of a defined form ; still, however, destitute of true walls.* Probably the walls of the vessels are formed around them at a later period, when areolar tissue, muscular tissue, and epithelium, in ac- cordance with the general laws of development, surround and enclose the ramifying masses of blood. When the new vessels are perfectly formed, the walls become distinctly visible ;\ indeed, when subjected to the action of acetic acid, they exhibit a regular nucleated arrange- ment which manifestly appertains'to the walls of the vessels and cor- responds with the cells in the different layers of the walls.if The perfectly formed vessels, with their contents, enter earlier or later into communication with the original vessels in their neighbourhood, and then take a part in the general circulation. At the earlier pe- riods of their existence the blood which they contain, although fluid, is motionless. The vessels whose pathological epigenesis I have observed were all larger than capillary vessels : they were not formed from cells, as Schwann imagines to be the case with capillary vessels, neither were they formed in intercellular spaces; for the formation of blood * Plate v. fig. 4. t Plate hi. fig. 5. X See Plate in. fig. 7,8, 9, of Henle's Allgera, Anat. EPIGENESIS OF THE ELOOD AND VESSELS. 167 always took place very early, before the formation of any other cells and even before the formation of areolar tissue. It is, however, not improbable that in the formation of capillary vessels the process is as Schwann* describes it, namely, that in the first place ramifying groups of cells are formed which contain blood, and which opening into one another, form a net-work of vessels, so that the original cell-walls which enclosed the blood become the walls of the subsequently formed capillaries. There are two ways of explaining the formation of vessels from the original vascular trunks. Either some of the original trunks are rup- tured, and blood is effused from them, which channelling its way through the cytoblastema becomes subsequently enclosed wjthin walls. But this is an explanation against which much may be alleged ; for it is not easy to see why the blood effused in the cytoblastema should not be equally distributed, instead of confining itself in certain ramifying courses, and finally again discharging itself into other normal vessels, On the con- trary it is not very probable that extravasated masses of blood, can, in the like manner, as newly formed blood become surrounded with regular walls. This much, however, is certain, that extravasated blood cannot always give rise in this manner to the formation of new vessels; it may, in- deed,,suffer many other modifications, as has been already mentioned, and will be often again noticed. On the other side it may be supposed that in accordance with the law of analogous formation, there arise from the normal vessels, walls, which are alt first altogether closed, but which afterwards communicate with them, and receive blood from them. This process would differ from the former only in this, that here the vessels are formed without their usual contents (blood.) Future experience must decide whether any thing of this kind actually occurs. What are the causes of the epigenesis of blood and vessels ? It may be supposed that here also the law of analogous formation plays a part, since the influence of the normal blood-vessels calls forth this process of formation from the exudation ; in fact we find that this epigenesis of vessels is not only of most common occurrence in highly vascular parts, as, for instance, upon the skin, but is also most frequent under those circumstances where the vessels are most replete with blood and where hyperaemia exists, as for instance in * Mikrosk. Unters. Plate x. fig. 12, 168 PATHOLOGICAL EPIGENESES. granulations. Whether the extravasation of blood facilitates the epigenesis of vessels must remain yet undecided. We must at all events acknowledge that the true causes of this epigenesis still re- main in much obscurity. Sometimes the epigenesis of vessels only become apparent when the previously invisible capillaries become enlarged, receive more bloody and thereby become visible to the naked eye. This is the case in hyperaemia of most parts of the bocly, at least of such as are superficial, and can be observed during life, as for example the con- junctiva of the eye. The time requisite for the epigenesis of blood and of vessels appears to be very short in proportion to that required for the development of other epigeneses. I have myself seen blood arise' in an exudation within forty-eight hours after its effusion. Home observed numerous vessels formed within the course of twenty-nine hours. Usually, however, a much longer time is re- quired for its formation. The chemical relations of this epigenesis are very imperfectly understood; in the formation of vessels, the same chemical forces are doubtless exerted as in the formation of areolar tissue, of elastic tissue, and of simple muscular tissue; that is the protein-compounds of the blastema become converted, partly into a substance yielding gelatin, and partly into other substances, with whose chemical com- position we are still more ignorant. With respect to the chemistry of the formation of blood there is not the least difficulty in account- ing for the production of the blood-plasma from the exuded fluid ; both being in fact identical. Moreover there is no difficulty in sup- posing that the globulin of the blood-corpuscles is formed from the proteinrcompounds of the exudation, although it has not yet been artificially procured. The formation of- the haematin is equally ob- scure in this case, and in the ordinary formation of blood. EPIGENESIS OF EPITHELIUM AND EPIDERMIS. The epidermis, as well as most forms of epithelium, as for instance the pavement epithelium consisting of several layers, exhibits in the normal condition a continuous epigenesis on the one hand, and a continuous destruction on the other. On the surface which is turned to the subjacent cutis or mucous membrane, new cells are continually forming from the blastema afforded by the vessels of the subjacent membrane; these become further developed, undergo the ordinary GRANULATIONS. 169 changes, and at length having arrived at the surface, are gradually rubbed off and removed. A precisely similar process takes place when these formations, after being destroyed by any morbid cause, are reproduced—the most frequent class of all pathological epigeneses. In a case of this nature so long as any inflammatory irritation is present, the cytoblas- tema afforded by the vessels of the subjacent membrane becomes converted into pus. Usually as this irritation decreases the forma- tion of pus ceases, and in its place there is the production of epi- dermic or epithelial cells which folldw the same process in their de- velopment as is observed in their normal formation. An identical law of formation is pursued when the epithelium or epidermis be- comes thickened, or when epithelium is pathologically formed where in normal circumstances it does not exist, as for example, in encysted tumours; the cyst on its inner surface being very generally invested > with epithelium.* The chemical like the morphological relations of development in all these cases precisely follow the normal type GRANULATIONS.f In the preceding sections the epigeneses of areolar tissue, of ves- sels, and of epithelial structures have been considered as so many isolated processes. Cases are, however, frequently observed where all these formations are combined, where they simultaneously occur at one and the same part of the organism from the same cytoblastema. apd are usually accompanied with suppuration. Such complicated epigeneses are usually distinguished by the term granulations. They occur under extremely various circumstances—in suppurating wounds. on the surfaces of serous membranes, in abscesses, fistulae and so forth. They are produced by the simultaneous formation of areolar tissue, vessels, and pus, from a solid, or more commonly fluid blas- * Plate v. fig. 6. Plate ix. fig. 2. t Compare Henle in Hufeland's Journal, vol. lxxxvi. p. 56; Travers on Inflamma- tion London, 1844, p. 110, &c.; Giiterbock, de pure etgranulatione; and the principle works on Inflammation, as those of Hunter, John Thomson, Allen Thomson, Kalten- brunner, &c. Liston has published a description (with instructive plates) of the for- mation of new vessels in granulations. Medico-chirurg. Transactions, 1840, p. 85, &c, Plate i. 15 170 PATHOLOGICAL EPIGENESES. tema. The physical and histological characters of granulations vary in accordance with the preponderance of one or other of these pro- ducts, and according to the degree of development in which they occur. When the vascular formation predominates, they appear of a blood-red; when there is a paucity of vessels, they are of a pale colour; when the areolar tissue prevails, they are firm; when the blastema remains amorphous, they have a lardaceous appearance; when it contains a large number of pus-corpuscles, they are soft and spongy. Hence granulations, when examined under the microscope, sometimes exhibit numerous blood-corpuscles, (the walls of the ves- sels being seldom clearly indicated, but sometimes becoming so on the addition of acetic acid,) sometimes numerous pus-corpuscles, sometimes a perfectly amorphous mass, sometimes areolar tissue in various stages of development, and sometimes all these elements together; they generally contain a fluid which coagulates on the addition of acetic acid (pyin.) Granulations represent a transition state. They are an epigenesis in the act of development. In pro- portion as the granulations become further developed, the formation of pus disappears, and the cytoblastema becomes more and more changed by the formation of areolar tissue, vessels, and sometimes also of other elements, as cartilaginous and osseous tissue, simple muscular fibre, &c. and at last they form a solid persistent epigenesis. They occur both on the external and internal free surfaces of the body, and finally become invested with epithelium or epidermis. Beyond this stage of their progression, they are no longer termed granulations, but receive names corresponding with their future re- lations. Since granulations in most cases contain vessels which are usually in a state of hyperaemia and consequently give rise to an effusion of fibrinous fluid, they supply the cytoblastema requisite for further development. And since a portion of the blastema is converted into pus, we can understand why granulations secrete pus; but the formation of pus is not necessarily associated with the presence of granulations. EPIGENESIS OF FAT AND ADIPOSE TISSUE. Fat occurs in the normal body under very different conditions. It is present as adipose tissue, when cells with an amorphous cell- EPIGENESIS OF FAT. 171 wall contain fluid fat; as fat-globules, or granules (the latter being usually very minute) in many fluids ; and as dissolved or imbibed fat. There are as many, and, indeed, greater differences in those fats which result from a pathological epigenesis. Those of most com- mon occurrence are morbidly formed adipose tissue, as in fatty hy- pertrophy (the fatty dropsy, or polysarkia of some writers ;) abnor- mal adipose tissue, as in the fatty degeneration of many organs, for example, of the muscles and the kidneys; independent fatty tu- mours, which either consist entirely of fatty tissue, as lipoma, or of a union of that with areolar tissue, forming steatorna. All these for- mations are characterized by the fat being enclosed in peculiar cells,) (fat-cells,) which more or less resemble those of norma] adipose tissue.* These fat-cells sometimes (especially when cold) contain crystalline depositions of margarin.f In other cases, the newly formed fat oc- curs free, in larger or smaller vesicles, which are usually so minute, that they can only be recognized with the microscope. They may be distinguished by the peculiar manner in which they refract light, and by their solubility in ether. These fat globules occur either free amongst other histologic elements, as, for instance, between the hepatic cells in many forms of fatty liver; between the different coats in obliterated vessels ; in the substance of encephaloid ; and in certain fluids, as in blood, pus, &c. • or, they are found in the interior of cells, as in those of the liver.J Where these accumula- tions of fat do not occur as distinct globules, but infiltrate the tis- sues of the body, they are then recognizable by chemical analysis rather than by the microscope. Depositions of fatty granules occur under the same circumstances as those of fat-globules ; in fact the two are usually associated, and the latter are only distinguished by containing chiefly solid fat—margarin, cholesterin, and serolin— whilst the former consist of fluid fat (olein.) The fatty granules are for the most part small (elementary granules ;) sometimes single, sometimes in groups, and forming various kinds of aggregate corpus- cles, and granular cells, and often deposited in very considerable quan- tity. They must notbe confounded with the elementary granules * Plate vn. fig. 1. ' f Pic 4.3 x. fig. 3. t Plate i. fig. ix. 172 PATHOLOGICAL EPIGENESES. arising from the protein-compounds which occur under similar cir- cumstances, but differ from fat-granules by their insolubility in ether. Many deposits of fat assume a crystalline arrangement; thus, mar- garin and margaric acid form acicular crystals united in tufts and stars,* while cholesterin forms rhomboid tablets.! Pathological depo- sitions of fat form the transition between organized and unorganized epigeneses; whilst newly formed adipose tissue must be regarded as truly organized, crystalline depositions of fat must undoubtedly be regarded as concretions. The horny scales described by ValentineJ and Gerber§ are doubtless crystals of cholesterin; so, also, in all probability are the rectangular tablets described and depicted in several places by Gluge. The.causes, morphology and chemistry of the development of these products present very great differences. The question concerning the ultimate causes of this formation of fat is connected with the still imperfectly understood theory of nutrition, and this brings us to the much disputed subject respecting the formation of fat from the food, which we shall not at present consider, in consequence of the undecided state in which itremains. Very probably, in all cases where fat is produced, not only the cytoblastema, but also the blood from which it is derived, is more than usually abundant in fat. We often, indeed, meet with fat occurring as fat,-globules and granules in many amorphous blastemata ; this fat remains, whilst the rest of the blastema disappears either by resorption or organization, and in this manner those pathological collections of fat are formed which we find in a crystallized state. WTiether fat can arise from the pro- tein-compounds of an exudation, or from its other constituents, through a chemical metamorphosis, must be left at present unde- cided, as also must be the question, whether, under certain condi- tions, a plasma consisting entirely or principally of fat can be sepa- rated from the blood ; in other words, whether the vessels can in a direct manner secrete fat. If this were the case, the process of the for- mation of fat would be much simplified, and more easily explained. * Plate x. fig. 3. t Plate x. fig. 1. t Reportorium. 1837. p. 265. § General Anatomy of Man and the Mammalia. English Edition, by Gulliver, LondoB, 184g, p. i)36. EPIGENESIS OF MUSCULAR TISSUE. ITS? There is no doubt that in many cases actual fat is secreted by pecu- liar morbidly formed secreting organs, similar to the sebaceous glands of the skin, the ceruminous glands, &c. which in the nor- mal state secrete fat. This is, for instance, the case in many kinds of encysted tumours. Of the development of organized adipose tissue and fat-cells we have no certain knowledge ; indeed we do not know in what manner the normal formation of fatty tissue occurs. We may assume that in accordance with the general scheme of cellular formation, cells arise from a cytoblastema more or less similar to the blood-plasma, and that at a later period they become filled with fat, or that a cell- wall occurs as a secondary formation around the fat-globules, where- by, probably, Ascherson's* theory of the formation of the haptOgen membrane might find a practicable application. I have never met with a case tending to give either of these explanations a greater degree of probability than the other. The law of analogous forma- tion appears to be here so far in force, as, that pathological fat-cells are most frequently formed in those parts where in the normal con- dition an accumulation of fat exists, as we shall show when we speak of fatty tumours. The chemical elements of morbidly formed fat are the same as those of normal fat. Olein is the prevailing element in fluid, and margarin and cholesterin in solid1 fat. Sometimes butyrin is found in small quantities, recognizable by the peculiar odour of butyric acid, which it evolves on becoming rancid. Whether serolin, and the brain-fats, of which- we know very little, occur in morbid format tions is unknown. EPIGENESIS OF MUSCULAR TISSUE, The normal muscles are divided into those containing simple^ non-striated fibres, and those consisting, of compound striatedT primitive fasciculi. The same division holds,, also, with regard to morbidly formed, muscular substance. a. Muscles with compound, striated, primitive fasciculi. To these- belong in the normal body, the voluntary muscles of the trunk, heacl, » Midler's Archiv. 1840. p. 44, &c. 15* 174 PATHOLOGICAL EPIGENESES. and extremities, and the muscular walls of the heart.* There is no doubt that muscular substance of this kind may be produced by a morbid process, but this can only be argued from consequences, and net directly observed. This epigenesis always consists in a hyper- trophy of muscular substance existing in the normal condition, and is of most frequent occurrence in the heart. It appears that the volume of the muscles is increased without the single primitive fasciculi gaining in thickness ; hence it must be concluded that their number is increased; that is, that new ones have arisen amongst those previously existing. This epigenesis is sometimes the con- sequence of a morbid process, as in hypertrophy of the heart; sometimes it results from normally increased nutrition, as in the case where a muscle is strengthened by exercise, and consequently in- creases in the thickness and number of its primitive fasciculi. This is one of those cases where no decided boundary can be esta- blished between a normal and morbid process, and where our division becomes arbitrary. Here the epigenesis entirely follows the law of analogous formation ; the cytoblastema is, doubtless, the general nutrient fluid which continues to be secreted in increased quantity for a considerable time. The newly formed muscular fasciculi so closely'resemble the previously existing normal formation, that they eannot be distinguished from each other. The morphology of this epigenesis is, therefore, unknown ; even the normal development of this form of muscular tissue is still in several respects unexplained.! The chemical relations of this epigenesis are, probably, very simple, for the chemical composition of muscular tissue is very, similar to that of the protein-compounds. It is an interesting observation that after loss of substance in the muscles, new muscular substance is not formed even in cases where a large quantity of cytoblastema is at once secreted. The cicatrices seen in muscular tissue, are formed from areolar tissue and the exu- dation from the surface of muscular tissue (as for instance of the heart,) is converted, not into muscular substance, but into areolar tissue. These facts serve to confirm the general law that the cyto- * See Henle's Allgem. Anat. Plate iv. fig. 4. t The different opinions respecting the developement of this tissue may be seen in Henle's Allgem. Anat. p. 600 ; BischofTs Entwick-hingsgeschichte, p. 446 ; and ¥alentin in Wagner's Handwdterbuch der Physiologic vol. i.p, 715. EPIGENESIS OF MUSCULAR TISSUE. 175 blastema more readily follows the law of analogous formation in proportion as it is given out in small quantities, and that very complicated tissues are only formed when its quantity is very small. Those cases in which it has been asserted that the formation of muscu- lar fibres form large masses of exudation, after inflammation, and similar morbid processes, has been observed, are doubtless founded on error. In fact, the microscopic examination (the only decisive test,) had been altogether neglected, as in the cases observed by Leo-Wolf.* Since the tendons of the muscles are, histologically, closely connected with areolar tissue, so also is there an intimate analogy between these pathological epigeneses in cases of regeneration. . b. Simple, non-striated muscular fibres.—These are found normally in the muscular coat of the stomach and intestinal canal, in the excretory ducts of glands, in the ureters, the bladder, the uterus, and the fallopian tubes. They are often morbidly produced, causing thickening (hypertrophy) of the walls, either at circumscribed points, or over a considerable extent of surface; and as independant (fibroid) tumours. They likewise sometimes form a constituent of scirrhus. In the majority of cases this epigenesis is to be explained by the law of analogous formation, for a cytoblastema secreted in excess is, through the influence of the surrounding tissue, converted into a similar substance, as in cases of hypertrophy. In this point of view it is interesting to observe that independent tumours of simple muscular fibres (fibroid) so far, at least, as my experience reaches, are only to be found where in the normal condition simple muscular fibres were previously existing; as in the substance of the uterus, which in their most common seat, and in the muscular coat of the stomach and intestinal canal. Morphology and chemistry of their development. The pathologi- cal and normal development of simple muscular fibres are perfectly identical. In both cases nuclei are formed in an amorphous, and, usually, a fluid cytoblastema, which are at first roundish, but sub- sequently become elongated and pointed, somewhat in the form of an oat grain, and sometimes arched. Around these there are formed * Traclatu* anatomico-pathologicns sistens duas observationes rarissimas de formatione fibrarum muscularium in pericardio atque in pleura obviarum. Heidelb. ct Lips. 1832. and Wutzer's Critique oh it in Mailer's Archiv. 1834. p. 451. 176 PATHOLOGICAL EPIGENESES. elongated cells, which gradually join at the extremities, and at length become fibres.* It is not, however, always that this mode of formation can be clearly detected during development. In many cases we see only perfect nuclei, whilst the rest of the cytoblastema between them seems to be converted into muscular fibre without any preceding formation of cells, as has been previously described in the development of areolar tissue. After complete development, the newly formed muscular fibres sometimes perfectly resemble the normal ones. Homogeneous fibres, varying in diameter from the 800th to the 400th of a line and parallel to each other, are formed with nuclei scattered lengthways over them. These nuclei are often distinctly visible, or, at any rate, always become so after the addition of acetic acid.f It is not always, however, that newly formed muscular fibres are so distinctly marked ; sometimes an aggregation of them will form a more or less amorphous mass, in which the tendency to fibrillation can be discerned, but the separate fibres cannot be clearly distinguished. On treating such a mass with acetic acid, the nuclei appear in con- sequence of the fibres vanishing. These are cases where the development of the muscular fibres is either incomplete, or where it remains stationary at a lower and imperfect stage. They occur most frequently in tumours, where, probably, in consequence of too large a quantity of cytoblastema, the law of, analogous formation only acts imperfectly, and the epigenesis never attains its true type. Large masses of simple muscular fibres, such as frequently occur in morbid epigeneses (both in cases of hypertrophy and in tumours,) manifest on being cut through so close a similarity, in their physi- cal appearance, with cartilaginous tissue, that they are frequently mistaken for it. Both are of milk-white colour, are semi-transpa- rent, apparently homogeneous, and very solid, so as to craunch under the knife. Many morbid growths described both by ancient and modern authors as morbid cartilaginous tissue consisted, with- out doubt, of this newly formed muscular tissue. The difference between these tissues is perfectly obvious under the microscope. The chemical processes in this epigenesis appear to be extremely simple, for this muscular substance in its chemical properties, and * Plate iv. fig. 4. t Plate iv. fig. 4. Plate vn. fig. 2. Plate vm fig. 2 and 7. EPIGENESIS OF ELASTIC TISSUE. 177 probably, also, in its ultimate composition, differs but slightly from the coagulated protein-compounds. As in the tissues consisting normally of fibrin, there is immense variety in the volume of the fibres, rising gradually from the fibres of areolar tissue, which are the finest and most delicate, and have a diameter varying from the 2000th to the 1200th of a line, to the thickest simple muscular fibres with a diameter varying from the 400th to the 300th of a line, so does the same variety exist in the morbid epigenesis of fibrous tissues. Newly formed fibres are fre- quently met with, which seem to hold an intermediate place between those of areolar and those of muscular tissue ; so that it is no easy matter to decide to which they belong. This is the case in some imperfectly developed formations. The above observations respecting the similarity of many of these formations to cartilaginous substance holds, also, with regard to many of those structures which consist of imperfectly developed areolar tissue. EPIGENESIS OF ELASTIC TISSUE. Elastic tissue consists of fibrous elements, and closely approxi- mates, histologically, to the fibres of areolar tissue, of fibrous tissue, and of simple muscular fibre. The chief distinction between it and them is a chemical one, namely, the insolubility of its fibres in acetic acid ; it is also morphologically distinguished from the above tissues by the fact that its fibres are thicker than those of areolar and fibrous tissues ; while, on the other hand, they are thinner than those of simple muscle. It is further characterized by a frequent dichotomic separation, and reticulated ramification of its fibres. The nucleated fibres of areolar tissue range themselves immediately with those of elastic tissue; they may, indeed, be considered as a de- generation of these latter.* Pathological epigeneses of this tissue doubtless sometimes occur; they are, however, but imperfectly known. It has been already * Full information respecting the histological relations of this tissue may be found in Henle's Allgem. Anat. p. 399. Plate n. fig. 9, 10, 11. Valentin in Wagner^ Handwortcrbuch der Physiologie. vol. i. p. 667 178 PATHOLOGICAL EPIGENESES. observed, that in pathological epigeneses of areolar tissue, nucleated fibres sometimes occur amongst its ordinary elements. In scirrhus, I have myself frequently observed an epigenesis of genuine reticulated elastic tissue, as I shall show in the section on that morbid process. MELANOSIS. In the normal body, granular pigment holds a very subordinate place. It is found only in the eye, and in some individuals also in the hair, and in some parts of the skin.* It consists of fine granular molecules of brown or black colour, which are usually enclosed in cells of different forms and size. This is the case in the choroid coat of the eye and in the coloured portion of skin, in which latter, however, in addition to pigment-granules, coloured nuclei are also present (Bruch, Krause.f) Pathological epigeneses of granular pigment are, however, very frequent. They appear as colourations of the skin, in the form of sun-burn, freckles, &c. ; in the internal organs they appear as me- lanosis in the lungs and bronchial glands, on the surfaces of the liver and of the spleen, on the inner and outer surfaces of the intes- tinal canal, and in tumours; also as frequently accompanying sup- puration in the walls of foul abscesses. The morphological and chemical relations, as also the causes of these morbid formations of pigment are very various, and therefore a general consideration of them is difficult. The following may be offered as a mere provi- sional sketch. In some cases the newly formed pigment is contained in true cells, analogous to the normal pigment cells, which are surrounded with a distinct cell-wall, provided with a nucleus, and enclose very fine granular pigment-molecules of a brown or black colour. Such pigment-cells are found in melanotic tumours, in melanosis of the lungs and bronchial glands, and in the skin. They are more or less perfectly formed, but seldom or ever so regular as the pigment- cells of the choroid coat. They are usually of an indefinite round- ish form.J I have never seen them united in a continuous layer, * See Bruch's Untersuch. z. Kenntniss des kornigen Pigments. 1844. Henle's Allgem. Anat. p. 279. t Article, Haut in Wagner's Handworterbuch der Physiologic X PI. i. fig. 10 ; pi. ix. fig. 7. See also Bruch, op. cit. fig. 22, 23, 25. GRANULAR PIGMENT. 179 and so greatly compressed as to form polyhedra. In animals, (the horse and calf,) where collections of pigment occur in the con- junctiva after inflammation, they ramify and sometimes assume a stellar form. Bruch appears to classify the granular cells under this head ; but they contain molecules, which consisting of fat, only ap- pear dark in refracted light, and are rather, on the contrary, white when seen by reflected light; they therefore differ essentially from the dark-coloured molecules of true pigment which appear dark by reflected light. Sometimes the cells enclosing pigment-molecules are very indistinct, or appear to be entirely wanting ; indeed, in one and the same melanotic lung, aggregations of pigment are often found, some of which, when carefully sliced and examined under the microscope, are found to be enclosed in cells, whilst other ag- gregations in the same lung, on the most careful examinations, pre- sent no enclosing cells, but the pigment-molecules appear to be de- posited in a state of freedom in the parenchyma. I have never yet succeeded in directly observing the process of development of these pigment-cells. It may be supposed that the cells are first produced, and that at a later period, the pigment- granules are by a metabolic power generated within them; in fa- vour of which view, we may quote those cases occurring in children with leucosis (albinos,) in whom the pigment, originally absent, was afterwards developed.* We know also that in white rabbits, whose choroid membrane contains no pigment, it is only the pigment- granules and not the cells which are deficient. When, therefore, pigment is subsequently produced in albinos, it can only happen by the originally empty cells becoming afterwards filled with pigment- granules. According to this view, the above cases in which pig- ment-granules without surrounding cells occur, may be explained by the supposition that the cells were originally present; but that after the deposition of the pigment in them, they became again re- sorbed, whilst the pigment itself remained. On the other hand, it may be supposed that the pigment-granules are first formed, and be- come afterwards surrounded by cells. I believe that I have myself once observed this occurrence in pigment-cells in expectoration, where aggregations of black pigment-granules were surrounded by cells more or less clearly indicated, and it appeared as if secondary * A case of this nature is recorded in Muller's Archiv. 1836. Jahresbericht, p. 192. 180 PATHOLOGICAL EPIGENESES. cells formed around the pigment-granules, just as in pus-corpuscles they form around the nucleus. But these observations which from their nature are most difficult, I do not regard as decisive. In a chemical point of view, the newly formed pigment closely resembles the normal pigment of the eye. The intensely black pig- ment, in melanotic lungs and bronchial glands, rendered as pure as possible by boiling in hydrochloric and diluted nitric acid, and then extracting with water, ether, and alcohol, appears from my repeated observations to be insoluble in sulphuric and hydrochloric acids, caustic ammonia, potash, and dilute nitric aCid ; it dissolves only in concentrated nitric acid, at the same time undergoing decomposition. It is not decolourized by chlorine, though Bruch asserts to the con- trary. Dr. Schmidt analysed in our laboratory two portions taken from different bodies, which appeared to correspond in their chemi- cal relations, and in their action towards the above re-agents; the first, taken from the intensely melanotic lung of a miner in C^austhal, gavq, after the deduction of 12.48| of ashes, consisting of 10.6 silica (pulverized quartz,) and 1.88 sulphate of lime : Carbon . . . . 72.95 Hydrogen .... 4.75 Nitrogen . . . . 3.89 Oxygen . . . . 18.41 100.00 In the other experiment, on a lung, hepatized inferiorly, and whose bronchial glands were thoroughly melanotic, the determination of the hydrogen could not be regarded as certain, in consequence of the smallness of the quantity subjected to analysis. It gave, after the deduction of 3.735$ of ashes, consisting of silica (powdered quartz):— Carbon . . . .66.77 Hydrogen . . . . 7.33? Nitrogen .... 8.29 Oxygen .... 17.61 100.00 These two analyses show but little similarity. It would appear from them, that the newly formed pigment has a variable composi- GRANULAR PIGMENT. 181 tion, which is probably connected with its development. They prove that the opinion that the pigment deposited is pure carbon, is, at least in these cases, altogether incorrect. Further, they show that this pigment is not the same as the normal pigment of the eye, in which Scherer* found 58° carbon, and 13.7„ nitrogen ; yet with all the respect that I entertain for Scherer's accuracy, it appears to me that the analysis should be repeated in consequence of the ex- treme difficulty of obtaining the pigment of the eye in a state of purity. Another kind of morbid pigment evidently arises from decom- posed blood, and from a change in its colouring matter. Extrava- sated blood has sometimes, for instance in gangrene, and when it has a tendency to become decomposed, a brownish red, or even blackish colour, forming either soft clots or a granular mass.f This change appears not only to affect extravasated blood, but also that which is still contained in the vessels; whilst some parts of vessels contained red blood, in other parts it becomes brownish or almost black. This change of the blood appears to be of a purely chemi- cal nature, since it is observed in those cases where blood is extra- vasated into the stomach. It is then always changed in the above- mentioned way, for the acid of the gastric juice communicates to the colouring matter of the blood a brown or blackish tint, and at the same time coagulates the albumen of its serum in larger or smaller masses, so that ultimately the well-known "coffee-grounds" appearance is produced which occurs in "all cases when blood has been effused into the stomach during the presence of the gastric juice. In fact, the same takes place, and may at any time be pro- duced out of the body, when defibfinated blood is mixed with sul- phuric or hydrochloric acid. What is done in these cases by acids, appears in others to be effected by gases, especially by sulphuretted hydrogen and hydrosulphate of ammonia, as for instance in the course of the intestinal canal and in the adjacent parts. In other parts also, changes of the blood into a mass similar to granular pig- ment are presented without our being able to perceive their chemi- cal cause. An interesting case of this kind was recently communi- cated to me by my colleague Ruete. In a case of haemorrhoids * Liebig u. Wohler's Annalen d. Chem. u. Pharm. vol. xl. p. 63. t See pi. ix. fig. 10. 16 182' PATHOLOGICAL EPIGENESES. with disease of the liver, there occurred without any apparent cause an effusion of blood under the conjunctiva of the eye, in the form of knots, by which the conjunctiva was projected forwards ; the effused blood was not resorbed, but gradually became of a black colour. The knots broke, and discharged a mass which was im- mediately brought to me for examination. It was intensely black, and with the naked eye could not be distihguished from the black pigment of the choroid. Under the microscope it appeared as an undefined granular mass, with blackish brown portions. Neither pus-corpuscles nor granular cells were to be seen, nor any other trace of organization or cellular formation. The pig- ment was not changed either by nitric acid or by chlorine ; in its appearance it resembled blood-pigment changed by gangrene or by acids. The chemical composition of this abnormal pigment is not accu- rately known, but this much is certain, namely, that it is not changed by chlorine, or by acids; and this is important as a means of dis- tinguishing it from the following variety. A third kind of morbidly formed granular pigment is not an organized epigenesis, but a simple chemical precipitate, and con- sists of sulphuret of iron. It appears most frequently as a black or blackish blue pigment on the walls of unhealthy fetid abscesses ; but also as a slate-gray pigment on the surface of the liver, spleen, and intestinal canal. Under the microscope it appears as an aggre- gation of black granules of indefinite form—of molecules varying in size to the 100th of a line in diameter. These molecules are found sometimes singly, sometimes collected together in larger or smaller quantity between and among the elements of the tissue. In some few cases these, granules are enclosed in cells.* This pig- ment has morphologically a great similarity to the first kind, but chemically the two are easily distinguished. It dissolves in acids, (acetic acid, nitric acid, &c.) whilst the first and second kinds are not affected by them. By supersaturating the acid solution with hydrosulphate of ammonia, it apparently returns to its original form, that is, it is again precipitated as sulphuret of iron. Concentrated acetic acid is the best test, for the other acids, by coagulating the * See Plate ix. fig. 5. GRANULAR PIGMENT. 183 albumen, conceal the minute black granules, just as if they dissolved them. The second and third kinds of morbid pigment-formation, some- times occur together. On making a microscopic examination, we then observe black granules of sulphuret of iron between the brown patches of altered and coagulated blood.* After the preceding observations, the conditions under which the two last kinds of morbid pigment occur may be easily explained. Acids change the blood-pigment in the stomach, and probably also in gangrene, since gangrenous fluids frequently have an acid re- action. Sulphuretted hydrogen and hydrosulphate of ammonia, which frequently occur in the intestinal canal, effect changes in the blood-pigment, either in that canal, or (escaping from it by endos- mosis, or in cases of perforation through the newly formed open- ing,) upon the surfaces of the spleen and the liver. When, either simultaneously or independently, the iron of the blood is dissolved, > and by means of hydrosulphate of ammonia is again precipitated, the deposition of sulphuret of iron takes place. But there is still much that is obscure in these processes. How happens it, for example, that the iron of the blood-pigment is so easily dissolved, when it is so difficult of extraction in normal hcematin, as Mulderf has shown to be the case. Probably the preceding decomposition of the blood plays an important part in this stage of the process. There can be no doubt but that the seeond kind of morbid pig- ment arises from the blood, and, further, from its colouring matter, Many writers, amongst whom Bruch is found, trace the origin of all kinds of granular pigment to the colouring matter of the blood. This is not impossible, but it can be nothing more than a supposi- tion. For that both are coloured in the same way is no proof that the one arises from the other. We are acquainted with many examples in zoo-chemistry where colourless matters give rise to coloured products; and it is highly probable that in the formation of blood in the embryo, the haematin arises from colourless matter. I have made a number of experiments by injecting blood.into the abdominal cavity of animals, with and without the addition of sul-. * See Plate ix, fig. 10. t Marchand u. Erdmann's Journal fUr praktische Chemie, 1844, No. xi. p, 136, &c. 184 PATHOLOGICAL EPIGENESES. phuretted hydrogen and hydrosulphate of ammonia, in order to convert it into granular pigment; but all my attempts have been unsuccessful, nor was I more fortunate in producing even a trace of granular pigment by treating either fresh or putrid blood with various reagents. The generality of writers designate the patholo- gical epigenesis of granular pigment by the general name of melan- osis. But the three kinds above described must each have distinct names, In the following pages I shall, therefore, designate the first kind as true melanosis, and the last two which depend upon chemical changes in the blood-pigment, and on the formation of sulphuret of iron, I shall name false or pseudo-melanoses. Gluge laughs at this distinction, and observes that the latter has nothing false but its name.* Names have always formed a subject of con- tention, although they are of little importance. Happily facts can never be set aside by witticisms. Further details on melanosis will be given in our observations on melanotic tumours, and in the special department when we treat of the individual organs. EPIGENESIS OF NERVOUS TISSUE. The normal nervous substance consists of many elements histolo- gically differing from each other. There are primitive nervous fibres which again are divided into cerebro-spinal, sympathetic (Volkmann and Bidder), and central; further there are central and peripheral nervous corpuscles (ganglionic vesicles.)f: The pathological epigenesis of nervous tissue is rare, and only afew of the above named elements have been observed to be morbidly pro- duced. In the way of regeneration, it is confined so far as we at pre- sent know to the epigenesis of nervous fibre (cerebro-spinal and proba- bly also sympathetic), since after division, and indeed after the exci- sion of small portions of the primitive fibres, the separated extremities unite with one another by newly formed nervous tissue.^ The nervous * Atlas d. patholog. Anatomie. Fasciculus. 3 Melanosis, pp. 7 and 16. t Compare Henle's Allgem. Anatomie, p. 613, &c.; Valentin in Wagner's Hand- wOrterbuch der Physiolog. vol. i. p. 686, &c.; Volkmann u. Bidder Die Selbstandig- keit d. sympath. Nervensystems, Leip. 1842. X Compare C. O. Steinruck^ de nervor regeneratione, Berol. 1838; H. Nasse in MaUe?'a Arcluv. 1839,,p. 405.; Gunther u. Scbon. Mailer's Archiv. 1840,p. 270. CARTILAGINOUS AND OSSEOUS TISSUES, 185 fibres thus formed are very similar to the normal fibres,* only that ac- cording to Nasse, they are somewhat smaller. The morphological process in this formation is little known, but indeed our knowledge of the normal process is very deficient. Doubtless the nervous fibres are formed from a fluid cytoblastema—the general fluid of nutrition—in accordance with the law of analogous formation. But the formation is very slow, being not complete till five weeks, sometimes till three or more months after the injury. It is much slower than the forma- tion of areolar tissue, blood-vessels, &c. Here is in all tissues of composite structure and of high physiological dignity, the epigenesis is limited, that is, all the fibres that have been destroyed are not again formed, and the regeneration itself only proceeds under fa- vourable conditions. Probably there are similar relations in force here as in the striated muscles previously described. Whether central nervous fibres and nervous corpuscles (gangli- onic vesicles) can be again formed, is unknown., That encephaloid is not a morbid production of the nervous system, as was formally supposed, is shown in the section on that subject. Further details concerning hypertrophy of the nerves, nervous tumours (neuroma,) regeneration of the substance of the brain, &c, will be given in the spe- cial department. EPIGENESIS OF CARTILAGINOUS ANI> OSSEOUS TISSUES. These two- tissues, in relation to their pathological epigeneses, are so intimately connected, that we shall consider them together. Normal cartilage consists of two elements histologically distinct —the cartilage cells, and an intercellular substance. The latter differs in the different kinds of cartilage ; in true cartilage it is amor- phous ; in fibrous cartilage it consists of fibrous tissue; in other car- tilages it exhibits an intermediate character, being sometimes amor- phous and slightly channelled, at other times fibrous.f The morbid production of cartilaginous tissue is not uncommon, but still it is confined within narrow limits ; true cartilage is not re- generated, the loss of substance being supplied not by fresh cartilage,, but by areolar tissue. This, arising from the perichondrium, in ac- * Plate v. fig. 10 and 11. .t See Henle's Allgem. Anat. p. 791, and Valentin in Wagner's Handwfiiterbuch* der Physiologie, vol. i. p. 720. 16* I8G PATHOLOGICAL EPIGENESES. cordance with the law of analogous formation, depends in part upon the fact that true cartilage has no vessels, and that therefore after its destruction, the cytoblastema in its vicinity is chiefly supplied to the areolar tissue of the perichondrium, and follows its law of formation. This circumstance is, however, insufficient to explain the fact that in bone similar conditions occur, and yet it is commonly true osse- ous substance, and not areolar tissue which is formed as a conse- quence of regeneration. Fibrous cartilage, on the other hand, which does contain vessels, is regenerated, but not so much by the new formation of cartilage-corpuscles as by the reproduction of fibrous tissue. The morbid production of true cartilaginous tissue is con- fined to cases of morbid formation of bone, (which are commonly, if not always preceded by the formation of cartilage), and, to the for-? mation of a peculiar kind of tumour consisting of cartilaginous sub- stance, and named enchondroma. To this we shall return when we come to speak of tumours. It has been already mentioned that many morbid formations of an apparently cartilaginous nature, con- sist in reality of fibrous tissue, more or less perfect areolar tissue, or simple muscular fibre. Normal osseous tissue consists of different histological elements—of radiating bone-corpuscles, and of an inter- mediate amorphous substance; these in their,union form tubes or laminae, which are differently arranged in different bones, and in- deed in different parts of the same bone, and in this manner are pro- duced the osseous canals, the cortical substance, the spongy tissue, &c. in whose interstices other substances foreign to the true osseous tissue are deposited, as marrow, vessels, nerves, and areolar tissue.* The pathological epigenesis of osseous tissue is of frequent occur- rence,, as, in the regeneration of destroyed or fractured bones, in hy- pertrophy of normal bone, which is sometimes local, forming a pro- tuberance on the external surface (exostosis) and is sometimes, ex- tended over the whole bone, or over several bones (hyperostosis.) It sometimes occurs in parts, where in the normal condition no bone existed -y as in the dura mater, the sesamoid bones, ossification of tendons, &c.; in osseous tumours (osteoid,) and in the ossification of cartilages which in the normal condition do not ossify, as for ex- ample, the larynx. In all these cases the newly formed osseous tis- * See Henle's Allgem. Anat. p. 813, and Valentin, op.,cit. p. 723. CARTILAGE AND BONE. 187 sue more or less resembles normal bone; it exhibits the osseous cor- puscles with their intermediate substance, and bony lamellae,* whilst the arrangement of these elements offers, as in normal bone, the greatest diversity. The morphology and chemistry of development are here as in nor- mal bone, still in many points obscure. What our experience has as yet taught us is as follows. In an amorphous cytoblastema which is either liquid or solid, and yielded by the nutrient fluid or by fibri- nous dropsy, cartilage-cells are first formed, and between them the amorphous intercellular substance of cartilage; in short true carti- lage. Simultaneously with this process, the original protein-com- pounds of the cytoblastema are converted into chondrin, which then changes into bone. In the first place the cartilage-corpuscles are increased in size or number, so that they preponderate over the volume of amorphous intercellular substance, and adopting a peculiar arrangement, collect together in groups. From these groups of cells, cavities are formed, which by connecting with each other, produce the future medullary canals, and the cells of the spongy tissue. In them are formed marrow, vessels, &c. The intercellular substance separating the cavities, simultaneously undergoes a change ; it sepa- rates itself into layers—the future osseous lamellae—in which the osseous corpuscles are formed. But since these ramifying canals extend over the original cartilage-cells (indeed frequently the canals proceeding from the different bone-corpuscles appear to be in con- tact) they must enter the intercellular substance either by resorption or prolongation. Together with these morphological changes, some of a chemical nature take place. The osseous substance becomes impregnated with calcareous salts, whilst its organic basis either remains chondrin, as in most pathological formations of bone, or is converted into common gelatin (colla.)f Whether a formation of cartilage invariably precedes the pa- thological formation of bone has never been determined by direct observation ; the analogy of the normal formation, however, ren- * Plate ix. fig. 7—9. \ Full particulars respecting the morbid as well as the normal formation of bone, the reader may consult, in addition to the works of Henle and Valentin already quoted : BischofT's Entwicklungsgeschichte, p. 432 ; Miescher de inflammatione os- sium eorumqne anatomia generali, Berol. 1836; Mayer in MQller's Archiv. 184Jvp. 210; Fleischmann in ditt", 1843, p. 202; Bidder in ditt^y 1843, p. 372. 188 PATHOLOGICAL EPIGENESES. ders this probable. In the regeneration of bone the pre-formation of cartilage is undoubted. Very many of what are termed patho- logical formations of bone or ossifications are nothing more than concretions, of which we shall speak hereafter. In the fqregoing pages we have considered the most important of the elementary tissues which admit of pathological re-formation: there are some others whose epigenesis can only occur under defi- nite and very limited conditions—as hair, nails, teeth, and glands, which will be considered in their proper places. TUMOURS. When the pathological epigeneses of the elementary tissues, treated of in the preceding pages, do not serve to unite portions of the body served by wounds, or to restore loss of substance ; when further they do not, as in hypertrophy, increase the mass of an or- gan by the addition of new substance similar to, and not to be dis- tinguished from the original; but when, on the contrary, the newly formed mass is more or less distinct from the surrounding parts, and when the scalpel of the anatomist can separate it from them and isolate it, such an epigenesis is commonly named a tumour. The idea attached to the word tumour is, however, very indefinite, and there is no distinct line drawn between tumours and regenera- tion of lost parts and hypertrophies. Again the tumours occurring in individual cases show an endless variety. There occur as ele- ments in their composition, not only the several tissues of whose epigeneses we have already spoken, but also many others which find no place in the normal body; and these several elements appear in certain cases under infinitely varied combinations. Hence a classi- fication of tumours is extremely difficult, and all attempts to arrange them (as we do animals and plants) into genera and species must necessarily fail; this does not, however, prevent us from ranging them in some sort into groups, in order that we may the more easily proceed in our consideration of them ; but we must always bear in mind that there is no definite division between one and another of them, and that through the various combinations of their composite elements, they offer an infinite variety of form. TUMOURS. 189 In a histological point of view, tumours may be arranged in two great divisions. To the first belong those whose elements may be considered histologically to agree with those of the normal body, and which further being once formed, discharge the duties of the normal constituents of the body, take a part in the general meta- morphosis of tissue, and are nourished and increased like other parts- These are homologous, non-malignant tumours. In the second division, we must place those whose elements in a histological point of view differ mqre or less from those of the nor- mal body, and which (as in the process of suppuration) from their nature give way, soften, and destroy the organic parts which sur- round them or which they enclose-r-heterologous, malignant tumours. But even this division cannot in all Cases be strictly adhered to, for if there are not peculiar intermediate structures, there are at any rate combinations of tumours, in part belonging to the one, and in part to the other division; as for instance, scirrhus, in which there is invariably a combination of homologous with heterologous ele- ments.* Although there are many tumours which can be most distinctly sepa- rated from all others, as for instance* many encysted, adipose, and fibrinous tumours, and some forms of encephaloid and colloid, yet in many, indeed, in the majority of cases this is not possible; hence such divisions as have been attempted by Plenck in accordance with the suggestion of Baglivi, into genera and species, necessarily fail, at least for the higher problems of science. Pathological anatomy must attempt to arrange them according to their histological elements, but since these in individual tumours are combined in the most varied manner, and to a certain degree appear vica- rious in relation to one another, it is impossible to arrange them as spe- cies, and we can only classify them according to their formations. * The most important literature on the general relations of tumours, and on their classification, is embraced in the following works: J. J. Plenck, novum systema tu- morum, Vienna;, 1767; Dictionn. des sciences medic, vol. tvi. p, 107; J. Abernethy, an attempt to form a classification of tumours. Surgical observations, London, 1804; Laennec in the Diclionn. des sciences m6dic. vol. n. p. 54; Meyen, Unters. uber die Natur parasitischer Geschwulste, Berlin, 1828; Joh. Mullwr uber den feineren Bau und d. Formeh der krankhaften Geschwulste, Berlip, 1838, or Dr. West's English translation, London, 1840 ; F. Th. Frerichs de polvporum structura penitiore, LeersB, 1843 ; and the various treatises on pathological anatomy hy Voigtel, Meckel, AndraJ, and Lobstcin. 190 PATHOLOGICAL EPIGENESES. The above leading division of tumours, into homologous or non-malig- nant, and heterologous or malignant, whilst it avoids the dangers of mis- leading, appears to me to be conformable to nature, and practically use- ful. Lobstein has preceded me in adopting it. Objections have recently been raised againgt it on the ground that heterologous epigeneses de- pend on the same laws (cellular formation, &c.) as the normal, and that in some of them, homologous formations likewise enter, as in scirrhus. This objection seems to refer only to epigeneses in the mass, and not to the individual elements. The more accurately we become acquainted with these the more sure shall we be that in the second division of these tu- mours, elements actually occur which are foreign to the normal organism, and that these foreign elements are the-true ground of their malignity. The fact must, however, be borne in mind that these heterologous elements cannot at every degree of their development' be with certainty distin- guished from the homologous, and consequently many cases arise in which after the most careful histological examination, it is impossible to discover whether a tumour is of the non-malignant or the malignant class. Finally it has not always been clear wherein consisted the non-malignant or the malignant character of a tumour. It has been generally agreed that the non-malignity of a tumour consisted in the circumstance that it would not be reproduced after extirpation; those which after extirpa- tion were again produced being held as malignant. This view 1 regard as incorrect; tumours which are manifestly non-malignant, as for instance encysted tumours, may again reappear though the same originating force which first produced their development, whilst tumours notoriously ma- lignant may never return after their extirpation, or may even vanish of themselves provided that the disposition to their formation no longer exists, as has been undoubtedly shown in relation to pulmonary tubercle. The malignity which forms the grand principle of division between these two classes of tumours is connected with the very nature of the tumour itself, and depends upon its histological elements. Indeed the clear distinction between malignant tumours and unhealthy suppuration, &c, disappears ; but this separation is only artificial and not based on nature. The above provisional remarks are sufficient to give the reader an idea of the principles I adopt in the classification of tumours. OF NON-MALIGNANT TUMOURS ANALOGOUS TO THE NORMAL ELEMENTS OF THE BODY. To this class belong those tumours whose elements agree with the newly formed tissues, occurring in cases of regeneration and NON-MALIGNANT TUMOURS. 191 hypertrophy. The tissues which occur in them are areolar, fibrous, and simple muscular tissue, adipose tissue, vessels, granular pigment, cartilaginous and osseous tissues, and in a few cases also hair, teeth, &c. Sometimes they consist principally of a single tissue, but more frequently of several in conjunction, and in the utmost possi- ble variety of combinations. Some of them are intimately connect- ed with the surrounding normal parts of the body, and arising from the same elements, form as it were a sort of hypertrophy. Others are quite distinct from the surrounding parts, sometimes even so far as to be surrounded by a membrane which either con- sists of the normal elements of the surrounding parts (chiefly areolar tissue) compressed by the tumour, or else is itself a patho- logical epigenesis. This membrane is most clearly seen in those tumours which are termed encysted. As in their histological composition, so also in their modes of origin and development, there is an entire similarity between these tumours and cases of regeneration and hypertrophy. They follow in all respects the general law which has been previously laid down for the pathological formation of the elementary tissues. They further resemble cases of regeneration and hypertrophy in their physiological functions and in their further progress. Like them they exhibit various properties in their several stages of develop- ment; like them they are nourished and increased, and form persistent constituents of the body, often enduring many years be- fore death supervenes, usually increasing and very rarely becoming smaller. It is upon these circumstances that their non-malignity depends. In those cases where they become hurtful to the organ- ism, and even soften like malignant tumours, that depends not on their own nature, but on fortuitous external circumstances. They may, for instance, become injurious from their size, and from their pressure on surrounding parts; they may proceed to inflammation and suppuration when they are situated on the outer surface of the body, where from their prominent position they are particularly exposed to mechanical injuries, as blows, the pressure of dress, &c. They may also be combined with malignant growths, especially with tubercles and encephaloid, which may be deposited in them exactly as in normal parts of the body. In scirrhus as we shall presently see, such a union of non-malignant and malignant ele- ments occurs. 192 PATHOLOGICAL EPIGENESES. Pathological anatomy has as yet done but little in elucidating the causes of their formation. In their commencement they are usually small, and they undoubtedly depend on the formation of a cyto- blastema which becomes organized and gradually forms a tumour. Sometimes a mechanical injury, as a thrust or a blow, appears to produce a cytoblastema of this kind, which is then doubtless extra- vasated blood and coagulated (rarely fluid) fibrin. A cytoblastema of this kind appears, however, usually to be produced by internal causes, such as locally increased secretion with hyperemia of the capillary vessels, and only seldom to arise from true inflammation. The organization of this blastema usually follows the lawT of analogous formation; thus in adipose regions of the body, tumours appear which consist principally of fatty tissue ; in parts Consisting chiefly of areolar and fibrous tissue, we have fibrous tumours ; and in muscular coats, tumours of simple muscu- lar fibre; under the skin we often find encysted tumours whose membranes have a histological composition analogous to that of the cutis, with glands, hair-bulbs, and epithelium. But all the rela- tions connected with the formation of non-malignant tumours, do not admit of this mode of explanation. Many of them are quite inexplicable, as, for instance, the formation of hair, teeth, and bone in encysted tumours of the ovaries. When a tumour is once formed, it takes its share with the rest of the body in the general metamorphosis of tissue, and the part is often an active one, since most of these tumours possess considerable vascularity, and there can be no doubt that they usually owe their increase to the irrita- tion which they set up in the surrounding parts, their vessels becoming hypersemic, and therefore yielding more than the ordinary quantity of cytoblastema. Most of the above tumours maybe arranged under one of the following groups. FIRST GROUP. TUMOURS CONSISTING PRINCIPALLY OF VESSELS. Vascular Tumours. Non-malignant tumours which dOnsist principally of blood-vessels With small quantities of intermediate areolar tissue have received VASCULAR TUMOURS. 193 the name Telangiectases. More or less synonymous with these are those denominated : Aneurysma per anastomosin, Tumeur erectile, Tumor splenoids, Hcematoma, Hcematoncus, JYcevus vasculosus, &c. These tumours are of red or bluish-red colour, of various forms and sizes more or less firm, and more or less capable of temporary erection, like the normal erectile tissues. They generally appear on the external skin, or in the subjacent cellular tissue upon various parts of the body; as on the head, scalp, cheeks, eyelids and lips, also, on the trunk, the arms and the lower extremities. They are usually congenital but afterwards increase in size ; in some cases, however, they are first produced after birth ; and occur both in children and in adults, often without any perceptible cause, but sometimes after a mechanical injury, as for instance, a contusion. On examining one of these tumours in the dead body, or after extirpation, it usually appears white and bloodless, because the fluid contents very rapidly escape ; but on placing a small .por- tion under the microscope immediately after extirpation, the smaller vessels, at the least will be seen partially filled with blood. A section after b,eing thoroughly washed, is observed either by the naked eye, or by a lens, to have a cribriforra'appearance, the orifices corresponding with the sections of the divided vessels..* On ex- amining carefully prepared sections under the microscope, the walls of the vessels may be discerned, and between them perfect or par- tially developed areolar tissue, caudate cells and nuclei. The ves- sels have usually a tolerably large diameter," being very distended capillaries, small arteries, and small veins ; when arteries predomi- nate; the tumours during life exhibit pulsation; and when veins, the}' present a bluish colour.f Their development depends either on dilatation of the normal capillaries, the ends of arteries and the commencement of veins, at first only temporary and produced by the same causes which give rise to local hyperemia and subsequently becoming permanent; or else on an epigenesis of vessels in the manner previously described. When Telangiectases form true prominent tumours, in addition to * J. Muller, Uber den fein. Bau und die Formen der krank. Geschwulste, Plate m. fig. 15 and 16. t J. Muller, op. cit. Plate in. fig. 17. 17 194 PATHOLOGICAL EPIGENESES. the formation of vessels, there is alwTays an epigenesis of areolar and fibrous tissue. True Telangiectases are never encysted, but are intimately con- nected with the surrounding parts, and are altogether non-malig- nant. When they are situated in the subcutaneous cellular tissue, they may sometimes become dangerous, by the gradual tension and attenuation of the skin, by spontaneous rupture of their' vessels, bleeding, inflammation, suppuration, &c. Most kinds of tumours, non-malignant as well as malignant, are in some degree furnished with vessels. These tumours when the vessels predominate, may be regarded as a combination of some other form with trie vascular. Such combinations frequently occur at a certain stage of malignant tumours, namely when they soften, break up, and form on their surface luxuriant and very vascular spongy granulations. Hence arises a peculiar form of malignant epigenesis, termed Fungus hcematodes, of which we shall speak hereafter, and which must not be confounded with true Telangiec- tasis. Common as vessels are in other forms of tumours, yet except in the case of common vascular tumour, they play only a subordinate part, the cha- racteristic properties being dependant on other tissues. Hence that ap- pears an unsuitable arrangement of Abernethy,*'in which he places tu- mours containing vessels in a class or species by themselves; for his " com- mon vascular or organized sarcoma," embraces within its range many tumours differing exceedingly from one another in their essential proper- ties. In our observations upon the different tumours, we shall continually return to the consideration of the relation in which vessels stand to the remaining elements of their composition. With regard to the varieties of ,vascular tumours, we shall say more in the special part in which we treat of tumours in the-different organs. * Abernethy's Surgical Observations, p. 19. FATTY TUMOURS. 195 SECOND GROUP. TUMOURS CONSISTING PRINCIPALLY OF ADIPOSE TISSUE. Fatty Tumours. In many tumours fatty tissue is the prevailing element; indeed some tumours consist of it alone. To such we apply the term Li- poma. In appearance they resemble normal fatty tissue : when re- cent, they present to examination a soft mass of yellowish colour, with a fatty feeling, which on being dried or heated gives out fluid fat, forming greasy spots upon paper. Under the microscope they appear to be composed of an aggre- gation of fat-cells, which perfectly accord with those of the normal fatty tissue. These fat-cells vary from the 12th to the 21st of a line in diameter, and are round or else laterally compressed into a polyhedric form. They consist of an amorphous cell-wall which sometimes but not often, encloses an undoubted nucleus, and of fluid fat contained in the interior. The fat may be thoroughly taken up by boiling alcohol or ether. It is chemically identical with the ordinary human fat, and consists of a mixture of olein and marga- rin. Sometimes the latter is present in so large, a,'quantity, that as the body cools after death, or the tumour after extirpation, it forms accicular crystals, which appear either singly or in stellar groups in the interior of the fat-cells.* The cell-wall probably consists of a protein-compound. When a fresh tumour of tfiis kind is submitted to pressure under the microscope, some of the' fat cells burst, and the fat escapes from them in the form of oil-globules. These appear, therefore, to be an artificial product. In a true lipoma, I have never seen free fat-globules. In the normal fatty tissue, there are vessels and fibres of areolar tissue, in greater or less abundance, between the true fat-cells ; and the same is the case in fatty tumours.. Sometimes the vessels, and more espe- cially, the areolar tissue are very sparingly found. In other cases, on the contrary, the areolar tissue abounds, forming tough fibrous par- * Plate x. fig. 3. 196 PATHOLOGICAL EPIGENESES. titions between the parcels of fatty cells.* The tumour is firm and solid, assuming more or less the physical qualities of lard, in propor- tion as the areolar tissue abounds. It then receives the name of lardaceous tumour {Steatoma or Tumeur lardacee.) Fatty tumours are thus histologically combined with the next group, namely ,'fibrous tu- mours. Between the true fatty and the true fibrous tumour, there seems an almost infinite number of transition forms. Fatty tumours, are more or less clearly distinct from the surround- ing parts. Sometimes they are most intimately connected with the normal fatty tissue, and these must be regarded as cases of local hypertrophy. In other cases they are more or less clearly Sur- rounded by a cyst. This cyst usually consists of a kind of sheath of areolar tissue, which is, however, generally very imperfect and of different thickness at different parts; it is connected with the inner layer of areolar tissue which penetrates the tumour, and thus serves rather to connect the tumour with the surrounding parts than to separate it from them. In some cases, however, this sheath is more clearly formed, becoming, indeed, a perfect cyst, entirely dividing the tumour from the parts in its vicinity. These cases form the transition between the true fatty tumours and the genuine .encysted tumours. Of this transition we shall speak hereafter in our obser- vations on encysted tumours. . The vessels in fatty tumours are usually few, and for the most part small, as is also the case in nor- mal fatty tissue. Fatty tumours are sometimes congenital, but they likewise arise at every age and in various parts of the body ; commonly in the subcutaneous fatty tissue of the shoulders and the buttocks, but also on the face, the extremities, and the internal parts of the body, especially the omentum. They appear to be more frequent in women than in men (v. Walther, Chelius.) Their growth is more Or less rapid, and they often attain a very consider- able size. Those of the size of a cherry have been observed in- creasing to the size of an apple, and indeed to that of the head, and have been known on extirpation to weigh as much as twelve, twenty-one, or twenty-five pounds, and even more. They some- times appear singly, sometimes several occur simultaneously on different parts of the body of the same individual. Fatty tumours are in themselves always non-malignant, yet th*y are apt frequently * Plate vii. fig. 1, FATTY TUMOURS. 197 to reappear after extirpation.* They may be injurious to the organ- ism in many ways and may even prove dangerous. By pressing upon nerves they sometimes cause frightful sufferings (Weidmann, v. Klein.) These injurious effects increase .with their size. Those occurring on the external parts disfigure the appearance and distend the skin, causing dilatation of the superficial veins in consequence of their having to take on the duties of the deeper vessels, which are compressed by the tumour. They become incommodious from their weight. The distended skin and compressed adjacent parts inflame, suppurate and ulcerate, and these actions proceeding with increasing virulence, the patient ultimately sinks from hectic fever and exhaustion. Many steatomatous tumours are combined with malignant growths and become scirrhus ; at least so it is believed, though as histological proof is wanting, it is not impossible that sometimes, their destruction by suppuration may have been con- founded with the formation of carcinoma. ■ The causes giving rise to fatty tumours are still very obscure. It may be that the first foundation of these tumours is in a local increased deposition of cytoblastema converted into fatty tissue. In this change the law of analogous formation takes an active part, for these tumours prin- cipally arise in those regions which in the normal condition abound in fat. External causes frequently give rise to an increased secre- tion of blastema ; a blow or thrust may cause it; but, as often we can point to no external cause. This need not surprise us, when we consider how frequently, without any appreciable external cause or even symptom, extravasations of blood and collections of-fibrin- ous fluid, coagulated fibrin, &c, present themselves in the interior of the body, which under favourable circumstances might doubtless be converted into fatty tumours. As in the normal formation of fat, there is much that is still obscure, so in the formation of fatty tumours, we are stillmore in the dark in relation to the mode in which their nutrition is conducted. It is further probable, that sometimes as Abernethyf has conjectured, an imperfectly formed tumour of another kind, as for instance, a fibrous tumour, through a change in the mode of its nutrition may take up fat and thus become * See the description of Plate vn. fig. 1. t Surgical observations, p. 9. 17* 198 PATHOLOGICAL EPIGENESES. converted into a fatty or lardaceous tumour. When a tumour has once formed, it increases in accordance with the law of analogous formation, which in this case is identical with the laws regulating normal nntrition. As the histological examination of tumours is only of very recent origin, it is difficult and often impossible to de- termine the nature of the tumours described by the earlier observers. From the absence of microscopic examination and description, it is im- possible to identify the tumours described by the older writers* Of the tumours belonging, according to the old terminology to,this group, there are: lipoma, some cases of lupia (many belonging to encysted tumours,) some cases of steatoma (which, as has been already remarked, forms the transition to fibrous tumours,) and a small portion of the cases of sarcoma (Abernethy's adipose sarcoma; most, however, belonging to the group of fibrous tumours.) Miillert distinguishes the following varieties of h'poma: 1. Lipoma simplex-:—the true fatty tumour. 2. Lipoma mixtum, with penetrating membranous layers—the combination with the fibrous tumour, forming steatoma; and 3. Lipoma arborescens—ramifying productions consisting of fatty tissue, and occurring in the joints, especially at the knee joint. Growths of this sort are covered by a prolongation of the synovial membrane, and hang loosely in the cavity of the joint, forming arborescent tufts somewhat swollen at their extremities. V. Waltherf distinguishes as a peculiar variety, the Nxvus lipomafodes, a lipoma appearing at birth in the subcutaneous fatty tissue, and connected with a change in the cutis. Gluge§ describes under the name of Lipoma colloides, a particular kind of fatty tumour, upon which I can at present offer no opinion. The che- * The following works constitute the most important literature of the subject: Abernethy's Surgical Observations, 1804, p.26; Ph. Fr. v. Walther, uber die ange- bornen Fetthautgeschwulste, Landshut, 1814, m. 2 Tab.; J. P. Weidmann, Annotatio de steatomatibus, Moguntiaci. 1817, ace. 5 Tab.; J. Fr. Meckel, Handb. der Pathol. Anatomie, vol. n. Part. n. 1618, p. 119, &-c.; v. Klein, uber Speckgeschwuls'te, V Graefe und v. Walther's Journal, vol. i. p. 109 ; Chelius, Handb. d. Chirurgie. unter Fettgeschwulst und Steatoma; J. Muller, tiber den feineren Bau und die Formen der krankhaften Geschwulste, 1838, p. 49; G. Gluge, Abhandlungen zur Physiologie u. Pathologie, 1839, p. 130, 1841, p. 185 ; D.Heyfelder delipomate et steatomate, 1842; numerous references to, arid -quotations from the older authors, are given in these works. * t Op. cit. p. 50, or West's translation, pp. 153—4. X Op. cit. p. 22. § Op. cit. 1838, p. 131, &c; 1841, p. 185.&.C. FIBROUS TUMOURS. 199 mical relations-of fatty tumours may be easily deduced from the foregoing observations. After the preceding observations, it will not be expected that we should attempt a division of fatty tumours into precise species and sub-species; but if it be desired to form a tolerable idea of the several possible and actual forms which they take, or changes which they experience, the following arrangement may be serviceable. The true fatty tumour may pass: 1. Into general infiltration of fat (polysarcia, obesitas,) by local hypertrophy of the adipose tissue. 2. Into fibrous tumour, by the accession of areolar tissue. 3. Into encysted tumour, by the production of a decided cyst. Probably there are occasional transitions into other kinds of tu- mours, even into those ofa malignant nature. The transition into the vascular tumour is doubtful, since vessels in fatty tumours always play a very subordinate part. In reference to their diagnosis it must be mentioned that many forms of malignant tumour—as encephaloid—have in their physical properties, the greatest similarity to fatty tumours, and can only be distinguished from them by microscopic examination. For particu- lars on this subject we must refer to the section on m'alignant tu=- mours. .' THIRD GROUP. TUMOURS CONSISTING PRINCIPALLY OF FIBROUS TISSUE. Fibrous Tumours. Tumours of which the prevailing element is fibrous tissue are very frequent, but they appear under so many varieties of form, not only in their physical properties, but also in their histological arrangement, that it is difficult to assign to them any general characteristic. Their varieties are not merely dependant on their being combined with other forms of tumour, but also on the different stages of develop- ment of the tissue. We shall therefore in the first place attempt to give certain ele- mentary types of these tumours. The forms which are most definite 200 PATHOLOGICAL EPIGENESES. and easy of determination, are thosewhere the fibrous tissue appears perfectly formed. This tissue as seen under the microscope consists of fibres, which can be more or less easily separated, and are sometimes very fine, sometimes tolerably thick, their diameter varyingbetween the the 2000th and the 400th of a line. The fibres of the same tumour, are, however, pretty generally of nearly the same thickness. Histologically these fibres resemble either those of normal areolar tissue, in which case they are fine and measure from the 2000th to the 1200th of a line'; or theyresemble those of the normal fibrous tissue, as of fibrous membranes and tendons, in which case they are somewhat thicker and measure from the 1200th to the 900th of a line ; or lastly they re- semble normal simple muscular fibre, in which case they are broader, and have a diameter varying from the 900th to the 400th of a line. All these fibres are rendered transparent by acetic acid, becoming gradually pale till they disappear: occasionally,, however, a few larger ones (varying from the 1000th to the oOOth of a line) remain unchanged in acetic acid; these divide in an irregular manner and penetrate the tumour. These fibres insoluble in acetic acid, corres- pond with the nucleated fibres of areolar tissue.- On the other hand, after-the application of acetic acid, there appear more or less nu- merous groups of oval, or sometimes pointed, oat-shaped nuclei, presenting occasionally a curved appearance, similar to those which appear in the normal formation of fibrous tissue. In none but ma- -ture and perfectly formed tumours are these nuclei ever absent. We may also frequently remark between the perfect fibres, fusiform nucleated cells, apparently arrested in their development. They are found when a.fresh section of the tumour has been pared off with a blunt knife, and is placed in water under the microscope.* In future for the sake of simplicity, we shall subdivide this class into tumours of areolar tissue, tumours of fibrous tissue, and tumours of simple muscular fibre. It is frequently, however, impossible to follow this arrangement, for fibrous tissue when morbidly reproduced, shows various degrees of inclination to one or to another of these varieties, so that after the most careful examination, it is not always possible to determine whether the fibrous tissue of a tumour most approxi- mates to areolar tissue, normal fibrous tissue, or simple muscular * See Plate vn. figs. 2, 3, and 4, and their explanation. FIBROUS TUMOURS. 201 tissue. But the division, if not pushed too far, will be found to be grounded on their true nature, and practically useful in relation to the genesis of the tumour. Notwithstanding the similarity of their elements, the tumours of this group'present very material differences in the histological ar- rangement of their fibres, and together with this they present also great variations in their physical properties. It is only in rare cases that the fibres are loosely connected with each other, easily isolated into either single fibres, or connected fasciculi with an undulating appearance, as in normal areolar tissue. In these cases-, the tumour is soft, flexible, more or less elastic and coriaceous, resembling in its physical properties the tissue of the cutis [Desmoid tumour.) More frequently the fibres are closely compressed, separated with difficulty, and united into a solid mass. • The tumour is then solid, firm, and very elastic, cannot be drawn asunder, and craunches under the knife; and the section presents a map-like appearance. This form is called Sarcoma, or Fibroid. When the union and fusion of the fibres reaches a yet higher degree, the tumour becomes very firm, almost homogenous, and of a milk white colour; it is more easily cut into thin layers than separated into fibres, and has in its physical properties the greatest similarity to cartilaginous tissue, without, however, resembling it in a histological point of view {Chondroid tumour.) This form presents the transition to the second class of fibrous tumours, where instead of fibres, a more amorphous mass is presented. • Other differences in fibrous tumours are dependant on the manner in which the fibres are arranged. Sometimes they run irregularly in every direction, as in the normal cutis; this is usually the case in those fibrous tumours which are developed upon the external skin, or upon mucous membranes, (warts, condyloma, fibrous polypi, Sec.) In other cases the fibres are arranged in a regular manner, in con- centric or twisted circles, and sections of such tumours sometimes present very beautiful designs, visible to the naked eye; this is the case with the so termed fibroid of the uterus.* Not less various are the ways in which fibrous tumours are con- nected with their surrounding parts, and also the forms in which * Sec (luge's Atlas der pathol. Anatomie, Part iv. Tab. 4. fig. 14, 15; and Hope's Principles and Illustrations of Morbid Anatomy, fig. 215. 202 PATHOLOGICAL EPIGENESES. they occur. Many of them are most intimately connected with, and as it were, fused into the surrounding parts, and form the tran- sition to the hypertrophy of such organs as in the normal condition consist of fibrous tissue. Thus in the stomach, the intestinal canal, and the uterus, we frequently.meet with every stage of transition from isolated fibrous tumour to local hypertrophy: and condylomata, warts, and fibrous polypi form transitions from the isolated fibrous tumour to local hypertrophy of the cutis and mucous membrane. In allthese cases it-must of course follow.that just in proportion as the tumour is less isolated, and more connected with the. surround- ing parts, in such proportion its form must be undefined. Other fibrous tumours are definite circumscribed and less closely connected with the surrounding parts, usually being separated from them by a kind of cyst of areolar tissue, which, however, as we have already mentioned in our observations on fatty tumours, is more closely united to the surrounding parts than to the tumour. In these cases the external form of the tumour is more defined ; it is commonly irregularly round, but occasionally presents an interlaced or ragged appearance. Sometimes the fibrous tumours are so perfectly iso- lated, that they show scarcely any connexion with the surrounding parts, but lie free from them as it were in a sheath, and on cutting the surrounding capsule fall out. This is occasionally noticed in fibrous tumours of the uterus, which are sometimes quite detached (like a knot in a board) in the parenchyma of that organ or in its cavity, so that, in some cases even during life, they can be removed without suppuration or other process of destruction, simply by ute- rine contraction. In such cases, the form of the.tumour is usually clearly defined, sometimes appearing perfectly round like a musket- bullet or billiard-ball, and -sometimes nodulated. Doubtless the direction taken by the fibres is the most influential cause in modify- ing the form and properties of the surface. All perfect-fibrous tumours contain vessels; it is only in very small tumours of this kind that I have been unable to discover them. It is, however, probable that the isolated tumours just mentioned are non-vascular, and that they receive the blastema necessary to their growth from the vessels of the neighbouring parts. It appears, however, probable, that some, if not all of these tumours, have in some of their stages possessed vessels, but that subsequently in pro- portion as the connexion of the tiimonr with its surrounding parts FIBROUS TUMOURS. 203 became slighter, they were gradually obliterated, and at last en- tirely disappeared. Usually, however, the vessels of fibrous tumours are few in num. ber, and it is only in rare instances, or in cases where changes occur of which we shall speak presently, that such tumours are rich in vessels. But that pathological formations of fibrous tissue may be combined with vascular formation, we have already seen in our remarks on vascular tumours,, (see p. 192.) But these vascular tumours are essentially distinguished in their entire character from proper fibrous tumours. We have likewise already spoken of the combination of fatty and fibrous tumours. • This combination presents the most manifold va- rieties. Sometimes the two elements are so intimately connected, that only microscopic examination can distinguish them. In other cases, and indeed most commonly the two elements are arranged in large groups, easily discernible with the naked eye, so that the same tumour examined at one part, will sometimes appear as a fatty tumour, examined at another, as a fibrous tumour,-and at a third, as a tumour composed of the combined elements. The other principal histological variety of fibrous tumour is cha- racterised by the fact that it contains no perfectly formed fibres, but rather presents the appearance of an amorphous mass, in which a more or less strongly expressed tendency to'fibrillation is discernible. These tumours exhibit under the microscope a mass entirely amor- phous, amorpho-granular, or amorpho-fibrous, in which oil-globules or fatty granules are sometimes found. By the application of acetic acid the mass becomes transparent, and more or less clearly exhibits nuelei, which resemble those of the fully developed fibrous tumours. Between this almost amorphous mass, and the perfect fibrous tu- mours, there is every intermediate stage. These amorphous fibrous tumours have a lardaceous appearance, and the transition-forms springing from them, are firm and similar to cartilaginous tissue, with a milk-white or yellow colour. They are never rich in ves- sels, and sometimes altogether devoid of them. They must be re- garded as fibrous tumours, whose histological development is yet at a low stage, or whose substance is incapable of development car- ried to any high degree. They may, however, be known to belong to the class of fibrous tumours by the fact that, in one and the same tumour, there are found parts which are entirely amorphous, alter- 204 PATHOLOGICAL EPIGENESES. nating with others which exhibit fibrous tissue. It is highly proba- ble that a large number of fibrous tumours arise from an amorphous solid blastema, and that consequently most fibrous tumours at an early stage of their development, exhibit this amorphous character. The chemical relations of fibrous tumours present many differ- ences. The perfect fibrous tumour yields gelatin analogous to that of areolar tissue (colla), while from those consisting of simple inter- laced muscular fibre, no gelatin is yielded on boiling. Neither by boiling can we obtain gelatin from the fibrous tumours which are yet undergoing development, and are amorphous. Accurate ulti- mate analyses of these tumours are still wanting. Their occurrence. The various forms of fibrous tumour occur in all parts of the body which in the normal condition, contain much fibrous tissue; on the external skin and the mucous membrane, as cases of hypertrophy, condylomata, warts, and polypi; in the Sub- cutaneous cellular tissue; upon the periosteum and in the interior of the bones ; on the muscular coat of the intestinal canal, in the muscular tissue of the uterus, and in the ovary; in tjie cavities of the thorax and abdomen, where they, often reach a very considera- ble size and in the cavity of the skull, where they frequently arise from the dura mater. • And here the fact is exemplified, that when fibrous tumours arise in parts where areolar tissue prevails, they consist principally of more or less fully developed.fibres of areolar tissue, whilst tumours consisting of simple muscular fibre, are only found in those parts which consist in the normal condition of simple muscular fibre. Of the causes leading to the origin of these tumours, the same may be repeated as was formerly said with regard to fatty tumours. They are sometimes congenital, but more frequently appear after birth, and often, indeed, not until an advanced period of life : this is especially the case with fibrous tumours of the uterus. Their first germ is probably always dependant on the deposition of an amor- phous blastema (extravasated blood and coagulated fibrin) which, in accordance with the law of analogous formation, they convert into fibrous tissue, and the occasion of this deposition is very usually a mechanical injury, as a blow, a thrust, or fall. But the cause when the mischief occurs in deep-seated parts is often beyond the power of art to trace. Experiments on animals are very well calcu- lated to throw light on the origin of these tumours. I will here FIBROUS TUMOURS. 205 quote one case which appears to me very instructive in this point of view. I injected several ounces of an aqueous solution of hydro- sulphate of ammonia into the abdominal cavity of a large dog, through a small wound in the linea alba, and then immediately closed the orifice by a suture. For the first quarter of an hour after the operation, the animal appeared to suffer violent pain; within an hour, however, he recovered and remained afterwards as well as if nothing had happened. At the expiration of twenty-four hours he was killed. There was an amorphous exudation of coagulated fibrin on several convolutions of the intestinal canal Under the peritoneum, and blood was extravasated between the muscular and serous coats. On the anterior surface of the stomach there was a coagulum of j^lood of the size of a hazel nut, surrounded by a thick layer of co- agulated fibrin, and firmly attached to the outer wall of the stomach. I am thoroughly convinced that this coagulum would, in time, have been converted into a fibrCus tumour, if the animal had not been killed. I had frequent opportunities of making similar observations. This appears to illustrate the probable origin of .fibrous tumours in man, at least of such as occur in the stomach, the intestinal canal, and more especially in the uterus, where there are frequent opportu- nities for the formation of coagula and of fibrinous exudations. In proportion to the smallness of the exudation, is the influence of the surrounding normal fibrous tissue, and the facility with which the exudation can be organized: consequently the most perfectly formed fibrous tumours are cases Of hypertrophy, where the exudation is gradual and never in large quantities; and conversely, when the exudation is in large quantity, it is probable that the amorphous fibrous tumours are formed. When the tumour has once arisen, it is easy to explain its further growth. In those tumours which are provided with vessels, this growth takes place not simply at the sur- face, but through the entire mass. Moreover, in very large tumours we observe on making a thin section, fibres in the course of de- velopment—caudate cells. The further progress of fibrous tumours is very similar to that of fatty tumours. They "are in themselves throughout their whole course non-malignant, but they may in various ways become injuri- ous, as by pressure on nerves, vessels, &c.; or by their size which often becomes very considerable, such tumours attaining a weight of twenty pounds or even more. They then distend the skin, cause 18 206 PATHOLOGICAL EPIGENESES. its veins to swell, and give rise to inflammation, suppuration, and ulceration. Many fibrous tumours, especially those seated in the uterus, ossify ; that is concretions are formed in them—unorganized depositions of calcareous salts, which are often falsely regarded as newly formed osseous substances. Of these we shall speak in our observations on concretions. We shall presently notice the combinations of fibrous tumours with malignant epigeneses. Though it is impossible to divide fibrous tumours into proper species, yet the following forms and transitions may be distinguished. Perfect or fully developed fibrous tumours approach nearly to areolar tissue, to normal fibrous tissue, or to simple muscular tissue. They exhibit transitions: 1. Into the amorphous forms of fibrous tumours. * 2. Into vascular tumours (rarely.) 3. Into fatty tumours. All these transitions arise spontaneously from the above form. 4..Into cartilaginous and osseous tumours. 5. Into encysted tumours, through the compound Cystoid—in a manner to be described, when we come to encysted tumours. 6. Into malignant tumours, of which hereafter. This transition is of especial importance, but often very difficult to diagnose. 7. Of other transition-forms we shall speak in the appendix to the tumours. In these as in fatty tumours, it is very difficult to understand the earlier classifications founded on external signs.* To this class belong, as has been already mentioned, some forms of hypertrophy of the exter- nal skin and mucous membrane—condylomato and polypi, desmoid, some cases of steatoma and of sarcoma, the greater number of cartilaginous tumours, {Chondroid,) many cases of osteosarcoma, and fibrous tumours. * Some of the literature of the subject, (that namely referring to steatoma) has been already given in p. 198. To the works there named we may add: J. Muller in his Archiv. for 1836, Jahresber.; J. F. Meckel's Patholog. Anatomie, vol. ii. Part n. p. 165, 242; Gluge's Atlas d. pathol. Anatomie, Part iv. Fasergeschwulste: G. Val- entin in his Repertorium, 1837, p. 270. Several histological delineations are given by Muller; see Plates ii. and in. of Dr. West's translation. The above literature has relation chiefly to the peculiar form of fibrous tumour occurring in the uterus, and we shall return io this subject in the special department, when speaking of that organ. CARTILAGINOUS TUMOURS. 207 Muller* distinguishes tendinous and albuminoid fibrous tumours; the former are fully formed, and on boiling yield gelatin ; the latter are either not fully developed or consist of simple muscular fibre, and on boiling yield no gelatin. For information with regard to the chemical properties of these tumours, we have to thank J. Muller and Valentin for their ex- tensive investigations. Muller has shown that we may distinguish fibrous tumours into those which yield gelatin, and those which do not yield it. Valentin endeavoured to prove that the elementary matter of fibrous tu- mours in the uterus is coagulated fibrin and not albumen, but the reac- tions on which he founded his opinions, cannot at present be regarded as decisive. Decisive ultimate analyses are still desiderata. It cannot be doubted but that in a chemical point of view, the laws regulating the development of these tumours, correspond with those influencing the development of the normal fibrous tissues. FOURTH GROUP. TUMOURS WHICH CHIEFLY CONSIST OF CARTILAGINOUS TISSUE, Cartilaginous Tumours. Tumours into the composition of which cartilaginous tissue en- ters, are of much less frequent occurrence than those hitherto de- scribed ; they are, indeed, rarer than we might be led to judge from physical characters alone; since, as already stated, many swellings apparently cartilaginous belong, in reality, to fibrous tumours. Most frequently true cartilaginous tumours appear as hypertrophies and abnormal growths of bones—as callus, exostosis, &c. They then consist of. true cartilaginous tissue, but only in a state of transition, since they gradually pass into osseous substance, and thus into osse- ous tumours in the manner described in page 185. Isolated carti- laginous tumours occur more rarely, and it is only within a-few years, and chiefly by means of J. Muller'sf elaborate investigations, that they have been known with any degree of accuracy and designated * Archiv. 1836, Jahresbericht. t Compare J. Muller uber d. fein. Bau d. krankh. Geschwulste, p. 31, &c.; or West's translation, p. 96, &c.; Dr. Jac. Herz, de enchandromate, Erlangos, 1813; G. Gluge, Atlas der pathol. Anatomie, Part 4. 208 PATHOLOGICAL EPIGENESES. by the term, enchondromata. We must now proceed to the closer consideration of these tumours. Enchondroma appears under three distinct forms: in the bones, either 1, in the interior; or 2, on the surface covered by the perios- teum; and 3, in soft parts, as for instance, glandular organs. It forms a roundish, and generally a smooth tumour of variable size, which oh a section being made allows even the unaided eye to recog- nize two distinct constituents, one fibro-membranous, and the other gray, transparent, and soft, resembling firm jelly or softened carti- lage. The latter element shows under the microscope roundish or elliptic cells varying from the 150th to the 50th of a line in diameter, and sometimes even larger, which enclose a granular nucleus ranging from the 200th to the 300th ofa line in diameter. These some- times occur as primary cells, and contain several nuclei, or even one, two, or three more recently formed and proportionally smaller cells in their interior.* Besides the nuclei we also occasionally observe irregular, oblong, pointed bodies which are suggestive of bone-cor- puscles.f These cells resist the action of acetic acid better than most other animal cells, and, in general, are but loosely connected together, being readily isolated by slight pressure: in some more rare cases there exists between them, as in normal true cartilage, an amorphous firm intercellular substance -r\ the entire mass in this case is firmer, and in its physical characters more closely resembles true cartilage. The fibro-membranous portion appears under the microscope as fibrous tissue, arranged into sheaths or nets, in the meshes of which is lodged the cellular substance. The latter is sometimes of irregular form, but usually globular, and then frequently pro- trudes upon the surface of the tumour in the form of rounded eminences.§ Hence, in the rarer cases, in which a firm, amorphous, intercel- lular substance exists between the cells (cartilage-corpuscles) en- chondroma, viewed histologically, resembles true cartilage ; in the more frequent cases, on the other hand, in which the cartilage-cor- * Compare J. Muller, op. cit. tab. in. fig. 4, 5, 6, 7. •t Mailer, op. cit. tab. in. fig.. 8. X Herz,, op. cit. fig. 2. § J. Muller, op. cit. tab. i. fig. 12; G. Gluge, op. cit. tab. i. fig. 1, 2. CARTILAGINOUS TUMOURS—ENCHONDROMA. 209 puscles are more isolated, and have a fibrous tissue between them, it presents a greater resemblance to fibro-cartilage, with this differ- ence, however, that in normal fibro-cartilage the cartilage-corpus- cles are more isolated and scattered in a thick net of fibrous tissue, whilst in fibrous enchondroma masses of cartilage-cells lie between bundles of fibrous tissue, just as in steatoma accumulations of fat- cells are lodged between masses of fibre. We may, therefore, re- gard fibrous enchondroma as a combination of the cartilaginous with the fibrous tumour. In its chemical relations enchondroma resembles ordinary cartilage before ossification, i. e. upon boiling, it generally yields chondrin. This was obtained by J. Muller from enchondroma of the bones and of the testicle; on the other hand a much softer enchondroma of the parotid gland yielded, upon boiling, not chondrin, but ordinary gelatin (colla.) From this it would appear that chemical differences exist, upon which we require to be further enlightened. The three above mentioned forms of enchondroma depending upon locality present, also, in their structure certain differences which deserve an especial consideration. a. Central enchondroma in the interior of the bones. This form,, the most frequent of all, usually appears in the metacarpal and metatarsal bones, and in the phalanges of the hand and foot, as rounded, smooth tumours of variable size, encased in a vesicular, expanded, osseous cortex. The very characteristic external form of these tumours will be best understood from illustrations.* The tumour is found, upon closer investigation, to be enclosed in a bony case, which varies in thickness in different spots,, but is not unfre- quently absent at some points, as if the tumour had burst through its wall. This bony covering arises less from the mechanical disten- sion and expansion of the tumour than, doubtless, from the circum- stance that new bone is constantly formed upon its surface during growth, but that its deposition is modified in arrangement by the presence of the tumour. A section of the tumour shows the ele- ments formerly described—portions of soft cartilaginous substance interlaced by bundles of fibres. Here and there appear also in its * J. Muller,.op. cit. tab. iv. fig. 1,2, 3; Herz, op. cit. fig. 1, 3, 5, 6; Gluge. op. cifc tab. n. fig. 2_ 18* 210 PATHOLOGICAL EPIGENESES. interior portions of bone—remains of the spongy substance of the original bone.* b. Peripheral enchondroma of the bones agrees with the former variety, insomuch as it also originates in the bone: it is formed, however, not in the interior, but on its surface, and has, therefore, no bony sheath, being covered only by the periosteum. Its form is less regularly round, and its surface is rendered rugged and uneven by the separate, rounded cartilaginous formations, which protrude as distinct nodules varying from the size ofa pea to that of a cherry, f The internal structure does not differ from that of the former variety, small portions of bone being, likewise, occasionally found between the fibres and the cartilage-cells. This form is principally observed in flat bones, namely, the ribs and the cranial and pelvic bones, seldom in the cylindrical bones. c. Enchondroma of soft parts is much rarer, and was observed by J. Muller only four times in thirty-six cases of the disease, once in the parotid gland, once in the mamma, and twice in the testicle, thus occurring only in glandular parts. This variety isy distin- guished by containing no bony matter, either as an external cover- ing or in its interior, and by the fibrous tissue intervening between the cartilage-cells, being sometimes replaced by a more amorphous intercellular substance, so that the mass closely resembles true car- tilage. The fibrous substance of enchondroma contains but few vessels. These tumours are non-malignant and unaccompanied by pain, and are sc-slow in their development that they often exist and increase for ten or twenty years, attaining a considerable size without ma- terially incommoding the patient. Gluge describes a tumour of this kind, which, on extirpation, weighed nine pounds and a half.J They may, however,, when large, like the non-malignant tumours formerly described inflame and ulcerate, and become dangerous from the quantity of the discharge. The origin of enchondroma can often be referred to mechanical injuries, as contusions, bites, &c. which appear more capable of giving rise to this species of tumour in childhood than in adult life. Enchondroma is not, however, in all cases referrible to a local in- * Gluge, op. cit. tab. n. fig. 2. t Gluge, op. cit. tab. l fig. 1, 2. X Op. cit. explanation of tab. i. CARTILAGINOUS TUMOURS—ENCHONDROMA. 211 jury ; sometimes it occurs in several parts of the body at the same time, resulting from a general or constitutional cause. There can be no doubt that in enchondroma of the bones, the law of analogous formation performs a determinate part in the organization of the exu- dation ; but it should not be forgotten, that in these cases, the carti- laginous substance of the enchondroma does not correspond alto- gether with true cartilage. At present we cannot even hazard a conjecture as to the originating cause of enchondroma in glandu- lar organs. From what has been stated, it will be seen that there exist two distinct forms of cartilaginous tumour: cartilaginous exostosis and enchondroma. They sometimes so closely resemble each other, that they can only be distinguished by a close anatomical inves- tigation. Enchondroma sometimes presents, in its interior,*cavities filled with fluid,* and thus passes into the category of cyst formations [Cystoid.) In a diagnostic point of view, the transition from enchondroma to fibrous tumour is highly interesting. This is accomplished, in en- chondroma of the bones, by the gradual increase of the fibrous part, the cartilaginous portion diminishing in the same ratio. Indeed, many tumours which, judging from the external form,# might be taken for enchoridromata, in reality consist entirely of more or less developed fibrous tissue, and contain no cartilaginous substance. The external form and appearance of a tumour are, therefore, not sufficient evidence of its being an enchondroma, a microscopic in- vestigation being essential to a certain diagnosis; Enchondroma, the most important of the forms of tumour belonging to this class, was only made known to us a few years ago by the valuable investigations of J. Muller. These tumours were previously grouped with many others-occurring in the bones, and designated by the various names of atheroma nodosum, spina ventosa, osteo sarcoma, and osteoste- atoma : it is not possible, therefore, from the name alone, to recognize the previously observed enchondromata. In the living subject before opera- * Compare Gluge, op*, cit. explanation of tab, i. It is possible that two of the cases described by Frogley (Mccfico-chirurg. transactions, 1843, p. 133) as osteo-sarcoma of the femnr belonged to this category; in consequence, how- ever, of there having been no microscopic examination, it is impossible to decide with certainty. 212 PATHOLOGICAL EPIGENESES. tion it is often difficult to distinguish cartilaginous exostosis from enchon- droma, the diagnosis is easier on making a section of the tumour when the internal structure—the soft cartilaginous portion with the fibrous layer—enables us to recognize the microscopical characters of enchondroma. True enchpndromata do not ossify, although the ramify- ing corpuscles which they occasionally exhibit, are strongly suggestive of osseous particles,* The great resemblance which many fibrous tu- mours bear to enchondroma demands especial attention in a histological point of view, and requires great caution in the diagnosis, although the distinction between true enchondromata and fibrous tumours is of. little consequence to the practical surgeon, since both forms of tumour appear to exercise an entirely similar action on the human organism. I have examined some tumours (one on the pelvis, one on the toe, and two on the hand) regarded as enchondromata and which in their external characters they perfectly resembled, especially the one figured by Herz (fig. 9 ;) they showed no trace of cartilage-corpuscles, but consisted en- tirely of more or less developed fibrous tissue. These observations might lead us to judge that apparent enchondroma is almost as frequent as the true form, or at all events must induce us to exercise caution in the diagnosis, and forbid us, without minute investigation, to characterize a tumour of which the bony case alone remains, as true enchondroma. For further inforrnation concerning the relation of' enchondroma to other tumours occurring in the bones, as well as concerning cartilaginous ex- ostosis, I must refer to. the chapter on the bones, in the special part of the work. FIFTH GROUP TUMOURS CONSISTING CHIEFLY OF OSSEOUS SUBSTANCE. Osseous Tumours. Tumours, in which bony tissue is morbidly formed, present in individual cases such great differences in form and structure that it is impossible, as in most of the forms of tumour which have been considered, to give a general description of them. They usually appear in or upon bones, and their peculiarities can only be clearly elucidated by a comparison with other pathological changes which * Mailer, Plate in. fig. 8. OSSEOUS TUMOURS. 213 take place in the bones themselves. We will, therefore, leave their detailed consideration to the special part, and confine ourselves here to some of their general relations. It is especially important to distinguish the true from the false or apparent osseous growth. The former presents in its histological and chemical relations, all the characters fonrierly described (see page 186) as appertaining to true bone ; the latter consists of an unorganized deposition of calcareous salts between different histo- logical elements, and belongs to the concretions, under which head it will be treated of at greater length. Most of the so termed os- sifications, including those which occur in tumours, belong also to this class, and are not true bony structure. The tumours in which true osseous substance appears, either con- sist entirely, or for the most part of newly formed bone ; or contain it in smaller proportion, forming, according to the terminology whieh we have hitherto adopted, combinations of the osseous with other forms of tumour. To the former belong the osseous formations unconnected with normal bone, which most frequently occur in fibrous membranes, especially the dura mater, in. tendons, (the sesamoid bones) and oc- casionally in the eye (Valentin ;) and the osseous tumours which are connected with normal, or diseased bone, and known as exostoses. As they arise, like normal bone, from true cartilage, they sometimes before their perfect ossification, consist in part of true cartilaginous substance, and are thus connected with the cartilaginous tu- mours. Moreover tumours which consist only in part of true osseous sub- stance, appear from the observations hitherto made, almost always to arise from diseased bone, but in addition, to the newly formed morbid osseous matter, there are also produced other histological elements—fibrous tissue, vessels, cartilage, fluids enclosed in cysts, and even malignant elements, as encephaloid and tubercle. The newly deposited bone forms very irregular masses, generally of a porous structure, which project in the form of plates, or spicula amongst the other elements of the tumour, or fonn cellular spaces enclosing these elements. The newly formed osseous substance is either connected with the original bone, which, upon the removal of the soft part by maceration, appears covered with bony excre- 214 PATHOLOGICAL EPIGENESES. scences, as in true exostosis f or it lies in loose patches in the soft parts, and is lost by maceration. It sometimes forms only a small part of the whole tumour, sometimes more than half. The latter cases are connected with the exostoses. The great variety of these compound bony tumours renders it ex- tremely difficult to characterise and classify, the individual forms ; * since almost every case hitherto described differs more or less from the others. We cannot, therefore, speak of distinct species or varieties of these tumours, but must follow, as well as possible, the method which we have hitherto adopted, and regard the individual forms as combinations of the bony tumour with other elements ; thus it may be combined with the fibrous tumour, the vascular tumour, the cartilaginous tumour, the fatty tumour, (?)the gelatinous tumour, the encysted tumour and the cystoid, and with all the malignant forms of tumour. The subject is rendered more intricate by the circumstance that there may occur not only one of these combina- tions but several, indeed almost all simultaneously in the same tumour. Causes and mode of origin of osseous tumours. From the above observations it can hardly be doubted that the formation of bony substance in tumours follows the same laws which hold good in the development of bone generally, and which have been already dis- cussed, although this structural process has, as yet, been directly observed in only a few cases. It may, moreover, be safely assumed that the cytoblastema of the new osseous structure is a fibrinous fluid derived from the blood. The increased exudation, occurring some- times rapidly and abundantly, sometimes more slowly but therefore continuing the longer, which gives rise to the pathological formation of bone may be occasionally ascribed to external causes—mechani- cal injuries as a blow, kick, fall, &c.; at other times it proceeds in- sidiously from constitutional or local internal causes, and is fre- quently only perceptible by its consequences. In the metamorphosis of the blastema into bony substance we find in many cases the law of analogous formation in operation, acting sometimes alone, at other times in opposition to a tendency to malignant formations. If we * A very characteristic preparation of this kind is delineated by Weidmann : An. notatio de steatomatibus, tab. v. MELANOTIC TUMOURS. 215 consider that normal bone itself is a very complicated structure, and, besides the proper osseous substance, contains medulla, vessels, pe- riosteum, in short very different histological elements, it will be ap- parent that the law of analogous formation serves to explain many compound forms of osseous tumour. It should, however, be borne in mind, that all such laws admit of only a general application, and are frequently insufficient to the elucidation of a special case. The peculiar causes of the osseous formations which are unconnected with bone—as for instance those of the dura mater—remain entirely unknown. • Osseous tumours are invariably non-malignant: nevertheless when combined with other elements they may be destroyed by ulceration, &c. and this destructive process may proceed in the form of caries or necrosis to attack the newly formed osseous tissue itself; this is especially the case with the bony tumours combined with malignant elements. Our knowledge of the bony tumours is still very imperfect, especially with regard to their histological relations* The classification and nomen- clature of the tumours belonging to this group are also very confusing; there belong to it the different species of exostosis, some of the osteo-sar- romata, oste.o-steatomata, some cases of spina ventosa, the osteo-phyte of Gluge, and the osteoid of Muller. The more minute characteristics of all these tumours will be given in the special part. SIXTH GROUP. TUMOURS ENTIRELY OR IN PART CONSISTING OF DARK PIGMENT. Melanotic Tumours. In many tumours there occurs a dark pigment as a more or less prevalent constituent. This pigment appears, however, so far as the * The special literature is given in the chapter on the morbid changes in bone. In addition to the references previously given, respecting the morbid epigenesis of osseous tissue, we may notice: G. Gluge, Atlas der patholog. Anatomie, Part n. (osteophyten;) and J. Miiller in his Archiv. 1843. Ueber ossificirende Schwamme oder Osteoid-Geschwnlste, p. 396, &c; in both places there is a copious bibliography of the earlier writers. 216 PATHOLOGICAL EPIGENESES. still scanty histological investigations of such tumours enable us to judge, to present very different characters. . In many cases it consists of dark (brown or black) granules en- closed in more or less distinct rounded or elongated cells, sometimes it is altered blood:pigment, arid occasionally it is composed of gra- nule's of sulphuret of iron. The pigments of melanotic tumours admit, therefore, of distinction into the same varieties as were for- merly pointed out in the pathological|epigenesis of granular pigments generally, (see p, 183) namely into true and false melanosis, the latter further resolving itself into that produced by altered blood- pigment, and that consisting of deposited sulphuret of iron. The pigment is never the sole constituent of melanotic tumours ; it forms only a portion of the whole and is scattered amongst other histological elements, such as perfectly developed or comparatively amorphous fibrous tissue, vessels (which, however, are never,abun- dant,) and malignant formations, as tubercle, encephaloid,'and scirrhus. Melanotic tumours are, therefore, always compound. The pigment-molecules are sometimes equably distributed amongst the other elements, at other times accumulated at particular points : the tumour, therefore, appears sometimes equally dark throughout, sometimes spotted, and sometimes presents alternating light and dark strata. In true melanosis the. colour is brown, of a bistre tint, blackish, or, if only a little pigment is present, gray ; in the false variety depending upon sulphuret of iron, it is slate-gray, or greenish black: in that resulting from altered blood-pigment it is blue, violet, or brownish black. The discrimination of these three varieties is easily accomplished by means of the microscope with the aid of che- mical reagents, according to the rules given in pp. 180—2. Occa- sionally the melanotic colour which appears in tumours in the form of spots, depends upon decomposed blood in the interior of vessels (veins.) Melanotic tumours have been observed up^on almost every part of the body, in the eye, the female genital organs, the lungs, liver, &c, also upon the external surface^ the skin, subcutaneous cellular tissue, &c. Sometimes they appear solitary, sometimes in great numbers; and gradually extending over the whole body, form a general dis- ease terminating in the death of the patient. They occur more fre- quently in the female than in the male sex. The progress of melanotic tumours depends upon their combina- MELANOTIC TUMOURS. 217 tions. True melanosis is of itself non-malignant, and so is its com- bination with fibrous tumour ; on the other hand its combination with malignant elements is naturally malignant. False melanosis is generally injurious from its very nature, since its occurrence pre- supposes an important decomposition of the fluids; when, however, it remains localised it is of less importance. The causes producing them vary with the nature of the tumour: in false melanosis they are usually of a chemical nature, and can frequently be recognized, as has been already shown. The causes of true melanosis are obscure, although the law of analogous formation appears, at least occasionally, to perform a conspicuous part; thus melanotic tumours in the eye usually arise from the choroid, and melanotic tumours of the skin in the Rete Malpighi, in which the formation of pigment is a very frequent phe- nomenon. Our knowledge of melanotic tumours is still very deficient: every tumour which was entirely or in part of a dark colour, has been arranged under this division, and thus the most different structures have been promiscu- ously thrown together. A clear insight into the nature of these tumours can be expected only from more extended histological investigations: this is especially the case with those forms which, having spread over the entire body, have become constitutional, and which, hitherto have not been ex- amined in a sufficiently accurate manner: and hence a more minute de- scription of the individual forms, and a discussion on the question of their malignity or non-malignity, with a critique of the views hitherto adopted of their mode of origin, are quite unnecessary.* The chemical relations of melanotic tumours may be regarded as still quite unknown. A portion ofa melanotic tumour of the brain analysed by A. Vogel, jun. yielded:! Carbon . . 49.885 Hydrogen . . 7.156 Nitrogen . . 23.784 Oxygen . . 19.175 100.000 * The most important literature is comprised in: Carswell's Pathological anatomy. Melanoma; Schilling de Melanosi, 1831; Gluge, Atlas der pathol, Anatomie, Part m.; Cruveilbier, Anatomie pathologique, liv. xix. and xxxn. fol. plates, Paris, 1830 —42. t MOnchner gelehrte Anzeigen, 1844, No. 143, p. 108, &c; 19 218 PATHOLOGICAL EPIGENESES. This analysis differs very considerably from that given in page 180 of the colouring matter from melanotic lungs. In that case, however, the histological examination was totally neglected, and therefore we cannot now precisely determine what was analysed, so that unfortunately it is of no value to pathological anatomy. SEVENTH GROUP.* TUMOURS CONTAINING A GELATINOUS SUBSTANCE. Gelatinous Tumours. In many tumours there occurs a viscid, gelatinous substance, partly infiltrated amongst the other firm elementary tissues, and partly con- tained in appropriate spaces or cavities, sometimes in such abun- dance and so greatly exceeding the other elements, that the tumours may, with great propriety, be termed gelatinous. The elements co-existing with the gelatin in these tumours are of very various kinds, generally fibres, vessels, and sometimes even cartilaginous tissue, so that these tumours may be considered combinations of the fibrous tumour, enchondroma and encysted tumour; even cancer- cells occur conjointly with this gelatin, and the most frequent form of gelatinous tumour is the so named gelatinous cancer (colloid.) This substance is always transparent and colourless, sometimes fluid, resembling thick mucus, at other times firmer like half softened jelly. Under the microscope it appears completely amorphous and so perfectly transparent, that it is not easy to see it. In the cases which I have examined, it coagulated, on the addition of acetic acid, into a colourless, striated, amorphous mass: the same reaction was caused by sulphate of the protoxide of iron, infusion of galls and (to a less degree) by alum, alcohol, and bichloride of mercury. Nitric acid and nitrate of silver caused only a slight turbidity which was doubtless dependant on the presence of albumen. It was insoluble both in cold and boiling water. Its quantity was too small to admit of ultimate analysis; until, however, this is effected nothing certain can be determined concerning its chemical constitution. It may be inquired whether the gelatin possesses the same pro- perties in all tumours. In six cases, which I have now investigated its character seemed perfectly identical, and it presented the above, reactions. I consider this substance which in its chemical and phy- GELATINOUS TUMOURS. 219 sical characters is analogous to mucus and pyin (as far as its pro- perties are known), to be non-malignant; when a tumour is com- posed of it, as in the gelatinous cancer (colloid), it appears to me that this results rather from mechanical causes—distention of the tissues by the deposited mass, &c. than from a specific action, as in the strictly malignant tumours. Nothing can as yet be stated with certainty concerning the origin of this substance ; it arises, how- ever, in all probability like normal mucus, from changed protein- compounds of the blood. The elucidation of these relations can only be expected when the chemistry of the metamorphosis of tis- sues shall be better known than it is at present. Under the head of gelatinous tumour, J. Muller has described Collo- nema, a peculiar tumour which I myself have not yet seen and which I shall notice here* since I do not perceive where else it can be included. According to him, it consists of " a remarkably soft gelatiniform tissue, which trembles upon touching. The organized elements form very scanty bundles of fibres and vessels. The chief mass consists of gray globules, some of them much larger than blood-corpuscles. Crystalline needles lie scattered in immense numbers throughout the whole tumour; they consist of a peculiar, non-fatty animal matter, and can be readily re- cognised by the microscope in every part of the tumour. They are inso- luble in acids and alkalies; the latter by dissolving the non-crystalline portion of the tumour, isolate the needles and render them more apparent. Upon boiling a portion of the tumour in water, the crystals are destroyed ; at the temperature of the body, however, they remain unchanged. They are insoluble in hot spirit, but,dissolve in boiling ether. This tumour has been observed once in the brain, and once in the female breast; the crystals were similar in both cases: the uncrystallized mass, on the other hand, was different. . The decoction of the tumour from the brain was not precipitated by tannin, spirit, mineral acids, acetic acid, ferro-cy- anide of potassium, alum, sulphate of iron, acetate of lead, or bichloride of mercury, and, therefore, most closely corresponded with ptyalin, or the mucus of English authors; the decoction of the tumour from the breast, on the contrary, contained a very small quantity,of casein, which was precipitated by a drop of acetic acid and by its ordinary tests. * Archiv. 1836, Jahresber. 220 PATHOLOGICAL EPIGENESES. EIGHTH GROUP. TUMOURS ENCLOSED IN A PROPER CYST. Encysted Tumours. These tumours are peculiarly distinguished by being enclosed in a proper membranous sac which isolates them from the surrounding parts. In the numerous differences which the individual forms of encysted tumour present, this character, however, is not always dis- tinctly marked, and there occur many intervening forms between this and other tumours. We discriminate, therefore, between the true, sim- ple encysted tumours (tumores cystici) and the compound—combina- tions of this with other forms of tumour (cystoid.) a. The true simple encysted tumours not only possess a perfectly closed membranous sac, but is also essential to their character, that the contents of this sac are either not at all, or only very imperfectly organized, and show no organic connexion with the sac itself. This forms the distinction between encysted tumours and the en- closed fatty and fibrous tumours formerly described, in which the envelope, consisting of areolar tissue, throws out organized elonga- tions, and processes not only into the substance of the surrounding parts, but even into that of the tumour itself; thus, not so much separating the tumour from the surrounding parts, as forming a me- dium of connexion between them, This form of encysted tumour presents many varieties both with respect to the state of the cyst, and the nature of its contents. It admits of being grouped into two tolerably well characterised sub- divisions. The first embraces encysted tumours with aqueous or serous con- tents, which approximate more or less to the fluids of serous and fibrinous dropsy, and sometimes entirely correspond with them. I will call them serous cysts, lifeless hydatids. These also present differept forms, most of which scarcely deserve the name of encysted tumours, and would, more properly be regarded as modifications of a local true or false dropsy. .Their principal forms are the following: 1. When, in a local circumscribed serous dropsy, the fluid is effused in a part consisting of lax areolar tissue, or under a thin membrane, as for instance a serous membrane, it forms a vesicle ENCYSTED TUMOURS;. 221 resembling the blisters so frequently "observed upon the skin after burns or vesicants, in erysipelas bullosum, &c. In this case the cyst is not a new structure, but consists of normal tissue distended by the dropsical fluid; moreover, it does not form asymmetrical, perfectly closed sac ; it frequently shows in its interior irregular cellular spaces communicating with each other, and has no internal epithelium, like the true encysted tumours. The fluid'is precisely the same as that of serous dropsy, or of its varieties. Its essential constituent is fluid albumen which coagulates upon boiling, or ex- hibits the modification of this protein-compound which is not pre- cipitated by boiling, but is readily thrown.down by acids and alco- i hoi. These misnamed hydatids are, therefore, only local oedema modified by the histological condition of the affected part, and ori- ginate according to the same laws as oedema generally. They are observed rather frequently on. many parts of the body, especially on such as consist of a lax areolar tissue, as the spermatic cord (forming hydrocele of the cord,) in the choroid plexus of the brain, also be- neath serous membranes, i. e. between the. membrane and the cel- lular tissue which connects it with the subjacent parts, beneath the pleura pulmonalis, under the peritoneum, and. on the surface of the fallopian tubes ; also in the parenchyma of many organs, especially in that of the ovaries. A large proportion of the tumours known as ovarian dropsy belong to this group. These vesicles appear some- times solitary, at other tiraesin clusters ; this seems to be dependant partly upon the anatomico-histological structure of the organ, and; partly upon the extent of the disease. I have repeatedly examined hydatids of the cord; and they always exhibited the above mentioned character. That is, they consisted of lax areolar tissue distended into.membranous vesicles, containing, in irregular cellular spaces, a clear, transparent, aqueous, fluid, which coagulates on- boiling. When the fluid was evacuated by puncture; the areolar tissuei collapsed and no trace of the previous cavities could be subsequently de~ tected. The following case may serve as an example of a, hydatid in which the fluid did not coagulate by heat., In 1837 while instituting am examination of the body of a deformed woman aged fifty-six years, who> had been greatlyafflicted with ventral hernia and anasarca, I found under the left kidney (which Was healthy) between the peritoneum and lumbar muscles, a false hydatid of the size and shape of a human kidney. It was covered, over by the peritoneum, and was attached to th° Jumbatv 1.9* 222 PATHOLOGICAL EPIGENESES. muscles by lax areolar tissue: its sac consisted of a very delicate trans- parent membrane, which was formed merely of areolar tissue, possessed no internal epithelium, and was most intimately connected with the sur- rounding parts. It contained about two ounces of homogeneous, trans- parent straw-coloured fluid, in which no solid corpuscles could be detected by the microscope. This fluid was not affected by heat, but coagulated readily and abundantly on the addition of alcohol, nitric acid, and nitrate of silver; it was, no doubt, the same which formed the cedema in the sub- cutaneous cellular tissue, and evidently was produced by the same cause.' Another kind of these false hydatids clpsely corresponds with the false dropsy, which was formerly described (p. 64.) It originates in an obstruction of the excretory duct of a secreting part: the re- tained secretion accumulates and distends a certain portion of the duct or of the secreting organ itself into a tumour invested with an apparently closed sac, and containing an aqueous fluid, which, at first, chemically resembles the normal secretion, but may, subse- quently, undergo changes by means of endosmosis and, exosmosis. This kind of serous cyst is of less frequent occurrence than the pre- ceding ; it occurs in the kidneys, the fallopian tubes,, the pancreas, and in the parenchyma of the lungs ; it may easily be confounded with the first kind, from which, indeed, it cannot always be dis- tinguished with certainty, especially after the secretion has be- come changed. Through the kindness of my colleague Prof Bergmann, I recently ob- served an undoubted instance of this kind in a kitten, about fourteen days eld. The occluded uterus and the fallopian tubes were distended like a bladder, and upon the fimbria which were united by irregular adhesions, there were found several hydatid-like vesicles, the contents of which were clear and contained no albumen. With respect to the hydatid-like vesicles which are not unfrtequently observed upon the surface of the kidneys, it is often impossible to deter- mine even by the most carefuj investigation, whether they belong to the variety under consideration, and are to be regarded as distended urinife- rous tubes, or whether they should be cqmprehended in the first variety. Probably the ovvla nabolhi should be classed here, and may be viewed as distended uterine glands. 3. A third variety of serous cysts deserves the name of encysted tumours better than the two preceding. It consists of a perfectly closed cyst which externally is firmly connected with the surround- ing parts, but internally exhibits a smooth surface resembling that ENCYSTED TUMOURS. 223 of a serous membrane, and contains a clear serous fluid, devoid of regular corpuscular particles. The cyst itself consists of areolar tis- sue, and is soft and resembles a serous membrane, or firm, larda- ceous or even apparently cartilaginous, according to the degree of development of the aforesaid tissue (see page 160.) It varies in thickness in different cases, and its inner surface in general (in per- fect forms probably always) becomes coated with a delicate epithe- lium, which essentially resembles that of normal serous membrane. In the perfect forms, moreover, the cyst contains vessels. The fluid in the interior closely corresponds with that of serous dropsy. I believe that this form of serous cysts arises in the following man- ner. As the first form owed its origin to serous dropsy, so does this to fibrinous dropsy; in the first place there is formed a false hydatid (resembling our first form) whose walls are composed of expanded normal tissue. The dissolved fibrin gradually, however, becomes deposited upon the walls in the form of a closed saccular membrane, which usually consists of several layers; the fluid thus deprived of its fibrin becomes identical with that of serous dropsy. The sac, at first amorphous and consisting of coagulated fibrin, be- comes partially organized, is usually converted into areolar tissue, receives vessels, and becomes invested internally with an epithe- lium. The encysted tumour has now become permanent, and is not capable, like the first kind, of being entirely removed by ab- sorption ; for if by the altered relations of endosmosis, the fluid ori- ginally effused, should become changed or decreased, nevertheless, on account of the internal epithelium, closure of the cavity by coa- lescence of its walls will not readily occur, and the cyst will main- tain its independence, even through the changing relations of en- dosmosis, and the varying quantity of its fluid contents. These cysts can only be obliterated by means of adhesive inflammation; an illustration of this mode of formation of cysts from effused fibri- nous fluids is afforded by a case described in the second part, in the chapter on the morbid anatomy of the brain, &c, where a cyst filled with fibrinous fluid had formed iiself in the cerebral substance. The case figured and described in Plate v. fig. 5 and 6, also illus- trates this mode of formation ; at the same time it serves to eluci- date the orio-in of a more complicated form of these serous cysts, which, up to the present time, has in general been erroneously in- cluded amongst the living hydatids. In this form, a membranous 224 PATHOLOGICAL EPIGENESES. cyst consisting of areolar tissue, connected with the surrounding parts, and furnished with an internal epithelium, encloses, but is unconnected with a second shut sac of a hyaline semi-transparent character, which generally admits of separation into many very thin layers, and consists of amorphous coagulated fibrin. . It is filled as in the other cases with a serous fluid. The origin of this second sac, as evidently results from the description of Plate v. fig. 5 and 6, must be explained in the following manner : from an already ex- isting organized sac there takes place a new exudation of fibrinous fluid, which by means'of the coagulation of its fibrin forms for itself a second membrane within the first. In the same way, it can be readily explained why such cysts sometimes contain altered blood, pus-corpuscles, granular cells, &c. For the means of discrimi- nating these enclosed serous cysts from the living hydatids, we must refer to our chapter on the entozoa. Hence it appears that this form also of serous cysts is essentially nothing more than a variety of fibrinous dropsy, and is directly con- nected with the encysted dropsies. It occurs partly in serous cavi- ties, as in the pleura, pericardium, and peritoneum, and partly in the parenchyma of organs, especially in those whose texture is soft, and admits of the easy formation of a cavity by the pressure of the effused fluid—as the substance of the brain, the cellular tissue, &c. It is little to be wondered at if any one with Bichat and his followers, regards this form of serous cysts as newly formed serous membrane, since, like this, it certainly consists of areolar, tissue with an internal epi- thelium : nothing can, however, be gained by such a course; on the con- trary, this mode of considering it possesses the disadvantage that it might easily lead us to suppose the serous membrane first formed, and the fluid in the interior only secondarily secreted from it, whereas, in fact, as we have already shown, the converse process of formation takes place. The enclosed serous cysts, whose mode of origin until- now has been consi- dered inexplicable, have usually been included in the entozoa under the name Acephalocysts. In general, the fluid of these cysts contains no cor- puscular particles; sometimes, however, there are observed in it fat-glo- bules and minute corpuscles (elementary granules;) in some rare cases it contains small organized formations, which are suggestive of the living hydatids presently to be described, and may raise a doubt with respect,to the diagnosis of this form. For the particulars of the following case, I am indebted to the kindness of my friend Dr. Kohlrausch of Hanover. ENCYSTED TUMOURS. 225 " In the clear aqueous fluid contained in cysts in the kidneys of a man, there swam an innumerable quantity of corpuscles which, although very different in size and appearance, were all connected by evident transi- tions. The smaller of these bodies were more or less regularly round, not smooth, but transparent. In their centre was observed a, point which might be regarded either as a nucleus, or as an optical illusion. To this central point, which was of variable size, converged radial striae which gave to the whole corpuscle the appearance as if its capsule was plicated from the periphery to the centre. The diameter of these corpus- cles varied from the 190th to the 280th of a line; smaller ones of the 370th, and larger to the 140th of a line were less frequent. There were also observed corpuscles which, possessing a rough coarsely granular surface and little transparency, appeared, at first sight, to be very diffe- rent from those just described. Their diameter varied from the 112th to the 80th of a line. On properly arranging the focus, there was seen, however, within the rough surface a smooth rounded outline wbich, when the enveloping layer was not thick or was partially absent, showed a double border. In many of these inner cells there were also seen the central point, and the striated radiations. The external layer was granu- lar. On causing the corpuscles to rotate, it was seen that they were round. In addition to the above, there were observed larger and more opaque bodies, varying from the 50th to the 24th of a line, with a round granulated figure. Upon being treated for twenty-four hours with con- centrated acetic acid, the corpuscles underwent no change; nor were they affected within ten minutes by dilute hydrochloric acid. Upon boil- ing with ether they likewise remained unaltered and no fat was extracted from them. They were insoluble in cold dilute nitric acid, but readily dissolved on the application of heat. This solution yielded on the addi- tion of carbonate of potash ,a finely granular, amorphous precipitate. After evaporation of the nitric-acid solution, there remained a yellowish mass; the purple-red reaction of uric acid could not be produced. In caustic potash the corpuscles readily dissolved, in carbonate of potash less readily, but nevertheless perfectly and without the development of gas." In conclusion I will add a few words concerning another possible mode of origin of serous cysts. It may be readily imagined, for instance, that elementary cells, whose general histological mode of formation was for- merly considered, might become so distended through the absorption of fluid as to form serous cysts. I am unacquainted with any case which seemed to derive its origin in this manner; indeed, all the elementary cells at present known, are far too small to permit of the supposition that even in their maximum degree of distention they could form cysts, which are always readily visible to the unaided eye. If, however, such a mode 226 PATHOLOGICAL EPIGENESES. of origin is possible, it may be especially applied to the explanation of many of the so-named hydatids of the choroid plexus, since, this part in the normal state already contains numerous large globular cells, which also perform a part in the concretions of this organ. This will be further discussed in the special part. The second division of the simple encysted tumours is distin- guished from serous cysts by the circumstance that the contents do not consist of an.aqueous fluid, but contain peculiar corpuscularparticles which render them thick and pulpy. They sometimes resemble honey, sometimes boiled groats, and occasionally they have a gelati- nous appearance. In accordance with these varieties in the contents, these tumours have received different names, and been termed hygroma, meliceris, atheroma, gummy tumour, &c. Such names are, however, in the highest degree, vague and unscientific. In this form the cyst is always perfectly closed, and firmly con- nected with the surrounding parts by adhesions of areolar tissue. It is organized, usually consisting of areolar tissue woven into a membrane, and containing vessels.* There usually may be distin- guished upon its internal surface" a decided epithelium consisting, of cells,f which separates the contents from the membrane of the cyst. Thus far the membrane of these encysted tumours resembles that of true serous cysts; but frequently it is more highly organized, so that whilst in serous cysts the membrane occupies a position parallel with serous membrane, it may in these cases be compared to mucous membrane or the cutis. Sometimes, for instance, the internal sur- face of the cyst presents, upon certain spots, cauliflower excrescences —granulations which correspond more or less closely with the pa- pillae of the skiri or of mucous membrane; indeed, in some cases, it contains glands which resemble the sebaceous and spiral follicles of the integument, as they haye been represented by Kohlrausch.| In these cases the epithelium is more perfect than in serous cysts; it resembles stratified pavement epithelium or thin epidermis, and con- sists of several layers of cells which, in complete analogy with the corresponding normal formations, show different stages of develop- ment. * See Plate ix. fig. 3. t Plate ix. fig. 2. t M.uller's Archiv. 1843, p. 365.- ENCYSTED TUMOURS. 227 The contents of these tumours, as already stated, present many varieties which are explained with tolerable sufficiency by histologi- cal and chemical examination. We find in these encysted tumours : 1. Cells of different kinds, which usually lie loosely .together: sometimes they are large, irregularly rounded or oval, mostly very much flattened, and, therefore, seen laterally, appear fibrous, either with or without a distinct nucleus, resembling the external.layers of pavement epithelium and of epidermis; sometimes they are small, with a distinct nucleus and nucleoli, perfectly analogous to the cells of the deeper (more recent) layers of epidermis and pavement epithelium; and more rarely they are elongated, resembling cylinder epithelium.* There can exist no doubt concerning the origin of these cells; they are epithelium rubbed from the sac. In this case as in the pave- ment epithelium and the epidermis, the outer layers are continually being thrown off'whilst their under layers are being formed; as the free epithelial cells cannot escape externally, they accumulate in the sac ; this they do the more readily as they rather strongly resist che- mical influences, and being insoluble in the fluids of the body, can- not become resorbed. A gritty matter presenting a perfect resem- blance to the contents of these encysted tumours, sometimes occurs as a morbid accumulation under the toe nails; it forms a white, greasy, caseous mass, and likewise consists of exfoliated, but re- tained epidermic scales. These cells are usually mixed with the other contents. When the cyst resembles a serous membrane, and throws off little or no epithelium, these cells are comparatively rare, or appear to be altogether absent. In other, instances, on the con- trary, the cells prevail, and sometimes, indeed, form almost the whole contents. The last described encysted tumours have, generally, a thin surrounding membrane without secreting glands. 2. Fatty matters of various kinds are almost invariably present in the contents of these tumours. They are partly the ordinary fats of the human body—olein and margarin, and oleic, margaric, and butyric acids; partly cholesterin. They occur in the most varied proportions, and consequently although encysted tumours can be ar- ranged into well marked groups, they are not strictly separable from each other. Sometimes the fats predominate; being either the com- » Plate ix. fig. 1, 2 and 4. 228 PATHOLOGICAL EPIGENESES. mon fats—olein and margarin—when the contents consist of irregu- lar drops or masses, or when cells filled with fat, resembling the nor- mal fat-cells are present: these form the transition from the encysted to the capsular fatty tumours, but are comparatively rare;—or the contents consist for the most part of cholesterin, which occurs partly in the amorphous state, and partly in the form of distinct crystalline tables.* This variety of encysted tumour frequently presents, upon the interior of the cyst, several superimposed layers- of cholesterin which glisten like mother of pearl; it was, therefore, named the laminated nacreous fatty tumour, by Cruveilhier, and cholesteatoma by Muller.f These groups are, however, not strictly separated, since in differ- ent encysted tumours the individual fats are not merely mixed with each other, but also with the previously described cells in the most diversified proportions. The source of these fats, and the causes of their secretion cannot be shown with the same certainty as to those of the cells. There can be no doubt that a part of the fat is secreted by the sebaceous follicles which Kohlrausch has demonstrated in the cyst, but such sebaceous glands cannot be discovered in all encysted tumours ; and the production of the cholesterin, which sometimes occurs in great abundance, and often forms almost the entire contents of an encysted tumour, cannot at present be sufficiently explained. 3. Besides the substances which have been named, there are al- ways various extractive matters, (water-extract, alcohol-extract, &c.) and salts, in the contents of encysted tumours. If the calcareous salts (phosphate and carbonate of lime) are deposited in considera- ble quantity, the cyst, as well as its contents, becomes entirely, or in part converted into a concretion, or, as it is usually expressed, the encysted tumour appears ossified. Such ossifications of encysted tu- mours rarely depend upon a new formation of true bony substance. The preceding observations are sufficient to afford a general view of the structure of encysted tumours and their contents. In addition to the cases in the description df the plates to which reference has been made, We may refer for examples of the individual forms to a case of meliceris * Plate ix. fig. 1 and 7. t See Muller, op. cit. p. 50, or West's translation, p. 155. ENCYSTED TUMOURS. 229 described by Valentin,* and to the description of cholesteatoma by Muller. Gluge's descriptions of the tumours belonging to this group,t are neither accurate nor come up to the present state of our knowledge ; he regards the crystals of cholesterin as horny exfoliations, and describes them as rectangular crystalline leaves, which is not the case. For chemical ana- lyses, (with the exception of the older and less accurate,) see those of Berzelius4 Valentin, rnyself§ and F. Simon.|| The quantitative analyses naturally show no great correspondence, since in every separate case the quantity of the individual elements may be very different, as may be seen by a comparison of my analysis with that of Valentin. In 1000 parts there were contained: . , Valentin. Mysplf. Water . 887.15 751 Fats . Cholesterin 3.52 ) Olein and oleate of soda . 32.16 > 37.90 38 Stearin (?) . _ , . 2.22 ) Fluid albumen and-potash 10.35 ). Chloride of sodium 2.21 ! 2.12 j a trac^ Lime Magnesia 1.04 j Cellular substance (which * Valentin regards as co- agulated albumen) 59.23 92 Alcohol-extract with lactic acid 92 Water-extract . - 27 1000.00 1000 Fee examined a "lardaceous tumour" from the lefthypochondrium of a venereal patient who had been treated with mercury; it contained 87.5$ of cholesterin, and, therefore, was probably a cholesteatoma. This tumour enclosed in its inner layers much fluid mercury.^f Dalrymple** has given a brief description of an ossified encysted tu- * Repertorium, vol. in. p. 307. t Untersuchungen, Part i. &o, &c. X Lehrbuch der Chemie, translated by Wohler, 4th Edition, vol. ix.p. 726. •§ Anleitung z. Gebrauch d. Mikrosk. 1841, p. 460. || Beitrage z. physic-log. u. patholog. Chemie, 1843, p. 436. IT Leop. Gmelin, Chemie, ir. 2. p. 1373. ** London Med. Gaz. June 1843; or Medico-chirurg. Transactions, 1843, p. 238 with plates. 20 230 PATHOLOGICAL EPIGENESES. mour {i. e. one impregnated with calcareous salts.) The encysted tu- mour was situated beneath the tarsal cartilage of the upper eyelid in a middle aged man ; instead of the usual caseous matter, it contained an earthy or osseous deposition. This tumour was rather larger than a pea and consisted of a hard earthy substance arranged into concentric layers, which under the microscope were seen to be entirely composed of firmly agglutinated epithelial cells; instead, however, of forming transparent, thin scales with a central nucleus, they were thick and hard, and con- tained granular, earthy molecules which dissolved in dilute hydrochloric acid. Between the cells there was no amorphous earthy deposit, but the whole consisted of epithelial cells which were opaque, of light brown colour, with a distinct large .central nucleus. The deposition consisted, according to Gulliver, chiefly of phosphate of lime with a trace of car- bonate of lime. The above cited chemical analyses very distinctly show the gradual increase of the calcareous salts as ossification progresses. In my case the contents of the tumour contained only a trace of fixed salts ; in that of Valentin, on the contrary, more than 3g ; finally, Simon found in one of his cases 25.7$ of fixed salts, namely 21.7g of phosphate o^ lime and 4$ of carbonate of lime, with a trace of iron and chloride of so- dium. In Dalrymple's case the salts probably existed in still greater proportions. Similar encysted tumours occur in the inferior animals. I have ob- served one in the abdomen of a cat, between the skin and abdominal mus- cles. It contained about half an ounce of a brownish yellow, limpid, inodorous fluid, mixed with white flocculi, Its solid particles were shown by the microscope to be chiefly crystals of cholesterin ; besides these, masses of flattened, irregular, non-nucleated cells, completely analogous to those of the epidermis, and numerous brownish granules were ob- served. The cyst consisted ofa stroma.of areolar tissue, from the inner surface of which there sprung, in various spots, soft, cauliflower excre- scences, which resembled granulations or the irregular papillae of the cutis and mucous membrane: glands could not be detected in the cyst, even by the most careful examination. The inner surface was furnished with a fine epithelium consisting of delicate nucleated cells which perfectly correspond with those of the Rete Malpighii. Although the most simple encysted tumours only enclose the elements which have been specified, others are occasionally ob- served, which likewise contain more highly organized tissues, as, for instance, hair, true bony substance, teeth, and horny structures. Of these substances hair appears most frequently in the contents ENCYSTED TUMOURS. 231 of encysted tumours. It is found partly loose, unconnected with the walls of the tumour, agglomerated into irregular lumps, or scattered amongst the other elements ; and partly implanted and rooted in the cysts. This hair is usually light coloured, white, blond or reddish, more rarely brown or black ; sometimes it is short, a few lines in lengih, sometimes long, and occasionally it extends to several feet, and is not inferior in length to the longest hair of a woman's head. In histological structure it perfectly resembles normal hair, exhibit- ing a medullary and cortical substance, having the usual squamous sheath upon its surface, and running to a point at the peripheral ter- mination. Loose hairs commonly show a stunted bulb, like spon- taneously detached normal hairs; those which are' inrooted, on the other hand, possess a perfectly organized hair-root, a hair-sac presenting the normal structure, and likewise are frequently accom- panied by sebaceous glands. The inrooted hairs are sometimes scattered over the entire sac, sometimes are collected in bunches upon certain spots of its surface, the rest of the sac presenting no hairs; the latter is particularly the case with, the longer hairs: the sac at the points where the. hairs are affixed shows precisely the same structure as the normal cranial integument.*~ The sac of these tu- mours, moreover, affords the same varieties as were described of the encysted tumours generally ;■ it is frequently of unequal thickness and exhibits "patches of earthy depositions. The contents, besides the hairs, usually consist of fatty substances,.which are chiefly olein, raargarinj and fatty acids: cholesterin and epithelial cells are gene-' rally very scanty, or altogether absent. -It admits of no doubt that all these hairs, like the normal hairs of the human body, originally developed themselves from hair-sacs, and were at first implanted in the cyst: the loose hairs have subsequently become detached and fallen out, and being insoluble, and therefore resisting absorption, have accumulated in the sac in precisely the same manner as was described of the epithelium in the interior of encysted tumours. It may happen that such detached hairs, at differ- ent points of their length (but net at their extremities,) become again fastened to the sac by fibrinous exudation, calcareous depositions, cellular tissue, &c, (Cruveilhier ;) this, however, is only a mechani- * A series of instructive plates and descriptions of encysted tumours containing hair and given by Cruveilhier, Anat. patholog. livr. xviu. Plates in. iv. v. 232 PATHOLOGICAL EPIGENESES. cal, not an organic connexion. The fat which forms the remaining contents of these tumours is, without doubt, the product of secre- tion of the sebaceous glands which accompany the hairs, as Cru- veilhier conjectured and Kohlrausch has demonstrated. Many encysted tumours contain only hairs and fatty substances ; others, however, present, in addition to these, portions of bone and teeth. These seldom lie free in the interior of the tumour ; but are most commonly between the layers of the cyst, or are enclosed in fibrous, semi-amorphous, knotty masses, so that these tumours are connected with the compound cystoids to be presently described. The bony portions consist of true osseous substance with osseous canals and bone-corpuscles (which are sometimes, however, more scanty than in normal bone) and are generally invested with a more or less perfect periosteum ; with respect to size, form, and number, they present, however, the utmost diversity. Attempts- have been frequently made to compare them with bones of the normal or feetal body, and to explain them in this manner, but all such endeavours must necessarily fail. The teeth perfectly resemble normal teeth, sometimes those of the first-, sometimes of the seconds dentition, and like them possess a crown and root, and consist of osseous substance, dentine and enamel. Some resemble the incisors, others the canine, and molar teeth. Occasionally, however, they differ in form from normal teeth, being bent, or crooked; and sometimes two are blended together. These teeth are usually, but not invariably connected with the above mentioned pieces of bone, and are sunk into cavities in them, as into true alveoli. Sometimes we are enabled to observe the pre- ceding stages of development of these teeth ; they appear enclosed in distinct teeth-sacs, show in their interior a tooth-germ, fragments of dentine, &c, and, in short, evince a progressive formation; whence it follows that the development of these teeth in this unusual site, proceeds in entirely the same manner as that of the normal teeth (Kohlrausch.) The number of these teeth is various, some- times only a few are observed (as from one to six) sometimes a larger number (to forty-four,) indeed in one case, a single tumour of the ovary contained three hundred teeth !* * Cruveilhier, op. cit. livr. xvm. in which will be found plates and descriptions of this class of tumour. ENCYSTED TUMOURS. 233 Sometimes all the teeth are arrested atone stage of development; sometimes at very different stages, so that there are found co-exist- ing in the same tumour, teeth which correspond to the first, and to the second dentition. In all the cases hitherto observed, encysted tumours, enclosing bone and teeth, have also contained hairs. In some more rare cases there is formed within encysted tumours a horny matter, which is connected with, or rather grows out of the sac. When such tumours are situated near the surface of the body they commonly break, and the horny substance grows out of the opening, and sometimes attains a considerable size. Home de- scribes a case in which a horn arising in this manner acquired a length of 11 inches with a circumference of 2| inches; generally, however, they remain much smaller. Sometimes also they are thrown off and then re-appear ; or they first form themselves when ■ a common encysted tumour has become accidentally opened, and its sac thus exposed to external influences. These horns of varying fornl and size are usually curved like rams' horns, and sometimes spirally twisted : sometimes they are transparent like true horny substance, sometimes rough upon their surface, and opaque ; they are easily cut with a knife, and in their physical characters present the greatest similarity to the malformed hypertophied nails, which are not unfrequently observed upon the toes. The same resem- blance is maintained in their histological structure. I have closely examined several horns of this kind in our pathological collec- tion. They consisted of a horny substance which could be easily cut into shavings. Under the microscope the substance appeared entirely indefinite, and almost amorphous, like the tissue of the nails, but upon digestion for a considerable time in caustic pot- ash, the tissue separated into small scales, perfectly resembling those which are obtained by similar treatment from callous skin, corns, &c. The data which have been furnished preclude further doubt of the origin and signification of these horns: they. are exuberant local growths of the epidermis of the sac, and bear the same relation to the cellular contents of the common encysted tumours, as the cal- lous excrescences of the epidermis upon the surface of the body to the furfuraceous separation of the cuticle in pityriasis. Further particulars and descriptions of such horns may be found in E. 20* 234 PATHOLOGICAL EPIGENESES. Home, Philosoph. Transact. 1791; J. F. Meckel, Handbuch der pathol. Ana- tomie, ii. 2. p. 276; A. Cooper in A. Cooper's and Traver's Surgical Essays, p. 2,1820, p. 233 et seq. with illustrations.. These horns are similar in every respect to those which occur upon the external surface of the body, several of which have been described and figured by Cruveilheir, livr. xxiv. Plate in. Encysted tumours with hairs are also found in Ihe inferior animals! in these cases the hair always resembles the normal hair of the animal: in sheep, encysted tumours contain wool; and in birds, tumours which enclosed feathers are found. Occurrence and further progress of the simple encyted tumours belonging to thesecond division. Simple encysted tumours containing fat and epithelial cells, Oecur in almost every part of the body, most frequently in the sub-cutaneous cellular tissue, particularly upon the cranium and the eyelids, but. also in the face, upon the shoulders and the back ; more rarely they exist in the internal organs and of these most frequently-in the ova- ries. They appear sometimes solitary> sometimes simultaneously upon many parts of the body ; there have been observed, not unfre- quently, four, five, six, and even nine upon one person. A. Cooper saw sixteen upon the head. They vary from the size of a pea to that of the fist, or even of a cocoa nut; their diameter, however, seldom exceeds one or two inches. They occur at every age and in both sexes, and are sometimes congenital, although they usually arise later in life. In some cases they appear to be hereditary, and not very unfrequently are observed in several members of the same family. v The forms which contain hairs are most frequently situated in the neighbourhood of hairy parts, on the temples, near the eyebrows, &c.; these which, besides hairs, also enclose teeth and bone, have been hitherto met with only in the ovaries; those which contain horn, most frequently exist upon the upper part of the head. All these encysted tumours are perfectly non-malignant: although, like all non-malignant tumours, they may either from exciting causes, or, spontaneously, if they have attained a considerable size, become inflamed and break. Frequently, however, they exist throughout a whole life without injurious results. They can be removed without again forming ; if, however, the extirpation has not been complete, and a part of the sac remains behind, this, on account of its epi- ENCYSTED TUMOURS. 235 thelial investment, cannot become united to the adjacent parts ; it continues to secrete, and the encysted tumour reappears in its for- mer condition. Causes and origin. Some of the encysted tumours which enclose cells and fat, most probably, arise from sebaceous glands of the skin, which, owing to some obstruction in their excretory duct, become distended with their-accumulating secretion. This mode of origin is, however, certainly not so frequent as A. Cooper believed,* and, at all events, can only apply to such as exist in or immediately beneath the skin: it cannot take place in encysted tumours-of the internal parts, nor in those which contain hairs, bone, and teeth. Certainly in very many, if not in most instances, they are new or- gans formed by morbid processes, and we can readily suppose that their development is similar to that of serous cysts. If any patholo- gical exudation, which is incapable of further organization, as for instance pus, becomes deposited in the body, in such a manner, that it cannot escape, but irritates the surrounding parts, and gives rise to exudation, it becomes surrounded by a capsule of coagulated fibrin, which gradually organizes itself in granulations, and at length is converted into a membrane resembling mucous membrane or cutis, and becomes furnished with an epithelium—a proceeding frequently observed in fistulae, &c. At first the original contents are still pre- sent; they are, however, gradually resorbed, and give place to the secreted product of the newly formed sac-membrane, which always becomes further organized. In this way probably extravasations of blood, accumulations of pus, &c, which have no tendency to exter- nal rejection, may become the cause of encysted tumours. The origin of such tumours can frequently be attributed to external influences, contusions, &c, but more especially, continued pressure upon one spot: they may also arise, however, from constitutional, and internal causes acting in an insensible manner. The following example appears to me to contribute to the confirmation of this view of their mode of origin. A parrot in confinement died with a scrofulous deposit which had destroyed the skin by ulceration, and had caused caries of the cranial bones, &c. Upon dissection, the cavity of the abdomen appeared almost completely filled with a * Surgical Essays, vol. u. p. 236. 236 PATHOLOGICAL EPIGENESES. clear reddish fluid, which upon evacuation, spontaneously coagu- lated and characterized itself as fibrinous dropsy. In the neck were found after the removal of the skin two tumours of the size of wal- nuts, which from external appearance must have been regarded as glandular enlargemei ts, but upon dissection presented peculiar cha- racters. They both formed imperfect encysted tumours: their rather thick sac was formed of the substance of the hypertrophied distended gland, and upon its inner surface were numerous highly vascular gran ulations, covered with epithelium ; the contents formed a soft mass, which presented some irregular pus-corpuscles, bnt for the most part consisted of cells, perfectly similar to the epithelial cells, and the cells in the contents of encysted tumours, and which, therefore, no doubt had become separated from the walls of the cyst. The encysted tumours which contain hairs, bone, and teeth, are also undoubtedly formed in a similar manner, and it is not necessary to assume, with Cruveilhier (op. cit.) and Bricheteau,* that these are the enclosed remains of a partially absorbed foetus. Nevertheless we are far from clearly understanding why, in these cases, there are developed in the sac-membrane such complicated formations as hair- sacs, with hairs, sebaceous glands, bony substance, and tooth-sacs with teeth. The above opinion of A. Cooper, that superficial encysted tumours are occluded and distended sebaceous glands, is founded chiefly upon the ob- servation frequently made by him, that by the introduction ofa probe, the excretory duct can be again opened, and in this way the contents of the tumour may be evacuated without any special operation. Ph. von Wal- ther,| with a view to weaken this theory even for the superficial encysted tumours, alleges that, notwithstanding frequent endeavours, he has never been able to perceive the sac-mouth, nor express any portion of the con- tents. The decision of this question is.difficult, and in individual cases it is often impossible to say whether the encysted tumour has arisen in one or the other manner. The opinion of Cruveilhier and Bricheteau that en- cysted tumours which enclose hairs, teeth, and bones are the enclosed remains ofa partially absorbed foetus, is liable to such weighty objections, that it must be totally abandoned. - Cruveilhier himself admits that the tumours containing hair, which so frequently occur upon the scalp and . * Diction, des Sciences mtdic.t. xxvu. Kyste. . t Grafe u. v. Walther, Journ. d. Chirurg. vol. iv. part m. p. 384. ENCYSTED TUMOURS. 237 eye-lids, and vary from the size of a pea to that of a walnut, are not in every case to be regarded as the remains of a foetus, or as an enclosed embryo; the more so, as such tumours, in many instances, obviously originate after birth. Moreover, the perfectly analogous encysted tumours containing feathers, which are observed in-birds, cannot be explained in this manner, since the egg is developed externally to the body. Nor is any such admission required to account for bony structures in the interior of encysted tumours, since a pathological formation of new osseous matter not unfrequently takes place in other localities. Again, there exists no reason why, through the agency of local influences, the pathological for- mation of tooth-sacs and teeth in them, should be less readily effected than that of hairs, glands, and bones. In the inferior animals, teeth are not un- frequently observed in abnormal situations when intrafcetation is out of the question ; as for instance upon the temporal bone. Even admitting the possibility of the mode of origin assumed by Cruveilhier, its application to the cases in question, presents far greater difficulties than that of the other explanation. How does it happen, for instance, that every part ofa foetus becomes completely resor.be.d with the exception of one solitary moth, which remains perfectly unacted upon? Cruveilhier himself has collected a number of cases where, in extra-uterine pregnancy a foetus was retained and became petrified by the deposition of calcareous salts,* but not one of the cases which he has described, presents the slightest resemblance to an encysted tumour containing bones and teeth. Moreover, how can it be accounted for that the teeth resemble not merely the milk teeth, but frequently also those of the second dentition1? A foetus dead and under- going absorption for seven years is stated, in some unknown manner, to cast its milk-teeth and get a new set! Also the number of the teeth some- times met with, militates against this view: in one case, which Cruveilhier certainly terms doubtful (but upon what grounds7) there were found in a single tumour three hundred teeth, a mass which we must suppose to be furnished by the accumulated remains of at least ten foetuses! To the more simple encysted tumours which have been hitherto considered are allied b. More compound.and less regular forms presenting transitions between these and other kinds of tumours ; to distinguish them from the simple, true encysted tumours (cysts,) I shall, after J. Muller, call them cyst-like tumours {cystoids,) premising, however, that they * Anat. Fatholog. livr. xvm.'Plate vr 238 PATHOLOGICAL EPIGENESES. no more form a strictly separated group than the other forms of tumour. They resolve themselves into many sub-species or varieties which likewise cannot be strictly bounded, and result from combina- tions with other forms of tumour. As such varieties, we may dis- tinguish : 1. Foreign bodies which have penetrated into the organisation from without, as bullets, &c. also parasites, and entozoa; and un- organized epigeneses formed in the organism, as calculi and con- cretions, which sometimes invest themselves with sacs and become encased as in a capsule. In this case the foreign body is the primary cause, and the sac a secondary structure which arises in this manner: the irritation of the foreign body causes an exudation whose fibrin organises itself, and usually passes info a vascular cellular, tissue, which assumes a membranous form, and becomes furnished with an epithelium upon its internal surface. Somewhat similar phenomena ensue after extravasations of blood (apoplectic clots:) but in this case the sac-membrane is generally more or less blended with its contents. 2. Compound cysts. It has been formerly stated that from the same cause several (true or false) independent serous cysts may be formed in the same vicinity. These formations are not to be regarded as compound, but as accumulations of simple cysts, It sometimes happens, however, as has been shown by Hodgkin,* that new, se- condary cysts are formed.out of the wall of the original cyst. These compound cyst-formations may present a double type ; for the secon- dary cysts develop themselves either: a. By the side of the primary cyst, chiefly towards its external surface, and there thus arise Jocular cystic structures \yhose separate cysts vary in form and size ; or, b. The secondary cysts develop themselves onjthe interior of the wall of the parent-cyst in its cavity, and appear either pedunculated, or sessile with a broad base. They form clustered aggregations of cysts, which are filled with a serous or mucous fluid.f Such pedun- culated or sessile growths from the waif into the interior of the cyst, do not, however, always form secondary cysts, but are often much more solid, and consist of various kinds of tissue. They are then * Medieo-chirurg. Transactions, vol xv. p. 265,&c, with plates. t See Hbdgkin, op. cit. fig. J — 6. ENCYSTED TUMOURS. 239 to be considerad as a more extended development of the above- mentioned granulations, which are frequently formed upon the inner surface of the wall of simple cysts. 3. Combinations of cyst with other forms of tumour. It not un- .frequently happens that- tumours which, in their histological struc- ture, belong to the amorphous or organized fibrous tumour, to en- chondroma, &c., contain in their interior-cavities of various kinds, which are furnished with more or less smooth walls, and enclose a serous, mucous, fatty, or gelatinous fluid. These are the combined cysts and cystoids: on account of their fleshy stroma, J. Miiller* comprehends them under the common name of Cystosarcoma. He distinguishes three separate forms of them: a. Cystosarcoma simplex, in which the cysts, enclosed in a fibrous sarcoma, have each their distinct membrane, the inner wall of which is simple, smooth, or at most beset with a few vascular nodules. This form may be described as the cystic formation combined with the simple cyst. b. Cystosarcoma proliferum, in which the cysts enclosed in the sarcomatous mass, contain younger cysts in their interior, which are attached to their walls by pedicles ;—cystic structure combined with compound cysts. c. Cystosarcoma phyllodes, in which the cysts, included in a sar- comatous substance, are ill-defined, form several cavities and cham- bers without a distinct proper membrane, and are filled more or less completely with solid, foliaceous, cauliflower growths from the floor and walls of the cavity. This form corresponds with the cystic for- mations where solid granulations spring exuberantly from the walls of the cyst. The forms already described may serve to afford an idea of the com- plicated relations of the compound and combined cyst-formations. The subject is as yet very insufficiently worked out,, and there still exists great obscurity concerning it, especially with respect to the relations and causes of their development. Although, perhaps, in individual cases the origin may be sufficiently explained, general laws of formation eannot, at pre- sent, be laid down. The most important literature is to be found in the works referred to in the text, by Hodgkin and J. Miiller: descriptions and * J. Miiller uber den feineren Bau der Geschvviilste, p. 56, or West's translation, p. 170. 240 PATHOLOGICAL EPIGENESES. illustrations of some forms are given by Gluge in his Atlas d. Patholog. Anatomie, Part iv. under Cyst-formations ; also by Andral in his Patholog. Anatomie. Hodgkin includes malignant tumours amongst the compound cyst-formations; a view which will be presently criticised. MALIGNANT HETEROLOGOUS TUMOURS. Pseudbplasmata. The nature of non-malignant tumours consists essentially in this, that they are formed of the-persistent elements of the body, and as such maintain their existence and participate in the general meta- morphosis of the tissues. They may indeed be destroyed by soft- ening and ulceration, but this is effected through the agency of causes which are not inherent in their nature, but are only accidental and exoteric. Malignanf. tumours, on the other hand, proceed of necessity to softening from esoteric causes ; the softening being a necessary con- sequence of their development.* This circumstance sufficiently distinguishes the two classes of tumours. But other pathological formations also soften without being, on this account, malignant. Thus, for instance, softening takes place in all suppurations in which the pus is developed from a solid cytoblastema. In this case, however, the morbid epigenesis alone softens, the original tissues taking no part in it; if the pus'is evacuated externally or becomes resorbed, they return to their ori- ginal condition, and re-assume their previous functions; the affected part, with the exception of some trivial changes which occasionally remain, is restored in integrum. The case is far different with ma- lignant tumours. In these the softening is not confined to the mor- bid epigenesis amongst the original histological elements, but the latter become themselves involved in -the process of softening, and , are also destroyed, so that the expulsion of the mass from its place of formation is attended with a loss of substance. The. softening of the pseudoplasmata, therefore, it is not innoxious, but malignant * It certainly happens that tumours, whicli at iheir commencement we should re- gard as malignant, occasionally do not soften, but this is dependant on a< cidental or external causes, much like those which induce softening in non-malignant tumours. MALIGNANT TUMOURS. 241 and ulcerative ; it consists not in a healthy suppuration, but in a process of ulceration. The difference between non-malignant and malignant softening is not confined to the above points ; it extends even to the morpholo- gical formation of the product of the softening. In the non-malig- nant softening this consists of the normal pus-corpuscles formerly described; in the malignant, on the other hand, of very irregular molecules, which show scarcely a trace of organization, and resem- ble the products of the putrefaction of organic bodies, mixed with fragments of the destroyed tissues. This statement perfectly corresponds with that which was form- erly advanced as the distinction between non-malignant and malig- nant suppuration. In fact no strict line of demarcation can be interposed between malignant or ulcerative suppuration (ulceration) and the malignant tumours; some kinds of the latter—the typhous, the scrofulous, and some of the tubercular depositions---form a debateable territory, which may be as justly annexed to the former as to the latter. This, however, holds good only for some forms; others, as encephaloid and scirrhus, are histologically distinct from common ulceration. The view maintained by C. Wenzel,* that pseudoplasmata (carcinoma) and ulceration are identical, is there- fore, with certain restrictions, perfectly correct: it does not how- ever, hold good in all cases, and may be more accurately expressed by stating that the two are connected by a neutral ground. Besides the morphological distinction between ulcerations and pseudoplasmata, there is another which has relation to the extent of the malignancy. In ulcerations the malignancy is usually local, the destruction of the tissues, and the entire pathological process con- tinuing, for the most part, topically circumscribed. In the pseudo- plasmata, on the contrary, the epigenesis, and with it the destructive process is frequently propagated from the spot originally affected to other parts, and this propagation and extension attain such a degree that the death of the patient ensues. These different degrees of malignancy can be discriminated as local, and as general. Upon further consideration it will be perceived, however, that even this distinction is untenable. There are ulcerations which do not re- Ueber die Induration und das Geschwiir in indurirten Theilen, Mainz, 1815. 21 242 PATHOLOGICAL EPIGENESES. main locally circumscribed, but spread extensively and attack diffe- rent and often widely separated parts of the body, and finally, by an exalted influence upon the whole organism, induce death ; in these, therefore, we perceive not merely a local but a general malig- nancy. On the other side, there exist tumours absolutely corre- sponding in all other points with the malignant, but in which the destruction is merely local, and the loss of substance even becomes repaired without its exerting an influence upon the organism suffi- ciently exalted to occasion death. This is observed to be frequently the case with tubercles, and sometimes with scirrhus. For although some surgeons maintain that every scirrhus after its removal by operation again returns, other experienced practitioners, amongst them Travers,* maintain the contrary ; and it can be no longer doubted that pulmonary tubercles may heal without recurring. Hence in this point of view ulcerations and malignant tumours are not strictly separated. After this preliminary consideration of the relations in which the pseudoplasmata stand to the other pathological epigenesis, we shall proceed; to examine more attentively those points which the differ- ent pseudoplasmata possess in common. These tumours do not arise, as was formerly supposed, from a transmutation of the normal tissues ; they are, rather, new formations which penetrate amongst the previously existing histological ele- ments of the body. Their cytoblastema is always originally fluid and only subsequently becomes solid : it generally fills up the inter- stices of the tissues amongst which it is deposited, as completely as mortar the spaces between the stones of a wall. This may be di- rectly observed in pulmonary tubercle and in scirrhus, and it results from these observations that the cytoblastema is secreted in a fluid state, even in the cases where we find it solid: for this perfect im- pletion of all, even of the smallest spaces between the elements of the tissues can only be effected by a fluid. The cytoblastema is undoubtedly derived from the vessels, and is probably effused through the agency of the same causes which give rise to fibrinous dropsy. We possess no accurate knowledge respecting the chemical com- * Medico-chirurg. Transactions, vol, xv. p. 219, MALIGNANT TUMOURS. 243 position of the cytoblastema: although all observations hitherto made, tends to show that it contains the same elements as fibrinous dropsy, and that its coagulability depends upon 'dissolved fibrin. It may be possible that the cytoblastema of the different pseudoplas- mata contains specific chemical principles—peculiar modifications of the protein-compounds : the present state of animal chemistry does not, however, allow of a positive affirmation or denial of this question. The effused cytoblastema undergoes changes which are very dis- similar in different pseudoplasmata: in some forms it becomes or- ganized, and is converted into cells, amongst which, in certain cases, fibres and blood-vessels are formed: in others, scarcely a trace of organization can be detected, the cytoblastema remaining amorphous, or showing only very feeble indications of cellular structure. In all cases, however, the new formation finally softens, and be- comes disintegrated, and in the disintegration there are involved not merely the permanently amorphous, but also the organized parts. The product of the softening is not, as in normal pus, an emulsion of organized corpuscles, but a fluid with irregular broken up organic molecules,—an organic detritus, which, only in the highly organized pseudoplasmata, contains a few integral or broken cells. The softened pseudoplasmata are thus also morphologically dis- tinguished in an essential point from normal pus, and correspond more nearly with the unhealthy pus of ulceration. The fluid re- sulting from the softening of the pseudoplasmata, is not bland and innocuous, on the contrary, it is usually ichorous, corrodes the sur- rounding parts, and has a putrid odour. Upon what substances these injurious properties depend, has not been chemically de- termined, but the fact itself is undoubted. The period which elapses between the deposition of the cyto- blastema and the softening is various in different cases, but is always longer than that which is requisite to develope normal pus from a cytoblastema ; here, again, the softening of the pseudoplasmata co- incides with ulceration. As in suppuration, so also in the pseudoplasmata, the softening is not confined to the newly formed products; the normal tissues amongst which the cytoblastema was deposited are also involved in the destruction, and simultaneously soften. 244 PATHOLOGICAL EPIGENESES. These facts enable us to explain in a sufficient manner the locctj malignancy of the pseudoplasmata. It is determined by entirely the same causes which we formerly recognized as conditions of ulcera- tion. There exist, however, two causes of which, no doubt, either may be efficient, or both may co-operate. In the first place, from the long incarceration of the coagulated cytoblastema the tissues be- come injuriously compressed, and since they are in some measure isolated, their nutrition is impaired and their death thus occasioned. Secondly, the corrosive property of ichor, which frequently resembles a putrid fluid, exerts its action upon them, and likewise contributes to their death. Allowing that these causes account for the local malignancy of the pseudoplasmata, we have still to seek for an explanation of their extension, and of their pernicious influence upon the whole organism. It has been mentioned that these consequences do not always en- sue, that for instance, tubercles sometimes continue local, and the destruction caused by them may, as in other instances where loss of substance has occurred, heal by cicatrization. This, however, is not usually the case; in general, the pseudoplasmata progressively extend until they germinate in death. As the non-malignant tu- mours grow by the conversion (conformably to the law of analogous formation) of the nutritive fluid secreted in their surrounding parts into a structure resembling themselves, also so may malignant tu- mours be propagated according to the same law. Since, in this manner, the increased extent of the tumour is accompanied by an extension of the softening, the loss of substance and the destruction are constantly increasing. The softening of malignant tumours usually commences not upon their surface, but in their interior; the product of the softening, therefore, not being immediately discharged, the ichorous pus con- tinues for some time in contact with the walls of the vessels, and, by endosmosis, its fluid parts are taken up into the lymph and blood ; exerting a morbific influence, in a manner at present but little un- derstood, upon these fluids, and thus gradually inducing a general cachexia. Moreover, the vessels which intersect the tumour be- come involved in the process of destruction, some indeed, be- coming obliterated by it, whilst others are opened, and into the gap- ing mouths of such veins and lymphatics, not only the fluid but the solid particles of the softened mass enter, and proceeding further MALIGNANT TUMOURS. 245 into them, excite phlebitis and inflammation of the lymphatics with their consequences. These evil effects of their increase and of their general morbific influence upon the collective organism are shared by the pseudo- plasmata and by ichorous suppurations ; the former, however, com- monly possess them in a higher degree, being mostly deeper seated, and, therefore, retaining the ichor for a longer period, and more- over increasing with greater energy. These consequences may be obviated by the removal of the pseudoplasma by operation previous to its softening, and upon this rests the advantage to be derived from the employment of the knife in the malignant epigeneses. In order to be useful, such an operation must be radical, i. e. no part of the pseudoplasma should be left behind. But the general malignancy of the pseudoplasmata is not confined to this ; there commonly arise also on other spots of the body in the vicinity of the original pseudoplasma, or distant from it, simulta- neously with the first or subsequently, other pseudoplasmata of the. same kind. Upon what this depends we know not, and pathologi- cal anatomy has thrown no more light upon this point, than re- specting the causes which give rise to pseudoplasmata generally. That the pseudoplasmata are not produced by metamorphosis of the normal tissues, but that like, all other pathological formations, they take their origin from an amorphous cytoblastema, is indubitable: observa- tions which establish this will be adduced in our observations on the in- dividual pseudoplasmata. It is no less indisputable that this cytoblaste- ma is furnished from the vascular system, especially from the capillaries It is possible that the cytoblastemata of the pseudoplasmata from their earliest stages differ from those of the other pathological epigeneses. \ have had repeated opportunities of examining such cytoblastemata, but have never been able to detect any peculiarity in them., Our know. ledge of the different modifications of the protein-compounds is, however, still very imperfect, and we possess no means of recognizing mere mi- croscopic quantities. This question must, therefore, for the present re- main unanswered. Our knowledge is not more definite regarding the causes which lead to the formation of the pseudoplasmata. The present state of this subject may be thus briefly summed up : firstly, it may be assumed that the formative cause consists in a depraved condition of the fluids, i. e. certain elements of the blood become changed, or there occur in it new and peculiar substances which after their deposition in the pa- renchyma of organs, necessarily become converted into pseudoplas- 21* 246 PATHOLOGICAL EPIGENESES. mata. According to this view, therefore, there already exists in the blood, previous to the formation of any pseudoplasma, a cancerous or tu- bercular matter whose deposition upon a definite spot may determine the localization of the disease, or its propagation to several organs may re- sult from the first deposition not removing the whole of this matter from the blood. Through the continual production of this matter, and its de- position in various parts of the body, the disease becomes constitutional. Against such a view, which attempts to explain the disease solely on the principles of humeral pathology, there maybe urged weighty objections. In the first place such specific morbid principles have not as yet been demonstrated ; indeed, the failure of every attempt to trace them, renders their existence very improbable, and if, nevertheless, in modern times, certain physicians speak of such matters, (stating for instance, that tu- bercles consist of casein,) this only shows the deficiency of their know- ledge of organic chemistry. Moreover, it cannot be conceived why such a principle circulating in the blood throughout the system, becomes de- posited only in certain spots, and does not, with the nutritive fluid, ex- ude every- where from the capillary vessels ; and consequently why pseu- doplasmata do not arise simultaneously in every part of the body. We are, then, compelled to assume, that certain parts of the body possess a peculiar attractive power for these principles, something similar, we must suppose, to that by which the parenchyma of the kidneys especially separates urea : for this separation cannot be ascribed to peculiarities of the vascular system, since pseudoplasmata may arise in nearly every part of the body. This could not be an orgin-d, innate, attractive force, because for the reason last mentioned, all parts of the body would then possess it, and thus the local occurrence of pseudoplasmata would remain un- explained. It must be first acquired by a change in the constituents of the body, which may be either direct or mediately transferred from the nervous centres. With this admission, however, the morbific cause be- comes, partly at least, transferred from the province of humoral pathology to that of nervous pathology, or solidism. A second view, which is closely allied to the first, seeks the cause of the pseudoplasma in a contngium animatum : for instance, it ascribes to the specific cells of cancer the power, like that of the spores of crypto- gamic plants, of propagating the disease by the expulsion of new cells or by the genesis of such cells in their interior. Two distinct modi- fications of this view may be exhibited. According to one, all pseudo- plasmata in every case spring from such a germ: according to the other, this is but one of the modes of propagation, and is especially adapted to explain the formation of new pseudoplasmata in an organism already infected. There are very weighty objections to both opinions, which MALIGNANT TUMOURS. 247 shall state at length in speaking of cancer, where this view can be sup- ported with greater plausibility than for the other pseudoplasmata. It may in this place be provisionally remarked, that by the assumption ofa contagium animatum, neither the origin of the pseudoplasmata, nor even propagation in an organism already infected, is sufficiently explained. The other theories which have been advanced are still less tenable. I deem it, therefore, right that we should candidly avow our ignorance of any thing certain, respecting the general formative causes of the pseudo- plasmata. In the consideration of the individual forms we shall fre- quently revert to this subject. The malignant epigeneses are as little capable of precise classifi- cation as the non-malignant tumours. They may, however, accord- ing to the higher or lower degree of organization which they attain before their disintegration, be reduced into certain groups, but these are still less strictly separable than in the case of the non-malignant formations; transitions between the individual forms are of common occurrence, and indeed, the same tumour not unfrequently shows totally dissimilar elements; the reduction of these formations into numerous species with a multiplicity of names is, therefore, quite unjustifiable. We discriminate, firstly, pseudoplasmata which are slightly or not at all organized; and secondly, such as attain a higher grade of organization. As representatives of the former class may be pointed out the depositions in typhus, and in scrophulous tumours ; of the second, encephaloid and scirrhus. Many varieties of tubercle form a connnecting link between these leading divisions. In the classification of the pseudoplasmata there has hitherto prevailed and still, to some extent, prevails a very great confusion. In fact, there is scarely a part of medicine where more obscurity and prejudice prevail than here. In the following pages I shall consider the pseudoplasmata mainly in a histological point of view: the question whether the com- monly received distinctions between the morbid processes which generally accompany the different pseudoplasmata are positively established, does not properly belong to our subject; it will, however, be borne in mind, although we shall not permit it to carry us too far from our especial sub ject. 248 PATHOLOGICAL EPIGENESES. FIRST CLASS. PSEUDOPLASMATA SLIGHTLY OR NOT AT ALL ORGANIZED. The tumours belonging to this class are characterized by the cir- cumstance, that during the whole process of their development, from their first appearance to their softening, they show a very low de- gree of organization. The mass forming them appears either en- tirely indeterminate and amorpho-granular, or it attains, in the most highly developed cases, to a very imperfect Cellular structure: the product of their softening is an indeterminate granular detritus. Morphologically, as well as pathologically, (that is to say in rela- tion to the concomitant local and morbid phenomena,) these new formations are most closely allied to ulceration, from which indeed they cannot be strictly separated. In general, however, they do not remain local, but appear simultaneously on several parts of the body. But this propagation does not, as in the more highly organized pseu- doplasmata, depend upon the conversion (in conformity with the law of analogous formation) of the nutritive fluid in their vicinity into a mass resembling them, but is rather due to the same cause which gave rise to the first'pseudoplasma becoming repeated in its vicinity or in a distant part of the body. The cavities and ulcers produced by the softening of these depositions can, therefore, spontaneously heal wj^h much greater facility, than those which ensue from the softening of the more highly organized pseudoplasmata. From the second class—the more highly organized pseudoplas- mata—they are histologically distinct, although even here transition forms are not wanting. They appear absolutely non-vascular, and if vessels are found in them, these are not of recent development, but belong to the normal tissues, amongst which the epigenesis was deposited. Their common termination is the softening of the deposited mass. The period which elapses between the deposition and softening is very different in individual cases ; it may vary from a few davs or weeks to several months. In general the softening extends to the enclosed normal tissues, and the united product opens for itself a passage, and is discharged externally. An ulcer is thus formed: this either spreads by continuance of the original process (new de- TYPHUS DEPOSITS. 249 position with softening) in the surrounding parts, until it terminates in death ; or the ulcer heals by cicatrization, whilst the loss of sub- stance is repaired by permanently organized epigeneses. In other cases the softened mass does not become discharged but is gradually resorbed, and the loss of substance is repaired by a similar cicatrization to that which occurs in the preceding case. Sometimes the reparation is interrupted by the deposition, instead of softening, becoming converted into an earthy or cretaceous mass, and thus forming a concretion. The separate forms of these epigeneses have generally been dis- tinguished less by histological and anatomical characters than ac- cording to the true or pretended peculiarities of the morbid pro- cesses with which they are usually associated. I shall follow this classification as it has the most special relation to practical medicine. DEPOSITIONS IN TYPHUS. In the majority of the cases of typhus, pathological epigeneses occur in different parts of the body, most frequently in the intestinal canal between the mucous membrane and the muscular coat, in Peyer's glands, (especially at the termination of the small intestines) and in the mesenteric glands : less frequently in the spleen and lungs, and in and under the mucous membrane of the trachea. These formations usually appear as a more or less firm lardaceous mass of a yellowish or whitish colour, which is deposited in greater or less abundance, amongst the normal tissues, gradually softens, and as the normal elements of the region become also involved in this process, forms ulcers which either heal by cicatrization, or con- tinue until the death of the patient. In many cases death takes place before the commencement of softening. Of the phenomena which attend the softening and cicatrization in the different organs We shall treat in the special part: in this place our attention will be directed to the mass alone. This must, in every case, be deposited in the fluid state, and sub- sequently assume the solid form by coagulation: otherwise it could not so completely fill up all the interstices of the tissues. Upon ex- amination, however, it is invariably found coagulated: at least, I am acquainted with no instance where it has been observed still fluid. 250 PATHOLOGICAL EPIGENESES. Under the microscope the following constituents are recognized in the mass. 1. An amorphous, semi-transparent stroma. 2. Molecular granules from a size too minute to estimate, to the 800th of a line in diameter; sometimes interspersed with larger fat globules. 3. Larger corpuscles (imperfect cells and cytoblasts) from the 800th to the 300th of a line in diameter, rarely larger. Some of these enclose smaller corpuscles (elementary granules and nucleoli) which are wanting in others.* By acetic acid the amorphous substance is rendered more trans- parent, and at length invisible; the granules as well as the cytoblasts and nucleoli remaining unchanged, whilst the cells become paler and gradually disappear. By alkalies, on the contrary, the entire mass is rendered diaphanous, and tiere remain visible only a greater or smaller number of granules: this reaction is produced more rapidly by potash, than by ammonia. These three elements, in different cases, are present in very vary- ing quantities, the amorphous matter seldom predominates; most commonly the granules are in excess, and in this caSe has, in re- fracted light, a grayish brown appearance. The cells and cytoblasts are sometimes so thinly scattered that they are with difficulty per- ceived ; in other cases they are more frequent, but it is very seldom that they are the predominating element. When softening takes place, the amorphous matter disappears ; the granules, however, and the cells and cytoblasts appear suspended in a fluid, as in an emul- sion. The softened mass frequently contains unsoftened particles of considerable size which, by the solution of the surrounding parts, become isolated, and are thus discharged as agglomerate masses. The softening of typhous matter usually proceeds rapidly, follow- ing the deposition in the course of a week or only a few days; it is but seldom that several weeks intervene. The typhous matter can- not be histologically distinguished from the deposits which occur in scrofulosis and tuberculosis : distinctions may, indeed, be some- times perceived between these different deposits but these are not greater than are observable between the varieties of typhous matter. * See Plate vi. fig. 12, 13, 14, 15. TYPHUS DEPOSITS. 251 Neither can it be distinguished with precision from many forms of inflammatory exudation in the early stages of development, nor from the product of many malignant suppurations, from exudations in gangrenous parts, and similar processes, whilst its differences from normal pus, and from the more highly organized pseudoplas- mata are very obvious. The question of the origin and signification of this typhous matter can be only partially answered by pathological anatomy. It appears to be ascertained that this matter is secreted in a fluid state from the capillary vessels. Moreover, the cause of this separation is, doubtless, a local hyperaemia of these vessels; as, indeed, in typhus may be readily proved by direct observation. The secreted matter is, therefore, a part of the blood which, shortly after its separation, coagulates. But we are acquainted with only one principle in the human body, which is capa- ble of spontaneous coagulation, namely, fibrin. Of this, therefore, the typhous matter chiefly consists: it is, however, as in all similar cases per- vaded by the other elements of the blood. The question here sug- gests itself: Is this fibrin normal or has it, whilst still in the blood, undergone a specific change 1 The possibility of such a change cannot be denied, since we know that fibrin is very transmutable: but the assumption of such a change without a demonstration of its nature by organic chemistry, is of no advantage in a scientific point of view. By such a hypothetical transmutation of the fibrin, we may endeavour to explain why the typhous exudation is not converted into normal pus, but breaks up without any distinct organization. This view, however, may be opposed by another equally plausible: it is very probable that in typhus the normal properties of the tissues are de- prived of their ordinary energy, and that their formative power is im- paired. In this diminished energy of the original tissues may, likewise, be sought the reason why the exudation does not become organized, but undergoes disintegration. Probably, however, neither the one nor the other view alone is correct, and doubtless there are a multiplicity of con- current causes in action, whose manifold intricacies cannot be at present unravelled. With this brief view of the subject, I wish to express myself as opposed to the opinion, that there exists in the blood a specific typhous matter, with the deposition of which, in certain parts of the body, the dis- ease localizes itself and terminates. At the same time the local import- ance of this deposit cannot be questioned. A great number of cases of typhus proceed to a fatal termination from the effects of these depositions, from ulceration, perforation of the intestine, &c. With respect to the histological arrangement of typhous matter, it re- 252 PATHOLOGICAL EPIGENESES. mains to be observed that foreign ingredients are frequently intermingled with it—as epithelial cells, chyle-corpuscles, &c, which must not be con- founded with the histological elements of the matter itself. SCROFULOUS DEPOSITS. . In scrofulosis, as in typhus, depositions occur in various parts of the body—-most commonly in the lymphatic glands and their vicinity, but also in other glands, and. other organs. In an anato- mical and histological point of view, the scrofulous matter bears so great a resemblance to the typhous, that here we shall only notice their distinguishing characters. The essential difference is, that here the whole proceeding is ac- complished much more slowly—the deposit and the softening gene- rally lasting as many weeks, or even months, as in the other case days. The matter also exhibits in different cases great anatomical vari- ations ; it is sometimes dense and firm, so that thin sections can be made; sometimes it is lardaceous, sometimes soft and crumbling like new curds. It is likewise sometimes colourless and semi-trans- parent, sometimes whitish, sometimes of a yellow tint. Histologi- cally, it is perfectly similar to typhous matter, and consists essen- tially of the same elements: it presents an amorphous stroma, molecular granules, and undefined cells and cytoblasts, varying in diameter from the 600th to the 300th of a line, occurring in very different proportions and mixed with fat-globules. The granules are partly protein-compounds, partly fat, and in part calcareous salts: the latter disappear with effervescence on the addition of nitric acid. After its softening, the matter consists of the same indeterminate granular " detritus" as the typhoid deposit. Softening and ulceration do not, however, always ensue: in many cases the above mentioned calcareous deposition becomes predominant, and the mass is con- verted into a concretion. Scrofulous matter cannot be with certainty distinguished histolo- logically from typhoid or tubercular matter. There occurs every intermediate grade between it and ordinary suppuration. The statements formerly made respecting the mode of origin and the signification of typhous matter hold good equally here. Further obser- TUBERCLE. 253 vations concerning the conditions of the lymphatic glands infiltrated by scrofulous matter, follow in the special part. The reader will find a his- tological and chemical investigation of these tumours by Valentin in his " Repertorium," vol. u. p. 282. TUBERCLE.* Tubercles form the most frequent and therefore the most import- ant of this class of deposits. They have especially attracted the attention of physicians, and for this reason merit an attentive consi- deration. Originally the name " tubercle" was a very general one; in ac- cordance with its proper signification,- it expressed all nodular tu- mours, and even at the commencement of the present century, Baillie applied the term to fibrous tumours of the uterus. At the present day, however, its meaning is much more limited, and by tubercles we now understand those pathological epigeneses which are engendered in consequence of a specific disease or morbid ten- dency—tuberculosis. In establishing this definition, however, sufficient care has not been taken to point out, firstly, that all tumours which are regarded * The literature of tubercle is remarkably copious ; in addition to the various works on pathological anatomy and pathology generally, we may mention ; Laennec, de l'Auscultation mediate; Carswcll's Pathological Anat. Tubercle, fasc. 1, 1833; Schroder van der Kolk, Observationes anat. patholog. fasc. ], 1826; Clark, on Con- sumption ; Sebastian, de orfgine, incremento et exitu phthiscos pulmon. obs. anat. Groningse, 1837; Louis, Recherches sur la phthisie, 2nd edition, Paris, 1843; or Walsh's translation, London, 1844 ; Boudct, recherches sur la guerison naturelle ou spontanee de la phthisie pulmonaire, Paris, 1843 ; Zehetmayer, uber die Lungentu- berculose, Zeitschrift der Gesellsch^ift der Aerzte in Wien, Jahrg. 1, No. n.; Engel, die Tuberculose, ditto, 1844, No. v. Further references are given in the special department. A very perfect view of the literature of the subject is given by Cerutti, Collectanea quaedam de phthisi pulmon. tuberculosa, Lipsiae, Ib'Si), 4. For information on the histology of tubercle we may especially refer to: Gerber, llandbuch der allgemcine Anatomie, 1840, p. 187, &c, or Gulliver's English edi- tion, p. 305, &c.; Gluge, Untcrsuchungen, No. n. p. 162, &c.; Klencke, Unter- suchungen und Erfahrungen, vol. n. p. 12, &c.; Lebert in Miiller's Archiv. 1844, p. 190, and in his Physiologie pathologique, 1845, voL i. p. 351, &c.; Gun- burg, die Pathologische Gewebelehre, 1845, vol. l. p. 100, &c.; Addison in the Transactions of the Provincial Medical and Surgical Association, vol. n. 1843, p. 287, <&c. 22 254 PATHOLOGICAL EPIGENESES. as effects of tuberculosis, invariably show the same anatomical and histological constitution, and can be distinguished with certainty from all other pathological epigeneses ; secondly, that, on the other hand, the appearance and course of tumours which, from their ana- tomical structure, must be regarded as tubercles, are always attended with the morbid phenomena which are pointed out as characteristic of tuberculosis; and thirdly, that tuberculosis is positively always the cause and not merely the effect of local tubercles ; on the con- trary, it was conceived that enough had been done when this cor- respondence was rendered probable for only one organ—the lungs, where they certainly appear most frequently. It is,,however, cer- tain that physicians frequently regard tumours in the brain, under the peritoneum, and even in the lungs to be tubercles, when their histological structure shows that this is not the case ; moreover, as was stated generally of the pseudoplasmata belonging to this class, true tubercular matter cannot be distinguished with certainty from other epigeneses, namely from the scrofulous and typhous, and from many other ulcerative processes. In a pathologico-anatomical view, therefore, the definition of tubercle is by no means strictly limited; whether or not this is the ease with the morbid process which is named tuberculosis cannot in this place be investi- gated.* I will now endeavour to consider the general relations of this pa- thological epigenesis : its peculiar relations in individual organs will be considered in the special part. With respect to the origin of tubercle, there can be no doubt that its formative substance is secreted from the capillary vessels in a fluid form, in perfectly the same manner as was stated of typhoid matter. It afterwards fills up all the interstices of the tissues in a manner too perfect to be accomplished fcy any substance that was not originally fluid. Probably this secretion results from the same causes as that of fibrinous dropsy "generally, and is preceded by a local hyperaemia of the participating capillaries. Whether or not this proceeding should be termed inflammation, is a question which will be subsequently considered. Pathological anatomy fails to demon- * See Engel, op. cit. TUBERCLE. 255 strate an especial cause for this secretion from the blood into the parenchyma, in the formation of tubercle. Whether or not this se- creted fluid contains other elements than in the normal state, and whether there exists ready formed in the blood a specific tubercular matter which, on this occasion, becomes separated, can be answered with as little certainty for this, as for the typhous and scrofulous depositions. Hitherto all attempts to demonstrate such a specific principle in the blood have failed : this speaks certainly against its existence, although we cannot deny that with our present means, we are unable to demonstrate every modification of the protein- compounds, and this would be the point to be considered. This fluid condition of the tubercular matter cannot be directly observed. Some, indeed, assert that they have seen it, but the dif- ficulties of satisfying ourselves of the presence 01 a specific cytoblas- tema of this kind, differing from the normal nutritive fluid are so great, that the correctness of such observations may reasonably be called in question. Whenever tubercles are-observed in what may be presumed to be their earliest stages, they appear solid, form a more or less dense mass, and fill up all the interstices of the elementary tissues in which they are deposited. The tissues are usually neither displaced nor altered by the tubercular matter; on the contrary, they in general retain their normal position ; they are, however, as closely and perfectly invested by it, as the stones of a wall by the solidified mortar which has been applied between them. We can most readily convince ourselves of this condition by treating fine sections of tubercular deposit from the lung with acetic acid or caustic ammonia. By means of these reagents the opaque tubercular matter is rendered transparent, and under the microscope, the enclosed portions of lung (the intersecting fibres) are perceived to be arranged amongst the tubercular matter just as in the normal state. This ex- periment, however, does not always succeed, for sometimes the tu- bercular matter contains numerous molecular granules which are not rendered transparent by these reagents ; in this case the prepara- tion, even after the above treatment, remains opaque or at least tur- bid. . On microscopical examination, turbercular matter is found to be composed of different elements, whose proportions are extremely various in separate cases, but which essentially correspond with the 256 PATHOLOGICAL EPIGENESES. elements of the typhoid and scrofulous matters formerly described. There are :-— Firstly, a transparent, amorphous, vitreous stroma, occurring'in large masses, which perfectly resembles coagulated fibrin and micro- chemically reacts like it: that is to say, acetic acid and alkalies render it pale, and finally cause its disappearance ;* Secondly, minute granules (molecular granules) varying from the 800th of a line in diameter to inappreciable minuteness, chiefly of a roundish form, and occurring in large masses of a brownish colour. These granules do not always exhibit the same chemical reactions; they seem, therefore, to be differently constituted. Some of them appear modified protein-compounds, such as we have formerly had occasion to" notice: they are insoluble in acids and alkalies, and in ether, and are little or not at all attacked by other reagents. Others consist of fat, and dissolve in boiling ether. Amongst them we frequently notice larger fat-globules presenting the same chemical character. Finally, a third kind of these granules are Calcareous salts (phosphate and carbonate of lime:) they dissolve in acids with partial effervescence.t Thirdly, imperfectly developed cells and cytoblasts, with or with- out nucleoli: the former are partly soluble in acetic acid; the latter are insoluble : both disappear on the addition of caustic ammonia or potash. The cells are generally very imperfectly developed, and a distinct nucleus can seldom be recognized. Their size usually varies between the 400th and the 300th of a line, their diameter rarely attaining to the 200th of a line4 With these more or less fully developed cell-formations in tubercular matter, we must not confound other structures, presently (p. 259) to be described, which are frequently found in the vicinity of tubercle. These three elements occur in.individual cases in very different proportions. The amorphous stroma seldom predominates; the granules more frequently—sometimes, indeed, almost the entire mass of tubercle appearing to consist of them; of these, the pro- tein-granules are generally predominant; the fatty granules are less * This substance does not admit of expressive delineation ; it is intended to be shown in Plate vi. fig. 1. a. b. ; fig. 2, a. ; fig. 3, a. ; fig. 5, b. a. t These granules are most obvious in softened tubercles, being set free by the so- lution of the amorphous stroma enclosing them. See Plate vi. fig. 6. Ij See Plate yv fig.. I; fig. 3,. a,, b; fig. 4» a; fig. 5, a. TUBERCLE. 257 frequently in excess ; and there are cases in which the calcareous granules prevail. The cellular formations are sometimes entirely absent, so that.it is often impossible to discover even traces of them in tubereular matter : in other cases almost the whole mass of the tubercle appears to consist of cells and cytoblasts. The degree of organization of the tubercle depends on the prevalence or deficiency of these cell-structures. The naked eye is itself sufficient to reveal differences in different cases of tubercle. As the extremes of these differences, we may notice two which have been characterized as distinct varieties of tu- bercle. In one variety of the tubercular matter is of a gray or whitish colour, semi-transparent and homogeneous: this has been named gray infiltration. In the second variety the matter is yel- lowish, opaque, dense, lardaceous or mellow, like some sorts of cheese {yellow tubercular matter.) Between the two varieties, however, there is presented every gradation. These two varieties present histological differences ; in the former we have an amorphous mass and cellular structures; in the second, the granu- lar elements prevail. The absence of these granules is a suffi- cient explanation of the greater transparency, the grayish white colour, and smooth section of the former; while their occurrence ae- counts for the opacity, yellow colour, and irregular, granular section of the second variety. These varieties of tubercular matter have been regarded as the same substance in different stages of development, and in many cases this view is undoubtedly well-founded ; thus gray tubercle in the. process of its development, as it approaches to softening, usually assumes a granular appearance, and? may be con- verted into the yellow variety. But on the Other hand'we also meet with tubercles of the yellow variety in apparently the very earliest stages of development. Hence there can be no doubt that this va- riety can exist primarily, since, from the very commencement, gra- nules are separated from this tubercular mass as from gray tubercle. Further changes of tubercular matter: softening. Of the above- constituents of tubercular matter^ the amorphous substance is pre- sent from the commencement, as soon as the tubercle becomes- firm : it is, without doubt, the product of the coagulation of fibrin : moreover, the greater part of the granules are frequently present from the first. The imperfect cells and the cytoblasts make their* appearance gradually ; their development is the only trace of the- 22* 253 PATHOLOGICAL EPIGENESES. process of organization of which tubercle is capable. Other or- ganized structures such as we have learned to recognize as pro- ducts of formative activity, and such as occur in the more highly organized pseudoplasmata, are here absent. In tubercle there are formed neither fibres nor vessels, and in fact, even the normal ves- sels of the part in which the deposition occurs, become compressed, emptied, and impervious ; none but a few of the larger vessels with thick walls remaining uninjured. Hence, if, in examining tubercle, vessels capable of being injected are found in it, they must not be regarded as epigeneses, but merely as the remains of the original vessels. The ordinary course of tubercular matter is to soften, and this occurs in the following manner. In the first place the amorphous stroma liquefies ; the elementary granules then separate and the cells and cytoblasts become liberated, in part break up, and form a sort of emulsion either with a pre-existing or a newly secreted fluid. In this process of softening most of the tissues, between which the tu- bercular matter has been deposited, take a share ; they also break up, the more delicate first, the firmer resisting the destructive action for a longer period, and the product of their disintegration mixes with the softened, tubercle, presenting the appearance of a thick, quasi-purulent fluid, which therefore forms an organic detritus satu- rated with fluid (serum,) and under the microscope exhibiting very indefinite characters. It appears as an aggregation of elementary granules with cytoblasts and cells in various states of preservation.* Sometimes crystals of cholesterin or of ammoniaco-magnesian phos- phate, or certain organized structures originating from the textures surrounding the tubercle are present. In the fluid of the softened tubercle we usually find a viscid (pyin-like) substance which coagu- lates on the addition of acetic acid. The softened mass usually exhibits a tendency to external rejection, in this point of view re- sembling the pus of an abscess. > In some few cases it becomes gra- dually resorbed, disappears, and the cavity formed by the, destruc- tion of the tissues is filled by the formation of a cicatrix, or else a portion of the tubercular matter remains as a compact and sometimes even as a quasi-cartilaginous mass, or undergoes a species of fatty degeneration. In other cases the development of the tubercular matter proceeds * See Plate vi. fig. 6. TUBERCLE. 259 in a different manner. A copious deposition of calcareous granules occurs in the tubercular matter, and continues to increase, while the other constituents are removed by resorption. In this manner tu- bercle becomes converted into a white pulverulent, or chalkly mass, or else into a dense stony substance. This modification of tubercle is usually surrounded by a kind of cicatrix formed of thickened fibrous tissue, and may remain for years in the organism without undergoing further change, or becoming incrusted on its surface. We shall return to this subject in our remarks on concretions. Its relation to the surrounding parts.—Tubercular deposits form either nodules of very varying size, or are continuously distributed through a whole organ, or its greater part. We consequently make a distinction between tubercular nodules and tubercular infiltration; when the former are very minute, not exceeding a millet-seed in size, but yet visible to the naked eye, we name them miliary tuber- cles. These two forms of tubercular deposit are not .separated by any definite limit; there are, however, the following distinctions whose establishment frequently varies in accordance with the sub- jective opinion of the observer. Neither form of deposit has got a well-defined limit, each usually extending almost imperceptibly into the surrounding healthy tissues, unless in certain cases arrested by some peculiar anatomical arrangement, as in the case of glands. Some- times, however, a secondary limitation of tubercular deposition is brought about by other pathological epigeneses appearing in the surrounding parts; this may arise either from the influence of the surrounding tissues on its metamorphosis, being stronger at the mar- gin where the amount of deposit is small, than in the centre, and in this way, other products being formed at the periphery of the mass; or from the deposited tubercle exciting irritation in the surrounding parts, and thus giving rise to a cytoblastema distinct from that of tubercle, and becoming converted into pus and granular cells. Hence at the margin we frequently find histological elements dis- tinct from those in the centre of tubercle—namely pus-corpuscles and granular cells; we may also expect to see epithelial cells, and other elements of the original normal tissues, which on making a microscopic examination, must not be confounded with the ele- ments of tubercle. After the process of softening these elements mix with the liquefied tubercular mass, and thus increase the num- ber of the constituents of the detritus deposited by it. 260 PATHOLOGICAL EPIGENESES. Whether the cytoblastema of these peripheral formations is iden- tical with, or distinct from that of the tubercular matter itself, this much is certain, that the latter can exert no great influence on it, and that its generative power is very small. This is an essential difference between tubercular matter and the more highly organized pseudoplasmata. We shall see that they possess this capacity in a high degree, and that the cytoblastema separated in their neigh- bourhood, is excited to analogous development; while in tubercles this is not the case, or at most only occurs occasionally to a slight degree. The extension of the tubercular deposit is dependant only on the unknown cause which in the first instance gave rise to it (the tuberculous diathesis.) For this reason tubercles frequently heal without any artificial aid, when this tendency, and, at the same time, the occurrence of the deposition terminate. The cure is effected, either by the cavity- becoming filled by the formation ofa cicatrix, by its being invested by newly formed membrane (mucous membrane with epithelium,) by the tubercular mass becoming resorbed, or finally by its be- coming converted into a concretion by the deposition of calcareous salts. The details of these processes are different in the various organs, and we shall enter with more minuteness into the subject in the special part, in the chapter on the morbid anatomy of the lungs. This deposition occurs most frequently in the lungs and the lym- phatic glands, but likewise in the kidneys, liver, spleen, mucous membranes, external skin, bones, and almost every part of the body. The period intervening between deposition and softening, varies extremely in different cases ; in some it does not exceed a week or two, whilst it may extend to many months. The diagnosis of tubercle is sufficiently explained by the preceding observations. To determine the presence of tubercle with accuracy, the microscope is generally requisite, and with the aid of that in- strument, it may be distinguished with certainty from most other pathological epigeneses. It is difficult, indeed frequently, quite im- possible to distinguish it from typhous and scrofulous matter, and from certain forms of unhealthy suppuration. In the softened con- dition, it is much more difficult to recognize than in the unsoftened state, since, as we have already mentioned, other elements are then mixed with it. TUBERCLE. 261 Respecting the chemical composition of tubercle, nothing is at present definitely known. Such statements as those of Preuss,* in which he asserts that tubercle consists in part of casein, are founded on investigations which do not at all correspond with the present state of our chemical knowledge, and any one expressing his belief at the present time, that tubercles consist of casein, would show that his ideas of zoo-chemistry were extremely lax and unsatisfactory. At present all that we can say is, that tubercular matter consists principally of a protein-compound, as has been shown by Lehmann,t and has been repeatedly confirmed by myself. There can, however, be no doubt that during the progress of softening, the tubercles undergo chemical changes ; Lehmann has shown that during this process the phosphorus and sulphur in the protein-compounds diminish, and that ultimately they altogether disappear. Scherert has submitted to ultimate analysis the tubercular matter from various organs. The very interesting results which he has obtained, appear to show that tubercle in different cases, presents a different composition, and is not always identical with protein. We must, however, be cautious in drawing general conclusions from such isolated analyses, valuable though they be, for as it is hardly possible to obtain tubercle perfectly free from enclosed tissue, or other foreign admixtures, elementary analyses do not in this case give sucb certain results, as in cases where the substance to be analysed can be ex- hibited in a state of chemical purity. In addition to the protein-com- pounds, there naturally also exist fat, extractive matters, a substance re- sembling pyin, and various salts, as constituents of tubercle. When the tubercles become converted into concretions, the calcareous salts pre- dominate over the organic constituents ; thus in cretaceous tubercles of this nature, Thenard found only 3§ of organic matter, and 968 of salts. Lebert's§ opinion that cretaceous tubercles consist chiefly of chloride of sodium, and sulphate of soda, and that the salts of lime are present only to a small amount is incorrect. The analysis of Boudet on which he founds his opinion, does not bear on the question, for a tubercle con- taining in 1000 parts only 0.697 of inorganic matter is not calcareous, and other analyses of tubercles actually calcareous, show that the salts of lime occur to a very large amount. Most calcareous tubercles, although * Tuberculorum pulmonis crudorum anal, chemica, Berol. 1835. t Physiologische Chemie, vol. l. p. 197. X Untersuchungen zur Pathologie, p. 212, &c, or Simon's Animal Chemistry, vol. n. p. 478, »&c. § Mailer's Archiv. 1844, p. 289. 262 PATHOLOGICAL EPIGENESES. only slightly soluble in water, dissolve almost entirely on the addition of an acid. There is, moreover, a chemical- impossibility in Lebert's opinion : salts which dissolve as readily in all the fluids of the body as these soda-salts, cannot exist in the body in a solid form, and produce concretions which remain exposed to the action of those fluids for months and even years : they would dissolve and be carried away in a few hours, or at any rate in a day or two. The preceding view of the structure of tubercle is based on hundreds of original-observations made during a se- ries of years, and coincides in all its principal points with the statements of most unbiassed observers, as for instance, with the valuable Memoir of Lebert in Mailer's Archiv, which unquestionably contains the best histo- logical account of tubercle yet published. We shall only notice a few of the numerous opinions that have been promulgated on this subject. Gerber* whose opinion on the formation of tubercle in general corres- ponds with mine, draws a distinction between albuminous and fibrinous tubercle, regarding the former as unorganized, the latter as organizable. A distinction of this nature is certainly possible theoretically, but can be of no practical value, since the capability that tubercles possess for or- ganization is very small, and no definite limit can be drawn between those that possess it to a greater or lesser degree. This bears on the long controverted point, whether tubercle is or is not organizable: it is unnecessary, however, to say any thing further on this point. But that unorganizable tubercle consists of albumen, and organized tubercle of fibrin is a hypothesis whose admissibility I might be inclined to question. Gerber further distinguishes the organizable fibrinous tubercles, accord- ing to the degree of their organization, into hyaline tubercle, cytoblast tubercle, cell tubercle, cellulo-fibrous tubercle, and filamentous tubercle. These distinctions are not altogether unfounded, but they have relation to the deposition rather as it occurs in the domestic animals than in man. Addisont regards tubercles as a deposition and accumulation of abnormal epithelial cells, and the evil consequences of this deposition in the lungs and other internal organs are dependant according to him, on the epithe- lial cells not being removed (as occurs on normal free surfaces,) but re- maining and exerting an injurious effect on the surrounding parts. These abnormal epithelial cells consist, according to Addison, of colour- less blood-corpuscles which stagnate in the pulmonary capillaries, and afterwards become converted into these cells. Addison regards many tissues, for instance, epithelial cells and pus-corpuscles, as formed from the colourless blood-corpuscles. Here then there is an elementary view * General Anatomy of Man and the Mammalia, English ediiion, p. 305. t Transactions of the Provincial Medical and Surgical Association, vol. ii. p. 287, &c. TUBERCLE. 263 of the structure of morbid tissues differing essentially from mine. As, however, it is shown in numerous parts of this work, that these struc- tures are formed from an amorphous cytoblastema, a special refutation of Addison's views appears unnecessary. A few other points belonging to this subject may be elucidated by a statement of the views which have been laid down by J. Engel, in his very interesting essay on tuberculosis.* Engel distinguishes between interstitial tubercle (miliary tubercle) and infiltrated tubercle. The former is the result of a peculiar condition of the blood, closely approximating to its state in typhus ; the latter is in all cases an inflammatory product. The conversion of the inflammatory exudation into tubercular matter, and not into other structures, depends, according to Engel, on various conditions :—in the first place on the ex- udation itself, under which head we may consider: a. Too large a quantity of the coagulated fibrinous exudation, by which the complete infiltration of the whole mass with moisture is prevented, b. Deficiency of the fluid of organization generally, and, in this way, too great a dry- ness of the exudation, c. Foreign admixtures, namely blood-corpuscles. tl. Pre-existing tubercular matter, acting in accordance with the law of analogous formation already laid down. A second series of conditions depends on the part affected, and the whole organism. Under this head we may arrange : a. The activity of the metamorphosis of tissue—in pro- portion to the inertness of the metamorphosis, is the tendency to the for- mation of tubercle. /;. And what is essentially the same thing, contiguity with vascular organs—the greater this is, so much the less is the tendency to tuberculization ; and c. The condition of the vital powers—in propor- tion to their weakness, the facility for tubercular deposition is increased. There is a third series of exoteric conditions, amongst which we must mention pressure, and very likely cold. Engel likewise attempts to elucidate the further changes of tubercle and their consequences. As soon as the tubercular deposit has assumed the solid condition, it begins to act on the tissues, and to destroy them. It afterwards softens, and this softening is, according to Engel, a kind of putrefactive process depending on a chemical alteration in the exuded fibrin. Sometimes, however, this softening does not proceed from a pri- mary decomposition of the tubercular matter itself, but is induced by ex- oteric influences, as for instance, by inhibition of the deposit with water from adjacent cedematous parts, or by inflammatory products deposited in the vicinity of the tubercle. The softened tubercular matter reacts on the blood, in which it (or at least the fluid portion taken up by resorption) * Zeitschrift d. Gesellsch. d. Aerzte in Wien, Jahrg. 1, p. 353. 4 264 PATHOLOGICAL EPIGENESES. may induce modifications. The softened tubercular matter may also be converted into an ichorous fluid, if there is a sufficient quantity of it, (for minute depositions do not undergo this change,) if there is a due amount of moisture, if it is far removed from highly vascular organs and there is consequently little metamorphosis of tissue, if the vital powers of the or- ganism are depressed, if it is in contact with extraneous matter, as at- mospheric air, fragments of food, bile, faeces, urine, &c, and finally, if there is an undue excess of warmth. Other changes may accompany, or may occur in place of the above alteration ; thus a portion may liquefy and be resorbed ; the conditions for this change are, that there shall not be too large a mass of exudation, that it shall be in a position to be freely infiltrated with fluid, and that the age of the patient shall be ad- vanced. When the amount of water contained in tubercle is reduced by absorption to a minimum, the tubercular matter shrinks and becomes in- durated. The conditions for this change are a densely compressed mass of exudation, and generally speaking, advanced age. In all essential points, this is the same as what is meant by the tubercles becoming obso- lete. These changes relate to the still unsoftened tubercle. The changes occurring after softening are : a, cicatrization, the conditions of which are that there must not be too great a destruction of tissue, that there should be a healthy condition of the surrounding parts and no induration, and that the age of the patient be not very far advanced, b. Entire or partial resorption, which occurs the more readily in proportion as the deposit is small, and the surrounding parenchyma healthy, c. The ad- mixture of the softened tubercle with pus, &c.; and d, the conversion of tubercle into atheroma or calcareous concretions. All these terminations of tubercle are usually associated with the curative process. In order, however, that a perfect cure may ensue, it is necessary, that the fresh formation of tubercular matter should cease, and on this point, Engel gives it as his opinion, that in a certain condition of the blood, these de- positions do not occur. I have entered thus fully into Engel's views, because I regard his attempt to explain the formation of tubercle as very important and praiseworthy. In the leading points I agree with Engel, and if there is much in his Essay that is not very strictly defined, as for instance, the term " inflam- mation," which without further explanation, he puts down as the cause of infiltrated tubercle, and if also his views regarding the peculiar condi- tion of the blood are not based, as they ought to be, on accurate chemical analysis, still he appears to have adopted the only true mode by which we can hope to arrive at accurate conclusions regarding the nature of tu- berculosis and similar processes. The formation of tubercle by a conta- TUBERCLE. 265 gium animatum—by semi-individual cells as Klencke* supposes—ap- pears to me perfectly untenable, and I do not consider that we have suffi- cient evidence of the accuracy of his inoculation-experiments. More- over, how can tubercles, not consisting of cells, propagate in this way? 1 shall, in a subsequent page, return to the consideration of this point. Another opinion has also been put forward, namely, that tubercles consist of hydatids; this is based on the observation that occasionally quasi-tuber- cular deposits are found in encysted tumours (as we have already seen,) and in hydatids and the cysts of certain entozoa (as will be shown in a future page.) These facts show, at all events, that from the above-men- tioned structures a quasi-tubercular mass can be produced, but they do not conversely show that tubercles must always arise from these structures. Respecting the causes of softening I entirely agree with Engel in think- ing that they may be referred partly to influences residing within tuber- cular mass, and partly to external influences, as extreme moisture, sup- puration of the surrounding tissues, &c. The investigation of the condi- tions, in individual cases, which alone can be serviceable to practical me- dicine, must remain to be undertaken by our successors. SECOND CLASS. EPIGENESES OF A MORE HIGHLY ORGANIZED CHARACTER.f The forms of tumour belonging to this class are extremely various, exhibit in their anatomical and histological relations, in their progress, and in their duration, very great differences ; and hence we find that many members of this group have received distinct names. But in these tumours it is just as impossible as in the non-malignant, to have genera and species such as we have in descriptive zoology and botany. .„_„_„- * Undersuchungen und Erfahrungen, vol. i. p. 121. t The literature of this class of tumours is very abundant. We may especially notice the chapters devoted to the subject in the treatises of J. F. Meckel, Andral, and Lobstein, on Pathological Anatomy. Their appearances as presented to the naked eye, are to be seen in Carswell's Pathological Anatomy, Carcinoma, fasc. 2,3, and Cruveilhier's Anatomie pathologique. For the microscopical appearances we may especially refer to J. Muller uber den feineren Bau der krankhaften Geschwulste, or WeBt'e translation ; A. Hannover, Svar paa Sporgsmaalet, Hvad er Cancer ? Kjo- benhavn, 1843 ; Gluge's Atlas der patholog. Anatomie, Parts 1 and 4, and bis Ana- tomish-mikroskop. Untersuchungen, Parts 1 and 2; and Klencke's Untersuchungen und Erfahrungen, vol. ii. 23 266 PATHOLOGICAL EPIGENESES. Such a fine distinction and separation of species, based on unimpor- tant points, would from the very first lead to each individual tumour being regarded as a distinct species, and we should thus have mil- lions of names. I shall, therefore, endeavour to group and consider these forms in accordance with their essential common points, and shall only describe the most prominent ones as peculiar varieties. As familiar illustrations of this class we may notice the terms, cancer and carcinoma, which in the following pages must always be re- garded as synonymous. Carcinomatous structures are distinguished from the preceding class^—the slightly organized epigeneses—by a higher degree of or- ganization ; they not only show a more highly developed cellular structure, but frequently also fibres, vessels, and granulations enter into their composition. They are not, however, strictly limited from the former class, for although the tumour as a whole can be easily distinguished from one of the former class, it-frequently contains particular portions which cannot be distinguished with certainty from tubercular deposition. Neither is there any strict limit between these and certain forms of non-malignant tumour, namely fibrous tumour, and cases frequently occur in which it cannot with certainty be de- termined whether a tumour belongs to the carcinomatous or fibrous group, that is to say, whether it be malignant or non-malignant. The malignancy depends here, as in the former class, on softening and a disintegration of the elements, commencing with the cellular struc- tures, but gradually proceeding to the fibrous parts and the elemen- tary tissues of the affected organ. The anatomical and histological relations of carcinomatous tumour exhibit the greatest variety ; indeed, even in the same tumour, dif- ferent parts often present very different characters. Their characters further vary with their stage of development. These tumours are sometimes soft, resembling cerebral substance; sometimes firm, like lard; and sometimes hard, like cartilage ; sometimes they are highly vascular, and ofa reddish tint; sometimes pale; sometimes they are distinctly separated from the adjacent parts, whilst in other cases there is no line of demarcation between them and the surrounding tissues. Hence in a general consideration of the subject, these re- lations are of no value. Moreover the histological elements of individual carcinomatous tumours are very different, and arranged in various ways.- I shall CANCEB. ■*"' therefore notice them separately. In carcinomatous tumours there occur: 1. A firm, dense, amorphous substance, bearing a close resem- blance to, and probably identical with coagulated fibrin. It is ren- dered transparent by acetic acid, and by ammonia and other caustic- alkalies, and sometimes encloses molecular granules consisting of modified protein or fat. This substance is doubtless to be regarded as the solid cytoblastema of cancer, and is subsequently converted into cells or fibres, which may sometimes be very clearly detected* It is characteristic of a definite stage of the development of cancer, and is consequently often entirely absent in perfectly developed specimens. Indeed, it appears that in some cases, cancer arises only from a fluid cytoblastema, so that during its whole course this substance does not present itself. In rare cases it occurs as the pre- ponderating constituent; and then the nature of the cancer can only be recognized in more highly developed portions of the tumour; or, indeed, the diagnosis may be altogether impossible. This firm amorphous substance is in itself not characteristic of cancer; in fact it closely resembles and appears to be identical with the ordinary solid cytoblastema of all other epigeneses, namely coagulated fibrin. 2. Molecular granules which appears to consist partly of a modi- fied portein-compound, and partly of fat, and which we have already had occasion to notice as constituents of morbid epigeneses, occur also in cancer,f and along with them we frequently meet with large fat-globules and fatty granules.:): Elementary granules consisting of calcareous salts appear but rarely in cancer. These molecular gra- nules are sometimes entirely absent; in other cases, namely in soft- ened parts, they are very numerous, and sometimes unite into large masses, forming aggregate corpuscles. These structures are, how- ever, not characteristic of cancer. 3. Cellular structures form a very important class of elements, which are never absent in perfectly developed forms of cancer. They sometimes predominate to such an extent, as to form nearly the whole tumour, as in cases of encephaloid, but are only of secondary importance in hard cancer (scirrhus.) The cellular structures oc- curring in cancer are of two kinds: a. Such as during its whole pro- * See Plate vni. fig. 9. a. b. t See Plate vi. fig. 8, 11; Plate vui. fig. 1, 4, 6. { See Plate vm. fig. 4, b. • 268 PATHOLOGICAL EPIGENESES. cess of development can never exceed the cellular form. These cells—transitory cells according to our scheme in p. 122—are the characteristic cancer-cells, b. Such as are capable of development into other structures, namely into fibres, and therefore only to be regarded as cells in a transition state—developmental or fibre-cells. a. The characteristic cancer-cells present extreme variations, from the simple cytoblast through every modification of which a simple cell is capable, up to highly developed cellular forms—varieties which in every case depend for the most part on the degree of development of the primary cells, and are sometimes transitory, and sometimes per- sistent stages of development. The primary forms of these cells pre- sent no peculiarity. The nuclei vary from the 450th to the 250th of a line in diameter, are insoluble in acetic acid, and often contain nu- cleoli ;* the cells are nucleated and round, or oval, vary from the 300th to the 100th of a line in diameter, f entirely dissolve on the addition of the caustic alkalies, and disappear, with the exception of their nuclei, on the addition of acetic acid. Still more characteristic of carcinomatous, tumours are the cellular forms, which frequently, bat not invariably are associated with the above primary forms, and only rarely occur independently of them. To this class belong : «. Peculiarly formed., caudate, ramifying cel-ls.J 0. Cells containing a large number of nuclei (from two to twenty or thirty) or enclosing in their interior perfect young cells. § They are usually of considerable size, varying from the 100th to the 30th, or even 20th of a line in diameter. y Cells with a very thick wall, exhibiting a double contour. || £ Double cells formed either by division of one, or the fusion of two cells. i. Cells filled with granules (granular cells) and others in which granules appear to be scattered over the surface.il In some forms of cancer there also occur : * See Plate vi. fig. 8 b, 9 b; Plate vm. 1 d, 4 d, 6 d, 8 a. + See Plate vi. fig. 7, 9, 11; Plate vm. fig. 1 a, 4 d, 6 a, a, b, 8 b. X See Plate u fig. 11 ; Plate vi. fig. 7, 8 a. § See Plate l. 5, 6, 7 ;; Plate vi. fig. 7, 8. I) See Plate i fig. 2 a'; Plate vm. fig. 6% 9 b. * See Flatp *ikfig. 11 * pkite vm. fig., 6. CANCER. 269 £. Cells of various forms and sizes enclosing dark (generally black) granular pigment (pigment-cells.*) Between these different forms of cells, there occur innumerable transitions, and they are all doubtless to be regarded as primary cells in different stages of development. Some of these forms occur principally in certain varieties of cancer, of which they may be deemed characteristic, as we shall presently see. Hence it follows, that of all the above forms, there is none that can be deemed as solely pertaining to cancer; in fact that there is no such thing as a distinctive cancer-cell; and consequently that from observing a sin- gle Cell under the microscope, it is impossible to decide with cer- tainty whether it is cancerous or not. On examining a mass of these cells we can often decide with certainty on their being cancer- cells, from the varieties which they present, and from the occurrence of the above forms. b. The transitory cells occurring in cancer are chiefly fibre-cells, that is to say, they are fusiform cells prolonged in the same axis in both directions, such as occur in the development of areolar tissue, and of simple muscular fibre.f They occur for the most part in the firm, rarely in the soft forms of cancer. In the numerous forms of cancer which I have examined, I have always found these fibre-cells playing only a secondary part, and Hannover's ex- perience coincides with mine. J. Muller appears to have found them as the sole, or at all events as. the predominating ingredient in many cancer- ous tumours.f I think, however, that the cases in which they predomi- nate belong more to non-malignant (fibrous) tumours than to actual cancer. 4. Fibres of various kinds form a further histological element of cancerous tumours. Some are perfectly identical with those of fibrous tumours ; these either resemble the fibres of areolar tissue, are very delicate, and vary in diameter from the 2000th to the 800th of a line, or else they resemble the fibres of simple, non-striated » These cells are precisely similar to the pigment-cells from a melanotic lung, de- picted in Plate ix. fig. 7. t See Plate vi. fig. 9 ; Plate vm. fig. 7 c, fig. 9 c. X Uebcr den feineren Bau, &c, r>. 2J, Plate \u fig. 11 ; or West's translation, p. 64, Plate iv. fig. 11.. 270 PATHOLOGICAL EPIGENESES. muscular fibre, being thicker than the former, and vary in diameter from the 800th to the 300th of a line. Sometimes both these kind of fibres are seen perfectly developed ; in other cases the formation of the fibres is less distinct, the whole mass having an almost amor- phous appearance, as if the fibres were blended into one another—just as we have already seen in the amorphous variety of fibrous tumour. As in the case of fibrous tumour, the fibres arise sometimes from undoubted cells, and sometimes from an amorphous cytoblastema, independently of any regular cell-formation. These kinds of fibres may be distinguished by their becoming pale on the addition of acetic acid, and frequently entirely disappearing, at least nothing but elongated oval nuclei remaining in their place.* The second kind of fibres occurring in cancer are identical with Henle's nucleated fibres,f and with the fibres of elastic tissue. They frequently present a ramifying, sometimes a dichotomic arrangement, and are chiefly distinguished from the preceding group by their be- haviour with acetic acid—instead of disappearing, their outline be- comes more clear and distinct. In some forms of cancer,, as for instance, in encephaloid, these fibrous structures are altogether absent; in other forms as for in- stance, scirrhus or fibrous cancer, they predominate. By the pre- dominance of these fibrous structures, of which the former is by far the more common, cancerous tumours connect themselves with the formerly described fibrous tumours, and indeed it is sometimes im- possible to distinguish whether a cancerous or a fibrous tumour had first existed. The arrangement of these fibres and their relations to the cells is also extremely variable. Sometimes the cells and fibres are so ar- ranged, that on making a microscope examination, some parts are found to consist only of fibres, and others only of cells. Usually the fibres form the ground-work or stroma in whose interstices the eells are deposited. Sometimes the fibres assume a radiating ar- rangement, proceeding from the centre to the periphery of the tu- mour, as for instance, in cancer of the liver.J In other cases a tis- * These fibres are shown in Plate vm. fig. 2, 3, 5, 7. t Allgemeine Anatomie, p. 194. X See Carswell'a Pathological Anatomy, Carcinoma, fasc, 9, PI. iv. fig. 1. CANCER. 271 sue with roundish meshes is formed, in which the cellular masses are deposited*—an arrangement very similar to that of the elastic tissue in the healthy human lung. In certain forms of cancer we observe the fibres and cells in very peculiar relations to each other; the fibres form roundish capsules, of which the interior is filled with cellsf—a formation similar to that which occurs in certain ganglia, where also cells (ganglionic corpuscles) are found enclosed in cap- sules composed of fibres. These fibrous capsules are sometimes isolated,J and are sometimes connected by fibres issuing from them with similar tissue in their vicinity. The formation of these singular capsules appears to proceed in the fol- lowing manner; in the first place, there is formed a cell with a thick cell- wall, exhibiting a double contour.} In this, as in a parent cell, there is a new cell-formation, while the thick cell-wall assumes a fibrous character. This peculiar metamorphosis of a cell is analogous to nothing hitherto ob- served ; I have, however, so frequently made the observations leading to this view of the case, that I regard it as beyond a doubt. This structure is chiefly formed of the fibres soluble in acetic acid; those which are insoluble in that re-agent—the elastic fibres—occur much more rarely in cancer, and never in large masses. They ap- pear also regularly arranged in a reticulated form, cross-barred, or else in irregular meshes. 5. Blood-vessels also form an element (although not an essential one) of cancerous tumours. In some forms they are altogether absent, in others they are present, but appear to belong to the normal tissue, within which the cancerous matter has been deposited; as for instance, in the soft forms of cancer, where the newly formed cancerous matter is not sufficiently firm to compress the vessels of the tissues infiltrated by it. Some forms of cancer, on the other hand, undoubtedly contain new vessels which appear for the most part between the fibrous elements; rarely, if ever, between the cells. In open cancer (cancerous sores) granulations are formed which are remarkably vascular; of these, however, we shall speak presently. The cases of cancer which are furnished with very numerous new » See Plate vm. fig. 10. X See Plate vm. fig. 3 b. t See Plate vm. fig. 3 a, b. § See Plate vm. fig. 9 b. 272 PATHOLOGICAL EPIGENESES. vessels, form a distinct variety to which the name Fungus hcematodes has been given; but many cases which have been described by dif- ferent authors as fungus heematodes, do not in reality belong to cancer. In cancer as in other forms of tumour, it often becomes a disputed point, whether or not there are blood-vessels present. It appears to me that the whole question of dispute is made clear by the preceding observations, and indeed, after all, it is a point of no great importance. Some, after injections, have found only arteries, and no veins; we may understand this, if we re- member how much more easily the veins may be compressed and-ob- literated by the pressure of the cancerous matter, and likewise how much more easily they may become rilled with it, than the arteries. Whether lymphatics and nerves occur in cancer is doubtful; if they are present, they are undoubtedly not newly formed, but belong to the parent tissue. 6. Another element which enters into the composition of cancer- ous tumours—which indeed, is seldom altogether absent, and often occurs in very large quantity—is a viscid fluid perfectly analogous to the essential constituent of the gelatinous tumours described in p. 218. This viscid fluid is characterized by the presence of a sub- stance resembling mucin or pyin, which on the addition of acetic acid, sulphate of iron, or infusion of galls, coagulates into a colour- less, streaky, amorphous mass, as may be observed under the mi- croscope ; a similar but less marked effect is produced by alum, alcohol, and corrosive sublimate. The ultimate composition of this substance, its mode of origin, and its uses are unknown. The above elements are the essential constituents of cancer. In the process of softening they undergo changes which in all essential points are identical with those observed in the softening of tubercle. Of these we shall speak presently. According as one or other of these elements predominates, and according to the various modes in which they are associated and arranged, we have the different forms and varieties of cancer, which, however, cannot be strictly separated from one another, but exhibit every possible transition-stage. The most important of these forms will be presently noticed. In addition to the above, elements, we sometimes meet with others which, however, do not belong to the cancer itself, but to the parent- tissue in which it was deposited ; as for instance, striated muscular fibre, fatty tissue, glands, &c. As many of the above mentioned CANCER. 273 elements of cancer occur also as normal constituents of the body— as areolar tissue, simple muscular fibre, elastic tissue, and vessels— it is not always easy to distinguish whether such elements, when they occur in a cancerous tumour are newly formed or belong to the parent-tissue. Causes, formation, development, distribution, further course, and consequences of cancer. Pathological anatomy has not yet succeeded in throwing any very great light on the causes giving rise to the formation of carcinoma- tous tumours. It is probable that here, as in the formation of other morbid epigeneses, a whole series of causes are in simultaneous action, and mutually checking one another; these causes lying partly in the property of the cytoblastema, and partly in that of the organ or of the whole organism in which the cancer becomes developed. The cytoblastema of cancer, as of all other morbid epigeneses, arises doubtless from the blood, is originally fluid, and identical with the liquor sanguinis. Sometimes an increased quantity of blood- plasma is separated in consequence of a local capillary hyperaemia,* arising from some mechanical cause—as compression, a blow, &c. In other cases, namely when the formation of the cancer is very gradual and imperceptible, no signs of local hyperaemia can be de- tected, and it is possible that then the ordinary nutrient fluid (not increased in quantity, and either changed or unchanged) may by local influences be converted into cancer. In some cases the cyto- blastema appears to remain fluid, and in this fluid condition to undergo development; in other cases it coagulates before the com- mencement of development, and the cancerous matter is formed, either wholly or in part, from a solid cytoblastema.f The circumstance of the coagulation shows that the cytoblastema consists, in a great measure, of fibrin. The solidification of the cytoblastema yields one of the histological elements of cancer, namely the solid amorphous substance. But since there is nothing charac- teristic in this mass—for, indeed, it is perfectly identical with the coagulated exudation of fibrinous dropsy—it is impossible from it alone, to diagnose the presence of cancer; indeed, this is only pos- * As in the case illustrative of Plate vm. fig .9 ; and I have met with many similar cases. t See Plate vm. fig. 9. 274 PATHOLOGICAL EPIGENESES. sible when other parts of the tumour are in a more advanced stage of development. Moreover, the molecular granules described as a second consti- tuent of cancer, are formed (in part, at least) at a very early period, and probably in a fluid as well as in a solid cytoblastema. Their formation is undoubtedly dependant on some (still unknown) che- mical peculiarity of the cytoblastema, as on its containing a super- abundance of fat, or some peculiar modification of one of the protein- compounds. When these conditions are not fulfilled', the molecular granules are altogether absent, or are only very sparingly present.* These primary molecular granules must not be confounded with those which make their appearance during the process of softening, and of which we shall discourse presently. The further development of cancer consists in the organization of the cytoblastema, and in its conversion into the cells and fibres, which we have already described.! In this early stage, the forma- tion of vessels is probably extremely rare. It is not easy to trace the development of the cells, for, in general, from the very first we observe them of very different forms, and apparently in various stages of development. Sometimes, in the examination of a cancerous tumour, we observed very large knotty masses, varying in diameter from the 30th to the 10th of a line, or even larger, containing irre- gular cells, and exhibiting a tolerably distinct outline. They pro- bably have the same signification as the large cells already described, in whose interior young cells are formed, while the cell-wall becomes converted into fibrous tissue. The fibres soluble in acetic acid, arise partly from undoubted fibre-cells, and partly from the amorphous blastema without any definite cell-formation. No certain observations have yet been made regarding the formation of elastic fibres; they appear, however, in some cases to arise from a channelled or reticu- lated thickening of the solid, membranous cytoblastema. Regarding the chemical metamorphosis of the blastemal fluid, by which the viscid substance of which we have made mention, and which is of such frequent occurrence in cancer, arises, we cannot offer even a probable conjecture. * See Plate vm. fig. 9. t We have attempted to depict this early stage of development from a solid, amorphous cytoblastema, in Plate vm. fig. 9. CANCER. 275 Hence it follows that cancer is a thoroughly morbid epigenesis, and is not in the smallest degree produced by a metamorphosis of the tissues between which it is developed. Another question to be considered is : What influence do the surrounding parts exercise on the development of cancer? I mean by this, not the altogether unknown influence which the modified energies of the tissues doubt- less exhibit in the formation of cancer, but simply the influence which the parent-tissue exerts on epigeneses in accordance with the law of analogous formation. An influence of this nature can have no weight in the formation of cancer-cells, since they are heteroge- neous tissues, and their first appearance can be as little explained by that law, as the appearance of pus-corpuscles. On the other hand, the fibrous structures and the vessels of cancer may very possibly be formed by the influence of the surrounding parts, in accordance with the law of analogous formation—at least in those parts which in their normal state contain vessels. According to this view, those kinds of cancer which contain fibres must be regarded as a combination of malignant tumour containing cells, with non-malig- nant fibrous tumour, and we shall show in a future part of this work, the importance of it, for the more the fibres predominate in a can- cerous tumour, so much the more innocuous and less malignant do we generally find it. The cancerous matter occurs between original elementary parts of the parent-tissue, and occupies, more or less perfectly, all the interstices. A slight infiltration of cancer in a tissue, frequently escapes the observation of the unaided eye, and can only be de- tected by careful microscopic examination—as for instance, in fatty tissues.* When the interstices are not thoroughly filled, and the cancerous deposit is soft, the parent-tissue, at least in the first stage, is comparatively little injured. If, on the other hand, the infiltra- tion is complete and the cancerous deposit very firm and solid, then the elements of the tissue become compressed, appearing to be blended with the deposit into a homogeneous mass, and gradually become atrophied and disappear. This disappearance of the ele- ments of the tissues by atrophy and resorption, which is peculiar to the first stage of cancer, previous to softening, must be clearly dis- « See the description of Plate vm. fig. 6,7. 276 PATHOLOGICAL EPIGENESES. tinguished from the destruction of the entangled tissue, wnich is de- pendant on the softening of cancer, and of which we shall speak presently. It is beyond all doubt that by the gradual increase of a cancerous tumour, the parts in its vicinity must be displaced ; this applies, however, more to whole organs than to the elements of tis- sues, and is much rarer than is usually supposed. Thus, for in- stance, in cancer of the liver the hepatic cells do not become dis- placed, but get enclosed in the cancerous deposit, and thus gradually become atrophied. Finally, after its full development, the cancer proceeds to soften ; the process being essentially identical with that occurring in tuber- cle, and which we have already described. It proceeds in cancer, even independently of cell-formations. It is only in those cases where other processes—as gangrene, tubercle, or typhous deposit— are combined with cancer, that the amorphous blastema around and in the cancerous tumour breaks up directly, without the previous formation of cells. These separate from one another, break up, and form a quasi-purulent fluid, which sometimes contains decided (although partially injured) cancer-cells, and sometimes a mere de- tritus, consisting of molecular granules, crystals of cholesterin, &c, perfectly similar to softened tubercle. On what this disintegration depends, is unknown ; it appears to be dependant on the nature of the process itself*—as in the formation of pus from a solid cytoblas- tema—for although it can be hastened or retarded by external in- fluences, it cannot be entirely arrested. As a general rule the soft- ening proceeds very gradually, commencing at individual points of the tumour, often at several simultaneously. A section of the tumour at this stage, shows at one or several spots collections of purulent fluid, consisting of softened cancer-cells. I think it is not improba- ble that these points at which the softening commences, when they are very minute, and at the same time very few, gradually disap- pear by resorption, the slight loss of substance healing by cicatriza- tion, and the injurious progress of the cancerous tumour, being thus prevented ; this, however, only occurs in those forms of cancer which consist for the most part of fibres, and contain only a few * Vegetable physiology furnishes us with an analogous proceeding.in the normal softening of many fruits (as for instance, that of solanum nigrum) which depends on a separation and solution of the (merenchyma) cells forming their tissue. CANCER. 277 cells. The ordinary course of a cancerous tumour is very different; the softening continuing to progress, and thus gradually extending to the whole cellular structure within the tumour. In this manner the minute and isolated specks of pus enlarge, and by uniting, form large masses, (such as occur in the formation of abscesses,) till finally the collected fluid forms for itself an external outlet, thus converting occult into open cancer. But further, another change occurs in the softened cancerous matter; it undergoes chemical modifications, becomes decomposed, acrid, fetid, and of an un- healthy appearance ; in short, the softened cancerous matter be- comes converted into an ichorous discharge, the chemical proper- ties of which are not accurately known, and probably vary in diffe- rent cases. These changes, like those of an analogous character occurring in tubercle, are dependant on a species of putrefaction, of which the conditions have not yet been accurately investigated ; but—as in that case—probably are a large quantity of the product of the softening, impeded metamorphosis in the surrounding parts, and an admixture of matter inducing putrefaction—namely blood. Until the commencement of the ichorous discharge, the softening is usually restricted to the cellular portions ; at the same time the solid parts, namely the fibres and blood-vessels, which in themselves have no tendency to soften, undergo putrefaction and disintegration through the influence of the ichor; their destruction is, however, usually very gradual. In this stage, a section of those forms of cancer which contain fibres presents a very peculiar appearance. It exhibits irregular cavities filled with ichor, whose walls are very- tough, often as hard as cartilage, and are composed of fibres, pre- senting, as it were, a corroded appearance. Isolated fibrous bun- dles frequently softened and half destroyed at their superficies pro- ject into the cavities, or extend across them in the form of rafters or arches. We sometimes discover the open mouths of corroded blood-vessels ; in these cases effused blood, coagulated in clots or mixed with ichor, fills the cavities. The above series of processes occurring in the development of cancer, occupy very different periods of time in different cases; they always require several weeks or months, and sometimes seve- ral years. In proportion to the extent of cellular structure in a case of cancer, so much the more quickly does the process of de- velopment attain its termination, and it has long been remarked that 24 278 PATHOLOGICAL EPIGENESES. the forms of cancer, in which cells predominate, (encephaloid) usually run their course and terminate fatally in about as many months as those forms in which fibres predominate (scirrhus) re- quire years. Simultaneously with the process of development the cancerous lumour undergoes other changes ; it increases to such a degree, that from a very limited origin it often becomes distributed over a large space, occupying one or even several organs. This enlargement is undoubtedly dependant on the cellular structure of the cancer, and probably also on the fibres acting upon the nutrient fluid in the neighbouring parts, in accordance with the law of analogous forma- tion. The increase of the cancerous cells is forwarded by the cir- cumstance that many of them act the part of parent-cells, and con- tain in their interior young cells, which in all probability are capable of a similar mode of increase. Moreover, the numerous cytoblasts frequently observed in a cell, probably all become themselves deve- loped into distinct cells. With these facts before us, there is clearly no limit to the increase of cancer-cells, neither is there any neces- sity for regarding them as distinct organisms similar to the lowest fungi and alga?. It is clear, however, that the fibres and the vessels (if any are present) cannot be increased by means of the cancer- cells : in all probability the increase of the fibres—and in fibrous cancer such an increase undoubtedly occurs—is dependant upon the influence of the pre-existing fibres, just as is the case in the growth of pure fibrous tumours. The innate capacity for augmen- tation possessed by cancer, is very energetic, and forms an essential distinction between cancerous tumours and scrofulous depositions ; for in the latter this capacity is either altogether absent, or only pre- sent to a very slight degree. Hence the growth of cancer is most rapid when an increased cytoblastema is yielded to it from any source, as for instance, from inflammatory exudation, especially from fibrinous dropsy in the adjacent parts. It always increases on the supervention of softening and ichorous discharge, in conse- quence of the irritation to which these processes give rise in the surrounding parts. The exudation thus yielded by the neighbouring hypersemic parts is converted into cancerous matter, and hence can- cer is not, as is frequently the case with tubercle, separated from the surrounding parts by granular cells or pus, nor is it retarded in its growth by a line of demarcation. The newly formed cancerous CANCER. 279 matter goes through precisely the same course of development as the original; proceeding of necessity to softening. In some cases, we find the peripheral portion of the cancerous matter, and the sur- rounding parts contending, as it were, for the cytoblastema, and sharing it between them. There are formed, as may be observed in cancerous ulceration, fungoid and extremely vascular granulations, but these are always so infiltrated with cancerous matter, that, after a very brief existence, they soften and become disintegrated, never contributing to the formation of persistent tissues. Distinct from this local enlargement of cancerous tumours, there is another mode of increase, which usually occurs in the latter stage as softening commences, or sometimes earlier. There are formed other cancerous tumours distinct from the original tumour, often many in number, some being situated in close proximity with the original seat of the disease, namely in the adjacent lymphatic glands, whilst others occur in remote parts of the organism. The causes of this distribution of cancer are still very obscure—an obscurity which is increased by the circumstance that we are in a great mea- sure ignorant of the causes of the primary deposition. Doubtless the same cause which gave rise to the first tumour, influences the formation of the others. This cause appears to be in operation when long after removal of a cancerous tumour—often years after, and when the wound caused by the operation had long healed —a new cancerous tumour becomes developed in another part of the body. To this cause we usually apply the term cancerous dia- thesis, a phrase against which no objection can be raised, since it is merely the expression of an unknown fact, just as x represents the unknown quantity in an unsolved equation. Another, mode in which a cancerous tumour may increase, has beeen noticed by B. Langenbeck.* When cancer-cells make their way into the veins and lymphatics opened by the softening of the cancer, and thus enter the circulation, which is by no means a rare occurrence, they become retained in the smaller capillaries, in con- sequence of their size, and thus becoming further developed at these points, give rise to secondary cancerous tumours. Langenbeck succeeded in inducing secondary cancerous tumours in the lungs of * Schmidt's Jahrbilcher, vol. xxv. p 09, &c. 280 PATHOLOGICAL EPIGENESES. a dog, by injecting into its blood-vessels fresh cancer-cells from a tumour while still warm, which had been removed two hours and a half previously from the humerus of a man. A cancerous tumour being once formed, its distribution in this manner, into different parts of the same individual, is by no means unlikely ; but it is undoubt- edly not the only way in which it can be extended, and it admits of several very serious objections. After this notice of the development and extension of cancer, we are now prepared to consider its consequences to the organism. These vary in accordance with the stage of progression of the tumour. In the first place, previously to the commencement of softening, they are purely local, and frequently barely perceptible. The cancerous matter is injurious to the adjacent elementary textures simply by its pressure and by its checking their nutrition, and these symptoms are the more urgent in proportion to the firmness of the tumour, and to the closeness with which it includes the elements of the parent-tis- sue ; these causes frequently leading to the atrophy, and occasionally to the disappearance of these elements. Sometimes we observe especial phenomena from the pressure exercised on a neighbouring organ, on a nerve, or on. a canal; these are, however, simply me- chanical effects, and not to be distinguished from those to which non- malignant tumours might give rise. On the supervention of softening, the consequences become more serious; we now usually observe an (inflammatory?) reaction of the surrounding parts, xind the tumour commences to be painful. Still more injurious are the effects of the unhealthy suppuration which en- sues ; the surrounding parts being affected by the ichorous dis- charge ; the blood-vessels and lymphatics in the tumour and in its vicinity becoming destroyed; and the veins, unless they had pre- viously been obliterated, often giving rise to such very serious haemor- rhage, as to threaten life itself. The softened cancerous'matter may enter the veins and lymphatics, and give rise to inflammation of those vessels, and its consequences. Cancer-cells may, also, as we have already mentioned, enter into the circulation, and becoming deposited in the capillaries, give rise to secondary cancerous tumours. But independently of any laceration of the vessels, the fluid portion of the ichorous discharge may enter into the blood by endosmOsis, and induce changes in it, in a manner typt at present understood. To this passage of the ichorous dis- CANCER. 281 charge into the blood, there are usually ascribed a series of general symptoms, which are frequently noticed in the later stages of cancer, and known collectively as cancerous cachexia ; the chief of these are a peculiar, yellowish gray colour of the skin, disturbances in the nutritive process, and in the functions of the nervous system. It need scarcely be mentioned that the degree to which these symp- toms are developed is proportional to the amount and the malig- nancy of the ichorous fluid which enters the blood. Hence it follows that in encephaloid, which softens rapidly, yields a large amount of ichor, and is tolerably vascular, the course of events is much more rapid and severe than in scirrhus. That under these circumstances, the vital powers must become exhausted, and death sooner or later occur, appears to be perfectly self-evident. Such being the course and the consequences of cancer, we can readily understand the advantages to be gained by the surgical re- moval of the tumour, or its destruction by means of caustics; in fact its pathological anatomy indicates the mode of treatment. Since, as we have seen, every true cancerous tumour is continuously in- creasing, and 'nature has not adopted any means of limiting its growth, as we observe in tubercular and some other tumours, we see a theoretical indication of the necessity of an operation—a view confirmed by practical experience. It likewise follows that every extirpation or destruction by caustic must be radical, for otherwise the remaining cancerous matter enlarges after the operation, and,in consequence of the more abundant secretion of cytoblastema, grows, more rapidly than before. It is only after the entire removal of the cancerous matter, that the influence of the surrounding healthy parts can induce normal granulations, and lead to cicatrization. If the surrounding parts are not in a healthy condition, or the original canr cerous diathesis not eradicated, then even after a perfect operation, a cure will not result. The accurate determination of these eases must be left to the judgment of the surgeon. Since the most in- jurious consequences are dependant on the occurrence of softening and unhealthy suppuration, it is expedient that the operation should be performed, if possible, before these changes ensue. It is very true that previously to these changes taking place, the diagnosis of a cancerous tumour in the living body is very uncertain; but still it is fax better that we should- run the risk of occasionally extirpating; . 24* 282 PATHOLOGICAL EPIGENESES. a harmless tumour, than that, by delaying the operation, the patient be subjected to the risk of certain destruction. Cancerous matter appears to be sometimes deposited in other tu- mours originally of a non-malignant character: these subsequently become converted into cancerous tumours, or form combinations of cancer with the preceding groups. I have hitherto avoided entering minutely into the question regarding the causes of cancer, in order that I might not interfere with the conti- nuity of the subjects discussed in the preceding pages. The parasite- theory appears to afford an obvious and intelligible mode of accounting for the formation of this adventitious product. According to this view, the cancer-cells are independent organisms, (or according to Klencke's nomenclature semi-individual cells,) in all cases possessing the property, when conveyed into the interior of the living body, of their further deve- loping themselves, and forming cancerous tumours. We may, there- fore, explain the primary formation of cancer by assuming that a eancer-cell accidentally getting into the body, gives rise to the develop- ment of a tumour of this description. This view is principally sup- ported by experiments with inoculation, in which local cancer has been produced by transmitting recent cancer-cells into the organism, as in the experiment of B. Langenbeck to which we have already alluded. But on elo?e consideration, it appears that very weighty doubts suggest themselves against our acceptation of the view, that all primary cancers arise in this manner, even if we allow that in every inoculation-experi- ment actual cancer is produced, and not merely a tumour of some other kind, such as we frequently meet with in the examination of the dead body after injuries.. Although I have no reason to doubt the accuracy of Langenbeck's experiment, yet in other cases, the necessary microsco- pic examinations are wanting. If, further, cancer-cells can serve to transmit cancer from one individual to another, when they have got into the interior of the organs (that is, within their parenchyma,) the ques- tion then suggests itself—how can they, under ordinary conditions, get there? Even if we assume that they can be distributed into the sur- rounding atmosphere from open cancer, in the same manner as the spores of algaa and fungi (which, however, is very improbable, since the cancer-cells, are for the most part, tolerably large, and exceed the 100th of a line in diameter,) and are deposited on the outer or inner sur- faces of the body, still they are not in the parenchyma of the organs, and they can only enter, if there are wounds or lacerations, which as a gene- pafrule donot precede the formation of. cancer. Moreover,, in this sys- CANCER. 283 tern of propagation we must assume that the cancer-cells retain their vitality for a considerable period after their removal from the organism, and that they remain unaffected by external influences, such as a lowered temperature, dessiccation, &c. I will mention one experiment which appears to bear strongly on this point. From the body of a man who died from encephaloid of the tes- ticle, which had extended itself along the vertebral column as far as the diaphragm, and formed a very large tumour, I took, about thirty hours after death, a portion which contained an immense number of uninjured cancer-cells, expressed from the soft mass some of these cells, mixed them with luke-warm water, and filtered the fluid through a piece of linen, in order to remove any large clots which might mechanically tend to close ihe capillaries. The#fluid thus prepared, contained millions of perfectly integral cancer-cells, averaging the 100th of a line in diameter, together with numerous molecular granules, besides fluid albumen and fat, from its odour there was not the slightest indication of putrefaction. This fluid was injected into the jugular vein of an adult healthy dog, so that I am convinced that at least thousands, very probably millions of cancer-cells were thrown into the circulation of this animal. With the exception of the respiration being disturbed for the first few minutes after the operation, the dog exhibited no morbid symptoms, and when killed eight months afterwards, not the slightest change could be detected in any organ, although a single cell might, according to this view, have given rise to the development of cancer. This experiment (like others undertaken by Valentin, Dupuytren,* &c, with similar results) shows that cancer-cells lose their capacity for development very shortly after their removal from the body or after death, and tends to render it ex- tremely improbable, that cancer should often be propagated in the above manner. But many other experiments are opposed to the production of cancer by contagion, as for instance, the cases in which it arises from mechanical influences, as a blow or a fall. On these grounds, the view that cancer is formed1 by the transference of cancer-cells, appears to the unprejudiced investigator, to be very improbable; at least this mode of formation can at most only occur in a very restricted class of cases. But on the other hand, this view*, seems better adapted to explain the further distribution of cancer in an individual' already suffferirg from it. And yet on close examination doubts arise regarding even this limited ap- plication, as may be seen by a reference to the explanation of fig. 9 in Plate vni. In this case cancer of the lungs succeeded the primary affec- tion of the testicle.. * Compare Hanover, Hvad er-Oancer? p. 91. 284 PATHOLOGICAL EPIGENESES. Here the recent cancer consisted of a* solid cytoblastema, which was partly amorphous and partly becoming cellular, there being only a few spots in which perfect cancer-cells could be discovered. If I allow that here one or several cancer-cells became impacted in the same capillary vessels, and gave rise to exudation, it still remains problematical how a few cells could exert so strong an influence on a proportionally large mass of exudation as to convert it entirely into cancerous matter, whilst in other cases, the plastic force of an organic cell is limited to its most imme- diate vicinity. And here arises a second doubt. Many cancers consist not merely of cells, but also contain fibres. How do these fibres arise 1 We may, indeed, assume that in certain cases the cancer-cells, are con- verted into fibres; but, from numerous experiments, I am induced to be- lieve that such an assumption is altogether false, since it is the peculiar nature of cancer-cells not to enter into other forms, but to undergo disin- tegration. Langenbeck,* however, asserts that he has observed that after transmitting cancerous matter into the circulation of a dog, cancer con- sisting not merely of carcinomatous cells, but also of "very strong, clear, juicy fibres " has formed in the lungs. But how can he explain their pro- duction as due alone to the influence of the cancer-cells? These remarks afford a sufficient refutation of a hypothesis respecting the formation of cancer, which has recently been regarded by many, without sufficient ex- amination, as based on indubitable evidence. In opposition to this view, there is nothing to hinder us from assuming that cancer-cells are origi- nally formed in the body, like other cells which occur in morbid epige- nesis, as for instance, pus-corpuscles. But the conditions giving rise to one or other form of cell are still for the most part unknown ; and I deem it unnecessary to submit to a similar examination the other opinions which have been promulgated regarding the causes of cancer, since they would lead us too far from our subject, and afford no valuable results. Attempts of this kind finally lead to the subject of miasm, contagion, &c—points which belong rather to general pathology than to pathological anatomy. The preceding observations respecting its propagation, lead to the belief that cancer proceeds chiefly from the vascular system, namely, from the veins—a view supported by certain anatomists, and amongst others* by Cruveilhier. The cancerous matter observed in the veins is certainly very rarely formed there as a primary product, but is usually secondary, depending on a propagation of the cancerous matter in the blood. Indeed, in many cases no cancerous matter is observed in them, * Op. cit, p. 104. CANCER. 285 but merely pale coagula of fibrin, similar to those which occur in phle- bitis : this has been shown by Hannover.* The assertion, that cancer can only form in certain organs, as, for instance, in cellular tissue, is ne- gatived by direct observations. For other views on the subject of cancer, and for the literature with which they are supported, we must refer to J. Midler's original work, or to Dr. West's translation. I must here revert to the opinion maintained for many years by Hodgkin, and still again re- cently! brought forward by him in opposition to the view that cancer is formed from the cells. It consists essentially in this—that all cancerous tumours both in man, and in the lower animals, arise from the compound cysts already de- scribed. The following considerations may serve as a cine to the correct esti- mation of tfiis view, which appears to me to contain much truth, although not to admit of the general application that Hodgkin supposes. We have already seen that cysts may arise from morbid blastemata under very different relations, when the surrounding parts or the peripheral portion of the blastema become organized. The same may happen in certain cases when the greater part of the blastema is converted into a pseudo- plasma ; the cancer may then be associated with a more or less compli- cated cyst-formation. Moreover, those forms in which masses of cancer- cells appear to be enclosed in fibrous capsules, indicate the possibility of such processes. In this sense, Hodgkin's opinion appears, at all events, as established, and deserving of the consideration of future investigators. But, on the other hand, we must not conclude with Hodgkin, that all pseudoplasmata proceed essentially from compound cysts. We can cer- tainly never succeed in recognizing this structure in the infiltrated forms of tubercle, encephaloid, and scirrhus. Again, when cysts occur together with the pseudoplasmata, the latter do not arise from the former, but both are formed simultaneously. The cysts render tbe pseudoplasmata more complicated, and exert an influence on their form, but have nothing to do with their production. It is on this point that the objection is based which Professor Grose of Cincinnati, has urged against Hodgkin, namely, that there is an essential difference whether or not the contents are produced by the wall of the cyst. If it is assumed that the membrane of the cyst gives rise to the pseudoplasma, such an opinion is just as false as that all tu- bercles arise from hydatids. In the explanation of these points we must not refer to cystoid of the ovary; for, in consequence of the structure of the Graafian vesicle, pecii- * Op. Cit. p. 86. t Medico-chirurg. Transactions, 1843, p. 242. 286 PATHOLOGICAL EPIGENESES. liar conditions are there present; in fact, these vesicles may be regarded as normal cysts, differing, however, in character, from those of any other part of the body. In an excellent memoir recently published by Engel,* the very praiseworthy attempt to explain, on physico-chemical principles, the formation and development of cancer, has been made in the same manner as was formerly done in the case of tubercle. I believe that here, as in that case, this is the path the exact investigator must follow; but the difficulties in this case are greater even than in the former, because cancerous tumours are generally much more highly organized than tu- bercle, and the modification of the blood, which is assumed by Engel to be the basis of the formation of cancer, not merely requires confirmation, but an accurate chemical examination. Our chemical knowledge of can- cer is very slight; the older observations, as, for instance, those of Lob- stein, are at present of little value. More recently J. Miillerfand SchererJ have occupied themselves with its chemical investigation, but their results have not thrown any great light on the subject. In the chemical analysis of cancer, as in that of all other organic structures, the most essential point-to attend to is, that the chemical and histological investigations should proceed hand-in-hand, and that we should endeavour to give a suitable account of the seat, form, and signification of each substance re- cognized by the chemical analysis. Cancer, however, consists of solid portions infiltrated with fluids: these solid portions are an amorphous blastema (probably fibrin,) elementary granules (whose chemical compo- sition has been already considered,) fibres, and cells. In chemical compo- sition the fibres are probably identical with those that occur in fibrous tumours, and must be regarded as forming an intermediate link between the protein-compounds and gelatigenous tissues. The composition of the cancer-cells is still unknown ; it doubtless varies with their development. The fluid constituents of cancer are, undoubtedly, extremely various, ac- cording as the tumour is crude, softened, or discharging. Hence, to com- plete our knowledge of the subject, a large number of analyses is requisite, and we proceed on a very false principle, in attempting to deduce general conclusions from isolated investigations. We shall return to this subject in our remarks on the different forms of cancer. For statistical informa- tion relative to cancer, we must refer to Herrick and Popp,§ and Leroy d'EtiolIes.|| _________________ * Zeitschr. d. Gesellschaft d. Aerzte zu Wien. Jahrg. i. p. 267, fcc. t Op. cit. p. 24, or West's Translation,^ p. 73, where the analyses of the earlier chemists are quoted and criticized. X Untersuch, p. 220. § Ueber bosartige Fremdbildungen. Regensburg, ] 841. [| Gazette Med. de Paris. Mars, 1843. CANCER. 287 The diagnosis of cancer in a pathologico-anatomical point of view, is in many cases very easy, whilst in others it is extremely difficult, and, indeed, almost impossible. Even after its extirpation, or in the dead body, when we can examine it at our leisure, and with all our aids to diagnosis, we cannot always decide with certainty on its nature. In this case, as with the former tumours, our diagnosis must be based not. so much on the coarser physical characters which in cancer are liable to extreme variations, as on the histolo- gical relations as viewed throughthe microscope. The diagnosis must be based: 1. On the peculiarity of the development of the tumour, namely, on its softening. But softening may also occur in other tumours, as in tubercular tumours, and in cases of unhealthy malignant sup- puration, accompanied by loss of tissue and induration of the sur- rounding parts. Here we must adopt the second of our means for diagnosing cancers: we must search for the cancer-cells which are characterized by their form and size, and by the number of cytoblasts and young cells, and may be readily distinguished from pus-corpus- cles, as well as from the indefinite cellular structure of tubercular swellings. In most cases the softened cancerous matter exhibits these cells, or fragments of them ; but when these are absent, and when the cancer-cells generally are not perfectly formed, then a certain diagnosis is impossible; and the difficulty is, if possible, in- creased in those cases where a tumour approximates equally to can- cer, tubercle, and unhealthy suppuration. Hence, it is sometimes impossible to distinguish whether we are examining an open cancer, or some other foul ulcer. It is not in accordance with the princi- ples of human reason to erect an arbitrary and constrained distinc- tion, where nature herself has fixed no definite limit. 2. Before the commencement of softening, the diagnosis is ex- clusively founded on the presence of cancer-cells ; and it is certain, in proportion to their abundance, preponderance, and perfect con- dition, and to the facility with which they admit of being distinguished from other primary or developmental cells. The irregular caudate cells* are especially characteristic, as also are the large cells with many cytoblasts and young cells,! the cells with a thick wall,| and » See Plate i. fig. 11. t See Plate vi. fig. 7, 8. X See Plate vm. fig. 6. b. 288 PATHOLOGICAL EPIGENESES. the accumulations of cells in fibrous capsules.* The other forms of cells are very slightly or not at all characteristic, since they occur in the development of other tumours; thus, for instance, the elon- gated fusiform cellsf occur also in the strictly fibrous tumours. Hence, when a cancerous tumour is met with at a very early stage, and the amorphous cytoblastema predominates, or the cells assume a primary form, and present no marked characteristics, the diagnosis is very problematical. Another circumstance, rendering the diagnosis uncertain, presents itself when the cells are secondary in quantity to fibres or other structures. In this case, however, the uncertainty of a true diagnosis is only apparent; for such tumours lie in reality between cancer and non-malignant fibrous tumour; they are a com- bination of the two forms, and become innocuous as the latter pre- dominates. The relations are very similar with the combinations of cancer with melanosis and vascular tumour. Several cases illustrative of the diagnostic value of the microscope in relation to cancer in its various stages, are given in the description of the plates to the second volume. Further observations on the diagnosis of cancer will be found in our remarks on the individual varieties. With respect to its surgical diagnosis, and the detection of cancer of the internal organs during life, we shall add nothing further in the present place, since they are based on many phenomena which are not included in the domain of pathological anatomy. FORMS AND VARIETIES OF CANCER. Cancerous tumours, although they all exhibit the essential cha- racters of carcinoma, yet in their physical properties and in the ar- rangement of their histological elements, present the greatest varieties, which are, however, dependant on two causes: 1, on the organ in which the tumour is developed—a point to which we shall return in the second volume; and, 2, on a difference in the arrangement of the histological elements entering into the formation of the tumour. These differences we shall consider at some length. In the exami- nation of a cancerous tumour we sometimes find cancer-cells, and sometimes fibrous tissue predominating, and the degree of develop- * See Plate vm. fig. 9. b. t See Plate vm. fig. 9. c. ENCEPHALOID. 289 ment of these tissues also varies in different cases; sometimes the principal constituent is a firm, amorphous cytoblastema, and occa- sionally the most abundant ingredient is a viscid tenacious fluid. This is the case not merely with different cancerous tumours, but it is even observed in different parts of one and the same tumour; so that frequently, indeed most commonly, on taking two neighbouring sections, we find that they present very different physical properties, and a perfectly distinct histological arrangement. Attempts have been made to regard these differences as different species of cancer; but here, as we have already shown in the case of the other tumours, a division into species, such as is adopted in natural history, is im- practicable: like many minerals, cancer presents a group of forms merging into one another without any fixed line of demarcation, the individual constituents being, to a certain degree, vicarious, and reciprocally displacing one another. The following are the chief of these forms : first Form. CELLULAR CANCER—ENCEPHALOID.* Synon. Medullary sarcoma; fungus medullaris; cancCr medullaris; carcinoma medullare ; milk-like tumour. Encephaloid is that variety of cancer in which the cancer-cells predominate over the remaining histological elements of the tumour. It appears to be generally developed from a fluid cytoblastema, and hence in examining it during its early stages of development, we rarely find the firm, amorphous cytoblastema, which is usually met with in other forms of cancer. The fibrous tissue is never so pro- minent an ingredient as the cancer-cells: indeed, in some cases it appears to be altogether absent, so that the cancer-cells are directly deposited between the normal histological elements of the affected organ ; more frequently, however, it occurs in a subordinate degree, * Compare J. Muller, uber den feineren Bau, &c, p. 19 ; or West's translation, p. 58; Hannover, Hvad er Cancer ? p. 9; G. Gluge, Atlas der pathologischen Ana- tomie, Part 1: Valentin, Repertor. vol. n. p. 277. The three first works give a tole- rably perfect sketch of the previous literature of the subject. 25 290 PATHOLOGICAL EPIGENESES. forming a stroma in which the cancer-cells lie. When the fibres predominate, encephaloid merges into fibrous cancer, and we sometimes observe that while one portion of a tumour resembles encephaloid, another more closely approximates to fibrous cancer. The viscid fluid likewise occurs almost constantly in encephaloid after softening; it is, however, rarely the leading constituent; in these cases encephaloid approximates to gelatinous cancer. In conse- quence of the extreme softness of its elements, encephaloid com- presses the, parent-tissue in a less degree than solid cancer. It admits of the passage of blood-vessels through its structure, and as they do not become obliterated so frequently as in fibrous cancer, its appearance is usually vascular. In some cases newly-formed vessels occur in it. When, during the softening of encephaloid, the vessels become opened, the effused blood more readily enters the soft tissue, and mixes with it, than in the harder sorts of cancer; the whole mass assumes a sanguineous appearance, and in this way encephaloid merges into fungus haeroatodes; it must, however, be observed, that the term fungus haematodes is applied to many tumours which have no connexion with encephaloid, as for instance, telangiectases and other non-malignant vascular tumours. Black granular pigment may likewise entier into the composition of encephaloid, forming melanotic cancer (carcinoma melanodes.) There are certain forms of cancer-cells which are characteristic of encephaloid, for instance, parent-cells with young cells in their in- terior, cells with numerous cytoblasts,* and the irregular caudate and ramifying cells, f My own experience leads me to assert that these forms are not often found in other forms of cancer; but, on the other hand, they do not occur in all cases of encephaloid. Encephaloid grows more quickly, distributes itself more rapidly, and attains a more considerable bulk than any other form of cancer; tumours of this nature often being as large as a man's head, or even exceeding that size. It also softens more rapidly than the other forms of cancer, because the cells which are the element on which softening especially depends, are here the predominating ingredient; and for the same reason it is the most likely to form a discharging ulcer, and the most rapid in assuming that condition. Hence of all * See Plate vi. fig. 7 a, 8 d. t SeePlatei.fig.il. ENCEPHALOID. 291 forms of cancer encephaloid runs the quickest course, is the most malignant, and causes death in by far the shortest time. It often destroys life in a few weeks, or at furthest in a few months after its first appearance, unless it has been removed by an operation at an early stage. Encephaloid appears to occur primarily or secondarily in nearly every organ and portion of the body, at every age, and in both sexes. From the above observations it may be easily imagined that the coarser anatomical and physical relations of encephaloid are ex- tremely variable ; and this view is supported by experience. The colour of encephaloid tumours varies considerably ; they are some- times whitish, sometimes of a yellow tint, sometimes almost gray, so that in the same case there are some parts that may very fairly be compared to the white, and others to the gray substance of the brain. In other cases, when the tumour is penetrated by numerous minute vessels, we have a reddish, flesh-coloured, or pink tint. When blood extravasated from the injured vessels has become mixed with the substance of the tumour, as usually happens at the Commencement of softening, the whole mass, or certain portions of it appear of a dark red colour, or if the haematin of the extravasated blood has begun to change, the tumour may present a brownish-red or mahogany tint. These tumours likewise differ in their consistence ; before soften- ing they are firm, varying from the consistence of solid lard to that of the brain; after opening they sometimes become more granular or fibrous, and sometimes as they soften, they cease to discharge, but on pressure are converted for the most part into a milky and ap- parently purulent fluid. In those cases, in which from the very first the consistence has been- slight, if the tumour is deposited near the external surface, as under the skin, or in certain muscles, it fre- quently communicates a deceptive feeling of fluctuation, before the commencement of softening. With regard to its anatomical arrangement in the mass, encepha- loid sometimes forms only a single tumour, and sometimes many; and varies from the size of a hemp seed to that of a man's head. These tumours are usually blended with the surrounding parts (in- filtrated encephaloid,) but occasionally they are perfectly separated from the adjacent tissues, being enclosed in an indefinite capsule of mi PATHOLOGICAL EPIGJENESES. areolar tissue, which sometimes exhibits the characters of cartilage (the combination with fibrous cancer) just as is generally observed in newly formed areolar tissue. Sometimes encephaloid occurs in small patches enclosed in fibrous partitions, presenting a certain re- semblance to the normal structure of the pancreas (pancreatic tu- mour.) There are other varieties which are less striking to the eye, and which from the absence of any thing with which to compare them, have received no special names ; they all, however, serve to elucidate the histological arrangement of encephaloid, and its rela- tions to the parent-tissue. The latter is usually so concealed by the morbid deposit, that frequently even the most careful examination fails in detecting its elements. When encephaloid is developed in external parts of the body,, as in the bones of the extremities, or the subcutaneous cellular tissue, it gradually becomes blended with the skin, which is thus rendered distended and cadematous, the superficial veins standing forth like blue cords. It finally ulcerates, and there are formed fungoid growths, irregular leafy and cauliflower granulations, which are usually extremely vascular, and bleed on the slightest provocation (fungus haematodes ;) these granulations are not inclined to become organized; they unite, and discharge to such a degree, as rapidly to induce death by colliquation. The diagnosis of encephaloid is essentially characterized by the same signs as those of cancer generally. From scirrhus it is dis- tinguished by its. greater softness, by its more rapid course, and by its small amount of fibrous tissue. There is, however, no strict line of demarcation between them ; and many very characteristic cases have been at first sight regarded as encephaloid, which after a more careful examination seemed doubtful, or to occupy a transition-form between the two. The accurate limitation of encephaloid, is rendered more difficult by its combining with other forms of tumour, as with melanosis (cancer melenodes) or with telangiectasis.* This combination may probably occur in several ways ; the melanosis and the vascular structure may be superadded to the encephaloid, or con- versely the encephaloid may be the last formed, or finally the two epigeneses may be simultaneous. There is also a species of false encephaloid, a morbid epigenesis * See R. Froriep in the Encyelop. Wflrterbuch der medic. Wissenschaft, vol. £iu. Berlin, 1835, art.Fuugus. ENCEPHALOID. 293 which in its physical properties appears identical with true encepha- loid, but in its histological and physiological relations is essentially different from it. I once observed a tumour of this nature in a lung; it was of the size of a walnut, of a reddish-white tint, about as soft as brain, and wras declared to be encephaloid by all the physicians who were present. When examined under the microscope it was found to be merely a deposition of oil-globules (fat) in the normal tissue of the lung, and hence there remained no doubt of its non-malig- nant nature.' This example may serve to show the possibility of such mistakes; future carefully conducted histological investigations will probably lead to the discovery of other forms of tumour which may be mistaken for encephaloid. As instances of the coarser anatomical and physical, as well as of the histological relations of encephaloid, I may refer to the description o^ Plate vi. fig. 7—11. An instance of the transition-form merging into fibrous cancer, is given in the description of the case of cancer of the knee-joint represented in Plate vm. fig. 6—7. The following case will serve to give a good idea of the mode in which encephaloid extends itself. A joiner about forty years of age, had for three years a swelling of the tes- ticle which gradually enlarged. There was subsequently formed a tu- mour in the abdomen which was perfectly visible on a mere ocular exa- mination. He died after having experienced paralysis of the lower ex- tremities and the bladder. The left side of the scrotum was much en- larged, and on piercing its walls a considerable amount of a clear yellow fluid spirted out. A large portion of the tunica vagin. propria testis was attached to the albuginea by fresh adhesions, which admitted of ready separation by the finger. The testicle and epididymis of the left side were much enlarged, weighing fourteen ounces. They, however, re- tained their normal shape and exhibited, independently of the recent ex- udation, a smooth surface. They were both of a tolerably firm consist- ence, and their section exhibited a yellowish tint.. Internally the mass was coarsely granular, resembling fresh curds. The cord traced from the testicle, exhibited minute knotty swellings before entering the ab- dominal ring. In the abdominal cavity these increased in frequency and size, and finally became fused together into a large encephaloid mass, the size of a child's head, covering the whole of the left side of the vertebral » See Plate vi. fig. 10, a. b.. 25* 294 PATHOLOGICAL EPIGENESES. column as far as the diaphragm, enclosing the aorta and the left kidney, but not extending into the right side of the abdominal cavity. It was of a white colour, resembling brain, was soft, and when pressed between the fingers, was easily reduced to a pulpy consistence. Histologically the soft encephaloid in the abdomen consisted of minute cells of the most varying forms, between which were very numerous fat-granules and oil- globules. In the testicle these cells were likewise found, but they were deposited in a firm amorpho-granular mass. The chemistry of encephaloid is in much the same condition as that of cancer generally. The analyses which have been hitherto published are either far behind the present state of science, or must be regarded merely as starting points for future chemists, and in their present state do not admit of the deduction of any general conclusions. In the first category we may place the analyses communicated by Lobstein,* and those of Hauser.t and Baudrimonf;J in the latter those, of Brande,§ Valentin,|| J. Muller, and Scherer.^ Of the chemical nature of the principal ingre- dient of encephaloid—the cancer-cells—we are altogether ignorant; the other constituents are not so essential, and to a certain degree vicarious. As a general rule encephaloid contains much more fat than fibrous can- cer. Cholesterin is often present, frequently occurring in softened en- cephaloid in the form of crystals. Whether the phosphorized fats dis- covered, in, encephaloid by some chemists (Brande, Beaudrimont) are of any especial importance, must be determined by future investigation. J. Muljer distinguishes three varieties of encephaloid : l\ Encephaloid abounding in roundish cells, though intersected by a- delicate fibrous net work. 2". Encephaloid with an exceedingly soft cerebriform base, composed of pale elliptic corpuscles devoid of caudate appendages: 3.. Encephaloid with caudate or fusiform corpuscles. The latter he regards as cells in the process of conversion into fibres ; it seems to me, however, to be very doubtful, whether tumours consisting merely of fibre-cells, should be regardedas encephaloid. Moreover, it is not always easy to determine whether the caudate cells must be regarded as always progressing into fibres,** or whether they should be viewed as peculiar encephaloid-cells incapable of further development. Glugett regards the * Lobstein, Anatomie pathologique> vol. i. i Oesteneiehische medic. Jahrb. Mtirz, 1841, p. 317. X L. Gmelin, Chemie, vol. n. p. 1373. § Berzelius, Lehrbuch der Chemie, 4th Ed. vol. ix. p. 729. \\ Reperjorium, vol. n. p. 277, IT TJntersuchungen, p. 220, 221. *fc See Plate vin. fig. 9. tt Atlas der pathologischen Anatomie, Part 1, p. 19. SCIRRHUS. 295 caudate bodies described by Muller as an artificial product arising from the action of spirit. It is certainly true that encephaloid preserved in spirit is no longer fit for histological examination, and that albumen co- agulated by alcohol may sometimes assume forms, which under the mi- croscope present a remote similarity to elongated cells : however, none who are used to microscopic investigations could mistake such artifieiaf products for actual, unaltered cells, and Midler's experience in this de- partment, as well as the" figures of these cells, which he has depicted, utterly overthrow Gluge's supposition. Respecting the causes, mode of formation, and importance of encephaloid, we can merely apply the same observations as were previously made in relation to cancer gene- rally. Some writers have endeavoured to establish an especial connex- ion between encephaloid and nervous tissue, regarding the former as merely an abnormal development of the latter structure. Such opinions have not even a shade of probability: they are based on an accidental similarity existing between the two, in colour, consistence, and certain chemical constituents. The microscope at once reveals the essential difference between these structures. SECOND FORM. FIBROUS CANCER--SCIRRHUS. Synon. Cancer scirrhosus ; carcinomatous sarcoma; hard cancer;- carcinoma simplex; carcinoma fibrosum.* Under the term scirrhus we include those forms of cancer in which the fibrous tissue predominates, and which are consequently firmer and harder than encephaloid: hence its name.f In its early stages we find more frequently than in encephaloid, a firm, amor- phous blastema ; hence scirrhus does not invariably exhibit decided and perfectly formed fibres, for here as in the genuine fibrous tu- mours, the blastema does not always, even in the more advanced stages, undergo transformation into distinct fibres admitting of iso- lation, but sometimes permanently remains as an indefinite fibrous * See MQller, op. cit. or West'* translation ; Hannover, op. cit. p. 22, &c.; Lob- stein, Anatomie patho^lol. i.; and G. Gluge, Untersuchungen,Part l,p. 139,Part 2, p. 138. t riufpof, hard, firm. 296 PATHOLOGICAL EPIGENESES. mass, holding a position both morphologically and chemically be- tween coagulated fibrin and the gelatigenous fibrous tissue. The fibrous portions of scirrhus coincide in every point of view with those of non-malignant fibrous tumours, and hence, as we have already mentioned, scirrhus must be regarded as a combination of encepha- loid with fibrous tumour. There are thus an endless number of transition-forms, the extremes of the series being on the one hand encephaloid, and on the other fibrous tumour. The mutual relations between the fibres and the cancer-cells vary extremely in scirrhus; sometimes both elements occur with a certain degree of regularity, the fibres forming net-work or capsules, whose interstices and cavi- ties are filled with cells, or else radiating-from certain points ; some- times on the other hand the fibres and cells are separated from each other. When, in the latter case, the tumour is divided into several portions, it is frequently impossible to distinguish some of these parts from encephaloid, and others from fibrous tumour. In scir- rhus we frequently find the cellular structure less developed than in encephaloid; we rarely observe in it either large parent-cells, or cells with numerous cytoblasts; more frequently the cells are small, roundish or oval, and granular. Elementary granules are common after softening has commenced. Moreover, the viscid fluid is, as a ■general rule, present in scirrhus; when it occurs in excess, it forms the transition to gelatinous cancer. Since, scirrhus is slower in its development, and more solid than encephaloid, so also is its action on the parent-tissues previously to softening more strongly marked ; the elements of these tissues being more firmly compressed, become more readily atrophied. Hence, unsoftened scirrhus exhibits fewer and smaller vessels than encephaloid ; if they are not altogether ab- sent, they are at all events very small, and may be easily overlook- ed by a careless observer. Large vessels in scirrhus are, however, not rare, and we frequently find the milk-ducts previous in mam- mary scirrhus of long standing. Corresponding with these histological differences between scirrhus and encephaloid, there are also variations in their development, growth, and consequences. The growth of scirrhus is much the slower, for the cells on whose propagative power the enlargement of encephaloid is chiefly dependant, are here of Mere secondary im- portance ; hence scirrhus rarely attains to the same magnitude as en- cephaloid. On the other hand, the mechanical consequences of the SCIRRHUS. 297 tumour arising from pressure on nerves and vessels, contraction of canals, &c, are sooner and more energetically manifested than in (.■ncephaloid. Conversely the process of softening is slower in scirrhus, the cells forming minute radiating islets of pus, which do not become so easily converted into ichorous discharge, but are not more liable to resorption ; hence the softening is less likely to extend to the adja- cent tissues. Consequently scirrhus is much slower in conducting to a fatal result than encephaloid, and must be regarded as far less dangerous. While the latter often causes death in a few months, scirrhus usually continues for years. When the softening of scir- rhus has progressed to a certain degree, there occur in it cavities, such as have been previously described, partially filled -with a red ichorous fluid, and having fibrous or semi-cartilaginous walls united by irregular bands and arches. The granulations of scirrhous tu- mours resemble in all essential points those of encephaloid ; and.in the later stages when open ulcers are once formed, the progress of scirrhus becomes more rapid, and more closely approximates to that of encephaloid. Scirrhus occurs on a secondary product in nearly every organ of the body, but its appearance as a primary affection is much rarer than that of encephaloid, and it seems for the most part to attack glandular organs. It appears most frequently during the latter half of life—from the fortieth year; and does not attack children. Finally it is more common in the female than in the male sex, in consequence of the female breast being the most common seat of the affection. As there are great differences in the histological arrangement of scirrhus, so likewise are there extreme variations in the coarser anatomical relations of this form of tumour. Scirrhus usually forms a roundish tumour with a more or less nodulated surface. Its con- sistence is generally very firm; the tumour in this respect resembling cartilage or even stone (cancer eburneus ;) this hardness depends on its fibrous structure, and (as in the case of fibrous tumour) varies with the toughness, compactness, and amorphous character of the fibres. Its nodules, in cases where the tumour is superficial, are frequently observed, on the application of the hand, to be of a lower temperature than the surrounding parts. This is probably depend- ant on the.circumstance, that in consequence of the limited supply of blood to these parts, the metamorphosis of tissue is much check- 298 PATHOLOGICAL EPIGENESES. ed ; however, I do not regard this hypothesis as a conclusive answer to the question. On passing a knife through them, scirrhous tu- mours craunch in just the same manner as fibrous tumours. A section of one of these tumours sometimes appears of a bluish- white or milky colour, transparent, opalescent and shining—charac- ters dependant on the fibrous portion, and exhibited in like manner by fibrous tumours ; sometimes it presents a more opaque appear- ance, and is of a white or gray colour, with a shade of yellow—a character depending on the cells; and occasionally it presents a reddish tint if many blood-vessels are present. In most cases the unaided eye will detect difference of structure at different points; some parts being fibrous or transparent; while others are opaque, yellow or green ; when softening has commenced, a caseous appear- ance is sometimes presented. By scraping a tumour of this nature, we usually obtain a whitish creamy fluid. Specks of blood are rarely observed, and coagula never unless softening has advanced, arid the blood-vessels are injured. As a general rule, scirrhus is in- timately blended with the surrounding parts, not being enclosed in a capsule or presenting a definite border. In regard to the diagnosis, and pathologico-anatomical appear- ance of fully developed scirrhus, we have nothing further to add ; but even the most experienced observer, with every aid to diagnosis at his command, will frequently be in doubt, whether or not he is examining true scirrhus, since this form of cancer presents so many transitions into other sorts of tumours. These are, as we have al- ready had occasion to mention. First, the transition into encephaloid. It often appears to be a point of indifference whether a tumour should be referred to ence- phaloid or to scirrhus ; the cancer-cells, and the fibrous structures being so equally balanced, that neither element predominates. Sometimes again, one portion of a cancerous tumour resembles en- cephaloid, whilst another more closely resembles scirrhus. These are cases belonging strictly to neither encephaloid nor scirrhus, but embraced in one of the numerous forms of cancerous tumour, which do not find a place in our artificial arrangements, however much we may extend them. A second transition-form is that into gelatinous cancer, of which we shall speak presently. The third series of transition-forms are those into non-malignant SCIRRHUS. 299 fibrous tumours. These are of the highest pathological importance, and are more likely to occur in proportion as the scirrhus is removed from encephaloid. In tumours previous to softening, it is often im- possible to distinguish whether the few cells observable amongst the fibres are cancer-cells, or whether they are the 'developmental cells of other tissues, and this is a point on which microscopic examina- tion can throw little light. Even after the establishment of soften- ing, the diagnosis is sometimes uncertain, .since non-malignant fibrous tumours may also undergo that change. It is a question which must be answered by future observers, whether in such cases cancer-cells are superadded as secondary formations to a fibrous tu- mour, originally non-malignant. I regard this secondary formation as not improbable, for we frequently observe that tumours which have existed for'years without giving rise to more than mechanical annoyance, rapidly soften and become converted into cancer ; I have, in several cases, observed this to occur in fibrous tumours of the uterus and mammary gland. Hence many forms of scirrhus should be regarded as combinations of encephaloid with fibrous tumour, and I must express my conviction, that many cases which from their pathology and morbid anatomy have been termed scirrhus, have been merely epigeneses of fibrous tissue. Although Andral first called attention to it, yet almost daily we observe simple hypertro- phy of the muscular or cellular coat of the intestinal canal, mistaken for scirrhus,—an error I have myself repeatedly witnessed. A further difficulty in the diagnosis arises when a cancerous tu- mour consists for the most part of an amorphous solid cytoblastema. There are no means of distinguishing this from the solid cytoblas- tema of a non-malignant tumour, and a certain diagnosis can only be established when a portion of the tumour becomes characterized as more perfectly developed scirrhus. Hence it follows that the determination, whether a tumour is, or is not of a scirrhus nature, is sometimes, even with the best aids to diagnosis, merely presumptive, and occasionally the opposing cha- racters are so equally balanced, that not even a conjectural opinion can be hazarded. A very characteristic form of scirrhus is exhibited in Plate vm. fig, I, 2 and 8; fig. 4 and 5 illustrate a case of cancer of the liver, which may be regarded as pertaining either to scirrhus or encephaloid; fig. 6 and 7, ex- 300 PATHOLOGICAL EPIGENESES. hibit soft cancer of the knee-joint, belonging more correctly to encepha- loid than to scirrhus. Fig. 9, illustrates the formation of scirrhus from an amorphous cytoblastema. Other cases of scirrhus are illustrated in the second volume. Under the term carcinoma reticulars J. Muller* describes a peculiar variety of cancer which must be here noticed. It embraces those forms in which accumulations of cancer-cells are deposited on the meshes of a fibrous stroma, so that a section of the tumour exhibits a more or less re- gular appearance of net-work.f The fibrous masses occur in the form of thin transparent bands; the accumulated cells are whitish'; but present a dark appearance when examined under the microscope by refracted light. The individual cells sometimes resemble the ordinary granular cells. Like the preceding forms of cancer ; it is not strictly defined, and hence it is not to be regarded as a peculiar species. Another form of cancer described by J. Muller,J under the term carci- noma fasciculalum seu hyalinum, appears histologically to be referable to this class, since it consists of very delicate fibres. It is, however, not firm like true fibrous cancer, but as soft as encephaloid, and highly vascu- lar: according to Muller, it contains no cancer-cells. Notwithstanding the great number of cancerous tumours which I have examined, I have never yet met with this variety; hence my opinion with regard to the cor- rectness of placing it in the above category must be considered only provi- sional. All that is known in relation to the chemistry and causes of scirrhus has been already, given in our remarks on cancer generally. THIRD FORM. COMBINATION OF MELANOSIS AND CANCER. Melanotic Cancer. Synon. Cancer melanodes; carcinoma melanodes.§ We have already had occasion to mention that dark granular pig- ment may occur as an incidental constituent of cancerous tumours. This pigment is either enclosed in cells^ which are only slightly, or not at all different externally frGm the ordinary cancer-cells (true * Op. cit. p. 15, or West's translation, p. 44. t See Plate vm. fig. 10 ; also Mailer, op. cit. Plate i. fig. 1—9. X Op. cit. p. 23, or West's translation, p. 66. § See Muller, op. cit. p. lgj or West's translation, p> 55 : Hannover, op. cit. p. 32. SCIRRHUS. 301 melanosis,) or it Occurs in the form of free granules, and then some- times consists of sulphuret of iron. Hence we have here the same differences as we formerly noticed in our remarks on melanosis. The characters of melanotic cancer vary with the quantity and arrangement of the black pigment. When a small number of pig- ment-elements (cells or granules) are equally distributed over a large amount of cancerous structure, the tumour presents a gray colour. If an excess of pigment is deposited at special points, the cancer presents a dark speckled or marbled appearance. Finally if the amount of pigment is very excessive, the cancer presents throughout a blackish brown colour, and resembles in its appearance a true me- lanotic tumour. Melanosis is associated both with encephaloid and scirrhus ; the former, according to my own experience, being com- bined with true, the latter with false melanosis. In its progress and relations melanotic cancer presents no especial peculiarities. FOURTH FORM. GELATINOUS CANCER, OR COLLOID. Synon. Cancer alveoiaris; carcinoma alveolare; cancer areolaire; cancer gelatiniforme* We have previously described the viscid fluid, which forms a to- lerably constant, and, therefore probably essential ingredient of can- cerous tumours. This gelatinous fluid is so increased in certain forms of soft cancer, as to give the tumour a very peculiar appear- ance. In some cases this jelly-like matter is enclosed in cellular cavities, varying from the size-of a pin's head, to that of a walnut, or even of an egg : the cancerous tumour then presents a very cha- racteristic appearance, and receives the name of gelatinous cancer, or colloid. The stroma of these tumours is invariably fibrous, being sometimes a delicate net-work, and in other cases being very thick, * See Muller, op. cit, p. 16, or West's translation, p. 50; Hannover, op. cit. p. 29 ; Otto's seltene Beobachtungen zur Anatomic, Physiologie, und Pathologie, Plate i. fig. 4; Cruveilheir's Anatom. patholog. Iit. 10, tab. 4 ; copied in Hope's Principles and Illustrations of Morbid Anatomy, fig. 180, 181 ; Carswell's Pathological Ana- tomy, fasc. 3, tab. 1, fig. 8; Broers, Observationes anat. patholog. Lu^d. 1839 c. 4 * tab.; G. Gluge's Untersuchungen, Part 1, p. 132. 26 302 PATHOLOGICAL EPIGENESES. tough and apparently cartilaginous, such as occurs in fibrous cancer. In the interstices 'between these fibres, there lies this colourless, transparent jelly, which, when examined under the microscope, is found either to retain its transparent and amorphous appearance, or else to enclose very pale cells,* differing, however, from true cancer- cells, being, generally speaking, larger and more delicate, and the walls not being so thick. Occasionally, we observe crystals of am- moniaco-magnesian phosphate enclosed in the gelatinous matter. No true softening-or suppuration occurs in this form of cancer; in the intestinal canal where it is most frequent, the surrounding tissues become gradually infiltrated by the jelly ; strictures are thus formed in the gut, and the contents of the canal being pressed on the soft gelatinous mass, give rise to perforation of the walls. Hence gela- tinous cancer is in some degree different in its progress from the other forms of carcinoma. Regarding the causes of this variety of cancer nothing certain is known. Miiller believes that its gradual enlargement is dependant on a further development and increase of the cells containing the jelly; young cells being formed within the parent-cells. Colloid, in its characteristic form, most commonly occurs in the intestinal canal between the stomach and the rectum, from whence it proceeds to the peritoneum—especially the omentum; it more rarely occurs in other organs —in the breast bones, &c. The external characters of this form of cancer are so very striking, that no one who has once seen a case, or even a good plate of it, can well err in his diagnosis. The peculiar interstices formed by the fibrous meshes and filled with jelly, present no variation, at least in cases of fully developed colloid. When colloid presents transitions •into other forms of cancer, as, for instance, when the jelly is not en- closed in its proper interstices, but is deposited free between the fibrous structures and the cells, the diagnosis can only be established by micro-chemical examination, and there is a difficulty in assigning to the tumour its proper place in the scale of cancerous formations. The reader will find a description of several cases of colloid, with plates, in the chapter on the morbid anatomy of the stomach and intes- tinal canal, in the second volume. i * See Plate vm. fig. 11. UNORGANIZE PATHOLOGICAL EPIGENESES. 303 Many forms of tumour which have received special names from morbid anatomists and surgeons, do not, in a histological point of view, merit such a distinction. To this class belong polypi and fun- goid growths. The former have only this in common—that they arise from, or are invested with mucous membrane. But if every epigenesis invested with mucous membrane, and developed in or under such a membrane, be termed a polypus, it is obvious that that there may be great differences-in the histological arrangement of such a class.* The nucleus of a polypus may, however, be formed by almost any form of tumour, either by a non-malignant structure—as lipoma, fibrous tumour, or encysted tumour; or by a malignant structure—as caroinoma. The same is the case with fun- goid growths, which may arise from any discharging tumour, ulcer, &c. We shall have more to say in relation to these tumours in the second volume. SPECIAL RELATIONS. OF UNORGANIZED PATHOLOGICAL EPIGENESES. The unorganized epigeneses occurring in the human body are very numerous, and present many varieties. In the following pages, de- voted to their special consideration, we shall commence with cer- tain general considerations, beginning with their elementary relations. All these forms arise from fluids—mother-liquids, holding the mat- ter of which the future deposit is composed, in a state of chemical solution. Nearly every fluid in the body may act as a mother-liquid, since they all contain matter which, under certain conditions, may be separated in a solid form. The conditions for this separation are in all respects identical with those which chemistry teaches us to re- * Regirding the histological relations of polypi, consult the treaties of Frerichs, de Polyporutn Structura Penitiori. Leer®, 1843 ; and regarding the coarser relations, see Meissner uber die Polypen in verschiedenen Hohlen des menschlichen Korpers, Leipz. 1820. 304 PATHOLOGICAL EPIGENESES. cognize in relation to the separation of solid bodies from their solu- tions, that is to say, the deposits invariably follow chemical laws. As a general rule, the separation ofa substance from a fluid takes place when the conditions on which its solution depends, are checked. The causes which may hinder it from remaining dissolved are vari- ous ; they may, however, for convenience, be arranged in the two following classes: 1. The dissolved substance "may undergo a chemical change so as to become altogether, or in a great measure, insoluble in the fluid in which it was previously dissolved. Cases of this nature are re- markably numerous, and occur under a variety of circumstances. Thus, for instance, bicarbonate of lime dissolves in water, but if it becomes converted into the neutral carbonate it is no longer soluble, and becomes deposited. At the temperature of the human body, urate of ammonia and the other uric-acid salts are soluble to a cer- tain extent in water; if, however, they are decomposed by the ad- dition of an acid, the uric acid becomes liberated, and being much more insoluble than the majority of its salts, forms a deposit in the fluid. If oxalic acid is mixed with an aqueous fluid containing a soluble salt of lime, oxalate of lime is formed, which, being insoluble in water, separates as a deposit. Another cause, closely allied to the preceding, is a change in the solvent fluid. Phosphate of lime, for instance, is soluble in acid, but not in alkaline fluids; hence, if an acid solution of this salt should in any way become alkaline,' a precipitation takes place. Another view may, however, be taken of this process ; it may be supposed that phosphate of lime in an acid fluid becomes converted into a super-phosphate—the free acid taking up a part of the base from the neutral salt of lime—and that the super-salt is soluble in water: and that the alkaline fluid, on the other hand; removes a portion of the acid from the lime and forms a basic salt insoluble in water. Hence, taking this view of the question, the two causes are in reality identical. 2. All substances soluble in aqueous fluids are merely so to a cer- tain extent, that is to say, a certain amount of water is requisite in order to retain a certain amount of the substance in solution. The solution is then saturated. If a portion of water is removed, a cor- responding amount of the substance must separate in an undissolved form. UNORGANIZED PATHOLOGICAL EPIGENESES. 305 Both of the above cases occur in the human body, and give rise to numerous separations of matters no longer soluble—precipitates. The former cause is frequently in operation, and acts under very dif- ferent conditions, as we shall perceive when speaking of the different forms of precipitate. The second cause is comparatively rarer, and depends for the most part on evaporation and endosmosis. By evaporation, a concentrated fluid occurring in a part of the body exposed to such an influence, may lose so much water that a part of the matter dissolved in it (or, indeed, the whole amount) may separate in a more or less solid form. This cause is very fre- quently in operation in the nasal cavity, more rarely in the mouth, the cutaneous glands, the vagina, behind the glans penis, and possi- bly also (although very rarely) in the lungs and bronchial glands. It is probably never effectual in parts more remote from an exposed evaporating surface. Endosmosis, as is well known, occurs when two fluids of unequal concentration are separated from each other by a thin animal mem- brane ; an interchange of their constituents taking place under these circumstances, and the thinner fluid becoming more concentrated. When a thin fluid of this sort is saturated with substances requiring a large amount of water for their solution—as, for instance, the urates—then if endosmosis comes in play, they no longer remain entirely dissolved, but a portion becomes separated. This view is, however, rather founded On general theoretical considerations than on special experiments, arid requires further proof. Precipitates separated by either of the above causes may, as can be readily conceived, disappear, if conditions arise which render them again soluble. Precipitates are the commencement of all unorganized pathologi- cal epigeneses. They bear the same relation to perfectly formed concretions as the elements of the tissues to tumours. They fre- quently occur in such small quantities as entirely to escape detection by the naked eye; the microscope is then requisite to detect their presence,-and to elucidate their formative relations. From microscopic investigation we learn that precipitates occur in three different forms—the amorphous, the indefinitely granular, and the crystalline. Amorphous precipitates form a transparent, gelatinous mass, diffi- 26* 306 PATHOLOGICAL EPIGENESES. cult to observe under the microscope—as, for instance, basic phos- phate of lime, or silica in the gelatinous state. . Granular precipitates consist of very minute granules of indefinite size and form (generally roundish,) in all respects identical with the elementary or molecular granules already described. Minute ac- cumulations of them are generally colourless; in large patches they appear dark when viewed by refracted, and white by reflected light; we may instance albumen precipitated by an acid, or granular de- positions of fat. In some few cases they present a coloured appear- ance ; thus the finely-granular deposits of urate of ammonia fre- quently present a brownish red, and sometimes a beautiful pink colour. Crystalline precipitates consist of more or less perfectly formed crystals, which, however, are usually only microscopic. Many of the forms occurring in these precipitates are very characteristic, as, for instance, those of uric acid,, ammoniaco-magnesian phosphate^ cholesterin, and margarin. Others are less perfect, or so minute that their crystalline form cannot be recognized under the highest powers. These three forms of precipitates are, however, not strictly sepa- rated from one another; and it frequently depends upon accidental circumstances whether a precipitate assume one or other of them. The amorphous is generally the primary condition of the precipitate; it subsequently assumes the granular or crystalline state. In just the same manner, as an amorphous cytoblastema becomes metamor- phosed into a cell, which again undergoes a higher transformation and becomes converted into an integral, constituent of tissue, so can an amorphous precipitate become converted into one of a granular character, and this again assume a crystalline form. This progres- sive metamorphosis does not, however, always occur. Many pre- cipitates, as for instance, the protein-compounds, are incapable of crystallization, never being able to advance beyond the finely-gra- nular state. On the other hand, crystals maybe formed directly from a fluid, without previously assuming the amorphous or granular state. Chemistry teaches us that precipitates assume the crystalline form with a facility proportional to the slowness of their formation, and, on the other hand, that in proportion to the rapidity with which they are formed, they assume the amorphous or granular state. UNORGANIZED PATHOLOGICAL EPIGENESES. 307 This law holds good in the same manner in relation to analogous morbid formations. Hence, as a general rule, it matters little whether a precipitate be amorphous, finely-granular, or crystalline;. and the occurrence of crystals in the human organism is usually not of that importance which many have attributed to it. With the exception of some few cases, as, for instance, the crystals in the inner ear (otolithes) it is only of importance in indicating the pre-existence of certain forma- tive processes, or in enabling us to recognize, from the form of the crystal, the chemical composition of the substance composing it. We shall now consider the individual substances which occur as constituents of the precipitates in the human organism, their form, chemical relations, and mode of formation. 1. Protein-compounds. We have nothing to add to the observa- tions already made (see page" 70) regarding fibrin coagulating in the amorphous state. It cannot be doubted that the protein-compounds often separate in a granular form, and constitute the elementary gra- nules which have been so frequently mentioned. But the special relations of the individual protein-compounds, their metamorphoses, and the different degrees of solubility of their modifications are still imperfectly known, and must be left for future investigators to work out. As a general rule, precipitates formed from protein may be re- cognized by the following characteristics: they are never crystalline, usually finely-granular, occasionally amorphous; when treated with an aqueous solution of iodine, they assume a yellow colour; they are insoluble in ether and mineral acids; acetic acid renders them transparent without entirely dissolving them; by prolonged action they dissolve in caustic potash; when they can be isolated and ob- tained in large quantity, they dissolve by prolonged ebullition in concentrated hydrochloric acid, yielding a lilac-coloured fluid. When a finely-granular precipitate simultaneously presents all these reactions, it may be declared with certainty to be a protein-com- pound. If only a few of these reactions are exhibited, the diagnosis becomes comparatively less certain. The causes of the formation of these precipitates are still very obscure. We do not know, whether in individual cases, they con- sist of fibrin, albumen, or globulin, if we except those instances in which the fibrin coagulates in an amorphous state; and we are 308 PATHOLOGICAL EPIGENESES. equally ignorant regarding the causes giving rise to the precipitation. Albumen, as is well known, is precipitated by the mineral acids, by heat, by alcohol, and by metallic salts—as, for instance, corrosive sublimate: the precipitates caused by these influences are likewise amorpho-granular: but it is extremely seldom that albumen is pre- cipitated within the organism from any of the above causes. Other modes of explanation more closely approximate to the truth. Thus a modification of albumen has been lately recognized, which is pre- cipitable by acetic acid, and another which is thrown down on the simple addition of water. It is probably of these and similar (still unknown) modifications of protein that these precipitates are formed. A wide and fruitful field for investigation is here open before us. It has been already mentioned that Lehmann referred certain granular precipitates insoluble in caustic potash, to the protein-compounds. I must here remark, that after repeated examinations, I still regard the existence of these protein-granules as very doubtful. In all tfie cases in which I have met with molecular granules insoluble in caustic potash, I have found, on continuing my examination, that they were perfectly soluble in ether, and therefore consisted of fat. Whether other organic substances occurring in the human organism, as ptyalin, pepsin, extractive matters, &c, form constituents of pre- cipitates, must for the present remain undecided; the probability is that (with the possible exception of pepsin) they do not, since, under ordinary circumstances, they are readily soluble in aqueous fluids. 2. The fats very often occur as constituents of precipitates. The forms in which they present themselves differ with their chemical composition; thus some form very characteristic crystals, whilst others are amorpho-granular. The following are the fats requiring especial consideration: a. Cholesterin, which frequently occurs in a crystalline state, and then forms very characteristic rhomboid tablets, with angles of 80° and 100°.* These crystals are insoluble in water, acids, and alka- * See Plate x. fig. 1. The numbers given in the text are the. mean of twenty ad- measurements made by me with the camera lucida. The individual admeasurements of the acute angle, varied from 78° to 83°, which affords sufficient evidence of the accuracy with which crystals may be measured in this way. PRECIPITATES OF FAT. 309 lies, but dissolve in ether and hot alcohol. We have no certain knowledge regarding the causes of the separation of cholesterin ; in- deed, we do not even know how this substance, which in the normal condition occurs in small quantity in the blood, and many other animal fluids, and in larger quantity in the brain and nerves, is re- tained in solution. It probably exists in some still unknown combi- nation which renders it soluble, and whose gradual decomposition gives rise to its separation in a crystalline state. Cholesterin sepa- rates in large masses during the period of old age; and, in this point of view, the statement of Becquerel and Rodier,* that from the 40— 50th year the amount of cholesterin increases in the blood of both sexes is very interesting. The augmentation of this substance in the blood is probably connected with an increased separation of it in the various parts of the body. . A similar increase may, how- ever, take place in young persons in consequence of a morbid process. b. Margarin and margaric acid. These are crystallizable, forming very characteristic shapes, similar in both cases. They form micro- scopic needles which rarely occur alone, but usually in stellar or tuft-like groups.f They are most commonly devoid of colour, but sometimes, when occurring in large masses, appear of a dark brown- ish tint, when viewed by refracted light. The crystals both of margarin and margaric acid are insoluble in water and in acids, but dissolve readily in ether and hot alcohol, and. after prolonged ebul- lition, in the caustic alkalies. Crystals of margaric acid may be distinguished chemically from those of margarin, by the circumstance that the former dissolve when boiled in weak spirit, while the latter require strong alcohol for their solution. The formation of crystals of margarin may be explained in the following manner. Human fat, as it occurs in adipose tissue, con- sists of an admixture of olein and margarin in indefinite and ex- tremely varying proportions. The margarin, which at the ordinary temperature of the body is solid, is held in solution in the fluid olein, which naturally has a greater solvent power at a high than at a low temperature. Now, when this fat at the temperature of the human * Comples rendus, 1844, ii. p. 1083. t Plate x. fig. 3. 310 PATHOLOGICAL EPIGENESES. body is nearly saturated with margarin, it follows, that on cooling, a portion of the margarin separates in the crystalline form. Hence crystals of margarin are chiefly (if not exclusively) found after death, when the body has become cold. When human fat contains only a little margarin, then of course these crystals do not present themselves on cooling. Their occurrence must be regarded as forming the ex- ception rather than the rule. Crystals of margaric acid are most commonly found in gan- grenous parts, and appear to be a product of the decomposition of the margarin of the fat. The actual cause of this decomposition is still unknown, but may probably be traced to the presence of a free acid, which is frequently observed in gangrene. c. Olein at the ordinary temperature of the body is fluid, and separates in drops of all sizes (fat globules,) the larger of which are characterized by the peculiar manner in Which they refract light. They occur partly free in the liquids of the body, and partly enclosed in cells.* These globules are insoluble in water and in acids, but dissolve readily in ether and hot alcohol, and, after prolonged ebul- lition, in potash. The behaviour of oleic acid (a rare constituent of the human body) is precisely similar. It is seldom that these fat- globules consist of pure olein or oleic acid ; they most commonly contain a portion of solid fat in solution. The causes influencing the formation of these fat-globules are not always clear. In general this is the original form of olein— that in which, when it enters the body in large quantity, it proceeds from the food into the chyle. Subsequently, however, it appears to undergo changes, and to enter into combinations by which it passes into a state of solution. These combinations being destroyed, the olein again appears in the form of independent drops. Sometimes the free fat-globules proceed from the destruction of fatty tissue in which fluid fat is enclosed in fat-cells—as, for instance, in gangrene, ln the softening of tumours, and in suppuration occurring in parts abounding in fatty tissue. d. Moreover fat is often separated in a granular state, as fat- granules, to which some have incorrectly applied the term stearin- granules, for stearin in appreciable quantity does not exist in the * See Plate i. fig. 9; Plate m. fig. 16; Plate v. fig. 1, b, fig. 4*; Plate vi. fig. 10 A ; Plate vn. fig. 1 c. PRECIPITATES OF URIC ACID. 311 human body. The fat in this condition usually occurs in mole- cular granules of indefinite form and size, their diameter rarely ex- ceeding the 1000th or 800th. of a line.* These granules are insolu-' ble in water, acids, and cold caustic potash, but dissolve in ether and hot alcohol. Of what fats they consist we are still just as igno- rant as we are regarding the causes leading to their formation and separation. It is possible, and indeed probable, that the serolin of the blood, which is uncrystallizable, and solid at ordinary tempera- tures, takes a share in their formation. In addition to the fats that we have named, it is probable that others are sometimes separated, as, for instance, the fats con- taining phosphorus, and the fatty acids of the nervous system (Fremy's cerebric acid ;) nothing is, however, yet known with'cer- tainty-on these points. 3. Uric acid, and the urates. When uric acid occurs in deposits, we usually find it in the crystalline state. The primary form of its crystals is the rhombic prism, which frequently appears cut down to a tablet, whose principal surfaces are rhombs. The crystals are not unfrequently united in masses with the form of rosettes.f The crystals, which, when perfectly pure, are colourless, often present a reddish tint; they are insoluble in alcohol, ether, and acids ; nearly so in water, and only dissolve slowly in caustic potash. Crystals of uric acid have hitherto only been found in the urine. For the causes giving rise to their formation, we must refer to our observations on urinary calculi. Of the various salts of uric acid, the urate of ammonia demands the fullest consideration. It never occurs in the crystalline form, but always as a finely granular precipitate,^ whose granules are sometimes connected by a tenacious membranous substance. These precipitates are scarcely ever colourless; they present every shade, from a clay or yellowish red tint, to a brownish red or bright rose colour. They are only slightly soluble in cold 'See Nate in. fig. 1 and 7 b ; PU? iv. fig. 1 A; Plate vm. fig. 1, 4 and 6 ; Plate ix. fig. I and 4.' + The most striking forms of uricacid crystals are depicted in Simon's Animal Chemistry, Plate n. fig. 23. X See Simon, op. cit. fig. 28 a. 312 PATHOLOGICAL EPIGENESES. water, but dissolve more readily on the application of heat, and separate again from the hot saturated solution on cooling. They are insoluble in alcohol and ether; acids decompose them, liberating the uric acid—a circumstance which greatly aids their diagnosis under the microscope ; for on adding an excess of acid to a precipitate of this nature under the micro- scope, the granules gradually disappear, and are replaced by rhom- bic tablets of uric acid.* Urate of ammonia existing in the sedi- mentary form has hitherto been found only in the urine : we shall, therefore, postpone our observations on its mode of formation till we speak of urinary Calculi. The urate of soda is likewise found in a separated condition in the human body, occurring in many of the gouty concretions of which we shall presently speak. For certain other sediments which occur solely in the urine (as those of cystin, uric oxide, &c.,) we must refer to our observations on urinary calculi. 4. Salts of lime. The following insoluble calcareous salts are of frequent occurrence as constituents of precipitates in the human organism. a. Oxalate of lime forms octohedric crystals, insoluble in water, alcohol, ether, and acetic acid, but soluble in hydrochloric.acid. They are sometimes so minute that it is impossible to recognize their crystalline form, and they present the character of a granular precipitate. They have hitherto been only observed in the urine. b. Basic phosphate of lime, (8 Ca 0 + 3 P05 according to Berze- lius) forms, when recently precipitated an amorphous, transparent, colourless jelly, scarcely visible under the microscope, but gra- dually becomes converted into an indefinite granular mass. 'It is insoluble in water, ether, alcohol, and alkalies, but dissolves in acids without effervescing. Phosphate of lime forms a common precipitate in nearly every animal fluid. In the normal condition of the body, it is either held in solution by an acid, or forms soluble compounds with certain organic matters, as protein-compounds, gelatin, (?) &c, a * See Simon, op. cit. fig. 28 c. PRECIPITATES OF AMMONIACO-MAGNESIAN PHOSPHATE. 313 class of combinations which have not yet been sufficiently studied. If a compound of this nature is decomposed, and the phosphate of lime meets with nothing to redissolve it, it separates as a pre- cipitate. Whether neutral phosphate of lime occurs as a precipitate in the human organism is unknown. c. Carbonate of lime occurs both as an indefinite granular preci- pitate, and as a crystalline mass. Perfect rhombohedric crystals of this substance have not yet been observed in the human organism, but have been frequently noticed in animals and plants. They are insoluble in water, ether, alcohol and the alkalies, but dissolve with effervescence in acids—reactions which, when observed under the microscope, are sufficiently characteristic. Precipitates of carbonate of lime occur in almost every fluid of the body. How they arise is a purely Conjectural point. Either the salt exists in the animal fluids as bicarbonate, and becomes pre- cipitated when by the abstraction of carbonic acid, it is reduced to the state of the simple carbonate, or calcareous salts soluble in the animal fluids (as the oleate, or lactate of lime, or chloride of cal- cium) on meeting with the free carbonic acid which pervades all the usual juices, become decomposed, and form carbonate of lime. Sulphate of lime is probably an occasional constituent of precipi- tates ; it has, however, not yet been observed. 5. Ammonia co-magnesian phosphate is crystalline ; its form how- ever, varies in accordance with the rapidity with which its crystals are produced. If formed quickly we have stellar groups consisting of acicular crystals, or leafy aggregations presenting a great simi- larity to the indented leaves of the leontodon taraxicum.* The crystals, when slowly produced, have a very characteristic form • their regular appearance being that ofa three-sided prism, in which the angles at the extremities of one margin are truncated by planes passing through the opposite angles at either end. Sometimes other corresponding angles are also truncated, as in fig. 4 b and c of Plate x.f * See Simon, op. cit. fig. 30, where, however, most of the crystals exhibit a more perfect form. t See Plate x. fig. 4 a, or Simon, op. cit. fig. 27. 27 314 PATHOLOGICAL EPIGENESES. It is not easy to explain the causes of the numerous deviations in form, which these crystals present, and to reduce them to their common primary form, which appears to be the rhombic prism.* Crystals of ammoniaco-magnesian phosphate are insoluble in water, alcohol, ether, and alkalies, but dissolve readily, and without effervescence in acetic and the mineral acids. This chemical reac- tion, combined with their characteristic crystalline form, renders their diagnosis sufficiently easy. The former and less decided crystalline form of precipitate, generally speaking, only occurs when ammonia is added to the animal fluids, and a rapid precipitate is thus induced. Precipitates formed naturally within the body appear, as far. as my experience goes, to consist invariably of the latter and more perfect form of crystals. The formation of this precipitate is easily explained : all the fluids of the animal body contain, as a general rule, phosphate of magne- sia, and if ammonia is brought in contact with this salt, crystals of ammoniaco-magnesian phosphate are produced. Hence it is that these crystals are amongst the most common that are met with in the microscopic examination of the human body. In the dead body, in which ammonia is developed as a product of decomposi- tion, all the tissues, as well as all the fluids, are often filled with them. Moreover, on examining under the microscope almost any animal fluid to which ammonia has been added, we observe groups of crystals of the first form. 6. Sulphuret of ironi when it occurs in large patches, appears to the naked eye as a black, dark blue, or blackish-green deposit. Under the microscope We observe it as a granular precipitate, whose granules vary from mere molecules to the 400th of a line in diameter. It is insoluble in water, but dissolves in acids; on treating an acid solution with hydrosulphate of ammonia, a black precipitate is again formed. The manner in which this precipitate is formed has been already (see page 182) explained. 7. Bile-pigment (the cholepyrrhin of Berzelius, the biliphcdn of Simon) appears as a finely-granular precipitate (sparingly inter- spersed with minute microscopic crystals) of a yellowish-brown, * See the description of Plate x. fig. 4. VARIOUS PRECIPITATES. 315 very fiery colour,* insoluble in water and in most acids. Nitric acid changes its colour in a very characteristic manner; first into a green, then into a blue and a red tint, and finally decolorizes it entirely. As a general rule, it only occurs in the bile. We shall return to the subject in our remarks on gall-stones. 8. Silica undoubtedly occurs as a precipitate in the animal fluids, but only in such small quantities that it has not hitherto been detected by the microscope. 9. Precipitates may be formed of substances which are readily soluble in the animal fluids, and are only separated by concentration or evaporation of the liquids in which they are dissolved. To this class belong, in addition to many organic substances, most of the salts with alkaline bases, as chloride of sodium, the phosphates and sulphates of soda and potash, &c. These precipi- tates form amorphous, granular, or crystalline masses, in accordance with their chemical properties and the time occupied in their sepa- ration. They invariably appear, when we examine, under the mi- croscope, fluids which have been exposed to the influence of evapo- ration ; but these are mere artificial products, and do not require to be considered in this place. It would be very desirable if our knowledge of these crystalline forms were more accurate, as it would materially assist us in the chemical examination of the animal fluids. The question now arises : Do such precipitates occur in the living- body in consequence of concentration of the fluids? There are cases in which this certainly appears to occur. Thus, after the in- ternal use of sulphate of magnesia as a purgative, I have observed microscopic crystals of this salt in the liquid evacuations; and pro- bably other purgative salts appear in the faeces in a similar manner. This is, however, a point of little importance in relation to patho- logical anatomy. On the other hand, it has been recently stated by F. Boudet,f that in concretions containing phosphate and carbonate of lime, there is also a large quantity of salts readily soluble in water (chlo- ride of sodium, sulphate and phosphate of soda.) If this is really * See Plate x. fig. 5. t Journal de Pharmacie et de Chimie, Nov. 1844, p. 335, &c. 316 PATHOLOGICAL EPIGENESES. the case, it is a very interesting fact, since it appears extremely re- markable that such salts do not, in a very short time dissolve, and thus disappear in the fluids moistening and surrounding them, which are not saturated, and further, are continuously being modified by endosmosis. Hence I think that Boudet's statement requires further confirmation before it can be regarded as expressing an undoubted fact." These are the substances which have been hitherto regarded as the constituents of the precipitates occurring in the human body. Further investigation will probably lead to a considerable extension of the above list. From these precipitates, which are frequently invisible to the naked eye, and which, to be correctly observed in their various relations, require a microscopic examination, there are formed large concre^ ments or concretions in a manner differing in individual cases, and not always very obvious. The various concretions may be arranged into two large groups :■ 1. Such as arise in the fluid secretions of the body; arid, 2. Such as are formed in the parenchyma of organs. FIRST CLASS. CONCRETIONS IN THE FLUID SECRETIONS. These are invariably formed from the above-mentioned precipi- tates, but the mode of formation varies. They may arise in any or all of the following ways : 1. From an amorphous or crystalline precipitate there may beform- ed a tenacious crystalline mass—a concretion ; the same process taking place on a large scale, as on a smaller scale influences the conversion of an amorphous into a crystalline precipitate. 2. A portion of a loose, disconnected precipitate, may be held together by mucus or some other connecting medium. 3. The precipitate may attach itself to a foreign body in just the same manner as crystals deposit themselves around such a body in- serted in a saline fluid, forming an incrustation. In fact, there are two ways in which a foreign body exerts an influence in the forma- tion of concretion ; one being, that it fuequently excites a disposition CONCRETIONS. 317 in a fluid to form a precipitate. Thus, for instance, by exeiting in- flammatory irritation, it may give rise to the secretion ofa too alka- line state of the serum, or of pus, which on their part produce a precipitation of the earthy phosphates held in solution in an acid fluid, as, for instance, the urine. The other manner in which a foreign body acts, is by its eausing a precipitate which, without it, would have been discharged, to collect around it, and thus form a concretion. Pessaries act in this manner in the vagina; and foreign bodies, in the nasal cavity and intestinal canal. They first be- come encrusted, and ultimately form the nucleus of a concretion. In one of these three ways the nucleus of the concretion becomes formed, and as precipitates are continually being deposited around the nucleus, the concretion gradually increases. The augmentation proceeds either by layers, or in another manner. The mode of in- crease, and the consequent texture of the concretion, depend on the character of the deposits: if they consist of large pieces or crystals, the concrement is uneven and angular; if, on the other hand, the deposit consists of fine granules, it is regularly laminated and smooth. Hence the external form of concretions presents many varieties; generally it is round, but if several are simultaneously present, and they are at all soft, as, for instance, is the case with most gall-stones, their mutual pressure and friction render their form polyhedric. Their shape also depends on that of the organ in which they are formed; if it is a narrow canal, the concretion is elongated, acicular, or sausage-like; if it is of an irregular form, so also is the concretion ; in cavities dividing into branches, as, for instance, in the pelvis of the kidney, the concretions have frequently a ramifying form. These relations are too obvious to require further comment. When these concretions are large, they receive the name of calculi, or stones; when they are minute and numerous, they are termed sand,. or graveL We now proceed to the consideration of the various sorts of con- cretions. 1. URINARY CALCULL To this class belong all concretions whose mother-liquid is the urine. They may be formed in any part of the urinary apparatus; their most common seats of formation are, however, the kidneys andi 27* 318 PATHOLOGICAL EPIGENESES. bladder, and we consequently distinguish renal and vesical calculi. Calculi found in the ureters and the urethra are usually not formed there, but in the kidneys or bladder, and getting into those canals, become impacted there. It has happened, after injury to the urinary organs, that calculi have formed in the adjacent tissues into which there has been infiltration of urine. According to the above terminology we distinguish between urinary calculi, and urinary gravel or sand. Under the latter deno- mination we include the innumerable minute concretions which are so small that they can be discharged through the urethra without pain. Urinary calculi present great differences, not merely in their phy- sical characters—as form, size, hardness, and colour—but also in their chemical constitution and in the relations inducing their forma- tion. They sometimes consist of the same chemical ingredient throughout, sometimes of a mixture of several substances; hence they are simple and compound. We shall first consider those which contain only a single in- gredient.* \. Calculi of uric acid and urates are the most common of all: urinary concretions, but, according to the substances of which they are composed, they present many varieties. Calculi of uric acid are very frequent, and often attain a consider- able size. It is very seldom that the uric acid is perfectly pure, and that the calculi are white ; it is most commonly associated with the colouring matters of the urine, which communicates to such concre- tions a yellow, red, or reddish-brown tint. They are sometimes smooth, sometimes (but more rarely), verrucose, and frequently con- sist of regular lamina?. They almost always contain minute quantities of other ingredients. This species of calculus is very easily recognized by. the charac- teristic reaction of uric acid; on dissolving it in nitric acid, with the aid of a gentle heat, evaporating nearly to dryness, and then adding. * The literature of urinary calculi is very copious. A list of the older writers would occupy too much space. Of the more recent authors we may especially men- tion: Berzelius in his Lehrbuch der Chemie, translated into German by Wohler,vol. ix. 4th Ed. p. 486, &c.; Scharling de Chemicis calculorum rationibus, Havnise, 1839 ; or Dr. Hoskin's English translation, London, 1842; and Taylor's Catalogue of the Calculi in the Royal College of Surgeons, London, URINARY CALCULI. 319 a little ammonia, a very beautiful purple colour is evolved. Be- ginners may easily commit the error of exposing the nitric-acid solu- tion to too powerful a heat, in which case the expected reaction does not occur. This is best avoided by adopting Jacobson's plan of gently warming a minute .portion of the stone—not larger than a mustard-seed—in a watch-glass, with a couple of drops of nitric acid, till by evaporation the solution forms a thick fluid mass; this must now be inverted over a second watch-glass containing a few drops of caustic ammonia. The vapour of the ammonia will saturate the nitric acid, and the red colour will appear. This reaction occurs equally whether the stone consists of pure uric acid or of urates. We now proceed to explain how the latter may be recognized. Calculi consisting entirely, or for the most-part, of urate of am- monia, are rare, and usually small. They are seldom white, being more commonly of a clay or yellowish-red colour. Their surface is smooth, or studded with minute warts; on making a fracture,.they appear earthy or laminated. The first step in the recognition of urate of ammonia is afforded by the characteristic reaction of the uric acid, from which, however, it may be distinguished by the following means: Uric acid is almost insoluble in water, while urate of ammonia dissolves in hot water to a very considerable extent. We, therefore, boil a little of the pulverized calculus in water, and filter the saturated solution while still hot. On cooling, a portion of the dissolved urate of "ammonia separates from the filtered solution as a granular preci- pitate. On treating it under the microscope with a little mineral acid, it gradually disappears, and is replaced by crystals of uric acid. As the other urates, which, however, seldom occur in calculi, ex- hibit the same reaction, we must carry our researches further, in order to be convinced of the presence of urate of ammonia. We must extract the pulverized calculus with cold water, previous to its treatment with boiling water, in order to make sure that it is freed from any ammoniacal constituents of the urine that might be present. The urate taken up by extraction with hot water, may then be shown in two ways to be urate of ammonia. If we burn it, it will be found to be entirely volatile, while the urates with fixed bases leave an incombustible residue; and if we treat it with a weak solution of 320 PATHOLOGICAL EPIGENESES. potash, and apply a gentle warmth, it developes ammonia, which may be detected by the smell, by the white vapour produced on holding over it a glass rod, moistened in hydrochloric acid, or by its communicating a blue tint to red litmus paper placed above it. The other urates—the soda, magnesia, and lime salt's—do not often form the sole constituent of urinary calculi, but sometimes occur in larger, or smaller quantity in calculi of which the principal mass consists of other substances. The means of detecting these salts are similar to those employed for the urate of ammonia. They must first be obtained in a state of purity by extraction with hot water, filtration, and evaporation. On the application of a strong heat, the uric acid is destroyed, and the composition of the residual fixed basis must be determined by the ordinary rules of inorganic chemistry. Causes and mode of formation of these concretions. The ordinary proximate cause leading to the formation of all calculi containing uric acid, is a peculiar condition of the urine—its saturation with urates. The practised physician detects this property of the urine by ob- serving, that on cooling it becomes turbid, and deposits a sediment consisting of urate of ammonia. But, besides this, there is a second condition requisite, namely, that a portion of this excess should be precipitated either as urate of ammonia or as free uric acid, in the urinary passages within the body. In by far the larger number of cases, the precipitate, consists of uric acid, arising from the urate being decomposed by a free acid in the urine ; the uric acid being much less soluble in urine than its salts, the greater portion becomes separated. Whether the urates can separate from the urine, as a primary precipitate within the body, appears to me to be doubtful, since the ordinary cause giving rise to the formation of a sediment of urates __namely, the cooling of the urine—does not occur there. Such a precipitate may, however, be formed if urine, saturated with urates, remains for a long time within the bladder, and loses water in con- sequence of endosmotic action established with the blood. The above conditions do not, however, lead to the formation of a stone, but merely of a precipitate, which frequently consists of such minute granules that they can only be detected by the microscope, and do not form a sediment till the urine has stood for some time. From CALCULI OF URIC ACID. 321 these precipitates there may be formed urinary gravel, if its consti- tuents, in consequence of any of the above-mentioned causes, adhere within the body, and there form larger masses. For the production ofa stone, it is requisite that there should first be a nucleus formed; this may consist of uric acid gravel retained in the urinary passages in consequence of its size or position, or a clot of mucus, blood, or - fibrin, or a foreign body. For the formation of uric acid calculus, it is requisite that the above-mentioned uric acid diathesis should persist for some time, that is to say, that there should be a conti- nuous excess of urates in the urine. The precipitates separated from the urine then deposit themselves by preference, around the nucleus; these precipitates may consist either of uric acid liberated by the presence of a free acid, or of urates, which separate themselves from the saturated urine, in consequence of the presence of a stone. Such are the formative relations of calculi containing uric acid, as far as morbid anatomy has yet taught us. The investigation of the causes inducing this diathesis, fall under the department of general pathology. Chemistry has been directly applied by Liebig and others to its elucida- tion. It, at least point's out the path which the investigator must follow, even if the special results already attained, are not to be regarded as de- cisive. In accordance with these principles, the occurrence of the uric acid diathesis must be explained in the following manner.* It can hardly be doubted that the greater part of the protein-compounds contained in the nutriment and in the constituents of the body, are meta- morphosed into urea and uric acid, and in this form are discharged by the urine, even if we are ignorant of the intermediate links between the pro- tein on the one hand, and the urea and uric acid on the other. This meta- morphosis can only be effected by the addition of oxygen, as may be shown by calculation ; and undoubtedly more oxygen is requisite to con- vert, theoretically, one atom of protein into urea, carbonic acid, and water, than is necessary to form uric acid with carbonic acid and water: for I equiv. protein. . . — C48 H36 N6 014 f 3 equiv, urea. . . = C6 H12 N6 06 is equivalent to< 42 " carbonic acid. . = C42 084 (_24 " water. . . = H24 024 C48 H36 ^6 0114 * See H. Bence Jones on gravel, calculus, and gout, London, 1842; Valentin's Lehrbuch der Physiologie, vol. i. p. 759, &c. 322 PATHOLOGICAL EPIGENESES. Hence in this metamorphosis there are consumed 100 equivalents of oxygen. But if, in place of urea, uric acid is formed, the case is different; 1 equiv. protein yields 3 equiv. uric acid. . . == C15 H6 N6 09 33 " carbonic acid. . = C33 066 30 ". water. . . . _^_______H3o O30 C48 H36 N6 O105 Hence for the conversion of protein into uric acid, there are required only 91 equivalents of oxygen. This explains how a diminished quantity of oxygen may be the cause of the formation, of an extraordinary quantity of uric acid in the body, at the expense of the urea. Extending these considerations to the food, we see how certain forms of diet favour this uric acid diathesis. As in the metamorphosis of protein, the greater part is discharged as urea and uric acid, so it cannot be doubted that many kinds of food devoid of nitrogen, at the termination of their metamor- phoses, are for the most part discharged as carbonic acid and water. More- over, for this purpose a combination with oxygen is necessary, which is supplied to the body by respiration. We may, however, show how different sorts of food require different quantities of oxygen, in order to effect this metamorphosis. Thus 100 parts of starch {== 44.5 C + 6,2 H+49.3 O) require: 118.5 parts of oxygen in order to form (163 C 02 (44.5 C-f118.5 O,) and 55.5 H O (6.2 H-f 49.3 O.) 100 parts of sugar (= 42.2 C-f 6.4 H-f 51.4 O) require: 112.4 parts of oxygen to yield 154.6 C 02 (42.2 C-f-112.4 O,) and 57.8 HO(6.4H+51.4 0.) 100 parts of fat (= 79 C-f-11 H+9 O) require: 289 parts of oxygen to form 289 C 02 (79 C-f-210 O,) and 99 H O (11 H-f 88 0.) 100 parts of alcohol (= 52.2 C-f 13 H+34.8 O) require: 208.4 parts of oxygen to form 191.2 C 02 (52.2 C-f 139 O,) and 117.2 HO (13 H-f 104.2 0.) If under certain conditions of life the quantity of oxygen taken into the body be sufficient to convert into urea, carbonic acid, and water, those constituents of the food which consist especially of starch and sugar, to- gether with the protein compounds, we may easily conceive that in food CALCULI OF URIC ACID. 323 rich in fat, associated with a free use of alcohol, the oxygen is no longer sufficient for the perfect conversion of the protein-compounds into urea, but that, in the place of the latter, uric acid will be formed. Experience also teaches us, that food when of a fatty nature, and the copious use of alcohol, together with an imperfect supply of the oxygen necessary to respiration, favour the uric acid diathesis. At all events, the above obser- vations point out the way which may lead to a true explanation of this formation, although we must not forget that there may possibly be many acting intermediate agents with which we are unacquainted, and that the above statements can therefore only be regarded as hypothetical. 2. Calculi of urous acid {uric or xanthic oxide) are of rare occur- rence, but resemble in every respect, those consisting of uric acid. A stone consisting of this substance, which was examined by Wohler, was externally of a light brown colour, mixed here and there with white ; on making a fracture it exhibited a faint brownish flesh colour, and was found to consist of concentric layers; by fric- tion it acquired a wax-like polish, and was of about the same hard- ness as uric acid calculi. The characteristic chemical reaction of this substance consists in its solubility in nitric acid without effervescence, and on the solution leaving after evaporation a substance of a bright lemon colour, which is not soluble in water, but is changed to a deep reddish yellow by caustic potash. The characteristic purple which uric acid exhibits when acted on by nitric acid and ammonia, is in no way to be com- pared with the above-named substance.* The structural relations of these calculi are unknown, but are most probably the same as those of the uric acid calculi. Thus the same reasons which have been given concerning the formation of the uric acid diathesis, may also explain the origin of this substance, since uric oxide exhibits no difference in its chemical composition from uric acid, excepting that it contains an atom less of oxygen than the latter. It is, therefore, probably formed, instead of urea and uric acid, from a deficiency of oxygen in the metamorphosis of tissues. 3. Calculi of cystin {cystic oxide) are also rare, although less so than those of uric oxide. They are yellowish, ofa smooth surface, and exhibit a crystalline appearance on fracture. The diagnosis of * See Wohler und Lfebig'a Annalen der Pharmacie, vol. xxvi* Part 3. 324 PATHOLOGICAL EPIGENESES. these calculi, and likewise of sediments consisting of cystin, will be most readily determined by the combined application of chemistry and the microscope. Cystin is almost entirely insoluble in water, but dissolves easily in alkalies. If its solution in caustic ammonia be left to evaporate, very well marked crystals—regular hexagonal tablets—appear; they are, in fact, tabular prisms.* But if the cystin be dissolved in a dilute mineral acid, and the solution suf- fered to evaporate at a moderate heat, groups of divergent radiating, acicular crystals appear. Cystin is also characterized by containing a considerable quantity (25.5§) of sulphur. On§ this circumstance is founded a method, proposed by Liebig, for ascertaining the pre- sence of cystin. The calculus is dissolved in a strong alkaline solution, to which are added a few drops of acetate of lead, but no more than can be retained in solution. When this mixture is boiled a black deposit of sulphuret of lead is precipitated, which gives it the appearance of ink. Calculi of cystin appear to be most prevalent in children. Scarcely any thing is known of their formation, relations, or the causes of their origin, although we may conjecture that the sulphur in the protein-compounds has something to do with the formation of cystin. 4. Calculi of oxalate of 'lime are tolerably frequent, and are either moderately large, with a rough surface, jagged, verrucose, and of a dark brownish colour—in which case they are. named, from their peculiar appearance, mulberry calculi—or they are small, more faintly coloured, and smooth, and are then termed hempseed calculi. They may be best known by the following reactions—they are in- soluble in caustic potash, but dissolve without effervescence when boiled in hydrochloric acid. If a portion of the stone is heated be- fore the blow-pipe, and then moistened with a drop of water, it exhibits an alkaline reaction, in consequence of caustic lime having been formed. The solution of the heated mass in Water is preci- pitated by oxalic acid. The causes from which these calculi originate are also in a great measure unknown, although in some cases their origin may be ex- plained by the action of oxalic acid which has been introduced into * See Simon, vp. cit. Plate in. fig. 32. CALCULI OF EARTHY PHOSPHATES. 325 the body by food, &c. Thus, after partaking of food containing oxalic acid, as sorrel, &c, a sediment of oxalate of lime appears in the urine, and a long adherence to a similar diet may give occasion to the formation of these calculL But it is not in every case that their origin can be explained by the oxalic acid taken in the food; and we are hence led to the conjecture that it may be formed in the organism from other substances. Indeed, Liebig and Wohler found in their investigations regarding the products of the decomposition of uric acid, that on treating it with peroxide of lead or with nitric acid, oxalic acid, together with other substances, was formed. And this fact renders it highly probable that oxalic acid may be formed in the organism from other substances; but what these are, and under what condition it is formed, are questions which it is impossible at present to answer. At all events, oxalate of'lime does not exist in the blood, since it could not pass undissolved into the urinary canals. Oxalic acid must either pass into the urine in a free state from the blood, or in some soluble combi- nation, and there unite with the lime, forming an insoluble com- pound. 5. Calculi of earthy phosphates (phosphate of lime and ammo- niaco-magnesian phosphate.) Calculi of phosphate of lime alone are very rare; those consisting only of ammoniaco-magnesian phos- phate less so, while the most frequent present a combination of both salts. These calculi are of a whitish colour, sometimes earthy, chalky, very light and porous ; sometimes laminated, in which case they are usually firmer. Those which especially contain calcareous salts are not easily fusible by the blow-pipe; they become more readily- fusible in proportion as the magnesian salts predominate, when they are termed fusible calculi. They are characterized by dissolving in acids without effervescence, and by being precipitated unchanged from an acid solution by means of ammonia. The following points may serve to decide whether a stone contain more lime or magne- sia :—1. The degree of fusibility before the blow-pipe. 2. If the acid solution of such a stone be saturated with ammonia, and then decomposed by oxalic acid, the lime alone, as oxalate of lime, will be precipitated. If the filtered solution be treated with an excess of ammonia, ammoniaco-magnesian phosphate is precipitated in the previously described crystalline form, and we may then draw 28 326 PATHOLOGICAL EPIGENESES. a comparison between the quantity of magnesian and calcareous salts. The formation of these calculi is clearly explained by the facts we have already laid down. The urine always contains phosphate of lime and phosphate of magnesia. If from any cause it becomes ammoniacal, both salts are precipitated. But if, on the other hand, it contains, an excess of carbonate of potash or of soda, then the phosphate of lime is alone precipitated. As the latter change of the urine occurs much less frequently than the former (only after the continued use of alkaline carbonates, and of vegetable salts which are converted in the organism into carbonates, while carbonate of ammonia very frequently occurs in the urine from the decompo- sition of urea,) and as phosphate of magnesia is generally found in larger quantities in the urine than phosphate of lime, it is easily explained why the magnesian salts should occur more frequently in urinary.calculi than phosphate of lime. As soon, therefore, as con- ditions tending to render the urine continuously alkaline are established, a simple precipitate will probably be converted into a stone ; and in this manner a calculus of this kind may be gradu- ally formed. 6. Differing from the calculi already considered, are those which appear to consist wholly, or partially, of indifferent organic matter (fibrin and other protein-compounds, mucus, &c.) They have hitherto been only seldom observed by Marcet, Morin, A. Cooper, Brugnatelli, and Scharling.) Concretions of this nature are almost entirely consumed before the blow-pipe, and yield an odour of burnt horn ; they are insoluble in acids, but dissolve in alkalies, and ex- hibit no trace of crystallization. They are produced in an entirely different manner from other urinary calculi, their formation resembling that of concretions oc- curring in the parenchyma of organs, which we shall consider presently ; they arise either from vesical mucus, or more frequently from coagula of blood and fibrin which accumulate in the pelvis of the kidney or in the bladder, and subsequently experience fur- ther changes. It is only in rare cases that- we find urinary calculi so simple as we have described them; they generally contain several constitu- ents, not merely those we have named, but also a small quantity of carbonate of lime, carbonate of magnesia, and silica. These are ALTERPJATING CALCULI. 327 often variously associated; sometimes two only occur, sometimes more, sometimes all are found combined in a single stone. Thus there are calculi which consist of a mixture of uric acid and urates; others of uric acid and urates with earthy phosphates; and others, again, which are formed from a combination of oxalate of lime and earthy phosphates. Some calculi have been found to contain uric acid, oxalate of lime, phosphate of lime, urate of ammonia, carbon- ate of lime, and ammoniaco-magnesian phosphate, being thus com- posed of six different substances.* These different constituents are sometimes intimately united, but more frequently disposed in more or less regular layers, so that the same calculus may exhibit dif- ferent chemical 'properties in the different strata, which have evidently arisen at various periods. The relations, and order of deposition of these lamina? differ considerably* in different cases, f Tbe progress of these varying laminae in the same stone may, in most cases, be explained with tolerable satisfaction by the aid of the observations we have already made on the mode of formation of the individual calculi, and throws a new light upon the manner in which these concretions are produced. Thus we have alternating laminae of uric acid and urates, if in a prolonged uric-acid diathesis the urine is occasionally very acid, by which the urates are decom- posed, and uric acid separated ; while at other times, on the con- trary, the excess of acid abates, and urate of ammonia is deposited from the saturated fluid upon the surface of the stone. When the uric acid alternates with the oxalic diathesis, alternating laminae of uric acid or urates and oxalate of lime are formed. The by no means uncommon calculi of uric acid or oxalate of lime with earthy phosphates, arise when the uric-acid or oxalic diathesis periodically abates, and in the interval the urine becomes ammoniacal by the decomposition of urea. This alkaline tendency is further increased by a copious discharge of mucus from the irritation of the stone, and the occasional retention of the urine by the stoppage of the urethra, or the outlet of the bladder. The alternating laminae of uric acid and phosphate of lime in the * Loir, Journ. de Chimie medic. Sept. 1834. t See Berzelius, op. cit. p. 501; Sandifort, Museum anatomicum, vol. in.; Benee Jones in Medico-chirurg. Transactions, 1843,.p. 100, &c. 328 PATHOLOGICAL EPIGENESES. same stone may sometimes be induced by medicines—as the alka- lies—which are given to hinder the enlargement of the uric-acid calculus, but may, in making the urine alkaline, induce an augmen- tation by the deposition of phosphates. The nucleus of urinary calculi is often differently composed from the rest of the body. Crosse* found the nuclei of one hundred stones thus composed : seventy-two consisted of uric acid and urate of ammonia, nine of uric acid and oxalate of lime, fourteen of oxalate of lime, one of carbonate of lime, and two of earthy phos- phates. In other cases the nucleus was found to consist of cystin, of organic matter, coagulated blood, mucus, or some foreign body. Sometimes the stone exhibits a cavity instead of a nucleus in its interior ; in these cases the nucleus was probably formed of mucus, which subsequently dried up. In some rare cases the nucleus has been known to rattle within the stone, which could only be ex- plained by a similar drying of mucus. Sometimes the calculus con- sists of gravel or several minute stones, united together by a cement whieh is occasionally of the same nature as the concretions. The occurrence of urinary calculi depends, as has been before mentioned, upon diet, but also on climate and other local relations, such even as the nature of the soil. The further prosecution of this inquiry, however important it may be to the right knowledge of the origin and mode of treatment of urinary calculi, appertains, more properly speaking, to pathology than to pathological anatomy.f We must accurately distinguish from urinary calculi those con- cretions which are not formed in the urinary system, but in the organs of generation. To these belong concretions of the prostate gland. Prostatic calculi have, for the most part, very characteristic properties, by * On the Formation, Composition, and Extraction of Urinary Calculi, London, 1835; G. O. Rees, an Introduction to the Chemical Analysis of the Blood and Urine, London, 1845. t See Windemuth, de lithiasi endemica, Marburgi, 1842; a work with copious references; and H. Textor,. Versuch uber das Vorkomen der Harnsteine in Ost- franken* Wurzburg. 1843. ALTERNATING CALCULI. 329 which they may be easily recognized ; they are always small, somewhat about the size of a pin's head, and are usually of a brownish, reddish-brown, or yellowish-brown colour. They are crystalline or laminated, and frequently exhibit a polyhedric or facetted surface, like a granule of phosphate of lead fused before' the blow-pipe. Their chemical constituents are phosphate of lime, with a little animal and colouring matter. They are doubtlessly formed by a precipitate of phosphate of lime, but the causes which tend to their formation are not accurately known.* An illustration of the quantitative composition of these concretions is given by an analysis by Lassaigne. It yielded in 100 parts: Basic phosphate of lime. .. . . 84.5 Carbonate of lime. .' . . 0.5 Animal matter (mucus, &c.) . . 15.0 Concretions of similar chemical composition are sometimes found in the vesiculae seminales and the vasa deferentia. They are formed, doubtlessly like prostatic calculi, from the secretion of these glands, when from any cause it contains more calcareous salts than in the normal condition. A precipitate then occurs, which, under- favoura- ble conditions, passes into a concretion. Peschier found in 100 parts of such a concretion-: Phosphate of lime. . . 90 Carbonate of lime. . . 2 Animal matter. . . 10 Similar concretions are found in the female generative-organs, consisting chiefly of earthy phosphates, which are formed in a simi- lar manner as urinary calculi composed of the same substance. Illustrations: A large calculus in the uterus, the nucleus, of which was a part of the tibia of a fowl, (consequently an incrustation,) consisted of phosphate of lime. Another large stone in the uterus consisted of ammo- » For further information regarding prostatic concretions, see Gluge's TJntersuch- ungen, Part I, p. 90; Cruveilhier, Anatomie pathol. liv. 30, pi. i.; Dupuytren bh Meckel's Archiv. vi. 3. 28*; 330 PATHOLOGICAL EPIGENESES. niaco-magnesian phosphate, surrounded by phosphate of lime (Brugna- telli.) A concretion from the vagina of an old woman was of a yellowish white colour, and consisted of phosphate of lime with animal matter mucus?) which remains in flocculi on dissolving the concretion in hydro- chloric acid. (Thomson.)* II. SALIVARY CONCRETIONS. The saliva contains amongst its normal constituents a very small number of those substances which under favourable circumstances, might give occasion to the formation of an insoluble precipitate. These are the insoluble earthy salts (phosphates of lime and magne- sia) whose solution is probably occasioned by an unknown combi- nation with organic substances, and soluble salts of lime, which, under certain conditions, can be converted by chemical decomposi- tion into insoluble carbonate of lime. If the quantity of these con- stituents be abnormally increased, and if at the same time condi- tions occur by which their solution in the saliva is hindered, a preci- pitate occurs. This precipitate is either carried off with the dis- charged saliva as quickly as it is formed, or it remains, accumulates, and unites so as to form larger masses—concretions. Salivary con- cretions are, however, of two kinds, forming salivary calculi, and the tartar of the teeth. Salivary calculi are formed when the precipitate occurs within the salivary glands, and there accumulates (in accordance with the ge- neral la,ws regulating the formation of concretions,) frequently at- taining such a size as to close up the excretory ducts, and prevent their being voided. Salivary calculi are thus continually increasing, by always receiving new precipitates. They occur either in the parenchyma of the salivary glands or in their excretory ducts. They are roundish or oblong concretions, varying from the size of an almond or olive, to that of a pigeon's egg, and are of a whitish colour; they are sometimes definitely laminated, consisting of con- centric layers, sometimes of indistinct laminae; they have a chalky, dead-white appearance, and are usually easily pulverized, but occa- sionally as hard as stone. They sometimes enclose a hard, thick nucleus of a greenish colour. Their principal constituents are * Leop. Gmdin, Chemie. 11. 2, 1372. SALIVARY CONCRETIONS. 331 always calcareous salts, viz., carbonate of lime united with animal matter (mucus, or modified protein.) If the precipitate does not occur in the salivary glands, but is first observed in the buccal cavity, it deposits itself over the whole sur- face of the mouth. Thus, on examining the fur on the tongue, we often find the epithelial cells encrusted with a granular deposition of calcareous salts. But as the epithelial cells of the cavity of the mouth are being constantly abraded, the precipitates cannot of course ac- cumulate to form concretions. It is only to the teeth, (and then from want of cleanliness,) that such an adhesion is possible, and thus we are able to explain the formation of the tartar which is deposited around the base of the gums, the body of the tooth, and between the teeth, exhibiting, when broken off, hardish particles ofa grayish- white colour. The formation of this tartar is probably more depen- dant on an increased quantity of lime in the secretion of the minute glands of the buccal cavity, than on a similar alteration in the saliva. An analysis made by S. Wright* will show how much the quantity of the calcareous salts of the saliva may be increased by morbid processes. The quantity of phosphate of lime which is only 0.6 in 1000 parts of normal saliva was once found to be increased to 14. A.nd in some pre- vious observations of the same author, the saliva was so calcareous that it stiffened to a white chalky mass. The following tables will give an idea of the quantitative composition of salivary calculi. They contained in 100 parts: i 2 3 4 5 6 7 Carbonate of lime 81.3 79.4 80.7 13.9 20 15 2 Phosphate of lime 4.1 5.0 4.2 38.2 75 55 75 Phosphate of magnesia — — — . 5.1 — 1 — Soluble salts 6.2 4.8 5.1 ) — — __ Animal matter 7.1 8.5 8.3 \ 38.1 !• 25 23 Waler and loss 1.3 2.3 1.7 6.3 2 — 100.0 100.0 100.0 101.6 10.0 98 100 1—3. Salivary calculi analyzed by Wright, op. cit. p. 57. 4—v. Bibra. Medicin Correspondenzblatt fiir baierische Aerzte, 1843. No. 47. The stone had a specific gravity of 0.933, contained only * Der Speichel, in Dr. Eckstein's Handbibliothek des Auslandes, Wien. 1844, p. 173. 332 PATHOLOGICAL EPIGENESES. in the nucleus, mucus and albumen. The above analysis ex- plains the composition of the lamina surrounding the nucleus. It contained together with .35£ of organic substances 3.1g fat with traces of soda. 5. Lecanu. This calculus consisted of a hard thick nucleus of a gray- ish colour with a white and easily pulverizable capsule. L. Ome- lin's Chemie, n. 2, 1399. 6. Besson in Gmelin, op. cit. The stone was taken from the Whar- tonian duct ofa woman, aged sixty years; it was roundish, white, pulverizable, and consisted of concentric layers; its specific gravity was 2.30. It contained, besides the above named constituents, 2& peroxide of iron.(?) 7. Golding Bird. Die Harusedimente, Handbibliothek des Auslandes, edited by Dr. Eckstein, p. 93. For further analyses see Berzelius' Chemie, vol. ix. 4th edit. p. 229; John in Meckel's Archiv. vi. 4; Rath im Baumgarten's Zeits. von Chi- rurgen fur Chirurgen, vol. i. Part 2, p. 29, &c. Tartar from the teeth was found to be composed of: Earthy phosphate (lime and magnesia) Carbonate of lime. Mucus (with epithelium?) Ptyalin. Animal matter soluble in hydrochloric acid. Water. ..... ~ 100.0 100 1. Berzelius. 2. Vauquelin and Laugier.* Denist has examined the brown fur of the tongue in cases of deranged digestion, after it had been scraped off with an ivory knife and dried. It then formed a firm, translucent, yellowish gray mass, which contained no crystals. Its chemical composition was as follows: Phosphate of lime. . . . 34.7 Carbonate of lime. . . . 8.7 Altered mucus (epithelium, &c.) . 50.0 Loss. . . . . 6.6 1 2 . 79.0 66 . — .9 . 12.5 13 . . 1.0 — . 7.5 5 . ■ . — 7 100.0 The sordes attached to the teeth of the same person were similarly composed. If, therefore, we, except the fact that the depositions on the * Berrelius, Thierchemie, 4th edit. p. 228. t L. Gmelin, n. 2, 1397. LACHRYMAL CONCRETIONS. 333 tongue must contain many more epithelial cells than the tartar of the teeih, there is a striking resemblance in the chemical composition of both, and it appears clear that they must originate from the same causes. Ac- cording to Mandl, the formation of tartar is in no way connected with the increased quantity of lime in the saliva, but produced by the skeletons of dead infusoria, agreeing in form with those of the vibriones which deposit themselves in viscid matter, and between the teeth, and thus form concre- tions. This view appears to me to be wholly untenable. I certainly have occasionally, but not always found vibriones in large numbers in the fur of the tongue, and in the viscid matter around decayed teeth, &c; they had, however, no calcareous skeletons, while on the other hand, granular precipitates of calcareous salts were to be met with together with these vibriones. If, therefore, the latter play any part in the formation of tartar, it must be a very subordinate one. III. LACHRYMAL CALCULI. These occur under similar circumstances to salivary concretions. Although, in the normal state, tears form a very watery fluid, they contain a small quantity of calcareous salts, which when conside- rably increased by pathological conditions, can give rise to concre- tions. These are either formed in the lachrymal glands, in the eye, the lachrymal ducts, or the lachrymal sac. In the latter concretions, the fatty matter secreted by the meibomian glands occurs as one of the constituent parts. Fourcroy and Vauquelin found in calculi of the lachrymal gland, a preponderance of phosphate of lime. The chemical composition of these concretions is often very complicated, as the following analyses show. These concretions contained in 100 parts: Phosphate of lime. Carbonate of lime. Carbonate of magnesia. Peroxide of iron. Chloride of sodium with soluble earthy matter Mucus. .... Albuminous matter. Fat. .... Water. 1 2 . 47.3 9 .' 8.4 48 1.1 — . 0.9 — r. 5.9 Traces. . 20.3 18 — 25 . 11.9 Traces. . 3.0 — 98.8 100 334 PATHOLOGICAL EPIGENESES. 1. A concretion formed in the eye of a blind man, and examined and analyzed by Wurzer, (Berzelius, Thierchemie, p. 722.) Yet it seems questionable tome whether this concretion can be reckoned as appertaining to lachrymal calculi. The fat was probably a pro- duct of the secretion of meibomian glands. 2. A lachrymal concretion found by Desmarres in the lachrymal duct and sac, weighed about six grains, and had a specific gravity of 1.4 : analyzed by Bouchardat, (Annales d'oculistique, A out, 1842.) Other cases may be found in Walther's Journal der Chirurgie, 1820, p. 164 ; Sandifort's Observat. anat. Patholog. vol. hi. p. 71, where many older cases are referred to. 4. Concretions in the nostrils, the throat, the tonsils, and the bronchi, originate in the same manner as salivary calculi, and have a similar chemical composition. Such concretions sometimes occur as incrustations around foreign bo- dies. Ruysch relates* that an amber bead which had accidentally lodged in the nose ofa child of five years of age, and was not expelled until the girl attained her fourteenth year, was surrounded by a stony crust. The same authority gives another case, where the same thing occurred with a cherry stone. Grandoni describedf a stony concretion, which had formed in the left nostril of a woman, and was extracted with the forceps. It weighed seventy-six grains, and contained phosphate and Carbonate of lime, carbonate of magnesia, and organic matter with traces of iron. Two other forms Of concretions had the following composition : Phosphate of lime. Carbonate of lime. Carbonate of magnesia. Chloride of sodium and other soluble salts. Animal matter. Water. 100.0 100.00 1. A concretion from the nose, which had occasioned a periodical hemicrania; it was of a yellow-grayish colour, and earthy: ana- lyzed by Geiger. The animal matters were noted as mucus, fibrin, osmazome and fat, (L. Gmelin, u. 2, 1397.) 1 2 46.7 79.56 21.7 6.41 8.3 — Traces 0.58 23.3 4.52 — 8.93 * Observat. anatomico-chirurg. centuria. Observ. 45. t Omodei annali universali di medicina. Ottobre, 1839. GALL-STONES. 335 2. A concretion from the nose of a woman aged seventy years: ana- lyzed by Brandes, (Berzelius, vol. ix. p. 722.) A concretion from the tonsils analyzed by Laugier, was greyish-white, rather hard, verrucose, and consisted of a rough crust, and a white nu- cleus. It contained : Phosphate of lime. . . 50.0 Carbonate of lime. . . 12.5 Mucus. . . . . 12.5 Water. . 25.0 100.0 V. PANCREATIC CALCULI. These are of rare occurrence, but appear to be occasionally formed from the pancreatic fluid, in the same manner as salivary and lachrymal calculi are formed from their corresponding secre- tions, and they resemble these latter in their chemical composition. Golding Bird has examined a pancreatic calculus which contained in 100 parts: Phosphate of lime. . . 80 Carbonate of lime. . .3 Animal matter. . . 7 90 (Die Harnsedimente, Handbibliothek des Auslandes, edited by Dr. Eckstein, p. 93.) Plates of pancreatic calculi are given in Baillie's engravings, fasc. 5, Plate vn. p. 117. VI. GALL-STONES. Under this terra are included all concretions which are precipi- tated from the bile. They appear in all parts of the biliary appa- ratus, but most frequently in the gall-bladder, rarely in the biliary ducts of the liver, in the ductus hepaticus, cysticus or choledochus, and in the intestinal canal. Gall-stones exhibit great differences in their chemical composition, and vary in a corresponding manner in their physical properties. Their chemical constituents are as follows: 1. Cholesterin, which may easily be recognized by the rhombic 336 PATHOLOGICAL EPIGENESES. tablets, in which it separates from a solution of the gall-stone in hot alcohol. 2. Bile pigment (cholepyrrhin of Berzelius, biliphsein of Simon,) has a fiery, brownish-red colour, and is easily known by its reaction with nitric acid, which changes its colour first to green, then to blue? violet, and red; the mixture lastly becoming colourless. It dis- solves in boiling potash, producing a greenish-brown solution. Several modifications of this pigment occur which do not exhibit the characteristic reaction with nitric acid ; as for instance, 3. A dark brown almost black pigment. 4. Other constituents of bile, as choleic acid, choleate of soda, and their modifications, bilifellinic acid, dyslysin, &c. 5. Mucus and epithelium of the gall-bladder and the biliary ducts. 6. Earthy salts, namely, carbonate of lime. 7. Margarin and the margarates. These constituents enter in different relations into the composi- tion of gall-stones. They are seldom all found united in one stone, and those which are composite are generally blended equally, or one constituent predominates over the others. Cholesterin is usually the preponderating substance; cholepyrrhin rarely; in some few gall- stones the black pigment occurs in the largest quantity ; while car- bonate of lime is rarely thus met with. It is only in very few cases that gall-stones consist principally of inspissated bile. Gall-stones likewise vary in their physical characters. As in uri- nary calculi, so also here, they may present every transition, from a minute precipitate visible only by the microscope, to concretions of considerable magnitude. Hence we may distinguish between biliary deposits, biliary gravel, and gallstones, which may be either consistent, or soft and doughy. The forms of these concretions are likewise, variable ; sometimes they occur as soft, amorphous masses; some- times they have a distinct and well-marked shape. When occur- ring singly they are round; when several are present, they assume a polyhedric form. There are two kinds of gall-stones which possess very character- istic forms—those consisting of crystallized carbonate, of lime, which are pointed and jagged ; and those formed of dark pigment, which usually present a nodulated appearance, like mulberry-calculi. The GALL-STONES. 337 colour of gall-stones depends on their chemical constituents, and is hence by no means constant. The following may be regarded as the principal forms of biliary concretions, arranged according to their physical character : 1. Fine precipitates of bile-pigment and crystallized cholesterin imbedded in mucus," mixed with epithelium whose cells are some- times incrusted. 2. Biliary gravel—minute concretions of the size ofa hempseed, or grain of sand ; occasionally many such concretions are united by mucus so as to form a large mulberry-shaped calculus. 3. Soft biliary concretions, which in a recent state readily admit of being moulded between the fingers, consisting of crystalline depo- sitions of cholesterin, between which there is bile-pigment.* 4. Crystalline calculi consisting for the most part of cholesterin, nearly colourless, transparent, with a crystalline fibrous fracture, gra- nular on the surface, and usually covered with minute crystals of cholesterin. . 5. Dark calculi of a reddish-brown colour, and earthy fracture which does not become bright by friction. These consist for the most part of bile-pigment. There is a variety of this species, which is of a dark-brown almost black colour, and exhibits a red, mulberry-like appearance. These calculi seem to consist of a peculiar modification of bile-pigment.f 6. Calculi consisting for the most part of carbonate of lime : they are crystalline, with rough surfaces terminating in sharp angles, of a clear or sometimes rather brown colour.| 7. Gall-stones of whitish colour, saponaceous feeling, and con- centric laminated arrangement, which on scraping assume a polished appearance, and consist for the most part of cholesterin. 8. Gall-stones consisting of alternate white layers of cholesterin, and dark yellow layers of bile-pigment. The two last kinds are by far the most common. Gall-stones frequently exhibit a nucleus differing from the remain- der of the mass, and consisting for the most part of mucous and * See Plate x. fig 5. t See Simon's Beitrage zur physiolog. u. pathol. Chemie, Part 1; p. 117, with a plate; Scherer's Untersuchungen, p. 105. X Bouisson, de la Bile, 1843, p. 220, Hate n. fig. 2. 29 338 PATHOLOGICAL EPIGENESES. epithelium coloured by bile-pigment: this, while the stone is fresh, is soft; but, on drying, shrivels up, and gives rise to a central ca- vity. Sometimes the nucleus consists of foreign body—as a worm, or a portion of a needle.* The nucleus does not invariably lie in the middle of the stone, showing that the growth of the concretion has not been uniform ; this is especially observed in calculi sacculated in a diverticulum of the gall-bladder. A gall-stone has sometimes more than one nu- cleus, namely, when several originally distinct concetions unite with, and become fused into one another. The following analyses may serve to give an idea of the varying- che- mical composition of gall-stones. I 2 3 4 5 6 Cholesterin 96 65 67 50 4 __ Bile-pigment Mucus z) 25 -I 35") 89 — Biliary matter 3 17 -J — Calcareous salts — 2 — 8 3 100? 99 95 84 93 96 These analyses made by various chemists are nearly all to be found in L. Gmelin's Chemistry, ii. 2, p. 1431. I have somewhat modified them in order that they might admit of better comparison with each other, the biliary matter (choleic acid and its modifications) being determined ac- cording to the different Views maintained by the different chemists. Whe- ther the lithofellinic acid detected by Gb'bel, Wb'hler, &c, in certain intes- tinal concretions of unknown origin, ever occurs in human gall-stones, as some have conjectured, cannot as yet be determined with certainty; it is however, improbable. Scherer has submitted to ultimate analysis, the black pigment which occurs in many gall-stones; but in the absence of an analysis of healthy bile-pigment, we have no means of ascertaining its deviation from the normal standard. The formation of gall-stones follows the same laws as those of concretions generally. In order that a gall-stone may be produced, it is first necessary that a precipitate should be formed, and that this should not be dis- charged with the bile, but remain and accumulate into a larger mass; * Bouisson, op. cit. p. 215. GALL-STONES. 339 in this manner a nucleus is formed, which, under favourable condi- tions, becomes augmented by further depositions. In order that these depositions may take place, it is necessary that: 1. The bile should be in a state of concentration, which occurs when it has been retained for along time in the biliary ducts or in the gall-bladder. By prolonged contact with a denser fluid—the blood—water is removed from it by the laws of endosmosis, and those substances become deposited from it which are the most diffi- cult of solution—as the cholesterin, the bile-pigment, the salts of the fatty acids, and also the choleate of soda ; the last named substance is, however^ very rarely separated, for it is only very seldom that we find it in any quantity in biliary calculi. Probably it undergoes decomposition even in the biliary passages, since by an acid it is converted into felinic and cholinic acids, and dyslysin—substances which probably exist in considerable quantity in many gall-stones. However, further experiments are required on this subject. 2. In most cases in which gall-stones are formed, the bile is pro- bably more abundant in certain constituents—as for instance, cho- lesterin—than in the normal state. It is true, that such a peculiarity has never yet been detected by chemical analysis, but an augmenta- tion of the cholesterin in the bile, is in the highesfdegree probable, since it is known that in advanced age, it increases to a considera- ble degree in the blood. Moreover, an augmentation of bile-pig- ment appears to occur, and to give rise to its deposition. In those rare cases in which gall-stones consist entirely, or for the most part of carbonate and phosphate of lime, the amount of calcareous salts in the bile is probably increased. Moreover, an increased secretion of mucus in'the biliary apparatus, appears to take part in the forma- tion of gall-stones, since it acts as a connecting medium between other precipitated matters, and consequently prevents their being discharged: moreover mucus forms the most common nucleus of gall- stones. There are also certain mechanical relations which influence the formation of these concretions; as, for instance, diverticula of the gall-bladder or ducts, which receive and retain precipitates or fo- reign bodies forming nuclei around which precipitates can be depo- sited. The concentration of the bile caused by its retention appears, however, in most cases to be the most efficient agent, even when the other causes are also in operation. It is probably also the rea- 340 PATHOLOGICAL EPIGENESES. son why gall-stones are mostly composed of biliary mucus. If a gall- stone is once formed, its further enlargement follows very easily, since the biliary constituents which are most difficult of solution—es- pecially the cholesterin if it be present in tolerable quantity—become deposited on it. Although the preceding observations tend in some measure to elucidate the mode of formation of gall-stones in general, yet it is hardly possible in a given case to explain all the causes in- fluencing the development from the first commencement, till it be- comes a perfect calculus. The literature of this subject is very abundant. We must especially notice the treatise of Bouisson de la bile, pp. 176^—252, in which are con- tained an immense number of references to the older writers. See also J. F. Meckel, Path. Anat. n. 2, p. 455, and Sdmmering, de concrementis biliariis, Francft, 1795. We must likewise refer the reader to the chapter on the morbid ana- tomy of the liver and biliary apparatus, in the second volume. VII. INTESTINAL CONCRETIONS. Concretions are not often formed in the human intestinal cana., being much rarer than those hitherto considered. We meet with them after death in any part of the digestive tube, between the stomach and the rectum, or they are removed by vomiting, or with the faeces. There are two distinct kinds to be considered : 1. Concretions formed in the intestinal canal itself, from its own contents—-true intestinal concretions. 2. Concretions formed in other parts, and which find their way into the intestinal canal. In the latter class belong all gall-stones, which getting into the duodenum are discharged by vomiting or by the rectum, or are oc- casionally found in the intestinal canal after death. They may be easily recognized by the characteristic properties of gall-stones. That actual gall-stones consisting of biliary constituents are prima- rily formed in the intestinal canal, is not improbable, although the individual constituents of the bile (modified bilin, dyslysin, &c.) are not rare in true intestinal calculi. Moreover, it occasionally seems to happen that true gall-stones, when retained for some time in the INTESTINAL CONCRETIONS. 341 intestinal canal, serve as nuclei for other -depositions, and then be- come converted into true intestinal concretions. Pancreatic calculi may also, in some few cases, escape through the orifice of the duct, and may be readily mistaken for true intestinal concretions, the chemical composition of both being very similar. Moreover, we must not mistake for true intestinal concretions the hard matter which has been observed by Gurlt, as forming in the mucous glands of the duodenum. True intestinal calculi exhibit great differences in their characters, their chemical composition, and in their mode of formation. They ar- range themselves in certain groups between which there is no very distinct line of demarcation. 1. Many intestinal calculi are formed in precisely the same man- ner as concretions in the parenchyma of organs, of which we shall speak presently. Their formation is due to an exudation of fibrin, or a coagulum of blood retained in the intestinal canal, ands un~ dergoing further changes, the constituents soluble in the intestinal fluid being gradually removed and merely the insoluble portion— the calcareous salts—remaining. Such calculi consist for the most part of protein-compounds—coagulated fibrin—mixed with salts of lime and fragments of food ; they are formed after inflammatory ex- udation of the intestinal mucous membrane, and after haemorrhage into the canal. To this class belong the concretions which were analysed by Dublanc They were discharged by a child after inflammation of the bowels, and formed irregularly shaped, smooth, yellow, hard, transparent pieces de- void of taste or smell. They consisted of fibrin with a trace of fat and phosphate of lime. Two concretions of a similar nature analysed by Davy, yielded in 100 parts : 12 Fibrin. # . . . 78 74 Salts. . . . . 21 7 Other constituents (pigment, . resin, faecal matter, &c.) .5 19 104 100 Sometimes these calculi contain a foreign body as a nucleus, as for in- siance, a plum or cherry stone, which in consequence of the inflamma- 29" 342 PATHOLOGICAL EPIGENESES. tary irritation it excites in the intestinal canal, becomes surrounded with fibrinous deposits. These intestinal concretions may be known by their insolubility in water, spirit, and dilute acids, which last only dissolve the salts of lime ; they are partially soluble in a solution of potash. When boiled in con- centrated hydrochloric acid, they for the most part or entirely dissolve, forming a lilac-coloured solution. 2. A second kind of intestinal concretion consists principally of earthy salts (phoshate and carbonate of lime, ammoniaco-magnesian phosphate, and phosphate of magnesia.) These either form the en- tire concretion, or are mixed with fragments of food, namely vege- table fibres. They frequently contain a foreign body as a nucleus. These concretions correspond in all respects with the salivary arid lachrymal calculi already described, and are formed in a similar manner, namely by the earthy salts dissolved in the contents of the intestine becoming from any reason insoluble and being precipitated. Such precipitates are usually thrown off from the system, and we frequently meet with them in the intestinal excretions. The liquid evacuations of persons suffering from diarrhoea, almost invariably contain precipitates consisting of ammoniaco-magnesian phosphate, and phosphate of lime. If these precipitates are retained, and become connected together by intestinalmucus, or deposit themselves around a foreign body, they give rise to the formation of a concretion. Calculi of this sort are most frequently'found in diverticula, as for instance, in the ap- pendix, vermiformis of the caBcum. The salts forming these calculi seem to rise from two sources— partly from the food which contains salts of lime and magnesia, and partly from the intestinal fluid itself, which, like the tears, saliva, and other animal fluids, under certain conditions of which we are ignorant, contains an excess of earthy salts. -The earthy salts con- tained in the food are dissolved by tb,e acid gastric juice, and if they are not previously resorbed, are again precipitated, when the chyle is neutralized in a lower portion of the canal by the alkaline intesti- nal fluid. About three years ago I found a concretion of this nature in the ap- pendix vermiformis of a phthisical patient. It had the thickness of a oose-quill, was about an inch in length, and perfectly filled the culdesac INTESTINAL CONCRETIONS. 343 of this intestinal diverticulum. It was of a whitish yellow colour; in- ternally it presented a crumbling appearance, while the external portion was composed of thin, concentric layers. It was easily reduced to the form of a white powder, which under the microscope presented an in- definitely granular appearance, and dissolved in hydrochloric acid with con- siderable evolution of gas. It consisted of carbonate and phosphate of lime with a little magnesia. Two concretions of this nature—the former analysed by Thomson, and the latter by Davy-^-contained in 100 parts: Phosphate of lime, Ammoniaco-magnesian phosphate. Animal matter (fibrin ?). Vegetable fibrin, resin, &c. 100 98 Sometimes, as has been already mentioned, calculi of this nature form around a foreign body as a nucleus. Children has analysed concretions from the large intestine of a man who had swallowed plum-stones. They were formed of the stones surrounded by a clear brown, smooth, firm mass, consisting of alternate concentric layers of earthy phosphates and fibrous matter (the vegetable fibres derived from the food.) The outer portion consisted of: Animal matter soluble in water, with traces of soluble calcareous salts. . Phosphate of lime. . Ammoniaco-magnesian phosphate. Woody-fibre. Resin (modified bile?) 100 If the amount of fibrin be increased, these concretions merge into tlie first class ; if the amount of vegetable matter (remnants of food) be large, they become almost identical with the third class. They are soluble for the most part in acids, which take up their earthy salts. The residue ia best examined by the microscope which sometimes enables us to deter- mine the nature and origin of the concretion. Many intestinal concretions consist for the most part of undigested fragments of food, vegetable cells, &c. They frequently exhibit a 1 2 ' 4H 56 . 5$ . 25 42 . 24 — 25 46 5 20 4 344 PATHOLOGICAL EPIGENESES. woody appearance^ and generally have a foreign body as their nucleus. The following seems to be the mode of their formation: Many portions of our food are absolutely indigestible, as, for in- stance, hair, epidermis, all the woody parts of the vegetables in general use, the shells and husks of fruit, &c. These cannot be digest- ed, but pass through the system unchanged. It can scarcely be doubt- ed that from these cells, united by a viscid connecting medium, woody concretions may take their origin. But we are ignorant of the conditions necessary for the production of this rare form of con- cretion. Probably in this, as in most other concretions-of this na- ture, the presence of a diverticulum or a coarctation of the intestine is necessary to retain these masses, and thus to allow of the gradual formation of a concretion. Laugier has analysed a concretion of this nature taken from the rectum of a man. It Contained as a nucleus, a piece of bone, and was surrounded by interwoven vegetable fibres, from which water extracted 14§ of animal matter, with a stercoraceous odour, together with some muriate of am- monia, and chloride of calcium. In a man aged forty-one years, wfio always lived regularly, but subsisted chiefly on vegetables, oat and barley- meal, and pulse, there were formed a large number of intestinal concre- tions, which after causing much pain were discharged by the anus. They had a smooth surface, were brown, and was formed of concentric laminae; in the centre there, was a nucleus resembling dried blood, which was sur- rounded by a thin layer of carbonate of lime. The analysis of these concretions yielded albumen, faecal matter, fat, soluble vegetable matters and salts, silica, phosphate of lime (20£) and fibrous matter (36§) consisting Of undigested remains of oat grains.* An intestinal concretion which had formed around a cherry-stone, consisted chiefly of the colouring principle of rhubarb, together with phosphate of lime and ammoniaco-magnesian phosphate.f Intestinal concretions of this class naturally exhibit very different phy- sical and chemical characters, according to the nature of their predomi- nating ingredient. The best method of ascertaining their nature is by a microscopic examination of the residue left after successive extractions with water, acids and alkalies. * London and Edinburgh Monthly Journal of Medical Science, vol. i. p. 630. t Valentin's Repertor. 1^37, p. lie. INTESTINAL CONCRETIONS. 345 Lassaigne. Robiquet. 74 60 21 8 4 30 1 — 4. Other concretions consist for the most part of fatty matters, with which a little fibrin and salts of lime are usually combined. They must not be confounded with gall-stones consisting of choles- terin. We know less of the mode of formation of this class of con- cretions than of any of the preceding.* It must remain still undecided whether they derive their fat directly from the food, or whether they obtain it from the secretion of the intestinal canal and the fflands D connected with it. In all probability they may obtain it from both sources, but, I conceive, more frequently from the former than the latter. In order to give an idea of the chemical composition of these concre- tions, I will give two analyses, one made by Lassaigne and the other by Robiquet. Fatty matters. Animal matter. Phosphate of lime. Chloride of sodium. . 100 98 The concrements analysed by Lassaigne were discharged from the bowels of. a phthisical girl. They were passed in great numbers, varied from the size of a pea to that of a musket-ball, were laterally compressed and smooth; externally they were ofa yellow colour, internally they were white and granular; and they could be easily pulverized. The fat ap- peared for the most part to consist of the fatty acids (oleic and stearic (?) acids;) the animal matter resembled fibrin, and was undoubtedly a protein- compound. In Robiquet's case, the fat resembled spermaceti; no par- ticulars are given of the animal matter. Caveritou has likewise analysed fatty intestinal concretions, which were surrounded with a coriaceous membrane. Such concretions may be recognized by their being for the most part soluble in boiling alcohol, and by the fat not separating, as the solution cools and evaporates, in the tablets which indicate cholesterin. They fuse when heated, and burn with a clear, but carbonaceous flame. Some concrements which have been regarded as intestinal calculi probably owe their origin to some other source. . This is not merely the case with biliary and pancreatic calculi, but with certain others. Thus Brugnatelli analysed concretions which were stated to be 346 PATHOLOGICAL EPIGENESES. passed from the rectum of a woman, and which were composed of urate of ammonia with a little phosphate of lime, and a tolerably volatilizable animal matter of a not unpleasant odour. That intestinal concretions should have urate of ammonia for their principal consti- tuent, is so improbable, that we must be allowed to suspect that there must be some error. I believe that this concretion was either not discharged from the rectum, but from the urinary passages or the vagina; or else that in this person there was a communication be- tween some of the urinary organs and the rectum, through which the urine passed, in which case there would be no great difficulty in accounting for the presence of a concretion of urate of ammonia in the latter organ. The literature referring to intestinal concretions is very scattered. Most of the illustrations which Ihave given, may be found in Berzelius' Thier- chemie, p. 355, and L. Gmelin, u. 2, p. 1446, &c. In the article "Entero- lithen," by Jaeger,* the reader will find a full and very excellent account of intestinal ctncretions in man and animals, together with a copious biblio- graphy : a Memoir by Meckel on the concretions in the human intestinal canal, and published in the first volume of his Archiv. may also be con- sulted with advantage. VIII. CONCRETIONS IN THE CUTANEOUS GLANDS. Nearly all the glands of the human body seem capable, through a change of their secretions, of giving rise to the formation of con- cretions, and the minute cutaneous glands, although very rarely affected in this manner, form no exception to this rule. The ana- tomical relations of the concretions occurring in these glands are still imperfectly known; however, it is probable that they occur not merely in the sebaceous glands—both those that are free, and those accompanied by hair, forming hair-glands—but also in the sudaminous glands with spiral ducts. Two kinds of these concretions may be distinguished, which are, however, associated together, and may pass one into the other. If the normal or slightly changed secretion is retained in the gland by the stoppage of the duct, or for any other reason, it thickens and * Encyclop, Worterbuch der medicinischen Wissenschaften, Berlin, 1834. vol. n. p. 172—204. CONCRETIONS IN THE CUTANEOUS GLANDS. 347 forms a concretion. In this case the concretion consists principally of those substances which constitute the normal secretion, namely fats and fatty acids, epithelium, extractive matter, and a certain amount of salts. If the salts predominate, the concretion belongs to the second class. These concretions occur for the most part in tbe sebaceous glands: they are essentially identical with the false encysted tumours formerly described, which are formed by an accumulation of the secretion in an occluded gland, and are distinguishable from them onfy by their more solid contents. ^ 2. The secretion of the gland may deviate from the healthy standard, and contain an excess of earthy salts; in this case preci- pitates will be formed which, on drying, will be gradually converted into stony concretions^ The following may serve as illustrations of concretions in the cutaneous glands. A concretion of the former sort, analysed by Fr. von Esenbeck * consisted ofa soft mass, which when dried by exposure to the a'ir, formed a yellowish white powder. On triturating it with water, a milky liquid was produced which, after standing for several days, did not putrify, and which did not coagulate on boiling, but was precipitated by acids, corrosive sublimate, and infusion of galls. It consisted of: Solid fat. ..... 24.2 Alcohol-extract with a trace of oil. . .12.6 Water-extract. . . . .11.6 . Albumen (cells?). .... 24.2 Carbonate of lime. . . .2.1 Phosphate of lime. .... 20.0 Carbonate of magnesia. . . .1.6 A trace of acetate and hydrochlorate of soda, and loss. . . , . .3.7 100.0 A concretion of the second kind formed in the scrotum, and analysed by myself, is described in the explanation of Plate x. fig. 2. It consisted chiefly of calcareous salts. In these two cases, although it was not strictly proved that the concre- tions actually had their- seat in the cutaneous glands, and not in the adja- cent parenchyma of the skin, yet the former is the more probable. * L. Gmelin, ii.;2, 1397. 348 PATHOLOGICAL EPIGENESES. With the concretions already considered, we must associate others in which the organs yielding the secretions from which the concrements are formed are themselves morbid epigeneses. To this class belong the ossified encysted tumours mentioned in p. 234, where the epidermic or epithelial cells, which invest their walls or fill their interior, become incrusted by the deposition of calcareous salts, and, adhering together, form a concretion; and the cases in which cholesterin occurs in solid masses as a cholesteatoma. More- over, the reported ossifications of many entozoa—of hydatids, the trichina spiralis, &c, of which we shall speak presently—belong to this category. SEC OND CLASS. CONCRETIONS IN THE PARENCHYMA OF ORGANS. Concretions not only occur in the glands and their excretory pas- sages, but frequently also in the parenchyma of organs. These con- cretions are generally formed in accordance with the same princi- ples and in the same manner as those already considered, but they do not exhibit so great a diversity, since the mother-liquids from which they are formed almost always present the same, or very similar chemical properties. Their physicarproperties exhibit great variations. When they occur in small quantity, they form extremely fine precipitates, which are generally only visible through the microscope, and appear as incrustations of foreign bodies or of organized tissues ; collected in larger masses, they form more or less isolated, and more or less solid portions—cretaceous masses, stones; or they become as it were, fused into the organized por- tions, and form the so-called ossifications. All these distinctions and terms are, however, very indefinite, since they are only based on external, and for the most part, fortuitous and unessential cha- racters. The manner in which these concretions are formed be- ing different in individual cases, it. is not easy to deduce any general law on the subject; however, in most cases, the fol- lowing remarks will be found to approximate tolerably closely to the truth. All the vascular tissues of the body are infiltrated by a fluid which proceeding from the vessels, and consequently from the CONCRETIONS IN THE PARENCHYMA. 349 blood, is being continuously renewed, since a portion is being continuously removed by the lymphatics, and further, because it is subjected to a continuous metamorphosis of its constituents by endosmosis with the contents of the vessels. To this fluid we may apply the term general nutrient fluid, although it is not always the same, but exhibits many differences, not only in different parts of the body, but also in the same part at different times. In gene- ral this fluid resembles the liquor sanguinis, and its changes are principally only qualitative. Some of its constituents under certain conditions become insoluble, and separate as precipitates; these most commonly are the earthy salts—the phosphate and carbonate of lime, ammoniaco-magnesian phosphate, carbonate of magnesia, and silica ; more rarely, the salts soluble in water—chloride of sodium, phosphate and sulphate of soda, and sulphate of lime; fats—as for in- stance, cholesterin, and very rarely, some other salts of difficult solu- bility in water—as Urate of soda. The conditions which must be ful- filled in order to give rise to the separation of these substances from the general nutrient fluid, are identical with those already described in our remarks on the individual precipitates. It is, however, very difficult in individual cases, to recognize the acting causes. One frequent cause is an extraordinary relative augmentation of certain substances in the blood, as when concretions are formed not only at isolated spots, but in considerable number, and over a great part of the system, as, for instance, in the extensive ossification of the arteries, so commonly observed in aged persons. In such cases we can easily trace the formation of concretions to a general dispo- sition or diathesis. Depositions of this nature form precipitates, or incrustations, or (where they occur in large masses) ossifications; we use the word in the popular sense, and mean only to imply that organ- ized tissues become surrounded, enclosed, and thus, in a manner, petrified: it is very rarely that they form isolated calculi. They may occur in all vascular organs of the body, and in morbid fluids, as for instance, pus. For the special relations of these concretions in individual organs, we must refer to the second volume. In the present place we shall only give one or two illustrations by way of showing how their chemical com- position varies in different cases. 30 350 PATHOLOGICAL EPIGENESES. Thus twelve concretions found in "pus taken from the pleural sac of a man aged sixty-six years yielded :* Phosphate of lime. Carbonate of lime. Insoluble mucus (modified protein Fat. . . . Soluble salts. 49.1 21.1 27.8 1.8 0.2 100.0 In this case the concretions lay perfectly free in the fluid, and were only united by a mucoid mass. Examples of incrustations of this kind are very frequent. To this class belong the depositions which are not unfrequently met with in the choroid plexus of the brain, consisting of round microscopic cells, coated with phosphate and carbonate of lime.f When occurring in large masses, these incrustations resemble ossifications in the cellular tissue, the muscles, the biliary ducts, and especially in the heart and arteries. The following examples will serve to give an idea of their chemical com- position : Areolar tissue yielding gelatin on boiling. Carbonate of lime..... Phosphate of lime. .... Ammoniaco-magnesian phosphate. 1 2 3 68 26 — 8 23 a trace 24 51 80 — —- 20 100 100 100 1. Concrement in the muscles of the thigh of a man, analyzed by Las- saigne, (L. Gmelin, n. 2, 1367.) 2. Annular ossification of the tricuspid valve, (Walchner, ditto.) 3. Pulmonary concretion analyzed by Henry, (L. Gmelin, ii. 2, 1370.) In the above cases the earthy salts predominate : whether there exist concretions in which, as Boiidet supposes, the soluble (namely the soda) salts form the principal ingredient, must still remain questionable. There are still two kinds of concretions occurring in the parenchyma of organs, presenting distinct chemical characters:* 1. The depositions of cholesterin which are of tolerably frequent occur- * Prus—Valentin's Repertorium, 1837, p. 118. t Henle's Allgem. Anatomie, p. 10. CONCRETIONS IN THE PARENCHYMA. . 351 rence in the arterial tissue of aged persons.* The diagnosis of these depositions are very easy, being based on their seat (the arterial walls) and on the well-known microscopical and chemical characters of cho- lesterin. Their formation is probably dependant on a great excess of cholesterin and serolin in the blood, but the causes are not by any means obvious, why this fat is only deposited in particular spots of the body and of the arteries, instead of being equably distributed. More- over these fatty deposits sometimes occur in other parts besides the arteries, as for instance in obsolete tubercle. 2. Concretions consisting principally of urate of soda (sometimes with a little urate of lime) are deposited in the neighbourhood of the joints and sometimes in their interior, in the areolar tissue, and in the ten- dons of gouty persons. They occur as earthy masses of indefinite form and size, are very light and porous, and of a yellowish white colour: they are smooth to the touch, and may be readily scraped by the knife. The following analyses will serve to give an idea of their chemical composition: 1 2 3 Water. . . . . .8.3 10.3 (2.00) Animal matter (areolar tissue yielding gelatin.) . . . .16.7 19.5 10.34 Uric acid. . . . .16.7 20.0 59.43 Soda. . . . . .16.7 20.0 15.09 Lime. . . . . .8.3 10.0 8.25 Chloride of Sodium. . . . 16.7 18.0 5.60 Chloride of potassium. . ,. . — 2.2 — Loss. . . . . , . 16.6 —. 1.29 100.0 100.0 100.00 The first analysis is by Laugier, the second by Wurzer (see Berzelius's Thierchemie, p. 723,) and the third by H. C. van der Boon Mesch, in Bijdragen tot de natuurkundige Wetenschapen, Deel L Amsterdam, 1826, p. 131. The reader would do well fo consult J. Moore, Medico- chirurg. Transactions, vol. i. p. 112, &c., where the progressive forma- tion of these concretions is explained ; and Lobstein, Compte rendu sur jes Travaux anatomiques, Strasburg, 1824. These concretions may be easily recognized by their exhibiting the characteristic reaction of uric acid. Their formation depends on the circumstance of there being an excess of urates in the blood, but why the urate of soda should, as it were by preference, be deposited at particular parts of the body, is by no means clear. * See Plate x. fig. 1, 352 PATHOLOGICAL EPIGENESES. There is also another mode by which concretions are produced within the parenchyma of organs, differing theoretically from the preceding, but actually very often associated with it. The fol- lowing observations will serve to explain it. It has been already shown (p. 101) that many pathological epi- geneses arise from a mixed plasma, that is to say, from a fluid, which may at the same time serve as the formative material for or- ganized and unorganized epigeneses. The source of this formative fluid is generally, probably always, a fibrinous dropsical effusion, whose fibrin coagulates. In this exudation, two formative processes are simultaneously going on-—an organization of the fibrin, and the formation of concretions consisting generally of earthy salts. The product of this formation consists chemically of two distinct steps, one relating to the conversion of the fibrin and its modifications into areolar tissue, pus-corpuscles, granular cells, and typhous, scrofu- lous, and tubercular matter; the other, to the constituents of con- cretions, as the salts of lime and magnesia, the urates, fat, &c. The individual constituents of either group may assume a vicareous po- sition ; moreover, the whole of the first group may assume the place of the second, and conversely the second may replace the first, so that the one is subordinate in the same degree in which the other predominates. This explains the extreme differences in chemical composition, which are observed in this class of concretions. As illustrations of their chemical composition, we may refer to the urinary and intestinal concretions formerly described (p. 358 and 376,) which belong to this class, and may add the following analyses: 1 2 3 4 Protein-compounds and water. 35 10 24.3 53.16 Soluble salts. — 4 4.0 — Phosphate of lime 61 30 65.3 43.67 Carbonate of lime , 4 54 — 3.17 Carbonate of magnesia. . a trace — 6.5 — Phosphate of magnesia. . a trace — — a trace 100 98 100.1 100.00 1. A concretion from the thyroid gland, (Prout, quoted in L. Gmelin, n. 2, 1370.) 2. A concretion from the thyroid gland of a cretin, (Iphofen uber den cretinismus, Dresden, 1817.) CONCRETIONS IN THE PARENCHYMA. 353 3: A concretion from the pericardium, analysed by Robinet and Pe- troz, (Berzelius, Thierchemie, p. 721.) It was formed of several thick layers which were covered with earthy, pulverizable, ver rucose concretions. The organic constituents were partly or* ganized (areolar tissue which on boiling yielded gelatin;) and partly unorganized (soluble in liquid potash—fibrin;) the soluble salts consisted of sulphate of soda, with a trace of sulphate of lime. 4. A concretion from the uterine surface of the placenta, analysed by Wiggers (Berzelius, op. cit. p. 723.) The organic constituents were fibrin, with a little fat, areolar tissue, and albumen. The water amounted to 7§. The morphological relations of these concretions, present even greater diversities than their chemical composition : they are not, merely different in different "concretions, but may also vary in the same concretion in different stages of its development. Sometimes the epigenesis is soft, and the organic constituents predominate ; we can then discover by chemical analysis that there is a considerable increase in the salts of lime. In many cases the mass appears as an in- crustation, ossification, or calculus. Illustrations of these forms may be^ seen in the second volume, in the chapters on the individual organs. Almost all exudations may, under certain conditions, pass into concretions, as in the lymphatic glands, the kidneys, the spleen, the lungs, the areolar tissue, apoplectic sacs in the brain, scrofulous de- positions, tubercles, &c. The conditions governing these transitions* are not clear, but the following may be provisionally indicated: 1. Great abundance of calcareous salts in the primary exudations,, as appears to prevail in arthritic persons. 2. Subsequent separation of calcareous salts, &C;, in the manner mentioned in p. 349, at a period when the exudation predominates, and is either in the act of development or absorption.. The insoluble earthy salts remain in both cases, while the protein-compounds are either entirely or partially developed, or dissolved and resorbed. The relation that these concretions bear to true osseous formations, deserves especial attention. As a rule they have, as we have al- ready mentioned, no resemblance to true bone, and the term ossifi- cation is therefore very unsuitable and liable to be misunderstood ;. still there appear to be cases in which these concretions occasional]'<* 30* 354 PATHOLOGICAL EPIGENESES. reach a higher degree of organization, and thus form transitions to new formations of true bony substance.* The mode of transition is, however, little known, and requires more accurate examina- tion. Of the works treating especially of concretions, the following, besides those to which we have already referred, deserve mention: John, che- mische Tabellen des Thierreiches, p. 60 ; Duncan, jun., Edinburg med. and surgical Journal, vol. I. p. 407 ; J. F. Meckel, pathol. Anat. n. 2, Gurlt medicin. Vereinszeitung, 1833, No. 31; Gluge, mikrosk. Unters. Part 1, p. 90, &c.; Henle, allgem. Anatomie, p. 7, &c.; Remak, Casper's Wochenschrift, 1842, p. 1, &c. * See Valentin in his Repertorium, 1836, p. 317, &c. • CHANGES OF COLOUR. 355 CHAPTER VI. PATHOLOGICAL CHANGES IN THE PHYSICAL PROPERTIES OF THE TISSUES AND ORGANS OF THE BODY. Hitherto we have, with the exception of the changes in the blood, treated only of substances which, either do not occur in the normal body, or are at least modified and in different combinations—as those presenting themselves in many pathological conditions. These pathological epigeneses, taken in the widest sense of the word, are accompanied by certain pathological changes, affecting the physical properties of the body. These changes are numerous and extend to all the perceptible properties of the tissues and organs of the body, most frequently, however, altering their colour, size and consistence. They seldom occur singly, but generally simultaneously with other pathological changes, which, indeed, give rise to them ; it is therefore impossible to separate them accurately from one another. Their consideration is only so far important to pathology, in as much as a description of them, and a knowledge of their differences may tend to clear up their causes and consequences. But such an attempt would at present be accompanied with great difficulties, since the causes of these changes are still very little known, and are extremely numer- ous and involved. The most important of these changes are the following : 1. CHANGES OF COLOUR. Every part of the body has in its normal condition a specific co- lour which depends upon very different causes—solid and fluid pig- ments—and whjch may differ considerably within certain limits, without being abnormal. But when the change in the normal co- 356 CHANGES IN PHYSICAL PROPERTIES. louration exceeds these limits, it becomes pathological; it is, how- ever, neither theoretically, nor practically possible to separate accu- rately these normal and pathological alterations. Sometimes these changes are of no importance, but in many cases, they afford valua- ble aid in recognizing and judging of other pathological conditions. It is of course necessary to be well acquainted with the normal colour of the various parts of the body, in order to form a judgment of the changes it has undergone ; and this knowledge, at least in re- ference to minute shades of difference cannot be learnt from descrip- tions alone, but must be sought in the frequent observation of nature. Colour in most cases depends upon the blood, which circulates through all the vascular parts of the body ; and the changes thus effected are of the highest importance to pathology. They gene- rally accord with the changes already described (p. 87—99) in the quantity and distribution of the blood, and appear as increased or diminished blood-colouring (paleness, and heightened redness) or as an alteration of the normal colour into other shades. Abnormal paleness. This, as a general rule, leads to the conclusion that there is a diminution of the colouring matter of the blood in the part affected ; and may depend upon very different causes. 1. On a contraction of the capillaries, by which the'quantity of the blood-corpuscles, and consequently the intensity of the red co- louring is diminished. There are many familiar examples of this state; as, the paleness of the face, in consequence of emotions of the mind, and the transient deadness of the fingers. The diagnosis of this condition may be determined by the microscopic investiga- tion of the dead body, by which we learn by measurements that the capillaries have a smaller diameter than in the normal state. But this process presents some peculiar difficulties, which often prevent our obtaining the desired result. For during the preparation of the parts for microscopic investigation, the blood often flows out of the capillaries, which then contract in consequence of their elasticity. The diagnosis in the living subject is more certain since local pale- ness, during a state of unchanged redness in other parts, allows of our drawing a conclusion regarding this condition. 2. Paleness may depend upon a diminution of the corpuscles in relation to the other constituents of the blood, and as they are the conveyers of the colouring matter, a less intense redness is naturally occasioned. CHANGES OF COLOUR. 357 3. Upon a diminution of the colouring matter, or a chemical change by which its intensity is diminished, so that while the num- ber of the blood-corpuscles remains the same, each separate one, or at least, a given number contains less colouring matter, than in the normal state. The last two causes appear to bear on anaemia, chlorosis^ and similar conditions, but our knowledge is still so deficient on this point, that we must look to chemical investigations for affording Us some better grounded, and more certain information on the subject. It will be clearly seen that the changes mentioned under 2 and 3, combine with 1, and may occasion in addition to a general pale- ness, a more decided local pallor. A limited local, or a generally diffused pallor may be occasioned by causes, only taking effect during the last moments of life, or even after death. This cadaveric paleness is caused by the contraction of the capillaries in conse- quence of their natural elasticity, when the heart's movements have ceased, or the blood following the laws of gravitation is poured forth, (see the chapter upon the changes of the body after death.) This gives us no insight into the pathological conditions during life. The paleness, thus elicited by various causes is not always purely white, but has frequently a tinge of green, blue, or brown ; and this is owing to the tissues themselves not being ofa pure white colour, and to other faint tints from granular or fluid pigments, as bile-pig- ment, haemaphsein, &c, (which, in a normal condition, are con- cealed by the deeper colour of the blood,) now appearing more dis- tinctly ; moreover the blue colouration of the veins, which we shall presently notice, contributes to these results. Besides the paleness, which depends upon the blood, other causes may induce a pallor in parts which are, normally, coloured—as fatty depositions, fatty degeneration of the muscles, liver and other or- gans, coagulated fibrin, tubercular matter, especially non-vascular epigeneses, and unorganized depositions of the most various kinds. They act in a twofold manner first by compressing the vessels of the part, whose normal redness depended upon their quantity of blood, and secondly by thrusting a new and faintly coloured mass into the original tissue. Local pallor is further called forth by a deficiency of pigment in parts where in a normal condition it exists, as in the skin, the hair, 358 CHANGES IN PHYSICAL PROPERTIES. and the eyes in cases of leucosis (Albinos.)* For further particulars of all these changes of colour, and their causes, we must refer to the special part. Abnormal redness appears much more frequently than abnormal paleness, and likewise admits of classification under different heads, according to its causes; although it is easier to do this theoretically than to decide, with certainty, empirically upon any individual case. We may have : . 1. Redness from hyperaemia of the capillaries, the characteristic properties of which have been already described, (p. 89.) The co- lour is, as a general rule, of a vivid red, and appears to the naked eye, on account of the smallness of the capillaries, as if the paren- chyma of the part were tinged with red; and it is only by microsco- pic examination, that the colour is seen to resolve itself in red capil- laries and colourless interstices.f 2. Redness from venous hyperaemia, (p. 88.) Here there is mostly a bluish red, but sometimes a brownish red, or even black- ish brown colour exhibited by the dead body, frequently changing into a clear red, after prolonged exposure to the air. The hyperse- mic viens are distinguishable with the unaided eye or with a lens, and their interstices appear colourless. Iri this category we have the blue disease, (cyanosis,) in which several parts of the body, as the lips, cheeks and finger ends, are more or less deeply tinged with a purple hue.J - In both these varieties of abnormal redness from vascular hyperae- mia, the deepened colour may not depend alone upon hyperaemia of the normal vessels, but may be occasioned by newly formed vessels, as in granulations, telangiectases, and in encephaloid. 3. Redness from extravasated blood (p. 92—98) is frequently as- sociated with that which arises from capillary hyperaemia. 4. Redness from infiltration of dissolved haematin, (page 98—9.) The diagnosis of, and the distinctions between these different con- ditions, were so fully discussed in their proper places, that nothing further remains to be added. * See Meckel, Patholog. Anat. n. 2. p. 2. t See Plate n. fig. 1 a , b. X See a plate elucidating this point in den chirurgischen Kupfertafeln, 1820, Plates LIU—LV. CHANGES OF COLOUR. 359 I will merely remark, that by changes in the dead body, a state of hyperaemia of the capillaries, having existed during life, may dis- appear ; and conversely that venous hyperaemia, and infiltration of haematin, which did not exist during life, may be called forth, so that in judging, of these conditions of the dead body, much circum- spection should be used. In all these cases of increased redness from hematin, the blood may present manifold shades of colour, appearing either of a light or dark red, purple, brownish red, of the colour of tar, &c, without our being as yet able to give with certainty the causes of these changes in every individual case, (see p. 67, &c.) Sometimes as in extravasated blood, these changes go so far that the red colour entirely disappears, and gives place to another tint; thus extrava- sated blood becomes at times blue, orange, bistre-brown, or even black. The little that is as yet known concerning these changes has been already mentioned, (see p. 181, &c.) These modifications in the haematin may occur after death, as well as before ; and our judgment regarding their causes and importance in the dead body, demands the same careful attention that we recommended in the case of abnormal redness. In addition to the changes of colour already considered, there are others, of which the most important are : Dark coloration from granular pigment (melanosis) which has already been specially noticed, (see pp. 178 and 215.) Yellow coloration of the tissues, depending as far as is yet known upon two very different causes. The most frequent form in which it appears is dependant on the bile-pigment, (the cholepyrrhin of Berzelius,) and occurs to the greatest extent in jaundice, when it accumulates in the blood, and passes from thence into all the fluid secretions, colouring all solid and fluid parts of the body. Thus we find it in the brain, in cartilage, bone, nerves, lungs, liver, kidneys, ovaries, &c; there being different shades of colour, according to the extent of the deposited pigment, alternating from pale yellow, to yellowish green, or even olive green, or dark blackish tint. Under the microscope we sometimes observe that the tissues are merely saturated with a yellowish fluid, while at other times, we discover firm, granular, accumulated depositions of a deep yellowish red colour, between the interstices of the primary histological elements of the tissues. Independently of icterus, the elementary cells of 360 CHANGES IN PHYSICAL PROPERTIES. the liver frequently appear to be tinged yellow and to be filled, or covered with minute deeply yellow granules.* The diagnosis of the coloration dependant upon bile-pigment is easy, and is based upon its peculiar reaction when treated with nitric acid (see p. 69.) Another yellow coloration which appears occasionally in the organs, but which is invariably local, depends upon a change of the haematin in extravasated blood. It is observed after sugilla- tions, pulmonary and cerebral apoplexy, and similar morbid pro- cesses. Green coloration of the tissues is but rarely met with. It is sometimes observed in the lungs, the intestinal canal, and the mus- cles. Thus the upper lobe of the left lung of a soldier, which was emphysematous and void of blood, appeared to the unaided eye of a grayish-green colour. Under the microscope, the pulmonary tissue itself was tinged with green; the coloration was, with the exception of a few intensely green spots tolerably regular, did not originate from granular pigment, and could not be washed off with water. The cause of the colour could not be discovered. The same is the case with the green coloration occasionally perceptible in the intestinal canal. Most of these green tints probably belong to the changes in the body after death; and at present we can do no more than hazard a conjecture concerning their causes. Many may depend upon sulphuret of iron, which in a very finely divided state sometimes exhibits a blackish-green colour ; many may origi- nate from the effects of putrefaction, with which we are but ill ac- quainted. Probably many changes of this kind depend upon the bile-pigment, which permeates the walls of the gall-bladder after death, and spreads itself, by imbibition, into the surrounding parts, or even sometimes to a considerable distance, as the following case will show. A hawk that had been dead three days was opened. The muscles of the abdomen appeared tinged with green, while those of the chest, the extremities and other parts still exhibited their normal colour. Under the microscope the greenish muscles and the surrounding tissues appeared saturated with a yellowish- green fluid, without the presence of any abnormal, granular pig- » See Plate i. fig. 8. CHANGES OF COLOUR. 361 ment. On the addition of nitric acid, the green changed first to blue, then to violet, and lastly, to purple and pale red. The colouring fluid was, therefore, precisely similar to bile-pigment. „A closer examination of the abdominal cavity showed that the gall- bladder, which -was very full, formed the central point of coloration. Further investigations must determine whether this kind of colora- tion of the dead body is seen in man at any distance from, or whe- ther it is confined to the immediate neighbourhood of the gall- bladder. Blue coloration of the organs is very uncommon, excepting in those cases which have been already named, where it depends upon venous hyperaemia. To this head belong the rarely observed cases of coloration of the skin by blue sweat* As yet very little is known regarding the composition of this blue pigment, or the causes of its origin. I have several times observed, that in microscopic prepa- rations of the different parts of the body—as of the human skin, exhibiting roots of hair—which had been laid in sugared water be- tween cemented glass plates, a very finely granular deposit of a beautiful blue colour was precipitated, which, however, was yielded in too small a quantity to admit of chemical analysis. A further prosecution of this subject may lead to an explanation of the blue coloration of the skin which appears during life. Many abnormal colorations depend upon matters which have reached the body from without; in this manner we can account for the red bones of animals, which have been fed upon madder, the yellow colour which the pigment of rhubarb yields to many organs, and the ashy-gray or olive-green tint imparted to the skin by the internal use of nitrate of silver. To tfiese may be added accidental, or intentional colourings of the skin (tatooing,) by means of the penetration or rubbing in of gunpqwder. For some other cases of such colorations by means of medicines, &c, with notices thereof, see Otto's Lehrb. d. Patholog. Anatomie, p.;34, or South's translation, p. 33. A full enumeration of the different patholo- gical colorations which appear in the human subject, may be found in Hodgkin's Lectures on the Morbid Anatomy of the Serous and Mucous Membranes, vol. i. pp. 297—327. * An interesting case of the secretion of a bile-pigment from the skin has been described by Dr. Bilchner.—Schmidt's Jahrbucher, vol. xxxvi. No. 2. 31 362 CHANGES IN PHYSICAL PROPERTIES. II. CHANGES OF FORM AND SIZE. In a general point of view, the observations already made, re- garding the changes of colour, may be applied to those of size and form. Every organ has in a normal state a. certain size and form, but these relations are not so accurately defined, but that many in- dividual modifications of both may appear. By disease these devia- tions may be so far augmented as to transfer their consideration to the department of pathological anatomy, without, however, enabling us to draw any very strictly defined limits between their normal and abnormal conditions. On dissection, when these modifications are in any degree considerable, they are the first to attract the attention of the most superficial observer, and hence in pathological anatomy they have been regarded before other changes, and thus in its in- fancy usurped a large portion of the consideration of this science, The more the science is developed, and its attention is directed from the accidental to the essential, and the more it seeks to clear up the causes and importance of individual changes, the less im- portance will be given to external modifications. A general con- sideration of these alterations is of very little value to science; it leads to a mere abstract system of arrangement, wdiile the actual significance of the changes, the category of their causes and conse- quences, must vary with almost every individual case. I will, therefore, leave a more minute consideration of the subject to the special part, and limit myself here to a few general remarks. To the department of pathological anatomy belong, as we have mentioned, only the higher degree of those changes which may be distinguished with certainty from mere physical modifications; but as no strict line of demarcation can be drawn between health and dis- ease, it is useless to, dispute concerning individual cases, as to whe- ther certain changes do, or do not, belong to pathological anatomy. The causes of these changes, on which as a rule their character depends, are very different, and in a great measure unknown ; yet, from what has already been observed regarding them, they may be divided into the following groups; Many deviations in form and size are congenital. Of these some are inherited by children from their parents, and thus appear to be inherent in the peculiar properties of the generative matter of the CHANGES OF FORM AND SIZE. 363 germ—in an extended sense of the word. As many species of ani- mals, so are also many races of men distinguished both externally and internally by peculiarities in the form and size of certain organs of the body. Examples of this fact are so numerous, and must be so familiar to all, that it would be useless here to adduce any. But in these cases, it often happens that it is not possible to decide the difference between pathological and physiological deviations. (This subject will be more fully treated, under the head of mal-for- mations.) Other differences of this nature depend upon abnormalities of de- velopment. In the foetus and the child many parts are relatively larger or smaller, and even of a different form from the correspond- ing organs in adult age. If, now, the subsequent and natural de- velopment of these parts be arrested by morbid causes, that which was previously normal will appear to us as disproportionate to the rest. The special causes of this impeded development may be very different, and are for the most part still obscure. Examples of such deviations occur, for instance, in the unusual size of the thymus gland, at an age when it is generally reduced to a minimum. In the foetus, the left lobe of the liver is proportionately larger, and the walls of the heart are proportionately thicker than at a subsequent age, and this condition may continue to exist as a pathological de- viation from the normal type, if its further development be arrested. (For further information on this subject see malformations, and the special part.) Other changes in the form and size arise from external influences of a mechanical nature. We may mention the changes in the form of the skull, which many tribes effect in their children by compress- ing or binding the head in a peculiar manner ; also, the feet of the Chinese, which being arrested in their growth by mechanical means become deformed and contracted; also, the changes in the thorax from tight lacing. By means of tightened bandages and stays, es- pecially amongst women of the lower classes, the liver is so altered that it often exhibits a permanent ridge or furrow impressed upon the surface. The action of these influences is that the flow of the blood, and consequently organic epigeneses are impeded from pres- sure on the vessels, and the growth thus arrested, while the retro. gressive activity of the metamorphoses (disintegration and resorption) continue uninterrupted. By these processes even very hard parts 364 CHANGES IN PHYSICAL PROPERTIES. of the body—as bones—are by degrees modified, while the form of the softer parts is quickly and directly changed by such influences. What has been here mechanically induced through external agents is frequently effected in a natural way by pathological changes. Thus by the pressure produced by tumours, aneurisms, concretions, &c, soft organs may be changed in form and size, and the harder parts, as bones, gradually destroyed. Morbidly formed fibrous tis- sue presses by its elasticity, or by the spasmodic contraction excited by the nerves, on soft organs—as the lungs, liver, kidneys, &c, and thus diminishes their volume, and alters their form. In these cases also the action of the cause is compounded of several factors, being influenced by direct pressure on the tissues, the blood-vessels, and the nerves. Many changes of organs, especially those affecting their size, and, less frequently, their form, are dependant upon the intensity of their physiological functions, and their greater or less activity. By in- creased activity, the nutrition and growth, as well as the bulk of most organs are augmented; while, on the other hand, by decreased activity they remain small, or continue to diminish. Thus, for in- stance, the muscles increase in volume in proportion as they are ex- ercised. But in this case the increased nutrition is not the uncondi- tional consequence of increased activity ; both are only the final points of a series of processes connected together by causes, which are as yet but imperfectly known. By increased activity, a greater flow of blood—a capillary hyperaemia, the cause of which has hither- to not been sufficiently explained—is occasioned, attended by an augmented secretion of blastema, which induces the formation of new tissue, and causes a local augmentation. Hence we must not necessarily conclude that the increase of size in a part arises of necessity from its increased activity, since every cause which calls forth hyperaemia of the capillaries may also become the cause of an increase in the part effected. According to the dif- ferent modifications and consequences of hyperaemia, the increase of volume may also vary in its characters. Thus, for instance, ve- nous hyperaemia in the soft parts, may call forth transient enlarge- ment by the infiltration of serous fluid ; indeed^ hyperaemia may oc- casion an evanescent increase of volume by an augmentation of the mass of blood contained in the organ ; as, for instance, in the erec- tile organs—the corpora cavernosa of the penis. But capillary hy- CHANGES OF FORM AND SIZE^ 365 peraemia can lead in a very different manner to an increase of vo- lume, and it may do this independently of an augmentation of bulk resulting from the increased quantity of blood, by the copious se- cretion of fibrinous fluid. If the fibrin coagulate, a new form of in- crease of volume is called forth. A different one occurs when the exuded fibrin acts as a cytoblastema, and passes into persistent tis- sue, by which either a true hypertrophy, or a formation of some kind of tumour appears as the final result. But all these processes do not necessarily lead to an augmentation of bulk; and it only re- quires a slight alteration in the process to induce a diminution, rather than an increase of size: as, for instance, when exuded fibrin is converted into fibrous tissue, which in accordance with its character contracts and diminishes the part, as in most cicatrices. We ob- serve, therefore, in many morbid processes, first an increase of vo- lume, which subsequently diminishes, and is followed by a contrac- tion of the organ attacked, as in Bright's disease of the kidneys. In many cases of augmentation or diminution of the bulk of an or- gan, these conditions are extremely complicated, and much more conjectural than those already considered ; as in the tendency to cor- pulency (Polysarcia,) where there is often a very considerable depo- sit of fat in the form of adipose tissue in different parts of the body, as in the Panniculus adiposus, (see p. 171.) The explanation of this process must be gained from a knowledge of the nature of di- gestion, which we do not yet possess. It is the same with morbid emaciation, which is far from being satisfactorily explained by sup- pressed nutrition, or arrested epigenesis, since these explanations themselves need elucidation. Hollow organs are the most changeable in relation to form and size. They increase by the accumulation of their contents—as the stomach by food, and the intestinal Canal by gas—decreasing as these are voided. Such an evanescent augmentation or diminution may, however, become permanent, if the cause continue long ; thus, in great eaters, the stomach may attain a- considerable size, while in those not taking sufficient nourishment, the whole intestinal canal may appear permanently contracted ; and in eases in which an arti- ficial anus has existed for some time, the portion of intestine below it becomes much narrowed. Many hollow organs may entirely or partially disappear, as, for. 31* 366 CHANGES IN PHYSICAL PROPERTIES. instance, the gall-bladder after biliary fistula, with the simultaneous closing of the cystic duCt. As the causes, so also are the results of these changes of form and size very different. They depend upon special relations, upon the situation and importance of the part affected, on the nature of the change, &c.; so that no general laws regarding them can be laid down. Indeed, changes which affect the same organ, and arise from perfectly similar causes, are often very different in their conse- quences ; while, for instance, .an enlargement of the muscles of the arm of a blacksmith is a consequence of their increased use, and, so far from being attended with evil consequences, is a sign of power and Jiealth, if a corresponding augmentation had occurred in the muscular walls of the heart, arising likewise from a continuously heightened activity, very injurious consequences, and even death itself would, as a general rule, occur. We usually designate the diminution and augmentation of the bulk of an organ by the terms atrophy and hypertrophy. These names must, however, be regarded as nothing more than rubrics under which we in- clude a number of changes, which, as we haye already remarked, inde- pendently of accidental alterations of form, have often very little in common. It is of especial importance to the consideration of all these changes, accu- rately to ascertain their causes, to arrange these causes in suitable groups, and to estimate, qualitatively and quantitatively, the action of each. This is at the present time possible only to a very limited degree, and must, for the most part, be left to future investigators. The literature of these changes is, however, tolerably copious. Any one desirous of studying this somewhat unprofitable subject, will find a considerable amount of in- formation on atrophy in Otto's Pathological Anatomy (p. 23 of South's Translation,) and in J. F. Meckel, u. 1, p. 314; in the Treatises of Andral, Lobstein, and Carswell; and in the article " Atrophy," by Canstatt, in Wagner's Physiolog. Worterbuch; Regarding Hypertrophy, the reader may consult Otto (p. 25 of South's Translation;) Meckel, u. 1, p. 223; and the Treatises of Andral, Lobstein, and Carswell. III. CHANGES IN THE CONSISTENCE OF THE VARIOUS ORGANS. An importance has been attached to alterations in the consistence of organs which, as in the cases of change in form and size, has, CHANGES IN CONSISTENCE. 367 we think, been over-rated. The attempt to take a general view of certain conditions of the organs, which in regard to their causes, consequences, and importance have little or nothing in common— to arrange them as cases of induration and softening—is, from its very nature, one likely to yield no useful results. The view that we shall take of this subject in the following pages must be conse- quently limited to the consideration of certain changes of frequent occurrence. By hardening or induration is implied an abnormal increase in the consistence of an organ ; this may vary from a scarcely perceptible increase of consistence to a degree of stony hardness. It seldom happens that an entire organ is uniformly hardened throughout; we more commonly find the induration limited to particular spots. The cause of induration is very different in different cases. The consistence of a portion of the body may be increased by a deficiency of blood (Capillary anaemia,) since the solid elements of the tissue are belter able to retain their original degree of firmness, than when much blood is present, which, like any other fluid, tends to soften the animal tissue. This is frequently the case in the spleen, and appears sometimes to occur in the substance of the brain. How- ever, the increase of consistence arising from (relative) anaemia is always slight; I do not know of a single instance in which a great effect has been produced. Fibrinous dropsy is a frequent cause of induration, the fibrin coa- gulating and forming a solid substance, penetrating between the histological elements of the tissue, and thus increasing its consistence. This induration is naturally the more striking in proportion as the normal consistence of the part affected is less than that of coagulated fibrin: hence it is most marked in porous and spongy organs, as the lungs, cellular tissue, &c. In some organs it has received special names; thus in the lungs, it is termed hepatization, because to a certain degree it communicates to the pulmonary tissue a resemblance to liver. Numerous cases of induration are dependant on the formation of pathological epigeneses which penetrate between the histological elements, and render them firm and resisting. This effect may be produced by epigeneses of the most distinct kinds, as for instance, tubercle, scirrhus, fibrous structures, or concretions, (ossifications.) Since many of these epigeneses arise from coagulated fibrin, one 368 CHANGES IN PHYSICAL PROPERTIES. kind of induration may gradually vary in its nature, and be converted into another. Hence it follows that induration is often merely an incidental con- sequence of other morbid elementary changes which have been already described. The consequences, like the causes of induration, differ extremely, in accordance with their nature and distribution, and the importance of the organ affected. Copious information on induration in general, and in individual cases, may be found in J. F. Meckel, n. 2, p. 14, &c.; Andral, op. cit. and Bayle's Journal de Med. vol. ix. p. 285. The reverse of induration is softening—a rubric under which it has been attempted to include all abnormal diminutions of con- sistence. Theoretically we may distinguish between lesser and greater degrees of consistence, although there is no definite line, separating one from the other. Softening to a slight degree is often only transitory: it generally arises from an excess of fluid in the part, from saturation of its tissues with serum, or the accumulation ofa more than ordinary quantity of blood in it. In this way many organs lose their normal degree of consistence, and become soft and yielding. This arises from causes which have been already considered—hyperaemia and serous dropsy. Hence, it follows that some organs are more liable to this form of softening than others. Thus the spleen very frequently softens, since this organ more frequently than any other becomes overloaded with blood. The same is the case with the lungs ; moreover the brain whose tissue normally possesses but little firmness may, by the ad- dition of much fluid, become softer. There are other organs which from their very nature are incapable of undergoing softening of this nature, as for instance, the bones and elastic tissue. Many of these cases are merely transitory, disappearing when the hypersemia ceases, or the dropsical fluid is resorbed. Higher degrees of softening invariably lead to a partial solution and destruction—a death of the affected tissue—or rather, they arise from it. We have had, occasion to notice several of these cases of softening in our remarks on suppuration, and on the softening of tubercles and of the pseudo-plasmata. It is, however, at present CHANGES IN CONSISTENCE. 369 hardly possible to take a general view of these cases of softening, since their causes like their forms are very different, and we are not sufficiently acquainted with their various conditions. The only method by which we can possibly obtain correct views regarding the occurrence of softening, is by endeavouring to work out its various conditions, in the same manner as Engel has done, in rela- tion to the softening of tubercle, (see p. 263.) At present, however, scarcely an attempt has been made, and since the conditions are very numerous and highly complicated, there seems to be little prospect of attaining this object for some time. It has been at- tempted to explain individual kinds of softening by making their occurrence dependant on certain general processes, and thus distin- guishing inflammatory softening, softening from gangrene, and soft- ening from obliteration of the afferent arteries. Something is cer- tainly gained by this, but nothing very important, as long as the mechanism and the chemistry of the processes induced, are not better known. At present the following observations embrace most that is known on this subject. Most softenings arise from the deposition in the organism of sub- stances from the blood, which take no part, or but a small one in the general process of metamorphosis, either because, on account of their great size, they cannot be penetrated by the fluids of the body, or because their circulation has been entirely stopped by the stagnation of the blood in the vessels of the surrounding parts. As in these depositions, the separation of decomposed tissue, which is maintained in the normal state by means of the circulation and the secretions, ceases, these substances undergo further decomposition, and extend this process to the adjacent tissues, which they imme- diately infect. This term decomposition or putrefaction, is a mere illustration of the active cause of softening in these cases, which may convey a slight idea of these processes, but cannot be regarded as any comprehensive explanation, since we have as yet a very un- satisfactory chemical knowledge of the conditions of the decompo- sition of nitrogenous organic matter, and the concomitant processes. The same is the case regarding the transfer of this process of de- composition to the tissues, on which we as yet have no special knowledge. It is clear that all depositions and all tissues are not affected with equal facility by this decomposing process; hence, evi- dently the reason of the great differences which occur under this 370 CHANGES IN PHYSICAL PROPERTIES. process in individual parts. An accurate knowledge of all similar cases can only be gained, when the decomposition suffered by dif- erent organic substances, if left unmolested, or brought under certain conditions be more accurately studied than it has hitherto been. To this group belong further all those kinds of softening which we have previously included under the general term of suppuration —the deposition of fibrinous exudations, which pass into unhealthy pus; similar depositions of tuberculous, scrofulous, and typhous matter, and in part also the softening of cancer. These softenings have this peculiarity that they are mostly preceded by induration, as may be observed in many kinds of inflammatory softenings. The chief condition inducing the process of decomposition, seems to be local interruption of the circulation, and of the metamorphosis of tissue, as far as is dependant upon the circulation, that is to say, in relation to the removal of decomposed matter infecting the adjacent parts. In other cases, the softening originates in extravasated blood; which, when occurring in large masses, seems more disposed than any other of the constituent parts of the body to undergo decompo- sition ; it influences also the adjacent parts, if its products, in con- sequence of the large quantity of the extravasation, or owing to local disturbance of the circulation, be not carried off, but are able to exercise their influence upon the neighbouring tissues. To this head belong most cases of inflammatory gangrene.* The blood undergoes a peculiar change, being converted into brown or black- ish clots, in which granules of sulphuret of iron sometimes appear.| But the chemistry of these changes is almost entirely unknown. The modifications of the different histological elements in these gan- grenous softenings are extremely various. The soft tissues, as might be expected, are first altered, and some- times wholly destroyed. The areolar tissue Is either broken up into a fine granular mass, which at first has the form of fibrous bundles, or it is gradually softened, so that larger portions still exhibit the original contour, after the individual connecting fibres have disap- peared. The cells of adipose tissue disappear, and their contents * See Wagner's Handworterbuch d. Physiologie, vol. I. p. 340. t See Plate ix. fig. 10. i CHANGES IN CONSISTENCE. 371 become mixed, as drops of fat, with the surrounding fluid ; and crys- talline masses of margarin or margaric acid generally occur. The primitive bundles of muscles lose by degrees their striated appear- ance,* and at last become changed into a pale, gelatinous mass which for a long period retains the external contour of the primitive bundles.! Tissues with greater power of resistance, as the vessels, elastic tissues, bones, and epidermis are decomposed at a much later period, or not at all. Similarly to extravasated blood, other fluids which easily pass into a state of decomposition, as urine, intestinal excretions, &c, may give rise to a decomposition, and softening of the tissues, when in any manner they are infiltrated into them. To this class of soft- ening belongs unquestionably another, which depends more upon general than local causes : for instance, there are cases, in which the whole mass of the blood undergoes a certain change or decom- position, which we must designate under the term putrefaction, without at the present time knowing what are its chemical changes. The fluids separated from the blood, as the general nutrient fluid, being more or less modified, may induce a decomposition and soft- ening of the tissues. Thus in typhus, and when the blood is loaded with bile-pigment, (as for instance in severe cases of icterus,) very extensive softening occurs, which has been well designated under the term, gangrene. This condition is naturally susceptible of the most numerous modifications, and it is probable that it would ulti- timately lead to a general softening of the whole body, if, as a rule, death did not rapidly ensue. In such cases, the changes already begun, progress much more rapidly after death, but it is not gene- rally possible to decide from the examination of the body, how far this softening had proceeded before, and how much had occurred subsequently to death. In a few cases, a local softening of a higher degree, appears to be induced in the softer parts, by the mere pre- sence of serous fluid. Thus in the brain, we sometimes find in high degrees of serous dropsy, that the walls of the cerebral ventricles have a pultaceous appearance, extending to a slight depth (from half a line to a line.) That a naturally soft substance like the brain should be gradually softened and decomposed by the long continued con- * See Plate ix- fig. 9. t See Plate ix. fig. 8. 372 CHANGES IN PHYSICAL PROPERTIES. tact and saturation of so mild a fluid as that of serous dropsy, is not improbable, although experience seems to prove that such a softening is not perceptible in all cases of hydrocephalus. Possibly the softening only occurs when from the presence of a very large amount of fluid, or from other causes, the metamorphosis and fre- quent renewal of matter are arrested; so that these cases also rank under the previously described classes of softenings. In many cases a softening, or more correctly the death and decom- position of organs, may be traced to obliteration, or closing of the afferent arteries, as many writers (and amongst others Carswell) have correctly stated. But here the closure of the arteries does not directly occasion the softening; it is only the result of a series of pro- cesses, which finally result in softening. The most probable explana- tion seems to be, that by the closure of the arteries in the part affected, the necessary renewal of the nutrient fluid, through the afflux of ar- terial blood, is arrested, and that the part thus passes into a state of decomposition, which extends to the adjacent structures. According to this theory, these cases may also be ranked under the head of those previously considered. It appears very doubtful whether softening can arise from a direct influence of the nervous system, that is to say, differently from the manner in which the latter acts upon the vascular system, and indi- rectly induces softening by means of one of the previously men- tioned conditions. At any rate it is expedient to meet such assump- tions with some distrust, and only to receive them, when it can be proved that mechanical and chemical causes are not sufficient to explain the case. In all these softenings of higher degree, the softening itself is pro- perly only a secondary matter—the consequence of decomposition, the death of the tissue. Hence the various forms of death of the tissues in which no softening occurs, become directly associated with those previously noticed. To these belong dry gangrene, gradual dessiccation of dead organs (mummification,) and necrosis of bone. In these cases the absence of softening depends partly upon the cha- racter of the tissue, and partly on external influences, as want of humidity. For further information on softening in general, see Andral's Patholog. Anat., and Carswell, fasc. 5, Softening, and fasc. 7, Mortification. For the softehing, and gangrenous destruction of the individual organs, we must refer to the special part. / VENOUS HYPEREMIA AND NERVOUS DROPSY. 373 CHAPTER VII. MUTUAL COMBINATIONS OF MORBID ELEMENTARY CHANGES. The changes described in the preceding pages do not always oc- cur singly; many sometimes being manifested simultaneously in the same, or different parts of the body. The recognition of the con- nexion in which they stand to each other, forms consequently as im- portant a question as the investigation of the individual changes them- selves. We may pursue the investigation of this combination of different changes in two ways. The first is by means of the numerical me- thod, which leads to a correct conclusion, in as much as it shows the greater or less frequency of the simultaneous occurrence of these changes, but leaves the cause of these combinations and the intimate connexion of different changes entirely in the dark. The second me- thod endeavours to point out the intimate connexion of individual changes, and thus explain the facts elicited by the first method. In our introduction we spoke of the various degrees of importance ex- isting between these two methods in their application to pathological anatomy. We will here consider the latter mode-, since, as far as is compatible with certainty, it deserves a preference over the former. In deciding between those pathological changes which occur simultaneously in the same part, and those which affect different parts at the same period, we must not lose sight of the fact, that here the question relates to the smallest parts visible through the mi- croscope—the elementary parts of tissue—and not only to larger masses, as whole organs, or those parts that are seen by the naked eye. In the earlier ages of pathological anatomy, observations were limited to what could be detected by the unaided eye, the conse- quence of which was that changes of whole organs were treated en masse, and brought under one category of common names; accu- rate histological investigations have, however, led to the conviction 32 V 374 COMBINATION OF MORBID CHANGES. that most of those changes, which were formerly regarded as sim- ple, are of a composite nature; and* the combinations of morbid changes have consequently been studied with increased attention, and show us that many which were formerly overlooked, are really of the highest importance to pathology. It further follows that changes, which are the opposite of each other in their nature, may yet co-exist in the same organ—as induration and softening, in- creased redness and pallor. The connexion between co-existing morbid changes may be more or less intimate. Many changes of this kind stand in the relation of cause and effect: in some the connexion is either very remote, or not to be traced; we might even term it accidental, if we could admit the idea of chance in the phenomena occurring in the human or- ganism. The pathological changes arising from a common cause may be ranged in certain groups, of which the following are the most im- portant. FIRST GROUP. VENOUS JIYPERJEMIA AND SEROUS DROPSY. Every venous hyperaemia may apparently occasion serous dropsy (see p. 49) and hence both changes occur very frequently in the same organ. We seldom meet with Venous hyperaemia without dropsical effusion, except in cases where the hyperaemia is so recent and slight that the effused fluid escapes detection on account of its small quan- tity, or of its having been carried off by the activity of the lymphatic vessels. We more frequently meet with serous dropsy without venous hyperaemia. This may arise from the fact that the venous hyperaemia has already disappeared, while its result—the serous dropsy still re- mains; or owing to the dropsy having originated from some other cause than venous hyperaemia, (see p. 50.) But these causes are still very obscure, and venous hyperaemia appears to be by far the most frequent origin of serous dropsy. This group is limited to these two changes, generally speaking the degree of softening pro- duced by serous fluid is only slight, but in the brain, a higher degree of the same change may be occasioned. .CAPILLARY HYPER2EMIA ANT) FIBRINOUS DROPSY. 375 SECOND GROUP. CAPILLARY HYPER2EMIA AND FIBRINOUS DROPSY. The consequences of these processes form a very comprehensive department, extending over most of the elementary changes already considered. The two principal links of this department are con- nected with each other, since fibrinous dropsy, as we have already shown, is a consequence of capillary hyperaemia ; but between them there are so -many intermediate links, that it appears advisable to separate this department into two divisions. 1. The province of capillary hypercemia, which is in the first place characterized by distension of the capillaries, and an accumulation of blood in them, and further by a stagnation of the corpuscles, and consequently a local stoppage, of the circulation (stasis, see p. 91.) As consequences of this state there may be laceration of the capil- laries, and consequently extravasation of blood. The latter may undergo the changes already described (see p. 95,) may be re- sorbed with or. without change,of colour, or may act as a cyto- blastema for organized, and a plasma for unorganized epigeneses-; it may further undergo decomposition, and thus lead to the destruc- tion of tissue, and gangrene. With this condition, there usually also occurs, (either preceding or accompanying it,) a solution of the haematin, and a saturation of the tissues with it. All these changes. although from the. nature of the case they succeed one another, are yet very frequently simultaneously present in the same organ. 2. The province of fibrinous dropsy. The occurrence of this fluid as a consequence of capillary hyperemia, leads us to a second very comprehensive series of morbid changes. To this class belong all the changes affecting the effused fluid, which have been formerly de- scribed (see p. 60.) The fibrin may coagulate, and thus give rise to false hydatids, apparent serous dropsy, induration of the affected organ, &c. Then follow the great number of changes which arise from' the further development of the fibrin—suppuration in the widest sense of the word, with all its modifications and forms, the formation of granular cells, and ulceration—epigeneses of the most varying kind, tumours, hypertrophies, concretions, changes of co- lour, softening, induration, &c. ; in short, almost all the above de- scribed elementary changes. 376 COMBINATION OF MORBID CHANGES. Connected with this subject are two questions, whose answers possess a high theoretical and practical interest. They are the fol- lowing: 1. Is every case of capillary hyperssiriia necessarily suc- ceeded by fibrinous dropsy ? And, 2. Does every case of fibrinous dropsy necessarily arise from capillary hyperaemia ? or may it arise in some other manner? Allusion was formerly made to these questions, but a perfect answer was impossible till the above facts had been individually considered. The former question, whether every capillary hyperaemia must be succeeded by fibrinous dropsy, is answered by experience in the negative. We often find the capillaries distended and loaded with blood, without being able to recognize the existence of an increased quantity of fibrinous fluid in the surrounding parts, and thus our separation of this department into two provinces is justified, and the independence of the former—capillary hyperaemia—established. However, we should assign to the above-mentioned experience no more value than it really deserves; it merely shows that all cases of this hyperaemia are not followed by a considerable secretion of fibri- nous fluid. The' exudation may be very slight, and we are alto- gether without means of distinguishing a small quantity of a fibri- nous fluid yielded by dropsy, from the ordinary nutrient fluid per- vading the tissues; moreover, as was stated in relation to serous dropsy, the whole or greater part of the exuded fluid may be re- sorbed by the veins and lymphatics. Further, in many cases of ex- udation the fibrin appears to undergo a chemical change which hinders it from being detected by the ordinary means of recognition ; thus it frequently becomes converted into a species of mucus. An instance of this nature is afforded by menstruation, which admits of no other explanation. The blood which is effused externally, un- doubtedly arises from the ruptured vessels, of the ovaries, and pro- bably, also, of the Fallopian tubes-and the uterus. Although this blood, when it is effused from the vessels, must necessarily contain fibrin, yet generally on its discharge this constituent is absent, and the fluid does not coagulate. In its place there is mucus, and a larger amount than arises merely from the vagina ; I have convinced myself of this fact by the. observation of a case in which the men- strual blood proceeded directly from an inverted uterus.* The * See R. Wagner's Lehrbuch d. speciell. Physiologic 2d Edit. p. 236. INFLAMMATION. 377 fibrin is doubtless converted, during the discharge of the fluid, into mu- cus, through certain chemical influences of which we are still ignorant, but probably through the influence of the alkalies. This fact elucidates an analogous relation of the mucous membrane. Whenever hyper- aemia exists in this tissue, there is thrown off a viscid fluid not con- taining fibrin ; the only exception being in what is termed croupy inflammation. The probable explanation of this fact is, that the fibrin of the blood-plasma, during its effusion on the surface of the mucous membrane, is converted into mucus. Hence I believe that all those cases in which, after capillary hyperaemia, no fibrinous effu- sion is observed, or rather apparent than actual exceptions to the general rule. The second question : Whether every case of fibrinous dropsy must necessarily have been preceded by capillary hyperaemia, or whether it may arise from any other cause ? is one regarding which experience is still more at fault., It is true that we frequently meet with cases of fibrinous dropsy and its consequences, without, at the same time and place, observing capillary hyperaemia; but in such cases the hyperaemia may possibly have disappeared, whilst its pro- duct—the fibrinous dropsy—remains. On this point we must still rest contented with theoretical speculations which, from their very nature, can lay claim only to probability, not to certainty. As.long as we suppose that the connexion between these two processes is the same as we have stated (p. 58,) namely, that fibrinous dropsy arises from an extravasation of blood through the attenuated walls ef the capillaries, then it will remain probable that every case is de- pendant on capillary hyperaemia, till it has -been -demonstrated that it may arise from some other cause. The processes occurring in this group are designated in pathologv by- different names, in part individually, in part collectively. Those most in use are ranged under the heads of congestion, stasis, unci inflammation ; they are, however, of little value in pathological anatomy : but pathologi- cally considered capilla)-y hyperemia would be a more appropriate term than congestion, which may, doubtlessly, lead to an incorrect hy- pothesis. Pathological anatomy can only, in very rare cases, give any explana- tion concerning the presence of a stasis, and that solely where a micro- scopic examination of the circulation in living structures is possible. Moreover, this does not appear to be the right place to enter upon a dis- 32* 378 COMBINATION OF MORBID CHANGES. cussion of the causes of the stagnation of the blood, since no very satis- factory explanation of this process has been given; and since, in all pro- bability, the views which for the moment seem most correct will soon yield to others, in their turn to give place to newer ones. Critical sur- veys of the views entertained on this subject up to the latest date, may be found in Henle u. Pfeuffer, Zeitschrift fur rationelle Medicin. Vol. 2. Jahresbericht von Henle.—Wharton Joneses Report on the Changes in the Blood in Inflammation. British and Foreign Medical Review, No. 35)—and Spiess, Physiolbgie des Nervensystems. Braunschweig, 1844, p. 269, &c. Inflammation belongs as little to pathological anatomy as stasis and congestion ; it is only the individual processes, or rather the changes af- fected by the latter in the body, that belong to this department of science. But as it is customary to speak of inflammation with reference to patholo- gical anatomy, it appears necessary to say a few words as to the extent to which we may receive the idea of it. Inflammation is not a simple process, but rather the common result ofa series of processes, standing in connexion one with the other. Such are the processes which we have already included under the department of capillary hyperemia and serous dropsy. These processes, however, show themselves different in almost every individual case. Sometimes the whole Series is not passed through, and the process is arrested in its development, while in some individual cases those processes which we consider as associated with in- flammation are changed in the most various ways. Hence inflammation is very variable in its manifestations, and it becomes almost impossible to fix its real definition, or to determine its limits. The same is the case regarding other complicated natural phenomena which occur externally to the human and animal organisms ; and it would, therefore, be just as great a waste of time for meteorologists to contend whether or not we should consider every flash of lightening in a clear sky, as a storm, as for us'to dispute upon the point whether we dared reckon certain pro- cesses in the human body as inflammation. Practical medicine, in its present condition, endeavours to hold fast to a peculiar idea of inflamma- tion for the sake of its bearing upon therapeutics ; trying at the same time, to include it within definite limits. We will not contest the point in this case; but general pathology and pathological anatomy, which have not the same mere temporary interests, should not allow such a view to be forced upon them. Yet these sciences will be unable to an- swer satisfactorily the questions of practical medicine, until general ideas have been elucidated by another form of language—that is, till they have een reduced to their elementary phenomena. On similar principles some other questions must be answered upon INFLAMMATION. 379 which we have cursorily touched; as, for instance, the opinion of Engel (pp. 289 and 313) and others, that tubercles, and the pseudoplasma gene- rally, are always products of inflammation. The consideration of this view resolves itself into two parts, one of which must be answered by pathological anatomy, the other by pathology. In relation to pathologi- cal anatomy, the term inflammation signifies capillary hyperaemia, with fibrinous dropsy and its results. Here we are led to ask, whether this appearance occurs in every formation of tubercle; but a direct answer to this question is impossible, since the earliest stage of tuberculous for- mation is in most cases hidden from our observation. Analogy alone enables us to draw the conclusion, that, as in most other pathological epigeneses, this appearance precedes, and seems to furnish matter for the nevy structure, so in the formation of tubercles the same is most probably the case. This, however, does not exclude the possibility that in many cases, a qualitatively changed, nutrient fluid, even without abnormal in- crease—without capillary hyperaemia and fibrinous dropsy—may di- rectly pass into tubercles. It is the province of pathology to discover, whether those appearances generally considered to belong to inflamma- tion, and which do not fall under the department of pathological anatomy —as disturbances of the nervous system—do, or do not occur in thefor- mation of tubercles. If even in the course of time science should succeed in being able to give ai*affirmatory reply to these two questions, it must still be left to the judgment of the individual physician to decide upon this point according to the idea that he attaches to the term inflammation. This one example may suffice to point out the principles en which similar points must be decided. We shall notice, in the special part, the elementary changes which occur simultaneously, but which unlike those considered above, ap- pear to be accidentally associated together, and not connected by one originating cause. 380 PARASITES. CHAPTER VIII. INDEPENDENT ORGANISMS IN THE HUMAN BODY.— PARASITES. All the pathological formations which have been hitherto con- sidered are products of the formative power proper to the organism; however much they deviate in form, they are still parts of the body. Contrasted with these, are other formations in the human subject, which must be regarded, not as parts of the body, but as independent individuals, although their presence is more or less clue to the con- dition of the organism in which they are found. These independent organisms are termed parasites, and they sqgfar have a bearing on pathological anatomy, that they are, more or less, oonnected with pathological conditions. As all self-existing organisms which are found upon the earth range themselves in two/great natural kingdoms, that of plants and animals, so also do these parasites. Hence we distinguish parasitic plants, without animal motion, with simple organization, developing themselves, and growing after the manner of plants ; and parasitic ani7nals w"hich, as regard motion, organization, and propagation, belong to the animal kingdom. But the line of demarcation between the two natural kingdoms is so indefinite, that with our present means of determination, it sometimes remains doubtful whether an organized individual must be regarded as a plant or an animal—as, for example., in the case of baciUaria, closteria, and other allied species, which some, with Ehrenberg, includein the infusoria; while others, with equal propriety, refer them to the vegetable kingdom. This uncertainty applies also to some rare parasites, as for instance, the naviada which appear in human excrements, and the sarcina ventriculi. To parasitic formations is superadded a condition, by means of NATURE OF PARASITES. 381 which it becomes difficult in many cases to determine, not merely to which of the two natural kingdoms a structure belongs, but even whether it is to be considered as an independent parasite,.or only a degenerated portion of the body. This, for instance, is the case. with the highly curious pathological structures which J. Muller has observed in fishes, and has named psorospermia* It is only by future observations, carefully conducted with an especial view to the origin of these structures, that the question can be decided whether they are to be regarded as cells degenerated through morbid in-? fluences, or as independent (parasitic) individuals. These forma- tions have not, as yet, been observed in man, and are, therefore, in our case, objects of subordinate interest. But even in-the humane- subject there are pathological structures respecting which it is ques- tionable whether they are to be regarded as independent individuals, or as mere degenerations of particles of the body. Thus cancer- cells and other similar structures are by many classed with parasites as independent structures (semi-individual cells.) It appears to me that the question, " what are parasites ?" is not yet ripe for decision, but I venture to predict that a more advanced knowledge will limit the acceptation of parasites to those organic structures whose germs have penetrated into the organism from without; although, in order that they may develop themselves, there must prevail not merely a general, but often a special pathological disposition of the system. This view pre-sup- poses that parasites never arise by equivocal generation, but by propaga- tion alone—a point which is no longer doubtful. Of cancer-cells, however, it is more than probable that the germs are not necessarily derived from without, and, accordingly I cannot regard them as parasitic formations. I will remind those who affirm cancer-cells to be parasites, merely because nothing like them is found in the normal body, that they must consequently also consign to the same class the pus-corpuscles which exist in the same cases. Confining our observations to those formations whose parasitic nature cannot be called in question, we are met in limine by two points of more than general interest, which claim our attention, before entering into a detailed account of the individual parasites. They are—1, the origin of parasites; and, 2, their baneful influence on the human organism. ________________ * Miiller's Archiv. 1841. p. 477, &c. 1842. p. 193, &c. 382 PARASITES. Respecting the origin of parasites, there have existed from the most remote periods, when they were first remarked, till the present time, two opposite opinions. According to one view they are gene- rated, in the same manner as most other animals and plants, by pro- pagation from progenitors of like species; according to the second view, they originate from equivocal generation. That many parasites can and actually do arise by descent from parents of a similar kind (by gemmules, seeds, and ova,) is at the present day allowed.even by the believers in equivocal generation. The controversy hinges only upon the question: can some parasites, in certain cases, also originate de novo, or are those at present occurring invariably .and in every case derived from parents of like species? A positive reply to this question, based upon convincing observations and re- searches, is as little possible now as at the time when Pallas wrote his interesting dissertation upon the subject,* although since that period numerous eminent investigators have devoted their attention to the formative relations of parasites; but, nevertheless, it appears to me that a majority of important reasons favours the view that at the present time no parasites are spontaneously developed,-but that all are, in some way or other, derived from parents of like species. It is out of the question in this place to submit the doctrine of sponta- neous generation to a comprehensive criticism; and I am satisfied, there- fore, to give for those of my readers who are not familiar with the subject, a brief abstract of the present state of the doctrine, and refer those who are desirous of further information to the interesting work of Hein.f The idea of spontaneous generation is a philosophical necessity. All organisms with which we are acquainted, that are now derived from pa- rents of like species, must at one time have arisen in another manner without parents. Whatever name may be applied to this primitive Ori- gin, or whatever view may be taken of it, whether it be termed creation, or receive any other name, it is in reality spontaneous generation in con- * P. S. Pallas, de infestis viventibus intra viventia. Lugduni Batavorum. 1760.— "Traditis nunc omnium sententiis de viventium intra viventia origine, expositisque argumentis propugnantibus singulas et contrariis, cujuslibet erit verosimillimam mente comprobare, donee experimenta quae in hac parte maximopere deficiunt, certos nos reddunt." t J. A. Hein, die Lehre von der Urzeugung, Halle, 1844. EQUIVOCAL GENERATION. 383 trast with derivation from parents. This necessity of a spontaneous origin of the organisms at present existing is, moreover, daily proved by experience. Geology demonstrates that many, indeed the greater num- ber of the organisms now on the earth's surface, did not exist at an earlier period, since we find no vestiges.of them. Accordingly, it is undeniable that spontaneous generation occupies a prominent position in the history of the world, as a mode of origin of all organisms. The question, there- fore, turns only upon this point: can existing organisms, which at a former period originated spontaneously, and have subsequently propagated them- selves in another manner, again rise spontaneously 1 or, in other words, is there a repeated spontaneous origin of creatures of the same species ? Let us now consult experience for materials in order to reply to this question. We find that in all cases where opportunity has been afforded of tracing, by direct observation, the origin of an organism, it has taken place by propagation; whilst, on the contrary, not a solitary unexception- able observation of a spontaneous origin exists in the records of natural history. Analogy is, therefore, completely in favour of the view that pro- pagation is the only manner in which existing organisms are engendered. The value of this evidence is further enhanced by the history of science. In earlier times it was admitted that even the vertebrate animals were produced by repeated spontaneous generations; geese and ducks from barnacles, (Lepas); the batrachiu and serpents from mud; and still, at later periods, insects, as the coprOphagi, from dung ; and fleas from putrid urine. No one, at the present day, doubts that all these animals are gene- rated by propagation alone. Indeed, in modern times, chiefly through the labours of Ehrenberg, even the generation of infusoria has been limit- ed to the propagative system. Analogy would, therefore, lead us to conclude that parasites are also produced in this manner alone. The ob- jections which have been urged against this view, and the arguments which have been adduced in favour of a spontaneous production of parasites, rest chiefly on the ground that in many cases the origin of these organisms, by means of propagation, is inexplicable ; and is, there- fore, held to be impossible. But it is overlooked that the assumption of their spontaneous origin is in reality merely a formal explanation,, which leaves us completely in the dark respecting the true reasons and condi- tions of their production. Moreover, many of these reasons have latterly become invalidated by the progress of knowledge, since not merely the possibility, but also the reality of their propagation to other organisms, and the inducing conditions, have been demonstrated in various parasites; and although in this respect at present much appears mysterious, yet the numerous experiences of latter years must raise a hope in every unbiassed observer, that the further advancement of knowledge will clear up the 384 PARASITES. obscurity which at present envelops this province, and will establish the origin of all parasites by propagation, to the exclusion of spontaneous origin. The prevalence in the belief of spontaneous generation was an important obstacle to the progress of knowledge, since it hindered accu- rate investigations regarding the formative relations of parasites; and with the general diffusion of the view, that all parasites originate by pro- pagation, observations concerning their actual transference from one indi- vidual to another, will, doubtless, also accumulate. We shall return to this subject in our remarks on the individual parasites. We shall now consider the relations of parasites to the organisms which they inhabit, and to disease. If we assume that parasites are invariably derived from parents of the same kind, and are never produced spontaneously, it follows that they are never a true pro- duct of a disease, and cannot, therefore, originate directly from degenerated particles of the body, depraved secretions, &c. It is, however, undeniable that morbid changes of portions of the body frequently exercise a certain influence upon their origin. These changes may favour their development, and, indeed, alone render it possible, by inducing conditions essential to it; they can again prove injurious to it, since they may remove conditions necessary to its occurrence. Thus, for example, vegetable parasites (fungi) do not in general develop themselves upon mucous membranes, until, by morbid processes, a deposit of coagulated fibrin, which serves as a bed, has become prepared for them, and until this exudation has passed into a state, of putrid decomposition. An abundant secretion of mucus favours the development of worms which have entered the intestinal canal from without. Some states of the or- ganism, on the contrary, disqualify it as a habitation for parasites. Thus, most Of the entozoa in the intestinal canal are expelled by increased peristaltic action ; some fluids of the body, as bile, urine, gastric juice, and some medicines, prove deleterious, and indeed, fatal to some of them ; inflammation, or at least suppuration, may injure, and even destroy them. As the organism exerts an influence on the parasites inhabiting it, so conversely the latter react upon the organism. They fre- quently prove injurious to the system, either by mechanical irrita- tion (even by their mere presence, when occurring in large quan- tity, or by obstructing canals,) or by exerting a specific action, possibly by fluids which they secrete or in some other unknown EPIPHYTES. 385 way. This pernicious influence of parasites upon the organism— their morbific power—varies extremely in relation to different spe- cies. Whilst some produce scarcely any apparent symptoms, so that their existence during life is frequently not ascertained, (as in the case of the acarus folliculorum,) others give rise to positive dis- eases, as the acarus scabiei, pulex penetrans, and filaria medinensis. This subject, therefore, allows of no general statements; and we must postpone the special consideration of the effects which the different parasites entail upon the organism, to the descriptions of the individual species. The disease which accompanies their pre- sence is, however, invariably either an effect of'their presence, and is called into existence by the influence which they exert upon the organism, and by the reaction of the latter ; or the development of the parasites is, in the manner formerly explained, first rendered possible by the presence of a disease : the parasite should never be identified with the disease itself. We now proceed to the consideration of the separate species of parasites, with especial regard to those hitherto observed in man, although, so far as they serve to elucidate the subject, we shall also notice, those which occur in animals. PARASITES DERIVED FROM THE VEGETABLE KINGDOM--EPIPHYTES. All the parasitic plants which, up to the present time, have been observed in the human organism, belong to the lowest forms of vegetation—the algae and the fungi. They are all very minute, so that, to the unaided eye the greater number are totally invisible, and others are only perceptible when accumulated in large masses. In order to recognize their peculiar structure, and thus to arrive at a more accurate diagnosis, the microscope is invariably necessary, and very high powers are often required. They are found either upon exposed surfaces, namely upon the skin and mucous mem- branes, or. floating in the fluids of the body. I am acquainted with no authentic case in which they have been observed during life in the parenchyma of human organs. Respecting the origin of vegetable parasites, there are the same two different views which have been noticed in relation to the ori- 33 386 PARASITES. gin of parasites generally. Whilst, for instance, Kiitzing,* who has devoted much of his attention to the lower algae, maintains that their origin by repeated spontaneous generation, is possible, others limit their origin to the mode by propagation. Although a positive decision of this disputed question may at present be impossible, it nevertheless appears to me that there are overwhelming reasons in support of the view that they invariably owe their origin to propa- gation alone. These reasons are chiefly founded upon the re- searches of Schwann on fermentation, upon similar investigations of Helmholtz,f and upon others which Dr. Merklein has abundantly instituted upon this subject, all of which show, that under condi- tions which otherwise prove favourable to the formation of fungi and algce, these do not present themselves, when the possibility of the transference of uninjured germs is precluded. Moreover, all the parasites hitherto observed, increase in enormous ratios by means of gemmules or spores: the latter are so infinitely numerous, so minute, and maintain their germinating power so tenaciously against the most common external agents, that by means of water and currents of air they certainly become universally diffused, and can, therefore, develop themselves wherever they meet with favour- able conditions. That we have hitherto, in most instances, failed to demonstrate the origin of fungi by transference of germs, can be no argument against this mode of propagation; for, even in the most careful examination, certain fungus-spores, whose diameters are sometimes less than the 1000th of a line, may, and indeed always will escape the notice even of the most practised observer. In some cases the transference of parasitic fungi, or of their spores from one subject to another becomes facilitated by distinct rela- tions, as immediate contact, &c. ; as may occur in porrigo, in some forms of impetigo, mentagra, &c. These are the cases which are especially regarded as contagious. In general, however, peculiar con- ditions appear requisite for the development and increase of the trans- ferred germs—conditions which are in general only realized by patho- logical relations. It appears, for instance, that the surface upon which * Phycologia generalis. Leipzig, 1843. p. 129, &c.;or his remarks inErdmann'i Journal f. prakt. Chemie. 1837. vol. xi. p. 391. t Mailer's Archiv. 1843. p. 453, &c. EPIPHYTES. 387 they are to develop themselves must in general, if not always, be in a certain state of chemical decomposition (putrefaction or fermen- tation ;) as, indeed, we find that externally to the human and animal » organisms most fungi are developed only on putrefying substances. Experience shows us that parasitic fungi are especially liable to oc- cur on foul ulcers, and probably only exist on the skin or mucous membrane, in the cases where these are furnished with a layer of decomposing exudation. Parasitic plants have so far a diagnostic value, that they indicate that a process of decomposition is going on, however locally circumscribed it may be. Hence it follows that they do not become developed at all spots on which the germs are deposited ; their growth indicates a certain morbid disposition. This view is opposed by the results of experiments made with the view of showing that parasitic plants can be transferred by inoculation to apparently healthy organisms, and there give rise to morbid phenomena : thus, for instance, Hassal* was able to transfer, by inoculation, parasitic fungi from diseased to healthy lettuces, in which they produced the same disease (softening of the stem.) These cases, however, prove but little; they merely show that in some instances the disposition to fungoid de- velopment need not be great; and they are, moreover, open to the ob- jection that the plants which were inoculated, having, perhaps, the same habitat, and living under similar relations, already bore within them the morbid disposition. The pathological signification of parasitic plants, that is to say, their power of engendering disease, appears extremely various in different cases. Sometimes through their great bulk they may be- come mechanically injurious, as by obstructing canals, &c. ; of this, however, no instance has yet occurred in the human subject; they may accelerate incipient decomposition of the secretions, and thus prove chemically deleterious ; in some cases they may destroy or modify histological elements, (for instance, hairs.) Moreover, it is deserving of notice, that, by their tenacity of life, which in many cases, especially in some cutaneous diseases, (impetigo and favus) defies most chemical agents, they ensure to the concomitant affec- tion a very long duration. To animals they are sometimes more injurious than to man ; in the smaller animals they may even, » Froriep's, N. Notizen. Oct. 1843, p. 54, &c. 388 PARASITES. through their bulk, occasion death, by obstructing canals, &c* At all events, the part which these parasitic fungi act in the diseases which accompany them, is a question which renders more extensive investigations still desirable. A classification of parasitic fungi might be carried out according to botanical principles. It would, however, be very difficult, since the greatest number show no distinct fructifications, and the mycelia of most fungi in their early stages of development resemble each other in an extraordinary degree. Their elementary forms are simple cells, which enlarge by the protrusion, of new cells, or by prolonga- tion into filamentous structures. Their fructification consists of spores which are either free and agglomerated into pulverulent masses, or appear enclosed in proper fruit-beds (sporangia.) The numerous experiments which I have instituted, compel me to join in the opinion of K lit zing, who, in his observations on the low forms of vegetation, occurring in fermenting fluids, says :f "It is extremely diffi- cult to reply to the question : Can these structures be arranged into genera and species? I once attempted this distinction at a time when I had examined and observed only a few of these forms, yet, even then, their * Instances of parasitic plants injurious, and even fatal to animals, in consequence of their mass, are already very numerous, and fresh cases will almost daily be re- vealed. Amongst the more important cases in which animals have been attacked by vegetable growths, we may place those noticed in the following memoirs ;—Regard- ing the muscardine of the silkworm, see Bassi, del mal del segno, calcinaccio, omos- cardino. 2d ed. Milano, 1837 ; Audouin, recherches anatomiques et physiologiques sur la maladie contagieuse qui attaque les-vers a, soie. Annales des sciences natur. t. 8, p, 229 and p. 257. Nouvelles experiences sur la nature de la maladie, &c. A. Hannover uber contagiOse Confervenbildung an, Wassersalamandern, in Mul- ler's Archiv. 1839, page 338, and 1842, page 72; Stilling uber contagiose Conferven- bildung auf Froschen; in Muller's Archiv. 1841, page 279 ; Deslongchamp, sur des moississures developpees pendant la vie a la snrface interde des poches aeriennes d'un Canard Eider. Annales des sciences natur. 1841, t. 14, p. 371 ; Klenke, Neue physiolog. Abhnndlungen. Leipz. 1843, pp. 1—93; J. Muller (iber pilzartige Para- siten in den Lungen und Lufthohlen der Vogel, in his Archiv. 1842, p. 198 ; F. J. G. Meyer uber Schimmelbildung im thierischen Korper (in the Membrana nictitans of falco nisus) in his Neue Unters. aus d. Gebiete d. Anat. u. Physiologie, Bonn, 1842, p. 34, &c.; B. Langenbeck, Confervenbildung in dem Nasenausflusseeihes rotzkran- ken Pferdes. Froriep's N. Notizen, 1841, v. xx. p. 58. Confervse do not, howeyer always occur in the mucus of glandered horses; Henle never found them, ^Patholo- gische TJntersuclningen, 1840, p. 69 ^ neither was I more successful. t Erdmann's Jsourn. f. prakt, Chemie, vol. xi. p. 409. THE YEAST PLANT. 389 astonishing variety discouraged me from it." This announcement from one who has devoted so much of his attention to this subject, applies, I believe, equally to the parasitic forms of plants occurring in man and - animals. There can be no doubt, that here, as well as in the other or- ganized productions of nature, there are distinct species which do not, as Kiitzing imagines, pass into each other; but they present such mani- fold varieties, and the lower grades of development of different species so closely resemble each other, that a definite separation of them cannot,. for a long time, be contemplated. It is, therefore, very questionable whether the division, which some have attempted, and which we shall adopt, of human parasitic plants into distinct species, will be confirmed by future investigators. With respect to the questions, whether defi- nite species of fungi are invariably found .only in definite forms of dis- ease, or conversely, whether in ihe same forms of disease, different spe- cies of fungi can sometimes occur, and the same species of fungus in different forms of disease, I believe that their reply must be for the pre- sent deferred, and that only by the unanimous co-operation of physicians and botanists, we can hope to arrive at a safe conclusion. The following are the forms which have been hitherto observed*. in the human subject. I. FUNGI IN HUMAN FLUIDS* 1. The Yeast plant. Torula cerevisiw, Turpin ; Saccharornyces; Mycoderma cerevisia?, Desmazieres ; Cryptococcusfennentum,[K\iiz\ng.. This plant not unfrequently occurs in vomited fluids and in foetal evacuations ; hence it is principally found in the intestinal canal, into which, in the majority of cases, it is introduced from without, with fermenting fluids, especially beer. It is also possible that it may be developed in this locality by morbid fermentation taking place in the stomach and intestines, particularly by lactic-acid fer- mentation. It exists also, in the saccharine urine of diabetes mel- litus, but, in all the cases with which I am acquainted, (and I have observed a considerable number) not until after its evacuation from the bladder. These plants are round or oval corpuscles (cells,) varying in di- ameter from the 800th to the 400th of a line, and many having smaller corpuscles in their interior. This is their most simple form. They grow by protrusion of gemmules which, after some time, attain. 33* 390 PARASITES. to the size of the original corpuscle, and germinate sometimes on one, sometimes on several spots of the primitive fungus-cell. These shoots throwing off" new gemmules, the yeast plant gradually forms rows of oblong cells, connected together like beads. A congeries of such cells Consisting of from three to five, frequently even more) commonly forms one plant.* This peculiar arrangement of the cells is characteristic of this plant, and in doubtful cases, ensures its di- agnosis by microscopic examination. They are not acted upon by acetic acid. As single cells detach themselves from the parent plant, they form new individuals which again pass through the process of develop- ment already described. In this manner they may increase abun- dantly. In rare cases a mother-cell enlarges and there are gene- rated within it, small granules (sporidia) which, after the rupture of the mother-cell, emerge and serve as germs for new plants. It appears to me that these fungi do not possess any peculiar pa- thological value; at most they serve as an indication that fermenting substances containing yeast, have been conveyed into the organism, or, that the animal; fluids contain elements susceptible of fermentation. In this manner we may infer that a specimen of urine in which they oc- cur contains sugar. Nevertheless, their presence in this fluid is far from a safe indication of a saccharine condition, for I have repeated- ly observed fungi, more or less nearly resembling the yeast plant, in urine which contained no sugar; as, for instance, several times in the urine of an uncleanly prostitute, and likewise in a specimen of urine which contained fibrous coagula corresponding to the uri- nary canals. In the latter case, besides simple cells, the fungi con- sisted of elongated, partially ramifying filaments, so.that their struc- ture approximated to the,more developed forms of the favus plant. In all these cases the fungi undoubtedly did not develop themselves till after the evacuation of the urine, and then probably from an espe- cial condition of the secretion presenting to them a genial soil for their growth. Fungi are probably not unfrequent in the fluids of the intestinal canal, but they readily escape observation when they occur singly, and form minute isolated cells. * See Plate x. fig. 8. SARCINA VENTRICULI. 391 Cases of this kind are specified and described by Bohm,* Henle,f my- self, Gruby,J and others. There are two totally different classes of cases, between which we must discriminate: 1. Those in which the whole of the yeast plants have been conveyed into the body with fermenting drinks, and have there undergone no fur- ther change, but have only passed through it (as in cases described by Bohm and Henle.) 2. Those in which the fungi, their single spores having probably penetrated unobservedly into the body, have become further developed and multiplied, in consequence of a special morbid disposition (by the formation of lactic acid, (?) and perhaps also of acetic acid, (?) cases of which have been observed by myself and Gruby.) The latter cases alone have a pathological signification. Sarcina ventriculi, Goodsir. This parasite has been hitherto found in only a few instances, and never except in vomited fluids. In its entire habitus it is allied to the species gonium, which although placed by Ehrenberg amongst the infusoria, is, however, probably a plant. The sarcina forms quadrangular or oblong plates varying in diameter from the 100th to the 120th of a line. The thickness of the plates amounts to about the eighth of their diameter. Under low powers the sides appear straight and the angles sharply defined, but under higher powers, the sides appear indented, and the angles rounded off. Each plate appears divided into four squares (secondary squares,) by two bands intersecting at right angles in the centre ; each of these four squares subdivides in a similar manner, into four ternary squares; and each of these sixteen ternary squares appears with stronger powers composed of four squares which are in immediate contact. § The cells are ofa brown colour, and their interstices are transparent. Iodine communicates to the sarcina a dark yellow or brown colour; alcohol renders it somewhat shrivelled ; it is not de- stroyed by boiling nitric acid. It propagates by division. Nothing is at present known with certainty respecting its primary origin, and its pathological indications. * Die krankc Darmschleimhaut in der asiatischen Cholera, Berlin,'1828, p. 57. * Patholog. Untcrs.uchungen, p. 42. X Compts rcndus, 1844, t. xvm. p. 586. § So j Plate x. fig. 11. 392 PARASITES. The sarcina was discovered by Goodsir in a fluid vomited at regular intervals by a man; the fluid was in a state of fermentation, and accord- ing to Wilson's analysis contained, besides some hydrochloric and lactic acids, a very large quantity of acetic acid.* It has since been observed in three cases by Busk.t Whether we place the sarcina with the genus gonium in the animal kingdom, or whether we regard it as a vegetable, it most probably, like the yeast plant, stands in the most intimate relation with chemical decomposition (phenomena of fermentation,) occurring in the stomach. Although it has been hitherto found only in the stomach, yet its germs may have penetrated from without. II. PARASITIC FUNGI ON THE HUMAN INTEGUMENT AND ITS APPENDAGES. Fungi of this nature have, during the last few years, been fre- quently observed in the human subject, and fresh observations are being continually made. As a general rule presenting but few ex- ceptions, they appear incapable of being developed immediately on the epidermis, or on the epithelium of the cutaneous glands, and can take root and multiply only when, by peculiar relations, a favoura- ble soil has become prepared for them. These conditions are pre- sented by fibrinous effusion of the cutis, the fibrin of which coagulates whilst the albumen, together with the other elements, dries and forms tenacious masses (crusts.) To these, when they have undergone a peculiar chemical decomposition, which is not at present clearly un- derstood, fungus-spores and gemmules seem to adhere, and there develop themselves. Uncleanliness appears greatly to favour this development. That under fixed relations the same definite forms of fungus are alone developed, although, no doubt, very different species of germs fall upon the skin, need occasion no surprise, if we consider that the evolution of fungi is generally confined to very decided re- lations of soil, and that most forms of fungus in their lower grades of development, when they exhibit only a mycelium, resemble each other in an extraordinary degree. Under favourable circumstances * Edinburg Medical and Surgical Journal, 1842, vol. lvh. p. 430, et seq. with figures. t Microscopic Journal, January, 1843. FUNGI IN TINEA FAVOSA. 393 by assisting in a direct transference of germs from one individual to another, the development of these fungi can, at all events, be facili- tated ; and thus far, some of these forms can be deemed contagious; but the vis contagiosa is very slight, and appears to be associated with a completely defined disposition, so that in a perfectly healthy individual, the transferred germs of most fungi are probably incapa- ble of developing themselves. We shall recur to this subject in our observations on the Separate forms. In their elementary form the fungi of this class usually consist of simple cells which, like the yeast plant, evolve new cells by gemma- tion : these, again;, commonly grow out into jointed filaments, of varying length, and it is only in rare cases that these fungi appear to undergo perfect development, and to exhibit decided fructification. Their botanical determination thus becomes very difficult. The Pathological importance of these fungi is in most cases small; occasionally, however, they acquire an importance from obstinately- resisting all efforts to eradicate them; and in certain cases, they ap- pear, by their development, able to destroy organized parts of the body, as for instance, the hair. In a diagnostic point of view their value is greater, since, where they occur in large masses, they are accustomed to impress upon the pathological change a peculiar cha- racter. The following are the most important of the forms hitherto ob- served. 1. Fungi in the scrofulous scald-head, (Tinea favosa—Porrigo lupinosa—Favus and .llphus: Fuchs.) The crusts in this disease consist for the most part of fungi, which are united by, or rather, are rooted in an amorphous matter, (dried fibrinous effusion.) The fungi of favus closely resemble yeast plants ; in their most simple form they appear as roundish or oval eells which increase by gem- mation. The gemmules are frequently elongated into filaments, which are either simple or ramified.* Acetic acid produces no change in these fungi, but renders them more distinct, in conse- quence of rendering transparent the amorphous mass in which they are enclosed. I am firmly persuaded that in tinea the (scrofulous) exudation from * See Plate x. fig. 6 and 7. 394 PARASITES. the vessels of the cutis, is the primary cause and essential condition; it prepares the bed in which-the transferred germs are developed. Attempts to inoculate the disease by transference of fungi to other parts of the skin of the same body, or to other individuals, com- monly fail, as has been shown by the experiments of Gruby, J. H. Bennett, and myself. That the development of the fungi originates within the epidermis or beneath it, is improbable: yet the germs may gain access to its inferior (most recent) layers by means of fis- sures in it, occasioned by the exudation, and thus it might seem as if they had been engendered beneath the epidermis. The most accurate description of these fungi has been given by Gruby,* although they were previously noticed by Schonlein,t and E. H. Fuchs.J See also, the memoir of J. H. Bennett.§ 2. Fungi in the sheath of the hair in cases of mentagra, have been observed by Gruby. They form a layer around the root of the hair, between it and the sheath, investing it as closely as a glove fits itself to the finger. The fungi resemble, generally, those of favus, but their spores are not oval, as in that case, but present a roundish ap- pearance, and the thallus-filaments proceeding from the spore-cells, have frequently small granules in their interior. In reference to the origin and pathological indication of these fungi, no doubt the same holds good, as has been stated in relation to tinea. || 3. Fungi in the interior of the hair roots have been observed in herpes tonsurans by Gruby and Hebra,, and in plica polonica by Giins- burg. They are developed in the interior of the hair-root, from small round spores; these soften, render the hair brittle, and finally cause it to break off'or to fall out.1I Under this head, we must include the fungi which are observed * Comptes rendus, July and August, 1841. t Muller's Archiv. 1839, p. 82, with figures. X Die krankhaflen VerSnder'ungen der Haut, Gottingen, 1840. § Trans, of the Royal Society of Edinburgh, vol. xv. Part ii. || See Gruby, Comptes rendus, 1842, t. xv. p. 512, where there are also laid down distinctions, which I, however, believe to be unessential, between this plant, and other parasitic fungi. TT See Gruby, Comptes rendus, 1844, t. xvm. p. 583 ; Gunsburg in Muller's Archiv 1845, p. 34,with figures; see also the chapter in the special part, on the anatomy of the hair. FUNGI ON MUCOUS MEMBRANE. 395 in certain cases upon the skin in gangraena senilis, and upon blis- tered surfaces a few days before death;* also a case described by Mayer, f in which fungi had developed themselves in the external auditory meatus of a girl—an observation which is especially inte- resting from the fact, that the fungi attained a much higher grade of development than in the cases previously described. Fungoid structures have been observed on the integument of animals more frequently than on man. In addition to the instances already cited Bennett, (op. cit.,) has found upon a domestic mouse, fungous structures perfectly similar to those which occur in the tinea favosa of the human subject. He also observed fungi upon the skin of a gold fish (cyprinus auratus.) III. PARASITIC FUNGI ON THE MUCOUS MEMBRANES OF THE HUMAN BODY. These are by no means unfrequent, a*nd in recent times have been seen by numerous observers. In essential relations they perfectly resemble those occurring on the skin, and they appear never to take root on sound mucous membrane, but always upon a decomposing exudation from the mucous surface. We find them in the apthae of children, and on the pseudo-mem- branes which cover the mucous membrane of the mouth and fauces in diphtheritis attacking adults; in certain cases they are found in ulcers of the mucous membrane in typhus and other diseases. In form they sometimes approximate to the fungi of favus; at other times they differ from them in growing out into long thallus- filaments, which at certain parts, commonly at their termination, present protuberances in which granules (spores) are developed. Vide A. Hannover in Muller's Archiv, 1842, p. 281, with figures, who also gives the earlier literature of the subject; also Gruby in the Comptes rendus, 1842, t. xiv. p. 634. Respecting the very frequent fungoid struc- tures on the mucous membranes of animals, see the above mentioned works. J. H. Bennett once found fungi in the sputa and lungs of a man • Heusinger, Berichl von der Konigl. zootomischen Anstalt in WQrzburg, 1826 p. 29. t Mailer's Archiv. 1844, p. 404, with plates. 396 PARASITES. with pneumothorax,* and several times in the black matter which invests the teeth and gums of patients in the last stage of typhus, (loc. cit.) PARASITIC ANIMALS. The parasitic animals occurring in the human subject, present in their relations a much greater diversity than the parasitic plants. Attempts have been made tov classify them according to various ar- rangements. 1, According to the parts of the body> and the organs which they are accustomed to infest. In this respect a distinction is drawn between epizoa (ectoparasites) which live upon the surface, and entozoa (entoparasites,) which inhabit the interior of the body. This division is, however, "somewhat arbitrary since, for" example, the intestinal cavity, which lodges by far the greatest numher of entozoa, com- pared with the external surface of the body, is undoubtedly and re- latively internal; compared, however, with the parenchyma of the organs it is relatively external. Moreover, some only of the para- sitic animals have^a definite part of the body or an organ for a ha- bitation, out of which they are never, or only rarely found, whilst others have a very wide distribution, and probably in different stages of development can exist in the most dissimilar parts. 2. They have been classified according to their position in the zoological system. This classification of parasitic animals is the most valuable even for the practical physician, since it alone leads to a perfect comprehension of the forms and distinctions of the se- parate species, and since we must look exclusively to scientific zoo- logical investigations for further infprmation respecting the obscure mode of origin of these animals, and their occurrence in the human body. 3. Parasitic animals may be distinguished into those whose spe- cial abode, ordained to them by nature, is the human or animal body —true, essential parasites; and into those, to whom nature has as- signed another habitation, and which only incidentally, and in con- sequence of peculiar circumstances, occur within the body, and are unable to survive there—incidental parasites. * See Plate x. fig. 12. PARASITIC ANIMALS. 397 Animals of almost every class, even vertebrata, as for instance, am- phibia (toads, frogs, salamanders, blind worms,) also insects, and their lame, snails, &c.,have been occasionally met with, forming incidental parasites. Many of the cases registered in the annals of science, are, however, at least doubtful, and some reports of the kind, are evidently founded upon false statements, or even intentional decep- tion. We shall not at present enter more deeply into the consideration of these incidental parasites. With respect to the different species observed in se- parate parts of the body, and the pathological changes elicited by them, we must refer to the special part. In this place we shall only consider the true parasites, especially those which occur in the human subject, citing those which are found in animals, only so far as they serve to the elucida- tion of the cases observed in man. The questions regarding their mode of origin, and the pathological phe- nomena occasioned by their presence will be had regard to, so far as our present deficient observations allow, partly in our remarks on the indivi- dual species, and partly in our remarks on special organs, since on these points general laws cannot be laid down. Every unbiassed observer must arrive at the conviction that the morbific power is very different in the separate species, and will regard it as a far from completed scientific labour to point out, exactly, the extent of this power in each individual case. According to the prevailing systems, pathology has caused the pa- rasitic animals to perform, amongst the causes of disease, sometimes a very subordinate, at other times, a very conspicuous part. Indeed, animal parasites have been regarded by some as the causes of almost every dis- ease. See J. C. Nyander, Exanthemata viva in C. Linnaei amoenitates academics, vol. v. Holmiag, 1760, p. 92—105; also in recent times F. V. Raspail, Histoire naturelle de la sante et de la maladie, &c, Paris, 1843, t. i. p. 285—496, t. u. p. 1—286, with numerous figures—a strange mixture of truth and fiction, yet, for the critical reader, containino- some interesting facts, and profitable suggestions, for further investigations. The reader may also consult the work of v. Olfers, which in some respects, however, is becoming a little antiquated, de vegetativis et animatis cor- poribus in corporibus animatis reperiundis, P. 1, Berol, 1816, c. tab* * I regret exceedingly that I had not the opportunity of consulting the excellent article " Parasiten," by K. Th. v. Siebold in Wagner's Handworterbuch der Phy- siolog. vol. if. p. 641, &c. ; which did not reach me till these sheets were printing; hence, instead of incorporating his results in the text, I must content myself with referring to his most important conclusions in the notes. 34 398 PARASITES. I. PARASITIC INFUSORIA. In the inferior animals, infusoria very frequently occur as true pa- rasites, both on the external surface of the body, and in their inter- nal cavities. Thus in the intestinal canal of the frog, Ehrenberg distinguished no less than five different species of bursaria. The infusoria occurring in the human body appear, on the contrary, to be not so much true as incidenal parasites. The condition most es- sential to their development appears to be a degree, however slight, of putrid decomposition, such as occurs normally in faeces and in many animal fluids'as a pathological phenomenon. Infusoria are consequently very frequently seen in fasces, and .sometimes also in foul and impure ulcers.. The infusoria which, under these circumstances, appear most fre- quently in the body are vibriones, especially a species of them which is met with in almost all putrescent fluids, containing protein (vibrio prolifer ? Ehrenberg.) Seen under strong magnifying powers these vibriones form sometimes simple, sometimes compound (from two to six) bead-shaped globules, ranged upon each other,* and exhibit a very active animal motion. By feeding them with carmine, I have sometimes succeeded in bringing the gastric cavity into 'view, I have frequently, but not invariably found these vibriones in faeces, especially in liquid evacuations, also in the -pus of foul sluggish ulcers. Donne has found thisor another species of vibrio (v. lineola 9) in the pus of chancres.f Of other infusoria, I have sometimes found in fasces the exuvias, and less frequently, active specimens of navicula. Upon foul ulcers and in the pus from them, vorticella and also cul- poda cucullus have been occasionally observed. DonneJ asserts that he has found a peculiar infusorium, which he names trichomonas vaginalis,^ in the vaginal mucus of syphilitic females; it is supposed by R. Froriep and Ehrenberg to be a species of acarus. I, however, agree in opinion with Gluge and Valentin, that probably this imaginary infusorium is not an animal at all, but separated ciliated epithelium from the uterus.1l * See Plate x. fig. 10. . . - t Recherches microscopiques sur la nature des mucus secretes par les organes'g©- nito-urinaires, Paris, 1837, X Op. cit. § See Plate x. fig. 9. II Siebold also maintains this opinion, op. cit. p. 660. PARASITIC INFUSORIA. 399 The occurrence in the living body of the infusoria which have been described, and of other species which probably will yet be occasionally observed, need occasion no surprise, if we consider that infusoria generally, and especially the specified forms, belong to the most abundant of all the lower animals, which make their appear- ance by millions whenever conditions favourable for their develop- ment are afforded. They have little or no pathological importance, and at most serve but to show that, where they appear, there exists a putrid decomposition of the elements of the body to a greater or less extent, not otherwise demonstrable by exact means. Donne maintains that the vibriones of chancres (and even the trichomonas) constitute the true contagion of syphilis, an'opinion which is directly controverted by the fact, that these animalculse do not .exist in the pus of syphilitic buboes, which, nevertheless, according to Ricord's experiments, by inoculation also produce actual chancres. Beaiiperthuys and Adel de Roseville assert that in cancer, as well before as after softening, they have invariably found animalcules, and believe that to these must be attributed the origin, progress, and fatal termination of this disease,*—a view which is undoubtedly erroneous, even allowing that infusoria do sometimes occur as incidental parasites in cancerous ulcers- Klencke states that he has observed in the human blood the appearance of animalcules resembling infusoria, and traces their connexion with,the occurrence of periodical attacks of vertigo.t. In the blood of animals, in- fusoria have been often found; thus proteus-like infusoria (amoeba of Ehrenberg) have been seen by Valentin in the blood of salmo fario,\ and by Gluge in that of frogs.5 How these animals gain access to the vascular system, is a point upon which at present we can only entertain conjectures, although I have no doubt that they penetrate from without, and are not engendered by equivocal generation. It is not every form of infusorium, which artificially (by inoculation) introduced into the circulation of an animal, develops itself further; this ensues only when the conditions are very favourable for their development, which is rarely the case; otherwise they are very soon lost. In this point of view, an experiment I instituted * Froriep's Neue Notizen, vol. v. p. 112. t Neue physiologische Abhandlungen, Leipzig, 1843, p. 163, &c.; see also Siebold on this point, op. cit. p. 649. 1 Muller's Archiv. 1841, p. 435. $ Comptes rendus, 1842, 14, p. 1050. 400 PARASITES. myself appears to be worthy of communication. From a full grown cat, about one ounce of blood was abstracted, and in the place of it, there were injected two ounces of a fluid containing very numerous infusoria. This fluid was water in which an ape had been macerated during a period of two months; it contained millions of infusoria which belonged to one and the same species; they were oval, the 200th of a line in length, and the 300th in breadth (either a species of monas, or the young of cyclidium glaucoma?).. Besides these infusoria no solid particles were contained in the fluid. After the lapse of twenty-three hours, about sixteen grains of blood were drawn from the cat. They contained no trace of these in- fusoria. Two days afterwards the animal was killed, and the blood care- fully examined; it contained no trace of infusoria; they had all (notwith- standing that millions had been injected) disappeared without leaving the least vestige. It was interesting to observe that, in consequence of the injection (?) the blood of this animal* presented a very decided increase of its fibrin. Whilst before the injection the blood contained in 1000 parts only 1.4 of this constituent, two days afterwards the same quantity yielded 6.68 parts. II. PARASITIC INSECTS. Insects have been very frequently observed as incidental parasites in and upon the human body; as the ear-wig (forficula auricularia,) the eggs and larvae (maggots) of different species of flies (sarcophaga carnaria, musca cadaverina, m. Caesar, m. vomitoria, &c.,) which are sometimes found in foul ulcers, even upon the living body. i To those might be added many other species, whose enumeration in this place would carry us too far; we shall revert in the special part to the most interesting of this class of cases. For those who desire to prosecute this subject, the above-mentioned work of Raspail, Histoire naturelle de la sante, &c, offers an abundant fund Of information, which, however, re- quires to be very cautiously employed* Of this class the only true human parasites are fleas, lice, and bugs. a. fleas, pulicina. The common flea (pulex irritans) lives upon the skin of man, but occasionally forsakes it, particularly in the summer, and is then to * See also Siebold, op. cit. p. 654. THE FLEA—THE LOUSE. 401 be found in gardens and woods, in sand, earth, &c. The female deposits her eggs in putrid materials, manure, saw-dust, decayed vegetable matter, rags, &c.: sometimes also under the toe-nails of dirty persons. From the eggs, which have the size of a small pin's head, there are developed minute apodal larvae, which after ten or twelve days become transformed into chrysales. Out of the pupae come the perfect fleas which then subsist as parasites on man and animals. The pathological importance of the common flea is known to every one ; whilst piercing the epidermis with its proboscis, it effects, by suction, a small extravasation of blood which appears as a red point surrounded by a paler red areola. Representations of the common flea may be seen in Duges Annal. des sc. natur. lere serie, 27, 14.7, pi. 4, fig. 1 ; in Raspail, op. cit. t. 2, p. 48, &c.; in Joerden's Entomologie und Helminthologie des menschl. Kb'rpers, vol. i. p. 41, taf. 4. The fleas of domestic animals (pulex canis, felis, gallinaa, &c.,) which likewise occur occasionally as transitory inhabitants of the human skin, are different from the true human flea. See also Bouche, Nova acta natur. curios, vol. xvn. Part 1, p. 503, and Duges, op. cit. 2. The chiggo, (pulex penetrans) is a smaller, almost invisible, black' flea, which inhabits South America. The female penetrates through the skin of man and the domestic animals into the cellular tissue of the toes, and there deposits its eggs which, if not removed in time, may produce very malignant ulcers, and even cause death. See Duges, Ann. des sc. nat. 2e serie, 6, p. 129, with figures; Perty in the Voyages and Travels of Spix and Martius: Delect. Insect. Brasil, p. 34; Pohl and Kollar, Bras. voiz. last. Insekten, Wien, 1832;* ib. LicE,;pedieulina. The crab-louse, (pthiiius inguinalis, Leach, pediculuspubis, Linne.) exists among the Iiairs around the genitals, and in the eyebrows of dirty persons. * .Siebold, op. Farre states that he has observed in it an intestinal canal with evident walls. On account of its symmetrical form, I hold the invest- ing capsule of the worm not to be a secondary cyst produced, as in the case of hydatids, by reaction of the organism which harbours it, but be- lieve that it pertains to the worm itself, and is the result of a kind of me- tamorphosis of the animals. This view is supported by the regular form characterizing these cysts, which are elongated and terminate in pestle- like extremities. Most trichina?, before they can escape from their cysts, undergo the calcareous incrustation already noticed. What becomes of those which quit the cysts is'unknown. The trichina? which.Bowman has observed in the interior of the primitive muscular fasciculi should be probably here noticed; possibly the animal afterwards becomes larger, and attains to a more developed form of the nematoidea. In favour of the origin of a trichina? by transference, it may be mentioned that they (probably the same species) have been observed also in animals. Diesing has found them in the horse; Siebold in several of the mammalia and birds: I have found perfectly similar animals in the peritoneum of an owl, and a few days ago, through the kindness of my colleague, Professor Herbst, I observed trichinae, completely resembling those occurring in the human subject, in nearly all the muscles of a cat. The detection by se- veral recent observers of filaria-like worms in the blood of different ani- mals, is suggestive of their mode of origin. See Rayer, Archives de med. comparee, 1843, t. I. p. 40 et seq.; Vogt in Muller's Archiv. 1842, p. 189; and Gruby and Delafond in Frpiiep's N. Notizen, Febr. 1843, p. 231. 5. The trichocephalus despair, (trichuris, Roed. and Wagl.) or long thread-worm is a thin, filiform animal, varying in length from an inch and a half, to two inches. It consists ofa very delicate, capil- lary anterior portion, which includes about two-thirds of the length * Transact, of Zoological Soc. vol. i. London, 1835, p. 315 et seq. t Medical Gazette, Dec. 1835. X Muller's Archiv. 1836, Jahresber. p. 227. § Froriep's N. Notizen, 1840, vol. xin. p. 309, vol xiv. p. 235. || Medicinische Annalen, vol.-vi. p. 232 and 485. TRICHOCEPHALUS DISPAR. 417 of the worm, and then passes rather suddenly into a strikingly thicker posterior extremity. It is usually white, although occasionally some- what coloured. The worm has separate sexes, the males and fe- males being essentially different; and hence the name dispar. The male is rather smaller than the female ; its capillary anterior part is pointed, the thicker posterior portion is spirally coiled, and exhibits on its extremity a long penis (spiculum,) invested with a proper sheath. In the female the capillary anterior portion is longer; the thicker posterior part being straight, and only a little inverted at the extremity ; the penis with its sheath is absent. The eggs are oval, with resisting shells, and when mature, measure the 40th of a line in length. The trichocephalus dispar is of very frequent occurrence in the large intestines, particularly in the human ccecum ; it sometimes oc- curs in nearly half the subjects examined. Sometimes it is found alone, at other times in great numbers. It firmly adheres by its ca- pillary head to the mucous membrane. The pathological importance of this worm appears slight, since it is frequently found in great quantities in persons, who during life did not exhibit any symptoms of its presence. Bremser, p. 76, PI. 1, fig. 1 to 5. On the anatomy of the trichocepha- lus, see Meyer, Beitr. zur Anatomie der Entozoen, p. 4 to 14. A similar trichocephalus, apparently the same species, is found in swine. 6. The trichocephalus affinis, Rud. a species other wise occurring only in the ruminantia (of the genera cervus, antilope, ovis and bos) is stated to have been once found in the human subject, on a soldier who had died in Fort Pitt from angina tonsillaris: this worm was found in the left ton- sil,* which was tumid and gangrenous. . 7. The spiroptera hominis, Rud. is a small, delicate, spirally coiled worm of white colour, and with separate sexes. The two sexes differ in their form and size. The male measures eight, the female ten lines in length. The head ends obtusely, and has one or two papillae, and an orbi- cular mouth. The body is round, tapering towards both extremities, especially towards the anterior. In the female the tail is thick with a short, blunted point; in the male, thin, with a tube—probably the sheath of the penis. An aliform appendix towards the tail is characteristic of this animal. * Monthly Jouraal of Medical Science, 1842. May. 418 PARASITES. The spiroptera hominis has hitherto been only found in one instance, by Barnett of London, and is stated to have been discharged with the urine by a woman. It possesses at all events no great importance. Figured by Bremser (PI. iv. fig. 6 to 10) who regards these worms as yOung strongyli. 8. The strongylus gigas, Hud. is a very large, round 'worm, vary- ing from five inches to three feet in length, and from two to six lines in thickness, and, when recent, of a blood-red colour. The sexes are separate, and differ in form. The male is smaller than the fe- male, and tapers somewhat towards both ends. The head is obtuse, the mouth orbicular, and surrounded by six minute papilla?. The body is marked by circular stria?, and presents several shallow longi- tudinal furrows. At the posterior extremity, the male presents an infundibuliform pouch, from which a very slender penis protrudes. The female is larger and has a straightly extended and obtuse tail, on which may be seen the oblong anus. Its vulva is one or more inches distant from the extremity of the tail, according to the size of the individual. The ova are almost globular. The strongylus gigas inhabits the kidneys, and the cellular tissue surrounding them. It is highly dangerous, and by its presence may occasion a total destruction of this organ, or even cause death. This species occurs also in several animals—the horse, dog, wolf, mar- ten, &c. See representations in Bremser, PL 4, fig. 3 to 5; Gurlt, Lehrb. der pa, tholog. Anat. der Hauss'augethiere, PI. 8, fig. 25 to 28, and Rayer, Mala- dies des reins, 9. The round worm, ascaris lumbricoides, Linne, is of common occurrence, and of considerable size, varying from six to ten, or even fifteen inches in length, although occasionally, however, smaller, as from one to two inches long. It is usually of a whitish or brownish red colour, and.occasionally blood-red. Its body is round, cylindrical, and pointed at both ends, but more decidedly at the anterior than at the posterior extremity. A delicate furrow runs along the body upon both sides. If the worm is examined under the microscope, it is perceived that the head is separated from the body by a kind of circular constriction, and presents three tubercles or peculiar valves, which can open and shut themselves, and have be- ASCARIS. 419 tween them the proper opening of the mouth. In the interior of the body we may recognise the brownish intestinal canal which termi- nates in the anus, a little anterior to the extremity of the tail. This worm has the sexes distinct. The male is somewhat smaller, and has a more curved tail, from which, at intervals, the double penis is seen protruding. In the female, again, we may recognise the sexual organs, ovaries and oviduct, as white, partly thread-, partly riband- like organs which when the worm breaks, readily fall out, and having become detached are frequently mistaken for individual Worms. The ova measures the 25th of a line in length, and have a thin smooth shell. The round worm is of very frequent occurrence in the small in- testines of the human subject, especially in children. Its presence is not so injurious as is commonly supposed, for it is often found in. great numbers without the slightest disturbance of the health. Yet it may certainly become troublesome 'and even injurious, either by reason of its accumulating in great numbers, and exciting mechani- cal irritation in the intestinal canal, or even closing it up,* and thus producing gangrene, or by entering into the stomach. In certain cases it appears to be capable of even perforating the intestine, by thrusting asunder with its head the fibres of the intestinal coats: it thus passes into the cavity of the abdomen, where it gives rise to in- flammation, suppuration and abscess. Sometimes it-even escapes externally through the abdominal walls.f These cases are, how- ever, very rare. This subject will be continued in the special part.! That round worms are not generated spontaneously,, but pass into the body from without, is scarcely questionable, although the man- ner in which this takes place cannot be, at present demonstrated. See Representations by Bremser, PI. i. fig. 13 to 17. Respecting its internal structure, vide Jules Cloquet, Anatomie des vers intestinaux as- caride lombricoide et echinorhynque geant, Paris, 1824. 10. The ascaris alata, Bellingham, is a species once found in the human subject, namely in Ireland, by Bellingham; the extremity of the head is * Haller observed an instance in which a girl aged ten years, died from the accumu- lation of ascarides in the fauces, mouth, trachea and bronchi. t See Oesterr. medic. Wochenschrift, 1843, p. 661. X See Siebold, op. cit. p. 667. 420 PARASITES. furnished with membranous, semi-transparent alae, similar to those occur- ring in the ascaris of the cat, (ascaris mystax) but so far different that, in a. mystax, this appendix is broader in front than behind, while in a. alala, on the contrary, it is broader behind than in front. Vide Dujardin, op. cit. p. 156. 11. The thread worm, (oxyuris vermicularis, Brems, ascaris verm. Rud.) is a thin white worm even smaller than the trichocephalus. These worms are of separate sex, and the male and female have a very dissimilar appearance. The male which is far the rarer of the two is much smaller, varying in length from a line to a line and a half, spirally coiled at the tail,, and often completely assuming the form of a ring. The head is not much thinner than the tail, and under the microscope, shows a transparent tuberosity apparently forming lateral ala?. The female^is hot annulated, but extends in a straight line, or at most slightly undulates. Its cephalic extremity corresponds to that of the male, and bears a similar vesicular tu- berosity. From its head to its anterior third, the worm increases somewhat in thickness; it then contracts in diameter, and terminates in the tapering awl-shaped tail, of which the extreme point is so fine, that it is totally invisible to the unaided eye. The eggs are not symmetrical, being more convex upon, One side than upon the other: they measure the 36th of a line in length, and the 62d in breadth. These worms occur very frequently, and in great numbers in the large intestines—particularly the rectum—of the human subject; they are especially.common in children ; and in the female sex, sometimes pass into the vagina. They are not particularly inju- rious, but frequently excite an intolerable itching of the xinus, and in this way become very troublesome. In the vagina they occasion still more violent irritation. See figures in Bremser, PL i. fig. 6 to 12. SECOND ORDER. TREMATODA. 1. The liver-fluke, (distoma hepaticum, Abilgaard ; and disl. lan- telatum, Mehlis.) These two species of distoma, resemble each bther very closely. They are flat, ovo-lancet-shaped worms, of THE LIVER-FLUKE. 421 yellowish colour, and somewhat truncated at both ends. With the aid of a lens, we perceive upon them, two round suckers, of which the anterior, situated on the head, forms an actual mouth. Between it and the body lies a short, scarcely distinct round neck, which merges very gradually in the body. The second sucker is situated upon the abdomen; it is roundish or oval, rather larger than the anterior, and instead of being perforated, forms only a blind sac. Between these two mouths, may be detected a third opening—the excretory duct of the sexual organs. The distomata are hermaphro- dites. It is only very recently, and mainly through the labours of Mehlis, that we have acquired a knowledge of the distinction between the two species. The distoma hepaticum is larger, the young being four lines long, and one and a half lines broad ; while the full grown animal varies from eight to fourteen lines in length, and from one and three quarters to six lines in breadth ; its intestinal canal is rami- fied ; the eggs are brownish, the 17th of a line long, and half that breadth. The distoma lanceolatum is smaller; from two to four lines in length, and scarcely one line broad; its intestinal canal is bifurcated ; the eggs range from the 77th to the 48th of a line in length. These two species of distoma ocqur but rarely- in the human subject. They have been found in the gall-bladder, in the biliary ducts, and once even in the vena porta? and its hepatic ramifica- tions, (Duval.)* In animals, especially in sheep, these entozoa are of much more frequent occurrence. Although the nature and mode of their transference have not yet been clearly shown, it can scarcely be doubted that these animals enter the system from with- out, and do not originate in it. For representations and descriptions, see Bremser, PI. iv. fig. 11 and 12; Mehlis, Observ. anat. de distom. hepaj. et lanceolar. Gotting. 1825 ; Gurlt, Lehrbuch der pathol. Anat. der Haussaugeth. PI. vm. fig. 29 to 35. Respecting the metamorphoses which the distomata undergo, which are bighly interesting in a zoological point of'view, see Steenstrup.f uber den Generationswechsel, Copenhagen, 1S42, (or Busk's translation, pub- lished by the Ray Society.) * Gazette, Medic, de Pari?, 1842, No. 49. t See Sicbold, op. cit. p. 6G9. 36 422 PARASITES. 2. The distoma oculi humani, Gescheidt, has been found only once (by Gescheidt;) it was observed in a child aged five months, who had suffered from cataracta lenticularis cum partiali capsular suf- fusione, and had died of atrophia meseraica. Four lancet-shaped distomata ranging from a quarter-to half a line, in length, and with dichotomously ramifying intestinal canals .('efts*, lanceolatum?) were present between the lens and. the anterior portion of the capsule.* To the trematoda also belong the eight portions of monostoma (monosioma lentis,) discovered by Nordmann in the opaque lens of a woman.f 3. The polystoma pinguicola, Rud. and Bremser.; hexathyridium pinguic. Treutl., has been found only once, and possesses no great value in relation to pathology. It was discovered in the human ovary by Treutler. The animal lay free in a cavity formed of fat, was about an inch in length, and from two to three lines in thickness.. Its form was a longish oval, above slightly arched, beneath somewhat hollowed out, pointed behind ; the anterior portion was obtuse, -and behind the head sofhewhat constricted ; it presented upon its underside, six minute open- ings (suckers) arranged in a semilunar form. An additional larger sucker was observed on the abdomen at its point of junction with the tail. The nature and mode of origin of this animal is involved in perfect darkness. See representations in Bremser, PI. iv. fig, 15 to 17. Treutler has observed another worm of this kind (hexathyridium ve- narum, polystoma. ven.;) it was found in a young man's tibial vein (which had been lacerated whilst bathing,) and he conceives it had dwelt in the blood-vessels. This explanation, however, is unquestionably in- correct, and the worm (perhaps a planaria) most likely, during the bath, entered the vein from without. Compare Bremser, p. 265. THIRD ORDER. TAPE WORM, CESTOIDEA. 1. The common tape worm, (taenia solium, t. vulgaris, t. cucurbi- iina,) is a riband shaped, very long worm of milk white or yellow- ish colour. Its lerigth may exceed twenty feet(and may reach even * Amnion's Zeitschr. f.- Ophthalmologic, vol. in. p. 434. t Mikrographische Beilr. Part 2, p. 9. TAPE WORM. 423 twenty ells;) its breadth at the extremity of the head is small, scarcely a quarter or third of a line; but in passing backwards, gradually increases to three, four, or even six lines. The thickness ranges from a quarter of a line to a line. The worm is jointed ; the individual joints are flat, more or less quadrangular, frequently of the form of a gourd seed with a blunted point, and commonly long- er than they are broad. They are characterized by the circumstance, that all or at least the greatest number, present upon the margin a maramillary projection with a distinct opening in the centre. These projections form the orifices of the sexual organs, and are situated without fixed order, sometimes on the left, sometimes on the right margin of the joint; occasionally, however, their position on the separate joints varies according to rule. The head of the worm oc- cupies the anterior thin extremity, and is very minute, commonly hemispherical, broader than it is long, and often appears as if cur- tailed in front. Its essential character only becomes evident upon the application of magnifying glasses. It then exhibits four lateral rnammillary suckers, and between these, in the middle of the head, an arched eminence upon which is always remarked a circle, in whose centre a minute, scarcely perceptible opening exists. Upon this circle are sometimes seated small hooks in double rows. This double circle of hooks may however, be absent; indeed.it appears, that with advancing age the worm always loses it. The head merges into a flat, unarticulated neck, which varies in length and is followed by the articulated body. The first joints are very short* the following almost square, while the more posterior are longer than they are broad ; the joints are narrower in front, thicker and broader behind, so that the posterior extremity of each, projects over the commencement of the following; the last joints are sometimes twice or three times as long as they are broad. The growth of the worm takes place in this manner : from the neck, new joints are continually evolved, which push those behind still further back, and develop themselves in proportion as they regress. The hind- most joints are, therefore, the oldest, and at the same time, the most perfect. Yet it appears that new joints are developed not only from the neck, but may be introduced between the perfectly developed articulations, even at the posterior end of the animal. The increase of the worm is, however, not unlimited ; when the last joints have attained to their perfect development, and are filled with mature ova 424 PARASITES. they detach themselves, and, either, uninjured, or in a state of de- composition, are evacuated by stool. Since the joints which are thus thrown off, are continually being replaced by new ones, it is absolutely necessary, in-order that the annoyance caused by the worm shall cease, that the whole animal, including even the ex- tremity of its head, should be evacuated. The taenia solum inhabits the small intestines of the human sub- ject, but only in certain districts; it occurs ordinarily—indeed, al- most exclusively—in, Germany, England, Holland, Egypt, and- the Levant. Commonly there is found but one tape-worm in the intes- tinal canal; sometimes, however, several are simultaneously present. It is pretty well ascertained that the innumerable ova which a single individual of this class may produce in a short time, cannot develop themselves in the intestinal canal of the patient, but.must quit him in order to experience unktiown changes but of his body. The manner in which this worm finds its way into the intestinal canal, cannot yet be pointed out; but numerous reasons entitle us resolutely to reject the opinion, that it may have spontaneously originated. We must, therefore, assume a transference of it from without. It cannot be denied that the tape worm, by its presence in the in- testinal canal, may cause derangement of the organism ; neverthe- less its pathological importance is commonly over-estimated. It often remains in the body for a long tihie without its presence being re- vealed by the slightest symptom ; sometimes, particularly when-of ^reat size, its movements become annoying and unpleasant. See representations in Bremser, PI. in. The disorders occasioned by it will engage our further attention in the special part. See Wawruch, Mo- nographic der Bandwurrnkrankheit, Wien, 1844, in which, however, the description of the worm and of its physiological relations, (p. 34, et seq.) do not perfectly correspond with the present state of our knowledge.—Th. v. Siebold, on the escape of a tape worm through the umbilicus, Oesterr. medic. Wochenschr. 1843, p. 660. , 2. The broad tape worm, (bothriocephalus lulus, taenia lata, in many respects, so closely resembles the preceding, that we may shorten its description, and content ourselves with noticing their dis- tinguishing characters. Like the taenia vulgaris, it is a flat, usually distinctly articulated worm, which can attain to a length of from one foot to twenty, or even forty or more feet, and likewise at the ce- TAPE WORM. 425 phalic extremity, is not more than a quarter or half a line broad ; posteriorly it acquires a breadth of four, six or twelve lines. Its colour is whitish or light gray ; its thickness from the sixth to half of a line. The individual joints of the worm are quadrangular, in general, broader than long ; their length, however, increases in pro- portion as they become- distant from the cephalic extremity. The well developed joints want the mammillary projection on the margin, but in the place of it have, each in its centre, a distinct depression-^ the genital opening—surrounded by an elevated ring. On the larger joints may sometimes be remarked, behind this opening, a second smaller one. The head of the worm, as in the case of taenia vulg. is very, minute ; but, the application of the microscope reveals well-marked differences. It has no suckers, but instead of them, two (not always evident) depressions, or furrows running longitudi- nally. The-neck is very short, often entirely absent. The discrimination of this worm from the taenia vulg. is easy, and is to be accomplished —partly through the well-developed joints, which are thrown dff not singly, as in the taenia'vidg, but in connected rows, and which are characterized with certainty as of the family bothriocephalus, by the presence of the above mentioned cavity in the centre and not,on the border of the joint—and partly through the examination of the cephalic extremity, when that is possible. The bothriocephalus likewise inhabits the small intestines of man, but only in certain countries—in Switzerland, in Middle and South- ern .France,, Russia, Poland and Eastern Prussia, where the Vis- tula forms the boundary between its territory and that of the taenia vulgaris .* When it occurs in .other districts; where the. taenia pre- vails, we may be assured that the patient is a native of; one of the above-named countries, or at least has caught it there. • With respect to its origin and pathological importance, there is nothing to add beyond what has been stated of the taenia vulgaris. See representations in Bremser, PI. n. See also the very interesting paper by D. F. Eschricht, anat. physiol. Untersuchungen Uber die Both- riocephaIen,'(Novaacta acad. Caes. Leop. vol. xix. suppl. 2,) which also contains some general remarks well worthy of consideration, against the view of the spontaneous origin of intestinal worms, * See Slebold, op cit. p. 652. 36* 426 PARASITES. FOURTH ORDER. CYSTICA. 1. The cysticercus cellulo$a, hydatis finna, Blumenb.) consists'of an oval vesicle varying in length from three to eight lines: it pos- sesses an extensible neck, terminating in a head, which together with the neck can be protruded and retracted, and in the latter case maybe entirely overlooked by a superficial observer. The head when protruded is quadrangular, and has, at each of its four corners, a sucker ; on the fore part of the head, situated at the base of a conical proboscis, is a double circle of hooks, amounting in number to about thirty-two. Extended to its full length the ani- mal may measure from half an inch to an inch ; its breadth at the cephalic extremity amounts to about one line ; at the vesicular por- tion, to about six lines. As in the case of the trichina, this worm is fountl in the muscles of the human subject—most frequently in the psoas, the glutcei, iliacus internus, the extensors of the thigh, and in the heart; also, however, in the cellular tissue, in the brain and pia mater, and sometimes, but very rarely, in the eye.. We sometimes observe a solitary worm ; sometimes they occur in great numbers. It is al- most invariably, at least when occurring in parenchymatous parts, surrounded by an enclosed capsule, which, however, is not essen- tial to it, but is a product of the part in which it dwells. It owes its origin to fibrinous effusion, of which the fibrin coagulates, and is organized according to the mode formerly explained (p. 223.) It appears that this capsule, as in the case of the trichina, may some- times becoine filled with calcareous salts, and after the death of the worm become converted into a concretion. The pathological importance of this worm is entirely dependant on the tissue or organ it attacks. Whilst in many instances, as for example, in the brain, it may occasion serious accidents, or even death, the presence of a small number in the muscles or cellu- lar tissue, often excites no symptoms of any sort.. It is figured in Bremser, PI. iv. fig. 18 to 26, who has collected a num- ber of the early cases in which it was observed in man, (p. 222.) See also Tschudi, die BlasCnwUrmer, Frieburg, 1837. An excellent microscopic CYSTICERCUS CELLULOSA. 427 representation is given by Gulliver, in his Observations on the structure of the entozoa, belonging to the genus Cysticercus. Medico-chirurg. transactions, 1841, p. 1 et seq. The following cases have been recently. described: Fournier mentions an instance in which seven or eight cysti- cerci occurred in a boil upon a child aged six years* It has been ob- served in the eye by Sommering, Mackenzie.f Heringf and Logan.§ It is extremely probable that the cystkerci are abortive and dropsical tania,\\ which have entered the body from ■ without; but chancing to establish themselves in a spot unfavourable to their development, gra- dually degenerate without leaving issue; ova are never found in them; the roundish bodies with the property of refracting light, which are per- ceived in their structures by the microscope are not ova, but calcareous deposits, which dissolve with effervescence in.acids. In the brain the cysticercus may produce dangerous symptoms. I examined a dog, which for some time had been completely blind, and in the highest degree apathetic. Upon dissection I found the whole substance of the brain in- terspersed with cysticerci. The existence of the cysticercus-visceralis described by some as a hu- man entozoon is extremely problematical. See Bremser, p. 244. 2. The echinococcus hominis, consists in the first place of an ex- ternal vesicle, which, as in the case of the cysticercus, is formed by, and is firmly united to the part of the body in which the entozoon is situated. It owes its origin to coagulated fibrin, which, however, becomes gradually organized, and even intersected with vessels. It generally consists of fibrous tissue, which on its inner surface is coated with a more or less perfect epithelium. This membrane is sometimes thick, and has the cartilaginous condition not unfre- quently shown by amorphous fibrous tissue generally (see p.' 202.) Within this membrane which does not pertain to the worm, there lies, perfectly loose and free from all organic connexion with it, a second membrane which forms a completely shut sac, filled with . * Journ. des connaiss. med.-chirurg. Juin, 18-11. t Gescheidt, in Amnion's Zeitschr. f. Opthalm. vol. in, p. 416. X Dublin Journal of Medical Science, Jun. 1841, p. 500. Other cases are recorded ' in Mediz. Vcrcinszcit. If38; Froriep, N.Notiz. 1838, No, 170 ; Annales d'oculistique, Mars, 1812; Oesterr. mediz. Wochenschr. 1S13, No. II; and Rayer, Archives de pathol. comparee, t. i. p. 125. § Todd's Cyclopaedia, art. Entozoa, p. 119. || Dujardin, Histoire des Helminthcs, p. 633. - 428 PARASITES. fluid. This second membrane presents a jelly-like transparency, but is sometimes milk-white ; under the microscope it appears per- fectly structureless, and may commonly be split into a very great (but indefinite) number of lamina?; this appearance is very obvious on placing a section of it under the microscope, when it is seen to resemble the leaves of a book. With chemical reagents this mem- brane behaves like coagulated fibrin. In the interior of this cyst, there exists a fluid which either encloses smaller vesicles of varying size^ or on standing for some time, deposits a finely granular matter, which almost resembles pus, or more closely approximates in ap- pearance to fine white sand. Under the microscope this granular matter resolves itself into a number of animalcules which present some resemblance to the diminished head of a cysticercus. Like this,-they usually bear on the one extremity a series of hooks, be- hind which there are several (usually four) suckers; the body usually contracts to an obtuse conical tail, which is sometimes separated from the fore part by a kind of constriction. This is the ordinary form of the animalcule; other forms, however, sometimes occur. They may present a double cordiform shape (like two contiguous hearts, as they are depicted on playing cards, with their apices cut off,) or they may appear circular when the animalcule is viewed from above—in which case the ring of hooks appears in the centre. It seems to be able to retract the cephalic extremity with the circle of hooks'; for the latter sometimes occupies the interior of the body. Sometimes the posterior extremity is drawn out to a pedicle,, and presents a distinct opening. Sometimes the circle of hooks is ab- sent, being apparently thrown off. Isolated hooks are then seen in the fluid. With higher powers, clear, vitreous globules.of varying size, which entirely correspond with those described in the cysticer- cus, and consist of calcareous salts, are seen in their interior. The animalcules vary from the 8th to the 20th of a line in length, and from the 10th to the 30th ofa line in breadth. Sometimes they are free in the interior of the cyst, and in this case form, with the fluid contained in it, a kind of emulsion ; sometimes they seem adherent to the internal wall, which then presents the appearance as if it had been sprinkled over with fine white sand. Sometimes these ani- malcules are enclosed in small vesicles varying from the size of a pea to that of a nut, which lie free in the interior of the cyst, or are attached to its walls, or there is found within the common paren- ECHINOCOCCUS HOMINIS. 429 chymatous cyst, instead of one simple vesicle, a large number of various sizes. In certain cases the animalcules have died, and dis- appeared without leaving even a trace ; on a microscopical examina- tion a large quantity of isolated hooks are then perceived in the fluid, or at least in its sediment, besides indefinite detritis and crys- tals of cholesterin. Wherever these are absent, we have no right whatever to regard the structure as the remains of an echinococcus. Sometimes after the death of the animalcule, the cyst becomes me- tamorphosed into a concretion; protein-compounds and calcareous safts are deposited within it, and it then closely resembles a creta- ceous tubercle. The echinococci are found by far the most frequently in the paren- chyma of the liver, but occasionally also in that of other organs, as the spleen, kidneys, brain, and lungs. Their pathological import- ance is principally a mechanical one; since, like other tumours, they exercise an injurious pressure on the tissues which invest them, or give rise to suppuration, abscesses, or fistula, in the neighbouring parts. The means by which they gain access to the body is still altogether problematical; yet I entertain no doubt, that they do not arise spontaneously, but that they owe their origin to an animal in- troduced from without, whose other states and grades of development are either still unknown, or are so widely different from the echino- coccus, that their connexion with it has hitherto escaped observa- tion. Representations and literature. Good representations of the echino- coccus are still wanting. I .cannot but question whether those of Bremser in PI. iv, fig. 27 to 32, represent this animal. But the representations of the echinococcus veterinorum of the dromedary, given by the same author in his Icones Helminthum, Vienna, 1824, PI. xviii. fig. 3 to 13, afford a tolerably correct idea of the human parasite, except that in the ecfnnococci depicted in fig. 6,.the circle of hooks is not distinct, and the isolated hooks there represented do not accord with reality. Tschudi, (die BlasenwLirme, Freiburg, 1837,) has copied Bremser's figures, and added a few very defec- tive one!*. Curling's Plate in the Medico-chirurg. trans. 1840, p. 385, PJ. n, fig. 3, is nothing remarkable. Two years ago I had an opportunity of examining a highly interesting case of eckinococcus in the liver, and am indebted to the kindness of my friend Dr. Kohlrausch, of Hanover, for the details and representation of another case occurring in the same organ. 430 PARASITES. A case, likewise in the liver, is also described by Lebert.* J. Muller has observed an instance in which echinococci, no doubt proceeding from the kidneys, were discharged with the urine.t Gescheidt has found this animal in the eye, between the choroid and retina.J See also Gluge, Abhand- lungen zu Physiol, und Path. Jena, 1841, p. 196; Roozeboom, Dissert, de hydatidibus, Schoonhoviag, 1836, in which there is a tolerably copious bibliography, from which I will here only quote the very laborious disser- tation by Liidersen, de hydatidibus, Gottingae, 1808, 4. These latter treatises refer partly to this, partly to the following sectidn.§ After the interesting researches of Siebold (Burdach's Physiologie, 2, 183,) we must suppose their growth to take place in the following manner; upon the in- terior of the primitive cyst minute points spring forth ; these gradually form echinococcus-animalcules which afterwards detach themselves from the parent cyst. Instead, however, of fsolated echinococci, secondary cysts may be developed from the parent cyst, which then give origin to isolated echinococci; from these secondary cysts, tertiary cysts may perhaps be developed, and so on. We might, accordingly, regard the echinococcus- vesicles as nurses (ammenthiere,) probably performing their office in the same way which Steenstrup has shown to occur in the case of the disto- mata. Our knowledge on this point is, moreover, still deficient, and further researches are very desirable. I conceive it to be possible that the vesicle lying within the parenchymatous cyst, is in many instances, the product not of the animal, bqt of the organism; see the description of Plate v. fig. 5.. 3. Acephalocysts—hydatids. Whilst the,true echinococci which have been just described, are undoubtedly animals, there are other structures closely resembling, them, whose animal nature is, at least, very questionable. These are the acephalocysts of Laennec. They, like the echinococci, consist of an external cyst, arising from the parenchyma, usually exhibiting evidence of organization, and doubt- less a product of the organism. Within this is a second cyst per- fectly similar to that of the echinococci, containing in its interior a clear fluid which, again, includes smaller vesicles. Sometimes these smaller vesicles are attached to the inner wall of the parent cyst. * Muller's Archiv. 1843, p. 217. t Muller's Archiv. 1836, Jahresber. p. 107. X v. Amnion's Zeitsch.-fttr Opthalmologie, vol.'m. p. 437. § See also Siebold, op. cit, 678. HYDATIDS. 431 In certain cases the parenchymatous cyst contains, not merely one simple vesicle, but several of various sizes. These acephalocysts are thus essentially distinguished from the echinococci, by their containing neither echinococcus-animalcules, nor the rejected hooks which might lead us to infer the presence of dead and disintegrated echinococcus- animalcules. The acephalocysts may, like the echinococci, assume a tubercular appearance, or be converted into concretions; they like- wise occupy the same localities, exist under the same relations and in pathological importance, resemble them in every respect. With regard to their origin, there are two opposite views. Ac- cording to the one, maintained by Laennec, Owen, Lallemand, and others, they are animals either specifically distinct from echinococci or identical with them—nurses (ammenthiere) which never attain to the development of echinococcus-animalcules. According to the other, they are no animals at all, but morbid products of the human organism, which are perfectly analogous to the hydatids, formerly noticed, and arising in the same manner (see p. 223.) Many struc- tures considered as acephalocysts—as for instance, the vesicular hydatids of the peritoneum and other serous membranes, the cystic moles of the uterus, and the greater number of the encysted drop- sies—are to be ranged, no doubt, in the latter category; and if the first mode of origin of the acephalocysts—their animal principle— should become positively established, (which future researches must decide, but which seems to me very improbable,) it will certainly prove that only a very small number of the so named acephalocysts, are of an animal nature. The literature respecting acephalocysts is exceedingly abundant, 1 shall here notice only the most important Memoirs: Diction.de med. art. Acephalocysts; H. Cloquet, Diet, des sciences med. t. xxn. p. 156; Phobus, Encycl. Worterbuch d. mediz. Wissensch. Berlin, 1834, v. x. p. 62; Tschudi, die Blasenwiirmer; Kuhn, Recherches sur les acephalo- cystes et sur la maniere dont ces productions parasites peuvent donner lieu a des tubercles, Strasbourg, 1832, avec planches; afto in Annales des Sciences natur. t. xxix. 1829^p. 275; Jaeger in Meckel's Archiv. 1820, vol. vi. p. 495 et seq.; Michea, Archives generates de med. Mars. 1841, p. 341; Aran in ditto> Sept. 1841, p. 76. In a chemical point of view, the contents of most acephalocysts correspond with the fluid of serous dropsy, whilst the cyst-membrane possesses all the characters of coagulated fibrin. The transition of hydatids into deposits resembling 432 PARASITES. tubercle and into concretions, long since attracted so much attention, that some inconsiderately have regarded all tubercles and concretions as pro- ceeding from hydatids. See Ruysch, Dilucid. valv. vas. lymph. Obs. 25, p; 25. Lallemand avers that he has perceived voluntary motion in the acephalocysts of the human subject.* Yet in such observations de- ception is so easily possible, that I do not attach any great weight to them. Klenke has communicated numerous observations respecting hy- datids, and states that he has very frequently propagated them to animals by maculation.t But most of his statements are impressed, in so high a degree, with the character of improbability and exaggeration, that I can- not resolve in this place to avail myself of his communications, which if true would possess a high interest.± ' PSEUDOPARASITES. The animals which have been described in the preceding pages are the only parasites which hitherto have been certainly recognised as inhabitants of man, although we may anticipate that more ex- tended researches in foreign countries and different climates will disclose many others. , Moreover, many incidental parasites have been observed which in part have been already mentioned, and in part will be considered, with their effects and with the pathological alterations to which they give rise, in the special department of the work. ^ If, however, we glance at the annals of science, we find exhibited a great number of cases, in which other parasites than those de- scribed are stated to have been observed, and new instances of the kind daily appear, in which physicians affirm that they have ob- served parasites on man, but where, in fact, no parasite was pre- sent. These cases may be reduced to two classes: 1. Cases in which Various animals are stated to have been eva- cuated from the human subject, by stool, urine, or vomiting. Here there can be no doubt respecting the animal nature of the object in question, but physicians, err in supposing that these animals were parasites. They did riot exist in til body, and only appeared inci- * Annales des sciences natur. t. xv. p. 292. t Ueber die Contagiositat der Eingeweidewurmer, &c, Jena, 1844. X See also Siebold's critique on these views, op. cit. p. 651. PSEUDOPARASITES. 433 dentally in the excretions; thus worms, larvsa, acari, and even bee- tles, are sometimes found in the urine; these, however, were not discharged with the urine, but previously existed in the utensil; the like occurs in the faecal evacuations, in vomited matters and in sputa. In some of these cases the deception is intentional, and pro- ceeds from the patients who assert that they have discharged these animals, when they have previously Cast them into the utensil; sometimes this is done with a view to excite interest, and often from totally inexplicable psychological motives, the patients having even previously swallowed them, in order more effectually to deceive the physician. 2. The substances supposed to be parasites may indeed have been actually discharged, but are, however, no animals, but other foreign bodies of the most varying description, as seeds and other vegeta- ble matter, morbid products (fibrinous coagula, &c.) In order to escape such errors which even in modern times, occur sufficiently often, whenever the physician entertains a doubt respecting the na- ture of an evacuated body, he should always consult an experienced naturalist. It is net our intention to enumerate all the pseudoparasites hith- erto met with, but merely, once for all, to caution the physician to be on.his guard in such matters, and neither to fall spontaneously into error, nor allow himself to be deceived by others. A series of pseudoparasites, which might be easily augmented by some more recent examples, as has been described by Bremser, and figured in the vignette on the title page of his work.* * Siebold's remarks on this subject are well deserving of the attentive perusal of every practical physician, op. cit. p. 683. 37 434 MALFORMATIONS. CHAPTER IX. CONGENITAL MODIFICATIONS OF THE HUMAN BODY— (MALFORMATIONS.) A special consideration must be devoted to those morbid changes which originate not, as is. for the most part the case with those hith- erto described, after birth*, but during foetal life, and which, conse- quently, the infant brings with it into the world. These congenital changes may be reduced to two divisions, which, however, are not strictly separable from one another. Those be- longing to the first division differ "in no respect from the morbid changes already considered ; ,indeed, it has been already frequently mentioned, that certain tumours are occasionally formed/in the fcetus in exactly the same manner as they arise after birth. This, for in- stance, was stated in relation to congenital telengiectasies, lipomata, encysted tumours, &c. These congenital changes, accordingly, pre- sent little or nothing peculiar; we shall, therefore, only briefly no- tice them at the conclusion of this chapter. In addition to these there are, however, other morbid changes, which occur only in the fcetus, and of which it has never yet been observed, that they have originated in the same way after birth. These latter are termed malformations—vitia primce conformation's. The peculiarity of these malformations, and their essential differ- ence from ordinary morbid changes, are explained by the following considerations :—immediately after birth almost all the organs exist in a condition which, with slight modifications of form, they retain throughout life. All organs, indeed, grow until they are perfectly developed ; but this growth is, for the most part, merely a simple augmentation of bulk. A few organs only, as the sexual apparatus and the thymus gland, undergo at a. later period comparatively im- portant modifications, either developing themselves more highly, or, on the other hand, disappearing. Indeed, in adults the changes of THEIR CAUSES. 435 the body are, in the normal state, almost solely confined to renewal of material (metamorphosis of tissues,) whilst the form of the organs, with very trivial modifications, remains unaltered. The case is dif- ferent with the embryorand fcetus. Here, as the laws of develop- ment teach us, the various parts and organs of the body are gra- dually developed from the simple stroma of the ovum. During fcetal life we have, therefore, not merely nutrition, as afterwards, but also development; and whilst, after birth, pathological influences only affect existing structures, or, at most, give rise to>.the introduc- tion of heterogeneous matters, previous to birth morbid influences extend their operation even to the development, so that pathologi- cal structures are generated, which differ considerably from those occurring after birth. This appears to me to be the best mode of expressing the essential na- ture of malformations, and their distinction from those pathological changes, which occur not merely in individuals after birth, but occasionally in the fcetus. The relation of malformations to pathological anatomy, sponta- neously results from it. If the latter, in the sense which we here receive it, is allowed to include all cognizable pathological changes occurring in the human subject, then malformations must be included in it. Whilst, how- ever, the study of ordinary pathological changes pre-supposes, in addition to an acquaintance with pathology and physiology, merely a knowledge of normal anatomy, the study of malformations, if it is to lead to the compre- hension of their origin, demands a profound knowledge of the history of development; indeed, these two latter subjects are in immediate relation. And hence I do not object to the view of those who, like Isidore Geoffroy St. Hilaire,* desire to form of the doctrine of malformations a special science, under the name of Teratology. Malformations have much less practical interest than other pathological changes, since the greater num- ber of them can neither be prevented, nor, having once arisen, can be re- moved by remedial measures. For this reason, and because the number of malformations is exceedingly great, I cannot here enter into the details of this subject with the fulness with which it has been treated in various other works on pathological anatomy. I shall content myself with a su- perficial exhibition of the various malformations ; and, for a complete study of the individual forms, must refer partly to the special department of this * Histoire des anomalies de l'organisation, vol. in. p. 447, &c. 438 MALFORMATIONS. work, and partly to the works and memoirs quoted in the separate cases, and to the special treatises on malformations; of which the following de- serve particular recommendation; A. v. Haller, de monstris, in oper. minor, t. m. Lausanne, 1768, where the best scientific collection of the older, literature is to be found ; J. F. Meckel, Handbuch der pathologischeh Anatomie, vol. i. 1812, vol. n. 1816 ; Isidore Geoffroy St. Hilaire, Histoire des anomalies de 1'organisation, t. i. Paris, 1832, t. n. and iii. 1836; W. Vrolik, Handbook der zicktekundige, Ontleqdkunde, vols. i. and n. 1840—1842, also under the-title: de menschel- ijke Vrucht beschouwd in hare regelmatige en onregelmatige.Ontwikkeling;* Otto, Monstrorum sexcentorum descriptio anatoanica. Vratislav. 1841, fol. —a splendid work, with thirty plates; F. A. Ammon, die angebornen chirur- gischen Krankheiten des Menschen. Berlin, 1840—1841; Gurlt, patholo- gische Anatomie der Hauss'Iugethiere, vol. n., treating of the-malforma- tions occurring in domestic animals—a subject which, in comprehensive study of this department, must not be disregarded. An excellent sketch of the general relations of malformations, with especial regard to the history of development, may be found in the Article " Entwicklungsgeschichte, mit. besonderer Beriicksichtigung der Missbildungen," by Bischoff, in Wagner's Handwdrterbuch der Physiol. vol. I. The fabulous malformations of the ancients have been collected by Ber- ber de Xivrey, traditions teratologiqUes. Paris, 1836. The causes of most malformations are, undoubtedly, pathological influences, perfectly analogous to those which occasion morbid Changes in the body after birth. Probably, like the latter, these also are very manifold; and it appears to.me a limited mode of viewing the question to endeavour, as is not unfrequently done in, pathology in relation to different diseases, to trace all malformations to one, or to only a few causes. Experience, as well as analogy,.leads to the inference that the causes not merely of different, but even of the same kinds of malformation, may be very dissimilar. , However, at present we unfortunately know very little respecting these causes. The following propositons represent the actual state of our know- * As, in consequence of the language in which it is written, this interesting work is accessible to comparatively few readers, I may refer to a very copious review of it by v.. d. Busch in the Hannov. Annalen. fur die gesammte Heilk. 1843,No. vi., and 1844, Nps. i. ii. and in. . THEIR CAUSES. 437 ledge on this subject: The human embryo is formed by the co- operation of the male and female generative matter—the semen and the ovum. By means ofa fruitful coition, an impulse to further de- velopment is communicated to the ovum. A normal development, therefore, primarily assumes normal generative matter in both sexes. In order, however, that a normal foetus may be produced,' it is fur- ther essential that the maternal organism should supply all the 'con- ditions necessary to the development of the embryo, and that the development should in no way be disturbed by external influences, or by diseases of the foetus. Accordingly, we may regard as causes of malformations: 1. Abnormalities of the generative matter of one or both parents. Numerous phenomena in.man and animals lead to the conclusion that the condition of the father exercises an influence upon the con- dition of the offspring, which in many cases at least, can be effected only through the intervention of the generative matter, and that this influence may be extended even to the production of malformations. Thus we frequently see that children exhibit -the peculiarities of the parents. Malformations are transmitted from-the parents to the chil- dren ; and if, in the case of the mother, the two causes, which will be presently noticed, possibly co-operate, this, at least, does not hold good in relation to the father. In this Glass we may also include the cases in yvhieh several children, whose parents present no pecu- liarity, suffer from the same malformations. Cases of this kind are by no means unfrequent, and may be daily ob- served. A large number has been collected by Meckel.* See, also Gurlt.f and Henle.i The great majority of these cases admit of no other explanation^ than that.the malformation had its origin in ah original abnormality of the generative matter. But in what this abnormality consists, and how it operates, are points upon which really nothing is known, although in solitary instances, an abnormal condition of the semen,. * Op. cit. vol. i. p. 15—59. t Op. cit. vol. ii. p. 5—172.. X Zeitschr. f. rat. Mediz. v. Henle u. ffeufer, vol. n. p. 7, 37* 438 MALFORMATIONS. (of the seminal animalculus,) or of the ovum (of the yelk) has been observed.* 2. As a second series of causes which, after impregnation has been effected, possibly take a part in the production of malformations, may be considered, abnormalities of the maternal .organism:—pa- thological alterations in the fallopian tubes and the uterus, bodily dis- eases and physical affections of the mother. Of all these causes it may, with probability, be conjectured that they exercise a disturbing influence upon development, but we are still very far from knowing in what this consists, and what share it exerts in the production of malformations. It is probable that these causes operate by arresting and interrupting development, and consequently giving rise to va- rious malformations, by arrest of structure. We must here also no- tice the opinion that some malformations owe their origin to an in- fluence on the imagination of, the mother during pregnancy—a psy- chical-affection, in consequence of. which the fcetus is stated to bear upon it certain characters which resemble the object that acted on the maternal imagination. This theory is in the highest degree im- probable, if it cannot be positively denounced as'false.f 3. Diseases and abnormal states of the placenta, of the membranes if the .ovum, and of the umbilical cord, may be^ regarded as causes of malformations. These generally induce an arrest of formation, by disturbing the process of development, and we may point out individual deviations from,.a norrnal.state, which can withmuch pro- bability be regarded as causes of certain malformations. Thus shortness of the funis and deficient union of the vessels forming it into one common cord* favour the origin of abdominal fissures, and of congenital umbilical hernia ; or if the funis be of disproportionate length, it may coil around the extremities, constrict them, and thus render their nutrition defective, or even Cause their amputation. Union of the fcetus with the amnion may likewise give rise to mal- formations, through pressure or tension,\ 4. Amongst the most frequent causes of malformations, we must * See BisehofF,Op. cit. p. 884. t See Bischoff, Op. cit. p. 885 ; and G. Rubner, uber das sogenannte Versehen der Schwangern. Dissert. Erlangen, 1839. X Several cases of this nature have been collected by Henle, in his Zeitschrift £, ration. Mediz. vol. n. p. 11, &c. THEIR CAUSES. 439 undoubtedly consider various morbid influences acting directly on the foetus, as mechanical injuries, and diseases affecting it. From the experiments of Geoffrey St. Hilaire and Valentin,* it appears that by various mechanical influences to which hen's eggs are submitted during incubation, the development of'the embryo is partly inter- rupted and partly modified in such a manner as to give rise to mal- formations. Many observations tend to the conclusion that by means of mechanical influences (ill treatment by kicks, blows, or falls,) affecting the womb in the early months of pregnancy, certain malformations by arrest may be produced, as hemicephalia. The experience that malformations, such as acephalia, which depend upon a very decided arrest of development, usually occur in twin or triplet pregnancies, is favourable to the view that pressure and confined space are to be regarded as causes of certain monstrosities; for the objection which has been made, that twins and triplets are also born perfectly normal, only shows that, notwithstanding the limited space, a normal development is possible ; but not that, under specially un- favourable relations, the presence of a second embryo cannot exer- cise an interrupting influence upon the development of the other. Of diseases of the fcetus which are capable of causing malformations, we at present recognize dropsical accumulations of water in its vari- ous cavities—no doubt one of the most frequent causes of hemicepha- lia, spina bifida, abdominal fissures, and hernia umbilicalis congenita; inflammation of certain organs at an early period, which through the agency of fibrinous dropsy may give rise to union, or even destruc- tion and atrophy of certain parts ; and nervous diseases, inasmuch as they cause spasmodic contractions of individual muscles or muscular groups, and in this way give rise to deformities of the trunk and ex- tremities (Curvatures. -)f The influences alluded to in the preceding observations are, doubtless, those which must be regarded as the most frequent and most important causes of malformations. But it is only rarely that we are able to point out in more minute detail the manner in which these causes operate.. By mere general terms, as " increased or di- minished energy of the formative power," such as were frequently *■- Repcrtorium, vol. n. p. I68. t Several cases of this nature are,collected by Henle, Op. cit. p.'9. 440 MALFORMATIONS. employed by earlier authors, and which usually are nothing more than an abstract expression of that which the most superficial con- sideration of a malformation teaches, we must not hope to be able to explain the complicated causes of these changes, or to comprehend their origin. There is here much untrodden ground for scientific investigators, and the most important results may be expected from their labours. A perfect knowledge of the history of development is essential to the clear comprehension of the manner in which a certain cause, by exerting a disturbing influence upon the development, effects a certain malformation. This especially holds good in relation to the numerous forms of malformation in which, by arrest of development at an early stage, some parts of the fcetus exhibit forms which cor- respond more or less closely with those of an earlier grade of deve- lopment (arrest of formation.)* Since malformations may affect the most different parts and organs of the body—sometimes one alone, sometimes several in connexion with each other—their number becomes very great; and, in order to regard them in a general point of view, it appears abso- lutely necessary to arrange them in certain classes. I regard the following classification as the most conformable to the objects of pathological anatomy: 1st Class. Malformations, in which certain parts of the normal body are entirely absent, or are too small.—Monstra deficientia. 2d Class. Malformations produced by fusion "or coalescence of organs. Coalitio partium—'Symphysis. 3d Class. Malformations, in which parts in the normal state united—as for instance, in the- mesial line of the body—are sepa- rated from each other—Clefts, fissures. 4th Class. Malformations, in which normal openings are occluded —Atresia. bth Class. Malformations of excess, or in which certain parts have attained a disproportionate size—Monstra abundantia. 6th Class. Malformations, in which one or many parts have an abnormal position-^ Situs mutatus. 7th Class1. Malformations of the sexual organs—Hermaphro- ditism. * See Bischoff, Op. cit. p. 892. DEFICIENT MONSTERS. 441 To these true malformations I append also: 8th. Diseases of the fcetus, and abnormal states of its envelopes. A classification of malformations presents numerous difficulties, and, in whatever manner it is attempted, must necessarily be very imperfect. In an anatomico-pathological point of view, it should, in my opinion, only claim to be in some degree a methodical register, affording an idea of the forms not merely actually occurring, but of all that can possibly occur, and thus enabling us to class a newly discovered malformation with known allied forms. This appears to me to be accomplished by the above classification. I regard- the objection which may be brought against it, that it is not perfectly logical, because the malformations of the genital organs form in it a class of their own, as unimportant; for there are strong reasons in favour of their collection into a special class. For other objects other classifications maybe more fitting, as, for example, that based on the causes of malformations, or on the influence'which malformations exercise upon life, health, and on the civil usefulness of the individual affected—a basis of classification which might be of more service to the medical jurist, but is of no value to us in this place. Ac- counts of other classifications, and critiques on them, may be seen in Geoffroy St. Hilaire and Bischoff, Op. cit.. _ FIRST CLASS; MALFORMATIONS, IN WHICH CERTAIN PARTS ARE ENTIRELY ABSENT, or are too small—Monstra deficientia. FIRST ORDER. DEFICIENCIES, IN THE STRICT SENSE OF THE WORD. We must here notice those cases in which certain parts of the body are altogether- absent. This order comprises a great num- ber of forms, of which the following constitute the best marked ' groups: 1. Completely shapeless malformations (amorphus, Gurlt; ani- deus* Geoffroy St. Hilaire.) The monster presents the appearance of a more or less shapeless lump, with no indication of definite organs ; it consists merely of integument, cellular tissue, serous fluid, * From * and tpfpc, form; hence, synonymous with amorphous. 442 MALFORMATIONS. fat, rudimentary bone, and vascular ramifications, with an umbilical cord. It has been hitherto rarely observed, and then usually co- existing with a normal twin; hence it is probable that through the presence of the twin, the other germ has been at a very early period so much injured that this anomalous formation, void of every ex- ternal and internal organ, has alone been developed from it; of course, these monsters are not viable. See representations of these-forms occurring in 'animals, in Gurlt, op. cit. PI. i. fig. 1., PI. xvi. fig. t to 4.; Geoffroy St. Hilaire, op. cit. PI. xii. fig. 1 and 2, vol. ii. p. 528.—A case occurring in the human subject is described by Bland, in the Philosophical Transactions, 1781, vol. lxxi. p. 363, in a note. 2. Malformations, which consist of only a more or less rudimen- tary trunk, while no signs of head or extremities exist. Like those belonging to the preceding group, they form externally a shapeless mass, which, however, in the interior, besides fat cellular tissue, ru- dimentary bone (vertebra?) and vessels, contains more or less de- cided traces of viscera. Malformations of this group are not viable. This form constitutes a division of the genus mylacephalus* of Geoffroy St. Hilaire.t In the human subject only one solitary case observed by Vallisneri, appears to have been observed. OttoJ has figured and briefly described a case of this nature occurring in a calf. The monster co-exist- ed with a well-formed twin,1] to whose secundines it was attached. Its origin therefore is, no doubt, to be explained in the same way as that of the first group. 3. Malformations, in which the inferior half of the body is wanting, and only some parts of the upper half—as, for instance, the head— are present—trunkless monsters (acOrmus, Gurlt.) The malforma- tions belonging to this group consist of a little else than a more or less rudimentary head, which, instead of neck and trunk, is furnished with a pouch-like appendage, containing rudimentary viscera, and pieces of bone of indefinite form. They are very rare, and invaria- bly accompanied by one or two well-developed children, so that, as * juv\h, a mole in the womb, and «;«2ao?. t Vol. ii. p. 488. X Op. cit. p. 3, PI. xxx. DEFICIENT MONSTERS. 443 in the case of the preceding groups, these are also to be explained by injury of the germ. These also are not viable. Cases of this kind are recorded in Meckel, vol. i. p. 57; Lycosthenes, chronicon prodigiorum ac ostentorum. Basil, 1557, p. 542; Delamarre! Journ. de med.,.chir., pharmac, t. xxxm. 1770, p. 174; Rudolphi, in the transactions of the Berlin Akademie der Wissench. 1816, p. 99 ; Nockher, medicin. Zeitung des Preuss. Vereins f. Heilkunde, 1837, No. 3; and Nicholson, de monstro humano sine trunco nato. Diss. Berol. 1837. 4. Malformations, in which the head, and sometimes a part of the upper half of the body is wanting, whilst more or less of the inferior half of the body is present—acephalic monsters (acephalus.) Numerous cases of acephaliahave been observed in the human subject. They form a complete descending series of varieties. In the most perfect acephali the head alone is absent; indeed, rudiments of this organ exist, but they are concealed under the skin, and are only recognizable on an anatomical examination. The trunk is deficient to a certain extent; the viscera are more or less developed ; the heart is commonly, but not always absent, and the same may be said regarding the lungs. In other cases the superior extremities are wanting. In more defec- tive formations of the kind, the greater part of the trunk is also ab- sent, and the two inferior extremities, with the rudiment of a pelvis, alone exist. Indeed, there are instances recorded in which the acephalus has consisted of only a lower extremity (as in the case of a goat, described by Hayn.) Acephali almost always occur in com- pany with one or two perfect or less defective twins, whence it ap- pears that in this case also the probable cause of the malformation is an injury of the germ, effected by the co-existing twin ; or some- times, perhaps, hydrocephalus, in a very early period of pregnancy. The acephali are not viable. The literature relating to acephali is very abundant, and the number of cases of this malformation which have been observed in the human subject may, perhaps, amount to 100 ; in animals they are less frequent The most important information may be found in Meckel, vol. i. p. 140, &c, Fr. Tiedmann, Anatomie der kopflosen Missgeburten. Landshut, 1813, with plates; E. Elben, de aceprwlis s. monstris corde carentibus. Berol, 1821 c. tab. (which contains an enumeration of most of the cases on record ;) and Geoffroy St. Hilaire, vol. n. p. 464. More recent cases are described by Pfotenhauer, de monstro acephalo humano. Berol. 1835; 444 MALFORMATIONS. Hildreth and Houston, In Valentin's Repertorium, 1837, p. 170; PJ. Gergens, Anat. Beschreib. eine's merkw. Acephalus. Giessen, 1830 ; J. H. Kalck, Monstr. acephal. hum. expos, anat. Berol, 1825; Herholdt, Beschreibung sechs menschl. Missgeburten. Kopenhagen, 1830, p. 21 and 38 ; Otto, op. cit. p. 4, &c. On the circulation in the amrdiac acephali, see Holland, "on the circulation in the acajxliac fcetus." Edjn. Med. and Surg. Journal, 1845, vol. lxii. p. 156, &e. Geoffroy St. Hilaire subdivides the acephali intothree genera : 1. True acephali, with perfect, or almost perfect thorax, which supports both upper extremities, or at least one of them. 2. Peracephdli,rrwithout upper extremities. 3. Mylacephali, with) very anomalous body, and either with very defective, rudimentary extremities," or with "no limbs at all. 5. Malformations in which not the whole head, but some of its Cdmponent parts are wanting—monsters with defective head (peroce- phalus.)* Malformations of this kind are very frequent in the human subject. They may be-reduced to several subdivisions, some of which form well-characterized groups. a. The head may be present, but only as a mere rudiment. This group (pdraCephalus, pseudacephalus) is immediately allied to the acephali, and similar observations apply to it. Plates 6f this somewhat rare form are given in Gurlt, op. cit. PI. i. fig. 4, and in Geoffroy St. Hilaire, PI. xi., who (vol.-n. p. 437, &c.) has also given the literature of the subject. He separates this group into three species; 1. Paracephalus, with malformed, but voluminous head; face distinct, with mouth, and rudimentary organs .of sense ; the upper extre- mities present. 2. Omacephalus, with the head as in the preceding class, but the upper extremities absent. 3. •Hcmiaceplialus, head veryjmper- fect, formed .by a shapeless tuberosity, with certain membranous appen- dages ; upper extremities present. 6. The brain and greater part of the cranium may be absent. Brainless monsters (anencephalus, hemicephalus, microcephalus.) Hemicephalia is comparatively frequent and presents different de- grees : in the highest, not only the brain, but also the spinal cord is absent, and at the same time there "ists a breach of continuity in * From vtipr, deficient. DEFICIENT MONSTERS. 445 the spinal canal (spina bifida;) in a lower grade of malformation the spinal cord is present. In a still smaller degree, the malfor- mation passes, into the cranial fissure, presently to be noticed. Of the cranial bones, the os frontis, ossa temporum, parietalia and the greatest part of the qs occipitis are commonly absent. Sometimes malformations of the trunk, Or of the extremities are at the same time present. The cause of this malformation is commonly dropsy of the head ; in many cases, alarms, diseases and ill-treatment of the mother have preceded it, and Geoffroy St. Hilaire regards these as its exciting causes. Hemicephali notwithstanding the absence of brain are usually born alive ; some have survived several hours, a few seve- ral days. Owing to the great frequency of these malformations (they form more than the third part of all cases of human monstrosities) their literature is very copious. We may especially refer to Meckel, op. cit. vol. i. p. 195, et. seq.; Geoffroy St. Hilaire, vol. n. p. 317, et seq. PI. 8 and 9; Otto, op. cit. (who describes upwards of fifty cases* and has figured several;) Sommering, Abbildung und Beschreibung einiger Missgeburten, 1791; E. Sandifort, Anatomia infantis cerebro destituti, Lugd. Batav. 1784, with six beautiful plates; Cerutti, razioris monstri, in mus. anat. Lipsiensi ad- servati descr. anat. c. tab. 2. Lipsia5, 1827 ; H. Mattersdorf, de anence- phalia c. rariss. casus anenceph. post part, vivi exposit. Berol. 1836; Krieg in Casper's Wochenschr. 1843, p. 543. Cases where the child lived for some time after birth, and was submitted to experiments, are described by Spessa, Gaz. med. Janv. 1833, and Midlers Archiv. 1834, p. 168, and by Panizza (Giornale del R. Instituto Lombardo, 1841, fasc. 3, and Oesterr. medicin. Wochenschr. 1843, No. 9.) See also Marshall Hall on the history of anencephali. Geoffroy St. Hilaire separates this group into two families with several species, whose characteristics I shall notice, since they afford an excellent view of the most important forms which occur. A. Pseudencephali, containing in place of the brain, a soft, reddish, vas- cular protuberance. They may be divided into: 1. Nosencephalic in which the skull is open only in the frontal and parietal regions, and the posterior fontanelle is distinctly present. 2. Thlipsencephali,\ when the skull is opened not merely in the frontal and parietal, but also in the occi- * yo?of, disease. t fai^-ic, pressure, destruction. 38 446 MALFORMATIONS. pital region, and a distinct posterior fontanelle does not exist. And 3. Pseudencephali in the strict sense of the term; in which there is not merely the fissure of the skull, but the medullary canal is also widely cleft, and the spinal cord is absent. B. Anencephali in which the brain is totally absent, without, as in the case of pseudenaephalt, being replaced by a foreign substance; they are reduced into: I. Derencephali,* in which not only the brain, but the spina] cord in the cervical region is also wanting; the skull and upper part Of the spinal canal being widely cleft. And 2. Anencephali in the strict sense of the word; in which the brain and the whole of the spinal cord are wanting ; the skull and the spinal canal being widely opened. Some of these forms, as already mentioned, constitute the transition to the fissures which will be presently Considered. c. Portions of the face—as the nose, eyes, facial bones, and at the same time more or less of the cranium—may be absent (aprosopus, microprosopus.) This class is reducible into many sub-orders, which are rare in man, but are frequent and comparatively abundant in animals. We must here place absence of the lower jaw, of the nose, of the eyes, of the mouth, &c, resulting from an extensive arrest of development. See Meckel, vol. i. p. 393, et seq.; Soemmering, Abb. und Beschreib. einiger Missgeburten, PI. 9; Otto, op. cit. No. 88, et seq. and Gurlt, op. cit. vol. it. p. 68, et seq. The deficiency of these organs individually, as absence of the eyes; of the eyelids, of the iris, of the ears, &c, whether occasioned by imperfect development or subsequent destruction, is noticed in tke special department. These malformations also stand in the most intimate relation to some fissures and fusions, as for instance, with cyclopia. 6. Malformations in which the whole body appears more or less defective, some parts being absent and others too small or unshapely (perosomus, Gurlt:) an indistinctly characterized group, whose oc- currence is rare in man, but more frequent in animals. They are not viable. Figures are given in Gurlt, op. cit. PI. in. fig. 5 and 6; PI. iv. fig. 1 and 2. * /{/>», the neck. DEFICIENT MONSTERS. 447 7. Malformations in which the trunk is defective, and too short, from the absence of one or more vertebra?; the head and limbs be- ing normal (perocermus—oligospondylus, Gurlt.) They arise either from an original defect in the formation of the vertebras or from fu- sion of several into one. In man they are never observed, and only rarely in animals. These malformations do not affect life. Gurlt, op. cit. PI. n. fig. 4 ; Otto, op. cit. No. 213, et seq. Absence of the tail in animals belong to this group. 8. The extremities may be deficient; all the limbs may be absent, or two or only one, or merely portions of the extremities may be want- ing. The head and trunk may in this case, be either normal or ab- normal (peromelus, Gurlt.) This group may be reduced to several subdivisions; the forms included in it arise partly through original abnormalities of formation—the germinal elements for the extremities being either not evolved at all, or experiencing an arrest at some stage of the development; and partly through mechanical agen- cies—the extremities when perfected or in the act of forming, be- coming atrophied from mechanical causes, as for instance, constric- tion by the funis. Such malformations are not unfrequently heredi- tary. The subjects of them are. viable. For the literature and illustrations of this group, we may refer to Meckel, vol. i. p. 748 et seq. where most of the earlier cases are collected; Otto, op. cit. p. 134; Herholdt, Beschreibung sechs menschl. Missgeb. p. 59; and Cruveilhier, Anat. pathol. livr. 28, Plate i. Geoffroy St. Hilaire names the higher grade of these malformations Ectromeles,* (vol. u. p. 307 et seq.) and reduces them into 3 genera. 1. Phocomdes,] in which hands and feet appear to exist independently of arms and legs, and to be inserted immediately into the trunk. 2. Hemi- meles, in which the upper or lower extremities are very defective—mere stumps—and the fingers and toes are entirely wanting, or are very imper- fect. 3. Ectromeles in the strict signification of the term; in which the -extremities are nearly or altogether absent. The slighter degree of the mal- formation, where only one" or more fingers or toes are wanting is named by Geoffroy St. Hilaire Ectrodactylie (vol. i. p. 676.) It is sometimes he- * enTgais/c, to cause to abort. + (pceicn, a seal in consequence of the similarity of the extremities to those of that animal. 448 MALFORMATIONS. reditary and may be referred to a defective development -r since the germs for the hand and foot are at first simple, and do not until a later date be- come divided into the individual fingers and toes. The cases in which certain internal organs or parts of them are absent—a class of malformations which are commonly first disco- vered by anatomical examination—will be found in the special part. SECOND ORDER. ABNORMAL DIMINUTIVENESS OF PARTS—DWARFISH STRUCTURE. Here we have all the organs of the body present, but some of them too small. This arises either from a primitive tendency of the germ or from a subsequent arrest of the development of parts which-are in process of forming, or from atrophy of parts. already perfected. The individuals affected with it are, in general, viable. 1. General dwarfishness (nanosomus* GurlU) If the entire body with all its parts is smaller than common, the individual constitutes a dwarf, whose component parts are more or less proportionate. This states (as is well known) is not unfrequent, and the individuals affected with it are always viable; it is often hereditary, or, at least, is extended to several children of the same parents. For cases see Otto, patholog. Anatomie, vol. I. p. 19, or South's translation, p. 21, and Geoffroy St. Hilaire, vol. i. p. 140, et seq. where many instances are collected, and a few described in detail. An account of a family of dwarfs may be seen in Casper's Wochenschr. 1842, p. 705. 2. Dwarfish head, (nanocephalus, Gurlt.) • The whole head or certain parts of it being too small, while the trunk and extremities are normal. The higher grades pf this group are allied to the pero- cephali, namely to the. microprosopi. In man they are rare, but are almost always viable. To this group we must refer arrested development of the lower jaw, Geoffroy St. Hilaire, vol. i. p. 259. * yxvoc, a dwarf. MALFORMATION BY COALESCENCE, 449 3. Dwarfish trunk, (nanocormus, Gurlt.) .The trunk, with or without extremities, being too small, whilst the head possesses its normal size. 4. Dwarfish limbs, (nanomelus, Gurlt.) Some or other part of an extremity being too small, and the whole limb being therefore too short, but yet no part of it being absent. Head and trunk are ge- nerally normal. This form is allied, as a lower degree, to the pero- meli. Cases belonging to the preceding groups are given in Geoffroy St. Hilaire, vol. i. p. 251, et seq. SECOND CLASS. MALFORMATION FROM COALESCENCE OF ORGANS. Coalitio partium—Symphysis. Parts which normally lie together unconnected, (usually in .the mesial line of the body,) may approximate more closely than in the normal state, and form a coalition; there thus arises a new and pe- culiar formation. In many cases this coalescence is only possible in consequence of the atrophy or total absence of parts, which -in the normal state separate the organs here united. In this way many of the cases included here are in the closest alliance with the pre- ceding class. We have the following well characterized groups. 1. Malformations by coalescence on the head. -These reduce them- selves into two subdivisions according as the upper part of the face with the eyes, or the lower part of it (the mouth,) is the seat of the malformation. a. Coalescence of the eyes (cyclopia', monopthalmus.) The eyes are very nearly approximated or even amalgamated in the mesial line of the face. The nasal eavities and some of the bones of the superior half of the face are more or less deficient." Moreover, a proboscis frequently exists above the eyes. The mouth is large and irregular, or altogether absent. The varietes of this malformation are very numerous. Cyclopia may be regarded as an interruption in development; the special explanation of its origin, however, differs according to the different view which is taken of the normal development of the 38* 450 MALFORMATIONS. eyes. If we assume with Huschke, that the two eyes originate from one primitive rudiment, which only at a later period becomes divided by the intrusion of the nose and face, the deficient development.of the last named parts, is the cause of- tbe non-separation of the eyes. If, on the contrary, we assume with Bischoff' that the two eyes are originally distinct, then the development of cyclopia, appears to re- quire an amalgamation of the germinal elements of the two eyes. Which ever of these views we advocate, cyclopia, in an anatomical point of view, always appears as a coalescence of organs, which in the normal condition are apart from each other ; and so far be- longs to this place, although at the same time, it is most intimately allied to the monstra deficientia. Cyclopic malformations in the human subject are not very rare ; and in many animals, for instance in .swine, they are frequent. Al- though usually born alive these monsters are not viable. Dlustrations and descriptions are given in Cruve^jiier, Anat. pathol. livr. 33, PI. vi.; Otto, op. cit. p. 83 et seq.; Knape, Monstri hum maxime notabil. descr. anat. Berol. 1823. See also J. F. Meckel, uber die Ver- schmelzungsbildungen, in his Archiv. vql. i. 1826, p. 238; Sieler, uber Cyclopie, Dresden, 1833; Vrolik, over den Aard en oorsprong der Cy- clopie, Amsterd. 1834, (or the abstract in Muller's Archiv. 1836, Jahresber. p. 177, et seq.;) and GeoffroyJSt.'Hilaire, PI. vn. and vol. n. p. 375, &c, and who names the whole group Cyclocephaliens, and makes the following sub- divisions, which, at the same time, serve as a view of the principal forms: a. There may be two orbits which, however, are very closely approxi- mated. 1. Ethmocephalus,* with two eyes distinctly apart, but very close; the organ of smell atrophied, and occurring only in a rudimentary form, which appears externally as a proboscis above' the orbits. 2. Ce- bocephalus,] with two very closely approximating, but yet decidedly sepa- rated eyes-; the organ of smell atrophied, no proboscis. B. Or there may be one orbit. 3. Rhinocephalus, with two adjacent eyes, or one double eye in the mesial line; the organ of smell being atro- phied, and forming a proboscis. 4. Cydocephalus, with two adjacent eyes, or one double eye in the mesial line; the organ of smell atrophied, but forming no proboscis. 5. Stomocephalus, with two adjacent eyes, or one double eye in the mesial line; the organ of smell atrophied, and forming •$[*<>(,. the root of the nose. f x>.'jS«, an ape. MALFORMATIONS OF COALESCENCE. 451 a proboscis; the jaw rudimentary, and the mouth very imperfect or en- tirely wanting. In reference to the coalescence of the eyes, we may distinguish the fol- lowing forms; I. The eyes may be double, completely asunder, and each with its own eyelid, but closely approximating. 2. Two perfectly deve- loped eyeballs may be in contact, and included within one common upper and lower eyelid. 3. The two eyeballs may be more or less amalgama- ted, but contain several internal parts doubled. 4. Only one eyeball may be apparent externally. 5. The eye may [not be apparent externally ; indeed sometimes it is absent altogether. b. The coalescence may be chiefly limited to the inferior half of the face, (monotia, agnathus, otocephalus.) The inferior, and more or less of the superior maxilla, with the bones in immediate con- nexion with them may be wanting. The mouth is then very small or altogether absent, the ears approach each other under the face or perhaps even unite. This group is closely allied with that of cyclo- pia, and the two malformations are not unfrequently combined ; con- sequently many cases belonging to this are referred by someto cy- clopia. There can be no doubt that the cause of this malformation is to be sought in a deficient development of the parts of the face, namely of those which form the commencement of the alimentary canal. Some of the literature cited in reference to.cyclopia, is equally applica- ble here; we may also mention, Otto, op. cit. p. 112, et seq. and Geof- froy St. Hilaire, vol. n. p. 420 <5t seq. The latter arranges this group, which he names Otqcephaliens, under the following subdivisions : a. With two distinctly separated eyes. 1. Sphenocephaly, the ears approximating under the face and uniting; jaw and mouth evident. B. With only one eye or two united in one socket. 2. Otocephalus, the ears approaching each other under the face or uniting; jawand mouth obvious ; no proboscis. 3. Aedocephalus,* the ears approximating under the face or uniting; the jaw atrophied ; no mouth ; a proboscis over the eye. 4. OpocephalusJ the ears" approaching each other under the face or uniting ; the jaw atrophied ; no mouth ; no proboscis. o. The eyes absent. 5. Triocephalus,\ the ears uniting under the face * tufa*., the organs of generation ; the proboscis having been regarded by some of the early observers as a penis. * t »4. the eye; since the eye with its appendages here forms nearly the whole head. X Since three principal parts of .the head— the mouth, nose, and eyes—are absent or deficient. 452 MALFORMATIONS. or approximating ; jaw atrophied ; no mouth ; no proboscis. The latter in its higher grade forms the transition to the acephali. 2. Coalescence of the inferior half of the body, namely of the lower extremities, (monopodia, sympodia.) The pelvis and the organs lying within it, are here incompletely developed; the lower ex- tremities coalescing, and at the same time more or less atrophied. There are different degre'es of this condition. In the lowest the two inferior extremities coalesce into one common limb which sup- ports two feet; in a higher, they are united to one limb and one foot; finally, in the highest, they form together only an undefined caudiform mass. This malformation depends upon a deficient de- velopment of the lower end of the trunk, whereby the germs of the inferior extremities approximate too closely, and thus become amal- gamated. The subjects of this malformation are not viable. From the rather copious literature of this subject, I may especially notice: Cruveilhier, Anat. pathol. liv. 33, PI. v and vi, and liv. 40, PI. vi; Otto, op. cit. p. 153 et seq.; idem, Monstr. hum. sex anat. et path. disquis. Francofurt, 1811, ; A. Kaw Boerhaave, Hist. anat. infantis, cujus pars corpor. infer, monstrosa. Petropol. 1754 ; Rossi, Diss. Jenens. 1800; Kohler, Diss. Jenens. 1831 ; Maier, Dissert. Tubingens, 1837; M.M. Levy, de sympodia. Diss. Havniae, 1833; and Huesker, de vitiis Syngeneficis, adjecta monstri sireniformis descr. Gryphise, 1841. Geoffroy St. Hilaire (PI. v, and vol. n. p. 237,). names these malfor- mations, Symeliens, and arranges them, according to the degree of the deformity, into three subdivisions : 1. Symeles, with the limbs amalga- mated, but otherwise almost perfect, terminating in a double foot, whose sole is directed anteriorly. 2. Uromeles, with the limbs amalgamated, very imperfect, terminating in a simple foot which is almost always im- perfect, and has the sole directed anteriorly. 3. Sirenorneles, when the two lower extremities are completely fused together, and are in the highest degree imperfect, terminating in a stump or point, without evident foot. 3. To these we may add.certain other amalgamations, whose ex- istence, however, does not affect viability. The principal and most frequent of these are : Coalescence of the fingers and toes (syndactylus, Gurlt.) This form occurs in. two degrees: in the lower degree, merely the soft parts— muscles, cellular tissue, and skin, or the latter alone—are united, and the bones are double : in the higher degree, the phalanges are MALFORMATIONS DEPENDING ON FISSURES. 453 also amalgamated. This malformation is sometimes complete on both hands and feet at the same time, bat more frequently it is confined to certain pairs of fingers or toes.* It is to be viewed merely as an anatomical, not as a physiological coalescence, since the germinal matter of the hands and feet is simple, and only at a comparatively advanced period of development is divided into individual fingers and toes. The congenital fusion of those viscera which normally oceur in pairs, as the 'kidneys and ovaries, are, for the sake of avoiding repe- tition, noticed in the special part. THIRD CLASS. MALFORMATIONS, IN WHICH PARTS NORMALLY UNITED ARE SEPARATED FROM EACH OTHER--FISSURES. In this class of malformations, parts which normally are united appear cleft at some spot in the mesial line. The manner in which these malformations originate, can be very clearly shown by the history of-development, although the causes giving rise to them are not very obvious. The cavities for the brain and spinal cord on the one hand, and of the chest and abdomen on the other, are known to be produced in the following manner; the parts of the embryo, at first forming laminae, rise on each side, and gradually approach each other, uniting in the mesial line of the body. If this union does not take place, or if, having already occurred, separation through any cause (as, for instance, the excessive accumulation of water in a cavity of the body) ensues, a fissure arises. It is usu- ally accompanied with SECOND ORDER. ONE OR SEVERAL SUPERNUMERARY ORGANS. This order presents a very great number of varieties, from the simplest cases, in which a single joint of a finger is supernumerary to those of a highly complicated nature, where two, or even three bodies are united by some one point—twin or triplet monsters. Great difference of opinion has prevailed respecting the causes and mode of- origin of these malformations with supernumerary parts. According to some, they arise by a coalescence of two separate germs, while according to others, they depend on a furcation of a single germ. Although,- at present, it is impossible to decide with certainty on SUPERNUMERARY ORGANS. 461 either of these views, yet in the majority of cases, (with certain ex- ceptions to be presently mentioned,) the latter appears to me by far the more probable. The chief arguments in favour of the latter view are the following: 1. The organs that are united are always similar organs: head with head, thorax with thorax, &c.; a fact that can only be explained in a very forced manner by the assumption of a coalescence of two germs. 2. There is a complete transition from tbe cases where two almost perfect individuals are attached at only a circumscribed spot of the body, to those where one individual bears only some trivial supernumerary parts, or other malformation, as, for example, fissure of the skull; in short, to cases whose origin no one would ascribe to a coalescence of two germs.* 3. Finally, it is totally incomprehensible, how, in the case of two sepa- rated germs or ova, of which each must have its own membranes, a union of two embryos can take place; and it is just as little to be comprehended how, in such a union, often more than the halves of the two systems can be so intimately fused together, as we sometimes find to be the* case. These are the. principal reasons which lead me to agree in the opinion, that all twin and triplet monsters, with the exception of the cases of.fcetus infoslu, proceed from a simple germ, or ovum. The question: how and from what causes-does it happen that a malfor- mation with supernumerary parts is-produced from xme ovum? can only be answered by experience, and-the materials necessary to this reply will doubtless be furnished to us by future observers. At present, little more than the following can be said upon the subject. In some cases the ovum or the germ is malformed ab origine (the yolk of abnormal form—ovum in ovo,) in others it becomes after impregnation, so effected, by causes still unknown to us,, that excessive nutrition of particular portions of it ensues, and hence supernumerary parts are formed. Sometimes, finally, the excessive number of parts is only apparent, and is founded upon an ar- rest of development. On those points the reader will find further details in Meckel, vol. u. part i. p. 11, &c, and in Bischoff, op. cit. p. 909, &c. * Sommering has pointed out this fact very convincingly in certain caees. See the vignette on the title.page of his Beschreibung und Abbildung einiger Missgebur- ten. 39* 462 MALFORMATIONS. The malformations belonging to this order may be arranged in two subdivisions, according as the head and trunk are single, and only certain portions of them, or particular limbs and their parts are supernumerary; or as the head and trunk are double or even triple. I, MALFORMATIONS IN WHICH THERE ARE SUPERNUMERARY PARTS, BUT A SINGLE HEAD AND TRUNK. Most of the malformations belonging to this subdivision are no- ticed in the special part, so that in this place a mere specification of them is sufficient. 1. Supernumerary parts on the head. v We may have multiplica- tion of the cranial bones, as double frontal bone, ossa wormiana which are properly formations of arrest; duplication of the lower jaw and of the tongue ; supernumerary teeth; and in animals, supernu- merary horns, 2, Supernumerary parts on the trunk, as an increased number of vertebras; the formation ofa tail in the human subject ^supernume- rary ribs, muscles, and mammae. 3. Supernumerary parts on the limbs. Supernumerary fingers and toes in the human subject are by.no means rare, and sometimes ap- pear to be hereditary. Six fingers on one hand are not unfrequent; a case in which there were seven fingers on one hand, and eight toes, on one foot is given in Geoffroy St. Hilaire, PK in. ; several cases are also given in Otto, p. 2,67, &c. Supernumerary extremities with a single head and trunk, very rarely occur in man, but are comparatively frequent in animals. These cases form the transition to the second division. Supernumerary parts in the intestines, as for instance, supplemen- tary spleens, are noticed in the special part. " II. MALFORMATIONS WITH SUPERNUMERARY PARTS, AND MORE THAN ONE HEAD OR TRUNK. The malformations belonging to this division form the so-called double or twin monsters (monstra duplicia, m. bigemina,) and triplet * See Meckel, vol. i. p. 385; and Geoffroy St. Hilaire, vol. i. p. 736. DOUBLE MONSTERS. 463 monsters (m. trigemina.) .They may be regarded (anatomically, but not physiologically, as two individuals, whose bodies are adherent, and, to a greater or less extent, fused together in a very symmetri- cal manner, by the coalition of corresponding parts. The literature on the general relations of these malformations is very abundant. We may especially notice Meckel, op. cit. vol. n. p. 38, &c. ; Meckel, de duplicate monstrosa, 1815; Burdach, Sechster Bericht von der anatomischen Anstalt in Konigsberg, 1823: Barkow, Monstra anima- lium duplicia per anat. indagata, Lipsise, vol. i. 1826, vol. n. 1836; and Bergholz, de monstro dupl. per implanat. ac de duplicitate, Berol, 1840. These malformations are further divisible into two groups; in the one, the united individuals are both equally developed, double monsters by coalition (autositaires, Geoffroy St. Hilaire;) in the other, only one individual is especially developed, the second being more or less atro- phied, and forming, in a manner, a parasitic appendage to the first, double monsters by implantation, (per implantationem—parasitaires, Geoffroy St. Hilaire.) A. DOUBLE MONSTERS BY COALITION. These double monsters may be separated into, a great number of forms, of which we must here give only a brief sketch, without entering deeply into their anatomy. They form a connected series from a single indivi- dual- with a few doubled parts, to two bodies almost completely separated, and only attached at a very circumscribed spot. 1. The duplication maybe so inconsiderable, that externally it can be scarcely or not at all perceived, while internal parts, vis- cera, or the upper portion of the vertebral column, with a corres- ponding part of the brain and skull, are doubled. All the forms of this duplication are very rare, and have hitherto been observed only in animals. The forms hitherto no- ticed are : a. Partial duplication of the vertex (dicoryphus* Barkow—dicranus, Gurlt.) The cranium is doubled, the face not so, or only partially. * K0£v4, the face. DOUBLE MONSTERS. 465 For the literature, see Barkow, vol. ir. p. 37, &c; and Otto, p. 221, plate xxiv. figs. 2 and 3. Geoffroy St. Hilaire* distinguishes the following forms: 1. .•Jt/iiilymus, in which the two heads are seated upon one neck, and the duplication descends as far as the atlas. 2. Derodymusf, in which the duplication extends to the neck; the thorax, externally simple, pre- senting one sternum and a double vertebral column. c The head, neck, and upper extremities may be doubled, while the chest and abdomen are single, or at least fused into one another, in the two bodies. Thoracico-abdominal duplication, (didymus sym- phyothoracogastrius, Barkow—thoraco-gastrodidymus, Gurlt.) Barkow, vol. n. p. 39, and vol. i. pi. m. fig. 1. Geoffroy St. HilaireJ names this form Xyphodynms.^ In this division we must place the twin monster known .under the name of Rita Cristina, who was, born on the 12th of March, 1829, at Possari (in Sardinia,) and was brought alive to Paris, but died there in the November of the same year, after it had been subjected to some interesting physiological experiments. Other cases are given in Otto, p. 217, &c, and W. Griiber, Anatomie eines Monstrum bicorporium. Prag. 1844, with six plates. d. The duplication may extend to the thorax, while the abdo- mina coalesce, (didymus symphyogastrius, Barkpw—gastrodidymus, Gurlt.) The lower extremities may in this case be single or doubled. Barkow, vol. ir. p. 39. Geoffroy St. Hilaire|| names this from Psody- mus.^ A case recently described in Froriep'sN. Notiz. vol. v. p. 152, of a double monster, born at Stammsried (Bavaria,) in January, 1838, should probably be placed in this division. e. The duplication may extend as far as the centre of the abdomen, while the lower halves of the body, from the umbilicus downwards, coalesce, (didymus symphyohypogastrius, Barkow—hypogastrodidy- mus, Gurlt.) The lower extremities are likewise sometimes doubled. "' * Vol. in. p. 191. t ^ Fio-.a °"^,.- Fig 10. V.......' s.£.v Figll. v a -, Fig. 14- h' ^ 3>V» p Flo: 13 i'-^D i^'j €U(- ■V1 «» J' ./W "JWrf -rf-Z X Sinclair 1M. CELLS. 5773 EXPLANATION OF THE PLATES. PLATE I. Contains illustrations of the different forms of cells occurring in th development of morbid epigeneses. Fig. 1. Is an ideal figure, illustrating the formation of a cell. In an amorphous substance (A A,) the cytoblastema, lie three ideal cells, (B, C, D.) The cell B appears oval; we distinguish in it a clear ring with a very distinct external and internal contour (x x,) the cell- wall; in the interior of the ring, an illiptical body (z) the nucleus or cytoblast; and in it, two round dark corpuscles, the nucleoli. The space between the cell-wall and nucleus, the cavity of the cell, is filled with a fluid which escapes observation. The cell C is round; here we observe an evidently distinct cell-wall, and an equally clear nucleus, with a single nucleolus in the centre; the cavity is filled with dark granular matter. The cell D is likewise round, and exhibits a clear cell-wall, with a more evident internal and external contour. The nucleus does not lie in the centre of the cavity, but on its circumference, on the inner surface of the wall, and contains distinct nucleoli. The contents of this cell are granular in the vicinity of the nucleus, but fluid and invisible in the re- mainder of the cavity. Fig. 2. A. Is a cell from encephaloid, occurring in the knee-joint. B. Cells from pulmonary tubercles. Magnified 220 diameters. These cells are perfectly round, and we distinguish in them a tolerably thick transparent cell-wall, and dark granular contents. Here there can be no doubt as to the granular mass being actually in the interior of the cell, in the cell-cavity. At A there are also separate granules on the outer circumference of the cell-wall; we see an undoubted pale nucleus with a nucleolus in the upper part of the cell-cavity; in the cells B, the nuclei are not evident. Fig. 3. A. Are cells from the substance of pulmonary tubercle. B. Cells from the expectoration in pneumonia. Magnified 220 diameters. These cells also appear granular, but we cannot decide with certainty whether the granular mass is in the interior of the cells, or whether it is situated on the exterior of the cell-wall. 484 EXPLANATION OF THE PLATES. Fig. 4. Very pale non-nucleated cells (?) of an indefinitely oval form, from the contents of an encysted tumour. Magnified 220 diameters. Fio. 5. Cells with two nuclei, magnified 220 diameters, a. an oval cell from encephaloid affecting the knee-joint, b. a cell of irregular form from the liver (normal hepatic cell.) Fig. 6. Cells containing many nuclei in their interior, from encephaloid o the uterus. Magnified 220 diameters. Fig. 7. Large cells, in the interior of which there are smaller but per- fect cells, (parent-cells with young cells,) from encephaloid of the bladder. Magnified 220 diameters. The cell A is complete; B is the mere outline. Fig. 8. Cells containing yellow pigment (bile-pigment) from a diseased liver. Magnified 220 diameters. Fig. 9. Cells containing fat, from a fatty liver. Magnified 220 diame- ters. The fat-globules are very small in. some; in others they are larger and more distinct. Fig. 10. Cells containing black granular pigment from a lung com- pressed by empyema. Magnified 220 diameters. Fig. 11. Nucleated cells of very irregular form, from encephaloid of the stomach. Magnified 220 diameters. Fig. 12. Very elongated caudate nucleated cells. A, from a simi-orga- nized exudation in the pulmonary pleura. B, from a newly formed sac, attached to the pulmonary and costal pleura, and containing a fluid of the same chemical composition as the serum of the blood. Magnified 220 diameters. In A and B the cell becomes gradually thinner and is finally elongated to a mere thread; in B b, several such cells are united by their pointed extremities, and form a single varicose fibre. Fig. 13 and 14 demonstrate the origin and growth of cells in morbid products. Magnified 220 diameters. Fig. 13. Represents different parts of a tuberculous lung. At A we per- ceive the earliest perceptible stage of the disease; many nuclei with or without nucleoli, in an amorphous cytoblastema. At B the cyto- blastema is consumed, and we can only trace a mass of neuclei lying closely on one another. C represents nuclei around which a pale soft cell-wall is already formed. At D there are wholly developed cells. Fig. 14. Shows portions of a scirrhous testicle. At A we see a firm amorphous cytoblastema, in which distinct cells are being developed; most of these exhibit an evident nucleus, while in some, the cell-wall merging into the cytoblastema, appears like a broad, clear ring. AtB the cells are more evident, and more distinctly separated from the cyto- blastema. VOGEL'S PATHOLOGICAL ANATOMY PLATE II ,//z/ I Tcgrf (M. Lif/i efl'Smrfatr. IKFuAMMATUW & EXUDATION. EXPLANATION OF THE PLATES. 485 PLATE II. INFLAMMATION, FIBRINOUS EXUDATION, AND THEIR DEVELOPMENT. Fig. 1. A piece of inflamed mucous membrane from the trachea ofa young man who died from febris mucosa. The respiratory mucous membrane was especially attacked by the disease; during life there had been difficult respiration, rhonchus sibilans in both lungs, and mo- derate expectoration, containing pus and mucus streaked with blood. On dissection, the mucous membrane of the trachea was found to be much reddened ; the colour passing into a violet tint, but on exposure to air soon changing to a clear red. (A) exhibits a piece of this mucous membrane, as it appeared to the naked eye. Seen under a power of 220 diameters, normal;ciliated epithelium was visible, the separate cells being for the most part rubbed off, so that the surface of the mucous membrane appeared free. (B) shows the free sur- face of the mucous membrane after the epithelium had been removed. Magnified 220 diameters. We saw a very thick vascular network, the vessels having a larger diameter than usual, and being entirely filled with stagnant blood, which was, however, still fluid, and flowed from them on pressure. On examining this expelled blood, the blood-corpuscles were seen to be little changed in their form; they were more globular than usual, and had lost the cup-like depression in their centre (Fig. 1, **.) The vascular reticulations were so close, that they in some places en- tirely covered the parenchyma of the mucous membrane ; and where the latter is visible, it was colourless, or of a faintly brown tint, and had the usual appearance of:normal mucous membrane. pIG. 2—5 illustrate different stages of development of effused and coa- gulated fibrin. Magnified 220 diameters. Fig. 2. Fibrinous exudation after bronchitis, in the earliest stage of orga- nization. A strong and otherwise healthy man, aged forty-one years, was attacked with acute bronchitis in consequence of exposure to severe cold and wet. There was cough, sharp pain on inspiration, hoarseness, and ex- pectoration, at first moderate, but afterwards very copious, forming a thin yellowish fluid,, which, showed under the microscope an immense 41* 486 EXPLANATION OF THE PLATES. number of pus-corpuscles ; on auscultation little respiratory murmur was heard, but general mucous rales. Membraneo-gelatinous masses were mixed with -the expectoration, which was copiously charged with pus, and thrown off to the amount of five or six ounces in the twenty-four hours. A mass of this kind of the size ofa hazel nut appeared entirely homo- geneous, yellowish, and in places of a rusty tint: it resembled stiffening glue, but admitted of being drawn asunder, and divided into membranous layers. These layers formed perfect membranes and appeared entirely structureless and like coagulated fibrin—showing neither granules or fibres (Fig. 2. A.) The mass was opaque in the centre, and ofa bluish yellow tint; but transparent and almost colourless at the edges. Acetic acid rendered it more transparent ; nitric acid, and ammonia did not affect it; but caustic potash rendered it more transparent, and softer, without entirely dissolving it. It did not dissolve when boiled with con- centrated hydrochloric acid, the colour of the acid as well as that of the membrane remaining unchanged even after prolonged ebullition. In some places this amorphous mass contained roundish, very pale, colourless bodies (Fig. 2. B, cells?) They varied from the 100th to the 60th ofa line, and contained no nuclei—the first traces of cellular for- mation. Fig. 3. An unorganized coagulum of fibrin from the heart ofa man aged fifty-six years—-constituting false polypus of the heart. Both ventricles contained thick coagula ofa white colour, which were closely combined with the columns? carnese, and could only be separated piecemeal with great difficulty. The observation of the progress of the disease rendered it probable that these coagula had been formed about ten days before death, while the patient remained for several hours in a state of syncope, without any evidence ofa pulse. The coagulum in the left ventricle was very thick and firm, of a faint red colour; in the interior it was soft, being saturated with a yellowish white fluid, which was declared to be pus by the physicians in attendance. Under the microscope the coagulum appeared as a perfectly structure- less mass, which was covered by a large number of globules and gran- ules of fat: it contained no trace of cells. On the application of acetic acid, the amorphous mass became very pale, and So translucent as almost entirely to escape observation; but even then no traces of nuclei or of commencing organization were visible. The fatty parts were not changed by the acid. The supposed pus in the interior contained no pus-corpuscles, but simply many globules and granules of fat in a colour- less fluid. The same was the case with the coagulum in the right ventricle. Fig. 4. Exhibits fibrinous exudation in the act of development, from EXPLANATION OF THE PLATES. 487 the areas uortse of a man who had died from inflammatory hypertro- phy of the heart with deficient action of the valves. The arcus aortas was externally reddened and covered with coagulated exudation, which was ofa yellowish white colour, soft, saturated with a yellowish white thickish fluid smooth and fatty to the touch, and formed irregular portions of tolerable thickness. Under the microscope the exudation appeared like an amorphous mass of an indefinite fibrous character (Fig. 4. A.) It became paler and more transparent on the application of ammonia, as well as of acetic acid. This amorphous mass contained a large number of cells of round, or roundish shape, varying from the 200th to the 100th of a line in diame- ter, and, for the most part, pale and without evident nuclei. There were, however, a tolerable number of little roundish granules, but it was im- possible to determine with certainty, whether they were contained in the interior of the cells, or whether they were situated on their exterior. These granules were not affected by water, common spirit of wine, caustic ammonia, caustic potash, or acetic acid, but dissolved in ether, in which they united and formed large fatty globules: they consisted, therefore, of fat. The cells became paler and gradually disappeared on the addition of ammonia, which also rendered the amorphous exudation paler, and, by prolonged application, softer, and more fibrous. In some parts of the exudation the cells preponderated, in others, on the contrary, the amor- phous stroma. No free fat appeared in the exudation. The pus-like fluid expressed from the mass showed under the micro- scope many isolated cells B, whieh were precisely similar to those con- tained in the exudation ; behaving in the same manner towards chemical agents. Fig. 5. Fibrinous exudation in the act of development, from an inflamed lung. The patient, a coachman aged forty years, addicted to drinking, enter- ed the hospital at Munich, with :,11 the symptoms of inflammation of the right lung. Fever with hard full pulse, severe pain on breathing, op- pression at the chest, and cough with sanguineous expectoration. In the lower part of the right lung the respiratory sounds could not be heard, but crepitation was distinctly audible. On the seventh day of the dis- ease the local symptoms yielded to an antiphlogistic treatment—vene- section and the internal use of large doses of tartarized antimony. The sounds on percussion-continued to be dull, but instead of the crepitation there was a loud mucous rattle, and the expectoration became more copi- ous. This was succeeded by a general prostration of strength, the pulse 488 EXPLANATION OF THE PLATES. was more frequent—small and weak; there was great distention in the region of the stomach, vomiting, and death. On dissection there was fatty degeneration of the liver in an advanced stage. The lower part of the right lung (the middle and lower lobes) was thickened, of a grayish red colour, which gradually became of a bright red on exposure to the air; and exhibited a granular appearance, when cut: it did not crepitate, and sank in water. The fluid from the thickened part of the pulmonary tissue was not frothy : it exhibited no air under the microscope, but a good many un- changed blood-corpuscles, and numerous pale cells varying from the 200th to the 100th of a line, some of which contained nuclei with or without nucleoli, and others a granular mass in a larger or smaller quan- tity, (Fig. 5. A B.) The cells appeared sometimes isolated as at A, sometimes united, in groups as at B. By the cells, fibrinous coagula of grape-like, or simply globular shape were seen, which in form and size corresponded with the air-cells of the lung. These coagula, when ex- amined under the microscope, were seen to consist of an amorphous mass (C) which contained cells filled with granules, and likewise isolated granules. The fibrin was here in the act of being converted into granu- lar cells. Larger portions of the thickened tissue of the lung appeared under the microscope (Fig. 5. D) as.an indistinct granular mass with very many small granules, and roundish granular heaps from the 200th to the 100th ofa line in diameter—granular cells. In some parts of the pulmonary tissue, the amorphous fibrinous exudation preponderated, while in others it was almost entirely converted into granular cells. VOGELS PATHOLOGICAL AXATO"MY TLATEJH FiP- ] ^»%^ i> ;M; Ficr.4 fe '^* 'art Fig.5. Fig. 6 ^v *J^*S»'..jigv. y ■V/;'.cX=. rig. 7 If. A' --o Fig.8. <&Tf\-.c d. *-** c it if* Kiit 10. • *-*^'?* •■•''c '? %-9 A X* > -i ftgll Pio-.IS (f'.y d «/*/. w/ <#/. Lifli.rr'T-.> *i'//c//7rr. PUS. EXPLANATION OF THE PLATES. 489 PLATE III. PUS AND GRANULAR CELLS. The three first figures exhibit normal pus from abscesses of the cellu- lar tissue. Magnified 110 diameters. Fig. 1. Shows pus-corpuscles (a) dark and compact, and covered with numerous granules. Besides the pus-corpuscles, we see manv smaller granules (b) partly isolated, partly united. They consist of fat—a mixture of olein and margarin. Fig. 2. Also normal pus, showing very soft, pale pus-corpuscles, which do not appear perfectly round, and are only covered by a few gra- nules. At (b) we see the nucleus appearing through the delicate cap- sule. This pus contains no fat granules. Fig. 3. Pus-corpuscles treated with acetic acid. The acid has more or less completely dissolved the walls, and only- left the nucleus remaining. At a we see a triple, at b a single nucleus, still surrounded by the faint remains of a wall. At c and d the wall is quite dissolved and the mere nuclei remain. The cup-like form of the nucleus on treating it with acetic acid, is the one common to normal pus- corpuscles. Fig. 4. Supposed pus (magnified 220 diameters) from the pelvis of the kidney ofa patient, who died of empyema* The pelvis of each kidney was completely filled with a yellowish white creamy fluid, which bore a perfect resemblance to pus: but on ex- amination under the microscope nothing could be seen but portions of epithelium mixed with a colourless fluid (urine;) a, a portion of epithe- lium varying between the cylindrical and pavement forms; b a single epi- thelial cell of this kind; c cylindrical epithelium seen from one^ide; d a portion seen from above. Fig. 5. Exudation in the act of conversion into pus: from the pleural sac ofa patient who died from empyema. In the pus discharged from the pleural sac, there were several concre- tions varying from the size ofa pea to that of a nut, ofa whitish colour and admitting of being easily torn. When examined under the micro- scope, they were found to consist of an indefinite fibrous mass, enclos- ing numerous pus-corpuscles. These fibres were observed crossing 490 EXPLANATION OF THE PLATES. each other in every possible direction. On the addition of acetic acid the fibrous mass entirely disappeared, leaving nothing but the nuclei of the pus-corpuscles. The whole substance, including the corpuscles, was entirely soluble in caustic potash. Magnified 220 diameters. Fig. 6. Exhibits the formation of pus in mucous membranes. In the fluid cytoblastema which is secreted, we observe the nuclei first pro- duced, and around them the capsules gradually forming. Magnified 220 diameters. A girl suffering from empyema, suddenly commenced to expectorate very abundantly—-in fact, to the amount of several pounds daily. It was perfectly fluid, creamy in appearance, and of a whitish yellow colour. Under the microscope there were seen (A) a very few perfect pus-cor- puscles (a. a.) which were very delicate and pale, while there was an increased quantity of nuclei of pus-corpuscles—single, double, and triple (b. b. b.) On the addition of acetic acid there was. a slight coagulation of mucus (see the lower portion of fig. 6;) the nuclei of the pus-corpuscles underwent no change, but in those corpuscles which were perfectly formed, the capsules became, as usual, transparent, and the nuclei be- came visible(**.) They had not the ordinary cup-formed shape, but had an indefinite roundish appearance. Similar appearances present themselves in all mucous membranes, in which there is a copious secretion of pus. Fig. 7—11. Various forms of abnormal pus. FtG. 7. Scrofulous pus magnified 410 diameters. The pus was obtained from a swollen cervical gland of a young man, with a well-marked scrofulous diathesis. It had a viscid appearance, was white, and, as is generally the case with scrofulous pus, contained numerous whitish clots. The corpuscles of this pus (A) deviated from the-normal form; they were smaller than usual, (averaging from the 400th to the 300th of a line,) irregularly roundish, rough, pointed, and almost angular. They disappeared on the addition of acetic acid, but the characteristic nuclei (B) did not make their appearance. The acetic acid coagulated a considerable amount of a viscid matter (pyin ?) which enclosed the corpuscles, and formed clumps of them (C.) A solution of alum acted in a similar manner. The clotted, caseous matter in this pus, exhibited, in addition to pus-corpuscles, stellar or striped portions of amorphous appearance, which were rendered transparent by acetic acid, and could no longer be detected by the eye (exudation not yet orga- nized.) • Fig. 8 and 9. Pus from abscesses in the cutaneous glands. Magnified 220 diameters. Fig. 8, Pus from a small abscess on the inner surface of the root of the nail of the second toe of a healthy man. EXPLANATION OF THE PLATES. 491 The pus which was evacuated by a puncture amounted to only a few drops, and was very thick. When examined under the microscope, there were observed not only pus and blood-corpuscles, but also modified epithelial cells (A,) which varied in diameter from the 75th to the 100th of a line, and were partly round (a b c,) and partly oval (d.) Some con- sisted of a large dark nucleus varying from the 110th to the 180th of a, line, surrounded by a transparent capsule (a,) while others exhibited a clear nucleus and nucleoli in a dark capsule (b—d.) On the addition of acetic apid, the pus-corpuscles underwent the ordi- nary change, the larger corpuscles being rendered paler and more trans- parent (B.) There was also an abundant coagulation of mucus (pyin ?,) forming a delicate membrane. Fig. 9. Pus from a minute abscess in one of the cutaneous glands in the nose ofa healthy man. Under the microscope the fluid was seen to contain a very large num- ber of pus-corpuscles, most of which were perfectly round, and exhibited no nuclei (a.) They were very unequal in size, varying from the 170th to the 300th ofa line in diameter; the average diameter was the 250th of a line. Many were united in a tesselated manner, forming a species of membrane ; hence they were somewhat angular (b. b.) These ap- peared to be extremely delicate. Amongst them were a few non-nucle- ated epithelial cells (?) of which some were granular (c,) but the majority exhibited a smooth surface {d;) these were united so a3 to form mem- branous patches. On the addition of acetic acid the pus-corpuscles un- derwent the ordinary change (B,) while the epithelial cells were un- affected. Moreover the acid coagulated a viscid mass, which enclosed the pus-corpuscles and epithelial cells. Fig. 10. Abnormal pus from the lung ofa person who died from typhus. The lung was very dense and hepatized ; it sank in water, did not cre- pitate, and on making a recent section, exhibited a dark violet tint. It appeared, on making a microscopic examination, that it contained no air, but much blood; when this was removed by washing, the pulmonary tissue appeared to be everywhere filled with pus. The corpuscles of this pus (A and B) deviated in some respects from the ordinary type; their form was more irregular than usual, they were not perfectly round, many of them being elongated, and some a little angular; their margin was for the most part very sharply defined, and their surface not so granular as usual. In size they varied from the 500th to the 150th of a line. On the addition of acetic acid they underwent the ordinary change; their capsules became transparent, and as they gradually disappeared, the nu- clei came in view; they did not, however, exhibit the ordinary cup-shaped form with any distinctness (C and D.) Ammonia entirely dissolved both 492 EXPLANATION OF THE PLATES. capsules and nuclei. A, B, and C are magnified 220, and D 410 diame- ters. Fig. 11. Pus from what is called a cold abscess on the right shoulder ofa vigorous young man. Magnified 220 diameters. The pus which was discharged amounted to about two ounces; it con- sisted ofa rather thin pale yellow fluid, and delicate thready flocculi of a yellow tint; hence it differed essentially from good creamy pus. It had a strongly alkaline reaction. The microscope revealed the presence of pus-corpuscles, almost all of which were transparent and delicate, with a distinct margin; and some slightly, others not at all granulated. In some the nucleus could be seen through the capsule (A.) On the addition of acetic acid there was an abundant coagulation of an amorpho-fibrous character; and on the addi- tion of alum there was an abundant coagulation of a granulo-amorphous character (pyin 1) The yellow filamentous flocculi which were swimming in the fluid con- sisted of accumulations of minute and imperfectly formed pus-Corpuscles, which were connected in irregular groups by an indistinct granulo-fibrous medium of communication. Oh the addition of acetic acid, this combin- ing tissue became somewhat paler, Without, however, disappearing ; and numerous fat-granules came in view. Ammonia produced little effect on this granular matter. Fig. 12—15. Granular cells (Gluge's compound inflammatory globules. exudation-globules,) magnified 220 diameters. Fig. 12. Elucidates the development of granular cells. All the cells in this figure were obtained from the same inflamed lung. At first we perceive the granular cells as simple cells without granules, with de- cided nuclei and nucleoli (a. a.) These cells are for the most part round, but sometimes elongated or even angular. < Their size varies from the 300th to the 100th of a line. We ^afterwards observe these same cells more or less covered with minute granules, varying in size from the 800th to the 1500th of a line. At first (in b. b.,) as long as the granules are only sparingly present, it is difficult to distinguish whether they are on the surface or in the interior of the cells. Finally, when the whole cell is filled with granules, the nucleus can- not be discovered (d,) and it can no longer be doubted that the whole of the interior of the cell is filled with granules. These granules appear to consist of fat. Fig. 13. Perfectly developed granular cells from inflamed lungs. A. from the lung of a man who died from pneumonia. The lung was in a condition of red hepatization. B. from the lung of a girl who died from pleuritic effusion. The left lung wa$ very much compressed by EXPLANATION OF THE PLATES. 493 the effused fluid, was of a brownish colour, contained no air, did not crepitate, and sank when placed in water. Under the microscope its tissue appeared unchanged, except that an immense number of granular cells were deposited in it. Fig. 14. Granular cells in the act of breaking up, and their remains. When the granular cells have attained their full development, the cell- wall disappears, and the granules contained in the interior are liberated, and form larger or smaller heaps. The granular cells in this figure were obtained from the lungs of an aged woman who died from pneumonia. The right lung was dense, red, hepatized, and contained no air. Under the microscope, the whole pul- monary tissue appeared filled with these cells, in various stages of dis- integration. Fig. 15. Granular cells from an inflamed and softened liver. Fig. 16. The corps granuleux or colostrum-gramdes of the milk, ob- tained from the duct of an extirpated scirrhous breast. Magnified 220 diameters. They are given in this Plate, since, from their similarity, they might be mistaken for granular cells. 42 494 EXPLANATION OF THE PLATES. PLATE IV. ePigeNesIS of areolar tissue and organic Muscular fibre. Fig. 1. Newly formed areolar tissue* in various stages of development, from a false membrane in the pleura. A young man was attacked with inflammation of the right pleura, which was succeeded by very considerable empyema. As the difficulty of respiration was so great as to threaten daily suffocation, paracentesis thoracis was had recourse to, by which a very considerable amount of fluid was discharged. The fluid coagulated spontaneously, and had the same chemical Composition as the plasma of the blood. It was again formed with such rapidity, that the operation had to be twice repeated- Soon after the last operation (on which occasion the fluid did not spon- taneously coagulate) but was a mere admixture of serum with a little pus,) thepatient died. On dissection, the right pleura was everywhere invested with a false membrane, which formed a shut sac, containing a yellowish serum with a deposit of blood-corpuscles. This membrane varied in thickness from half a line to a line ; when examined under the microscope, it was found to exhibit traces of more or less advanced organization. The most re- cent layer, lying next to the pleural cavity, Was partially fibrous, and contained many nuclei (A,) together with numerous globules and gran- ules of fat. On the addition of ammonia it became pale and transparent, the fatty granules being the only element unaffected by this re-agent. The mass tfiat presenter) itself after the removal of the most recent layers, consisted of irregular, for the most part elongated, membranous particles (cells, B,) containing one or more nuclei. Some of these cells were very irregular and composite B. a.,) while others had the ordinary form of the caudate, fusiform, fibrous cells of areolar tissue B. b.) Acetic acid produced a paleness and transparency of the walls of all these cells with- out altering their nuclei. In the older layers adjacent to the pleura, the development of the fibrous cells of areolar tissue was still farther advanced. The cells were much elongated and sharp at the two extremities, but still retaining the nu- VOGhl.'S J 'ATHoLOUCAL i * D A \" ATOMY TIATE rv Fig-. 1 v k J? -■■ ■'* "■■3" . <"a .fi'a fr • '. ' 'V 3 - V \ B~ A. % . \> ' " ^„ b \ \ \ /V * Fior.3. c..\W ^0 W I ^ ,^-' y „ 0* Tier 4 ■V ■V Vi#|l?? V n- \\ V J*/ Vwl del 1\ fuic7airjl ifA VOLUTION' OF FIBROUS "TISSUE. EXPLANATION OF THE PLATES. 495 cleus (C.) Other cells (D) formed parallel fasciculi of the fibres of areolar tissue, in which the nuclei were apparent. On the addition of ammonia, both the fibres and the nuclei gradually disappeared. Fig. 2. Areolar tissue, in part fully developed, and in part immature, from a false membrane from the pleura of another man, a muscular agricultural labourer, aged thirty-three years, who was attacked with pleuritis of both sides, and after six weeks maltreatment at the hands of a quack, was brought in a moribund condition into the Munich Hospital. On dissection, the pleural cavity on each side was invested through- out with a layer of solid exudation, varying from one to two lines in thickness. Shreds and flocculi were attached at various spots to the inner surface; they were of a yellow colour, and their formation was obviously ,of the most recent date. They were soft resembling coagulated and washed fibrin, and formed irregular patches, of varying thickness. Under the mi- croscope they appeared perfectly amorphous, but at some spots exhibited a slightly fibrous structure. On the addition of acetic acid they soft- ened, became transparent and gelatinous: they showed no trace of or- ganization. The older portion of exudation, lying directly in contact with the pulmo- nary and costal pleura, formed a regular layer, of tolerably equal thickness, which with careful dissection, admitted of separation into several strata, This portion was not so soft as that previously described, but was almost cartilaginous, and did not assume a membranous form. It exhibited in- dications of organization in proportion as the exudation approximated to the surface of the pleura, or in other words, in proportion to its age. The organization consisted in the formation of cells and in their con- version into fibres (Fig. 2.) The younger cells were fusiform, with a distinct nucleus (a.) Other cells, in a more advanced stage of develop- ment, consisted of thin parallel fibres, and formed a fasciculus of fibres of areolar tissue with nuclei (b.) In the laver of exudation in contact with the pleura, these cells under- going conversion into fibres, were compressed on one another (c.,) and the newly formed areolar tissue could only be distinguished from the nor- mal areolar tissue of the pleura by its less marked fibrous character, and by the presence of many nuclei. The nuclei were roundish, oval, caudate, or oat-shaped ; some contained nucleoli, others were devoid of them. In no place could their elongation into fibres be observed. On the addition of acetic acid, these newly formed fibres of areolar tissue became pale, and gradually disappeared; the nuclei remained unaffected. 496 EXPLANATION OF THE PLATES. Fig. 3. Illustrates the epigenesis of organic (involuntary) muscular fibre. The structures depicted are primary cells from a fibrous tumour in the uterus. They represent, in all probability, the earliest stage of the development of organic muscular fibre; and it is only very rarely that we have an opportunity of observing them. The following is the his- tory of the case. A female servant, aged forty-four years, was admitted into the Munich Hospital on account of severe abdominal pains. Her statement was, that for several years there had been a fluctuating tumour on the right side of her abdomen, but which had never hitherto caused her further pain or uneasiness than an occasional sense of weight or bearing down, as if in labour until just before admission, when there had suddenly occurred in it most intense pain, with tenderness on pressure. In defiance of the most energetic treatment—venesection and palliatives—this pain rapidly grew worse, and the woman died on the third day after its first occurrence. On dissection, the following appearances presented themselves. The right side of the great omentum was considerably thickened, and insepa- rably united on the one hand with the walls of the abdomen, on the other with a firm tumour, which extended downwards into the cavity of the pel- vis, and was of about twice the size of a man's fist. The surface of this tumour was somewhat tuberculated, and of a whitish colour. It was in- timately connected with the' fundus of the uterus. The upper part of this tumour had began to soften, and its substance was here and there hollowed out into irregular excavations, which were traversed by bands and shreds of tissue, soft and friable externally, but tolerably firm in their interior. These excavations were partly empty, partly filled with small grumous masses of blood, or with a greasy, grayish-white, purulent-looking mat- ter. The softening which was going on in this tumour had at one part approached quite to the surface, burst, and a portion of the softened mat- ter had escaped into the cavity of the peritoneum, inducing secondary peritonitis, from which had resulted the sudden severe pain, so speedily followed by death. The inner surface of the uterus was healthy, its mucous membrane being unaltered; but within its cavity was situated a roundish tumour about the size of a billiard-ball, tolerably firm, of a bluish-white colour, and covered on its surface with a yellowish purulent-looking matter. It lay quite free in the cavity, having no connexion, at any part, with the walls of the uterus. The parietes themselves were very thick; the degree of their thickness, however varied, being in some places as much as three inches. Imbedded within their substance were found numerous roundish EXPLANATION OF THE PLATES. 497 tumours, of all sizes, from that of a pea, to that of a billiard-ball. These tumours, for the most part, lay free, or at least so nearly free, that they could be separated without any difficulty from the substance of the uterus, within which they were imbedded: they were of a whitish colour, very firm in texture, and of a globular form, though most of them were irregu- larly tuberculated and nodular. When cut into, each tumour was found to consist of a firm, compact, polished, white tissue, but with the naked eye no trace of a fibrous or other well-marked structure could be discerned. In the vaginal portion of the uterus was situated another tumour, about the size of a pigeon's egg, somewhat soft in consistence, and inseparably connected with the substance of the organ; it had a whitish colour, and when cut into was found to be made up ofa fibrous net-work, the areolae of which were large, and filled with a thick albuminous fluid. A careful microscopic examination of the several parts described above, furnished the following results. The substance of the uterus was com- posed of its usual organic muscular fibres, from the 150th to the 300th of a line in diameter. Here and there, between these fibres, were scattered numerous granular cells, of a dark brownish colour such as are depicted in Plate in. fig. 12—15. The tumour, which was situated within the ca- vity of the uterus, presented a structure almost exactly similar to that of the uterus itself, being made up of fibres closely resembling those peculiar to organic muscle, and containing also the same dark-looking granular cells noticed between the fibres of the uterus. Similar characters were also presented by those tumours, both large and small, which were im- bedded within the parietes of the uterus. The softened mass at the upper part of the large tumour, which was situated outside the uterus, contained, besides small grumous masses of blood and separate blood-corpuscles, nu- merous pus-corpuscles, the presence of which justified the supposition that the softening of the tumour was the result of inflammation. The usual changes were produced on these pus-corpuscles by the addition of acetic acid, namely, the gradual disappearance of the cell-wall of each, and the coming into view of its double or triple nucleus; the nuclei were left en- tangled in a coagulum formed by acetic acid, and consisting ofa perfectly amorphous structureless mass, resembling coagulated mucus (pyin?.) The bands and shreds of tissue which traversed the excavations in this softened part, exhibited beneath the microscope the remains of areolar tissue, which had resisted the process of softening and destruction. The soft tumour situated in the vaginal portion of the uterus, seemed to be a fibrous tumour in the process of formation ; for the fibrous portion con- sisted of organic muscular fibre and areolar tissue, and the albuminous fluid which filled up the meshes, exhibited, under the microscope, nume- rous roundish or oval cells, some single, others arranged in groups, con- 42* 498 EXPLANATION OF THE PLATES. taining nuclei and nucleoli, (see Fig. 3.;) these were, in all probability, primary cells, which would eventually have become developed into or- ganic muscular fibres. Several of the other tumours contained in the substance of the uterus, were carefully removed, cut into small pieces, and after being repeatedly washed, were subjected to several chemical tests. They gradually dis- solved in boiling concentrated hydrochloric acid, forming a colourless solution. In acetic acid they swelled up, became transparent and gela- tinous-looking, but a complete solution was not effected even after the lapse of some weeks. Several pieces from these tumours, after being repeatedly washed and dried with blotting paper, were weighed, then thoroughly dried in a water-bath, at the temperature of 212° F, and again weighed. Of 1000 parts of the fresh substance, there remained, when thus thoroughly dried, only 220; consequently 780 parts consisted of water and other matters, volatile at a temperature of 212° F. Fig. 4. Newly formed organic muscular fibre from the hypertrophied muscular coat of the intestine of a man who died from peritonitis. The muscular coat at the commencement of the caecum was a line in thickness. A. Is a thin section made by the double knife, as seen under the micro- scope. We observe parallel fibres with nuclei. B. Are individual fibrous cells in the course of development into mus- cular fibres. C. Is a very thin section treated with acetic acid; the fibres are very pale, and the nuclei are distinctly visible. VOGELS PATHOLOGICAL ANATOMY: PLATE V Tier. 4 ,/ul KycJ del LitkcrFSmtUur REGENERATION OF Bi.OOD, BONE AND NERVE EXPLANATION OF THE PLATES. 499 PLATE V. EPIGENESIS of blood, bones, nerves, and serous membranes. The figures from 1 to 4 illustrate the pathological epigenesis of blood in the adult. The following case will serve as an illustration. A young man, aged twenty years, suffered from the encephaloid of the left arm, which slowly developed itself, and finally ulcerated. Repeated haemorrhages rendered amputation necessary. The amputated part could not be obtained for microscopical examination. About ten days after the amputation, fungoid growths, which came from the medullary cavity of the bone, appeared. When removed, they were of a whitish-yellow co- lour, soft, fatty, and anaemic. When examined under the microscope, they were found to consist of areolar tissue in the act of development, (granulations.) Two days subsequently, on renewing the bandage, another growth from the medullary cavity of the bone, of precisely similar appearance, was observed. It was as large as a cherry, and externally brown, (being discoloured by the liniment, ex. pulv cort, china,) and shrivelled, and internally of a yellowish-white, lardaceous appearance. Its consistence was so soft and mellow, that it could easily be broken off by the finger without the assistance of any sharp instrument. It had sprouted from the medullary cavity of the bone. Under the microscope, it appeared throughout as a granulo-amorphous mass, which, on the addition of acetic acid, became pale and transpa- rent. It was almost wholly unorganized, only exhibiting at a few spots traces of cells, partly of indefinite form, and partly elongated, (the fibrous cells of areolar tissue.) A recent section of the mass (Fig. 1. left side) showed many small points and streaks of blood. These small portions of blood in the midst of the mass, without any connexion with the vessels of the bone, must necessarily, from their place and position, have been formed there, and promised to afford some elucidation of the morphology of the formation of the blood, which can so seldom be directly observed. The result of a careful examination was as follows. 500 EXPLANATION OF THE PLATES. All the newly formed portions of blood were very large, and visible even to the unaided eye, as streaks or points: where the naked eye dis- covered no blood, none was to be seen under the microscope. It seems, therefore, that the larger and not the smallest capillary vessels are first formed. The form of these masses of blood varied considerably, being some- times roundish, or quite indefinite (Fig. 1.,) sometimes elongated (Figs. 3 and 4,) while at other times, several portions were united together in a star-like figure (Fig. 4.) The masses of blood were not definitely circum- scribed, and gradually lost themselves in the parenchyma; there were not as yet formed any proper vessels of uniformly equal diameter, and distinct vascular walls were still wanting. It is only in Fig. 4 that there is any indication of a distinct separation of the vessels from the parenchyma. The colour of the blood was even now red, varying from a pale yellowish red where it was thin and dispersed, to a dark red where the mass ap- peared more closely arranged. The blood was fluid, and could be pressed from the parenchyma; it showed also clearly defined blood-corpuscles, which lay partly scattered separately in the parenchyma (Fig. 1,) and partly collected in larger masses (Fig. 3 and 4;) the former was rarely ob- served. There was no evidence of a development of these accumula- tions of blood-corpuscles in common cells, (vascular cells.) The individual newly formed blood-corpuscles (Fig. 2,) were somewhat smaller than common; their diameter was the 600th, the 500th, or at most the 400th ofa line, and they had not the usual cup-like central depression, but were irregularly spherical and angular. Sometimes they appeared separate, sometimes several were united together. On the addition of water, they became pale and gradually disappeared ; the same thing oc- curred, but more rapidly, with acetic acid. There was no trace of nuclei. This blood had evidently originated in the interior of the parenchyma (plastic exudation,) and at first in portions which corresponded with the fu- ture larger vessels. It had not been formed in vascular cells, but free in the parenchyma, and appeared earlier than the vessels. It was formed sooner and more rapidly (in less than two days,) than any of the tissues, even earlier than the areolar tissue. Fig. 1. On the left hand shows a recent section of the fungoid growth in its natural size, with distinct points and streaks of blood. Fig. 1. On the right hand, exhibits newly formed blood-corpuscles, part- ly separate, and partly united in groups, scattered in the parenchyma. Magnified 220 diameters, a. blood-corpuscles, b. fat globules. Fig. 2. Separate, newly formed blood-corpuscles, magnified 410 diame- ters. Fig. 3. Annular accumulation of blood, in which the corpuscles can EXPLANATION OF THE PLATES. 501 be distinctly seen merging into the parenchyma. Magnified 220 diame- ters. Fig. 4. Larger star-like or radiating patch of blood, magnified 67 diame- ters. The vascular walls can be already traced ; the masses of blood are still unorganized and confused ; the separate blood-corpuscles not being evident even under a strong power. At * * globules of fat are scattered in the parenchyma. Fig. 5 and 6. Exhibit a perfect morbidly formed serous membrane with epithelium, which had been repeatedly in a state of inflammation. It likewise affords an illustration of the epigenesis of vessels. Magnified 160 diameters. A girl, aged twenty years, died after having frequently suffered from pleurisy. The left pleural cavity contained about three quarts of a clear limpid fluid. It was inclosed in three sacs, lying within one another. The outer one Was the normal pleura; the inmost one formed a struc- tureless, perfectly amorphous mass, without any connexion with the middle one, of which it was an inflammatory product. This middle sac was loosely united to the costal pleura and the diaphragm, (somewhat more firmly with the latter,) by means of areolar tissue and vessels, and was attached by adhesions to the pericardium ; forming a perfectly inde- pendent membrane, which was clearly distinct from the subjacent nor- mal pleura. It varied from half a line to a line in thickness ; externally it had a glistening appearance ; internally it was at spots of a bright red colour. It showed under the microscope (Fig. 5,) a very thick net-work of per- fect, distended (inflamed) blood-vessels. A granular epithelium (Fig. 6) could be scraped off its inner surface. The tissue of this false mem- brane histologically resembled normal serous membrane. It consisted of bundles of the normal fibres of areolar tissue, which were interlaced and crossed in various directions. In many places this areolar tissue was still in the act of development; we could observe nucleated cells, which were being elongated at both extremities, and nuclei which rested upon the perfect fibrous bundles. On the external surface nearest the pleura, the tissue of the false membrane was firmer, and could not be drawn asunder into fibres. Under the microscope it exhibited fibres, which were not twisted like those of areolar tissue, but straight, stretched out, frequently divided, and even branched, and when seen en masse, of a darker brown colour, resembling the elastic fibre of the arterial mem- brane, more than that of areolar tissue. Fig. 5. Free surface of the false membrane, with a perfect net-work of vessels in a state of congestion, Fig. 6. Nucleated epithelium of the false membrane. Both figures mag- nified 160 diameters. 502 EXPLANATION OF THE PLATES. Fig. 7 to 9. Illustrate the pathological epigenesis of osseous tissue. They exhibit the internal structure of a newly formed lamina of bone, which was found in the dura mater of an old apoplectic soldier. The bone was flat, about the size of a fourpenny-piece, and lay in the falx cere- bri, between the layers of the dura mater, at a spot corresponding with the anterior third of the commissure. All the figures are magni- fied 220 diameters. Fig. 7. From the edge of the piece of bone: it seems to be the most re- cently formed, and still imperfectly ossified. In a still amorphous streaky blastema (a. a.,) lie transparent fusiform corpuscles (* * *)— the future bone-corpuscles; they contain as yet no calcareous salts, and are therefore pale and transparent. Fig. 8. Section of the piece of bone, parallel to its long diameter. At A, we see the opening of an osseous canal, the walls of which consist of concentrically disposed annular lamellae; it has been somewhat obliquely cut. At B, the laminae run in a straight line parallel with each other, and with the surface of the bone. * * are bone-corpuscles, which run parallel with the direction of the laminae. Fig. 9. A section of the piece of bone at the pointed end, cut off at right angles to the surface. Darker and lighter laminae alternate with one another, parallel to the surface of the bone. The bone-corpuscles are not visible. Fig. 10. and 11. Show the regeneration of primitive nerve-fibre by a morbid process. Both figures are copied from Steinriick, (De Nervo- rum Regeneratione. Berol. 1833. PI. u. Fig, 5 and 6.) Fig. 10. A piece taken from a cicatrix on the infra orbital nerve of a rabbit, from which a portion, a line in length, had been excised ten weeks previously. Magnified 430 diameters. Primitive nerve fibres im- bedded in areolar tissue. Fig. 11. Separate newly formed primitive nerve fibres, precisely analogous to the normal uninjured primitive fibres of the same nerve. VOGELS PATHOLOGICAL ANATOMY PT ATK VI Fig 1. B 5?, D "^^^ 1 -- vv ■. u x l0>' |° ' B1'** Fio-. 6 V V -U V 1 \ Flg:4' %} D " Fior kVv ^ c c L b-cf C^e ft £fej& . FigT. ^ 'Si % \f ^v Fig 8 el ^ & Fin' 9, l,b^ T- *' £M \ \ ^c */\- ■fa I - **k- { tic < ,r J indf the lung; Under the microscope the tumour showed: 1. A very evident net-work of capillary vessels, which were filled with blood (the lower portion of the figure. Magnified 90 diameters.) 2. The tumour consisted for the most part of little oleaginous globules varying from the 200th to the 1500th ofa line in diameter (the upper portion of the figure.) Magnified 220 diameters. They appeared in great quantities, and were soluble in ether and alcohol, in which they collected in large drops; ammonia did not affect them. On the removal of these oleaginous drops by pressure and washing, the normal substance of the lung remained without showing any trace of ab- normal formation. The lung in the vicinity of the tumour was in a per- fectly healthy condition. Fig. 11. Encephaloid from the inguinal glands of an aged woman. The uterus as well as the inguinal glands on the right side were at- EXPLANATION OF THE PLATES. 507 tacked by encephaloid, which was similar in its microscopic and physical characters in both organs. It was of a yellowish white colour, fatty, and of the consistence of brain. Under the microscope its chief constituents appeared to be cells of irregular form varying from the 400th to the 150th ofa line in diameter (a.) They were mostly round or oval, comparatively few being caudate. There was also much fat in minute granules and glo- bules (b:) the granules were heaped together in large masses in some places (c.) A few granular cells (d) were also present. Magnified 220 diameters. Fig. 12—J 5. Typhous matter deposited in the various organs during the progress of typhus. Fig. 12. Typhous matter from the mesenteric glands ofa girl aged fifteen years, who died of typhus. The patient was brought to the Munich Hospital, after having been ill fourteen days, with a high pulse, and suffering from excessive heat. The lungs were less affected than usual, but the abdominal organs were espe- cially implicated, as shown by their tympanitic state, and profuse diarrhoea Her strength failed suddenly, and death ensued on the eighth day after her admission into the hospital; and at the height of the disease. On dissection, the brain and spinal cord were found to be normal; the lungs were sound, but somewhat congested in their lower lobes; the spleen was rather softened; but the intestinal canal presented the most important lesions. The lower part of the. small intestines was much thickened, all the glands both those ofPeyerand Brunner, being infiltrated with typhous matter. All the glands of the colon were also swollen and thickened: the mesenteric glands were much enlarged. A few of the mesenteric glands, about the size ofa bean, were carefully examined. They contained a soft medullary substance, which yielded readily to pressure. Under the microscope it appeared as an amorphous, slightly granular mass ofa brownish white colour, in which an immense number of small cells were deposited (A.) These cells had an irregularly roundish form; they were mostly small, almost all under the 300th of a line in diameter; only a few measuring from the 150th to the 200th of a line. Some few of these cells exhibited a distinct nucleus. By treatment with acetic acid the amorphous mass was rendered transparent, and gradually dissolved, upon which many very minute cells (nuclei?) with a sharp outline came in view (B.) being unaffected by the acid. Ammonia and caustic potash dissolved the cells as well as the cytoblastema. The glands of the colon contained a similar mass. Magnified 220 diameters. Fig. 13. Typhous matter from Peyer's glands. The patient, a shoemaker's boy, aged seventeen years, was brought SOS1 EXPLANATION OF THE PLATES. into the hospital in a very dangerous condition. The abdominal organs were especially affected. He had violent diarrhoea and considerable me- teorism. He died on the fifth day after his admission, with the symptoms of perforation of the intestine. On opening the body, both lungs were found externally covered witji a gelatinous exudation, (serum which had become infiltrated into the tissue of the pulmonary pleura.) The lungs themselves were tolerably healthy, but inferiorly they were in a state of congestion. The abdomen was much swollen and contained a very large quantity of sero-purulent exudation. The convolutions of the intestines were covered and partially agglutinated by a gelatinous exudation and by layers of coagulated fibrin. The mesenteric glands were much enlarged. The small intestine contained numerous ulcers; almost all the patches of Peyer's glands being in an ulcerated condition, and at one spot having given rise to perforation. At the spots where there was ulceration, the mucous membrane with its investment of epithe- lium was wanting, and in its place was a yellowish white lardaceous mass (typhous matter.) Under the microscope this - substance appeared to be indefinitely granular, amorphous, and of a brownish white colour. Both acetic acid and ammonia rendered it soft and transparent, much like coagulated fibrin. At various spots it contained irregular cells varying from the 300th to the 400th ofa line in diameter (Fig. 13,) and numerous fatty granules. Magnified 220 diameters. Fig. 14. Cells from typhous matter in Peyer's glands; taken from a sol- dier who died whilst the disease was at its height. All Peyer's and most of Brunner's glands were thickened and infiltrated with typhous matter. There was, however, no appearance of ulceration; the mucous membrane covering the infiltrated glands being perfectly en- tire, though highly reddened and vascular. The typhous matter, which was deposited between the muscular and mucous coats of the intestines appeared to be generally amorphous, although in some places there was a distinct cell-formation. Most of these cells contained several nuclei (Fig. 14.) Magnified 220 diameters. Fig. 15. Typhous matter in the lowest stage of organization, from the lungs of a soldier. Both lungs exhibited in almost every part tubercular-like nodules of a yellowish-white colour. Microscopic examination showed that at those spots there was an entire deficiency both of air and blood; neither was there any vestige of pulmonary tissue, but merely an amorpho-granular colourless mass covered with numerous fatty granules! It exhibited no trace of cellular structure. On the addition of acetic acid this mass be- came transparent, arid the normal pulmonary tissue which had been en- closed by it, was. brought in view. Magnified 220 diameters. VOGELS PATHOLOGICAL.ANATOMY. YiffA. X-o /**&" PLATE VII \ n •" r ■• k b YW ''"?: " ^ Va Fitr.l. tv Bff 3: • ■■A' H\ Pig-.: V- F <>1 ■• 1 I « V '-s>-.'-.-.: lift !: \. ,//// Vcifr'/dd. I. /Hi. tf'TJintlau: LIPOMA. "FIBROUS TUMOUR. EXPLANATION OF THE PLATES. 509 PLATE VII. FATTY AND FIBROUS TUMOURS. Fig. .1. A fatty tumour (lipoma or steatoma.) Magnified 160 diame- ters. A woman aged about forty years had several tumours on the head and neck. She had been operated on four times, but the tumours on each oc- casion reappeared. In September 1839, she entered the hospital at Erlan- gen for the purpose of being again operated on. At this period there were several tumours about her head and neck. There was one situated on the right side of the nose, extending from the root of this organ to the lower edge of the right ala, and so firmly attached to the subjacent bones, that in performing the operation, it was necessary to remove the- nasal bone, and the nasal process of the superior maxillary along with the tu- mour. There was another tumour seated at about the middle of the lower border of the inferior maxillary bone on the right side; it was in close connexion with an artery and vein, so that it was necessary to tie the former in removing the tumour. There was a third tumour situated in the middle line of the neck, about midway between the lower jaw and the larynx. Each of these tumours when extirpated, was found to be about the size ofa small apple; theyAvere irrregularly spherical and lobu- lated, had a lardaceous consistence, and were each enclosed in a thin cyst or capsule. These tumours exactly.resembled each other as regards their histological characters; they were each composed of fibres identical with those of ordinary areolar tissue (a,) and of fat-cells (6,) which corresponded exactly with those observed in common adipose tissue, Although there were no blood-vessels distinctly observed, yet they were undoubtedly pre- sent, though few in number, as is usually the case in adipose tissue ; the fact of their being so very indistinct in the present case is explained by the great loss of blood attendant on the necessary prolonged operation, whereby these vessels would be almost completely drained of their con- tents. On examination, under the microscope there were observed several 43* 510 EXPLANATION OF THE PLATES. drops of oil (c,) which doubtless had been squeezed out of the fat-cells by the pressure of the glass placed over the object. These several elements of each of the tumours were disposed in the following order; the fibres (partly separate, partly arranged together in undulating fasciculi.'as ob- served in ordinary areolar tissues,) formed the ground-work of the sub- stance of the tumours, whilst between these fibres the fat-cells were depo- sited. The arrangement of the fibrous fasciculi followed no regular order; they were observed crossing each other in all possible directions. Where the substance of the tumours was most firm and deep, there the fibres es- pecially prevailed; where, on the other hand, the texture was soft and adipose, there the fat-cells were most abundant. In these latter partsf Where the fat was most prevalent, the fat-cells were arranged in much the same order, as we observe to be the case with tbe cells of plants. At the parts where the tumours encroached upon the bone, the fat-cells were ob- served to.be in contact with the osseous substance, which itself, however, was quite unaltered. The enclosing cyst or capsule was thin, fibrous, and made up of densely interwoven bundles of areolar tissue, crossing each Other in all directions. It thus exactly resembled the structure of the membrane described as forming the cyst ofa true encysted tumour. See Plate ix. Fig. 1—3. Fig. 2. Fibrous tumour. The fibres in this case resemble those of or- ganic muscle, constituting the variety of tumour termed Fibroid. Fi- broid" from the stomach of a man aged forty-four years, who died from. renal disease.' Magnified 220 diameters. On the lesser curvature of the stomach and towards the cardia there was a morbid product of the size and form of an almond. It lay under the mucous membrane, or more correctly speaking, in the-muscular coat;. was of a whitish colour, and in form and consistence resembled an extir- pated tonsil. It was covered with a layer of cellular tissue, whieh sepa- rated it from the surrounding structures; there was, however, no definite capsule or cyst. The interior of the tumour presented the same appear- ance as the exterior. A recent section had a milk-white colour, and ap- peared perfectly^homogeneous; it was very dense and unyielding, and tore on attempting to stretch it. Under the microscope. there were seen traces of vessels- containing blood; on the whole, however, it was anaemic. At the first glance the histological structure of the tumour was not very obvious. On more careful examination, however, there were seen on making a thin section, many nuclei with nucleoli (C,) and some very delicate, tolerably broad, extended fibres, on many of which nuclei were apparent. (B & D.) There were no fibres of areolar tissue. On the addition of acetic acid, the broad fibres became pale and gradually disap- EXPLANATION OF THE PLATES. 511 peared, leaving only the nuclei. It was ascertained, by further investiga- tion, that these broad fibres, which were perfectly identical with those of organic muscle, and ran to a parallel direction, constituted the whole tu- mor (A.) They were not, however, very distinctly marked; the whole structure was to the highest degree delicate, and at some spots there was an amorphous blastema not yet developed Into fibres, which on the addi- tion of acetic acid became paler and less distinct. In what direction the fibres were arranged—whether they were concentric, circular and parallel, to the surface of the tumour, or whether their course was un- controlled by any fixed order—could not, on account of their extreme delicacy, be ascertained. Fig. 3. & 4. Fibrous tumours, whose histological elements are identical with those of areolar tissue. Fig. 3. Histological elements ofa fibrous tumour. Magnified 220 diame- ters. A man suffered from a polypus attached to the posterior portion of the nasal cavity, and projecting backward into the pharynx. It was re- moved by making a section through the soft palate. The portion re- moved was very firm, vascular, and homogeneous; when washed it had a white fibrous appearance. On microscopical examination, its tissue was seen to consist of fibres of areolar tissue, for the most part in the process of development. They appeared more or less twisted or woven together - and many of them exhibited nuclei with nucleoli. AH the stages of the development of areolar tissue, which we have depicted in Plate iv. Fig. 1 &, 2., were exhibited in this structure. A, Are primary cells, with nuclei and nucleoli. B, are the same ceils elongated and becoming caudate. C, is an indistinct fibrous blastema on which there are nuclei. D, very elongated cells, E, the same elon- gated cells loosely arranged together, so as to form fasciculi of areolar tissue. F, cells which, by a sort of channelling, separate into nume- rous fibres. G, a portion of the mature fibres of areolar tissue. On the addition of acetic acid, a portion of the mass became transpa- rent ; numerous isolated nuclei were then seen, as well as many unaltered fibres, in a semi-amorphous mass. The arrangement of the fibres ap- peared to be generally circular or spherical. The entire polypus was invested with a normal mucous membrane, the surface of which was protected by several layers of pavement-epithe- lium. « No ciliated epithelium could be observed. Fig. 3.* A, represents a patch of non-nucleated epithelial cells: B, of nu- cleated epithelium. Both forms occurred at different parts of the sur- face of the tumour. All the epithelial cells had a, puckered appearance. Magnified 220 diameters. 512 EXPLANATION OF THE PLATES. Fig. 4. Fibrous tumour of the skin (a wart.) Magnified 160 diameters. A pedunculated wart, which had been growing for the space of two years in the axilla ofa young man, was excised. After extirpation it appeared smooth, of the size and form of a lentil, covered with normal epidermis, and slightly corrugated. Its pedicle was short and thin. On making an accurate examination, the following appeared to be its true structure. The matter scraped from the surface of the wart formed a white, dirty powder, which, under the microscope^ was seen to consist of very thin, roundish, oval or angular scales, devoid of nuclei (A a.) They were in every respect identical with the flat cells forming the exter- nal layer of normal epidermis. The cells which formed the interior epi- dermic layers of the tumour were generally smaller and less flat, and ex- hibited decided nuclei (A. b.) Hence the investment of the tumour con- sisted of normal epidermis. The interior of the wart was formed of a very dense fibrous tissue (B,) and in some spots undulating bundles, of caudate fibres might be seen, on many of which nuclei were- perceptible. (C.) Throughout this structure, there were numerous caudate cells with nuclei (D,) representing all the stages of the development of areolar tis- sue ; which, we have depicted in Plate iv. Fig. 1 and 2, VOGELS PATHOLOGICAL ANATOMY TLATE VHI *Co ■ * Jio*.l. ';f *V**V- - 4 ''''■':. WW' Wc\*% il-nl^*","v,/l;-' %•!•' i \^\v Fig 4 fee.', ■ c «$ ■-■'£?." V 'V • .(.■ -V.-..- © 6c*- •.- °'|.:Sg. m n< \X N\ ■'' * Fiiil. ..... Fio.3. ■■■.'! 8 ^ .^ v-,-' A v,> J>». ynf o ° ■*> Fig.8. i3 :-.— //c ]?//,/ d,/ TSuid) taken from a fluid ejected in large quantities by a man suffering from stricture of the pylorus, (hypertrophy of the muscular coat of the stomach.) Mag- nified 220 diameters. It forms round colourless granules, or cells, which increase by gem- mation, and then form single or branching rows. Some have young cells within them (*,) others increase by simultaneous gemmation and epige- nesis of cells (**) in their interior. These fungi are found in the urine in Diabetes mellitus, Fig. 9. and 10. Epizoa—parasitic animals occurring in the fluids of the diseased (?) human body. Fig. 9. The Trichomonas viginalis ; an infusorium discovered by Donne, in the vaginal mucus of a woman. Magnified 300 diameters. (Co- pied from Donne, Recherches microscopiques surla nature des Mucus, &c. Paris, 1837, Fig. 3.) 534 explanation of the plates. Fig. 10. Vibriones, which develop themselves in large quantities in all putrid animal fluids, as putrid blood, albumen, &c, and are scarcely ever absent from foul ulcers. (Vibrio prolifer. ? Ehrenberg.) Mag- nified 410 diameters. Fig. 11. The Sarcina Ventriculi. a. In a perfect state, b. One of the four-celled frustules. Fig. 12. The upper portion represents Fungi in Tinea favosa. The lower portion, tubes observed in the sputa, and in tubercular matter. (Bennett.) END. f. f , r '. "\ ~> T / , ■4 / JEFFERSON MEDICAL COLLEGE. SESSION OF 1846—7. The regular Course of Lectures will commence on Monday the 2d day of November, and end on the last day of February. Koblet Dunglisox, M. D., Professor of Institutes of Medicine. Robeiit M. Hustox, M. D., Professor of Materia Medica and General Therapeutics. Joseph Pahcoast, M. D., Professor of General, Descriptive and Surgical Anatomy. John K. Mitchell, M.D., Professor of Practice of Medicine. Thomas D. Mutter, M. D., Professor of Institutes and Practice of Surgery. Charles D. Meigs, M. D., Professor of Obstetrics and Diseases of Women and Children. Franklin Bache, M. D., Professor of Chemistry. Every Wednesday and Saturday during the course, Medical and Surgical eases are investigated and pre- scribed for before the class During the past year not fewer than 1,000 cases were treated, and upwards of 172 were operated on. 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Hawker on Shooting, with cuts, preparing Her.^chell's Treatise on Astronomy, 1 vol. 12mo. cuts. Ilemaris' Complete Poetical Works, in 7 vols. 12ino. Heraans' Memoirs, by her Sister, 1 vol. 12mo. Uiiliard on Real Estate, 2 lartte vols. Svo. law sheep. Hill on Trustees, 1 large vol. 8vo. law sheep. . Iugersoll's History of the Late War, 1 vol. Bvo. Irvmg's Works, 2 vols, super-royal 8vo. , Irving's Columbus, in 2 vols. 8vo. Irving's Beauties,'in 1 vol. 18mo. Irving's Rocky Mountains, 2 vols. 12mo, cloth. Jesse's Court of England, in 3 vols. 12mo. Keole's Christian Year, in 32mo, extra cloth. Kirby and Spence's Entomology, 1 large 8vo vol., with plates, plain or colored. Life of Thomas Jefferson, by Judge Tucker, 2 vols. 8vo. Lights, Shadows, &c. of Whigs and Tories, 1 vol. 12mo Language of Flowers, 1 vol. ISmo, colored plates. Lockbart's Life of Scott, 7 vols. 12tno. Loves of the Poets, by Mrs. Jamison, 12mo. Marston; or the Soldier and Statesman, by.Croly, Svo; sewed, 50 cents. Mackintosh's Ethical Philosophy, 1 vol. Svo. Moore's, History of Ireland, in 2 vols. 8vo, cloth. Martin Chuzzlewit, by '■ Boz," clqth or paper. Millwright's and Miller's Guide, by Oliver Evans, in 1 vol. 8vo, sheep, many plates. Mill's History of the Crusades, and Chivalry, 1 vol. 8vo. Mill's Sportsman's Library, 1 vol. 12mo, extra cloth. Narrative of the United Slates Exploring Expedition, by Captain Charles Wilkes, U: 6. N. In S vols. 4to, 860 00; or 6 vols. imp. Svo, $25 00: or 5 vols. Svo, $10 00. Niebuhr's History of Rome, complete, 2 vols. 8vo. Nicholas Nickleby, by u Boz," cloth or paper. Oliver Twist, by '•Boz," cloth or paper. Picci'ola,—The Prisoner of FenestreJla, 12mo, sewed. Popular Vegetable Physiology, by Carpenter, 1 v. lam. Pickwick Club, by "Boz," cloth or paper. Rush's Court of London, new series, 1 vol. 8vo. Ranke's History of the Popes of Rome, 1 vol. 8vo, cloth. Ranke's History of the Reformation in Germany, to be complete in 1 vol. Ranke's History of the Ottoman and Spanish Empires. Rogers''Poems,.a splendid edition, illustrated, imp. 8vo. Roget's Outlines of Physiology, 1 vol. 8vo. Roscoe's Lives of the Kings of England, a 12mo series to match the Queens. Strickland's Lives of the Queens of England, 8 vote. 12mo, cloth or paper. Sportsman's Library, by Mills, 1 vol. 12mo. Select Works of Tobias Smollett, cloth or paper. sophical Theories and Philosophical Experience"— '' On, the Connection between Physiology and Intel- lectual Science"—"On Man's Power over himself to Prevent,or Control Insanity"—"An Introduction to Practical Organic Chemistry"— ''A Brief View of Greek Philosophy up to the Age of Pericles"— "A Brief View of Greek Philosophy from the Age of Socrates to the Coming of Christ"—" Christian Doc- trine anil Practice in the Second Century"—"An fix- position of Vulgar and Common Errors, adapted to the Year of Grace 1845"—"An Introduction to Vege- table Physiology with references to the works of Da •Candd'lle, Lindley, &c."—"On the Principles of Cri- minal Law,"—•'Christian Sects in the Nineteenth Century," &c.—each work in 1 small vol., price 25 cents, forming a neat and cheap series "The Con- nection between Physiology and Intellectual Sci- ence" and " Principles of Criminal Law" are now ready, and the others will shortly follow, with new work's now preparing for the series. Spence oh the Jurisdiction of the Court of Chancery, at press Thomson's Domestic Management of the Sick Room' 1 vol. 12mp, extra cloth. Tokjeah. by Sealsfield, price 25 cents. VValpole's Letters, in 4 lurge vols. Bvo, ex cloth. Waipole's New Letters to Sir Horace Mann, 2 v. 8vo. Walpole's Memoirs of George the Third. 2 vols. 8vo. White's Universal History, a new and improved work for Schools, Colleges &c., With Questions by Pro- fessor Hart, in 1 vol. large 12mo, extra cloth, or half bound. Wheaton's International Law, 1 voli large 8vo, law sheep or extra cloth, 3d edition, much improved. Wheatpn on the Right of Search, in 1 vol. 8vo. Mrs. Washington Ports, Ly Miss Leslie, 25 cents. WraxalPs Posthumous Memoirs, 1 vol 8vo. Wraxall's Historical Memoirs 1 vol. Svo. Youatt on the Horse, &c., 1 vol. 8»o. Youatt on the Dog, with plates, preparing. s TO THE MEDICAL PROFESSION'. The following list presents nearly all the works on Medical Science published, at press and preparing by the Subscribers. They will be found to be executed in a superior style, and sold at prices as low as can be, afforded consistent with correct editions. These works can be had in all the principal bookstores throughout the Union; froln which, or from the subscriber^, dit in- formation relative to prices, &c, can be obtained, on application, free of postage. JjEA « BLA.VCH.mv, Philadelphia. Anatomical Atlas, by Smith & Horner, imp. 8vo, 650 figs. Anion's Elemenisot Physics,new ed. 1 vol. bvo, 4s4pp. American Medical Jonrnal, quarterly at S5 a year. Abercrombie on the Stomach, 1 vol. Svo, 320 pages. Abercrotnbie on the Brain, new ed , 1 vol. Svo, 324 pp. Alison's Outlines of Pathology, in 1 vol. Svo. 420 pp. Ashwell on Females, one vol. 8vo, 520 pages. Andral on the Blood, 120 pages, Svo. Bird on Urinary Deposits, 1 vol. 9vo, 22S pp. Bird's Natural Philosophy, preparing. Burrows on Cerebral Circulation, preparing. Budd on the Liver, 1 vol. Hvo, 392 pp. Buckland's Geology and Mineralogy, 2 vols. 8vo, with numerous plates and maps. Berzelius on rhe Kidneys and Urine, 1 vol. 8v6,180 pp. Biidgewater Treatises, with numerous illustrations, 7 vols. 8vo, 3237 pp. Bartlett on Fevers, &c, 1 vol. 8vo., 394 pages. Banlett's Philosophy of Medicine, 1 vol. 8vo, 312 pp. Brigham on Mental Excitement, 1 vol. 12mo, 204 pp. Billing's Principles of Medicine, 1 vol. 8vo, 304 pp. Brodie on Urinary Organs, 1 vol. 8vo, 214 pp. Brodie on the Joints, 1 vol. Svo, 210" pp. Brodie's Surgical Lectures, 1 vol. Svo, 350 pp. Benedict's Compendium of Chapman's Lectures, 1 vol. 8vo, 258 pp. Chapman on Viscera, 1 vol. 8vo, 384 pages. Chapman on Fevers, Gout, &c, 1 vol. 8vo, 450 pp. Chelius' Surgery, by South and Norris. at press. Chitty's Medical Jurisprudence, Svo, 610 pp. Clater and Skinner's Farrier, 19mo, cloth, 220 pp. Carpenter's Principles of Human Physiology, 1 vol. 8vo, 644 pages, with cuts, second edition. Carpenter's General and Comparative Physiojogy, J vol. Svo, preparing, many plates. Carpenter's Vegetable Physiology, 1 vol. 12md, with cuts, 300 pp. Carpenter's Manualror Elements of Physiology, 1 vol. Svo, 569 pages, imamy «uU. Carpenter's Cyclopedia orNatural Science, preparing. Cooper, Sir Astley on HsYnia, imp. Svo, plates, 4158 pp. Cooper on Dislocations, 1 vol. 8vo, with cuts, 500 pp. Cooper on »he Testis and Thymus Gland, 1 vol. impe- rial Svo, many plates. Cooper on the. Anatomy and Diseases of the Breast. &c &.C, 1 vol. imperial 8vo. splendid lithographic plates. Condie on Diseases of Children, 1 vol. Svo, 652 pages. Churchill on Females, 3d edition, 1 vol. 8vo, 572 pjp. Churchill's Midwifery j 1 vol. Svo, 520 pp., many cuis Cyclopaedia of Practical Medicine, by Forbes, &c. Edited by Dunglison, in 4 large super-royal vols., 3154 double columned pages. Carson's Medical Formulary, in preparation. Dewees' Midwifery, with plates, lOui edit., 660 pp. Dewees on Children, 8th edition, 513 pp. Dewees on Females, with plates, 8lh e.lition, 932 pp. Durlacher on Corns, Bunions, &c, 1 vol. 12mo . 134 pp. Dungl;son's Physiology, 6th edition, 2 vols. 8vo, 1350 pages, with 370 cuts. Dunglison's Therapeutics and Materia Medica, a new edition, with cuts. 2 vols. 8vo. 986 pnyes. Dunglison's Medical Dictionary, 6ih edition, 1 vol. 8vo, 804 very large pages, double columns Dunglison on New Remedn-* 4th edition, (116 pp. Dunglison onCHuman Health, iu 1 vol ,-vo, 464 pp. Dunglison's Practice of Medicine, 2d edition, 2 vols. 8vo, 1322 pp. , Dunglison's Medical Student. 1 vol 12mo. 312 pp. Drum's Surgery. 1 vol. t-vo, 501.pp.. 2-: Tirol on Insanity, by Hum. 496 pp. |\n\ i es' ElerneiiMry Chemistry, 1 vol. royal 12rao, 460 pages, rrrauy cuts. Fevers. General and Special, adited by Clymer, 1 vol. 8vo, 600 pages. Fergusson's Practical Surgery, 1 vol. 8vo, 2d ed , 640pp. Graham's Chemistry, with cuts,;l vol. Svo,'f50 pp. Griffith's Chemistry of the Fotrr Reasons, 1 vol. 12rno. with cats. Griffith's Medical Botany, many illustrations, at press. Guthrie on the Blaitder and Urethra, 1 vol. Svo, 150 pp. Hobjyn's Dictionary of Medical Term*, by Hays, 1 vol. large 12mo, 402 pages. Harris on the Maxillary Sinus. 1 vol. 8vo, 166 pages. Horner's Special Anatomy, 2 vols. Svo, 7th ed., cuts. Horner's .New Dissector, 1 vol. 12ino, with many cats. Hasse's Pathological Anatomy, nearly ready. Hope on the Heart, 1 vol Svo, with plates, a new ed. Harrison on the Nervous System, 1 vol. Svo, 292 pp. Hughes on the Lungs and Heart, 1 vol. 12mo, 270 pp. Jones' tT. Wbarlon) Manual of Ophthalmic Surgery, with many cuts, at press. Jones and Todd ou the Ear, 1 vol., preparing. Kirby on Animals, many plates, 1 vol Svo, 520 pp. Kirby and ^pence's Entomology, 1 vol. fcvo, 600 pages, plates, plain or colored. Lawrence on the Eye, a new ed., many cuts, 1 vol. Svo. Lawrence oh Ruptures, 1 vol. Svo, 4-0 pp. Liston's Surgery, by Mutter,! vol. evo, 566 pp., many outs. Miller's Principles of Surgery, 1 vol. 8vo, 526 pp. Miller's Practice of Surgery, I vol. svo, 496 pp. Maury's Dental Surgery, with plates, 1 vol. Svo, 286pp. Muller's Physiology, 1 vol. 8vo, 6S6 pages. Medical News and Library, published monthly. Meigs' Translation of Colombat de l'lsere on the Dis- eases of Females, 1 vol. 8?0, 720 pp. Metcalf on Caloric, in one large vol , Svo, (at press.) Pioui on the Stomach, 1 vol. 8vo,coljdplates, 466 pp. Popular Merficine. by Qoate?, 1 vdI. 6v0. 614 pages. I hilip on Pretraeied'hklipestion. 1 vol.; 240 pages. Phillips on Scrofula, 1 vol Svo, 350 page?. Pereira's Materia Mediea,'2 vol? Svo. 15S-0 very large and olo»ely printed pnges. Second Edition. Royle's Materia Medica, with wood-cuts, nearly ready Roget's Animal and Vegeiable Physiology, with many ems 2 vols. Svo, ^72 pages, r >} Roget's Outlines of Physiology', 1 vol/ wo. Sw pages. Rigb> 's S> stem of Midwifery, 1 vol. Svo. 492 pages. Ruord on Venereal, new edition. 1 vol. Svo. 250pages, Ricon!V large work on Venereal Diseases, with nume- rous plates preparing Ramsbotham on Parturhioh, with many plates, 1 voi imperial bvo a new and improved edition, 520 pp. Robertson on the Teeth, 1 vol. Svo, 230 pages. Simon's Chemistry of Man. 1 vol. Svo, 730pages. Taylor's new work on Medical Jurisprudence, by Grif- fith, 1 vol Svo: 540 pages. Traill's Medical Jurisprudence, 1 vol. Svo, 234 pages. Trimmer's Geology a'nd Mineralogy, 1 vol. 8vo. 528 pp Todd.& Bowman's Physiology, publishing in'the Medi- cal News and Library, many cuts. Thomson on the Sick Room. 1 vol. l2rrjo, 360 pp , cuts. Vogel's Pathological Anatomy, with plates, preparing. IValshe on the Diseases Of the Lungs, 1 vol. 12rno, 310 pages. Watson's Principlen and Practice of Physic, by Con- die, 1 vol. Svo, HI60 large pages. Wilson's Human Anatomy, withcuts,l vol. 8vo,anew aqd improved edition. 60S pages Wilson's Dissector oi Practical and Surgical Anato- my, by Goddard, with cuts, 1 vol. 12mo, 444 pages. Wilson on the Skin, 1 vol Svo, 370 pagee. William-' Pathology, or Principles of Medicine, 1 vol. 8vo. 3?4 pages. Williams' Lectures on rhe Stomach. Ac, preparing. Williams on the Respiratory Organs, by Clymer. 1 vol. Svo. 50W pages. Youatt on the Horse, by SkinneT. cuts, 448pp. 1 vol. 6vo; Youatt and Clater's Cattle Doctor, 1 vol. 12mo, with cuts, 2S2 pages •$• They have other work* in preparation not included in this list 6 LEA & BLANCHARD'S PUBLICATIONS. Now Ready, CARPENTER'S NEW WORK. A MANUAL, OR ELEMENTS OF PHYSIOLOGY, INCLUDING PHYSIOLOGICAL ANATOMY. FOR THE USE OF THE MEDICAL STUDENT. BY WILLIAM B. CARPENTER, M. D., F. R. S., Fullerian Professor of Physiology in the Royal Institution of Great Britain, &e. With One Hundred and Eighty Illustrations, IN ONE OCTAVO VOLUME OF 566 PAGES. Elegantly printed to match his " Principles of Human Physiology." The sheets of this volume, in their passage through the press have been carefully examined by Dr. Meredith Clymer, the editor of Dr. Carpenter's Principles of Physiology. . The manner in which the work is brought up to the day, and its perfect adaptation to its purposes as an elementary text- book for students have rendered unnecessary any alterations or additions. The efforts of the pub- lishers have therefore been directed to obtaining a correct reprint of the London edition. "The auttior has shown singular skill in preserving so marked a'line of distinction between the present Manual and the ' Principles of Physiology' previously published by him. They are both on precisely the same subject; hut the one is neither a copy, nor an abstract, nor an abridgment of the other. In one thing, how- ever, they are exactly alike—in their general excellence, and in their perfect adaptation to their respective purposes. The reputation of Dr. Carpenter as a-physiologist is too well established throughput the whole medi- cal world to admit ofincrea.se from any commendation of ours ; but we should be doing injustice to our own feelings if we did not here express our admiration.of his great intellectual powers, of his extensive learning, of the comprehensiveness of his views, of the quickness with which he seizes the important points and bearings of each subject, of the logical order in which he arranges his facts, and of the clearness and precision with ■which he explains, and exposes his doctrines. Dr. Carpenter's various treatises are in fact models in their respective departments. It is their great and varied excellence which accounts for their unrivalled popularity. We can pay no higher compliment to the work before us, than to say, that it is equal in merit to the former productions of the author. This is equivalent to saying that it is. without question, the best manual or short treatise on physiology extant. Although designed for the student, and framed expressly to meet his wants; it is a work, we will venture to say, that may be consulted with advantage by most physicians and surgeons, how- ever learned."—The British, and Foreign Medical Review. CARPENTER'S HUMAN PHYSIOLOGY. PRINCIPLES OF HUMAN PHYSIOLOGY. WITH THEIR CHIEF APPLICATIONS TO PATHOLOGY, HYGIENE, AND FORENSIC MEDICINE. BY WILLIAM B. CARPENTER, M. D., F. R. 8.^ Yorlc Journal 0/Medicine. " These lectures will be found eminently practical, a point' of no small moment in a work on Surgery. Indeed, we have no hesitation in affirming, that it is a compendium of the modern practice of Surgery as complete and accurate as any treatise of similar dimensions in the English language.— The Western Lancet. Lately Published, a New and Much Improved Edition of DRUITT'S SURGERY. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY, By ROBERT DRUITT, Surgeon. FROM THE THIRD LONDON EDITION. ILLUSTRATED BY ONE HUNDRED AND FIFTY-THREE WOOD ENGRAVINGS. WITH NOTES Ai\D COMMENTS, Br JOSHUA B. FLINT, M. M., S. S. In One Volume, Octavo. "An unsurpassable compendium not only of surgical but of medicai practice."—London Medical Gazette. 8 LEA & BLANCHARD'S PUBLICATIONS. BRODIE'S SURGICAL WORKS. NOW READY, CLINICAL LECTURES ON SURGERY, DELIVEKED AT ST. OEOEGE'S' HOSPITAL By SIR BENJAMIN BRODIE, Bart., V. P. R. S., SERJEANT SURGEON TO THE 6.VEEN, ETC. ETC. IN ONE NEAT OCTAVO VOLUME. These Lectures, in passing through the columns of "The Medical News," during the last year, have received the unanimous approbation of the profession in this country, and will no doubt be eagerly sought for in their complete state. " Sir Benjamin Brodie has long been distinguished as a surgeon, even among those in the front rank, and may now be regarded as occupying the first place in Great Britain, if not in the world. It is not as a mere operator that he is distinguished—that, it must be conceded by all right thinking minds, is but a very humble part of the qualifications of a surgeon—but as a profound pathologist and therapeutist. We may be prejudiced or mistaken, but in theses higher and really intellectual qualifications, we know of no living surgeon that approaches him. His well considered opinions and practical instructions are conveyed, too, in language so appropriate, so simple, clear and chaste, that one scarcely knows whether most to admire the excellence of the matter'or the beauty of the style in which it is clothed. Theory and practioe go hand in hand throughout. Rarely is a pre- cept given without being illustrated by some apposite case, selected from his vast experience, and always in the fewest and most expressive words. Nothing more than is necessary to enforce the point is said, and nothing that is necessary is left untold."—The Medical Examiner. " It would not be easy to find in the same compass more useful matter than is embraced in each of these discourses, or indeed in this volume. We the less regtet the limited extracts ' 85- These works have acquired great popularity in England, and the publishers take pleasure iu introducing the series neatly printed, and at so low a price. LEA &, BLANCHARD'S PUBLICATIONS. 13 COMPENDIUM OF CHAPMAN'S LECTURES. A COMPENDIUM OF, LECTURES ON THE THEORY AND PRACTICE OF MEDICINE. DELIVERED BY PROFESSOR CHAPMAN IN THE UNIVERSITY OF PENN- SYLVANIA. PREPARED, WITH PERMISSION, FROM DR. CHAPMAN S MANUSCRIPTS, AND PUBLISHED WITH HIS APPROBATION, BY N. D. BENEDICT, M. D. IN ONE VERY NEAT OCTAVO VOLUME. p CONTENTS. remarks on the Classification of Diseases— Fever in General—Intermittent Fever—Remittent Fever —Continued Fever, (Mild, Intermediate, and Extreme Forms)—Yellow Fever—Endemic Pneu- monic, or Spotted Fever—Diseases of the Heart and Blood-vessels, (Inflammatory, Organic, and Nervous)—Acute Carditis, Pericarditis, and Endocarditis—Chronic Carditis, Pericarditis, and En- docarditis—Hypertrophy of the Heart—Dilatation of the Heart—Atrophy of the Heart—Rupture ot the Heart—Affections of the Valves of the Heart—Palpitations—Acute Arteritis—Degenera- rations of Arteries—Aneurism of Arteries—Phlebitis—Acute Inflammation of the Throat—Chronic Inflammation of the Throat—Dysphagia—Parotitis—Dysentery, (Inflammatory)—Dysentery, tCon- gestive)—Diarrhoea—Cholera Morbus—Cholera Infantum—Flatulent Colic—Bilious Colic—Colica Pictonum—Acute Peritonitis—Chronic Peritonitis—Acute Catarrh—Catarrhus ^stivus—Chronic Catarrh—Acute Bronchitis—Chronic Bronchitis—Catarrhus Senilis—Acute Infantile Bronchitis- Chronic Infantile Bronchitis—Croup—Acute Infantile Asthma—Whooping-Cough—Acute Laryn- gitis—Chronic Laryngitis—Pleuropneumonia—Congestive Pneumonia—Chronic Pleurisy and Pneumonia—Apoplexy—Palsy—Epilepsy—Hysteria—Chorea—Neuralgia—Diabetes. The subjects treated of iu this volume are entirely distinct from those considered in Dr. Chapman's two^orks on "Thoracic and Abdominal Viscera," and on "Eruptive Fevers," &c. These works are all printed and bound tp match, and form three very neat octavo volumes. LECTURES ON THE MORE IMPORTANT DISEASES OF THE THORACIC AND ABDOMINAL VISCERA, DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. BY N. CHAPMAN, M. D. PROFESSOR OF THE T.HEOEY AND PRACTICE OF MEDICINE, ETC. In One Volume, Octavo. CHAPMAN ON~FEVERS, &c. LECTURES ON THE MORE IMPORTANT ERUPTIVE FEVERS, HEMORRHAGES AND DROPSIES, AND ON GOUT AND RHEUMATISM, DELIVERED IN THE UNIVERSITY OF PENNSYLVANIA. By N. CHAPMAN, M.D., PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE, ETC. ETC. In One Neat Octavo Volume. " The name of Chapman stands deservedly high in the annals of American medical science. A teacher and a lecturer for nearly forty years, in the oldest and, we believe, the first medical school on this side of the At- lantic, the intimate friend and companion of Rush, Kuhn, Physick, Wistar, Woodhouse, Dewees, and a host of others, scarcely less renowned, Professor Chapman reflects upon the profession of this generation something of the genius and wisdom of that which has passed; he stands out the able and eloquent champion of the doc- trines and principles of other times, when Cullen's " firsi lines" formed the rule of faith for all the Doctors in Medicine throughout Christendom. In him is embodied the experience of threescore and ten, strengthened by readimr, and enlightened by a familiar intercourse with many of the ablest medical men in the New and Old World. In conclusion, we must declare our belief that the name of Chapman will survive when that of many of his cotemporaries shall have been forgotten; when other generations shalUread the great theatre of human affairs, and when other discoveries yet undisclosed, shall shed a brighter light upon the path of medi- cal science. The various lectures which he has been publishing, containing, as they do, the doctrines that he has so long and so eloquently taught to large and admiring classes, we doubt not will be welcomed with delight by his numerous pupils throughout the Union."— New Orleans Medical Journal. 14 LEA & BLANCHARD'S PUBLICATIONS. HORNER'S ANATOMY, NEW EDITION-To be Ready by October. SPECIAL ANATOMY AND HISTOLOGY. BY WILLIAM E. HORNER, M. D., PROFESSOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, &c. &c. SEVENTH EDITION, WITH MANY IMPROVEMENTS AND ADDITIONS. In tioo Octavo Volumes, with Illustrations on Wood. This standard work has been so long before the profession, and has been so extensively used, that, in announcing the new edition, it is only neces- sary to state that it will undergo a most careful revision ; the author will introduce many illustrations relating to Microscopical Anatomy, and will add a large amount of text on these various points of investigation that are rapidly advancing and attracting so much attention. This new edi- tion will be arranged to refer conveniently to the illustrations in Smith. and Horner's Anatomical Atlas, and. will be ready for the Fall Lectures. HORNER'S _piSSECTOR. THE UNITED STATES DISSECTOR, BEING A NEW EDITION, WITH EXTENSIVE MODIFICATIONS, AND ALMOST REWRITTEN, OF "HORNER'S PRACTICAL ANATOMY." IN ONE VERY NEAT VOLUME, ROYAL 12mo. With many Illustrations on Wood. The numerous alterations and additions which this work has under- gone, the improvements which have been made in it, and the numerous wood-cuts which have been introduced, render it almost a new work. It is the standard work for the Students in the University of Pennsyl- vania. BUDD ON THE LIVER. ON DISEASES OF THE LIVER. BY GEORGE BUDD, M.D., F.R.S., Professor of Medicine in King's College, London, &c. &c. With colored plates, and numerous wood-cuts. In one neat octavo volume. "We cannot too strongly recommend the diligent study of this volume. The work cannot fail to rank the name of its author among the most enlightened pathologists and soundest practitioners of the day."—Medico- CAirurgical Review. A IVIAGNTFICEJVT AND CHEAP WORK. SMITH & HORNER'S ANATOMICAL ATLAS. Just Published, Price Five Dollars in Parts. AN ANATOMICAL ATLAS ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BOUT. BY HENRY H. SMITH, M.D:, Fellow of the College of Physicians, t(c UHDER THE SUPERVISION OF WILLIAM E. HORNER, M.D., Professor of Anatomy in the University of Pennsylvania. In One large Volume, Imperial Octavo. This work is but just completed, having been delayed over the time intended by the great difficulty in giving to the illustrations the desired finish and perfection. It consists of five parts, whose contents are as follows: Pabt I. The Bones and Ligaments, with one hundred and thirty engravings. Part II. The Muscular ana Dermoid Systems, with ninety-one engravings. Part III. The Organs of Digestion and Generation, with one hundred and ninety-one engravings. Pabt IV. The Organs of Respiration and Circulation, with ninety-eight engravings. Part V. The Nervous System and the Senses, with one hundred and twenty-six engravings. Forming altogether a complete System of Anatomical Prates, of nearly SIX HUNDRED AND FIFTY FIGURES, executed in the best style of art, and making one large imperial octavo volume. Those who do not want it in parts can have the work bound in extra cloth or sheep at an extra cost. This work possesses novelty both in the design and the execution. It is the first attempt to apply engraving on wood, on a large scale, to the illustration of human anatomy, and the beauty of the parts issued induces the publishers to flatter themselves with the hope of thp perfect success of their undertaking. The plan of the work is at once novel and convenient. Each page is perfect in itself, the references being immediately under the figures, so that the eye tales in the whole at a glance, and obviates the necessity of continual reference backwards and forwards. The cuts are selected from the best and most accurate sources; and, where neces- sary, original drawings have been made from the admirable Anatomical Collection of the University of Penn- sylvania. It embraces all the late beautiful discoveries arising from the use of the microscope in the investi- gation of the minute structure of the tissues. In the getting up of this very complete work, the publishers have spared neither pains nor expense, and they now present it to the profession, with the full confidence that it will be deemed all that is wanted in a scientific «nd artisticaf point of view, while, at the same time, its very low price places it within the reach of all. It is particularly adapted to supply tlu place of skeletons or subjects, as the'profession will see by examining the list of plates n These figures are well selected, and present a complete and accurate representation of that wonderful fabne, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and ns superb artislical execution, have been already pointed out. We must congratulate the student upon the completion of this atlas, as it is the most convenient work of the kind thai has yet appeared; and, we must add, the very beautiful manner in which it is ' got up' is so creditable to the country as to be flattering to our national pride."—American Medical Journal. - . "This is an exquisite volume, and a beautiful specimen of art. We have numerous Anatomical Aliases, hut we will venture to say that none equal it in cheapness, and none surpass it in faithfulness and spirit. We stronelv recommend to our friends, both urban and suburban, the purchase of this excellent work, for which both editor and publisher deserve the thanks of the professioni.»-Jlf«W Examiner. * We would strongly recommend it, not only to the student, but also to the working practitioner, who, although grown rusty in the toils of hisWness. still has the desire and often the necessity, of refreshing his knowledge iu this fundamental part of the science of medicine. \-Mw York Journal of Medicine ""tfurg "The Dlan of this Atlas is admirable, and its execution superior to aiiy thing of the kind before published in fhia rountrv It is a real labour-saving affair, and we regard its publication as the greatest boon that could be conferredIon the student of anatomy. It will be equally valuable to the practitioner, by affording him an easy means of recalling the details learned in the dissecUng room, and which are soon forgotten."—American Medi- ^«*,,, Journal of Medicine and Surgery. his student. -^"rn\Vised With Part I, but the Second Part gratifies us still more, both as regards the attraet- «We\veremucnpit_ Dermoid and Muscular Systems.) and the beautiful artistical execution of the lve nature 01 in<- »u j , ^ deiineated the most accurate raicroseopic views of some of the tissues, as, for Jlustrauons. » <= , dinose .jggues, the epidermis, rete mucosum and cutis vera, the sebaceous and instance, the cellular»«a ■"£", nerspiraiory elands and hairs of the sk.n, and the hair and nails. Then perspiratory organ* onln«^"™> ^scTes, ana, lastly, their separate delineations. We would recommend U°,iXawrrdca?AU^ wTur readers in the very strongest terms.--*™ York Journal of Medicine and Sur- gery. 16 LEA & BLANCHARD'S PUBLICATIONS. THERAPEUTICAL LIBRARY. PEREIRA'S MATERIA MEDICA. WITH NEARLY THREE HUNDRED ENGRAVINGS ON WOOD. A NEW EDITION, LATELY PUBLISHED. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS, COMPREHENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPO- SITION, EFFECTS AND USES OF MEDICINES. BY JONATHAN PEREIRA, M.D., F. R. S. and L. S., Member of the Society of Pharmacy of Paris; Examiner in Materia Medipa and Pharmacy of the University of London; Lecturer on Materia Medica at the London Hospital, &c. &c. Second American, from the last London Edition, enlarged and improved. WITH NOTES AND ADDITIONS BY JOSEPH CARSON, M.D. In Two Volumes, Octavo, containing Fifteen Hundred very large Pages, illustrated by Two Hundred and Seventy-five Wood-cuts. Part I. contains the General Action and Classification of Medicines and the Mineral Materia Medica. Part II., the Vegetable and Animal Kingdoms, including diagrams explanatory of the Processes of the Pharmacopoeias, a tabular view of the History of the Materia Medica, from the earliest times to the present day, with the Introduction of the Processes of the New Edinburgh Pharmacopoeia, and a very copious index. It also contains additional articles on Mental Remedies, Light, Heat, Cold, Electricity, Magnetism, Exercise, Dietetics and Climate, and many additional Wood-cuts, illustrative of Pharmaceutical Operations, Crystallography, Shape and Organization of the Feculas of Commerce, and the Natural History of the Materia Medica. In passing through the press the second edition of this standard work, the opportunity has been taken by the editor to correct any mistakes or inadvertencies that may have escaped him or the author, in the first edition. It may now be considered as entirely worthy of the confidence of the physician and pharmaceutist, as an accurate edition of the most complete work extant on the subject. "An Encyclopcedia of knowledge in that department of medical science—by the common consent of the pro- fession the most elaborate and scientific Treatise on Materia Medica in our language."— Western Journal of Medicine and Surgery. THE STUDENT'S TEXT-BOOK OF MATERIA MEDICA. NOW AT PRESS, A MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By J. FORBES ROYLE, M.D., PROFESSOR IN KING'S COLLEGE, LONDON. EDITED BY J. CARSON, M.D., Professor of Materia Medica and Pharmacy in the Philadelphia College of Pharmacy, etc. etc. In One Octavo Volume, with Numerous Splendid Illustrations. This work will contain all the most recent information and investigations in the various branches connected with the Materia Medica, and under the supervision of its able editor, will receive whatever alterations and additions may be necessary to adapt it to the United States Pharmacopoeia, and to the practice of this country. The high character of the author will attract attention to the work as a text-book for ihe next session of the various colleges, if ready. The numerous and beautiful illustrations will far surpass anything that has as yet been attempted in this way. This volume will be brought out in a style to match Fer- guson's Surgery, Wilson's Anatomy, &c, and will be sold at a low price. LEA & BLANCHARD'S PUBLICATIONS. 17 THE GREAT MEDICAL LIBRARY. THE CYCLOP/EDI A OF PRACTICAL MEDICINE; COMPRISING TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA & THERAPEUTICS, DISEASES OF WOMEN AND CHILDREN, MEDICAL JURISPRUDENCE, &c. &c. EDITED BY JOHN FORBES, M. D., F. R. S., ALEXANDER TWEEDIE, M.D., F.R.S., AND JOHN CONOLLY, M.D. REVISED, WITH ADDITIONS, By ROBLEY DUNGLISON, M.D. THIS WOKK IS NOW COMPLETE, AND FORMS FOUR LARGE SUPER-ROYAL, OCTAVO VOLUMES, CONTAINING THIRTY-TWO HUNDRED AND FIFTY-FOUR UNUSUALLY LARGE PAGES IN DOUBLE COLUMNS, PRINTED ON GOOD PAPER, WITH A NEW AND CLEAR TYPE. THE WHOLE WELT. AND STRONGLY BOUND, WITH RAISED BANDS AND DOUBLE TITLES. Or, to be had in twenty-four parts, at Fifty Cents each. For a list of Articles and Authors, together with opinions of the press, see Supplement to the No- vember number of the Medical News and Library. This work having been completed and placed before the profession, has been steadily advancing in favor with all classes of physicians. The nu- merous advantages which it combines, beyond those of any other work ; the weight which each article carries with it, as being the production of some physician of acknowledged reputation who has devoted himself especially to the subject confided to him, the great diversity of topics treated of; the corhpendiousness with which everything of importance is digested into a comparatively small space; the manner in which it has been brought up to the day, everything necessary to the American prac- titioner having been added by Dr. Dunglison ; the neatness of its mecha- nical execution, and the extremely low price at which it is afforded, combine to render it one of the most attractive works now before the pro- fession. As a book for constant and reliable reference, it presents advan- tages which are shared by no other work of the kind. To country prac- titioners, especially, it is absolutely invaluable, comprising in a mode- rate space, and trifling cost, the matter for which they would have to accumulate libraries, when removed from public collections, The steady and increasing demand with which it has been favored since its completion, shows that its merits have been appreciated, and that it is now universally considered as the LIBRARY FOR CONSULTATION AND REFERENCE. 18 LEA & BLANCHARD'S PUBLICATIONS. WORKS BY PROFESSORS CHURCHILL, MEIGS, &c. CHURCHILL'S MIDWIFERY. A New Edition, Just Published. ON THE THEORY AND PRACTICE OF MIDWIFERY. BY FLEETWOOD CHURCHILL, M.D.. M. R. I. A., Licentiate of the College of Physicians in Ireland; Physician to the Western Lying-in Hospital; Lecturer on Midwifery, &c, in the Richmond Hospital Medical School, &c. &c WITH NOTES AND ADDITIONS BY ROBERT M. HUSTON, M. D., Professor of Materia Medica and General Therapeutics, and formerly of Obstetrics and the Diseases of Wo- men and Children in the Jefferson Medical College of Philadelphia; President of the Philadelphia Medical Society, &c. &c. SECOND AMERICAN EDITION. WITH ONE HUNDRED AND TWENTY-EIGHT ILLUSTRATIONS, ENGRAVED BY GILBERT FROM DRAWINGS BY BAGG AND OTHERS. In One beautiful Octavo Volume. The call for a second edition of Dr. Churchill's Midwifery, within so short a time after the ap- pearance of the first, is satisfactory evidence that the profession in this country appreciate the high value of the work. Both as a text-book for the student and as a manual for the practitioner, it has a deservedly great reputation, especially for tbe fulness and clearness with which the physiological details are wrought out and brought to illustrate the practical part. To render the present edition worthy ofa continuance of the favor and confidence so signally manifested towards its predecessor, the editor has carefully added all the new facts and observations which have transpired since the publication of the last edition, or such at least as appeared to him deserving of being recorded. These relate to some of the most important points in physiology and obstetrical practice. Various new illustrations have been introduced, and the whole brought up, as far as possible, to the day of publication. A NEW EDITION OF CHURCHILL ON FEMALES. THE DISEASES OF FEMALES, INCLUDING THOSE OF PREGNANCY AND CHILDBED. BY FLEETWOOD CHURCHILL, M.D., Author of " Theory and Practice of Midwifery," &c. &c. THIRD AMERICAN, FROM THE SECOND LONDON EDITION, WITH ILLUSTRATIONS- EDITED, WITH NOTES, BY ROBERT M. HUSTON, M.D., &c. &c. In One Volume, 8vo. " In complying with the demand of the profession in this country for a third edition, the Editor has much pleasure in the opportunity thus afforded of presenting the work in its more perfect form. All the additional references and illustrations contained in the English copy are retained in this." A TREATISE ON THE DISEASES OF FEMALES, AND ON THE SPECIAL HYGIENE OF THEIR SEX. WITH NUMEROUS WOOD-CUTS. BY COLO M BAT DE L'ISERE, M. D., Chevalier of the Legion of Honor; late Surgeon to the Hospital of the Rue de Valois, devoted to the Diseases of Females, &c. &c. TRANSLATED, WITH MANY NOTES AND ADDITIONS, D f ,™. . By C. D. MEIGS, M.D., Yrofessor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, &c. &c. In One Large Volume, 8vo. " We are satisfied it is destined to take the front rank in this department of medical science: it is beyond all comparison, the most learned Treatise on the Diseases of Females that has ever been written, there being more than one thousand distinct authorities quoted and collected by the inde- fatigable author. It is in fact a complete exposition of the opinions and practical methods of all the celebrated practitioners of ancient and modern times. The Editor and Translator has per- formed his part in a manner hardly to be surpassed. The translation is faithful to the original and yet elegant. More than one hundred pages of original matter have been incorporated in the text constituting a seventh part of the whole volume."—New York Journal of Medicine. LEA & BLANCHARD'S PUBLICATIONS. 19 WORKS BY PROFESSOR W. P. DEWEES. NEW EDITIONS. DEWEESrS^IDWIFERY. A COMPREHENSIVE SYSTEM OF MIDWIFERY. CHIEFLY DESIGNED TO FACILITATE THE INQUIRIES OF THOSE WHO MAY BE PUR- SUING THIS BRANCH OF STUDY. ILLUSTRATED BY OCCASIONAL CASES AND MANY ENGRAVINGS. Tenth Edition, with the Author's last Improvements and Corrections. BY WILLIAM P. DEWEES, M. D., LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. In one volume, octavo. That this work, notwithstanding the length of time it has been before the profession, and the numerous treatises that have appeared since it was written, should have still maintained its ground, and passed to edition after edition, is sufficient proof that in it the great practical talents of the author were fully placed before the profession. Of the book itself it would be superfluous to speak, having been so long and so favorably known throughout the country as to have become identified with American Obstetrical Science. DEWEES ON FEMALES. A TREATISE ON THE DISEASES OE FEMALES, BY WILLIAM P. DEWEES, M. D., &c. LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. EIGHTH EDITION, With the Author's last Improvements and Corrections. In one octavo volume, with plates. D E W E E S ONCHIL D R E N. A TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN, BY WILLIAM P. DEWEES, M.D., LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. ETC. EIGHTH EDITION. In one volume, octavo. This edition embodies the notes and additions prepared by Dr. Dewees before his death, and will be found much improved. The objects of this work are, 1st, to teach those who have the charge of children, either as parent or guardian, the most approved methods of securing and improving their physical powers. This is attempted by pointing out the duties which the parent or the guardian owes for this purpose, to this interesting but helpless class of beings, and the manner by which their duties shall be fulfilled. And 2d, to render available a long experi- ence to those objects of our affection when they become diseased. In attempting this, the author has avoided as much as possible, " technicality," and has given, if he does not flatter himself too much, to each disease of which he treats, its appropriate and designating characters, with a fidelity that will prevent any two being con- founded together, with tJte best mode of treating them, that either his own experience or that of others has sugeested. Physicians cannot too strongly recommend the use of this book in all families. ASHWELL ON THE DISEASES OF FEMALES. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. ILLUSTRATED BY CASES DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. By SAMUEL ASHWELL, M. D., Member of the Royal College of Physicians; Obstetric Physician and Lecturer to Guy's Hospital, &c. Edited by PAUL BECK GODDARD, M.D. The whole complete in one large octavo volume. « The most able, and certainly the most standard and practical work on female diseases that we have yet seen."—Medico-Chirurgical Review. 20 LEA & BLANCHARD'S PUBLICATIONS. LATELY PUBLISHED, A NEW EDITION OF WILSON'S HUMAN ANATOMY, MUCH IMPROVED. A SYSTEM OF HUMAN ANATOMY, GENERAL AND SPECIAL. BY ERASMUS WILSON, M.D., LECTURER ON ANATOMY, LONDON. SECOND AMERICAN EDITION, EDITED BY PAUL B. GODDARD, A.M.,M.D., Professor of Anatomy and Histology in the Franklin Medical College, Philadelphia. WITH OVER TWO HUNDRED ILLUSTRATIONS. Beautifully Printed from the Second London Edition, in One very neat Octavo Volume. " Mr. Wilson, before the publication of this work, was very favorably known to the profession by his trea- tise on Practical and Surgical Anatomy; and, as this is the Second American Edition, from the second London Edition, since 1840, any special commendation of the high value of the present work, on our part, would be supererogatory. Besides, the work has been translated at Berlin, and overtures were repeatedly made to the London publisher for its reproduction in France. The work is, undoubtedly, a complete system of human anatomy, brought up to the present day. The illustrations are certainly very beautiful, the originals having been expressly designed and executed for this work by the celebrated Bagg of London; and, in the American edition they have been copied in a masterly and spirited manner. As a text-book in the various colleges we would commend it in the highest terms."—New York Journal of Medicine. WILSON'S DISSECTOR. THE DISSECTOR; OR, PRACTICAL AND SURGICAL ANATOMY. BY ERASMUS WILSON, Author of "A System of Human Anatomy, &c. WITH ONE HUNDRED AND SIX ILLUSTRATIONS. MODIFIED AND RE-ARRANGED BY PAUL B. GODDARD, M.D., Professor of Anatomy and Histology in the Franklin Medical College, Philadelphia. In One Large Royal Duodecimo Volume, Sheep. " It strikes us as being all that a " Dissector". sho,uld be. The wood-cuts are numerous and will afford the student the most essential aid in the dissecting room."—West. Journ. of Med. and Surg. WILSON ON THE SKIN., A PRACTICAL AND THEORETICAL TREATISE njf THE DIAGNOSIS, PATHOLOGY AND TREATMENT OF DISEASES OF THE SKIN; ARRANGED ACCORDING TO A NATURAL SYSTEM OF CLASSIFICATION, And preceded by AN OUTLINE OF THE ANATOMY AND PHYSIOLOGY OF THE SKIN. BY ERASMUS WILSON, Lecturer on Anatomy and Physiology in the Middlesex Hospital Medical School, &c. &c. In One Neat Octavo Volume, Cloth. "It is a sound book of practice. As a practical guide to the classification, diagnosis and treatment of the dig eases of the skin, the book is complete. We know nothing, considered in this aspect, better in our language ■ it is a safe authority in all the matters which, in this range of diseases, engage the practitioner's attention and possesses the high quality, unknown, we believe, to every older manual, of being on a level with Science's'hiirh water mark.—Medwal Times, 6 ' LEA & BLANCHARD'S PUBLICATIONS. 21 A NEW AND COMPLETE WORK ON FEVERS. FE V"ERS; THEIR DIAGNOSIS, PATHOLOGY & TREATMENT. PREPARED AND EDITED WITH LARGE ADDITIONS, FROM THE ESSAYS ON FEVER IN TWEEDIE'S LIBRARY OF PRACTICAL MEDICINE, BY MEREDITH CLYMER, M. D., Professor of the Principles and Practice of Medicine in Franklin Medical College, Philadelphia} Consulting Physician to the Philadelphia Hospital; Fellow of the Col- lege of Physicians, ffC. Sft. In one octavo volume of 600 pages. The want of a distinct treatise on Fevers, embodying the received doctrines of their pathology and treatment has long been felt and generally acknowledged. To supply'this deficiency in medical literature is the object of the present volume. It has been prepared from the Essays on Fever contributed by Drs. Christison, Shapter, Burrows, Gregory and Locock, to Dr. Tweedie's " Library of Practical Medicine," and will be found to embrace the whole class of Idiopathic Fevers,—Continued, Periodical, Eruptive, and Puerperal. The additions of the Editor, amounting to about one-half of the volume, have been chiefly made with reference to the Fevers of this country. It has been his aim to render the work as complete as possible, and to adapt it particularly to the necessities of the American Practitioner. WILLIAMS' PATHOLOGY. PRINCIPLES OF MEDICINE, COMPRISING GENERAL PATHOLOGY AND THERAPEUTICS, AND A GENERAL VIEW OF ETIOLOGY, NOSOLOGY, SEMEIOLOGY, DIAGNOSIS AND PROGNOSIS. BY CHARLES J. B. WILLIAMS, M.D., F.R.S., Fellow of the Royal College of Physicians, &c. WITH NOTES AND ADDITIONS, BY MEREDITH CLYMER, M. D., &c. In one volume, Svo. WILLIAMS AND CLYMER ON THE CHEST, &c A TREATISE ON THE DISEASES OF THE RESPIRATORY ORGANS, INCLUDING THE TRACHEA, LARYNX, LUNGS, AND PLEURA. BY CHARLES J. B. WILLIAMS, M.D., Consulting Physician to the. Hospital for Consumption and Diseases of the Chest| Author of "Principles of Medicine," kc. &c. WITH NUMEROUS ADDITIONS AND NOTES, BY MEREDITH CLYMER, M.D., &c. In one neat octavo volume, with cuts. This work recommends itself to the notice of the profession as containing a more particular and detailed account of the affections of which it treats than perhaps any other volume before the public. "The wood-cuts illustrating the physical exmination of the chest, are admirably executed, and the whole mechanical execution of the work does much credit to the publishers. This work is undoubtedly destined to take precedence of all others yet published on the < Respiratory Organs,' and as a text-book for teachers and students, no better in the present state of the science is to be expected."- I\ew lerfc Journal of Mtdietm. 22 LEA & BLA CHARD'S PUBLICATIONS. KIRBY & SPENCE'S ENTOMOLOGY, FOR POPULAR USE, AN INTRODUCTION TO ENTOMOLOGY; OR, ELEMENTS OF THE NATURAL HISTORY OF INSECTS : COMPRISING AN ACCOUNT OF NOXIOUS AND USEFUL INSECTS, OF THEIR METAMORPHOSES, FOOD, STRATAGEMS, HABITATIONS, SOCIETIES, MOTIONS, NOISES, HYBERNATION, INSTINCT, &c, &c. With Plates. Plain or Colored. By WILLIAM KIRBY, M. A., F. R. S. And WILLIAM SPENCE, Esq., F. R. S. FROM THE SIXTH LONDON EDITION. Which was Corrected and Considerably Enlarged, In One Large Octavo Volume, extra cloth. This work, as It at present stands, is acknowledged to be the best extant as a popular introduction to the science, containing an immense amount of singular and interesting information, conveyed in a simple and agreeable manner. In preparing the last edition, from which this is printed, the authors have omitted the fwo last volumes, as being too scientific for popular use, and arranged it as it now is. forming a complete exposi tion of the principles of the study, unincumbered with Anatomical or scientific details. " We are well aware that the physician engaged in an engrossing practice, whether in town or country, has not much leisure for the perusal of books unconnected with his profession ; but we know just as well, that while the few are ihus immersed in business, the many have the command of more time than they are disposed to give to professional reading. How many are the hours wasted by nearly every young physician, waiting for practice—anxious, dreary hours, because unoccupied ! Why not spend these hours in the study of such. works as that of Kirby &, Spence, wherein the physiologist, farmer, horticulturist, philosopher, and moralist, may find matter to instruct him.— The Western Journal of Medicine and Surgery. "The republication of this work, which has for many years enjoyed a very high and constantly increasing popularity in Great Britain, confers a decided benefit upon natural science in this country. It is a free, careful and authentic exposition of the very extensive department of study, of which it treats, and has done much abroad to attract attention to a branch which, until its publication, has found comparatively little lavor with the scientific students of Great Britain. The treatise of Messrs. Kirby & Spence is well adapted, not only by iu intrinsic merit, but by its attractive style, to introduce the subject to popular favor. It is thrown into the form of letters, and although abounding to some extent in scientific terms, it is divested of technicality so far as pos- sible, and by a very agreeable intermixture of anecdotes. &c. is made a pleasant and entertaining, as well as very instructive and important work. It is now reprinted from the sixth London edition, which has been revised and corrected, and forms a very handsome octavo volume of about 600 pages. Those who have never given any attention to the subject of which it treats, will find embodied in it an immense amount of very inte- resting and useful information, set forth in an agreeable and attractive style."—JV. Y. Courier and Enquirer. THE CHEMISTRY OF THE FOUR SEASONS, BY THOMAS GRIFFITH, Lecturer on Chemistry at St. Bartholomew's Hospital, &c. &c. IN ONE VERY NEAT DUODECIMO VOLUME. With Numerous Wood-cuts. A New Work. The object of this little book is to show in a popular and agreeable manner the chemical agency exerted in tbe various phenomena of nature. It forms a neat volume for the Centre Table. A TEXT BOOK OF PRACTICAL GEOLOGY AND MINERALOGY. WITH INSTRUCTIONS FOR THE QUALITATIVE ANALYSIS OF MINERALS, BY JOSHUA TRIMMER, F. G. S. WITH TWO HUNDRED AND TWELVE WOOD-CUTS. A handsome octavo volume, bound in embossed cloth. This is a systematic introduction to Mineralogy, and Geology, admirably calculated to instruct the student in those sciences. The organie remains of the various formations are well illustrated by numerous figures, which are drawn with great accuracy. LEA & BLANCHARD'S PUBLICATIONS. 23 GRAHAM'S CHEMISTRY, THE ELEMENTS OF CHEMISTRY. INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS. With Numerous Illustrations. BY THOMAS GRAHAM, F. R. S. L. and E. D. Professor of Chemistry in University College, London, &c. &c. WITH NOTES AND ADDITIONS, BY ROBERT BRIDGES, M. D., &c. &c, In One Volume Octavo. The great advancement recently made in all .branches of chemical investigation, renders neces- sary an enlarged work which shall clearly elucidate the numerous discoveries^ especially in the department connected with organic Chemistry and Physiology, in which such gigantic strides have been made during the last few years. The present treatise is considered by eminent judges to fulfil these indications, and to be peculiarly adapted to the necessities of the advanced medical student and practitioner. In adapting it to the wants of the American profession, the editor has endeavored to render his portion of the work worthy the exalted reputation of the first chemist of England. It is already introduced in many of the Colleges, and has universal approbation. FOWNES'S CHEMISTRY FOR STUDENTS. ELEMENTARY CHEMISTRY, THEORETICAL AND PRACTICAL. By GEORGE FOWNES, Ph. D., Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c. With Numerous Illustrations. Edited, -with Additions, By ROBERT BRIDGES, M. D., Professor of General and Pharmaceutical Chemistry in the Philadelphia College of Pharmacy, &c. &c. In one large duodecimo volume, sheep or extra cloth. The character of this work is such as to recommend it to all colleges in want of an elementary text-book, and to all practitioners who wish to place a compendious manual in the hands of their students. It is fully brought up to the day, containing all the late views and discoveries that have so entirely changed the face of the science, and it is completely illustrated with very numerous wood engravings explanatory of all the different processes and forms of apparatus. Though strictly scientific, it is written with great clearness and simplicity of style, rendering it easy to be mastered by those commencing the study. The low price at which it is sold, places it within the reach of all. Though this work has been so recently published, it has already been adopted as a text-book by many of the Medical Institutions throughout the country. As a work for the first class student, and as an introduction to the larger systems of Chemistry, such as Graham's, there has been but one opinion expressed concerning it, and it may now be considered as THE TEXT-BOOK FOR THE CHEMICAL STUDENT. SIMON'S CHEMJSTRY OF MAN. ANIMAL CHEMISTRY. WITH REFERENCE TO THE PHYSIOLOGY & PATHOLOGY OF MAN. BY DR. J. FRANZ SIMON. TRANSLATED AND EDITED BY GEORGE E. DAY, M. A. & L. M. Cantab., &c. With plates. In one octavo volume, of over seven hundredpages, sheep, or in two parts, boards. This important work is now complete and may be had in one large octavo volume. Those who obtained the first part can procure the second separate. "No treatise on physiological chemistry approaches, in fulness and accuracy of detail, the work which stands at the head of this article. It is the production ofa man of true German assiduity, who has added to his own researches the results of the labors of nearly every other inquirer in this interesting braneh of science.— The death of such a laborer, which is mentioned in the preface to the work as having occurred prematurely in l-M-> is indeed a calamity to science. He had hardly reached the middle term oflife. and yet had made himself known all over Europe, and in our country, where his name has been familiar for several years as among the most successful of the cultivators of the Chemistry of Man.....It is a vast repository of facts, to which the teacher and student may refer with equal satisfaction."- The Western Journal of Medicine and Surgery. 24 LEA & BLANCHARD'S PUBLICATIONS. WATSON'S PRACTICE OF PHYSIC, New Edition by Condie. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. DELIVERED AT KING'S COLLEGE, LONDON. BY THOMAS WATSON, M. D., &c. &c. Second American, from the Second London Edition. REVISED, WITH ADDITIONS, BY D. FRANCIS CONDIE, M. D., Author ofa work on the "Diseases of Children," &c In one Octavo Yolume, Of nearly ELEVEN HUNDRED Large Pages, strongly bound with raised bands. ,, This large and beautiful volume contains THE ANATOMY OF THE BREAST; THE COMPARATIVE ANATOMY OF THE MAMMARY GLANDS; ILLUSTRATIONS OF THE DISEASES OF THE BREAST; And Twenty-five Miscellaneous Surgical Papers, now first published in a collected form. By Sir ASTLEY COOPER, Bart., F.R.S., &c. The whole in one large imperial octavo volume, illustrated with two hundred and fifty-two figures on "thirty six Lithographic Plates ; well and strongly bound. COOPER ON FRACTURES AND DISLOCATIONS, WITH NUMEROUS WOOD-CUTS. A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. By Sir ASTLEY COOPER, Bart., F. R. S., Sergeant Surgeon to the King, &c. A NEW EDITION MUCH ENLARGED ; Edited by BRANSBY COOPER, F. R. S., Surgeon to Guy's Hospital. WITH ADDITIONAL OBSERVATIONS FROM Professor JOHN C. WARREN, of Boston. With numerous engravings on wood, after designs by Bagg, a memoir and a splendid portrait of Sir Astley. In one octavo volume. ter, Sir Asiley th.edition The volume is embellished with ONE HUNDRED AND THIRTY-THREE WOOD-CUTS, and contains the history of no less than three hundred and sixty-one cases, thus embodying the records of a and rurgical Review 26 LEA & BLANCHARD'S PUBLICATIONS. A NEW MEDICAL DICTIONARY, In one Volume, large 12mo., now ready, at a low price. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES; By RICHARD D. HOBLYN, A.M., Oxon. FIRST AMERICAN, FROM THE SECOND LONDON EDITION. REVISED, WITH NUMEROUS ADDITIONS, By ISAAC HAYS, M.D., Editor of the American Journal of the Medical Sciences. Believing that a work of this kind would be useful to the profession in this country, the publishers have issued an edition in.a neat form for the office table, at a low price. Its object is to serve as an introduction to the larger and more elaborate Dictionaries, and to assist the student commencing the study of Medicine, by presenting in a concise form an explanation of the terms most used in Medicine and the Collateral Sciences, by giving the etymology and definition in a manner as simple and clear as possible, without going into details ; and bringing up the work to the present time by including the numerous terms lately introduced. This design the author has so ably executed as to elicit the highest encomiums of the medical press. It has been edited with especial reference to the wants of the American practitioner, the native medicinal plants being introduced, with the formula.for the various officinal'preparations : and the whole being made to conform to the Pharmacopoeia of the United States. It is now ready in one neat royal duodecimo volume of four hundred pages in double columns. TAYLOR'S MEDICAL JURISPRUDENCE. MEDICAL JURISPRUDENCE. By ALFRED S. TAYLOR, Lecturer on Medical Jurisprudence and ChemiBtry at Guy's Hospital, &c. With Numerous Notes and Additions, and references to American Practice and Law. BrR. E. GRIFFITH, M.D. In one volume, 8vo. " We recommend Mr. Taylor's work as the ablest, most comprehensive, and, above all, the m st practically useful book which exists on the subject of legal medicine. Any man of sound judgment, who has mastered the contents of Taylor's ' Medical Jurisprudence,' may go into a court of law with the most perfect confidence of being able to acquit himself creditably."—Medico-Chirurgical Review. " As we expected, it has become truly the manual of both the medical and legal professions, and is regarded by all as the standard authority on the subject; the author, also, as we find from the public prints, is the person consulted, almost as a matter of course, in the more difficult medico- legal cases.—The British and Foreign Medical Review. LAWRENCE ON THE EYE. New Edition—Now Ready. A TREATISE ON THE DISEASES OF THE EYE. BY W. LAWRENCE, F R. S., Surgeon Extraordinary to the Queen, Surgeon to St. Bartholomew's Hospital, &c. Sec. SECOND AMERICAN, FROM THE LAST LONDON EDITION, With many Modifications and Additions, and the Introduction of over one hundred Illustrations, BY ISAAC HAYS, M.D., Surgeon to Will's Hospital, Physician to tbePhiladelphiaOrphan Asylum, &c. &c. IN ONE LARGE OCTAVO VOLUME. The character of this work is too well known to require a word of commendation. It is justly considered the be6t we possess on tbe subject. In this edition will be found many important alterations and' improvements. bringing the work up to the level of the present state of knowledge on the subjects of Ophthalmic Surgery aild Practice. The chapters on the Anatomy and Physiology of the Organ have received especial augmentation* and many new cuts have been introduced, rendering the whole clear and comprehensible. LEA & BLANCHARD'S PUBLICATIONS. 27 MILLER'S SURGICAL WORKS. THE PRINCIPLES OF SURGERY. BY JAMES MILLER, F.R.S.E., F.R.C.S.E., Professor of Surgery in the University of Edinburgh, fcc. ^ In one neat octavo volume, to match the Author's volume on « Practice." p).shed° srgeZPenl8weailuh^:'hrt|lhe ^V^™ th&t he has been addressed *7 a» «com- to grace M^Xt^^Z^l^ rt*^ T* f" ^ &U<1 ^'know. how book deserves a strong recommendation and 1 'fl -°nr,/ap,d,y advanc">? physiology. The " We feel no hesitation in 7„„ ' d must secure ,t8elf a general perusal."—Medical Times. moreiftll? an"d did*)' nan«7KnJorani°in *" " "T^- ?• PhUo"PhJ of the «*»«» ladelphia Medical Examiner * languaee With wl»ch we are acquainted."—P/u- pcalflJ^ a/6ffl Facial knowledge of the pathology of sur- rer.'^^n^^^S^^S /SSi|bettarBB,d6 tha" thePreSent treatise by Mr. Mil- snrge^nl^tomeT^X^nntr "J'81?-1 "*?? °f the day" Bein^ written ^ a sound Poetical raZmentwh ^renders it Pn 'f^ing of h.s science, it has the clearness of diction and ar- tific and oractical infnrmL £T1,ent manUal for the 8tudent8 as wel1 as tha* amount of scien- ce", '"formation wh.ch makes it a safe and valuable guide to the practitioner."-^ JUST PUBLISHED. THE PRACTICE OF SURGERY. BY JAMES MILLER. Professor of Surgery in the University of Edinburgh. In one neat octavo volume. prefaced is not put forth Rivalry of the^e^tr^^Xs^^lS^^ we think we may take upon ourseves to sav that it will fi.\~ „ J i, d'reaay exist, rival to most of thin, wLe it does'no.o&t's mTa trlXe'l iZZTlt^r^ our recent text-books have been embellished, and while it wilfnot as TndieS is »« 7* !<*!?*£ aside the more complete and elaborate works of reference which the profession is in posseS of we have no hesitation^ stating that the two volumes form, together, a more compCeTbook ^MeTcIne aDy °n* heret0f°re °ffered t0 the ««*™">-The NoWhelnJ^ !.\3JIr*^Iilie,Liralready knTn,'n ]"' Profession a" a" able writer and a well informed surgeon and the book before us » calculated to maintain his reputation. We recommend ?tTo th0.7who want a sound guide or wish to refresh their recollections. The characteristics which especially distinguish the work are, its plain good sense, or the selection of the important from the Snort ant announcements in surgery ; the sound indications of the judgment to be exercised in the treat ment of surgical diseases."—The Lancet. uie treai. A NEW AND IMPROVED EDITION OF FERGUSSON'S OPERATIVE SURGERY. A SYSTEM OF PRACTICAL SURGERY, BY WILLIAM FERGUSSON, F. R. S. E. SECOND AMERICAN EDITION, REVISED AND IMPROVED. With Two Hundred and Fifty-two Illustrations from Drawings by Bagg, Engraved by Gilbert With Notes and Additional Illustrations, ' BY GEORGE W. NORRIS, M. D., &c. In one beautiful octavo volume of six hundred and forty large pages. "If we were to say that this volume by Mr. Fergusson, is one excellently adapted to the student and th* «« inexperienced practitioner of surgery, we should restrict unduly its range. It isof the kind which'evervmedi cal man ought to have by him for ready reference, as a guide to the prompt treatment of manv accidents and injur.es. wh.ch whilst he hesitates, may be followed by incurable defects, and deformities of structure ! ?no *hv death itself. In drawing to a close our notice of Mr Ferguson's Practical Surgery, we cannot refrain from •gain adverting to the numerous and beautiful illustrations by wood-cuts, which contribute so admirab v £ elucidate the descriptions in the text. Dr Norr.s has, as usual, acquitted himself judiciously in his office of Wmotator. His additions are strictly practical and to the point"—Bulletin ef Medical Science 28 LEA & BLANCHARD'S PUBLICATIONS. LIBRARY OF SURGERY. CHELIUS'S SYSTEM OF SURGERY, A SYSTEM OE SUEGEEY. By J. M. CHELIUS, Doctor in Medicine and Surgery, Public Professor of General and Ophthalmic Surgery, etc. etc. in the University of Heidelberg. TRANSLATED FROM THE GERMAN, . AND ACCOMPANIED WITH ADDITIONAL NOTES AND OBSERVATIONS, By JOHN F. SOUTH, SURGEON TO ST. THOMAS'S HOSPITAL. EDITED, WITH REFERENCE TO AMERICAN AUTHORITIES, By GEORGE W. NORR1S, M.D. Publishing in Numbers, at Fifty Cents each. Nine Numbers are now ready: and the whole is expected to be complete by September next, forming Three Large Octavo Volumes. That this work should have passed to six editions in Germany, and have been translated into no less than seven languages, is sufficient proof of its value. It contains what is, perhaps, embraced to an equal extent by no other work on the subject now before the public—a complete System of Surgery, both in its principles and practice. The additions of the translator, Mr. South, are very numerous, bringing the work up to the very day of publication, and embodying whatever may have been omitted by the author respecting English Sur- gery; while Dr. Norris will take equal care in representing the state of the Science in America. "Judging from a single number only of this work, we have no hesitation in saying: that, if the remaining por- tions correspond at all with the first, it will be by far the most complete and scientific System of Surgery in the English language. We have, indeed, seen no work which so nearly comes up to our idea of what such a pro- duction should be, both as a practical guide and as a work of reference, as this; and the fact tfyal it has passed through six editions in Germany, and been translated into seven languages, is sufficiently convincing proof of its value. It is methodical and concise, clear and accurate; omitting all minor details and fruitless speculations, it gives us all the information we want in the shortest and simplest form "— The New York Journal of Medicine. "The scope of Professor Chelius's Manual is indicated by it* title: it professes to treat, systematically, of the science and art of Surgery, but within such compass as to render the work an appropriate introduction and companion to his lectures. The care, however, which has been bestowed upon its construction, and the labor ^rhich its research evinces, would be ill repaid were it confined to this sphere; and we may conscientiously say, that we know of no Manual of Surgery, on the whole, more deserving of public confidence, or more valu- able as a guide and refresher to the young practitioner. It is not our4ntention at present critically to analyze Mr. South's labors; but we should be guilty of an injustice to him and to our readers if we did not cordially recommend his work as having fair promise of forming, what it is the translator's ambition it should be, a sound and comprehensive system of Practical Surgery. The notes and text are so intermingled as to render it con- tinuously readable, without presenting those abrupt transitions which are so disagreeable in many works simi- larly arranged. The faults of omission, &c, at which we have hinted in our comments on the first chapter of our author's wprk, (viz. that on ' Inflammation,') have been amply compensated by the.copious and excellent digest of his translator and annotator. who is justly proud of availing himself of the labors of our own coun- try men in this department of pathology, while he gives their due meedof notice and respect to the contributions of our continental brethren. The references which are given to original works have evidently been carefully collated, and will be found «f great value to the student and practitioner who may wish for more copious in- formation on any particular branch of Surgery; and the practical remarks and illustrations with which the work abounds, are a good guarantee of the translator's ability to do justice to his task, at the same time that they prove that Mr. South has not failed to avail himself industriously of the large opportunities which his Hos- pital appointment has afforded him."—The British and Foreign Medical Review. " We will, therefore, content ourselves for the present with directing the attention of the profession to it, as being the most complete'system of Surgery in any language, and one that isof equal utility as a practical guida and as a work of reference. The fact of its having reached six editions in Germany, and its having been trans- lated into seven languages^are more convincing proofs of its value than anything that we can say. Mr. South bas performed his task with much judgment, and has certainly made a most useful addition to the medical lite- rature of this country by rendering Chelius's work into English "— The Lancet. " This work has long been the chief text-book on Surgery in the principal schools of Germany, and the pub- lication of five editions of it in the original and of translations into no less than eight foreign languages, show the high estimation in which it is held. As a systematic work on Surgery it has merits of a high order. It is methodical arid concise—and on the whole clear and accurate. The most necessary information is conveyed in the shortest and simplest form. Minor details and fruitless speculations are avoided. Itis.-in fact,«ssen- tially a practical book. This work was first published nearly twenty years ago, and its solid and permanent reputation has no doubt led Mr. South to undertake the present translation of the latesVedition of it, which, wo are informed, is still passing through the press in Germany. We should have felt at a loss to select any one better qualified for the task than the translaior of Otto's Compendium of Human and Comparative Pathological Anatomy—a surgeon to a large hospital, whose industry and opportunities have enabled him to keep pace with the improvement* of his time."—The Medico-Chirurgical Review. "Although Great Britain can boast of some of the most skilful surgeons, both among her past and her present professors of that branch of medical science, no work professing to be a complete system of Surgery has been published in the British dominions since that of Benjamin Bell, now more than half a century old. "This omission in English medical literature is fully and saiisfactorily supplied by the translation of Professor Chelius's System of Surgery by a gentleman excellently fitted for the task, both by his extensive reading, and the opportunities of practical experience winch he has enjoyed for years as surgeon to one of our largest me- tropolitan hospitals. The fact ot Professor Chelius'3 work having been translated into seven languages is suf- ficient'proof of the estimation in which it is held by our continental brethren, and the English edition, now in course of publication, loses none of the value of the original from the treatment received at the hands of its translator. The notes and additions of Professor South are numerous, and contain the opinions resulting from his vast experience, and from that of his colleague. «' We are free to confess, prejudiced though perhaps we are. in favor of the English practice of surgery, that this work is one of great value, and one which every practitioner and advanced student should possess.''.—T!it Medical Times. WORKS m VARIOUS DEPARTMENTS OF MEDICINE AND SURGERY, PUBLISHED BY LEA & BLANCHARD. AMERICAN JOURNAL OF THE MEDICAL SCIENCES. Edited by Isaac Hays, M. D. Published quarterly at $5 00 per annum. ANDRAL ON THE BLOOD. Pathological Hematology ; an Essay on the Blood in Dis- ease. Translated by J. F. Meigs and Alfred Stille. In one octavo volume, cloth. ARNOTT'S PHYSICS. The Elements of Physics in plain or non-technical language. A New Edition. Edited by Isaac Hays, M. D. In 1 vol. 8vo., sheep, with 176 wood-cuts. ABERCROMBIE ON THE STOMACH. Pathological and Practical Researches on Dis- eases of the Stomach, Intestinal Canal, &c. Fourth Edition. In 1 vol. 8vo., sheep. ABERCROMBIE ON THE BRAIN. Pathological and Practical Researches on the Dis- eases of the Brain and Spinal Cord. A New Edition. In one octavo volume, sheep. ALISON'S PATHOLOGY. Outlines of Pathology and Practice of Medicine. In three parts, containing Preliminary Observations, Inflammatory and Febrile Diseases, and Chronic or Non-Febrile Diseases. In one neat octavo volume, sheep. BIRD ON URINARY DEPOSITS. Urinary Deposits, their Diagnosis, Pathology and The- rapeutical Indications. In one neat octavo volume, cloth, with numerous wood-cuts. BERZELIUS ON THE KIDNEYS AND URINE, in 1 vol. 8vo., cloth. BUCKLAND'S GEOLOGY. Geology and Mineralogy, with reference to Natural Theology. A Bridgewater Treatise. In two octavo volumes, with numerous maps, plates, &c. BRIDGEWATER TREATISES. The whole complete in 7 vols. 8vo., containing Roget's Animal and Vegetable Physiology, in 2 vols., with many cuts; Kirby on the History, Habits and Instinct of Animals, 1 vol. with plates; Prout on Chemistry; Chalmers on the Moral Condition of Man ; Whewell on Astronomy ; Bell on the Hand; Kidd on the Phy- sical Condition of Man; and Buckland's Geology, 2 vols., with many plates and maps. BARTLETT ON FEVERS OF U. S. The History, Diagnosis and Treatment of Typhus and Typhoid Fevers, and on Bilious Remittent and Yellow Fever. In I vol. 8vo., ex. cloth. BARTLETT'S PHILOSOPHY OF MEDICINE. Essay on the Philosophy of Medical Science. In two Parts. One neat octavo volume, extra cloth. BRIGHAM ON MIND, &c. The Influence of Mental Excitement and Mental Cultivation on Health. In one neat 12mo. volume, extra cloth. BILLING'S PRINCIPLES OF MEDICINE. The First Principles of Medicine. From the ' Fourth London Edition. In one octavo volume, cloth. CHITTY'S MEDICAL JURISPRUDENCE. A Practical Treatise on Medical Jurispru- dence With Explanatory Plates. In one octavo volume, sheep.. CLATER AND SKINNER'S FARRIER. Every Man his own Farrier. Containing, the Causes, Symptoms, and most approved Methods of Cure of the Diseases of Horses.— From the 28lh London Edition. Edited by Skinner. In one 12mo. volume, cloth. PI \TER AND YOUATT'S CATTLE DOCTOR. Every Man his own Cattle Doctor.— J Containing the Diseases of Oxen, Sheep, Swine, &c. Edited by Youatt, and revised by Skinner! &Wilh Wood-cuts. In one volume 12mo. nURLACHER ON CORNS, BUNIONS, &c. A Treatise on Corns, Bunions, the Dis- eases of Nails, and the General Management of the Feet. In one 12mo. volume, cloth. FI I lOTSON'S MESMERIC CASES. In one octavo pamphlet. PvirinRfil' ()\ IN>' \NITY. Mental Maladies, Considered in Relation to Medicine, Hy- iene and Medical Jurisprudence. Translated by E. K. Hunt, M. D, &c. In 1 vol. 8vo. nr/llRIE ON THE BLADDER, Ac. The Anatomy of the Bladder and Urethra, and tu Treatment of the Obstructions to which those passages are liable. In 1 vol. 8vo. HARRIS ON MAXILLARY HLXUS. Dissertation on the Diseases of the Maxillary Sinus.. In one small octavo volume, cloth. 30 LEA & BLANCHARD'S PUBLICATIONS. KIRBY ON ANIMALS. The History, Habits and Instinct of Animals. A Bridgewater Treatise. ■ In one targe volume 8vo. with plates. HARRISON ON THE NERVES. An Essay towards a correct Theory of the Nervous System. In one octavo volume, sheep. LAWRENCE ON RUPTURES. A Treatise on Ruptures, from the fifth London Edition. In one octavo volume, sheep. MAURY'S DENTAL SURGERY. A Treatise on the Dental Art, founded on Actual Ex- perience. Illustrated by 241 Lithographic Figures and 54 Wood-cuts. Translated by J. B. Savier. In one octavo volume, she,ep. MULLER'S PHYSIOLOGY. Elements of Physiology. Translated by Wm. Baly, M.D., and edited and arranged by John Bell, M.D. In one large octavo volume, sheep. PROUT ON THE STOMACH. On the Nature and Treatment of Stomach and Renal Diseases. In one octavo volume, sheep, with colored plates. POPULAR MEDICINE, BY COATES. In one octavo volume, sheep, with Wood-cuts. PHILIP ON INDIGESTION. A Treatise on Protracted Indigestion. In 1 vol. 8vo. ROGET'S PHYSIOLOGY. A Treatise on Animal and Vegetable Physiology, with over 400 illustrations on Wood. In two octavo volumes, cloth. A Bridgewater Treatise. ROGET'S OUTLINES OF PHYSIOLOGY. Outlines of Physiology and Phrenology. Im one large octavo volume, cloth. RIGBY'S MIDWIFERY. A System of Midwifery. With Wood-cuts. In 1 vol. 8vo. RICORD ON VENEREAL. A Practical Treatise on Venereal Diseases; with a Thera- peutical Summary, and a Special Formulary. In 1 vol. 8vo., cloth. ROBERTSON ON TEETH. A Practical Treatise on the Human Teeth, with plates. One small volume octavo, cloth. TRAILL'S MEDICAL JURISPRUDENCE. Outlines of a Course of Lectures on Medi- cal Jurisprudence. Revised, with numerous notes. In one octavo volume, cloth. THOMSON'S SICK ROOM. Domestic Management of the Sick Room, Necessary in Aid of Medical Treatment, for the Cure of Diseases. Edited by R. E. Griffith, M. D. In one large royal l2mo. volume, extra cloth, with Wood-cuts. WALSHE ON THE LUNGS. Physical Diagnosis of the Diseases of the Lungs. In one neat 12mo. volume, extra cloth. YOUATT ON THE HORSE. The Horse: containing a full account of the Diseases of the Horse, with their mode of Treatment'; his Anatomy, and the usual Operations per- formed on him; his Breeding, Breaking, and Management; and Hints on his Sound- ness, and Purchase and Sale. Together with a General History of the.Horse; a Dis- sertation on the American Trotting Horse, how trained and jockeyed, an account of his remarkable performances; and an Essay on the Ass and the Mule. By J. S. Skinner, Assistant Postmaster General, and Editor of the Turf Register. In one volume, octavo, with numerous Cuts. ...,, JinniClJj WORKS, at Press and Preparing: A MANUAL OF MATERIA MEDICA AND Therapeutics. By J. Forbes Royle,M.D.,&c. Edited by J. Carson, M. D., &c. In 1 vol. 8vo., numerous wood-cuts, (nearly ready).* TODD & BOWMAN'S PHYSIOLOGICAL ANA- tomy and Physiology of Man. Many wood-cuts, (publishing in the Medical News and Library). A TREATISE ON OPHTHALMIC MEDICINE and Surgery. By T. Wharton Jones. In 1 vol. beautifully illustrated. PRINCIPLES OF GENERAL AND COMPA- rative Physiology. By Wm. B. Carpenter, M. D., &c. From a new London edition, with numerous improvements and additions. In 1 vol. large 8vo., many steel plates. A TREATISE ON ANIMAL PHYSIOLOGY, with very numerous illustrations. By Wm. B. Carpenter.—To be followed by his other works on Natural Science. A NEW AMERICAN FORMULARY. By J. Carson, M. D., &c. In one volume, (preparing). A SYSTEM OF SURGERY. By J. M.Chelius. Translated by South, and Edited by Norris.— Publishing in numbers at 60 cents each. To be complete in three octavo volumes. HORNER'S AMERICAN DISSECTOR, in one large 12mo. vol., with many cuts, (nearly ready.) AN ANATOMICAL DESCRIPTION OF THE Diseases of the Organs of Circulation and Re- spiration. By C. E. Hasse. Translated and Edited by W. E. Swaine, M D., &c. In 1 vol. 8vo., (nearly ready). A TREATISE ON AURAL SURGERY. In 1 vol. 8vo., many illustrations. A COMPLETE MEDICAL BOTANY, especially adapted to the United States. By R. E. Grif- fith, M. D. In 1 vol. large 8vo., with many illustrations. LECTURES ILLUSTRATIVE OF VARIOUS Subjects in Pathology and Surgery. By Sir B. Brodie—completing his works. CALORIC, its Mechanical, Chemical, and Vital Agencies in the Phenomena of Nature. By S. L. Metcalfe, M. D., &c. In 1 large 8vo. vol. GOLDING BIRD'S ELEMENTS OF NATU- RAL PHILOSOPHY. With numerous wood- cuts. VOGEL'S PATHOLOGICAL ANATOMY.— Translated and Edited by G. Day, M. D., &c. In 1 vol. large 8vo., many plates. BURROWS ON CEREBRAL CIRCULATION, with plates. Together with other JYeiv Works. LEA & BLANCHARD'S PUBLICATIONS. 31 (See Page 32.) THE MEDICO-CHIRURGIGAL REVIEW, EDINBURGH MEDICAL AND SURGICAL JOURNAL, AND NUMEROUS OTHERS. WHILE FROM FRANCE THE GAZETTE MEDICALE DE PARIS—L'EXPERIENCE—REVUE MEDICALE —JOURNAL DE MEDECINE—JOURNAL DES CONNAISSANCES MEDICO-CHIRURGICALES, AND VAKIOUS OTHERS, WITH THE ZEITSCHRIFT FUR DIE GESAMMTE MEDICIN, WITH SEVERAL OTHERS FROM GERMANY, AND THE BIBLIOTHEK FOR L^EGER, OF DENMARK, TOGETHER WITH ALL THE AMERICAN JOURNALS, ARE PUT IN REQUISITION. It will thus be seen that the material for a full Summary of all NEW MATTERS AND IMPORTANT DISCOVERIES ie full and ample, while the exertions of the Editor and the time of publication insure a fulness and newness to this department. ALL THE LATE AND IMPORTANT AMERICAN INTELLIGENCE, is fully recorded—while THE MONTHLY NEWS furbishes the lighter and floating information, and embraces important Books for THE LIBRARY DEPARTMENT. Among those works already published in the Monthly Library and News, may be mentioned WATSON'S LECTURES ON THE PRACTICE OF PHYSIC, AS ALSO BRODIE'S LECTURES ON SURGERY, CONCLUDED IN MARCH OF THIS YEAR, (1846). The work for the year 1846 is a new one, TODD & BOWMAN'S PHYSIOLOGICAL ANATOMY & PHYSIOLOGY OF MAN. NOW PUBLISHING IN ENGLAND. This work has already earned for its authors a high reputation in Europe and this eountry. It will be reproduced entire, with all the numerous and beautiful wood-cuts. Each Work in the Library is regularly paged so as to be bound separately. THE TERIWIS ARE- For the Medical Journal and the Medical News, if paid for by the first of February of each Year, and the amount remitted free of cost to the Publishers, - - - - - Five Dollars. For the Journal only, when ordered without funds, or paid for after the first of February of each year, - - - Five Dollars. For the Medical News only, to be paid for always in advance, and free of postage, - - - - - - - One Dollar. gr^> In no case can the News be sent without pay in advance. .£$ 32 TWO MEDICAL PERIODICALS FOR FIVE DOLLARS A YEAR. !' T* TT V AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. D. SURGEON TO WILLS' HOSPITAL, ETC. Published Quarterly on the first of January, April, July and October ; each Number having at least 264 large and closely printed pages. WHEN NECESSARY, CASES ARE Fully Illustrated with LITHOGRAPHIC PLATES and. WOOD-CUTS. ALSO, Of 32 Large Pages, Published Monthly, is given Gratis to Subscribers to The Journal who pay, by the first of February of each year, Five Dollars free of expense to the Publishers. Under the new law the postage on the Journal is reduced to about 13£ cents per number, while the News and Library is sent through the mail as a Newspaper. Persons wishing to subscribe, to commence with the January number for 1847, should advise the publishers at once, as the whole quantity for the present and two past years was taken up e;irly in the year. The publishers do not deem it necessary to refer to the past course of the Journal. It is suffi- cient that for the last TWENTY-SEVEN YEARS it has received the approbation of the profession at home and abroad ; but they would call attention to the extended and liberal arrangement exit- ing and to be pursued that shall embody the latest intelligence from all quarters. ITS PAGES WILL BE DEVOTED FIRST TO ORIGINAL COMMUNICATIONS FROM ALL SECTIONS OF THE UNION, WITH REVIEWS OF ALL NEW WORKS OF INTEREST, AND BIII3ILDO©li&AI?(KIDQAIl. [Nl © TT Q © IE Ss While its QUARTERLY SUMMARY will embrace a full and extended RETROSPECT AND ABSTRACT FROM THE VARIOUS FOREIGN AND DOMESTIC JOURNALS. With reference to this department, the arrangements of the publishers are very extensive and em- brace for the gleanings of the editor the various Journals from GREAT BRITAIN, FRANCE, GERMANY, DENMARK, ITALY, AJYB OTHER SECTIONS OF THE WORLD. INCLUDING AS PROMINENT AMONG THE ENGLISH, BRAITHWAITE'S RETROSPECT, RANKING'S HALF-YEARLY ABSTRACT, THE LONDON MEDICAL TIMES, THE LONDON MEDICAL GAZETTE, FORBES' BRITISH AND FOREIGN QUARTERLY. (Continued on Page 31.) 55" This paper may be delivered to any physician if declined by the person to whom it is ad- dressed, or if they have removed—and Postmasters and others will particularly «blige the publish- ers by furnishing a list of the Physicians and Lawyers of their county or neighborhood. In addition to the business-it may bring to the office, a copy of" The Complete Florist," or such other volume will be sent by mail gratis for any ten or more names furnished free of cost. Philadelphia, July, 1846. >#■ i>#P)$P' •> ^spS&^T-^ iA-M-'-?'" • *'. • .-;-: > ■<&**& .v. )$^,-'^\: •'$&' .fir 1>'.--', '■