NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAR a0€t;0£68£ SLSl iUb$ 001 H/V\ NLM051930758 NATIONAL LIBRARY OF MEDICINE c. \< 3NiDia3w jo Aavaan ivnouvn A V!i V A 3NOia3w jo Aavaan ivnouvn CONGENITAL Occlusion and Dilatation OF LYMPH CHANNELS BY / I SAMUEL O. BTJSET, M.D. ' PROFESSOR OP THE THEORY AND PRACTICE OP MEDICINE. MEDICAL DEPARTMENT OP THE J UNIVERSITY OP GEORGETOWN; CONSULTING-PHYSICIAN TO ST. ANN'S INFANT ASYLUM; ' ATTENDING PHYSICIAN TO THE CHILDREN'S HOSPITAL: PHYSICIAN TO THE LOUISE HOME: EX-PRESIDENT OP THE MEDICAL ASSOCIATION, AND OP THE MEDICAL SOCIETY OP THE D. C.! FELLOW OP THE AMERI- CAN GYNECOLOGICAL SOCIETY; HONORARY MEMBER OP THE MEDICAL SOCIETY OF THE STATE OF NEW YORK; MEMBER OP THE PHILOSOPHICAL SOCIETY OP WASHINGTON, D. C, ETC., ETC. NEW YORK WILLIAM WOOD & CO., 27 GREAT JONES STREET. 1878 )o o 3311* I5?72 Copyright by S. C. BUSEY, M.D. 187& Trow's Printing and Bookbinding Co., 205-213 East iitA St., NBW YORK. TO THE MEDICAL PROFESSION OF THE D. C, WHICH HAS SO FREQUENTLY HONORED ME, TOTS VOLUME IS RESPECTFULLY AND GRATEFULLY BY THE AUTHOR. PREFACE. This volume, for the most part the republication of a serial contribution to the American Journal of Obstetrics, is the re- sult of an effort on the part of the writer to study and analyze the complex phenomena exhibited in the case numbered 1, in the collection of cases which have been herein comprehended under the general designation—congenital occlusion and dilata- tion of lymph-channels. In the execution of this purpose, the writer has mainly con- fined himself to the study of the subject in its clinical aspects, "> and of the coarser anatomico-pathological conditions, omitting thus the discussion of questions of minute structure, which are more specially attractive to the student of histology and micro- scopic pathology. The interest and importance of these re- searches, especially as regards nosological classification, is fully appreciated, but he must not only plead a lack of technical skill in the use of the microscope, but assert his intention to address himself to the busy practitioner, not as a teacher, but as a compiler—a more laborious, though less meritorious office. It may be that he has erred in not reproducing the reports of the cases in full. To have done so, would have increased the size of the volume beyond a reasonable limit. In submitting synopses of the collated cases, gathered from the English, French, and German authorities, he has endeavored to supply the description in the language of the reporter or translator, omitting only such portions of the original reports as were deemed unnecessary to the purposes in view. Recognizing, however, the difficulty of presenting the views and correct vi Preface. meaning of another in one's own language, or even by an hon- est effort, to eliminate useless verbiage and desultory addenda, it is not improbable that some mistakes have been committed, and, perhaps, injustice done. In only a few instances have the synopses prepared by others been accepted, for it soon be- came apparent, in the progress of the compilation, that in many cases a comparison of the published abstracts and synopses of previously reported cases presented the history in a different aspect from that which was believed to be a correct representa- tion of the meaning of the reporter. Hence, the synopses— or more properly, abbreviated reports—have been for the most part prepared directly from the original reports. It may be, that he has erred, also, in introducing cases, which did not properly belong to a collection of cases of occlu- sion and dilatation of lymph-channels, but he was of the opin- ion that correlative cases'would give additional value to the volume, and as all these cases contributed facilities for the study of the complex phenomena of the case which constitutes the basis of the investigation, he deemed it desirable that all Bhould be reproduced. Without the opportunities and library facilities supplied by the library of the Surgeon-General's office, through the kindness and courtesy of Surgeon John S. Billings, U. S. Army, the self-imposed task could not have been accomplished, and the writer feels impelled by a sense of justice, as well as by con- siderations of personal regard, to make ample acknowledgment of his obligations to Dr. Billings and his assistants, Drs. Wise and Fletcher and Mr. Stone. It may not be inappropriate, in this connection, to relate the following incident, as illustrating the care and diligence which Surgeon Billings has exercised in the collection of this very extensive and valuable library, as well as the completeness with which he has arranged and digested its treasures. After a laborious and fruitless search for a report of the case entitled," De Lactis E Scroto Secretione Anomala," the writer called on Dr. Billings, and related to him that the editor of the Gas. des Hopitaux civils et mllitaires (No. 127, T. x. 2d Series Nov. 2 and 4,1848, p. 508), had stated that after the debate in Preface. vii the Academy of Medicine on the presentation, by M. Yidal (De Casis), of his case of galactocele. M. Sichel, residing at Zurich, had written to the editor, calling his attention to the above case, which Sichel had witnessed in the clinic of Prof. Schonlein, in 1833, and which Koller had published, with great minuteness, in his inaugural dissertation, but that he could not secure a copy of the pamphlet; that, failing to find a copy in any of the medical libraries in Paris, the editor wrote to M. Lebert, who in his work (" Physiologie Pathologique," T. ii., p. 46, Paris, 1845), had briefly referred to Schonlein's case, which he had also seen at the clinic, in 1833 ; that in reply, Lebert supplied the editor with a synopsis, which he prepared from his memoranda made in 1833, which was published in the Gaz. des Hopitaux. After listening to this narrative, Dr. Billings, in a very few moments, placed at the disposal of the writer a copy of the thesis of Koller, written'in Latin, and published at Zurich, in 1833. A translation of this thesis, prepared by his accomplished friend, Dr. Murphy, is in the writer's possession, and will be given to the profession at some future period, in an essay enti- tled, " Lymph Scrotum." It affords the writer pleasure also to acknowledge his obliga- tions to Drs. Kleinschmidt and Lee, and the late Professor Drinkard. To the former he is indebted for the translations of the cases which originally appeared in the German language, and to Drs. Lee and Drinkard for the French translations. To medical student S. S. Adams, acknowledgment is due for his assistance in preparing the manuscript and in correcting the proof. To the late Dr. Drinkard, whose untimely death was univer- sally regretted, and whose memory will ever be cherished by those who enjoyed his friendship and confidence, the writer owes more than a mere acknowledgment for assistance ren- dered. His familiarity with the subject and varied information enhanced the value of his advice, and it is the privilege of the writer to acknowledge the influence of his judicious counsel and constant encouragement when, wearied with the dull and conflicting details, the writer more than once felt tempted to abandon the effort. viii Preface. To Drs. Munde and Castle, of New York, and Chadwick, of Boston, acknowledgment must also be made for their courtesy in calling the attention of the writer to cases which otherwise might have escaped his observation. The illustrations have been prepared from photographs, by Mr. Smiler, Photographer of the Smithsonian Institution, and Mr. Ward, Photographer of the Army Medical Museum, from the original illustrations, many of which have necessarily been reduced in size. The woodcuts were executed by Mr. Nichols. These gentlemen have performed their work with fidelity. The reader will recognize, from the frequent references to the N. O. Med. and Surg. Jour., that simultaneously with the appearance of the greater portion of this memoir in the col- umns of the American Journal of Obstetrics, there was being published in the consecutive numbers of the former journal an allied contribution, upon the acquired forms of the diseases herein considered. These two essays will aggregate more than 400 pages of printed matter. In addition to this there are at least 100 pages, yet unpublished, which includes the subjects of Lymphorrhagia, Lymph Fistula, and Lymph Scrotum. Re- calling the fact that during the past three years, in addition to these 500 pages of printed matter, the writer has examined sev- eral hundred volumes and pamphlets, read, and for the most part copied, 3,000 pages of manuscript—and all of this, while never neglecting a busy practice, and for the most part during the hours usually appropriated to recreation and sleep—he feels that he can appeal to his professional brethren for that forbear- ance, which a generous profession is always willing to accord, and indulges the hope that his shortcomings and mistakes will at least be offset by credit for an assiduous and unremitting effort to contribute something valuable to the common fund of useful information. The Author. Washington, D. C, January, 1878. CONTENTS. PAGK Introduction................................................. 1 Case I.—Congenital enlargement of right lower extremity. Lobu- lated arrangement of the panniculus adiposus; groups of cutane- ous vesicles. Nipple-shaped elevations...........The Author. 8 Case II.—Extraordinary enlargement of the right lower extremity, following an attack of phlegmasia alba dolens......Chevalier. 18 Case m.—Extraordinary enlargement of the left lower extremity. R. J. Graves. 20 Case IV.—Elephantiasis of left leg. Ligation of femoral artery, cure............................................Kappeler. 20 Case V.—Elephantiasis of right leg and foot. Fruitless attempts by compression six months after commencement of disease. Amputation of thigh in middle third after four years. Re- covery...............................................Bryk. 21 Case VI.—Elephantiasis congenita cystica............Steinwirker. 22 Case VIT.—Elephantiasis congenita cystica................Meckel. 23 Case VIII.—Elephantiasis congenita varicosa..............Martin. 26 Case IX.—Nsevoid elephantiasis...........................Smith. 27 Case X.—Enlarged right thigh and leg, much stained by cavernous nsevous growths......................................Smith. 28 Case XL—Lipomatosis congenita and elephantiasis congenita vari- cosa.................................................Rose. 29 Case XII.—Congenital hypertrophy of integument of right arm. The Author. 30 Case XLT|.—Congenital elephantiasis......................Jacori. 31 Case Xill.—Hypertrophy of index-finger of left hand, which bent over middle and ring fingers..........................Klein. 33 Case XIV.—Hypertrophy of right hand, which elongated in propor- tion to growth of entire body.......................Wagner. 33 Case XV.—Hypertrophy and elongation of second toe of left foot. Bohms. 33 X Contents. PAGE Case XVI.—Hypertrophy of half of palm of three first fingers of righthand.........................................WxJFF- 33 Case XVIL—Skeleton of a foot, showing elongation of the bones of the three middle toes.................................Busch. 34 Case XVIIL—Hypertrophy of third and fourth fingers and ulnar side of hand.......... .................Leg endre. 34 Case XIX—Enlargement of both feet Lipoma in right gluteal re- gion...........................................Ideler. 34 Case XX.—Congenital hypertrophy of middle finger......Bigelow. 34 Case XXL—Congenital hypertrophy of a toe. Amputation. Hamilton. 34 Case XXII.—Hypertrophy of left foot....................Simpson. 35 Case XXIII.—Singular case of hypertrophy of the right lower extrem- ity with superficial cutaneous naevus on the same side ... Adams. 35 Case XXIV.—Hypertrophy of ring and fourth fingers of left hand. Kappeler. 36 Case XXV—Congenital fibro-cellular tumor..................Gun. 37 Case XXVI.—Elephantiasis of the auricular and annular fingers of the hand in a child.................................Michel. 37 Case XXVII.—Hypertrophy and elongation of the third and fourth fingers..............................................Busch. 38 Case XXVIII.—Hypertrophy of toes. Elongation. Deformed articu- lating surfaces......................................Busch. 38 Case XXIX.—Deformity of the fingers of left hand___Annandale. 40 Case XXX.—Congenital hypertrophy of hand and arm. MacGillivrat. 40 Case XXXI.—Enlargement of both great toes..........Annandale. 41 Case XXXII.—Deformity of the great toe................. Jones. 41 Case XXXIII.—Congenital and progressive hypertrophy of left hand.,.............................................Ewald. 42 Case XXXIV.—Macrodactylia...........................Grurer. 42 Case XXXV.—Increased nutrition of left thoracic extremity.. .Reid. 45 Case XXXVI.—Increased nutrition in one toe................Reid. 45 Case XXXVII.—Increased nutrition in the thumb and first finger of the left hand..........................................Reid 45 Case XXXVIII.—Congenital hypertrophy of the extremities of the right side. Multiple sanguineous blotches; varices, etc. Chassaignac 46 Case XXXIX—Naevus Maternus lipomatodes, lipomatosis haemato- des congenita, lipoma congenitum diffusum...........Gherini. 46 Case XL.—General hypertrophy of second and third toes, and of re- spective metatarsal bones............................Burow. 46 Case XLL-Congenital hypertrophy of the left leg and multiple lipo- mata- • ............ .............................Poulain. 47 Contents. XI PAGE Case XLn.—Hypertrophy of the fused second and third toes of the right foot..........................................Busch. 48 Case XLIII.—Hypertrophied fingers and toes...............Adams. 48 Case XLIV.—Enlarged and distorted right thumb.....Annandale. 49 Case XLV.—Remarkable hypertrophy of fingers in a girl. . Curling. 49 Case XLVL—Hypertrophy and elongation of middle finger of each hand...............................................Owen. 50 Case XLVH.—Enormous hypertrophy of first and second fingers of right hand..........................................Paget. 50 Case XLVIII.—Giant growth of the right leg..........Friedberg. 57 Cash XLLX.—Enlargement of the right leg and thigh, with an occa- sional discharge of chylous fluid........................Day. 61 Case L.—Researches on lymphorrhagia and dilatation of lymphatic vessels........................................Demarquay. 62 Case LI.—Congenital lymphatic varix..................Paterson. 63 Case LII.—Lymphangiectasis..........................Thilesen. 64 Case LIII.—Cuticular vesicles on the thigh secreting a chyle-like fluid..............................................Hilton. 65 Case LIV.—Curious affection of the raphe"..............Hamilton. 71 Case LV.—Lymphorrhcea...............................Zambaco. 72 Case LVI.—Lymph varices...............................Gault. 73 Case LVII.—Elephantiasis Scroti........................Wiedel. 72 Case LVIII.—Varicose lymphatics of the prepuce, with milky dis- charge ............................................Hensen. 73 Case LIX.—Ectasia of the lymph-vessels of the internal organs. Virchow. 74 Case LX.—Morbid expansion of the lymphatic vessels.....Amussat. 74 Case LXI.—Hypertrophied inguinal glands, with varicose lymphatics similating hernia.................................Drinkard. 76 Case LXIL—Lymphatic tumors..........................Trelat. 77 Case LXIII.—Lymphatic varices...........................Petit. 78 Case LXIV—Lymphatic varices.....................Aime-David. 78 Case LXV.—Case of peculiar disease of the lymph-vessels.. .Fetzer. 80 Case LXVI.—A case of disease of the lymphatics of the abdominal integuments, with occasional discharge of large quantities of a chylous fluid......................................Roberts. 83 Case LXVH.—Lymphatic elephantiasis of the scrotum and of the thigh...........................................Verneuil. 85 Case LXVIII.—Local affection of the lymphatic system___Carter. 98 Case LXIX.—Great enlargement of the whole of the right lower ex- tremity, with at times a flow of milky-looking lymph from be- hind the ankle; lymphatic engorgement...........Cholmeley. 101 Case LXX.—Makroglossia and pathological new formations of stri- ated muscular fibre................................Virchow. 104 xii Contents. PAGI Case LXXL—Makroglossia and makrochilia.............Billroth. 108 Case LXXIL—By Billroth, under same title...................... 1UB Case LXXIIL—Lymphatic tumor.........................Broca. 109 Case LXXIV —Lymphangioma...........................Lucke. 112 Case LXXV—Lymphangioma cavernosum adnatum in a boy two months old......................................Hofmokl. 112 Case LXXVL—Congenital lymphangioma cavernosum cysticum in an infant aged one year and five months.............Reichel. 113 Case LXXVIL—Tumor cavernosus lymphaticus........Gjorgjewic 114 Case LXXVIIL—Fibroma molluscum, large, pouch-like tumor upon the anterior side of the thorax; removal by galvano-cautery. Recovery............................................Bryk. 115 Case LXXIX—Elephantiatic pediculated tumor of left labium majus. Removal by gcraseur. Recovery................Bryk. 116 Case LXXX.—Congenital elephantiasis of the labia majora in a child eighteen months old. Extirpation. Recovery...........Bryk. 117 Case LXXXI.—Lymphangioma fibrosum. Enucleation of vaginal fibroids containing lymphatics.....................Chadwick. 119 Case LXXXII.—Elephantiasis or lepra Arabica............Hecker. 121 Case LXXXIII.—Elephantiasis Arabum congenita, with plexiform neuromata.........................................Czerny. 124 Case LXXXIV.—Lymphangioma, with general enlargement of limb and elephantiasis of toes..............................Jones. 132 Case LXXXV.—Chylangioma cavernosum...........Winiwarter. 139 Case LXXXVI.—Elephantiasis mollis congenita.............Cuny. 144 Case LXXXVII.—Deformitiy of feet............Toledo Med. Asso. 145 Case LXXXVIII.—Lymphangioma......................Petters. 148 General Remarks............................................ 163 Treatment................................................... 166 ILLUSTRATIONS. PAOX Figure 1.—Hypertrophied right lower extremity, exhibiting the lobu- lated arrangement of the panniculus adiposus, and two nipple- shaped elevations on the anterior inner aspect................. 9 Fig. 2.—Corresponding limb of same child........................ 9 Fig. 3.—Exterior aspect of the limb represented in Fig. 1, exhibiting a group of depressible vesicles, communicating through a common dilated lymph-vessel....................................... 10 Fig. 4.—A view of some of the vesicles........................... 11 Fig. 5.—Exhibits the dismembered limb, greatly diminished in size. The lobules are shrunken and flabby.......................... 14 Fig. 6.—Another view of the same, exhibiting the sub-peritoneal tumor, consisting of five cysts............................... 14 Fig. 7.—Microscopic section of the nipple-shaped body exhibited in Fig. 1.................................................... 17 Fig. 8.—Microscopic section of the integument covering the vesicles shown in Fig. 3............................................ 17 Fig. 9.—Extraordinary enlargement of right lower extremity, divided by deep fissures into lobes................................... 19 Fig. 10.—Enlargement of lower half of the left thigh, and the leg and foot. The swelling below knee divided into lobes by deep fissures.................................................... 20 Fig. 11.—Truncated enlargement of right leg and foot. The hyper- trophied part divided by fissures into three tumors............. 21 Fig. 12.—A fetus with a tumor occupying the entire vault of the cranium, and parts of the face and neck...................... 22 Fig. 13.—The lower half of a fetus, exhibiting hypertrophic enlarge- ment of both lower extremities, the right exhibiting abnormal development of the veins, and the left excessive adipose develop- ment ..................................................... 26 Fig. 14.—Enormous enlargement of right lower extremity, the subcu- taneous tissue being occupied with spongy, erectile, venous cav- ernous tissue............................................... 27 xiv Illustrations. PAGE Fig. on page 29 represents a cavernous bloody angioma, hanging like a sack from the occiput. Fig. 15.—Enlarged and lobulated right arm...................... ow Fig. 16.—Skeleton of a foot..................................... °* Fig. 17.—Enlarged left foot, with lipomata on plantar and dorsal surfaces................................................... Fig. 18.—Enlarged toes on left foot.............................. 35 Fig. 19.—Enlarged fingers on left hand........................... 36 Fig. 20.—Enlarged right leg.................................... 37 Fig. 21.—Different parts of a deformed foot...................... 38 Fig. 22.—Deformed hand:...................................... 39 Fig. 23.—Enlarged left upper extremity with enormous enlargement, due to hypertrophy of all the tissues.......................... 40 Fig. 24.—Deformed left hand................................... 41 Fig. 25.—Deformed thumb and index finger...................... 42 Fig. 26.—General hypertrophy of left leg, with irregular tumefac- tions, and a large tumor on the plantar surface of the correspond- ing heel................................................... 47 Fig. 27.—Enormous hypertrophy of index and middle fingers. The latter elongated............................................ 48 Fig. 28.—Enlarged and distorted right thumb..................... 48 Fig. 29.—Hypertrophied and elongated fore, middle, and ring fingers of right hand.............................................. 49 Fig. 30.—Hypertrophied and elongated thumb, fore and middle fin- • gers of left hand........................................... 50 Fig. 31.—Colossal enlargement of right lower extremity. Commencing hypertrophy of left hand. Nsevoid formations on sternum and right arm................................................. 58 Fig. 32.—Extraordinary enlargement of both hands. (Same case as Fig. 31.).................................................. 60 Fig. 33.—Lymph varix, with escape of milky fluid, situated on thigh, near inguinal flexure....................................... 62 Fig. 34.—Right lower extremity covered by a mass of twisted and contorted lymph varices..................................... 63 Fig. 35.—A mass of dilated and twisted lymph-vessels extending from the pelvis to the diaphragm............................ 75 Fig. 36.—Abdomen studded with cutaneous vesicles, from which, when pricked, a milky fluid was discharged................... 83 Fig. 37.—Section of the integument of an elephantiatic foot, exhibit- ing the development of lymph-vessels in the papillae of the skin. 95 Fig. 38.—A " lymph scrotum," with enlargement of the inguinal glands, and a discharge of a milky fluid.................... 98 Fig. 39.—Microscopic appearance of the fluid discharged in the case above................................................ gg Illustrations. xv PAGE Fig. 40.—Longitudinal section through the ablated portion of a hy- pertrophied tongue, exhibiting its cavernous structure.......... 105 Figs. 41 and 42.—Microscopic views of the same as Fig. 40.....106, 107 Fig. 43.—Large cavernous chest tumor: its surface covered with sec- ondary nodules; numerous smaller growths upon different parts of the body.................................................. 115 Fig. 44.—A cluster of larger and smaller nodes springing from the labia majora, consisting of aloose, finely-meshed, connective tissue 117 Fig. 45.—Vein of the same after extirpation....................... 118 Fig. 46.—Large cystic tumor on back, extending from scapulae and involving the buttocks; also numerous smaller nodes on other parts..................................................... 121 Fig. 47.—Enormous tumor extending from the last dorsal vertebra, and hanging like a sack below the popliteal space............. 124 Fig. 48.—Another view of same as Fig. 47........................ 125 Fig. 49.—Nerve tumors......................................... 127 Fig. 50.—Microscopic section exhibiting caverns lined with endothe- lium...................................................... 128 Fig. 51.—Lymph-vessels injected................................ 129 Fig. 52.—Varicose lymphatics of thigh........................... 133 Fig. 53.—Enlargement of right lower extremity, with lobulated ar- rangement of panniculus adiposus........................... 145 Fig. 54.—Enlargement of right nates and right lower extremity..... 146 Fig. 55.—Front view of both lower extremities of same case as Fig. 54 147 Fig. 56.—Thigh of a female, with a group of cutaneous vesicles dis- charging a milky fluid..................................... 150 CONGENITAL OCCLUSION AND DILATATION OF LYMPH CHANNELS. INTRODUCTION. The selection of a title which would convey succinctly and completely the purport of this essay has been attended with serious perplexities. Brevity, always desirable, could not be secured in any single technical word. Lymphangiectasis,1 em- ployed by Thilesen in 1856, by Petters in 1866, and by Weber in 1872, sufficiently indicates the characteristic morbid condition of their respective cases; but I propose to consider the phe- nomena of occlusion as well as of dilatation of lymph channels. When the case numbered one first came under my observation, on the 8th of July, 1874, it was so novel and anomalous to me, that I neither knew by what nosological term to designate it, nor did I appreciate the significance of the associated morbid phenomena. The venous teleangiectasis,4 and the hypertrophy of the soft and bony tissues were, apparently, obvious enough; but not until it was suggested by Dr. J. S. Billings, did it occur to me that the vesicles were, probably, the dilated extremities of lymph channels. Subsequently, with the assistance of Dr. J. J. Woodward, so kindly proffered, and after a somewhat ex- tended research in the library of the Surgeon-General's office, 1 Dilatation of lymphatic vessels. 1 Dunglison, " Dilatation of far or capillary vessels ; " Hebra, " A tumor con- sisting of dilated and newly formed capillaries and finest divisions of cutane- ous vessels, and arising in the course of extra-uterine life ; " Rokitansky, " A network of enlarged capillary vessels, embedded in a delicate and partly un- developed cellular tissue, usually congenital, but may be acquired." 2 Congenital Occlusion and I concluded that the case belonged to some one of the forms of congenital elephantiasis; but the manifest and paramount in- volvement of the lymphatics, together with the further tact that elephantiasis was not a uniform characteristic of lymphatic teleangiectasis, and, like others of the associated phenomena, might be either congenital or acquired, excluded the case from the category of elephantiasis proper; and believing then, as subsequent investigation has demonstrated, that the essential features of the morbid conditions consisted in the occlusion and dilatation of lymph channels, I could not accept the elephantiatic development as the primary and predominating condition. Desjardinsx claims, though I think Demarquay is entitled to the honor of first having applied the word lymphorrhagia, signifying " a discharge of lymph from a lymphatic vessel, owing to a lesion of its coats; " but it, like the word lymphorrhcea, signifying " the escape of lymphatic fluid by spontaneous rup- ture or accidental wound, producing a fistulous opening of the lymphatic vessels," is only applicable to an occasional phe- nomenon. Lymphorrhagia has been generally employed to designate those cases in which lymph escaped through a wound, either accidentally or intentionally made, and, hence, may or may not be associated with either dilatation or occlusion of lymph chan- nels. Lymphorrhcea has been usually used to indicate the transudation of fluid through the walls of dilated and distended lymph vessels, and whether it indicates either the escape by transudation," or by spontaneous rupture, it is associated neces- sarily with either stegnosis or distention, and perhaps with both conditions of lymph channels. In its broadest signification it simply implies the spontaneous flow or escape of lymph, a phenomenon but rarely associated with dilatation and distention of lymph channels. Angiomata3 includes " those pathological alterations of the skin which consist either wholly, or in great part, of perma- nently enlarged and newly formed vessels," and may be "divided 1 Demarquay's case was published in 1853, Desjardins1 in 1854. 2 Demarquay applied lymphorrhagia to an intermittent, and Zambaco the word lymphorrhcea to a continuous flow. 3 Hebra, Diseases of Skin, vol. iii., p. 338. Dilatation of Lymph Channels. 3 into those which contain blood-vessels and those which contain lymphatics ; " hence lymph-angiomata would concisely indicate such alterations involving the lymph vessels of the skin—a dis- trict, in one sense, too limited for our present purposes, and, in another, inviting us into the limitless field of investigation in regard to " newly formed vessels." Elephantiasis may be either congenital or acquired, and may be associated with lymphangiectasis. Elephantiasis arabum, as defined and delineated by Hebra,1 presents in the varied as- pects of its development, progress, and symptomatology, many features analogous to those presented by occasional cases of lymphatic teleangiectasis. It is essentially an hypertrophy of the fibrous tissue of the cutis and of the subcutaneous con- nective tissue, affecting primarily the latter, and followed in the progress of further development by an increase in volume of all locally implicated, adjacent organs and tissues, caused by local disturbance of the circulation and chronic recurrent inflammation of the vessels and lymphatics. Some have, indeed, maintained that it was a disease of the lymphatics. Whether viewed as a disease primarily involving the lympha- tics, or implicating these vessels only in its development and progress, its objective features are so interwoven with lymph- stasis and lymphangiectasis that it is not always easy to deter- mine whether the lymphatics or the connective tissue of the skin was primarily affected, and it is not improbable that occlu- sion and dilatation of lymph channels may eventuate in the development of elephantiasis arabum. Virchow has applied the term elephantiasis teleangiectodes, and Hebra* the word lymphangiectodes, to a form of congeni- tal hypertrophy, usually occurring in acephalus and other non- viable monsters, and, occasionally, in viable children, which consists in lobulated cutaneous tumors " confined to a few localities or to one region of the body," and involving princi- pally the subcutaneous connective tissue and the blood-vessels of the corium, and which may remain without alteration in size or condition during life, or may become diffused and de- velop into a monstrous deformity, occasionally involving the 1 Loc. cit., p. 134. 8 Hebra, loc. cit., p. 159, vol. iiL 4 Congenital Occlusion and whole or a greater part of the entire body. Notwithstanding the remarkable participation of the blood-vessels in the morbid process, which, if communicating freely and extending into tne cutis, may result in the formation of vascular spongy tumors (" lobulated vascular fungus " of Schuh), or by free anastomosis, and amalgamation of the individual blood-vessels form blood cavities (the " cavernous blood tumors" of Rokitansky), the essential histological and clinical features of the affection clas- sify it as a variety of elephantiasis arabum. In this, as in other forms, the connective tissue is primarily affected, and as the morbid growth may predominate in the blood-vessels or in the connective tissue, so will the hypertrophied mass partake of the nature of a true elephantiasis or of a " vascular spongy tumor," or " cavernous blood-tumor." In addition, the mani- fest evidence of the implication of the lymphatic apparatus is found in the " slits, gaps (Kaposi) cystoid spaces—dilated lymph spaces " observed in the masses of connective tissue; but this pathological condition is not the predominant or char- acteristic feature, and this circumstance, together with the fact that the manner of formation of the blood cavities or blood spongy tumors is yet in controversy—one view maintaining that they are new growths, and the other that they are the re- sult of morbid changes taking place in existing vessels or structures,—necessarily renders the term inapplicable to the purpose in view, and would extend the limits of the inquiry beyond the prescribed boundaries. Rejecting, then, these several appellations as inapplicable, for the reasons set forth, and as inadequately expressing the precise purport of this memoir, I have adopted the one upon the title-page, which, I think, conveys to the mind distinct pathological conditions of the lymph channels, and is suffi- ciently comprehensive to include all that is essential to the study of the nature, etiology, and treatment of those conditions. While the purpose has been to limit the investigation to dis- tinctly defined conditions of the lymphatic apparatus, the rela- tion existing between elephantiatic development and occlusion and dilatation of lymph channels is so intimate, that it is impossible to draw a line so definite and distinctive as to ex- clude from consideration certain cases and varieties of elephan- tiasis; and if such a separation were possible, it would neces- Dilatation of Lymph Channels. 5 sarily impair the opportunities for study and the value of the deductions. Elephantiasis arabum is divided by Kaposi into two forms— Elephantiasis arabum cruris and elephantiasis of the genitals, which are markedly distinct from one another. Further di- vision is made by Virchow, into elephantiasis dura, in which the whole mass of the soft tissues of the affected part seems to be converted into connective tissue, which is not only increased, " but is made up of stiff, glistening, white fibres, and is very firm, almost scirrhous; " l and elephantiasis mollis, which is characterized by a uniformly soft and gelatinous condition of the tissues. These latter forms Kaposi insists are not distinct diseases, but simply indicate different consistencies of the hy- pertrophied structures. E. A. C. is a local disease, affecting isolated portions of the body, more rarely symmetrical parts, usually confined to one or both legs, most frequently to the right. Its immediate cause is an inflammation of the derma, involving the blood-vessels and lymphatics or primarily the lym- phatics, accompanied with effusion and resulting in hypertrophy, primarily beginning in the subcutaneous connective tissue, which may extend to and involve all the constituent soft tissues of the affected part and the bony structures. The fluid effused is believed, by Tilbury Fox, to be lymph, and by Kaposi to be a fibrinogenous substance, possessing a quantity of formed ele- ments like those of lymph. It coagulates on exposure to the air, and when first effused is slightly milky. Containing formed cells in great abundance, which are the most important mate- rial for the production of new connective tissue, it is readily understood why the hypertrophy commences in that tissue. The effusion is the result of the occlusion or obliteration of the lymphatics, consequent upon the inflammation ; and though there is a contrariety of opinion in regard to the condition of the lymphatics, it is generally conceded that the lymphatic vessels and lymph spaces are dilated, and in them, lymph, rich in connec- tive-tissue-forming elements, is stagnated. In the midst of the newly formed and dense connective tissue, cyst-like spaces filled with nutritive plasma, are not infrequently found, which are believed to be cystic dilatations of lymphatic vessels. Occa- 1 Hebra, loc. cit., p. 140. 6 Congenital Occlusion and sionally vesicles are formed upon the surface of the hypertro- phied part, containing a clear or milky fluid, which, escaping by puncture or spontaneous rupture, coagulates on exposure to the air, and is believed to be lymph. The vesicles are the dilated extremities of lymph channels. The blood-vessels, especially the veins, are involved in the morbid process. They are more numerous and of larger calibre, with sometimes thickened and sometimes thinned walls, and occasionally the smaller become occluded with coagulated fibrin. In elephantiasis of the genitals, erysipelatous and lymphan- giotic attacks of inflammation have been very rarely observed, never in cases attacking the scrotum; yet the macroscopic and microscopic observations are analogous to those of E. A. C, and find their cause in long-continued stagnation of the lymph in the interstitial lymph spaces. It is only during the later stages that the hypertrophied and dilated lymphatics rupture and lymphorrhcea takes place, and, as in E. A. C, cyst-like lymph spaces are found. It must therefore become manifest that, to completely grasp the issues involved, certain cases, though not presenting the uniform clinical and pathological characteristics of elephan- tiasis arabum, are certainly well-defined instances of some form of the disease, and cannot be excluded from consideration in connection with an investigation into the causes and nature of occlusion and dilatation of lymph channels. To these have been added a number of cases of congenital giant growth, with the view to more clearly illustrate some of the anomalous features presented by some of the cases, and to complete the opportunities for the study of the subject. congenital occlusion and dilatation of lymph channels. These abnormalities present themselves in various forms, and in association with very varied conditions of tissue develop- ment; usually they are complicated with some one of the many varieties of so-called congenital elephantiasis, which may be either a concurrent or consecutive phenomenon. Congenital elephantiasis may involve an entire extremity or may show itself at many places (Virchow) of the surface of'the Dilatation .of Lymph Channels. 1 body, either in the form of regular enlargements, involving a portion of an extremity or of the trunk, or in the form of tumors, either solid or cystic, " rising in larger or smaller masses upon the surface of the skin." Elephantiasis arabum is a condition which regularly com- mences with inflammatory processes, similar in character to erysipelas, in which the lymph vessels participate, and consists in the development of connective-tissue masses, which originate in the interior of the affected parts, and proceeds from a hy- perplasia of pre-existing connective tissue. The condition of the newly-formed connective tissue varies, and Virchow distin- guishes, according to its greater or lesser density, elephantiasis dura and elephantiasis mollis. For the most part the congenital forms belong to the variety of elephantiasis mollis, which, when carried " into after-life, is always partial, and does not present that lardaceous, tendinous hardness "—sclerosis, which belongs to the acquired forms. In such cases the principal seat of the change is usually in the subcutaneous tissue, and the result varies according as the mor- bid alteration begins sooner or later in the intra-uterine life. If the fat-tissue (Virchow) has already been developed, the ap- pearance is not unlike a polysarcia; if the change begins when the mucous tissue still lies under the skin, then a more or less loose, soft, sometimes gelatinous, tissue continues to exist.1 There are also other peculiarities which belong to the con- genital forms of elephantiasis mollis. The parts imbedded in the connective tissue undergo hyperplastic development, and the morbid process may involve the vessels, nerves, muscles, and even extend to the bones. The blood-vessels, most usually the veins, and the lymphatic vessels, may reach a colossal devel- opment, the enlargement taking place both in length and breadth, forming, occasionally, a varicose network, or a rosary- like dilatation, or presenting a cavernous condition. Not infrequently, in the congenital forms, the tumors, nodes, and enlargements present a cystic formation, which Virchow and Billroth2 maintain proceeds from dilated lymph channels, though it is not always easy to trace a direct connection. These cysts or caverns contain a lymphoid fluid which, microscopically •Virchow, Onkologie, vol. i., p. 316. 2 Beitrage zur Path. Hist., p. 215. 8 Congenital Occlusion and and chemically, so closely resembles lymph, in all its essential characteristics, as hardly to admit of any doubt of their origin in dilated lymph vessels or spaces. The purpose here is to group together all such cases of con- genital elephantiatic development, co-existing with cystic or cavernous formation, and such other congenital cases as more distinctly exhibit, primarily, abnormalities of lymphatic vessels, with the view of studying the condition of the lymphatic chan- nels and the relation which such alterations bear to the asso- ciated tissue changes. Case I.—On the 8th of July, 1874, I was called to see an infant, four days old, presenting a form of congenital disease, as hereafter described. O. K., the father, aged 37, a strong, healthy, but not a robust man, of sallow complexion, had enjoyed excellent health all his life, ex- cepting an occasional attack of intermittent fever, and a single attack of gonorrhoea, five years previously. The mother was 26 years old; always healthy, robust, short stature. Had borne four children, three by the present husband, one of which died at the age of six months of " summer diarrhoea." The three living children were aged, respectively, five years, two years and six months, and the infant, the subject of this report. The two older children were healthy, well grown, robust, and represented by their parents as having been healthy from birth. No traces of syphilis, either in the parents or children, could be discovered. Both parents white ; the mother Irish and the father of German descent. The infant was born at full term, after a brief labor, unattended by any unusual occurrence. The colored midwife, in attendance, in- formed me that the presentation was head, and the cord was not wrapped about the neck or lower extremities of the child. At the time of my visit the mother was doing well, and had a remarkably favorable puerperium. She worked much during her pregnancy on a sewing machine, using the right foot on the pedal, to which circumstance she attributed the affliction of her infant; adding, as a confirmation of her theory, that during the latter months of her pregnancy her right leg (corresponding with the diseased member of the child) was much swollen, and about which appeared several purplish spots. At the time of my visit the swelling had disappeared, and the purplish spots were recognized as very slightly varicosed veins. The infant, excepting the anomalous condition hereafter to be de- scribed, seemed well, slept well and quietly; nursed; bowels acted naturally; passed water as is usual. The cord separated on the fourth day, stump healthy; color of skin natural; tongue clean; cry not peculiar; pulse, counted during sleep, 120; respiration natural, quiet, and easy; inflation of lungs complete; temperature in rectum 98.4. Dilatation of Lymph Channels. 9 The comparative sizes of the sound and diseased leg are very dis- tinctly brought out by inspection of figures 1 and 2. The following measurements were taken August 2, 1874:' Healthy leg at groin, 1\ inches; at calf, 5 inches. Unsound " " 11£ " ' « 7 " No difference in length. The hypertrophy on the inside began at and involved the right pudendal labium, and extended throughout the leg, but proportionally less in the foot. The folds of the soft parts, with the flexures dipping deep towards the bones, with their surfaces closely coaptated, as if firmly pressed together, are well represented in Fig. 1. These folds, like the other portions of the Fig. 1.—Eepresents the inner aspect Fig. 2.—Represents the left or of the right leg. sound limb. soft parts, yield a firm, inelastic sensation, neither indurated nor oedematous. Firmer than normal flesh of so young an infant. The partial sclerosis is uniform, and invades all the constituent tissues of the soft parts. The covering integument of the folds, as it is of the entire limb, excepting as hereafter described, is in appearance normal. It cannot be pinched up, and is less movable than the natural skin Those taken July 8th lost, but believed not to differ materially. 10 Congenital Occlusion and over other parts. Does not pit on pressure; to a limited degree Bcleromatous, but not presenting the horny hardness smootn smn- ing. yellowish or waxy hue, dense and parchment-like leel, ana diminished temperature so characteristic of scleroderma. iher« ls n0 dermatolysic growth. At the base of the third flexure—the only one Fig. 3.—Represents the outer aspect of the diseased leg. below the knee—is seen a projecting body, which seems pendant from the apex of this flexure; but this is the vesicle represented at the base of the third flexure (see Figs. 1 and 3), as seen on the inside of the leg, and second as seen on the outside. The external edges of this flexure (second on outer aspect, see Fig. 3) are separated by the thin bevelled edge of a fleshy fold, which gives it the appearance as if two flexures (the middle and third on the inside) had terminated in one on the outside. Immediately anterior to the third flexure (Fig. 1), near its apex, and midway between this point and the anterior margin of the tibia, is situated a nipple-shaped tumor, and farther toward the same an- terior margin, and approaching nearer the knee-joint, another is located, similarly shapen, but less globular, with several depressions near its apex, at the bottom of each of which is a minute bluish- colored spot. Both these tumors are covered with the epidermis and cutis vera, are of a pale bluish-white color—the blue tinge deepening at several points, thus presenting indistinctly the appearance of a superficial vein. ^ These bodies are near the size of a female nipple ; contain fluid, which can be pressed from them, but they refill imme- diately upon the withdrawal of the pressure. Farther up the limb, on the inner aspect of the knee, between the patella and the apex of the middle flexure, is located a subcutaneous cyst* (see Fig. 1) measuring one inch in diameter at base, and three-fourths of an inch from apex to base, movable to a limited extent, and covered by normal skin, 1 At my visit, August 2d, accompanied by Dr. J. J. Woodward, neither of us could discover any trace of this cyst-like body. Dilatation of Lymph Channels. 11 which slips easily over and about it. It cannot be diminished by pressure. The small dark spots between the middle and third flexures and the nipple-shaped bodies, those below the third flexure, and the one below the tarsal flexure, are, in the living subject, bluish-colored puncta, like venous blood seen through a thin and anaamic integument. The tibia appears very much enlarged and illy-shapen; the femur seems natural in size. All -the joints are normal, though the ankle, in consequence of the hypertrophy of the surrounding soft tissues, and, in a measure, due also to the enlargement of the tibia, presents an awkward appearance, looking as if the bones of the leg were dis- located backward from the tarsal articulation; but a careful examina- tion of the joint failed to discover any abnormal condition or location of its articulating surfaces. The motions of the limb are perfect; the child moves both limbs alike, and does nob manifest pain from manipulation. On the outer side (Fig. 3) the hypertrophy commences at the small of the back, extending downward, but not crossing the spinal column, and involves the entire right buttock and right side of the leg. In this figure the anterior margin of the limb, and the awkward appear- ance of the ankle, are accurately drawn. The spot just above the apex of the second flexure is a superficial nsevus ; another, larger, is located higher up on the right buttock ; a third, still larger, is situ- ated just below the second flexure on the calf, and a fourth on the antero-lateral aspect of the ankle. The ends of the third and fourth toes are purple colored. The middle fold presents a broader apex surface, and the third is absent from this view. The flexure below the knee does not appear on the outside as a distinct one. Below the middle flexure (second, as seen in Fig. 3), on the outer and posterior surfaces of the right calf, is a cluster of vesicles—bladder- like, varying in size. (Fig. 4.) The largest is not greater than the end of the little finger. One is located in the centre of the nsevus, and others around its border. All these vesi- cles are covered with epidermis dis- tinctly marked with minute ramify- ing venous radicles. These vesicles, including the one rising through Fig. 4. the centre of the nsevus, are semi- translucent ; contain a serous colored fluid; can be inverted by very gentle pressure; communicate one with another and apparently with a subcutaneous cavern. When any one of them is emptied and its investing epidermis is inverted, by pressure, one or more of the remaining filled vesicles become fuller and tense with the accumulated fluid. Upon removal of the pressure the emptied and inverted vesi- cle refills and gradually returns to its previous condition and form. When inverted the sensation of a circular firm rim, with a well-de- fined sharp edge, is communicated to the touch. No communication exists between these vesicles and the nipple-shaped tumors on the 12 Congenital Occlusion and inside of the leg. The fluid in the vesicles is serous. About this group of vesicles, especially along the margin of the inlying nsevua, are a number of very small purplish puncta, and many cicatricial- looking spots, which the attending midwife alleges were vesicles, like those above described, but now emptied and contracted. She claims to have counted forty vesicles immediately after birth ; but both state- ments are discredited. Above this group of vesicles, nearly midway between them and the outer margin of the patella, a large vein, repre- sented by the dark wavy line in the cut, approaches the surface. To the touch it feels like a groove, with distinct and firm edges. No com- munication can be made out between it and the nipple-shaped bodies. Nov. 4th, 1874.—The child has continued to enjoy, uninterrupt- edly, good health; has not been sick a day since its birth. To-day, four months old, it weighs seventeen pounds; is bright, playful, and hearty. The measurements of the limbs are as follows ; Bight. Left. Around calf,.......9£ inches. 6| inches. Thigh, upper fold, .... 14 " 10 " Ankle,.........7f " ty " Right leg one-half inch longer than the left. April 4th, 1875. Eight. Left. Around calf,...... 1 i inches. 6£ inches. Thigh, upper fold,.....16 " ll| «« Ankle,........ 9 " 4£ " April 4th, 1875.—Right leg one inch longer than left; right foot one-half inch longer than left; two teeth. Healthy, thin. Hyper- trophied parts, soft, flabby ; integument less firm. Mother menstru- ating regularly since November. Child passes an unusual quantity of urine. In the foregoing description I have endeavored to correctly repre- sent the coexisting morbid phenomena presented by this somewhat remarkable case, as they were observed during the lifetime of the unfortunate child. The subsequent details of the post-mortem ex- amination will not verify these observations in every particular During the winter of 1874-75 the child suffered severely from a protracted attack of whooping-cough, which only entirely disappeared during the milder spring weather, leaving no other effect than loss of strength and some emaciation. During the ensuing months of May and June she suffered from several attacks of catarrhal diarrhoea, fol- lowed by increased debility and emaciation. These diarrhoea! attacks were always accompanied with marked diminution of the size of the dis- eased limb; the buttock and lobular masses became much softened, and the thickened integuments flabby. In the early part of July after haying been improperly fed upon blackberries^she was seized again with diarrhoea, more severe than any preceding 7+ Z£ T I resisted treatment, increased in intensity! Z'l^ ^'^t Dilatation of Lymph Channels. 13 entero-colitis, marked by stools varying in frequency and consistency, more or less mixed with blood, straining, abdominal tenderness, fever, and prolapsus ani. Occasionally the dejections were exclusively blood, never exceeding in quantity a drachm, though during several days this quantity was evacuated several times.1 Her appetite con- tinued moderately good. With intervals of apparent improvement, succeeded by more aggravated symptoms, she continued to suffer, losing strength and emaciating rapidly until August 12th, when she sank into collapse and died, aged one year, one month, and eight days. Autopsy forty-eight hours after death* Body very much emaciated, no cadaveric rigidity. Eight incisor teeth, anterior fontanelle very large. Measurements. Right Leg. Left Leg. From anterior superior process of ) , incheg fi} incheg> ilium to middle of patella, . . ) From middle of patella to internal \ a u cs « malleolus,.......f " to external malleolus of right leg, 6^ " Circumferences. Middle of thigh,....... 7 " 5f " Buttocks, .........12£ " 7| " Knee, .......... 8 " 6 Calf, ..........' 8 « H " Malleoli,..........5| « 4 " Tarsus,...........4£ « 4 Length of foot,........3| " 4 " Length of cadaver from occiput to ) „u « qq a the plantar surface of heel, . f 4 The following cut (Fig. 5) is from a photograph of the dismembered limb, and exhibits the relative shrinkage of the hypertrophied parts. The covering integument of the buttock hung in large flabby folds, which could be raised and moved as if unattached to the subjacent tissues. Beneath were several empty caverns, varying in size, and lined by an irregular jagged surface, seemingly made up of very small fat globules, thickly interspersed with minute cysts, mostly not larger than a pin's head. Several times during the progress of the intestinal disease, and once previously, following what she considered a very copious diure- sis, the mother called my attention to the apparent diminution of the rump and to the looseness of the skin, which led me to suspect the existence of lymph caverns. The sensation in several places was dif- ferent from that of a solid mass, but at no time could I detect fluctu- ation or cause diminution by firm and continuous pressure. 1 I suspected, from the repetition of this hemorrhage, some abnormal condi- tion or arrangement of the pelvic blood vessels, but none was discovered. * Present, Drs. Drinkard, Lamb, Healey, and Kleinschmidt. 14 Congenital Occlusion and The measurements last given were made from the limb as shown in Fig. 5. Heart, lungs, liver, kidneys, and spleen healthy ; stomach failed with a whitish gruel-like fluid; mesenteric glands enlarged; blood- vessels of mesentery engorged. Peyer's patches were enlarged ; folli- cles distinct and prominent. In the large intestines, the glands were ulcerated, intestinal walls large and translucent. On the right side, extending from the fourth lumbar vertebra (dis- placing the right kidney, pushing its convex outer surface up against Fig. 5. Fig. 6. the liver, into the under surface of which the kidney has made a marked depression) was found an extra-peritoneal tumor, which filled two-thirds of the false and true pelvis. This mass appeared like a number of the convolutions of the large intestine agglutinated to- gether and in a gangrenous condition. It was firmly attached to the bodies of the lumbar vertebra, fascia of right psoas muscle, along the crest of right Hum and right horizontal ramus of the pubis, to the fascia of the false and true pelvis and to the perineum The caecum Dilatation of Lymph Channels. 15 was displaced to the left side, and the rectum pushed far to the left of the median line. Uterus and bladder normal, and in natural posi- tion. Right ovary lying upon the anterior surface of tumor, attached to it (but not fixed) by the broad ligament, between the layers of which the tumor seemed to be. This tumor, as imperfectly shown in Fig. 6, consisted of five cysts, each containing a thick brownish-red fluid, composed of blood corpus- cles, granular matter, and debris. Three of the cysts communicated through apertures in the intervening septa, the other two were com- pletely closed. The communicating cysts were emptied of their con- tents and filled with quicksilver, and the non-communicating were treated in a similar manner, without discovering any connection with the adjacent parts. The blood-vessels in the neighborhood of these cysts were tied above and below and injected with quick-silver, but no communication could be discovered between the cysts and any of the vessels. Their walls and the intervening septa were composed of dense fibrous tissue, and the anterior surface of the mass was covered by the peritoneum. None of the cysts were separate and distinct, but so arranged that a portion of the membranous wall of each was common to two or more cysts. These cysts are believed to be devastated lymphatic glands. The skin covering the hypertrophied parts was everywhere thick- ened. The subcutaneous connective tissue was vastly increased, contained but little fat, was wide meshed, with very many small cysts, some as large as a pea, filled with a serous fluid, Between the skin and superficial fascia, in several places, were smaller or larger cavities, containing clusters of small serous-like cysts, in every respect like those found in the meshes of the subcutaneous areolar tissue. One of these cavities, about the size of a filbert, was found in the locality of the cyst-like body on the inner aspect of the knee- joint ; upon the fascia forming its base was a thick layer of dark pigment. The muscles of the thigh and buttock were pale and flabby, and everywhere in the inter-muscular connective tissue, varying in size from a pin's head to a pea, were to be found the serous cysts. The muscles of the leg were of a deeper color and appeared normal. They were not atrophied. The arteries and nerves were natural. The veins on the outer and posterior aspects were hypertrophied—the external saphena, before referred to as the dark-bluish wavy line on the outer side of the knee, was very large. From it a large branch ran to the large nsevus about the cluster of vesicles, and there sub- divided into a number of minute branches. The posterior tibial was as large as a goose-quill, and, in the immediate vicinity of the nsevus at the ankle-joint, divided into a number of smaller branches. From it extended a branch as large as a crow's quill along the dorsum of the foot, sending large branches to the third and fourth toes, which were discolored. The vesicles contained a serous-like fluid. From one the pouch- like covering was removed, and in the base two small openings could 16 Congenital Occlusion and be seen with the naked eye, through which a lymph-like fluid could be pressed. One of the vesicles was incised, and into it a small funnel was inserted and secured, into which quicksilver was poured. All of the vesicles, with a single exception, quickly filled with^ the metal, and a number of the cicatricial spots developed into vesicles filled with the metal. From the same reservoir of metal the lym- phatic vessels were injected ; one dipping down between the muscles terminated in a dilated pouch-like sinus, another followed the course of the posterior tibial vein, sending off numerous branches along its course; and a third, probably the same trunk, ran upwards, but could not be traced far above the knee in consequence of the previous dis- section of the parts above. No communication between the superfi- cial and deep-seated lymphatics could be anywhere discovered—none of the latter being injected with the metal. After the most careful examination we failed to discover either tne receptaculum chyli or the left thoracic duct.1 Portions of the sub- clavian and jugular veins were removed and carefully examined sub- sequently, but no vascular connection could be recognized as the left thoracic duct. The right duct emptied into the right subclavian vein. Beneath the nipple-shaped bodies, in the superficial fascia, was found a spongy vascular tissue, which extended into the bodies, seeming to compose the entire mass, except the covering integument. The bluish-colored puncta, before described, were the terminal dilated ends of venous radicles. Figure 7 represents a vertical section of one of these bodies. Microscopic examination by Dr. McConnel. It shows a central sinus, which in the recent state contained blood, clots of which may be seen represented upon different parts of the wall. Surrounding this is well formed connective tissue, exhibiting no evidence of any inflammatory process; other views of the same section exhibited here and there small clots of blood completely walled in. Mucous tissue was also to be seen. The sub-papillary layer of the skin was exceedingly vascular, and the sweat glands were enormously hyper- trophied. Figure 8 represents a microscopic section (vertical) of the integu- ment covering one of the vesicles. These vesicles were simply pouches of skin containing lymph, their walls consisting of nothing (McConnel) but the components of the skin, with here and there newly formed connective tissue which encroached upon the cavity. The tibia was very slightly, if any, enlarged. The articulating sur- faces were normal. The discrepancy in the measurements of the foot are due to the fact that in one instance the measurement is made from the posterior surface of the fat cushion on the plantar surface (see Fi«r 3) and in the other instance from the posterior surface of the heel proper. »This dissection was made under unfavorable circumstances. The portion of the body represented in Figures 5 and 6 vras removed and examined after several days' immersion in alcohol. Dilatation of Lymph Channels. 11 Fig. 7. Fig. 8. 2 18 Congenital Occlusion and I have failed to find any record of a case precisely similar, in all of its features, to this anomalous one; but a number of cases have been published, both congenital and acquired, pre senting one or more of its phenomena. By applying the infor- mation to be derived from an examination of the reported cases, a satisfactory explanation of all the abnormal conditions may be reached. This method of study will involve the grouping together of the cases illustrating particular phenomena, and though the special inquiry relates to congenital conditions, it will be necessary, occasionally, to amplify the illustration, to introduce into the group instances of the acquired forms. The feature which first attracts attention is the extraordinary enlargement, and the singular preservation, in such a marked manner, of the natural flexures of the skin and subcutaneous adipose tissue. The natural furrows and indentations of the covering integument are usually exaggerated in similar hyper- trophic developments; but this peculiar arrangement of the en- largement only finds its analogy in the case, reported1 by Thomas Chevalier, of " extraordinary enlargement of the right lower extremity," following an attack of phlegmasia alba dolens. Case II.—Sarah Rogers, aged 46, had suffered with a continuous enlargement of the right leg, until finally it became so unwieldy as to prevent locomotion, yet the knee and ankle-joints retained as much flexibility as the enormous increase of substance surrounding them would admit ; motion was painless. The cut (Fig. 9) exhibits on the outer aspect of the limb the lobules separated by the furrows. Autopsy.—Hypertrophy confined to skin and fat tissue ; muscles slender and pale; bones and joints unaffected ; arteries not enlarged; no change in the inguinal or pelvic glands detected. The cutaneous papillie on the foot were enlarged and elongated into pendulous cones rounded at the end, each being supplied with an artery which ter- minated " in villi upon its surface." The development involved the greater part of the thigh and the entire leg and foot. It followed an inflammatorv process; was at- tended with a " copious and exhaustive transudation of serous fluid from the surface of the hypertrophied part," and it is probable that the fat masses were interspersed with minute inter-communicating cavities filled with similar fluid. Somewhat similar, though less extensive, was the " enlargement of the left lower extremity," in the following case, Fi<*. 10. •Med. Chir. Trans. Lon., vol. ii., p. 63, 1817. Dilatation of Lvmvh Channels. 19 Fig. 9. 20 Congenital Occlusion and Case III.'—A young man, aged 25. The limb measured below the knee two feet nine inches in circumference ; had attained its size very slowly and gradually, unattended with any pain or inflammation of the skin, the subjacent adipose tissue, or of the inguinal glands. The swelling involved the lower half of the thigh, leg, and foot; on the foot, as in Che- valier's case, it overhung the toes. Below the knee the enlargement was divided into lobes by deep fissures. On the thigh, above the swelling, the skin was loose and flabby; below it was thickened and scaly; in the fissures the cuticle was very thin and the skin was reddish and constantly moistened with fluid, great quantities of which were discharged. Both the knee and ankle-joints ^\ retained their flexibility. He could walk and run. Non-congenital. Case IV.2—A. C, set. 52. In her sixth year suffered from ophthalmia, from twelfth to fourteenth year from spondilitis lunibalis, resulting in kyphosis of lumbar vertebra, unaccompanied by paralysis. In her nine- teenth year the affection of the left leg ■pfe jq began, with violent burning pains night and day, followed soon by the appearance on the skin of the foot and leg of closely arranged, translucent vesi- cles, not larger than filberts, and hemispherical, which disappeared without rupture, leaving white spots. From this time the leg began to enlarge, and from several cracks in the skin a large quantity of a clear serous fluid exuded. These openings closed in six weeks, and subsequently the integument of the leg was repeatedly attacked with an erysipelatous inflammation, attended with rigors and loss of appe- tite. After each of these attacks the leg became larger, nodular pro- jecting tumors and deep transverse sulci formed. Later a large ab- scess formed on the anterior surface of the leg, which opened spon- taneously and discharged a large amount of black, stinking blood and pus, and then the thigh began to enlarge. Four years after, at the time of the ligation of the femoral artery, the measurements of the circumferences were as follows, in centimetres: Eight. Left. After ligation. Foot at base of toes, .... 24 25 23 Middle of foot,...... 22£ 30£ 26 Around malleoli,.....234- 32£ 274- Middle of leg,......31" 454. 33 Knee,.........33 47^. 34 Middle of thigh,.....47 544. 40 1 R. J. Graves, Dub. Hosp. Rep., vol. iv., p. 521, 1827. s Kappeler, Ohirurg. Beobacht. aus dem Kantonspital Munsterlinffen d 260 1865, 1870. ' Dilatation of Lymph Channels. 21 This reduction had been gained in six months* and remained the same four years afterward, in 1874. Case V.—J. P.,1 set. 28. With the exception of an attack of typhus fever in his twentieth year, had enjoyed good health untti six months previous to admission to clinic, when he had accidentally cut the sole of his foot, which apparently healed without trouble, but was followed in two weeks by a painful abscess, and afterward by a fever which lasted several weeks. Then the leg began to swell, and numerous abscesses formed on the dorsum of the foot and leg, which healed slowly. Four years after, the affected parts had reached the enormous size shown in Fig. 11, and appeared like a truncated coue, com- posed of three tumors, the upper one resting upon a deep furrow encircling the ankle-joint, another surrounding the heel like a horse-shoe, and a third arch- ing across the tarsus and extending to the toes. In the horizontal posture the tumors became softened and flaccid; when erect they became hard and tense. The inguinal glands were swelled and hard, and a systolic murmur could be heard in both extremities from the in- guinal fold to the apex of the inguinal triangle. Fig. 11. Anatomical examination of the am- putated limb.—The superficial and deep veins, which communicated by numerous branches, were dilated; the saphena by varices of walnut size, and, in the territory of the tumors, by larger sacs filled with dry plugs adherent to the walls. The walls of the larger veins were thickened, did not collapse on section. The nerves were thickened, the neurolemma injected. The hyperplastic integument was thickened, covered with a bristly epidermis, and when incised discharged copiously a clear fluid, which, after standing, loosely coagulated. The upper tumor posteriorly was abundantly supplied with fat; anteriorly it was mostly composed, as were the other tumors, of a white tendinous callous tissue, which fused with a thickened and vascular periosteum. The tibia anterior- ly was covered with osteophytes; its cavity was mostly ossified and filled with a reddish marrow. The hair follicles and sebaceous glands were atrophied ; the latter everywhere were filled with cells under- 1 Prof. A. Bryk, in Cracow. Oester. Zeitschr. fur pract. Heilkunde, vol. xv., No. xi., p. 325. For the opportunity of examining the reports of Prof. Bryk, I am indebted to Dr. Jacobi, of New York, who kindly placed at mj disposal the number of the journal above referred to. 22 Congenital Occlusion and going fatty degeneration. The sudoriferous glands were in sparse groups and atrophied. , _, The single fat lobes of the calf-tumor were surrounded by a fibrous capsule, which sent processes between the smaller lobes and spread between the single fat cells in the form of a regular network of anas- tomosing nucleated spindle cells, in the meshes of which the fat cells could be recognized. With increasing density of the connective tissue the fat contents of the mesh-cavities decreased and the fat cells became smaller. All the transitions from the soft fat lobules to the sclerotic fibroma—only containing fibrous trabecular tissue, but always preserving the areolar character—could be traced. The lymph vessels were very numer- ous, dilated, and formed nets with mesh spaces. The vascular periosteum was attached to the bone by an osteoid layer. The bone in places was har- dened. Case VI.—A foetus,1 between the fourth and fifth month, weighing two hundred and fifty grammes, and meas- uring in length eighteen and one-fourth cm., and around the thorax fourteen. The tumor, as represented in Fig. 12, occupies the entire vault of the cra- nium and parts of the face and neck, extending like a cape from the edge of the scapulae across the neck, over the vault on both sides as far as the root of the nose. Below the super- ciliary ridge it extended in a curved arch to the corners of the mouth and to the chin. At the edges of the scapulae and on the neck and sinciput it could be raised from the subjacent tissues. By furrows it was divided into a frontal, temporal, facial, and neck lobe. In the furrow separat- ing the neck and facial lobes the ears can be seen unconnected with the tumor. Along the saggital suture a furrow separates it into symmetri- cal halves. No other abnormities, excepting thickened lips, and a thickened soft integument, marked by numerous rugae and folds, was discovered. The cranial lobes were firmly attached to the bones, and the frontal and cheek lobes were softer than the neck lobes The tumor mass was thickly interspersed with minute caverns, and had its origin in the cutis and subcutaneous tissue, and consisted mostly of connective tissue of varying density, rich in cells and abundantly supplied with vessels. The cells were principal^ the sni^dlp *ru\ stellate forms. The fibres of the basic suitanc'e SSS £d variously interwoven, forming irregular fissures. These and the 1 H. Steinwirker, Dis. Inaug., Halle, 1872. Dilatation of Lymph Channels. 23 caverns were lined with endothelium and either empty or filled with a eoagulum enclosing lymph corpuscles. The blood-vessels were very numerous, interrupted with frequent varicosities and densely filled with discolored, brownish-yellow discs. The following analagous case, reported by Meckel,1 exhibits a different arrangement of the masses, and caverns of pea size and larger: Case VII.—A six-months, foetus,2 male. Entire head covered with a fleshy, spongy lump, which extended anteriorly, hiding the face, down to the chest, and stood out in sharp outline from the latter. The integument of the face, ears, extreme points of the fingers and toes, was fine and smooth; the rest of the skin showed gelatinous softening and augmentation of substance, and was interspersed with numerous caverns, some collapsed and others filled with lymph. At the points of the fingers and toes the transition of normal to abnor- mal integument was imperceptible; at the face, however, it was bounded by a fold-like reflexion. The line of demarcation passed over the lower part of the forehead down to the ear, then closely behind the latter downward and forward to the lower edge of lower maxilla, and around the mouth. At all these points the delicate in- tegument suddenly passed into the enormous mask-like integument. The largest sac-like tumors were over the cerebral portion of the head and in the lumbar region. The skeleton was regular in form ; bones, however, thin and cartilaginous. The firm, painless, non-compressible and non-fluctuating masses, separated by furrows in the integument, which mark the flexures of the skin and the ordinary form of development of the panniculus adiposus in the thigh of the newly-born, are mainly composed of fatty and connective tissues. The formation of these fatty enlargements into lobules, masses, or folds, not unlike, objectively, lipomatous developments, is in a measure due to that peculiar and normal anatomical arrangement and structure of the connective tissue of the skin which at the natural flexures and furrows is either directly connected with the superficial fascia, or there is at such places but very partial formation of the panniculus; and consequently, if any, far less and much slower accumulation of fat along the course of such furrows or indentations. In Chevalier's case and in my own, as is usual in similar cases of hypertrophic J Archiv f. Anat. and Physiol., 1828, p. 149. 8 Cited by Steinwirker, Dis. Inaug., Halle, 1872. 24. Congenital Occlusion and development, the skin was much thickened, hardened, and firmly attached to the subjacent tissue. In the latter case the hyperplasia and condensation of the connective tissue, which imparted to the skin its abnormal firmness and immobility, was also exhibited in the firm, sharp edges of the circular openings through the cutis vera, through which the fluid escaped into the cuticular vesicles and in the groved character imparted to the superficial vein on the outer aspect of the limb. In those cases where the hypertrophy is associated with con- current and recurring attacks of erysipelatous inflammation, the enlargement is probably circumscribed by the limits of the inflammatory processes. The extension of erysipelatous inflammation may be limited or hindered by the increased thickness and firm attachment of the skin to the underlying struc- tures, as about joints and along superficial bony margins, also by the borders of portions of the integument where the direc- tion of tension changes—the track of extension being usually in direction of the greatest tension of the portion affected. The extension may also be hindered by the natural flexures of the integument. It is, nevertheless, true that the panniculua adiposus, in its normal physiological development, presents a more or less lobular structure and formation, and when, as in Case 1, the enlargements are defined by the outlines of the natural arrangement of the lobular structure of the panniculus, it is more than probable that the hypertrophy is simply an ex. aggeration of the normal physiological development. The foregoing examples of the division of the abnormal enlargement into lobes by deep furrows exhibit no general law governing such formations. It is found in both the acquired and congenital forms, and in cases in which the hypertrophy is limited to the integument, as well as in those cases in which the subcutaneous cellular tissue and panniculus adiposus are involved. The joint-flexures are exempt or but partially in- vaded, and flexibility is only disturbed by the mechanical obstacle presented by the size and close apposition of the masses. In the case of cranial tumor (No. 6), the furrows cor- responded partially with the course of the sutures, the neck lobes were apparently limited above and below by the integu- mentary furrows formed by the lateral flexion of the head upon the neck and of the neck upon the trunk, and in front by Dilatation of Lymph Channels. 25 the trachea. In neither of the acquired cases where the foot was involved, was the plantar surface invaded. In those cases, among the acquired forms, where the disease began in the thigh or leg, and subsequently extended, sometimes after a very long interval, to the leg or foot, the extension was not by continuity, but by separate invasion of the parts above or below the neighboring joint. These circumstances would indi- cate that the localities of tendinous and aponeurotic attach- ments, where the fibro-areolar fascia is less abundant, or nearly absent, as in the plantar and palmar surfaces, and where the deep fascia, an inelastic and less yielding membrane, serves the purposes of insertion and protection, were less favorable for such developments than the regions abundantly supplied with the loose superficial fascia and panniculus adiposus. But the immunity of the plantar and palmar surfaces, as will be shown further on, only attaches to the acquired forms. The movements of the joints (which fortunately are usually painless), in those cases where the lobules encroach upon the flexures of the limb, and continuous flexion of the member during the progress of the development, as is the case with the extremities of the foetus in utero, must be important factors in determining the boundaries of the masses situated in the immediate vicinity of the joints. In the following case (No. 8) both knees were involved, and but a few superficial furrows were preserved. This child was born in vertex pres- entation, and the equable tumefaction of the left lower limb would imply that in ntero the knee-joint was extended; yet the partial preservation of the furrows at the knee-flexure and on the inner and posterior surfaces of the thigh would indicate that at least a position of semi-flexion was maintained. ^ The pressure, if thus maintained, would seem to have been sufficient to have partially preserved the natural furrows of the integu- ment of the thigh. But in Case 9 (Fig. 14), in which the enlargement involved the entire right lower limb, invading alike both the knee and ankle joints, the surface was marked by several deep " transverse dimples," which did not, however, correspond with the usual anatomical arrangement of the in- tegumentary furrows of the lower limbs of the newly born, as they are marked in cases where the lobular formation of the panniculus adiposus is well developed, or in excess, as in Case 1. 26 Congenital Occlusion and These cases (8 and 9) are also in contrast with the acquired forms, in that the hypertrophy has invaded both the knee and ankle joints. These discrepancies are probably due to different pathological conditions. Case VIII.1—Description from an alcoholic preparation of a child which lived 11 days, and died of icterus. Fig. 13. The child measured in length 46 ctms. Both legs were enlarged. At the ingui- nal fold the left measured 18 ctms., right 16 (in circumference), at largest part above the knee, the left 20, the right 12 ; at the ankle the left 14, right 9. Distance of right heel from crista ilium 25 ctms., to point of great toe 10 ; length of left foot 9. On the left leg were a few nodes of pea size, and bluish red. The skin was everywhere thickened, covered with woolly hairs and immovable. The sole of foot was thickened and convex. First three toes greatly enlarged, second and third webbed. Skin covering ankle knee, four smaller toes, and external sur- face of thigh bluish-red. The swelling was mainly due to the proliferation of the subcu- taneous cellular tissue ; adipose tissue only being demonstrated by the microscope, ex- cept upon the anterior surface of thigh, ball of great toe and sole of foot, where it was greatly augmented. Fat cells not en- larged. Muscles on abdomen pale, on thigh and leg brownish-red. Venous sys- tem abnormally developed. Femorals and saphena absent; but two large veins arose one from each side of the great toe, which in their ascent received numerous large branches. All were without valves. Two of the three globular tumors upon the inner side of the knee, the large tumor upon the external and the more diffused one upon the posterior aspect of the thigh were colossal venous cavities, filled with blood coagulated in layers and imbedded in brown connec- tive-tissue layers. The large tumor on dorsum of foot consisted of a perpendicu- lar chain of varices, which communicated with the tumors about the knee. In the right leg the venous system was normally developed; the arteries were alike in both and natural. The enlargement of the right leg was due o excessive development of the adipose tissue, and wherever on the left leg and buttock there was deficient, or, cer- 1 Specimen presented to Obst. Soc. Berlin h-p rw x> ^ of Dr. Martin. Monatschrift far GabaS^S lm%Z%.m^°' Fig. 13. Dilatation o* Lymph Channels. 27 tainly, no excessive development of the venous system, the adipose tissue was in excess. This specimen presented a co-existence of fibromatous and lipomatous degeneration, yet everywhere either locally excluded the other, the fibromatous existing in immediate association with the venous angiectasis. Hence the inference may be de- duced that the excessive development of the connective tissue resulted from an excessive supply and stasis of blood in varicose and valveless veins, and perhaps to that condition was due the difference in the form of the hypertrophy and its invasion of the tissues about the joints. This genetic relationship of venous stasis to connective tissue hyperplasia is more clearly shown in the two next succeeding cases reported by Thomas Smith.1 Case IX.—K. R. was born with right lower limb enormously en- larged. The limb maintained the same proportion to the rest of the Fig. 14. body for a time, and then grew in excess. At the age of nine months she was lively, healthy, and robust. The enlargement extended up to the groin, and, following the line of the crista ilium, extended back- wards, involving the right buttock. The comparative measurements • St. Bartholomew's Hosp. Rep., Vol. V., p. 147, 1869. 28 Congenital Occlusion and of the circumference of the limbs, as represented in Fig. 14, were as follows : rn • l Ankle. Calf. Thigh. Left leg....... 4 inches. 5£ inches. 7 inches. Right leg........ 15 « 13* « 12* " The skin over these parts was thickened, rugose, very dense and hard ; here and there studded with fibrous tubercles; and on the leg and foot were a few long and coarse hairs. The foot was masked with thickened integument. The thigh was proportionally smaller than the leg and foot, and was covered with skin softer and exten- sively stained with a superficial narvus. Over the buttock the skin was soft and natural, but quaggy in places, and discolored with a few scattered nsevi. The whole limb was warmer than the left, and three inches longer, the increased length being due to thickened in- tegument on the sole of the foot. After a month's treatment with continuous compression, the child sickened and died. Autopsy.—Cutis vera deeply marked by transverse dimples, two crossing the thigh, one two inches deep across calf, and one an inch and a half deep across dorsum of foot. Texture of cutis natural over the buttock, uniformly thickened over thigh, and over leg and foot hypertrophied, condensed, and studded with numerous knots and tubercles. Subcutaneous tissue, from two to three inches thick, about the calf and upper part of thigh, and everywhere occupied by a dense, reticulate, spongy, erectile, venous cavernous tissue, which also in- vaded the intermuscular connective tissue, and extended on the right side within the pelvis and up into the loins behind the right kidney. The reticular and cavernous spaces varied in size, some large enough to receive the end of the thumb. Muscles healthy; abdominal aorta and branches healthy and of normal calibre. Right internal iliac vein enormously enlarged, and at its exit from the pelvis was joined by others of varying dimensions, some very large. At the back of the limb the abnormal system of veins belonged exclusively to the cavernous tissue, which everywhere pervaded the limb, and was supplied through large trunks formed by tributaries from the leg and foot. The nsevi consisted of a spongy, reticulate tissue, containing cavities and interspaces of various size. Case X.1—A girl aged 15, had suffered from birth with an en- larged right thigh and leg, much stained by cavernous naevous growths. The circumference of the right thigh, leg, and foot was from one to two inches more than corresponding parts of the left, and the tem- perature of the right was distinctly higher than that of the left. Over outer part of thigh was a large cutaneous nsevus; on the back of the thigh and inner side were large tortuous veins and mevus growths, and behind the great trochanter were very lar<*e venous sinuses, deeply situated. J ° 1 Smith, St. Bartholomew's Hosp. Rep., Vol. V. p. 150 Dilatation of Lymph Channels. 29 Cases 9,10, and 8 to a less extent, are examples of congenital cavernous angioma,1 the blood cavities or sinuses being imbed- ded in layers of connective tissue, and communicating with en- larged, sometimes erratic, and valveless venous trunks. It is also worthy of note that in Cases 9 and 10 the cavernous texture and naevous growths were connected with a system of veins on the posterior aspect of the affected limb which returned its blood through the great sciatic notch. In Case 8 the left lower extremity, in which the venous system was abnormally developed, the enlargement was mainly due to the new forma- tion of the subcutaneous cellular tissue, and in the corresponding member the increased size, though less than in the right limb, consisted of adipose formation, and was unconnected with any abnormality of the venous system. In Case 9 the thickened, indurated, and nodular skin, and immensely increased underly- ing cellular tissue, were coextensive with " a dense, recticulate, spongy, erectile, venous, cavernous tissue." In striking contrast with these cases (8, 9 and 10) is the fol- lowing case of lipomatosis congenita reported by Dr. Rose,' and the succeeding one, now for the first time published. Case XI.—The boy was three years old, delicate, and of well-formed family. Below the right axilla was a tumor, larger than a fist, with unchanged integument and indistinct margins. The brachial artery 1 It is probable that the following case, recently reported by Dr. Paschal, of Chihuahua, Mexico, is a similar devel- opment. At the age of nine a small, hard tumor was discovered on the lower and right side of the scalp, which enlarged rapidly, and when first seen by Dr. P. pre- sented the appearance as shown in the accompanying woodcut. It was sparsely covered with hair. A line drawn trans- versely across the top of the skull marks the commencement of the bag-like struc- ture, which measured from the line of commencement to most dependent por- tion fifteen inches, transversely from mas- toid process to mastoid process twelve inches, and was three inches thick at low- est part. It was abundantly supplied with blood.—American Medical Bi-Weekly, Vol. VI., p. 1, 1877. 2 Presented to Obst. Soc., Berlin, through the kindness of Dr. Aschoff, Monat- Bchrift f. Geburtsk., Bd. 29 and 30,1867. 30 Congenital Occlusion and did not differ from its fellow, and the veins were not dilated. The fourth finger of the right hand was enlarged like a sausage, elongated, and abnormally movable. The last phalanx could be placed without pain upon the metacarpal bone of the thumb, the dorsum of the finger touching the dorsum of the hand. Whilst hyper-extension was thus increased, flexion was absent, for the articular folds were replaced by an adipose cushion of the thickness of a finger. This cushion ex- tended to the end of the finger and made up the elongation. No fat cushion existed upon the dorsum, but it extended along the ulnar up to the elbow, and was directly continuous with the axillary tumor. Case XII.—Kate Burns, aged 6 years, now (August, 1876) a patient in the Children's Hospital, D.C., was born with right arm Fig. 15. larger and longer than left. The left was amputated near the shoulder-joint several years ago, and consequently no comparative measurements can be made. The skin covering right arm, fingers, axilla, extending behind as far as the scapula, and i£ front over the pectorahs, is thickened; over the arm it is marked by numerous transverse furrows, which divide it into many folds, as represented in SL ThW6 P 7 S C°nfined t0 the Skin and ^bcutaneous tissue. The folds are movable, and can be lifted from the subjacent tissues. Power, mobility, and temperature normal. No anomalous SIS l^h o^ S ^T^ disC0Verabl- ^neral nutrition good, the growth of the arm does not appear to be in excess Con- tinuous compression has been tried, without any apparent benefit. Dilatation of Lymph Channels. 31 The child is an epileptic, and is now under treatment, with prospect of complete success. Case XII£.!—A child, aged twenty months. At birth a tumor, as large as two fists, extended from the lower third of the occipital bone to the spines of the scapulae. The tumor had diminished to one- fourth, and there were formed five longitudinal folds of skin hanging from the occiput to a transverse ridge parallel with the spines of the scapulae. The left forearm was thicker than right, also left hand thicker than right. The two calves were thicker and harder than normal. Anomalies confined to skin and subcutaneous tissue. Cases 4,5, 6, 8, 9, and 10 apparently demonstrate the genetic connection of augmented venous supply, stasis, and retardation of current with connective-tissue hyperplasia; but there are in- stances (see Cases 2, 5, 6, 7, and 8), both congenital and acquired, in which the fibromatous and lipomatous degenerations are found occupying separate territories, or in conjoint develop- ment, in which case, in addition to the anomalies of the venous system, the tissues affected were interspersed with numerous caverns and cysts filled with a coagulable fluid, and lined with an endothelium, and, occasionally, communicating with cutane- ous vesicles, also lined with an endothelium, and containing a similar fluid. Thus the further inference seems deducible, that the two varieties of degeneration owe their origin to sepa- rate and distinct alterations of nutrition, and that in the lipo- matous form the lymphatic apparatus is primarily and chiefly concerned. In another class of cases the relation of the con- nective and adipose tissue developments are such as to indicate the subordination of the latter to the former—that is, with in- creasing connective-tissue hyperplasia and condensation, the adipose accumulations disappear.. Various stages of transition of lipomatous into fibromatous developments are found in dis- tinct cases, and sometimes in the same case, as in Bryk's and Steinwirker's cases. Such cases are characterized, when ac- quired, by inflammatory processes and transudation of fluid from the cutaneous surface, and, in both congenital and ac- quired forms, by anomalies of the circulatory apparatus, con- sisting, almost invariably, in dilated, varicose, and superabun- dant veins. There is another group, characterized by lipoma- tous formations and obliteration of all vascular systems, to •Jacobi, Amer. Jour. Obst., Vol. IV, p. 719. 32 Congenital Occlusion and which probably Cases 3 and 11 belong, and a fifth class, in which adipose developments exist in immediate association with lymph stasis. Case 1, which constitutes the basis of this inquiry, presents in association several of these conditions. But before proceeding further with this investigation into the histogenesis of these various phenomena, another marked characteristic which was present in Cases 8, 9, 11, and 12, demands con- sideration. The general growth of the child (No. 1) was satisfactory, and the nutrition of the hypertrophied limb was not only sustained, but in excess of the corresponding member, and in this particular the case followed the general law of one class of cases of congenital hypertrophies, affecting either the whole or any part of a limb. Such congenital excesses of growth may extend through the longitudinal and transverse measure- ments (or either) of the limb, or part of the limb affected, and may involve the osseous structure. The acquired forms of adipose and connective-tissue hypertrophies, so constantly associated with lymphatic teleangiectasis, are not usually con- nected with an excess of growth of the bony parts through their longitudinal axes. It thus becomes necessary, in the further prosecution of the inquiry into the nature of the phenomena presented in my own case, to introduce the cases of partial and colossal growths, which, though characterized by the absence of its predominant features, yet contribute important aid, and cannot be excluded from a comprehensive analysis of its complex conditions. Prof. Busch divides these congenital hypertrophies into two groups.1 In the first group the affected parts grow in proportion to the rest of the body; in the second group the giant forma- tion is in excess of the development of the rest of the body. My case, so far as regards the hypertrophy, manifestly belongs to the latter group ; for in its progressive development the right lower extremity was in excess of the rest of the body. After death the right lower extremity measured one and one-quarter inches longer than the left. 1 The classification which I have mart* io ««+ „u i i. i •i. • 4. •., . ve maae is not absolutely accurate because it is not possible in every case to dpl-Pi-min,* n,„ * n,^uuruMJ» Decause When it i. act dM^'«V,tZ " t^TtLSLJSS*T^ excess, tie case has beea classed with the fiTpoup Patt W33" Dilatation of Lymph Channels. 33 First Group.—The abstract of the cases of Klein, "Wagner, Wuff, Ideler, and of Legendre have been taken from the paper, entitled " Contributions to the Knowledge of Congenital Hy- pertrophies of the Extremities," by Prof. \V. Busch.1 Case XIII.!—The length of the hypertrophic finger of the left hand measured b\ inches; the third joint was 14 lines, second 1 inch, the first 1 inch thick. Greatest circumference, 4^ inches. The fingers stood in slight ulnar abduction in the articulation of the first and second, and in that of the second and third phalanx, so that it bent over the middle and ring-finger. Motion was good in the metacar- pal articulations. The articulation was not normal, as the articular ends of the first phalanx and of the metacarpal bone were much enlarged and malformed. Case XIV.3—Right hand of a boy, which enlarged in proportion to the growth of the entire body. In his fifth year a fatty tumor appeared upon the right breast, which extended from the sternum to the axilla, and was followed by the extension of the hypertrophy from the hand to the forearm and arm. The increase in thickness was caused by irregular pads. The thumb was smaller than natural, and separated from the index finger by a fatty tumor. The index finger measured in circumference 6^- inches ; the thinner third pha- lanx stood in hyper-extension. The middle finger measured around first phalanx 13£ inches, and decreased suddenly in its third pha- lanx. Fourth and fifth were hypertrophic and webbed. Be- tween the fifth and wrist-joint was a fatty tumor. Veins upon dorsum of hand varicose. Pulse equal on both sides. Movements of the hand, which weighed 12 pounds, not impeded. Case XV."—A girl, 16 years old. Second toe of left foot twice as long and thick as it should have been. The first and second pha- langeal articulation was supplied with a firm and callous ball. The first phalanx was in slight hyper-extension; movements of flexion and extension difficult. The plantar surface of first and second phalanx covered with a thick layer of fat. Arteries and nerves " showed nothing peculiar." The ligaments were tense, and formed by shining, firm fibres. Artic- ular ends corresponding to the hyper-extension, " somewhat de- formed." Case XVI.5—A man, 32 years old. From birth half of the palm of the three first fingers of the right hand had been deformed by an enormous development of the subcutaneous adipose tissue, which at first grew pari passu with the growth of the body, but in later years 1 Archiv fur Klein. Chir., Langenbeck, Vol. VII., p. 174, 1861. 2 Von Klein, Von Graefe and Walther's Journal, p. 379. 3 Wagner, Schmit's Jahr., iii., Supplement. 1842, p. 86. * Bohms. Inaugural Dissertation, Giessen. 1856. 'Wuff, Petersb. Med. Zeitschrift, 1861, No. 10, p. 281. 3 34 Congenital Occlusion and tl increased independently." The articular epiphyses of the metacarpo- phalangeal articulations were malformed. The metacarpal and phalan- geal bones were enlarged transversely. Thumb hyper-extended. Ar- teries alike on both sides. The weight of the hand rendered it unfit for function. Case XVII.1—The skeleton of a foot preserved in the Berlin Mu- seum. The bones of the three middle toes exceeded in length those of the pollex and little toe (see Fig. 16), both in the phalanges and in the metatarsus, and were thickened. The great toe was less developed, and the little toe was rudimentary, forming an append- age to the fourth metatarsal. The toes were in strong dorsal extension. The deformities grew in proportion to the rest of the body, and rendered walking difficult. Case XVIII.*—A child, 4 years and six months old. The third and fourth fingers and ulnar half of the volar aspect of the hand hy- pertrophied, third to the size of an adult. The fingers showed two curvatures—one along the dorsum, the other along the radial side. The last phalanges stood in rectangular hyper-exten- sion. The enlargement was due chiefly to in- „ lg crease of the subcutaneous adipose tissue—a thick elastic cushion, which was on the palmar surface. The little finger was not increased in length, but thickened by a cushion of fat on the palmar surface. Upon the palm of the meta- carpus was a very considerable layer of fat, corresponding to the third and fourth fingers, which was divided from the most of the palm by a well-marked line. Motion in the affected parts was limited. Case XIX.3—A boy, aged 12 years. Both feet enlarged. A large lipoma in right gluteal region, and several smaller ones beneath in- tegument of left thigh. Upon both feet (see Fig. 17), as shown upon the left, were large lipomata, both upon the dorsal and plantar surfaces, reaching even beyond the malleoli. The three middle toes were webbed and enlarged. Case XX.*—Healthy girl, aged 16. The fingers (middle) meas- ured 5£ inches&m length, and the same in circumference at base. Case XXI. —A boy, aged 10. At birth the second toe of right foot was elongated and thick, and has steadily enlarged, and now measures seven inches in circumference, and projects three inches beyond the other toes. Skin healthy and natural in color. The metatarsal and phalangeal bones were hypertrophied in the same 1 Busch, loc. cit. 5 Legendre, cited by Bohms, loc. cit. 3Ideler, Inaug. Dis., Berlin, 1855. «Bigelow, Boston Med. and Surg. Jour.. Vol XLIII t> 341 'Hamilton, Buffalo Med. Jour., Vol, VI. pp 154.5'' Dilatation of Lymph Channels. 35 relative proportion with the soft parts, and the cellular texture had degenerated into a light-colored fibrous mass, holding in its cellules whitish fat granules. The bleeding vessels were numerous, but only two or three required ligation. Fig. 17. Fig. 18. Case XXII.1—A. man, native of India. Right foot measured in circumference 9 in., left 15f; length of right big toe 1* in., left 4£ in.; circumference of right leg, near ankle, 8* in., left 7* in. ; circumference of left big toe 7\ in., of second and third toes together 8 in., of fourth and fifth 1| in.; length of second and third toes (united) 3* inches. (Fig. 18.) Case XXIII.'—George P., aged 19. The comparative measure- ments of the two lower extremities show the excessive development of the right. Eight. Left. Entire length of limb................. 30 inches. 28* inches. Circumference over malleoli........... 10 ' 9^- " of calves.............. 13* " 13* Junction of middle and lower thirds of thigh.............................i6* ;; 15* || Upper third of thigh................. 20 " 19 Of Sates.........7.................. 13* « 11* " A large superficial nsevus occupied the entire limb, extended up to the last dorsal vertebra, and completely covered one-half of the scrotum. Case XXIY.3—A girl, aged 6. The essential change consisted in large, painless, pad-like tumors upon the dorsum of the hand, and upon the dorsal surface of the middle, ring, and little fingers, all four 'Simpson, Month. Jour, of Med., Vol. XX., p. 173. 2 John Adams, Lon. Lancet, Vol. II., p. 140, 1858. 3 Kappeler, Chir. Beobacht. aus dem Kantonspital Miinsterlingen, 1865, 1870, p. 246. 36 Congenital Occlusion and divided by shallow sulci from each other. They were movable in a lateral direction, and were of the consistence of lipoma ; were firmly grown together with the tense, foldless, and thinned integument. The pads began at the metacarpo-phalangeal articulation, and passed with- out interruption and without pressure over the joint between the first and second phalanx to the articulation between the second and third phalanx, and there descended abruptly to the unchanged third phalanx. Upon the volar side of the first and second phalanx of the fingers there were also similar pads, which did not extend over the articulations, but were divided by the articular folds; upon the volar surface of the hand, opposite the heads of the metacarpal bones, another pad was located, which passed without defined limit into the integument. Right thumb, 4 ctms., Left thumb, 4 ctms. index finger, 4* " middle " 5 " ring " 4* " little " 4 index finger, 5 " " middle " 5| " " ring " 5* « « little " 4* " The elongated fingers were enlarged in circumference. The bones of the malformed fingers appeared thicker and bulky. Integument Fig. 19. was thinned and tense. The enlargement was due chiefly to lipoma- tous-hke tumors located in the subcutaneous cellular tissue which only interfered with the functions of the parts to a very slight degree; nothing abnormal could be discovered in the circulatory°apparatus, though the affected parts felt colder than the corresponding parts, and were much less sensitive. Case XXV.1—Child, aged 15 months. From birth the left leg "Gun, Chicago Med. Jour., Vol. XXVI., p. 707, 1869. Dilatation of Lymph Channels. 37 was enlarged, and from the fourth to the fifteenth month had doubled in size. The development extended from above the knee to the foot, nearly overlapping the toes, and measured in circumference at its largest part (see Fig. 20) 21* inches. The skin was smooth, attenu- Fig. 20. ated, and pliable. An exploratory puncture gave exit to serum which continued to flow for one hour. A section of the amputated part exhibited hyperplasia of the superficial fascia, the deep fascia and integument being normal. Case XXVI.1—Victor H., aged 7 years and 6 months. The ab- normal and congenital development consisted in enlargement of the annular and auricular fingers of the right hand, of the corresponding hypothenar eminence, of the anterior surface of the forearm, and ex- tended markedly in front of the chest of the same side. The right annular finger was quadruple its normal size, curved backwards, and convex on its palmar surface. Voluntary movements completely abolished. Auricular more like a toe than a finger. Its dimension interfered with the movements of the other fingers; semi-flexion was very limited. The bones participate in the enlargement. Sensi- bility perfect; no perceptible arterial pulsation in affected fingers. The palmar surface presented a large prominence, feeling like a lipoma, and the swelling on the forearm felt doughy. Fingers re- moved and examined. The hypertrophy was confined to the cellular adipose tissue and bone; skin was neither thickened nor attached. The fatty tissue was intersected by trabeculse, and the areolae which they circumscribed contained little adipose clusters, which were swol- len, and seemed to produce hernise on the walls of the cellules. Ten- dons atrophied; vessels rudimentary; arteries filiform ; veins difficult to find; nerves atrophied; bones lengthened. Temperament lym- phatic. 1 Michel, Recueil des travaux de la Societe Medicale d'Observation de Paris, Tom. I., p. 319, 1857-58. This is probably the same case submitted to the Society by Guersant. In that case the auricular and annular fingers of the right hand were enlarged, and the palmar surface of the hand presented a large swelling. The child was then between 4 and 5 years of age. Gazette des Hopitaux, No. 116, Oct. 3d, 1857, p. 463. Societe de Chirurgie, seance, Sept. 23d, 1857. 38 Congenital Occlusion and Case XXVII.1—A girl, aged 14. The third and fourth fingers were equably hypertrophic in length, width, and thickness, and to such a degree that the middle finger was one and a-half times the length of the well-formed index. All movements could be executed freely and usefully, and, with the exception of the size, the only ab- normity of the fingers was that they assumed a purple color when hanging down. Case XXVIII.2—A young man, aged 20, born with hypertrophy of left foot, which principally attacked the first, second, and third j,f& Fig. 21. t°ef'fi°I1Which ^\tw° lattei\were fused int0 a Armless mass. Fourth and fifth normal, but beneath the pad formed by the second and third toes. The development of the soft parts was due to lipomatous augmen- tation of the adipose layer, and was principally found in those places 1 Busch, loc. cit. * Busch, loc. cit. Dilatation of Lymph CJiannels. 39 where the bones were hypertrophic. The fat development was found upon the dorsal and plantar surfaces of the three first toes, extended on the sole to the os calcis, and on the dorsum overtopped the fourth metatarsal bone. It extended over the tibio-tarsal articulation, above which were several smaller lipomata on the anterior tibial sur- face. All three toes stood in very strong hyper-extension. On the dorsum of the last articulation (see 1, Fig. 21) of the great toe was a deep furrow, which bi-lobed the mass; one, not so deep, was situated over the metatarso-phalangeal articulation of the fused toes, and another was found over the last articulation. The patient could flex and extend the foot; but the motion was limited, and during it crepi- tus could be heard. Could not move the toes. The tibia? were of equal thickness, but of unequal length. The amputated foot ex- hibited fat intimately grown into the integumentary tissue. In some places the lipoma proper lay immediately beneath the thin skin, at others a thick, steatomatous sward lay between the toes, in which the fat was imbedded in very solid, firm, fibrous layers, and under- neath this softer lipomatous tissue. Between the dorsal lipomata, and buried into them, lay a network of colossal veins (see 6, Fig. 21), and at the junction of several branches a large ampulla was found. The enlargement of the veins was due to hypertrophy of their walls; arteries and nerves normal; muscles atrophic and pale, and the bun- Fig. 22. dies were pressed asunder by fatty tissue. The articular surface of the first metatarsal bone was divided into three facets (2, anterior view; 5, lateral); 3 and 4 show the 1st and 2d phalanx of the second toe, natural size. The diaphyses of the altered bones were narrow, whilst the epiphyses were tuberous, and covered by irregular osseous projections. 40 Congenital Occlusion and Case XXIX.>-M. M., aged 3 years was a ft^gJ^J^ formed child, with the exception of a deformity of the fingers ol the eft hand. At birth the index and middle fingers were much onger than the others. The fingers were quite useless, and possessed very little free movement. The remaining digits were natural. An ex- amination of the amputated fingers showed that the disease consisted of an hypertrophy of all the tissues. (Fig. 22.) .,,.,., Case XXX.2—R. S., aged 16 months. At birth his left hand and arm were larger than the other, and rapidly increased m size. The Fig. 23. whole limb, from the shoulder, as shown in Fig. 23, is very much enlarged, chiefly in thickness, although the length also is increased. The first, second, and third fingers are enormously hypertrophied. The fourth and fifth are of normal size. The metacarpals correspond to their digits, the first three being very large. Both sides of the hand are covered with a thick elastic cushion. The hypertrophy in- volves all the structures, the great size of all the bones, except of the fourth and fifth fingers, being very evident. The humerus, radius, and ulna are also thicker and rather longer than on the right side, but the enlargement of the arm is chiefly situated in the soft tissues. " The child can use the arm and all the fingers, but he cannot lay hold of anything, and the hand is perfectly useless." The measurements are as follows: 1 Annandale, Malformations of Fingers and Toes, p. 5. • MacGillivray, Australian Med. Jour., Vol. XVII., p. 9 1872. Dilatation of Lymph Channels. 41 Sound. Hypertrophied. Acromion to olecranon................ b\ 7£ Olecranon to wrist................... 4* 5 Circumference of arm................. 5* 9* Circumference of fore-arm............. 5* 8 Wrist to point of index............... 3* 6 Circumference of hand................ 4* 9* The brachial artery was ligated close to the axilla, which arrested the growth, and subsequently the fingers were amputated. The am- putated mass weighed 12* ozs. avoirdupois. The abnormal thickness was mainly subcutaneous fat. Case XXXI.1—Miss----, aged 16, had from birth an enlarge- ment of both great toes, which projected one inch beyond the other toes. She was constantly troubled with irritation and inflammation of the bursal swellings which formed on the toes. Annandale briefly refers to a case in which the great and second toes were elongated and enlarged. The phalanges and the part of the metatarsus connected with these two toes were very much enlarged. Case XXXII.2—The deformity presented the appearance of two great toes; but on dissection of the sole of the foot, it was found that Fig. 24. the large toe, which looked at first like a great toe, was really a second toe, in which the three phalanges were hypertrophied and anchylosed together. The hypertrophy was congenital. 1 Annandale, p. 8. * Sydney Jones, Lond. Lan., Vol. II., 1864, p. 549. 42 Congenital Occlusion and Case XXXIII.1—W. T., aged 19. Index and middle fingers o left hand exceeding corresponding fingers in length one inch. Ihey are also thicker. Circumference of left carpus one inch greater than right. Muscular tissue slightly more developed on left forearm than right. Motion impaired. Integument, panniculus adiposus, muscles and bones, are in equal proportion enlarged and thickened. Veins of left dorsum more developed than of right. Touch and sensation normal. Growth of hand in proportion to that of body. (Fig. 24.) Case XXXIV.2—Male, aged 20. Left thoracic cavity some- Fig. 25. what larger than right; left shoulder somewhat larger than right. Deltoid eminence of leftside more prominent. Left arm larger, but not longer. Half of hand belonging to thumb and index fingers ab- normally enlarged; left carpus larger than right, left metacarpus enormously wide. Position and condition of hypertrophic fingers shown in Fig. 25. Growth not in excess of the body. The maximum part of the excessive development of the limb iii Case 1 consisted in the hypertrophy of the adipose tissue, and certainly the greater, if' not the entire part of the excessive length was due to the fat cushion on the plantar sur- face. In this case, as is usual in congenital giant developments ^wald, Virch. Archiv, Vol. LVI., p. 421. » Gruber, Virch. Archiv, Bd. LVI,, p. 416. Dilatation of Lymph Channels. 43 associated with similar adipose formations, the lipomata are more strikingly exhibited upon the liexion side, differing in this respect from those originating in after-life. They also attack localities which are never selected later in life. There was not in this case any manifest bone-hypertrophy. From the observations cited, it appears that bone-hypertrophy not unfre- quently attacks the epiphyses, producing irregular development of the articular ends, which disturbs the normal movements of the joints. In this case the symmetry of the ankle-joint was not disturbed by any bone-malformation, but by the sur- rounding fat development. Among the peculiarities which distinguish the congenital giant formations from the acquired forms, Virchow enumerates bone-hypertrophy as an occasional lesion. In the higher grades of these developments, in which the connective tissue is principally involved, bone lesion is quite frequent, and1 fre- quently upon section through such diseased parts, from the sur- face downward to the bone, nothing but a " simple coherent, hard fibrous callosity " is found, which the older authors de- nominated lardaceous, but which Yirchow insists is "nothing but sclerotic connective tissue saturated with clear, expressible serum,2 rich in round cells," in which the different former tissues cannot easily be distinguished, being partly destroyed or so intimately grown into one another as to form a single mass, producing atrophy of the enclosed tissues, especially of the muscles and nerves, and consequently paralytic and anaes- thetic conditions. If this process should continue down to the bone, the perios- teum becomes implicated, and new layers of bone are produced. In some cases a smooth periosteum may be found ; in others it is irregular, wart-like, sometimes presenting " thorn-like forma- tions " of most singular appearance.8 These bone formations 1 Onkologie, Virchow, Vol. L, pp. 311, 312. 2 Hendy, Wiedel, and Kaposi insist that it is lymph. 3 In elephantiasis of the leg, the bones appear thickened, and either smooth, but hardened, sclerosed, or irregular on the surface, studded with pointed and tubercular stalactile exostoses, which project into the hypertrophied soft parts, and may be variously amalgamated together. In the midst of the sclerosed parts carious and necrosed spots are occasionally found. Hebra, Diseases of the Skin, Vol. III., p. 140, Syd. Soc. transl. 44: Congenital Occlusion and may extend into the extra-periosteal layers and even into the connective-tissue callosities. In the structure of these hyper. trophied bones Bohms found nothing abnormal; but Busch asserts that the adipose and medullary tissues of the bones are more strikingly developed than the bone lamella,—in fact, the latter may be remarkably thinned. Rokitansky1 divides bone-hypertrophy into internal and external hyperos- tosis ; in the former the increase proceeds from the " Haversian canals and medullary system; " the bone becomes more compact and the medullary cavity is diminished ; in the latter form the breadth and thickness of the bone is augmented by the forma- tion of new layers on the periosteal surface, without diminu- tion of the medullary canal. Both forms, he adds, may occur together, and " each is the result of the gradual formation of too great a quantity of the cartilage of bone, in which the normal salts of bone become deposited." The cases numbered from 13 to 34 (both inclusive), do not uniformly exhibit excess of bone development. Some cases (15, 20, 21, 23, 24, 27, 29, 30, 31, and 33) are characterized by increased thickness and elongation of the bones of the affected part, and fibromatous or lipomatous degeneration of the soft parts ; in other cases the hypertrophied (14,18, 19, 25, and 26) or elongated part (11, 13, and 17) is unaccompanied with any alteration of the bone either in thickness or length, and in such cases the excessive enlargement and elongation is owing entirely to lipomatous formations; in a third class of cases bone-hypertrophy without elongation is found in connection with adipose developments. In several instances, in which bone-elongation was combined with bone-hypertrophy, there were also found alterations of the vascular system ; in Case 21 numerous "bleeding vessels (probably veins with thickened walls) were found, and the cellular tissue had degenerated into a fibrous mass holding in its cellules whitish fat granules;" in 23 a large " naevus occupied the entire limb ; " in Case 27 the hypertrophied fingers became purple when hanging down; and in Case 14, in which the enlargement was due to lipoma- tous formations, the veins on the dorsum of the hand were vari- cose. Case 21 is especially interesting, inasmuch as it shows the probable transition of a pre-existing adipose into a fibromatous > Path. Anat., Vol. III., p. i04, American ed., 1855. Dilatation of Lymph Channels. 45 degeneration and bone-hypertrophy and elongation, in connec- tion with a superabundant supply of blood. Hyperostosis and increased length are also found in conjunction with augmented arterial supply. This condition is exhibited in the " three cases (35, 36, and 37) of partial hypertrophy of a portion of the organs of voluntary motion," reported by Dr. John Reid.1 Case XXXV.—W. C, aged 15. The right upper extremity was proportionate to the size of the lower extremity and to the trunk, while the left was hypertrophied in the hand, forearm, arm, and region of the scapula. The difference was dependent upon the difference of the relative size of the muscles and bone, from the phalanx up- wards to the clavicle and scapula, and in various muscles attached to these. The adipose tissue was not increased, but the cellular and cutaneous textures were probably developed uniformly with the mus- cular and osseous. The skin of the arm presented a number of red patches, one nearly extending over the scapula; the others were locat- ed on the outer side of arm and forearm. The whole arterial system of the left superior extremity was enlarged, and the pulsations of the subclavian, the axillary, and all its branches, down to the digital, beat with great strength. The temperature in right hand was 77°, in left 86°, in the right axilla 98°, and in the left 100°. The comparative measurements were as follows: Eight. Left. Circumference of middle arm........7 inches. 9-^g- inches. " an inch below elbow... 7^ " 9TV " Wrist............................5TV < 6TV « From inferior angle of scapula to cla- viculo-scapular articulation...... From inferior angle to middle of spine of scapula............... The movements of extension, pronation, and supination were im- perfect and painful. Case XXXVI.3—A girl, aged 2 years, healthy. The middle toe of the left foot projected three-fourths of an inch beyond the great, and equalled in bulk all the remaining toes. The phalangeal and metatarsal bones were hypertrophied, and the foot appeared as if the toe of an adult had been transplanted upon the foot of a child. The foot was of great breadth, caused by the increased thickness of the metatarsal bone and interosseous muscles. The dorsal artery of the foot beats with increased force. Case XXXVII.3—The thumb of the right hand was one-fourth of an inch longer, and was double in thickness of the corresponding finger, and the index exceeded in length the middle one-half inch. The temperature between the thumb and forefinger was 2° to 6° higher 1 Lond. and Edin. Month. Jour, of Med. Sci., Vol. III., p. 198. !Ibid. a Ibid. *T, 'TIT 46 Congenital Occlusion and than the same locality on left hand. The radial artery of the left was double the size of that of the right arm, and felt more distended with each pulsation. The three preceding cases (35, 36, 37) were all congenital, and probably belong to the second group, in which the growth of the hypertrophied part is in excess of the rest of the body. They are illustrations of increased nutrition, which affects uni- formly all the component tissues of the part involved, which were supplied with a redundancy of arterial blood. There are, however, other cases belonging to the same group which do not present the same anatomical relation of the different textures of the parts affected. In the report of the following case of M. Chassaignac,1 no allusion is made to any alteration of the arte- rial system, though the surface of the hypertrophied extremities presents a number of venous blotches and varices, which the reporter designates under the name of " taches erectiles cuticu- laires diffuses." Case XXXVIII.—C. L., aged 18. Had scrofulous glandular abscess on the right side of the neck. The two members of left side were those of an individual of ordinary stature, while those of the opposite side seemed to belong to a giant. The different parts of the two last members were not uniformly hypertrophied. The hand was much more so than the arm and forearm; its external half more than the internal; the thumb, index, and middle fingers were relatively much longer and much more voluminous than the two last fingers. The leg and thigh were less voluminous than the foot:—this was co- lossal. The great toe was enormous, but relatively less developed than the four last toes. The man affirmed that he had at least three times as much strength in the enlarged members as in those of the right side. Case XXXIX."—B. D., born with left lower extremity more de- veloped than the other. The skin presented diffused redness with circumscribed bluish spots. The right foot was also enlarged. The growth of the left extremity increased with astonishing rapidity. The child nursed, slept, walked, played, and at the age of three years, when, suddenly crying out, with her hands on her head, she died in a few moments. Case XL.3—In a six-year-old Polish Jewess existed general hy- I*™* L0an«ett« Fran fibrinous striae. FlG, 39f As a rule, the chyluria appeared with the cessation of the discharge from the scrotal vesicles and alternated with the tumefaction of the inguinal glands. These facts, though insuf- ficent to establish the hypothesis of Carter (see N. O. Med. and Surg. Jour., July, 1877), that the fluid was chyle, which by a retrograde movement found its way to the scrotum, inguinal glands, and bladder, do establish the identity of the fluid which collected in the inguinal glands, and which was alternately emitted from the scrotal vesicles and bladder. The three con- ditions were directly connected, and manifestly due to stasis of lymph. In Carter's case, impediment to the lymph-stream was 100 Congenital Occlusion and above the superficial inguinal ganglia. He ascribed the en« largement of the glands to increased function, in connection with dilated vessels extending inwards, even as high as the thoracic duct. The cases of Roberts and Carter (66 and 68) are patholog- ically identical, and the absolute identity of the discharges with lymph, or chyle, establish the similarity of the structures and of the morbid processes producing them. The objective phenomena in both cases consisted of obstructed and dilated lymph-channels and stasis of lymph, and in each case the lymphorrhagia alternated with the chyluria. It may, then (Roberts), be assumed that the condition producing the chylous urine was essentially of the same pathological nature as the disease of the abdominal walls in Roberts's case, and of the scro- tum in Carter's case. Roberts suspected from the discovery of the Bilharzia haematobia in endemic haematuria that chyluria might owe its origin to the presence of parasites in the lym- phatic vessels, which supposition has been verified by the more recent discovery, by Lewis, of the filiaria in cases of chylous urine, and, by Winckel (Case 45, JV. O. Med. and Surg. Jour), in a case of chylous ascites. Lewis supposed these parasites penetrated the walls of the lymph-channels, thus establishing apertures through which the fluid escaped." " Chylous urine," says Roberts, " prevails mostly in youth and middle-age, but no case has been traced to congenital origin." The youngest ex- ample Roberts refers to Prout, which occurred in a male infant eighteen months old, in which case a fatty substance mixed with triple phosphate was discovered " in the urine of a delicate child fed on milk." The vesicles in cases of pachydermia lymphangiectatica are "partial (Rindfleisch) ampullar dilatations of the superficial subpapillary lymphatic net." The inner surface of these vesi- cles is always lined with lymphatic endothelium, and the cover- ing is " formed by the epidermis and the papillary layer." Rindfleisch1 insists that regions most usually invaded with thia affection are the richest in organic muscle, which in the tunica dartos forms " a proper membranous organ." This structural element in this class of cases undergoes " a special hyperplasia and neoplasia," and by contraction compresses " the lymphatic 1 Text-Book of Pathological Histology, Amer. Translation, p. 313, 1873. Dilatation of Lymph Channels. 101 trunks which penetrate the cutis in a straight direction, and connect the superficial with the deep lymphatic net," thus pre- venting efflux of the lymph and consequent ampullar dilatation of the terminal radicles. A similar effect might also follow simple elasticity of the muscular parenchyma. These patho- histological conditions might stand in an etiological relation to the cutaneous vesicles, but certainly they are insufficient to explain the glandular engorgement and chyluria, and it may be that the hypertrophy of the dartos is an effect rather than the cause of the stasis of lymph. In another of Carter's cases, and in one of Hanson's cases of " lymph scrotum," a similar coexistence of phenomena was present; and in a number of the cases of " lymph scrotum," as in Wiedel's1 case of pachydermia lymphangiectatica, the vesicles which studded the skin of the scrotum were directly associated with engorged inguinal glands. These circumstances would lead to the conclusion that the " ampullar dilatations of the superficial 6ubpapillary lymphatic net," which Rindfleisch ascribes to hy- pertrophy of the organic muscle of the skin, were the remote effects of obstruction to the lymph-stream situated anatomically above the inguinal ganglia. In cases 54, 55, 56, 57, and 58 the vesicle formations were associated with cylindrical or monilli- form varicosities of the connected vessels. Among the acquired forms of lymphatic varices there are a number of cases (see the cases of Petters, Stewart, Bryk, Op- polzer, and Rokitansky, iV O. Med. and Surg. Jour., Septem- ber, 1877) in which lymph-variees were occasioned by obstruc- tive heart circulation, and a number of other cases in which dilatation and rupture of lymph-channels occurred in conse- quence of impediment to the lymph-stream, located at or near the entrance of the thoracic duct into the left subclavian vein; but among the congenital cases, the case of Virchow (59), prob- ably the case of Friedberg (48), and the following case re- ported by Cholmeley, are the only instances in which the heart circulation bore any causal relation to the lymph-varices : Case LXIX.*—Louisa R., the fourteenth of seventeen children; was, like her brothers and sisters, born at full term, but was deeply cyanosed; her lips and fingers were dark blue, her face livid, and the 1 Inaugural, Abhandlung, Wiirzburg, 1837. 'Cholmeley, Trans. Clin. Soc, London, vol. it. p. 116, 1869. 102 Congenital Occlusion and general surface of the body dark. Respiration was very labored and sighing, and for many weeks it was not supposed that she could live. Suffered for the first four or five years from frequent attacks of dysp- noea, and " inflammation on the chest," but " was always well nour- ished and fat," and is now (1869) " short, stout, and generally healthy looking, with a good, bright red color in the cheeks and lips, but is easily affected by colds, and then complains of " want of breath," and a feeling of tightness in the chest; and at such times the com- plexion assumes a markedly livid tint, respiration becomes somewhat labored and noisy, the extremities cold, and the nails dark blue. No morbid sounds are heard in the lungs. The pulse is normal in fre- quency, rhythm, volume, and force ; " but all over the heart is heard a soft, blowing, systolic murmur, which is loudest at the junction of the second left costal cartilage with the sternum." During her sixth year a swelling appeared on her right leg and ankle, which gradually extended upwards, though not above the knee, until two years had elapsed; but in the third year, when the patient was between seven and eight, " the swelling extended slowly and steadily upwards till the whole limb was implicated," but has not gone above the " inguinal line." The increase in the size of the swell- ing was always greater towards the evening, and did not affect the foot when a boot was worn or when the child first got up, but was very great in the foot if the boot was not put on. When treated in 1867, by rest in bed with elevation of the foot, graduating bandages from the toes to the groin, and pressure on the femoral artery, " the swelling diminished considerably, but returned rapidly as soon as she was allowed to be about again." At the date of the report the entire limb was uniformly enlarged, felt " soft, firm, and elastic "—the lower part being firmer and more tense than the upper—in color and temperature the lirub did not differ. The skin was smooth and soft as far downwards as the mid- dle third of the leg, below it was " harsh, rough, dry," and scaly. On the outer aspect of the ankle were a number of " soft, smooth, red flattened papules," not larger than a split pea. On the hypertrophied skin of the great, second, and third toes were " rough, hard eleva- tions, looking much like a half-aborted and dried herpetic eruption," from which occasionally a discharge took place ; and over the tendo- Achilles was a "humid patch, from which a milky-looking alkaline fluid dripped," similar in character to the fluid which issued through punctures made into the lower part of the limb, which exhibited under the microscope " broken-up cells, granular matter, some oil- globules, blood-corpuscles," and coagulated on boiliDg. The comparative measurements of the lower extremities were as follows: Left. Eight. At the ankle............. 8 inches............. 94 inches. Mid. leg................. 9 " ............ 14 « Below knee.............. 9$ " ............ 144- " Above the knee........... 10£ " ............ 164 " Upper part of the thigh.... 15 " ............ 174 « Dilatation of Lymph Channels. 103 There was no fulness or swelling of any kind detected in the groin or pelvis; nothing abnormal in the condition of the right nympha or labium; never any pain in the limb, nor any injury, accident, or known cause to account for the condition." The deeply cyanosed condition at birth, which never entirely disappeared; the frequent attacks of dyspnoea, which were always accompanied with increased lividity of the face and finger nails, and the " blowing, systolic murmur," which was loudest at the junction of the second left costal cartilage with the sternum, which was probably due to some congenital defect— all point to cardiac anomaly, and cannot, in view of the clinical histories and post-mortem appearances furnished by the cases of Stewart, Rokitansky, and Petters (see N. 0. Med. and Surg. Jour., Sept., 1877), be dissociated from a causal connection with the stasis of lymph, which first manifested itself near the ankle during the sixth year, and which gradually increased until the entire system of superficial lymph-vessels of the limb seem to have become involved. In Virchow's case (59), a thrombus partly lying in the outlet of the external jugular vein so oc- cluded the mouth of the thoracic duct, " that nearly all the internal organs were dilated to the utmost by ectatic lymph- vessels. The intestines were covered everywhere with broad bead-like canals." In Stewart's case (No. 55, N. O.Med, and Surg. Jour), " the heart was hypertrophied and fatty, the aortic valves much diseased and covered with vegetations; the auriculo-ventricular orifices were dilated and the valves dis- eased," and the intestinal villi and mesenteric lacteals were en- gorged with chyle and lymph. In Petters' case, in which there was stenosis of both auriculo-ventricular orifices, and dilatation of the right side of the heart, the lym ph-glands of the right inguinal region were transformed into cysts, and the mucous surface of the small intestines was covered with lenticular eminences filled with a transparent fluid. In Rokitansky's case (No. 37, N. O. Med. and Surg. Jour), a dilated and hyper- trophied heart, with mitral insufficiency, was found in connec- tion with dilatation of an extensive area of lymph-vessels, stasis of lymph and effusion of lymph and chyle into the pleural and peritoneal cavities. The venous teleangiectasis upon the thorax of Friedberg's patient (48), the nodes upon the left arm, and the venous network upon the anterior thoracic wall were observed 104 Congenital Occlusion and at birth. These, together with the dilatation of the cutaneous veins upon the inner side of the left arm, and the eruption which resembled hemorrhagic spots, which remained, point to a disturbance of the circulation. The grouping of these evi- dences about the left arm and left clavicular region suggested to Friedberg the hypothesis that the flow of blood in the " vena cava sinistra" had met with an obstruction which extended its influence over the adjacent portions of the lymphatic and venous systems. Fetzer believed the condition into which his patient sank, and the reddish color of the coagulum of the lymph which exuded from the ruptured vesicles during the existence of this condition, were attributable to the regurgitation of blood into the left innominate vein and its entrance into the thoracic duct, with which he supposed the diseased lymphatic vessels communicated. In Ormerod's case of chylous ascites (No. 40, iV. O. Med. and Surg. Jour., March, 1877), the left subclavian vein and its afferent vessels were clogged with a light-colored clot, which prevented the flow of the contents of the thoracic duct into the vein, leading to the effusion of chyle into the peritoneal cavity; and in Cayley's case (No. 39, JV. 0. Med. and Sur. Jour., March, 1877) of rupture of the receptaculum chyli, the thoracic duct was obstructed at its entrance into the left subclavian vein by fibrinous vegetations. These observa- tions establish the influence of the heart circulation on the movement of the chyle and lymph, and illustrate the agency of obstructive cardiac diseases in the production of lymph- varices. Independently of the other cases cited, the case of the new-born calf observed by Virchow, in which extensive and remote areae of lymph-varices were discovered, adequately illustrates the causal influence of an impediment to the free exit of the contents of the thoracic duct, produced by a thrombus pendent from the opening of the external jugular vein. With this brief resume of this important question, which the reader will find more elaborately discussed in the N. 0. Med. and Sur. Jour, (see Nos. for Sept. and Oct., 1877), I will proceed with the presentation of other forms of lymph-varices. Case LXX.1—A child, two years old, had from birth a thick tongue, 1 Virchow, Archiv fur Pathol. Anat. und Physiolog. und klinische Med., voL vii., p. 126. 1854. Dilatation of Lymph Channels. 105 which had greatly increased during the preceding two weeks. The tongue protruded from the mouth in a broad, thick, hard mass, and was closely encircled by the stretched lips. From two punctures made in the under surface a small quantity of blood was evacuated, but a tumor, situated below the right inferior maxilla, furnished sev- - eral tablespoonfuls of a lymph-like fluid. Subsequently a portion was removed, measuring one and one-half inches in length, one and three-quarter inches in width, and three-quarters of an inch in thickness. Across the dorsum of this part extended a thick epithe- lial covering, removable in flakes. A few of the papilla? retained their filiform appearance; the most of them appeared thicker and coarser. Towards the point of the tongue they were as usual, but flattened upon the edges. Upon the posterior under surface lay, in partly bead-like rows, bluish, transparent vesicles, varying from very fine, just visible bodies, to the size of large flax seeds. Upon section a pale, peculiarly cavernous tissue appeared, which differed from the appearance of ordinary cavernous tumors by the Contents of the inter-trabecular caverns, in which was found a clear, yellowish fluid, here and there somewhat turbid, in other places co- agulated into clear, transparent masses. The evacuated fluid coagu- lated upon exposure to the air, and contained albumen. Upon longitudinal section through one lateral half of the ablated portion the cavernous tissue was found principally in the middle part corresponding to the region of the transverse muscle, as shown in Fig. 40, Fig 40. Upon the top could be distinguished the whitish, tough layer of the mucous membrane and the papillae ; below it a longitudinally striated, very tough, and whitish layer; next, the cavernous mass, and below again a more longitudinally striated layer, which continued be- 106 Congenital Occlusion and yond the apex. The same result was found upon transverse section, and the cavernous structure appeared in the centre in very coarse meshes, whilst towards the lateral portions it became fine, and towards the periphery the mesh-cavities became smaller and smaller in such a manner that bead-like vesicles could be traced up to the papilla?. The^ cavities were elongated perpendicularly, and varied in size from the smallest, barely visible points, to over one line in their greatest diameter. The width of the trabecules varied. Many of the cavities communicated by nar- row openings; many, however, ap- peared closed, and the adjacent ves- icles could be seen shining through at the bottom; the trabecular and partition walls which bound them were sharply defined, more or less smooth, and pale. See Fig. 41. The smooth, regular walls, the bead-like course, the albumi- nous and fibrinogenous contents, the simultaneous disease of the gland below the inferior maxilla, from which the lymphatic fluid was discharged several times, the relatively rapid develop- ment of the large tumor, the complete freedom from pain, and the absence of any considerable hyperaemia, induced Virchow to ascribe the cavernous structure to the passive development of pre-existing lymph-vessels, in which an accumulation of fluid had taken place. " Wherever the mesh-cavities contained coagulum it con- sisted of fibrinous threads united in a net-like manner, in which was enclosed numerous round cells of the size, form, and character of lymph-corpuscles. They were slightly nucle- ated, and contained single or multiple nuclei, which became more distinct by acetic acid." Virchow failed to demonstrate the wall-elements of lymph-vessels, but occasionally found traces of epithelium. The connective-tissue stroma contained numerous granular formations and cell-forms, which were especially abundant in the basic stroma of the papillae. In the interior of the cavernous layer—as in the peripheral layers—he found the connective-tissue corpuscles in close proximity to other stellate cells, containing two or more nuclei, and as the inter- stitial tissue decreased the stellate bodies grew broader and larger, becoming arranged in rows and finally collecting in dark groups, as shown in Fig. 42. These observations led him to the conclusion that the cystoid cavities resulted from the pro- Fig. 41. Dilatation of Lymph Channels. 107 gressive development of the connective-tissue corpuscles, and that in the above case the lymph-vessels and connective-tissue corpuscles were simultaneously involved. These conclusions he subsequently verified by examining the part of the tongue re- moved by Casper von Seibold, in 1791, and which had been perfectly preserved in alcohol. "The tongue belonged to a girl aged 12, had been unusually thick at birth, and grown slowly to such a size that it finally protruded be- yond the edge of the teeth four and a half inches, was six inches wide, and two-thirds of an inch thick." The removed por- tion was covered with enlarged papillae and interspersed through- out its structure with numerous rounded and oblong cavities. Billroth1 concludes from his examinations of several speci- mens from the excised portions of congenital macrochilia,2 that the affection is analogous to macroglossia, and insists that the respective tumor formations occur in two forms essentially differ- ent externally; that is, they are either "connective tissue new formations between the muscular fasciculi, or cavernous cystoid degenerations, where the caverns contain a lymphoid fluid— a tumor formation, which, in contradistinction to cavernous blood-tumors, can be distinguished as cavernous lymph-tumors. Both forms can combine with one another, which may be the more easily comprehended, as both owe their existence to a proliferation of connective-tissue cells, whose eventual further development into fibrous connective-tissue, or transformation of their corpuscular elements into a homogeneous fluid determines the external difference of both forms of tumors." He maintains that the condition of the tongue in the cases reported by Wagner, O. Weber and Volkmann, was due to the enormous new formation of connective tissue between the mus- cles. In Langenbeck's cases of macrochilia, the excised por- tions showed hypertrophic development of connective tissue and considerable enlargement of the glands of the lip, but the congenitally thickened lip had no independent growth. The following case of congenital macrochilia was observed by Bill- roth in Langenbeck's clinic. 1 Beitrage zur Pathologische Histologic, p. 215. » Cases of Wagner and Langenbeck. 108 Congenital Occlusion and Case LXX1.—C. R, aged fifteen, was born with a thick upper lip: He often suffered with swelling of the glands of the neck during child- hood, without suppuration ever taking place, and several times the upper lip had been inflamed and much swollen, which had subsided, leaving only an increased enlargement of the lip. At the time of the observation (1859), the boy appeared well nourished ; the upper lip protruded beyond the lower, and was far beyond its normal size. The buccal mucous membrane turned outward, was corroded, bled easily; color dark-red. The tumor felt tensely elastic, not fluctuating, was not painful, and could not be diminished by pressure. The excised portion collapsed very much, and showed to the naked eye a distinct cavernous trabecular tissue, and a lymphoid serous fluid could be pressed from the deeper caverns, while coagula were found in the smaller caverns. The trabecular were formed in part of connec- tive tissue only, in part also by fibres of the orbicularis oris; the largest cavities were of the size of small peas, the smallest microscopic. Microscopic examination showed that the trabecular consisted mostly of inelastic connective-tissue fibres, mixed with many elastic fibres; in some of them lay also many striped muscular fibres in larger or smaller microscopic bundles, especially in the periphery; blood-ves- sels were recognized in many trabecular, especially small arteries. A single layer of small spindle-shaped cells surrounded most of the finer trabeculae in the manner of vascular epithelium. The serous fluid found in the meshes presented only small cells in a fluid containing albumen and mucin, which were so like lymph-corpuscles, that they could not be distinguished from them; similar cells were also found in the white coagula of the smallest meshes. Case LXXII.1—E. S., aged seven months, suffered from congenital macroglossia, which about every four weeks was attacked with some inflammation, attended with difficult deglutition, dyspnoea and consid- erable enlargement of the neighboring lymphatic glands. The volume of the tongue was increased after each attack, finally attaining the size of an ordinary apple, felt very tense to the touch ; was dark-red; its surface was covered with a thick, white coating. The strongly developed papilla? gave to the surface a thickly villous, furry appear- ance. The protruding portion was amputated, and on examination its parenchyma was found to have degenerated into a cavernous mesh- work, whose trabecular were partly formed of white, firm connective- tissue cords, partly by muscle bundles. The fluid within the meshes of the cavernous tissue coagulated into very white coagula, which looked like fibrin coagula and consisted of lymph-corpuscles. The examination of these specimens led Billroth to the con- clusion that the caverns were in connection with the lymphatic system, which was corroborated by the clinical histories of the Billroth, loc. cit. Dilatation of Lymph Channels. 109 cases. He failed to demonstrate any direct communications between the caverns and lymph vascular system, and examined the transition portions from the healthy to the diseased tissue, with special reference to this point, with the following result: " The source of development was in the connective-tissue cells, whose nuclei divided and gave rise to the cell-agglomerations found in the connective tissue as well as between the muscle-bundles. The cells which could be isolated formed the starting-point of the disease; the rapidly increasing cells produced either a firm connective-tissue substance, resulting in the fibroid form of tongue or lip hypertrophy, or the intercellular substance produced by the cells was fluid, and the cavernous form was the result—both may be combined, as was the case in the tongue, where a partly fibrous l and partly cystoid tissue was developed." Billroth coincides with Virchow, that in such conditions as were found in cases 71 and 72, a cavernous ectasia of lymph- vessels was the primary and predominant condition, but he dif- fers from Virchow in the opinion that all cases of congenital macroglossia and macrochilia find their cause in ectasia of lymph-vessels and spaces, and holds that in some cases the hypertrophy was solely a fibroid development. From these views Weber2 dissents, and maintains that it is an hypertrophy of the muscular tissue, having its beginning in an exudation of plastic material as the result of some obscure inflammatory process. Case LXXIII.3—A young girl, 10 years of age. For a year and a half the parents noticed that the nose increased in size towards the root and lateral parts ; the tumefaction extended by degrees to the two inferior eyelids and towards the inter-superciliary space; it increased gradually while remaining circumscribed in these regions. The tumor was punctured, but in two days was reproduced to the 1 Billroth asserts that cavernous lymph-tumors, like cavernous blood-tumors, may sometimes combine with fibroid and lipoma formations, and cites the case of a tumor extirpated by Langenbeck, in which the mesh-cavities con- tained a fluid, which under the microscope looked like lymph, and in which the fibroid and lipomatous formations were found. He also observed in a tumor of the lobe of the ear of bean size, that a third of it consisted of caver- nous tissue with lymphoid fluid, whilst the other two-thirds presented the structure of fibroma. 8 Archiv f. Patholog. Anat. und Physiolog.. vol. vii., 1854. 3 M. N. Dalbanne, eleve du service of M. Prof. Broca. Le Courrier Medical, No. 50, Dec. 12, 1874, p. 394. 110 Congenital Occlusion and same size as before. Subsequently she was committed to the care of M. Broca. At this time both lower eyelids were much enlarged, soft, giving a false sensation of fluctuation as in lipoma, and simu- lated two voluminous pads which encroached upon the eyeballs, par- tially covering them and elevating the upper lids. The base of the nose and the lower part of the forehead participated in the tumefac- tion, which effaced above the level of the frontal protuberances, and which descended on either side to the convex borders of the carti- lage of the nares. The facial mask presented a peculiar aspect; on the two sides, the swelling had produced a sort of levelling ; the deep depression which separates the bridge of the nose from the promi- nence of the malar bones was partially filled up ; the inferior angles of the eye were raised. The skin of the eyelids was slightly bluish; that of the forehead and nose was pale and shining. The thinned skin could be raised. The tumor could be but slightly diminished by pressure, but the contents flowed from one part to another. Broca punctured the tumor on the left eyelid and the entire tumor disappeared, proving a communication between the pouches. The fluid discharged was pale yellow, and exhibited, on microscopic exam- ination, red globules, some normal, others crenated and deformed ; no globulins nor fat granules. It coagulated on exposure to the air, the coagulum was slightly red and contained red and white cor- puscles. The scrum was alkaline. Broca concluded that the case was one of lymphatic angioma. Broca regarded the lesions in this case as closely comparable, if not identical, with those presented in the case of macroglossia reported by Virchow. In the latter case the lacunae varied from points scarcely perceptible to cavities measuring more than a line; many of the cavities communicated by minute openings in their intervening septa. According to Virchow the cavernous structure depended on the simultaneous dilata- tion of the lymphatic vessels and of the plasmatic channels in communication with them. Sappey rejects any hypothesis in- volving distention of the serous canaliculi of the connective tissue, but admits the ectasy of the vessels. Broca suggests that the cavernous condition may be produced by the dilata- tion of lymphatic vessels, which " elongate themselves, become tortuous, return upon themselves in the form of clusters com- parable to little bladders united to each other," and by the thin- ning and rupture of their walls become transformed into lacunae. Some of these lymphatic varices undergo a polycystic trans- formation, which some have attributed to obliteration of the vessel, but Sappey denies this and insists that the ectasy is due to a primary lesion of the walls of the vessels, which dimin- Dilatation of Lymph Channels. Ill ishes resistance and elasticity, and which " depends on a gen- eral influence as unknown as that which presides over the formation of venous tumors." Virchow insists that the " bead-like, bluish, transparent ves- icles, which varied in size from just visible'bodies to the size of hempseed," found on the under surface of the ablated portion of the tongue, were dilated terminal lymph-spaces, and commu- nicated by very fine apertures with deeper-seated vessels, or with the cavities of the cavernous tissue of the parenchyma. For, notwithstanding this connection could not be demonstrated, it could be shown that the cystoid spaces, probably dilated lymph canaliculi, became smaller and smaller towards the sur- face, and, finally, bead-like vesicles could be traced up to the papillae. The characteristics of the cavities with which the hypertrophied portion were interspersed, can only be explained upon the supposition of the primary ectasia of lymph-channels. Their smooth, regular walls, bead-like course, the albuminous contents, and the simultaneous enlargement of a neighboring gland, from wjiich lymph was discharged, point to a passive dilatation of lymph-channels. In one of Billroth's cases, cav- ernous trabecular tissue was distinctly visible to the naked eye, from which a lymphoid fluid could be pressed, and, in the other case, he found a cavernous transformation of the parenchyma containing a lymphoid fluid. Neither Billroth nor Virchow succeeded in establishing a direct continuity between the cav- erns and lymph-capillaries, but the microscopic character of the fluid was sufficient. In one of Billroth's cases it was not possible to distinguish the fluid from lymph, and in the other it consisted of lymph-corpuscles and fibrin. Virchow maintains that the cystoid formations found in the nodes of congenital hypertrophies are formed by the diktat ion of the lymph-spaces, though their communication with lymph-vessels may not be rec- ognized. Billroth, though holding that congenital macroglos- sia and macrochilia may be either solid or cystic, concedes that the cysts owe their origin to occlusion and dilatation of lymph- channels ; and O. Weber1 asserts that congenital lymphangiec- tasias of the tongne and lip find their cause in dilatation of the final terminations, or, more correctly, of the origin of the lymph- vessels. 1 Billroth and Pitha, Surgery, vol. vii., 2d div., 1st part, p. 72. 112 Congenital Occlusion and " In a clinicai aspect," says Billroth, " the connection of cav- ernous degeneration of the tongue and lip with disease of the lymphatic system is highly probable, especially in connection with a scrofulous diathesis." In both cases detailed by him, " rather considerable tumefaction of the submaxillary glands existed simultaneously with the affection of the tongue and lip, especially in the acute attacks, which, he suggests, may be traced to lymph thrombosis taking place in the cavernous spaces." In this connection I append the case of u elephanti- asis dependent on the scrofulous habit," reported by Ilufe- land.1 Case LXXIV.*—A boy, aged fifteen, had a congenital tumor of the upper lip, which protruded beyond the lower lip in the form of a hemisphere ; was painless, could not be compressed, not fluctuating, and tensely elastic. It was frequently attacked by acute inflamma- tion, and bled easily. After its excision, it presented, even to the naked eye, a cavernous trabecular tissue, whose mesh-cavities con- tained partly coagulum, partly serous fluid. The trabecular consisted of connective tissue which contained many elastic fibres and blood- vessels ; they were invested by epithelium. The fluid contained small cells like lymph-corpuscles. Case LXXV.3—Adolph A., set. two months. In the dorsal decubi- tus of the patient, the entire right half of the thorax and lumbar 1 A girl with a scrofulous constitution having had in infancy discharges from the ears, ulcerated eyelids, and all the symptoms of a scrofulous diathesis, was seized with small-pox in her eleventh year. She continued in good health for two years ; but in the course of her thirteenth year a swelling commenced on her left foot, which extended to the calf. This disappeared, but subsequently returned and extended throughout the entire limb, the left foot growing to twice the size of the right, was cool, pale, and so hard that the fingers could make no impression on it. Subsequently, a vesicle appeared on the inside of the left knee, from which a yellowish serous fluid was discharged. The vesi- cle healed, but reappeared, and the matter discharged this time resembled coagulated milk, and was so acrid as to inflame all the neighboring parts. The foot continued to swell and grow harder, until it felt in some places like leather. She had at varying intervals violent attacks of delirium, oppression, and congestion of the brain, beginning with the approach of the catamenia. The leg continued to grow, became overspread with a red color mixed with a bluish tint. A small, shining, very tense spot appeared on the calf. This and the vesicle ulcerated and discharged fetid pus. Nevertheless, the limb con- tinued to grow, became monstrous in stee, and scirrhous throughout; glandular swellings appeared in various parts, which inflamed and suppurated. Hectic set in, and death ensued. —A Treatise on Scrofulous Disease, Translated by C. D. Meigs, M.D., Philadelphia, 1829, p. 212. 8 Lucke. Billroth and Pitha, Surgery, vol. ii., div. 1, part 2d, p. 268. 3 Hofraokl, Langenbeck's Archiv, vol. xii., p. 685. Dilatation of Lymph Channels. 113 region was occupied by a tumor which extended upwards to the ax- illa, downwards to the crista ilii, inwards to within one inch of the sternum, and backwards to the transverse processes of the vertebrae. The covering integument was traversed by small dilated veins, and presented several bluish elastic places. Upon the external side of the tumor was a venous teleangiectasis one and one-half inches lon« by one wide. The surface of the tumor was hilly, and in one place the skin was retracted in an umbilicus-like manner. It was elastic, fluctuated at most prominent part, could be diminished somewhat by pressure, and became full and tense during the crying of the child. Nothing abnormal in the thoracic or abdominal organs. At its upper part it was somewhat transparent. The tumor collapsed after evacu- ation of the fluid, and seemed to consist of caverns which communi- cated one with another by numerous canals. The fluid was alkaline, coagulated spontaneously. Microscopically a small number of lymph- cells could be demonstrated. 100 grammes of the fluid contained : serum albumen, 2.385 ; fibrin, 6.085 gr. ; globulin in small quantity, and salts of the blood serum. No lymph-vessel epithelium could be discovered. Case LXXVI.1—A.W., set. one year and five months, had a congen- ital tumor of the size of a pigeon's egg, of hard consistency, situated to the left of the perineum ip the immediate vicinity of the scrotum. At the time of the observation the tumor had grown to the size of an infant's head, and extended from the scrotum attached to the left of the perineum, to behind the anus, sending the principal mass towards the left tuber ischii, and looked like a third buttock. The primary portion had grown but little and felt hardish, whilst the new growth felt more like a lipoma or cavernous growth, and formed the principal part of the mass. The child was otherwise healthy, ate, drank, and possessed all the normal functions. Microscopic examination of the ablated portion by Professor Wal- deyer. It consisted, for the greatest part, of normal cutis, with sub- jacent, perhaps inch thick, fat connective-tissue cushions. The fat clusters, however, were but little developed ; the interstitial connec- tive tissue was more prominent and formed in spots tolerably firm, but always elastic, yielding masses. In the place of the fat cushions, single, mostly pea-size, clear cysts, with thin walls, were seen lying in the connective-tissue meshes. In the larger integumentary por- tions one of the cysts attained nearly the size of a walnut. The smallest looked like beads, clear a3 water and of pin's-head size. A piercing injection filled several of the larger and smaller cystic cavities, so that a communication existed between them as well as with the lymphatic lacunae in the connective tissue. Upon section, a perfectly clear, slightly adhesive fluid of weakly alkaline reaction was evacuated, which coagulated spontaneously into a beautiful, con- sistent jelly. The microscope showed, besides isolated red blood- disks and a small quantity of finely granular coagulum, only amoe- boid corpuscles in moderate quantity, of the character of ordinary 1 Eeichel, Virch. Arch., vol. lxiv., p. 497, 1869. 114. Congenital Occlusion and lymph-corpuscles throughout. The cysts, even to the smaller ones, were composed of intercommunicating compartments. Their walls consisted of fibrillar connective tissue, upon the interior surface of which could be demonstrated the .contours of beautiful lymphatic endothelium. In the more compact connective-tissue accumulations were found, after hardening in alcohol, smaller, irregularly formed cystic cavities, and larger cleft-like lacunae, which were filled with granular coagulurn and lymphatic cells, such as were obtained from the larger cysts in the recent state. Prof. Waldeyer classed the case among lymph-angiomata. Case LXXVII.'—A female, aged nineteen. At the age of nine, while playing, was suddenly attacked with severe pain in the left groin, attended with redness and accompanied with vomiting and chilliness. These attacks recurred thrice a year until four years ago, when a number of small vesicles formed upon the inner side of the thigh, which ruptured spontaneously and have continued to discharge a clear fluid. At the present time (July, 1869), a tumor, about the size of a fist, indistinctly defined and perfectly soft, is situated upon the inner side of the left thigh, below Poupart's ligament. The cov- ering integument is traversed by several dilated vessels supplied with several openings, from which a fluid can be expressed, which coagulates into transparent, pale jelly. Instead of a cold abscess Prof. Billroth found a cavity of fine mesh-work from which the fluid ex- uded, which proved to be of a lymphatic character, as shown by the following analysis : Reaction, alkaline; sediment, large, consisting of fibrin. The fluid, in its principal bulk, consisted of albuminates, among which were serum-albumen, fibrin and caseine. The sediment contained fibrin coagula, in which were found numerous colorless blood-cor- puscles, a few red blood-corpuscles, some tissue debris, consisting of connective tissue and pavement epithelium. Quantitative analysis : specific gravity, 1.017 ; water, 978 ; ashes, 8.125; fibrin, 1.000; globulin, 1.204; serum-albumen, 5.494; caseine, 5.518; phosphoric acid, 0.200 ; lime, 0.252 ; chloride of so- dium, 2.245; and sulphuric acid, 1.034. Microscopic examination of the extirpated tumor byCzerny. The principal bulk of the tumor consisted of connective-tissue rabecular mesh-work, which contained lymph in its interstices. The walls of the lymph-caverns were lined by endothelium. Here and there, especially in the periphery, the connective tissue was richly infiltrated with cells, and columns of young cells passed into the sur- rounding tissue, which were connected with lymph vessels. The tumor seemed to owe its origin to the development of granulation tis- sue around the lymph-vessels, which, by cicatrization produced ectasia of the vessels, and thus led to the formation of a cavernous lymph-tumor.2 ' Gjorgjewic, Arch. f. klinisch. Chir., Langenbeck, Bd. xii., p. 646, 1870. ' The congenital character of this case is doubtful. The manner of its de- velopment is so nearly identical with the case of Demarquay (No. 50) that I have felt compelled to introduce it. Dilatation of Lymph Channels. 115 Case LXXVIII."—R. Z., set. 22. During his fourth year began to grow thin without assignable cause, and then his mother noticed a small, painless node upon the right side of the chest and a small protuberance upon his forehead. These were followed by numerous similar growths upon different parts of the body, but the chest tumor distinguished itself by its continued growth, so that in 1864 it measured in length thirty-five centims., and hung in a pouch-like manner from the third rib to a line drawn horizontally outward from the umbilicus. At its places of attachment, which extended from the axilla to the middle of the sternum, its circumference was thirty- four centims., and thence from above down- wards, flattening a little, reaching a thickness of fifteen to twenty centims. (See Fig. 43.) Its surface was covered with secondary nodes, from cherry to apple size, which lay closely together, and were distinguished from the dirty, corrugated and scarred skin by a red- dish, pale color; the skin was traversed by abundant venous networks, and along the con- vex edge was covered by bran-like scales. The entire sac felt strong and elastic to the touch, could be lengthened by traction, and could be thrown over the shoulders. No nipple could be discovered. Besides this tumor the trunk and extremities were abundantly covered with larger and smaller growths. Three were sit- uated upon the head; one as large as a pigeon's egg occupied the centre of the forehead ; two, each the size of hen's eggs, were situated symmetrically, one upon each mastoid process. The entire back was sown with smaller nod ules, and two were found on each side of the Fig. 43. linea alba. All these nodes had a smooth surface, were of soft consistency and of lighter color than the sur- rounding dirty brown skin. The tumor weighed after extirpation three and a half pounds, and presented upon the dry, pale brown cautery surface a firmly meshed tissue. The cortical layer, of an average thickness of three centims., consisted of round juicy nodes, of the average size of a cherry and of a yellowish color, and were in- closed by a strong, firmly-fibred interstitial substance in which the vessels and numerous cystic cavities of from millet to lentil size were found, from which a clear albuminoid fluid was discharged. Microscopic examination revealed cutis papillae, more broad than high, a relatively thin, brown rete-Malpighi, with superficial, sparse, horny epidermis cells. The sebaceous glands appeared at places to have degenerated into lentil-sized sacs filled with fat granules and closed toward the integumentary surface. The deep nodules of the cortex of the tumor were composed of aggregations of round or oval, ■Bryk, Oaster. Zeitschr. fur pract. Heilkunde, vol. xv., No. 41, p. 141. 116 Congenital Occlusion and mostly multinuclear cells of the size of pus-corpuscles ; the superficial, however, were composed of nets of anastomosing nuclear connective- tissue cells, whose branches bounded very small and regular mesh-cav- ities, and uniting with the fibre-layers of the interstitial substance in- closing them in a ring form, presented an areolar appearance. The fibre- trabeculse found between the latter consisted principally of elastic tissue. The lymph-vessels formed nets with wide, oval mesh-cavities. Their diameter varied from 0.03 to 0.05 mm. In such regions as were rich in lymph-vessels round or oval parenchyma-lacunas were seen, which, like the microscopically cystoid cavities, were lymph- vessels. The central portion differed from the peripheral layer by a firmer texture and a strikingly brown-red color. A strong, fibrous trabecular network, which passed from above downwards, correspond- ing to the longitudinal diameter of the tumor, received numerous dense connective-tissue nodes. Small fat lobules were scattered here and there, associated with a wealth of vessels, especially veins, so that the tumor acquired a teleangiectatic appearance. The entire tumor, adds Prof. Bryk, presented a congenital character. Case LXXIX.1—S. K., aged 50, had had from her earliest recol- lection a bean-like prominence upon the left labium majus. Observed after the menses had ceased for two years, that it enlarged, became pediculated and began to develop into a globular tumor, which hung between the thighs. Inguinal glands of left side swollen and painful; and upon palpation a diffuse, painful induration was felt in the left side of the pelvis. In consequence of a superficial ulceration a sero- purulent fluid had been discharging for several months from the tumor. The tumor, after removal, measured twenty-eight centims. in circum- ference. The bronzed-colored surface of the movable, hairless skin was smooth. Upon section a large quantity of serous fluid exuded, which coagulated spontaneously. White connective-tissue strands traversed the tumor in every direction, and gave it a finely lobulated construc- tion, which was interrupted by numerous cysts, varying in size from a millet-seed to that of a bean. Upon microscopic examination a cutis tissue could be demonstrated upon the most depending portions, the papillae of which, more broad than high, were supplied with capillary vessels with thickened walls. In all other parts the boundary be- tween the cutis and the bulk of the tumor was obliterated, and the latter consisted of a finely-meshed network of spindle-cells which were crossed in all directions by elastic fibres and undulatory connect- ive-tissue strands, between which, in many places, conglomerations of nucleated cells were imbedded, which were in a state of fatty de- generation. The lymph-vessels were very abundant, and in connection with the elastic and connective-tissue fibres, formed the principal part of the tumor. The bead-like, dilated larger branches showed thickened walls covered by layers of fine spindle-cells divided in the vicinity of the cysts into varicose networks with wide meshes, and here and there attained a diameter which corresponded to the lumen of the 'Prof. Bryk, loc. cit., p. 249. Dilatation of Lymph Channels. 117 cystoid cavities. They were lined by a delicate epithelium of small, round nucleated cells. Towards the periphery they gradually became smaller and smaller. Fat-cells were found only in the most dependent part of the tumor immediately beneath the corium in the form of isolated vesicles, and smaller than the cells of the normal panniculus adiposus. Case LXXX.1—H. K., set. 14 months, was born with a cherry-like, fiat node, situated upon the mons veneris, a little to the right, which began to increase very rapidly soon after birth, and at the age of one year and six months had attained the size and form of a bunch of grapes, as represented in Fig. 44, was movable in all directions, and rose from the integument of the mons by a short pedicle, which became distinct upon traction downwards and during the erect position Fig. 44. of the child ; it arched over the right inguinal region, covering the external genitalia, and descending in an oblique manner from above and the right side to below and to the left, between the thighs down to the knee-joint, with a vertical diameter of thirty centimetres; its circumference at the pedicle was twenty centimetres; at its base in the height of the inguinal fold thirty-eight centimetres. Upon eleva- ting the tumor it was discovered to have intimately grown with the labia majora, but the nymphae and clitoris were normal. The skin was traversed by numerous venous nets, could only be lifted up in a fold in the region of the pedicle and at the upper portion of the tumor, at other places it was firmly attached. Upon its surface rose larger and smaller nodes of soft consistency, disappearing under pressure, when a deep-seated annular constriction could be distinctly recognized as boundaries between the single protuberances. 1 Prof. Bryk, loc. cit., p. 208. 11$ Congenital Occlusion and After the extirpation of the tumor, one and a half pounds in weight, a large quantity of serum-like fluid, which coagulated spon- taneously, was discharged, after which the nodes collapsed, and only a loose, firmly meshed connective tissue remained, which was perme- ated by white tendinous strands in various directions. Vascularity was not considerable, only two small arteries had to be ligated; the veins were more numerous, and several were varicose. Upon microscopic examination a network of anastomosing connective- tissue cells, with regular mesh-cavities were found in the places of the soft, fluctuating nodes, surrounded by elastic fibre strands, be- Fig. 45. tween which capillaries with thickened walls and lymph-vessels were imbedded. Fat-cells were exceedingly rare in the form of single lobules at the base of the tumor. Fig. 45 represents another view of the growth. Prof. Bryk concludes the report of the last case with a refer- ence to a plaster cast in the collection of the surgical clinic at Cracow, of a case observed in a woman 30 years old, in which a " pale red prominence found at birth in the vicinity of the mons veneris, which gradually bulged forward to the size of an apple," and at the appearance of the catamenia began to grow rapidly, had at the time of the observation " extended down- wards between the knees and terminated in a rounded, melon- shaped intumescence," which measured forty-four centimetres in circumference. During the progress of the growth " little vesicles appeared at every menstrual period upon the surface of the Dilatation of Lymph Channels. 119 tumor, which ruptured spontaneously and discharged a milky fluid. Each vesicular eruption was followed by increase of the volume of the tumor." Prof. Bryk invites special attention to the difference in the progress of development which character- ized the tumors in case 79 and in the case just referred to, and insists that such growths are usually interrupted in their development, and, in the congenital forms, their course is very slow until the catamenia are established, when with every recur- ring menstrual period the volume of the tumor is greatly aug- mented. In case 80 the increasing growth seems to have been coincident with birth, and this, Prof. B. claims, constitutes its exceptional character. Others have observed the apparent con- nection between the menstrual recurrences and increased devel- opment of lymphatic tumors, but it is not an invariable rule. In case 79 the bean-like prominence which had existed from birth upon the left labium ma jus did not begin to increase until two years after the menopause. The following case re- ported by Dr. James R. Chad wick, of Boston, exhibited a marked connection between the development of the lymphangioma and the periodic discharges. Case LXXXI.1—Miss L., aged thirty-two, had suffered for six years with hystero-epileptic convulsions, which were supposed to be due to the presence of a tumor " at the vulva, first observed about the time the convulsions began," and which at the time of the examina- tion was " as large as a walnut," oval and elastic, and " lying pre- cisely beneath the arch of the pubis, between the anterior vaginal wall and the urethra, and projecting into the vaginal canal, so as to oc- clude the opening into the hymen." The tumor had increased with every menstrual period. During the catamenial period preceding its removal, "it had swelled to unwonted dimensions, had protruded from the vulva, whereupon she had picked off two scales from its surface. The tumor had since remained large, protruding, and at the two spots mentioned the tissues had budded out." The tumor, about as large as a hen's egg, was " found2 to be ex- ceedingly rich in delicate vessels, not containing blood, anastomosing one with the other in a very intimate manner ; the intervening spaces were more or less circular, and contained a fibrillated substance m which were occasional round and innumerable stellate cells. The latter were, in many instances, directly continuous with the vessels previously described, particularly with the smaller ones, which were likewise stellate in their distribution, and apparently differed from 1 Phil. Med. Times, Sept., 1875, p. 801. 8 Microscopic examination by Dr. R. H. Fitz. 120 Congenital Occlusion and the stellate corpuscles only in being more voluminous and having more abundantly nucleated walls." The anastomosing tubes pre- sented the characteristics of lymph-vessels.1 In this connection the cases of lymphatic tumors* involving tha absorbent vessels of the breast, become interesting. They are usually found in the " breast of females between the ages of fifteen and thirty-five, and are liable to recur frequently, where there exists comparative emaciation, accompanied with irregular or de- ficient menstruation, depression of spirits and general debility, and, hence, most frequently occur in suckling and sclerotic women, and are always associated with deficient circulation in the womb, manifested by the discharge of an imperfect secretion, or false membrane from its mucous surface."3 This relation of the menses to tumor developments is more distinctly exhibited in the succeed- ing case. 1 Vaginal fibromata have been quite frequently observed, a few of which were congenital, but only in a few instances were microscopic examinations made. It is probable, as suggested by Dr. Chadwick, that some of them may have been lymphangioma. See for references the papers by Drs. Bryk and Chadwick, previously referred to. a " These tumors are characterized by a painful, tender, and irritable swell- ing, varying in size and consisting of several cord-like, indurations, at times disposed in parallel rows, or connected after the manner of an anastomosis. The swelling is always transverse, following the direction of the absorbents towards the axilla, and consists of lymphatic vessels with thickened coats, imbedded in a stratum of condensed cellular tissue. The glands in the axilla, and, more rarely, those below the clavicle, become enlarged. Among the cases reported by Dr. Coley was one, in which the tumor was as large as a walnut, irregular on its surface, tender and painful on pressure, and situated in the upper part of the breast along the course of the absorbents. Every three or four weeks the uterus discharged a kind of false membrane instead of the proper menstrual secretion. The nipple was retracted; bowels relaxed. These tumors are to be distinguished from the chronic mammary tumors de- scribed by Sir Astley Cooper, and from the irritable tumor."—James Milman Coley, M.D., London Lancet, vol. i., 1843, p. 579. 3 Milk secreted from the axilla.—M. S., set 37. A swelling nearly the size of half a walnut was first observed in the right axilla, the night of her seventh confinement, and continued the same for a month, when it became painful and began to discharge a small quantity of a milky-looking fluid. A month later it had somewhat a doughy feel, was compressible, the covering integu- ment was normal. Ou pressure a small quantity of milky fluid wasdischarged, which on microscopic examination presented all the characters of true milk, and seemed to have been secreted from a portion of the mammary gland situ- ated in the axilla. Six months after the first observation the swelling pre- sented the appearances and character as previously described, and the dis- charge of milk continued. Hare, Trans. Patholog. Soc, London, vol. xi., p. 304, 1860. A case somewhat similar is recorded in Die. des Sci. Medicales t xxx p. 397. Dilatation of Lymph Channels. 121 Case LXXXII.1—Bosina Geng, set. 32, was of medium height, well proportioned, well nourished, never seriously ill, though of weakly constitution. At the age of 19 was compelled to abandon " service " because of a tumor of the external genitalia, from which after puncture a watery fluid was discharged. She menstruated regularly up to her 25th year, and gave birth to a healthy child in her 26th year. After the lying-in menstruation ceased entirely and the skin of the back began to thicken. The tumor grew rapidly, and in eighteen months had attained the size, when first seen by Hecker, as represented in Fig. 46. Fig. 46. The integument was flaccid, dirt fallow, yellowish, and especially from the occiput to the pedicle of the largest tumor much thickened, grayish and traversed by white lines and somewhat excavated spots, like the abdomen of women who had given birth to children, but was movable and could be elevated into large folds. Upon the skin in many places were sixty smaller and larger tumors, many about the size of a cherry, comparable to lipoma angiectodes; others compact like fat tumors; others soft, fluctuating, and containing a serous fluid. The integument of the solid tumor was thickened, but of normal color; that of the others was thinner, of a bluish color. A large, movable soft tumor was located upon the neck; another, of apple size, upon left buttock. The largest one commenced at the seventh cervical ver- tebra and from both scapulae, with a pedicle sixteen inches in diame- ter, which extended down to the first lumbar vertebra, occupying the entire back and drawing up the skin of the anterior and lateral por- 1 Carl W. Hecker. Die Elephantiasis. 1858. 122 Congenital Occlusion and tions of the trunk.1 It hung over the buttocks, measured longitudi- nally 2 ft. 2 in. at its base, in circumference 2 ft. 8 in., and just above its lowest portion 3 ft. 4 in. in circumference. After amputa: tion it weighed 31 lbs. The greater part of the tumor felt like a lipoma, but in a few places was soft and fluctuating. The integument was traversed by few vessels, but strongly pigmented, somewhat red- dened during fever, and upon its surface were cysts of pea size, and soft tumors filled with serum, like those situated upon other parts. From cracks and fissures a sickening, light yellow fluid dribbles at certain periods, which after standing separates into a thin, lighter, and thick, viscid, gelatinous portion. The quantity usually amounts to four or five pints in twenty-four hours; recurs every four or five weeks, lasting usually four or six days, and is accompanied with fever, lassitude, soreness in the limbs, nausea and vomiting, palpitation, dyspnoea and general malaise. A sound introduced through an open- ing entered a lardaceous mass supplied with caverns, from which was discharged a fluid rich in albumen, with the addition of several salts, especially chloride of sodium. Towards the lower end the tumor was divided by a deep furrow into a smaller left and a larger lower right half. Pathologico-anatomical examination of the tumor.* It lost by drainage, after amputation, of a serous, albuminous fluid several pounds. The microscope showed it to consist of hypertrophic con- nective tissue, the interstices of which were filled with serum and a firm, white, lardaceous mass. The skin was in some places an inch thick; only a few fat-globules were found. It was very vascular and traversed by thirty-six dilated, elongated and tortuous veins, which did not collapse, but remained patulous and rose more or less over the cut surface. The arteries were dilated, elongated and tortuous, but their coats did not exhibit any textural changes. These vessels trav- ersed the hypertrophic integumentary and cellular tissues in every direction. Beneath the latter the parts did not show the least struc- tural change. The foregoing examination does not prove the lymphatic nature of the tumor; but the presence of the numerous caverns formed by the greatly expanded connective tissue interstices 1 The patient insisted that these tumors were present from her earliest recol- lection, as prominences of the color of the skin and not as spots. 4 The brothers and sisters of Rosina Geng were healthy. Her parents had been long dead, but it was generally known that their maternal grandfather had upon his back and chest many tumors of about the size of a fist, and many wart-like excrescences upon other parts; that their father had in the later years of his life a large tumor on his left arm, which sometimes broke and discharged a stinking ichor. His brother had a tumor larger than Rosina Geng's upon his back, which hung far down over the buttocks, which rendered walking scarcely possible. This hereditary tendency has appeared in several instances, and ia attributed by Hecker to a peculiar diathesis, which is transmitted to offspring. Dilatation of Lymph Channels. 123 filled with a fluid rich in albumen and salts, and the fat masses, go far towards establishing this conclusion. This view derives confirmation from the analogous conditions found in several of the cases previously introduced. In Lucke's case (74) the tu- mor on the upper lip presented in its interior organization a cavernous trabecular tissue, with meshes filled partly with a coagulum and partly " with a serous fluid containing small cells like lymph corpuscles;" in Keichel's case (76) of congenital " lymphangioma cavernosum cystisus," the hard perineal tumor, which felt like a lipoma, proved on microscopic examination to be a conglomeration of larger and smaller cystoid cavities, with interposed fat and connective tissue. Prof. Waldeyer found in the meshes of the connective tissue, " transparent cysts, commu- nicating one with another and with the lymphatic lacunas of the connective tissue." The fluid found in these cysts was weakly alkaline, perfectly clear, slightly adhesive, coagulated upon exposure, and contained isolated red blood-disks and a few ameboid corpuscles resembling lymph corpuscles. Upon the interior surface of the cysts lymphatic endothelium appeared in perfect outline; in Hofmoke's case (75) the tumor consisted of caverns communicating with each other by canals. The inter- stices of the connective tissue mesh-work, which constituted the bulk of the tumor in Gjorgjewic's case, were filled with lymph. The cases (78, 79, and 80) reported by Prof. Bryk also present analogous conditions, but in all these cases the lymphatic nature of the cavernous structures was unmistakable. The case of Hecker exhibits other interesting phenomena; an enormously thickened skin, due to hypertrophied connective tissue, co-existed with a very remarkable and abundant supply of veins, which were greatly dilated, elongated, and tortuous. This extraordi- nary development of the veins necessarily led to stasis of ve- nous blood, and the fluid which filled to repletion the lymph spaces was probably derived, through transudation, from the venous plexus, and, consequently, represented a fluid poor in corpuscular elements, but comparatively rich in the constituents of blood-serum—hence the very marked proliferation of connec- tive tissue. The " cysts of pea size and soft tumors filled with serum," which studded the surface of the large tumor, were manifestly ampullar formations in open continuity with the widely dilated lymph spaces. The gelatinous coagulum which 121 Congenital Occlusion and formed characterized the exudation as an impoverished lymph- ous fluid. The " lardaceous" infiltration was probably a de generative process. Case LXXXIII.1—Therese Geng, the bastard child of Rosina Gem?, was born with a small tumor upon her back, which had grown to the size of a fist at the age of six. Never menstruated. From her fif- Fig. 47. teenth year the tumor grew rapidly. At the age of twenty-five she was small, well built, badly nourished, walked badly, and stooped towards the left side. The tumor, measuring 77 ctms. from base to 1 Czerny, Archiv. fur klinische Chirurgie, Vol. XVII., p. 357. Dilatation of Lymph Channels. 125 apex, extended from the last dorsal vertebra and hung like a bag be- low the popliteal space. A pear-shaped lobe, the size of a child's head, ulcerated at its lower end and discharged ichor, whilst another lobe, somewhat like a cock's comb, was prominent towards the right side. Circumference of the bag-like portion, 38 ctms. The external and an- terior side of the right thigh was covered with flat, hemispherical tu- mors, varying in circumference from the size of a silver dollar to that of a fist. The cutis was firm and thick, loosely attached, but not dis- colored. See Fig. 47. Fig. 48. In 1871 Prof. Hecker ablated the pear-shaped portion, and when Prof. Czerny took charge of the clinic several months afterwards, the tumor presented the appearance as represented in Fig. 48. The 126 Congenital Occlusion and skin was sallow, yellowish, muscular tissue flaccid, subcutaneous tis- sue rather fatty. The remaining portion of the tumor had increased considerably, and did not present itself as a sac-like elongation of the skin, but was very firm. The skin was firmly adherent, darkly pigmented, somewhat retracted at the seat of the operation, and gran- ulating. Upon the surface of the tumor were several fistulous canals, from which was discharged a thin serum, mixed with pus- flakes. The fluid, often secreted in large quantities, was clear, albu- minous, contained lymph corpuscles, coagulated readily and sponta- neously. Prof. Czerny made several ineffectual efforts to reduce the tumor. The patient died March, 1873. Sectio cadaveris. Both pupils equally dilated, hypostatic discolor- ations upon the back. Towards the left of the median line from the 10 th dorsal vertebra to 10 ctms. below the right trochanter, in a longitudinal extent of 45 ctms., the skin continued in a solid tumor, depending downwards. At the base of the tumor, 101 ctms. in cir- cumference, the skin could be lifted up in folds. At the greatest height, however, the skin was firmly attached. Surface brown, and covered by numerous, irregularly situated, white, smooth, cicatricial spots ; upon the greatest convexity several portions were oedematous, tensely stretched; the epidermis of these portions can be raised with ease. Upon pressure a moderate quantity of serum was discharged from a few openings. Through these openings a sound could be passed for several inches into a broken-down tissue. The rest of the body showed sparsely, softly elastic protuberances, of lentil to walnut size, over which the skin was thinned. Upon section they presented a reddish gray granulation tissue. The tumor, as large as two fists, over the trochanter was due to pus-collection in the bursa mucosa. An incision into the left temporal muscle re- sulted in the discharge of pus. The temporal plane of the parietal bone, the greater wing of sphenoid and a part of the squamous por- tion of the temporal bone, were rough, uneven, and upon the edges surrounded by a very vascular osteophytic wall. The diploe of this portion contained vessels filled with blood. Upon the inner side of the rather thin skull, corresponding to the site of the division of the middle meningeal artery, was an abscess as large as a walnut. Men- ingeal artery was pervious; dura mater on its external side, corre- sponding to the abscess, covered by thick granulations; inner surface smooth; cortical surface of brain firm, moist, and reddish gray. Mod- erate quantity of clear serum in the subarachnoid space and in the ventricles. The right arteria fossae Silvii was plugged by a solid reddish throm- bus, which extended into the three principal branches and could be traced into the internal carotid as far as the bifurcation. Thyroid gland as large as a fist, filled with small cysts containing colloid. The right lung attached to the thoracic wall. The middle lobe contained an old, encapsulated pus-focus. Subpleural eccbymoses at base of left lung. Dilatation of Lymph Channels. 127 Upon the convex surface and partly in the substance of the liver were several small encysted abscesses. Spleen attached to diaphragm and contained several old pus-foci. Right kidney contained an em- bolic focus ; ovaries smooth ; uterus virginal. After the intestines had been pushed aside, were discovered solid bundles of pad-like, yellowish white tumors, covered by the mesen- tery and parietal peritoneum, and lying upon the quadratus lum- borum. These tumors were enlargements of the anterior branches of the right lumbar nerve network. These nerve-tumors are repre- sented in the figure below (Fig. 49). Fig. 49.—a, n, Ileo-hypogastrium ; b. ileo-inguinalis ; c, genito-cruralis. The ter- minal portion of this nerve, in the illustra- tion lying alongside of the cruralis, crossed to the latter and took its course through the inguinal canal, d, », Cutaneous ext. Its situation in the figure is wrong. It crossed the genito-cruralis and passed outward to the anterior superior spine, e, n, Cruralis; g aorta (place of division into iliaca); i and * neuromata which were within the spinal canal. The lumbar nerve (a) was twice the size of the opposite one. The 2nd and 5th showed, at the place where the intervertebral ganglion should be, a pad-like, tortuous thickening, which in the majority of the anterior branches of the lumbar network reached as far as the nerves are contained in the abdominal cavity ; of the ganglionic swell- ings two were within the spinal canal—ganglion i within the sac of the spinalis, whilst k had grown to the outside of the latter. The latter, on account of its size (4 ctms. long, 2£ ctms. thick), had flattened the cauda equina, without, however, having disturbed the anatomical character, or the function of its nerves. The intumescences of the ileo-inguinal (b) and of the genito-cruralis (c) were partly within the intervertebral foramina. A freshly cut surface of the large tumor looked jelly-like, very moist, yellowish gray, very vascular, and tinged red. In places it was marbled and was of the consistence of the flesh of the sweet- water muscle. In a direction perpendicular to the surface it could be easily torn. Fine fibrillar, similar to those found in many lym- 128 Congenital Occlusion and phomata and spindle-cell sarcomata, could be split off. Upon ex- posure of the cut or torn surface to the air it turned pale pink, like lymph-gland tissue. In tearing the tumor were frequently met slit- like caverns, filled with a clear, readily coagulating fluid. The same fluid exuded from the cut surfaces upon the slightest pressure. The mass of the tumor was imbedded between the cutis and fascia, and forced itself between the single fat-lobes, so that a belt of fat-lobes ran through the middle of the cut surface. The develop- ment of vessels was as remarkable as in the patient's mother (case of Hecker). The veins as large as the little finger were supplied with valves and in their smaller ramifications possessed a sheath of lym- phoid tissue. Partly running parallel with, partly crossing the larger blood-vessels, were found—thickly crowded in many places, more sparsely scattered at others—solid cords of medullary whiteness, of the thickness of a crow- to that of a goose-quill, which showed many bead-like swellings, and which were connected with the dorsal branches of the lumbar and sacral nerves. The primary changes which led to the formation of the colossal tumor were best observed on the marginal portions. Along the larger vessels which ran between the fat-lobules of the subcutaneous tissue " there was an augmentation of the cells accompanying the adventitia, which partly possessed the form of migration cells, and partly the form of embryonal connective-tissue cells." This cell Fig. 50.—b, Caverns lined with endothelium, e, Juice-tracks in connective- tissue trabecule. increase accompanied the smaller branches imbedded in the adipose layers and those which penetrated the fat-lobules and surrounded the separate fat-cells, but not those which penetrated into the cutis proper. Embryonal connective tissue was developed around the sudoriparous glands and in the adjacent fat-lobules. The more deeply-seated fat-lobules were forced apart by the cell new formation, which had penetrated in some instances between the separate fat- cells. The covering epidermis was not thickened, the cells of the rete mal- Dilatation of Lymph Channels. 129 pighii were supplied with brown granular pigment. The corium was thinned and closely united to the mass of the tumor. The principal bulk of the latter consisted of connective tissue such as is found in the subcutaneous cellular tissue of embryonal life, or in myxomata; it was, however, in some places changed into solid, tendinous connec- tive tissue, in others into adipose tissue, but always retained the 1am- inous structure, so that along the vessels it could be split off in lamina which contained caverns between the fibres. A beautiful endothelium lined these caverns. See Fig. 50. By a piercing injection a blue injection fluid was forced into the channel system of caverns, which was abundantly developed below the cutis and finally terminated in characteristically pronounced lymph- vessels, which were traced as far as the centre of the tumor. FlQ. 51. —Lymph-vessels injected from greatest convexity of tumor, a; Lymph-sac around sebaceous gland, b. Sweat-gland convolution, c, Sweat- gland efferent duct, d, Lymph-vessel of papilla?. The hair-bulbs and sebaceous follicles were sparsely present and atro- phied; the efferent ducts of the sudoriparous glands were much elongated, the convolutions frequently lying 6 to 8 mm. below the surface. The glands were frequently drawn out of place. The seba- ceous glands were surrounded by sac-like cavities (Fig. 51) which united towards the hair-bulb and emptied into lymph-vessels which accompanied the hair-bulb to the surface of the cutis, where they surrounded the bulb in a wreath-like manner and afterwards passed. off into the superficial lymphatic network of the cutis, which frequently send centre lymph-vessels into single papillae. From the bottom of the sac occasionally a lymph-vessel took its origin and ran towards the subcutaneous tissue. There were also found lymph-sinuses (Fig. 51, b) surrounding sudoriparous gland convolutions, and lymph- sheaths around an efferent duct (c), yet within the cutis. In a general view of the cutis covering the tumor a superficial and deeper layer of lymph-vessels could be distinguished. The superficial layer was composed of smaller vessels, which anastomosed in a narrow network 130 Congenital Occlusion and and gave off a central lymph-vessel, rarely a loop (d), to many papillae. This layer was united by many branches with the deeper layer, which consisted of wider sinuous vessels, between which the sebaceous glands were situated. In the vicinity of the points of puncture the tensely filled lymph-vessels were covered with closely placed shorter and longer points, which Czerny regarded as the beginnings of the entering juice-tracks. It was further demonstrated that the juice-track system existed in the tissues of the tumor and were connected with large cavities forming a widespread system of canals. In this case, which Czerny entitled " elephantiasis arabum con- genita with pexiform neuromata," the tumor originated in a hyperplasia of the subcutaneous connective tissue, but in an em- bryonal form. The fat-cells were developed along the blood- vessels, and, in consequence of the close relation of the adipose with the connective tissue, it exhibits in some places new for- mations of connective tissue, and in other places fat-formations. As a whole the tumor characterized itself as a lymphoma, and presented in its interior structure conditions analogous to those found in several of. the preceding cases. Czerny claims to have found in the integumentary glands the periacinous lymph-caverns which Ludwig and Thomsa demon- strated for the seminal tubuli, Gianazzi for the salivary glands, and Boll for the lachrymal glands, and to have established a communication between the periacinous lymph-caverns of the sebaceous glands with the lymph-spaces of the skin. In a some- what macerated cadaver he succeeded in penetrating with an injection from the periacinous caverns of the sebaceous glands the lymph-spaces of the skin, elevating the epidermis in vesi- cles. " The presence of these lymph-sheaths," adds Czerny, " around the sebaceous glands, explains why in many cases of epithelial carcinoma the masses of epithelium which take their origin from proliferating sebaceous glands grow at once into the lymph-vessels and upon section imitate their ramifications bo exquisitely." Bizzozero, in a case of epithelial cancer of the cheek, injected the caverns around the cell-cylinders. What relation the continuity of these lymph-sinuses around the seba- ceous gland follicles with the lymph-spaces of the integument may bear to the development of pachydermia lymphangiec- tatica, cannot be conjectured, but it may not be improbable that the return of the lymph is obstructed by the contraction of the muscular fibres. Dilatation of Lymph Channels. 131 The combination of this tumor with the nerve-tumors, which has not probably been observed to the same extent, is peculiarly interesting. It may have been merely a coincidence. Czerny regarded the neuromata as mainly consisting of connective tissue, in which ganglion-cells and marrow-containing fibres were disseminated, and suggests that the hyperplastic process may have extended into the neurolemma of the nerves, or that the affection may have been propagated along the lyinph-sheaths of the nerves. The cavities in the tumor must be designated cavernous lymph-spaces, for they were lined with an endothelium and were in communication with the tubular lymph-vessels; hence, its proper classification is among the cavernous lymphangio- mata. The literature of the subject has supplied numerous cases of ectasia of lymph channels, but the instances of simple and cavernous lymphangiomata are comparatively rare. The cases observed by Amussat, Nelaton, Drinkard, Trelat, Petters and others, of ectasia, cannot properly be classed among the lymphangiomata, nor can the case of lymphangioma adnatnm (75) observed by II of moke, in the absence of an anatomical ex- amination, be certainly enumerated in this group, notwithstand- ing the evacuated fluid contained albumen, fibrin, globulin in a small quantity, and the salts of the blood-serum. Virchow was the first to invite attention to the cavernous structure of macro- glossia, and the cases of hypertrophic tongue and macrochilia described by him and Billroth must be accepted as typical illus- trations of the cavernous structures of the lymph apparatus. Virchow is undecided whether the caverns proceed from a pro- gressive proliferation of the connective-tissue cells, or whether the lymph-vessels and connective-tissue corpuscles are affected simultaneously. Billroth assumes the connection of the cav- ernous spaces with the lymph-vessels, and that the cavernous degeneration originates in the connective-tissue cells, the " mul- tiplication of their nuclei either producing a solidifying connec- tive-tissue substance, through which the fibrous form of macro- glossia originates, or else the interstitial substance generated by the cells is fluid, which leads to the origin of the cavernous form." Maas found in three of four cases of hypertrophy of the tongue a cavernous tissue, but the caverns contained red blood-corpuscles and fibnn-coagula, and he concluded the cav- 132 Congenital Occlusion and ems were partly thin-walled veins and partly " thickened arte- ries." Lymph-spaces were not demonstrated in the cases of Fischer or Waldeyer. Others have found only hyperplasia of the tissue composing the tongue, and others again have con- firmed the observations of Maas. Gies demonstrated hyper- plasia of connective tissue with abundant infiltration of round cells, and tissue-spaces containing coagulated lymph and lined by a distinct endothelium. Arnstein, in a case of macroglossia, observed considerable enlargement of the glossal papillae, and in the parenchyma distinguished two kinds of caverns, " one round and filled with red blood-corpuscles and fibrin threads, the other irregular, sinuous, with granular contents and scat- tered lymphoid cells." The former were probably ectatic blood- vessels, as observed in the cases of Maas, and the latter dilated lymph channels or spaces. In Arnstein's case the connective tissue, as in the case of Gies, was infiltrated with numerous round cells, which were grouped in forms resembling lymph- follicles. This adenoid structure he believed developed from the lymph-cells. The succeeding case of "lymphangioma, with general en- largement of the limb and elephantiasis of the toes," reported by Sydney Jones,1 though not of congenital origin, presents ad- ditional opportunities for the study of these developments, and offers an explanation of the phenomena observed by Maas in three cases of hypertrophy of the tongue, which he, perhaps, improperly ascribed to the cavernous expansion of thin-walled blood-capillaries. , Case LXXXIV. A laborer, set. 31, admitted to the hospital in 1874, had been seized, seven years before, with a painless swelling of the right thigh, consisting of knotty enlargements situated on the Vack and inner surfaces of the thigh and between the buttock and thigh. These swellings, at the time of admission, looked like varicose veins, varied in size from a pin's head to a vessel of about the dia- meter of one's little finger, some were pinkish and some white, with fluid contents. Most of them emptied on pressure, to refill on re- moval of the pressure. They often discharged spontaneously a white, milky fluid, sometimes as much as one or two quarts a day, at inter- vals varying from a week to a month. See Fig. 52. I The skin on the toes and lower third of the thigh was tuberculated 1 St. Thomas' Hosp. Kept. New series. Vol. V., p. 295. Dilatation of Lymph Channels. 133 and brawny. At other places were tuberculated prominences, from some of which a milky fluid was occasionally discharged. The patient stated that when he had been free from any discharge for some time, hard, painful lumps appeared in the right inguinal region. In the left groin several enlarged glands could be felt. Dilated vessels of the same character could be traced in the scro- tum, involving the right side, but encroaching beyond the median line,' showing white prominences, not larger than a pin's head, on the left side. Fig. 52. The whole of the right limb was much larger than the left, and always greatly increased when the patient was walking, or the limb hanging. It constantly increased during his stay in the hospital, and was several times attacked with an erysipelatous inflammation, accompanied with considerable constitutional disturbance, pain, red- ness, and marked engorgement of the lymphatic vessels. These attacks were greatly relieved by a copious discharge of milky fluid. _■-.",.' 134 Congenital Occlusion and Analysis of the discharge by Dr. Bernays showed a vast number of minute granules giving the milky character, lymph-corpuscles, and a few red blood-corpuscles. It contained from 1.56 to 4.27 per cent. of fat, and about 6.43 per cent, of albumen, coagulated firmly and was inodorous. Mr. Charles Stewart submitted two portions of the skin to a microscopic examination. One, which was removed from the back of the right thigh, formed the external wall of a semi-transparent bulla. This specimen exhibited " large, freely communicating cham- bers lined by a continuous layer of endothelium, presenting con- siderable variety of forms in different parts. The chambers were traversed in numerous places by trabecular; the remains of the skin which formed the outer walls of these chambers appeared much thin- ned, with probable flattening of the papillae." There can be but little doubt, adds Mr. Stewart, but that these chambers were greatly dilated lymphatic vessels. Vertical and horizontal sections of the brawny, congested and nodular skin removed from the dorsal surface of the toe " showed great hypertrophy of the connective tissue of the cutis with elonga- tion of the cuticular portion of the sudoriparous ducts; but the most remarkable feature was, besides the presence of large, thinned walled canals (lymphatics) in the deeper portion of the tissue, the existence of large spaces in the papilla?, often traversed by trabecular and lined with proliferating endothelium. They in some places freely communicated with subjacent blood-vessels, probably veins, and by their distention had produced great condensation of the surrounding connective tis- sue of the papillae and compression of the cells of the neighboring rete mucosum. Normal blood-vessels could be seen running by the sides of the spaces, especially in those sections taken in a horizontal direction from the skin." " The interior of the dilated chambers in the papillae being often traversed by trabecules, and the presence of normal blood-vessels by their sides, would lead one to suppose that they were dilated lympha- tics or lymph-spaces which had become continuous with a neighbor- ing blood-vessel by rupture, the blood during life rather regurgitating into the lymphatics than flowing directly into them." " But the direct continuity of the walls of the blood-vessels and space might lead one to suppose the blood-vessel itself by dilatation forms the space; if so, the trabecular would be the connective tissue between the capillary loops." " In addition to the above there were also occasionally beneath the epidermis small circumscribed areas traversed by fine fibres and cells; these were probably produced by local distention of the lymph-spaces compressing and producing the removal of the greater part of the bundles of connective tissue, leaving only fine fibres in their place. Minute spaces filled with blood Dilatation of Lymph Channels. 135 were not infrequent at different levels between the cells of the epidermis, having escaped from the distended chambers be- neath." The appearances found in the vertical section of the outer wall of the " semi-transparent bulla " are similar to, though more exaggerated than, those observed in a section of the integumen- tal covering of the vesicles present in Case 1. In the latter many of the spaces (see Fig. 8) communicated, but an endothe- lial lining was not recognized. Stewart also recognized lymph- spaces in the papillae of that portion of the integument which was congested, which corresponds closely with the conditions described by Teichmann (see Fig. 37) and Odenius. And the fact that such large lymph-spaces were only observed in the papillae of those parts of the integument in which inflammatory changes had taken place, and not in the papillae of the covering integument of the bulla, confirms the theory of Odenius, that when found in the cutaneous papillae they are newly-formed lymph channels. The additional .observation, by Stewart, of intercommunica- tion between the spaces found in the papillae and subjacent veins may afford an explanation of the origin of the pigment deposits, which have been so frequently found in cases involv- ing dilatation of lymph channels. So, likewise, may the collec- tions of blood, occasionally present, be accounted for. Winiwarter' observed a case of congenital macroglossia combined with hydroma cysticum colli congenita, in a boy 14 months of age, who died soon after the operation upon the tongue.2 The tumor upon the neck consisted of several large cysts, which penetrated between the muscles of the floor of the oral cavity, and passed into the cavernous tissue of the remaining stump of the tongue.8 The tongue 1 Langenbeck's Archiv f. klin. Chir., Vol. XVI., p. 655, cited by Weichsel- baum. a Tizzoni and Parona have published resume of all the cases of lipoma linguae in the Annali Universali di Medicina e di Chirurgia for March 1877. Also Month. Abst., Sept., 1877, p. 417. 3 Prof. Michel, of Nancy, in a report of seven cases of ranula, denies that there was in either of the cases any connection between the cysts and the salivary canals. In all the cases the cysts "had originated in the areola? o£ the connective tissue about the frenum of the tongue." Gaz. Hebdomad Nov. 16, 1877. Also Monthly Abst., Sept., 1877, p. 416. Talko reports a case of microphthalmus coexisting with a "congenital serous cyst of the orbit." In his summary of six cases he says that such 136 Congenital Occlusion and itself contained variously large and variously formed caverns, which were filled with granular coagula, or with blood-corpuscles and lymph- cells; in several places the connective tissue was infiltrated with new-formed cells. Winiwarter believed that a portion of the caverns originated from dilatation of pre-existing lymph-vessels, but that a majority were developed by division of the connective-tissue cells, which brought about a new formation of round cells, which grouped in masses as in Arnstein's case, and became encapsulated with con- nective-tissue fibres. In the centre of the follicular masses disintegra- tion of the cells takes place, progressing towards the periphery and thus leading to the formation of a cavern, which gradually is filled with a serous fluid, still containing the cell remains as a finely gran- ular mass. Weichselbaum suggests another mode of development of the caverns. The follicular proliferations become saturated with serum, " their cells are forced apart and in part disintegrate, whilst the supportive tissue with its mesh-cavities remains; finally this also disappears, and the small mesh-cavities unite together into larger caverns." Czerny, who examined the tumor removed from the thigh of the patient of Gjorgjewic, reached the conclusion that the cavernous spaces were formed from the granulation tissue which developed around the lymph- vessels. Volkmann traced the caverns of the hypertrophic tongue to a degeneration of the tongne papillae. Cavernous lymphangioma are identical in structure with the cavernous blood-tumors, hence the inference is clear that the developmental process is the same. Various theories concern- ing the origin of cavernous tumors have been suggested (Rokitansky, Virchow, Rindfleisch, and others), but the ques- tion remains unsettled. Rindfleisch (Text-hook Path. Anat., p. 144) asserts that every tissue supplied with blood-vessels can be transformed into cavernous tissue, the only pre-requisite being "cysts are commonly covered with the conjunctiva," and "are usually filled with yellow serous fluid, rich in albumen," Zehender's Monatsbiatter, Apr., 1877; also Month. Abst., Sept., 1877, p. 415. Tizzoni and Parona have also reported a case of fibro-lipoma of the sper- matic cord. Microscopic examination of the extirpated tumor " showed ordinary adipose tissue with fibrous septa and abundant vessels and nerves." The "vessels were affected with obliterative inflammation, being in some places completely occluded with proliferated epithelium. In the sheaths of the nerves, also, they noticed a dilatation of the lympathic spaces, together with a thickening of the sheath and infiltration of the same with leucocytes " Ibid., p. 419. Dilatation of Lymph Channels. 137 the presence of germinal tissue, which, by the cavernous meta- morphosis (loc. cit., p. 145), is converted along the vascular walls into spindle-cells and fibrous connective tissue, by which " a retraction vertical to the axis of the parenchymatous trabe- cule " and dilatation of the vascular tract are brought about. This excludes the hypothesis of new formation of blood-vessels or caverns, upon which Virchow insisted. All these hypotheses (Rokitansky's excepted) agree that the new formation of round- cell tissue is intimately concerned in the origin of caverns. Billroth, Liicke, Koester, and others have classed the con- genital cystic hydroma of the neck among the cavernous lymphangiomata. They consist (Weichselbaum) of a connec- tive-tissue trabeculae, within whose branched and intercommu- nicating caverns a serous fluid is contained. It would un- necessarily lengthen this memoir to reproduce the numerous cases, and I must therefore be content with a simple recital of the more characteristic phenomena, for which I am indebted to Wernher,1 who collected and analyzed fifteen cases. This form of congenital cavernous formations occurs most frequently among the female, has been usually observed in immature children, and generally complicated with other malforma- tions. The tumor always (Steinwirker) has its principal 6eat at the lower portion of the occiput and the upper part of the neck, is spheroidal, with a smooth surface, and divided in the median line of the body by a furrow into two symmetrical halves. In some cases the tumor extended from the ridge of the occipital bone to the middle of the scapulae, and anteriorly to the ears. In one case it extended forward on both sides, until its two halves nearly touched each other in front. Fluctua- tion is very constantly present in some part. In all cervical hydromata (Steinwirker) the integument of the entire body was infiltrated with serum, and in one case the oedematous skin was formed into folds, beneath which were many cysts filled with a clear fluid. They are usually composed of two sym- metrical cysts, divided into smaller compartments. The walls of the cysts are generally very delicate and transparent, but occasionally more firm and fibrous, resembling the pericardium. The cysts are frequently separated. In Wernher's case, the 1 Congen. Cystic Hydromata, Giessen, 1843. 138 Congenital Occlusion and walls consisted of distinct fibre-bundles, and in the fluid of the cysts floated many epithelial cells. In cystic hydroma the cavities present simple cystic con- glomerations (Steinwirker), or empty into each other. Wernher found epithelium in the cysts; Steinwirker demonstrated an epithelial lining of their walls, which are formed of condensed connective tissue. Both investigators found serum in the mesh- cavities. Steinwirker insists that cystic hydroma, like congeni- tal elephantiasis, find their origin in congenital dilatation of lymph-vessels, which conclusion is corroborated by the discovery of epithelium in the cysts containing serum and the presence of lymph channels in the connective tissue. If the dilatation of the lymph channels be only moderate, the cysts will be small, but in proportion to the degree of the ectasia will the cysts in- crease. With enlargement of the cysts fluctuation becomes more or less recognizable. Koester demonstrated in a case of cystic hydroma of the neck the general communication of the closely-crowded caverns with each other. He also proved the " direct transition of the cysts into ampullary canals and spaces, and recognized the connection of the latter with the sinuses of lymph-glands." Cystic hydroma of the neck must therefore be regarded a3 lymphangiectasiae, presented either in the form of circum- •scribed tumors or diffuse developments. In fact, the diffuse character of the affection pertains to all the cases, for Wernher asserts that " in all cases the integument of the whole body was dropsically infiltrated, in many cases so much so that the large tumor of the neck barely protruded." Accepting then the dif- fuse rather than the circumscribed nature of the affection, the two forms must be regarded as analogous diseases, differing only in the size of the existing cysts, and both forms must be classed among the congenital lymphangiectasiae. Steinwirker suggests that both forms are advanced stages of congenital elephantiasis, produced by enlargement and growth of existing cystic dilatations. He also asserts that "only the colossal hyperplasia or dilatation of the lymph-vessels distinguishes lymphangiectasiae congenitae from elephantiasis lymphangi- ectodes, in which the hyperplasia of the connective tissue, although the development of the lymph-vessels is also exces- Dilatation of Lymph Channels. 139 sive, still occupies a position predominant in a manner similar to that belonging to acquired elephantiasis." The cases of Steinwirker (No. 6), Meckel (No. 7), and of Jacobi (No. 12£), supply illustrations of this class of cases. The careful dissection and microscopic examination by Stein- wirker established the lymphatic nature of the developments in his case, and justify its classification in the same category with congenital macroglossia, as described by Virchow; the latter exhibiting the circumscribed form of congenital lymphan- giectasiae, the former the diffuse variety. The succeeding case (85) of chylangioma cavernosum pre- sents another variety of cavernous lymphangiomata, which is entirely unique in its mode of origin. Weichselbaum has re- ported a case under the same title (see Case 50, N. O. Med. and Surg. Jour),h\\t his was a tumor of the mesentery, caused by occlusion of the chyle-vessels, in which a cavernous expansion of the lymph channels had ensued. 1 reproduce without com- ment the case in full. Case LXXXV.'—Jane L., daughter of a laborer, who lives in rather poor circumstances, was born April 20, 1876, the seventh child of a feeble mother, who, though she wore an aged look at an early period, was said to be healthy. The other children all died Boon after birth, or else in early infancy. Immediately after her birth, mother and nurse were struck by the unusually large abdomen of the child; a physician was called in and stated that the child would hardly live, because it had a tumor in the abdominal cavity. Yet, in spite of her decrepit appearance, the child rallied, took the breast properly, and developed, although very slowly. The size of the abdomen, however, increased steadily, although with the excep- tion of a tendency to constipation, which had to be overcome by frequent injections, no real symptoms of disease were noticeable. It was only at the age of four months that the abdomen had attained a size to interfere with respiration ; the child vomited frequently when- ever she had nursed somewhat rapidly ; the water injections failed, and senna was given repeatedly ; yet evacuations remained retarded, and the intestines distended by gases, by which respiration was still more impeded. First seen in dispensary, August 22, 1876, set. four months. Status: body feeble; muscles but little developed; face somewhat cyanotic; thorax in its lower circumference strongly ex- panded; abdomen exceedingly enlarged (65 ctms. in circumference), tense, drummy, but not quite symmetrical. In spite of the colossal expansion there is distinct stronger bulging of right hypochondrium, 'Winiwarter. Jahrbuch der Kinderheilkunde, etc., Vol. XL, Nos. 2 & 3, 1877, p. 196. 140 Congenital Occlusion and passing without sharply defined limits into the surrounding region. Palpation out of question on account of tension of abdominal walls. Percussion gave exquisite tympanitic sound over entire anterior region; decided dulness in lateral portions, changing its level when the child was placed upon one side or the other. The exact limits of the latter could not then be made out; only this much was certain, that there must be free fluid in the cavity. The cause of this hydrops could not be demonstrated. Lower extremities not oedema- tous ; no albuminuria. The pressing indication was paracentesis, in order to relieve difficulty of breathing. An exploring trocar was passed into the left epigastrium at a perfectly dull spot, and after removal of the stylet, to the surprise of all present, there was evac- uated in a large jet a fluid looking exactly like milk. The resem- blance was all that could be imagined—the same color, the same con- sistency, nay, even the same odor like fresh milk. Slowly (on account of the small canula) a quantity of about three litres was discharged; I then removed the trocar before complete evacuation of the abdomen, in order not to lower pressure too suddenly. Al- though the abdomen had become much smaller, yet the tympanitic intestines rendered examination difficult. There still was promi- nence of right hypochondrium, and corresponding with it dulness extending from the hepatic dulness, from about the medial edge of the right lobe, and passing across the edge of the liver obliquely downward, where it merges into the dulness due to yet remaining fluid. It does not change its position in the upper portion upon assumption of the lateral posture. At this place there is felt upon deep palpation a tumor composed of several somewhat movable portions, apparently attached to the spinal column behind, and in consistency corresponding to a flaccid cyst or a conglomeration of such cysts. Fluctuation cannot be shown with certainty. An exact definition from the anterior edge of the liver is possible; whether the tumor is connected with the lower surface of the liver cannot be decided; it is not grown to the abdominal walls, and respiration does not displace it as a whole. No further revelations could be obtained. Above all, the milk-like fluid engaged our attention. It had a weakly saline taste ; did not coagulate upon standing, but deposited a thick layer upon the surface, as milk deposits cream. The mi- croscope showed no formation developments, with the exception of sparse cells, analogous to milk-globules. The idea lying next was to regard this fat-emulsion, for such it was, as pure chyle, and this hypothesis was confirmed by the chemical analysis made by Prof. Ludwig with great exactness, the results of which I will present farther on, as they were furnished by Prof. Ludwig. This fluid being looked upon as chyle, the question now arose, how does it get into the abdominal cavity, and what is its con- nection with the palpable tumor ? Before entering upon the diag- nosis, I will briefly furnish the further data of the case up to date (February 12, 1877), for the child still lives in a condition entirely unchanged. Dilatation of Lymph Channels. 141 Paracentesis had no local disturbing influence, and was followed by decided general improvement; the child again began to take food (she receives, besides the mother's milk, a little broth); respiration became free ; vomiting, constipation, etc., disappeared ; but the fluid reaccumulated rapidly, necessitating a second tapping on September 12, 1876, by which, as well as by all those following it, the same fluid was evacuated to the amount of two to three litres at each oper- ation. Tapping repeated November 18, December 19, and January 16, 1877; in the intervals the child sometimes suffered from diar- rhoea, bronchitis, vomiting, etc., yet remained in a general fair con- dition of nutrition, though very slowly increased in size. Al- ways felt worst before tapping; the latter always met an indicatio vitalis, because by the distention of the abdomen all reception of food was rendered impossible; after tapping, rapid recuperation. Upon the two last occasions I used (always in the left hypogastrium) a larger trocar, and emptied the cavity nearly completely. We now were able to recognize the tumor and its composition by several soft, flaccid pieces. Point of origin remained unsettled. The chyle-fluid can only reach the abdominal cavity in two ways ; 1st. By transudation. 2d. By solution of continuity of a larger chyle vessel. Cases are shown in which, after plugging or compres- sion of the thoracic duct, a milky fluid was found in the pleural and in the abdominal cavities, a phenomenon of stasis, the explanation of which affords no difficulties. In no case, however, were such im- mense quantities of milk-like fluid found, nor was there observed in these cases such a constantly continuing and rapid accumulation ; on the contrary, the results of the autopsy led to the conclusion that the transudation of chyle from lymph-vessels distended by stasis decreased in time, and for the simple reason that the lymph-vessels became impermeable. The milky fluid in them becomes inspissated into a cheese-pulp when efflux is insufficient, which gradually fills entirely the dilated vessels, and thus renders reception of new lymph impossible. In the free transudation also there were found precipi- tates, which led to the conclusion of the existence of a change in chemical composition. In the case under discussion transudation is indeed possible, if we assume that some obstacle prevents the flow of chyle from the entire intestinal track. It is difficult to determine in what this obstacle consists. It is most plausible to look upon the tumor as the obstructing agent. As to the point of origin of the tumor, two opinions may be held. It either had developed from the right kidney, or it proceeded from the retro peritoneal lymph-glands. I thought of hydronephrosis, of carcinoma of the kidney, of hyper- plasia of lymph-glands, of everything before I was able to more accu- rately palpate the tumor. But the more I thought of the matter, the more I reached the conclusion that the tumor was not cause, but effect of the chyle stasis, and I finally formed the following hypothe- sis : there exists an obstacle in the discharge of chyle from the abdo- minal cavity into the thoracic duct. The latter evidently performs its functions, because there exists no other visible phenomenon of 142 Congenital Occlusion and stasis. The obstacle is congenital; as to its nature, I cannot express even a supposition. Now, at the root of the mesentery, there have been formed, probably out of the large chyle vessels, cystic cavities (evidently in intra-uterine life already), entirely similar to those met with in hygroma colli cysticum and in macroglossia. How easily such cyst-formation from the lymph-vessels of the peritoneum is brought about has been proved, among others, by Wegner's experi- ments. He injected air into the peritoneal cavity of rabbits, so that they were blown up, so to speak, and continued this for weeks and months. The air was resorbed in greater part. Upon section of the animals, which had remained perfectly healthy, there were regularly found, at the root of the mesentery, cyst-like vesicles of nut-size, filled with air, and which, as could be proved by the lymph-vessel endothelium upon their walls, were nothing less than cystic dilated lymph-vessels. This cystic tumor in our case is not filled with air, but with pure chyle, for the simple reason that it is fed from the lymph-system of the intestine, i.e., directly by the products of nutri- tive absorption. The matter remained up to a certain point of time, which at present cannot be determined, thus : that there existed in the abdomen a large cystic tumor, but no free fluid. Finally, one of the cysts broke, probably before birth, the fluid poured into the peri- toneal cavity, and this communication exists at present. Only by these abnormal conditions can we explain how chyle formation pro- ceeds entirely without hinderance, and that stasis has not already led to inspissation of chyle and to obstruction of resorption from the side of the intestine. Whatever is absorbed from the alimentary canal passes into the abdominal cavity. Now it would be supposed that this enormous loss of nutritive material would lead to very rapid in- anition, and that the child must perish in a short time. That this does not happen, that the child lives, although per se it takes but little, and loses two litres of chyle every second month, is explained by the conditions of resorption of the peritoneum. The peritoneal cavity represents a large absorbing apparatus, whose capacity by far exceeds all conception. The direct road to the blood being denied to the chyle, the child can only be nourished by such portions of chyle as are resorbed by the peritoneum. This quantity is probably very considerable, as the fluid in the abdomen is under a high degree of pressure. The thoracic duct being assumed as obstructed, yet a suf- ficient number of other roads remained by which a sort of collateral chyle-circulation could be developed; especially the centrum tendi- neum of the diaphragm, the lymph-vessels of the parietal walls of the peritoneum, finally resorption upon the part of the blood-vessels. Thus it is explained, that in spite of losses of chyle the child was living, and has continued to develop. The communication of the chyle cyst with the peritoneal cavity is of great importance in this respect, because it alone renders possible the continuance of work of the entire nutritive and absorbent apparatus, although the work is done at a loss. If we consider that a child of the age of our patient takes up in twenty-four hours about two litres of milk (maxi- Dilatation of Lymph Channels. 143 mum), and that probably all that is absorbed finds its way into the peritoneal cavity; that furthermore the quantity of solids in the chyle evacuated is approximately as large as that contained in the milk, we can form some estimate what proportionately small fraction of the chyle formed in twenty-four hours cannot be overcome by the resorption of the peritoneal surface, and remains in the peritoneal cavity. For only in the space of a month the quantity of fluid in the cavity reaches to two litres—i.e., as much as is sent to the intes- tine in twenty-four hours. It is self-evident that this calculation is not exact, but it suffices to form a conception. Immediately after tapping absorption indeed must be somewhat diminished; there may even occur a transudation, because the sudden release to intra-abdo- minal pressure is calculated to produce hyperemia ex vacuo; after- wards, per contra, resorptive activity is again favored by the facili- tated mobility of the diaphragm. How long the mechanism will con- tinue to work in this manner, i.e., how long the child will live under these conditions, cannot be exactly determined. Spontaneous cure can hardly be expected; whether surgical interference might improve the condition, I will discuss presently. When I first examined the patient after tapping, the case appeared unique. There have indeed repeatedly been observed effusion of chyle into the large serous cav- ities, also into cavernous lymphangiomata, vide Gjorgjewic, Quincke, Weichselbaum; but nowhere was found a similar co-existence of an abdominal wall composed of lymph-cysts of such size, and hydrops chylosus as in the present case. A few weeks after I found an entirely analogous case in Schmidt's Jahrb. (Wilhelrn's).—See Case 42, N. 0. Med. and Surg. Jour. W.'s case proves what might be doubtful a priori, viz.: that a con- dition of this kind need not immediately lead to death. Therefore, in my case there existed no vital indication to operate. As, however, the parents asked again and again whether nothing could be done to cure the child, I commenced to meditate upon operative interference and its result. Here a circumstance existed which must offer an in- surmountable obstacle—the uncertainty by what, the stasis was caused. Even if by opening the abdomen in the linea alba, the chyle-tumor could have been drawn out and ablated at its root, there would probably have been no change in the chyle stasis; per contra, by extirpation of the cysts formed by dilated lymph-vessels and ligation of the pedicle, all, or at least the majority of the efferent canals, would have been placed out of function, and in a very short time there would necessarily have been stasis transudation, by which the condition of patient would have been essentially the same as before operating. The obstacle compressing the thoracic duct may also be in the thoracic cavity, it may be an enlarged bronchial gland, and even if situated in the abdomen, it may not be discoverable; in short, the diagnosis in this respect is to ascertain that in view of the possibility of continu- ance of life with the presence of the chylangioma, as shown by experience, there can be no thought of so severe an operation as laparotomy in a child five months old. Accordingly, the mother was 144 Congenital Occlusion and directed to properly feed the child; up to date it still receives the breast and broth—with some meat. In a short time it will have to be weaned, because the mother begins to suffer; it will then be seen what effect change of diet will have upon the diseased condition. Eesume of Ludwig}s Analysis. Fluid was odorless, of milky appearance ; reaction alkaline ; after standing there were found single fibrin flakes at the bottom of the vessel; its surface showed a layer of cream. Specific gravity 1.012. Chemical Analysis. Per 1,000 parts. Albumen................................ 45.01 Fat..................................... #6.80 % } Sugar................................... '0.20 * / Chlorine................................. 3.41 Sulph. acid anhydr. (S03)................... 0.23 Phosphor." " (PA): united with alkalies................... 0.14 " " alkal. earths.............. 0.01 Carbon, acid, anhydrid. (C02) : united with alkal..................... 0.484 " " " earths................ 0.099 Potassium............................... 0.24 Sodium................................. 2.85 Calcium.......................:......... 0.077 Magnesium.............................. 0.016 This analysis refers to the fluid of September 11, 1876 ; the fluids from previous and subsequent tappings had the uniform spec. grav. of 1.012, and upon evaporation by heat always showed the same amount of solids. Before proceeding to the consideration of another anomaly presented in Case 1, I must introduce the two succeeding cases. They should have been considered immediately follow- ing the history of Case 1, but one of them had not then been reported, and the report of the other case did not reach the library of the Surgeon-General's office until too late for inser- tion among the group to which it properly belongs. Case LXXXVI.1—History unknown. Tradition states that the preparation had passed from a private collection as a gift into the anato- mical museum of the University of Giessen. A female foetus, weigh- ing 3 lbs. 14 oz., apparently fully formed, small and of weakly build. Fontanelles widely open. Right lower extremity three times as 1 Cuny. Dissert. Inaug. Giessen, 1865. Dilatation of Lymvh Channels. 145 large as the left, right foot somewhat rotated inwards, and nearly four times as large as the left. Integument of entire extremity thick, leathery, and in numerous folds, more marked posteriorly. In the vicinity of the anus and at the lower edge of the gluteus maximus, a swelling began which extended to the inner side of the thigh, and passed in the hypertrophic right portion of the mons veneris. It was soft, elastic, and retained the pressure mark. Upon the integu- ment of the leg were small wart-like elevations. The right foot represented a misshapen mass, extending from the ankle to the point of the foot. Second and third toes of left foot elongated. See Fig. 53. Dissection exhibited enormous thickening of the adipose layer, with cavernous formations in the subcutaneous cellular tissue. The tumor previously mentioned consisted of fat, in which were several caverns communicating with the ends of veins. Lobular, cock's-comb-like ex- crescences projected into the caverns. The whole tissue of the anterior side is spon- gy, covered by numerous openings of vessels; . posteriorly there are also several such caverns, especially in the middle of the thigh and mid- dle of the leg, also lined with excrescences and communicating with veins as previously de- scribed. The entire diseased part was abundant- ly supplied with enlarged veins, with thickened coats, which in some places were dilated into large sacs. The right iliac from its point of entrance into the true pelvis was expanded into a large sac, with thin walls, and filled with a trabecular network. This sac passed into the great ischiatic notch and below the spine of the ischium. Arteries and veins normal. The condition of the lymphatic vessels could not be demonstrated. No special irregularity in the muscles. Those of the foot were displaced on account of bed- ding in of a fatty, fibrous tissue. Bones of the foot enlarged, elon- gated and thickened. Ductus Botalli open. Case LXXXVII.1—Eugene Berry, nine years old. Family free from constitutional vice. A half-brother had an additional finder on each hand. At birth his feet presented the same malformation as at the time of the examination, but they were as small as the feet of other babies. The left hip was slightly enlarged, but the thigh and leg were normal in shape and size; otherwise his form was perfect. His health has always been good. During the fourth week his parents observed the excessive growth of the left leg and foot, which was very marked at the close of the first year and has continued Fig. 53. 1 From a report by Drs. Woods, Collamore, and Fisher, a committee of the Toledo Med. Association. Toledo Med. and Surg. Journal Vol I t> 129 1877. • •> *" . 10 146 Congenital Occlusion and uninterruptedly since, but has never been accompanied by soreness, redness, pain, or any observable morbid process. The right nates presents a rather even, bulbous enlargement, projecting back- ward and extending beyond the poste- rior middle line about one and one-half inches, and dropping below the opposite buttock two inches. The right buttock measures three and one-half inches more in circumference than the left. On the right hip, as shown in Fig. 54, near the trochanter major, is a small enlargement, which, like the enlarged buttock, pre- sents a slightly irregular but smooth surface, and is soft and doughy. The right thigh (see Fig. 54) is some- what enlarged, being fourteen inches in circumference, while the left measures but eleven and one-half inches. Neither the thighs nor the legs are elongated, and the knees are normal. The right leg is enlarged, the soft tissues presenting an elastic feel and a somewhat irregular surface. Its greatest circumference is fourteen and one-half inches, while the healthy member is but ten inches. At no time has any enlarged or varicose veins been observed, but at the time of the examination the surface was slightly congested. The right tibia is much enlarged, the development seem- ing to have been lateral, as the fingers can be pressed beneath a ridge on both sides. (See Fig. 55.) The right os calcis is much enlarged, as are also all the tarsal bones. The metatarsal bones are thickened and elongated. The right great toe is slightly developed, but perfectly formed. The sec- ond and third are joined together and turned inward at a right angle. The remaining toes, three, making six on the right foot, are hypertrophied and turned downward, curving towards the sole of the foot. The circulation, muscular power, and sensibility are unim- paired. Motion is complete. The left foot is much less deformed, and has developed less rapidly. The great and second toes are nearly normal. The third and fourth are webbed, project forward, and are turned up. Both little toes are much enlarged. On the sole of the left foot is a mas- sive cushion.1 "The increased growth," remarks the reporter, "has not inter- fered with the relation of the parts, as the joints, even of the toes, are 1 To Dr. Chapman, of Toledo, I am indebted for the opportunity of supply ing the illustrations in this case. Dilatation of Lymph Channels. 147 perfect in action, save from the interference of the superabundance of the surrounding soft tissues. The action of the muscles of the feet and legs are also perfect. No varicosity has ever been observed, although the circulation through the lower extremity has been from birth above the normal standard." Fig. 55. These cases (86 and 87) present many phenomena analogous to those previously described in Cases 1 and 8. The case of Cuny presents the structural alterations found in Case 8, and yet exhibits the same marked lobular formation of the panni- culus adiposus of the thigh which characterizes the enlarge- ment in Case 1. It also presents the interesting phenomenon of apparent transformation of the adipose formation into bloody tumors. The latter case (No. 87), in addition to its analogies to Cases 1 and 8, also resembles, in the preserva- tion of normal sensibility, temperature, muscular power, and 148 Congenital Occlusion and progressive excessive growth, the conditions present in Reid's case (No. 35) of increased nutrition of the left thoracic ex- tremity, and Chassaignac's case of colossal development of the right extremities. Both of these cases probably belong to the second group of giant growths.1 To recur to the consideration of Case 1. In the description of the post-mortem appearances, I invited attention to the extra-peritoneal abdominal tumor, which consisted of five cysts (see Fig. 6) filled with blood-corpuscles, granular matter, and debris which I suggested were devastated lymph-glands. The inference seemed probable that the acompanying disturbance of the lymph circulation found its cause in the obstruction pre- sented by these obliterated glands. Among the congenital cases which I have been enabled to collect and reproduce in this memoir, no condition analogous to this phenomenon has been recognized. Fortunately, however, the following case, occurring in a female aged twenty-three, reported by W. Pet- ters, supplies data which may satisfactorily explain the condi- tion referred to. The case is so interesting and so replete with valuable information that I reproduce it in full. Case LXXXVIII.4—M. N, set. 23, wife of a private officer, daughter of healthy parents, began, three and a half years ago, to suffer from her present affliction. Healthy when a child, she menstru- ated first between the fourteenth and fifteenth years, since when the menses have recurred every three weeks, lasting for three days. Three years and a half ago she noticed, upon rising from the bath, a white papilla about the size of a pin's head, upon the left labium majus. This she scratched. This being repeated, a yellowish white fluid dribbled away from time to time. As the patient was engaged to be married, a so-called sexual physician was consulted, who treated her for six weeks by application of tincture of iodine. The discharge became less, and ceased for six months, when she again saw a few white drops. She now noticed that the white papillae had mean- 1 Dr. Henderson (Edinburgh Med. Jour., Aug., 1877, p. 123) reports the case of a boy aged sixteen, which presented a remarkable hypertrophy of the right hand and arm. He regarded the case as probably an example of ele- phantiasis teleangiectodes, as described by Kaposi in the third volume of Hebra on Diseases of the Skin. The cut accompanying these brief notes of the case exhibits a deformity closely resembling the hand in the case of Mc- Gillivray (No. 30, Fig. 23) and the case of Friedberg (No. 48, Fig. 32). He does not state whether congenital or acquired. 2W. Petters. Dilatation of Lymph Channels. 149 while increased in number, and that the left labium majus had become enlarged. Another physician was consulted, who first applied the tincture of iodine, and finally cauterized with nitrate of silver. This was at once followed by severe pains in the lower abdomen, so that the patient could hardly reach home. The discharge ceased. Pa- tient was obliged to go to bed; had fever, thirst, and a feeling of internal heat : fainted repeatedly on account of pain. This condi- tion continued for fourteen days; after this she recovered, and as for eight weeks the discharge failed to return, she was married Decem- ber 22, 1871, one year after the beginning of the sickness. During the wedding night her husband (according to his own confession) was struck by the fact that the left labium was larger than the right. Co- itus daily during the first period of married life, afterwajrds less fre- quent, and ordinarily only twice a week, always led to copious efflux of a whitish fluid. About two months after the marriage, patient placed herself in charge of a surgeon, who ordered three sitz-baths daily and a white ointment, after which treatment the discharge again ceased for eight weeks. Meanwhile patient became pregnant, and the white discharge ceased altogether. During pregnancy she frequently suffered from pain in the lumbar region and from abdomi- nal irregularities. She aborted in the third month (February, 1872), after having endeavored to lift a heavy weight. The abortion was followed by peritonitis of the right side of three months' duration. With this there appeared in the right inguinal region a tumor of the size of a pigeon's egg, which, however, gave no trouble and gradually disappeared. During convalescence the milky discharge reappeared.' When the discharge was about to be checked the nipples became erect and the mammae more tense. Another surgeon ordered baths of oak-bark, and iron internally. This treatment having failed after two months, the patient consulted still another physician, who ordered a powder to be applied locally, which caused severe pain, but brought no amelioration. The dis- charge gradually increased in quantity and frequency, and the patient now consulted Dr. Weiss, of Prague, who treated her for some time as an out-patient. At this time she is said to have 1 " In many discharges looked upon as milk-secretion by the older physicians, there may have been a mistake of lymph for milk. Thus, the milk-sweat ob- served by Dr. Storch in a woman aged thirty, parturient for the fifth time, which continued for eleven days, and was accompanied by milky lochia, was very likely only a lymphorrhagia."—Petters, loc cit. Buchanan, " in a case of lymphorrhagia in a woman aged forty-six, in whom the lymph exudation took place from vesicles upon the left thigh, as repre- sented in the accompanying figure, and who, during the period of the lymph discharge, lasting fifteen years, had passed through two pregnancies, alwaya accompanied by cessation of the lymphorrhagia, saw, during occasional cessa- tion of the lymph discharge, a swelling of the breasts with a feeling of fulness and tension, and once even milk-secretion." (See Fig. 56.)—Med.-Chir. Trans., Vol. LXV I., p. 57, 1863, Lond. :150 Congenital Occlusion and looked well, and there also was a striking increase in the size of the left thigh. Dr. Weiss, who ordered tinct. gallae and iodine exter- nally, and at first was willing to remove part of the labium, stated that upon one occasion he saw lymph in a jet flow from a pinhead- like opening of the labium. He, however, was unable to enter it to any distance with a bristle. He recommended her to go to hospital, Fig. 56. which she entered April 28th, after I had, on the day previous, made the diagnosis of lymphorrhagia and lymphangiectasis. The patient subsequently stated that the left thigh had become more strikingly enlarged during the cessation of the discbarge; that at the time of the flow she also felt herself getting thinner and losing strength. Questioned as to the cause of her. local affection, Dilatation of Lymph Channels. l5i she remembered that once one of her sisters, with whom she lay in bed, had pulled a few hairs out of the left labium ; this very likely had no influence upon the origin of her disease. Condition, April 27th: patient looks older than she is (like a woman of thirty); body medium; skin delicate; panniculus adiposus moderately developed; mammae small, but solid; nip- ples well developed ; muscular tissue thin and flaccid ; a few freckles on face; eyes brown, expressive; cheeks not reddened; visible mucous membrane red; tongue moist, clean; neck long; thyroid gland small. Elevation of thorax occurs regularly; right thoracic half slightly more rounded than the left. No venous dilatation upon neck or thorax. Cardiac impulse feeble in the fifth intercos- tal space, between left edge of sternum and the nipple. Percussion sound clear and feeble, extending to the upper edge of fourth rib upon the left, and to the upper edge of the seventh rib on the right side. Cardiac dulness measures 5 ctms. square. Respiratory mur- mur feebly vesicular in inspiration, ill-defined in expiration. Heart* sounds normal, without bruit. Pulse rather full, 76 per minute. Abdomen retracted; hepatic dulness extends to about 3 ctms. be- low the costal arch, and to the middle line. Spleen not enlarged. Left half of mons veneris, containing a thick fat cushion, projects beyond the right. Left thigh strikingly enlarged ; measurements: under pubic arch, 51 ctms. (right, 47.5); in the middle of thigh, 44 (right, 42) ; above condyles of knee-joint, 33.5 (right, 33.5). Whilst the right inguinal glands are mostly as large as beans and hazel-nuts, those on the left, above as well as below Poupart's lig- ament, are of the size of horse-chestnuts, so that the left inguinal region predominates; below the integument the touch discovers an irregular resisting mass—the greatly enlarged glands crowding each other. Left labium projects to the size of a pigeon's egg, is pale red, irregular, and covered with numerous nodules of rather firm consistency, some showing small centre depressions. The epidermis over the nodules seems somewhat less attached, but not quite loosened. The consistency of the labium is that of a connective- tissue stroma. The labium is somewhat sensitive to pressure, but the latter does not force out fluid. Nymphae small, covered en- tirely by the labium ; upon the external portion of the left, a small nodule, like those described. Mucous membrane of vulva and vagina roseate. The speculum showed slight chronic leucorrhea, and the sound a moderate retroversion and deviation to the ri << " Evening... 36 36.6 37 114 " " Dec. 4, Morning... 35.7 35.4 36.5 100 a n '' Evening... 35.2 35.4 37.7 96 These observations exhibit the harmlessness of the operation. In each case the temperature of the affected limb fell consid- erably within the first twelve hours after the ligation of the vessel, and in the succeeding twelve hours there was a very marked elevation, whilst during the same period the tempera- ture in the axilla was but moderately influenced. The collat- eral circulation was quickly established. In the foregoing review of the treatment, many additional citations might have been introduced, illustrating the several methods of treatment, but the object has been to present the subject in as succinct a form as possible, rather than to give undue prominence to any particular plan. The inadequacy of individual experience in the management of these compara- tively rare affections remands the various proposed methods of treatment to further investigation and more enlightened obser- vation, for which, it is hoped, the opportunity is now presented. » Reprint from N. 0. Med. and Surg. Jour., p. 140, case 57. 2 Ibid., p. 125 et seq. INDEX. Ablation of tumor in Case Ixxxiii., Hecker 125 Accumulations of lymph, causes of, 54 Adams, case of, 48-66 Adam3, John, case of, 35 Adipose tissue, hypertrophy of, 55 ; new-formed, 55 Aime-David, 74, 77, 80, 88, 92, 168 Amussat, case of, 74, 77, 79, 82, 90, 92, 93, 131 Ampullar dilatations, 89 Angioma, definition of, 2 Analysis fluid of Case lxxxiv., 134; of fluid in Case lxxxviii., 152 ; of Case lxxxv., 140; resume Case lxxxv., 144 Anaemia, lymphatic, 160 Anatomical examination of amputa- ted limb, Case v., 21 Annandale, case of, 40 ; case of, 41; case of, 49 Arnstein, case of, 132, 136 Aschoff, case of, 29 Author, cases of ,8, 30 Autopsy cases, ii., 18; ix., 28; hi., 65; Ix, 74; lxii., 77; lxvi., 84; lxxxviii., 154 Beau, treatment of lymph varix of prepuce, 173 Bernays, 134 Biesiadecki, 95, 96 Bigelow, case of, 34 Bilharzia, 100 Billings, 1 „ ... ,.a Billroth, 7, 107, 108, 109 111, 112, 181, 137 ; treatment of, 17b Binet, 88, 89, 92, 97; treatment of, 169 Bizzozero, case of, 130 Bohms, case of, 33, 44 Boll, 130 , ... 0 Bone, elongation of, 44; tborn-hke formations upon, 43 ; thickening, causes of, 52 « AA, Bone-hypertrophy, 43; *°™*°h*^. accompanied by alterations of vas cular system. 44 Branched cells, 56 Breschet, case of, 74 Broadbent, 68 Broca, case of, 110 Bryk, case of, 21, 31, 101 ; case of, 115; case of, 116; case of, 117, 118, 119, 123,159 ; treatment of, 176, 179 Buchanan, 160 Burow, case of, 46 Busch, 32 ; case of, 33 ; case of, 34 ; case of, 38, 44 ; case of, 48, 51, 56 Callender,68 Canalicular system, def. of, 56 Carter, case of, 98, 99, 100, 101; treatment of, 169 Case I. Author, 8, 23, 24, 25, 32, 42, 52, 53, 67, 84, 87, 89, 135, 144, 147, 148, 158 Case II. Chevalier, 18, 23, 31 Case III. Graves, 20, 32 Case IV. Kappeler, 20, 31, 53 CaseV. Bryk, 21, 31 Case VI. Steinwirker, 22, 24, 31, 139 Case VII. Meckel, 23, 31, 139 Case VIII. Rose, 26, 29, 81, 32, 147 Case IX. Smith, Thos., 27, 29, 31, 32, 66, 67, 87, 88 Case X. Smith, Thos., 28, 29, 31 Case XI. Rose, 29, 32 Case XII. Author, 30, 32 Case Xlli Jacobi, 31, 139 Case XIII. Klein, 33, 44 Case XIV. Wagner, 33, 44 Case XV. Bohms, 38, 44 Case XVI. Wuff, 33, 44 Case XVII. Busch, 34, 44 Case XVIII. Legendre, 34, 44 Case XIX Ideler, 34, 44 Case XX. Bigelow, 34, 44 Case XXI. Hamilton, 34, 44 Case XXII- Simpson, 35, 44 Case XXIII. Adams, John, 35, 44 Case XXIV. Kappeler, 35, 44 Case XXV. Gun, 36, 44 Case XXVI. Michel, 37, 44 Case XXVII. Busch, 38, 44 Case XXVIII. Busch, 38, 44 Case XXIX. Annandale, 40, 44 184 Index. Case XXX. MacGillivray, 40, 44 Case XXXI. Annandale, 41, 44 Case XXXII. Jones, Sydney, 41, 44 Case XXXIII. Ewald, 42, 44 Case XXXIV. Gruber, 42, 44 Case XXXV. Reid, 45, 46, 51, 52, 66, 67, 148 Case XXXVI. Reid, 45, 46, 51, 52 Case XXXVII. Reid, 45, 46, 51, 52 Case XXXVIII. Chassaignac, 46, 51, 52, 65, 67, 148 Case XXXIX. Gherini, 46, 52, 66 Case XL. Burow, 46 CaseXLI. Poulain, 47, 52 Case XLII. Busch, 48, 51, 52 Case XLIII. Adams, 48, 52, 66 Case XLIV. Annandale, 49 Case XLV. Curling, 49, 51, 52, 67 Case XLVI. Owen, 50 Case XLVII. Paget, 50 Case XLVIII. Friedberg, 57, 65, 67, 85, 101, 103 Case XLIX. Day, 61, 65, 68, 69, 84, 160 Case L. Demarquay, 62, 65, 69, 84, 90, 94, 158 Case LI. Paterson, 63, 65, 69, 84 Case LII. Thilesen, 64, 65, 69, 79, 84, 90 Case LIII. Hilton, 65, 69, 84 Case LIV. Hamilton, 71, 73, 84, 101 Case LV. Zambaco, 72, 73, 84, 101 Case LVI. Gault, 72, 73, 84, 101 Case LVII. Wiedel, 73, 84, 90, 101 Case LVIII. Hensen, 73, 84, 101 Case LIX. Virchow, 74, 84, 93, 101, 103 Case LX. Amussat, 74, 77, 79, 80, 83, 84, 90, 92, 93, 131 Case LXI. Drinkard, 76, 81, 84, 90, 131 Case LXII. Trelat, 77, 79, 80, 81, 84, 90, 131 Case LXIII. Petit, 78, 84 Case LXIV. Aime-David, 78, 84 Case LXV. Fetzer, 80, 84, 87, 88, 90, 91, 160 ; treatment of, 168 Case LXVI. Roberts, 82, 84, 87, 88, 100, 160, 161; treatment of, 169 Case LXVH. Verneuil, 85, 87 Case LXVIII. Carter, 98, 100 ; treat- ment of, 169 Case LXIX. Cholmeley, 101 Case LXX. Virchow, 105 Case LXXI. Billroth, 108, 109 ; treat- ment of, 171 Case LXXII. Billroth, 108, 109 Case LXXIII. Dalbanne, 109 Case LXXIV. Liicke, 112, 123 Case LXXV. Hofmokl, 112, 123, 131 CaseLXXVI. Reichel, 113, 123; treat- ment of, 171 CaseLXXVII. Gjorgjewic, 114, 123; treatment of, 171 Case LXXVIII. Bryk, 115, 123 CaseLXXIX. Bryk, 116, 119,123, 159 Case LXXX. Bryk, 117, 119,123,158 Case LXXXI. Chadwick, 119, 159; treatment of, 177 Case LXXXII. Hecker, 121, 123; treatment of, 176 Case LXXXIII. Czerny, 124; treat- ment of, 176 Case LXXXIV. Jones, Syd., 132 Case LXXXV. Winiwarter, 139 Case LXXXVI. Cuny, 144, 147 Case LXXXVII. Toledo Medical Ass., 145, 147 Case LXXXVIII. Petters, 148, 160 Casper von Seibold, case of, 107 Cavernous angioma, examples of, 29 Cavernous blood-tumors, definition of, 4 Caverns, lymph, periacinous, 130 Causes, p. 164 Cayley, case of, 104 Chadwick, J. R., case of, 119, 159 Chassaignac, case of, 46, 66, 148 Chevalier, case of, 18, 23 Classification, 163 Cholmeley, case of, 101 Chylous ascites, cases of, 55 Chyluria, 99 Collamore, case of, 145 Colossal giant-growth, case of, 65 Contents, ix. Cruveilhier, 89 ; division of varices, 92 Curling, case of, 49, 51, 52, 67 Cuny, case of, 144, 147 Cystic dilatation of lymphatics, 5, 7 Cystic hydroma, 138 Czerny, examination of tumor, 114; case of, 124,125,126,130,131,136 Dalbanne, case of, 109 Day, case of, 61, 68, 69 ; treatment of, 179 Demarquay, 2 ; case of, 62, 67, 69, 86, 90, 94, 158 Desjardins, 2,160 Diagnosis between phlebectasis and lymphatic varix, 70, 71 Drinkard, case of, 76, 80, 90, 131 Elephantiasis, 3 ; congenital or ac- quired, 3 ; nature of, 6 ; depend- ent on scrofulous habit, 112 Index. 185 Elephantiasis arabum, definition of, 3, 4; forms of, 5, 6, 7, 85, 94 Elephantiasis arabum cruris, 5, 6 Elephantiasis arabum congenita, with plexiform neuromata, 130 Elephantiasis and diseased lymphatics, priority of, 86 Elephantiasis dura, definition of, 5, 7 Elephantiasis mollis, definition of, 5, 7 Elephantiasis of the genitals, 5, 7 Elephantiasis teleangiectodes, defini- tion of, 3 Elongation of a limb, causes of, 52 Etiology, 164 Enlarged tongue, 107 Ewald, case of, 42 Examination, post-mortem, Case Ixxxiii., 126 Fatty atrophy, 56 Fat-tissue, new-formed, 55 Fatty and connective-tissue new for- mations interchangeable, 56 Fatty metamorphosis, 56 Fetzer, 79 ; case of, 80, 84, 87, 88, 90, 91, 104; treatment of, 168 Fibromata, vaginal, 120 Fibromatous and lipomatous degener- ation, coexistence of, 27 ; trans- formations of, 31 ; relation to ar- teries, 53 ; genesis of, 57 Filiaria, 100 Fischer, 132 Fitz, 119 Fluid, oedematous, composition of, 53 Fox, 5 Freidreich, case of, 175 Friedberg, case of, 57, 66, 67, 68, 85, 101, 103, 104 Gattlt, case of, 72 General remarks, 163 Gies, 132 Gianazzi, 130 Gherini, case of 46, 66 Gjorgjewic, 79; case of, 114, 123, 136 ; treatment of, 171 Graves, case of, 20, 83 Gruber, case of, 42 - Gun, case of, 36 Hamilton, case of, 34; case of, 71 Hebra, 3 Hecker, case of, 121, 123 ; ablation of tumor, 125 Hensen, case of, 73 Hilton, case of, 65, 69 Hofmokl, case of, 112, 123, 131; treatment of, 170 Huf eland, 112 Hydrocele (double), case of, 78 Hyperostosis, 45 Hyperplasia of connective tissue, gen- esis of, 54; relation of to venous stasis, 27 Hypertrophic fingers and toes, 51 Hypertrophy, divisions of, 32 ; three forms, 67; with varices, 66 Hypertrophy of limb, congenital in excess, 32 Ideler, case of, 34 Illustrations, xiii. Infiltration, serous, causes of, 70 Introduction, 1 Jacobi, case of, 31, 139 Jones, C. H., cases of, 97, 98 Jones, Sydney, case of, 41 ; case of, 132 Kaposi, 4, 5, 6 Kappeler, case of, 20 ; case of, 35 Klebs, 152, 154 Klein, case of, 33, 56, 93, 94 Koester, 137, 138 Krause, 153 Kiiss, 95 Langenbeck, 106 Lebert, 90, 92, 93, 159, 162 Legendre, case of, 34 Lewis, 100 Little, 51 Lipomatosis, case of, 29 ; transfor- mations of, 56; transitions of, 31 Lobulated vascular fungus, definition of, 4 Liicke, case of, 112, 123, 137 Ludwig, 130, 140, 144 Lymph, analysis of, 90 ; changes in, 162; derivative arterial blood, 53 Lymphorrhagia, definition of, 2; al- ternates with chyluria, 100 Lymphorrhcea, definition of, 2, 6 Lymphangiectasis, definition of, 1, 3, 4, 70, 71, 87 Lymphangiomata, definition of, 3; classification of, 163 Lymphangioma adnatum, 131; cav- ernosum cystisus, 113, 123 Lymphangiectasiae divisions, 92, 97 Lymphangiectodes, definition of, 3 Lymph channels, congenital defect of, 92; occlusion and dilatation of, 6 dex. 186 Int Lymph lacunae, 56 Lymph canaliculi, 93 Lymph scrotum, case of, 98 Lymph stasis, 57; caused by heart af- fections, 103 Lymphatic teleangiectasis, 2, 3, 32 Lymphatic radicles, dilatation of, 97 Lymph varix, treatment of 173 Maas, 131, 132 Macrochilia, 107; treatment of. 176 Macroglossia, 107 ; with hydroma cys- ticum colli, 135; treatment of, 176 MacGillivray, case of, 40 McConnel, 16 Manson, 98, 101 Martin, case of, 26 Meckel, case of, 23, 139 Meckel von Hemsbach, 66, 67 Mesentery, stasis of chyle in, 55 Michel, case of, 37, 97 Microscopic examination of ablated tumor, 113 ; of Casei., 16 ; of ex- tirpated tumor, 114 ; of portion of skin, 134; of tumor, 119; Case lxxxii., 122 Milk secreted from axilla, 120 Nelaton, 76, 79, 131 Neumann, 94 Nipple-shaped prominences, 87 Odenius, 95, 96, 97, 98, 135 Oppolzer, 101 Ormerod, 104 Osteophytes of tibia, 21 Owen, case of, 50 Pachydermia lymphangiectatica, 95, 98, 100, 101 Paget, case of, 50, 68 Panas, 86 Panniculus adiposus, 23, 24, 25 Paschal, case of, 29 Paterson, case of, 63, 66, 69, 90 Petit, case of, 78, 79 Petters, 1, 78, 101, 103, 131 Petters, W., case of, 148, 152, 153, 158 Phlegmasia alba dolens, 18 Preface, v. Polysarcia, 7 Prout, 100 Poulain, case of, 47 Quevenne, 90 Quincke, 55, 161 Receptaculum chyli, rapture of, 104 Recklinghausen, 56, 93 Reichel, case of, 113, 123 ; treatment of, 171 Reid, cases of, 45. 66, 67, 148 Rindfleisch, 98, 100, 101, 136 Roberts, 81 ; case of, 82, 84, 87, 88, 100, 160, 161, 162 ; treatment of 149 Rokitansky, 4, 44, 101, 103. 137 Rose, cases of, 26, 29 Sanderson, 68 Sappey, 110 Schuh, 4 Simpson, case of, 35 Smith, Thos., cases of, 27 and 28, 66, 67, 87 Stellate connective-tissue corpuscles, definition of, 56 Steinwirker, case of, 22, 31, 137, 138, 139 Stewart, 101, 103 Stewart, Chas., 134,135 Stokes, 82 " T A c H E s erectiles cuticulaires dif- i uses 46 Thilesen, 'l; case of, 64, 69, 70, 71, 90 Teichmann, 95, 96, 97, 135 Thomsa, 130 Trelat, 77 ; case of, 77, 79, 80, 86, 131 Treatment, Case lxxxviii., 153, 166; constitutional, 167 ; of anaemia, 168 ; lymph fistula, 168; of Rob- ert's case, 169 ; Carter, 169 ; Mo- nod, 169 ; Robin, 169 ; compres- sion, 170; puncture, 170; by Gjorgjewic, 171; by Ulmer, 172 ; by Beau, 173 ; by Friedreich, 175 ; amputation, 175 ; excision, 176; by Chadwick, 187 ; ligation, 177 ; Maunder, 177; compression of vessels, 178 Tumors, lymphatic, of breast, 120 ; of scalp, 29; lymphangiectatic, dif- ferential diagnosis, 79; of geni- tals, 119 ; wart-like, 88, 91; vas- cular spongy, 4 Ulmer, case of, p. 172 Vena cava sinistra, obstruction, 104 Venous angiectasis, 27; teleangiecta- sis, definition of, 1 Vessels, ectasy of, 110 Index. 187 Verneuil, 80; case of, 85, 86, 87 Vesicles, serous, 16; in pachydermia lymphangiectatica, 100 Vesicular formations, 88; causes of, 93 Virchow, 5, 6, 7, 8, 43, 54, 56,74,101, 103, 104, 105, 106, 109, 110, 111, 131, 136, 137, 139 Volkmann, 107, 136 Wagner, case of, 33, 53, 107 Waldeyer, 113, 123, 132 Weber, 1, 93, 107, 109, 111 Wemher, 137, 138 Weichselbaum, 55, 136, 137, 139 Wiedel, case of, 72, 98, 101 Winckel, 100 Winiwarter, 135, 136; case of, 139 Woods, 45 Woodward, 1 Wuff, case of, 33 Zambaco, case of, 72 I viiDia3w jo Aavaan ivnouvn 3NIDI03W jo Aava *TIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE >h/\ NATIONAL LIBRARY OF MEDICINE y \. - , y ^. 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