.s,tit:i- ti ;.; 1'-,i • j'W.'f /.::.'.'.'I'.'tf f- :•-••". >-;£££"» • PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA ; AND FORMERLY PROFESSOR OF PATHOLOGICAL ANATOMY IN THE MEDICAL DEPARTMENT OF THE CINCINNATI COLLEGE. THIRD EDITION, MODIFIED AND THOROUGHLY REVISED. UmlxM fog W%m Jraforrir mt& $0ttg-tto0 (Smptorap on 8Jta&. PHILADELPHIA: BLANCHARD AND LEA. 1857. pt/LfTYX p5! V\ v\ <* aJ- AJ£, ^0?9 <7?0'£ Entered according to the Act of Congress, in the year 1857, by SAMUEL D. GROSS, M. D., the Clerk's Office of the District Court of the United States in and for the Eastern District of Pennsylvania. PHILADELPHIA I T. K. AND P. G. COLLINS, PRINTERS. TO DANIEL DRAKE, M. D., PROFESSOR OP MEDICINE IN THE UNIVERSITY OF LOUISVILLE, ETC. ETC., Distinguished alike as an accomplished and successful teacher, an erudite and skilful physician, a zealous promoter of science and literature, and an ardent friend of pathological anatomy, the following pages, intended to illustrate one of the fundamental branches of medical science, are respectfully inscribed, as a testimony of esteem for his exalted talents and attainments, and as a token of sincere regard for his cha- racter, By his Friend and Colleague, THE AUTHOR PREFACE TO THE THIKD EDITION. The present edition of this work has been materially modified, and fully brought up, in so far at least as appertains to what may be considered as really worthy of acceptance, to the existing state of the science of which it treats. All that related to histology and diag- nosis, in the preceding edition, has been omitted in this; many para- graphs, and often whole pages, have been rewritten; and a consider- able amount of new matter has been introduced. While the general arrangement remains the same, the various topics embraced in the work have been more thoroughly systematized, and, wherever it was practicable, the language has been rendered more concise and terse. One hundred and thirty new cuts have been added. They were drawn, for the most part, from my own specimens, and under my immediate superintendence, by Mr. Daniels, and engraved by Mr. Baxter. These, added to those in the former edition, make the num- ber of original cuts nearly two hundred. The remainder have been copied from various sources, as Eeynaud, Marcet, Lawrence, Miller, Curling, Churchill, Bird, and others. Not a few of the figures thus borrowed have become, as it were, the common property of the pro- fession, and are no longer traceable to their respective authors. With the many changes and improvements now introduced, the work may be regarded almost as a new treatise. It affords me pleasure to state that, in the preparation of this edition, I have had the kind assistance of Dr. J. DaCosta, Lecturer on Medi- cine in the Philadelphia Association for Medical Instruction, whose contributions to pathological science have placed him in the front rank of the pathological anatomists of this country. A number of the vi PREFACE TO THE THIRD EDITION. topics discussed in the work are illustrated by drawings founded upon his own researches; and whatever relates to minute structure has re- ceived his special attention. While he has thus relieved me of no inconsiderable labor, he has, I am sure, not a little enhanced the value of the work. In submitting to the profession a new edition of this treatise, I flatter myself that it may, at least, have the effect of arousing their attention to the importance of a more thorough study of a department of medi- cal science which has made such astonishing progress within the last quarter of a century, and whose value, especially in a diagnostic point of view, is now universally acknowledged by every enlight- ened practitioner. That America, with its great hospital facilities, should have no school of pathological anatomy, is an anomaly which cannot fail to excite the wonder of the age, and the amazement of posterity. In the forty-five medical colleges which, at this mo- ment, exist in the United States, there is not, with perhaps a few exceptions, a chair of pathological anatomy; thus clearly showing that the teachers connected with these institutions have either no very exalted opinion of the value of this science, or that they are afraid of innovation. While almost everything else is taught, from a sesamoid bone and a globule of blood the j^^th part of an inch in diameter, up to the skeleton of the mastodon, hardly a solitary voice is heard, during the whole session of our colleges, in favor of patholo- gical anatomy. This is a strange and culpable oversight, and one which should be speedily corrected. We may cram our pupils with healthy anatomy, physiology, materia medica, chemistry, and, in short, everything else embraced in our curriculum of study, and yet, if we neglect to instruct them in this branch of knowledge, it will be in vain for us to attempt to make good diagnosticians and practitioners of them. Let us, then, while we hope for better things, endeavor soon to extricate ourselves, as the representatives of a great and noble pro- fession, from the false position in which we now stand in relation to this all important science, and its application to the nature discrimi- nation, and treatment of disease. The dedication of the work remains as it appeared in the former editions, when I was engaged in working, side by side, with the illus- PREFACE TO THE THIRD EDITION. vii trious man to whom it refers, and whose name has since become classi- cal. Daniel Drake was one of the earliest friends and patrons of pathological anatomy in the United States. The chair of pathological anatomy which he was instrumental in creating in the Cincinnati Col- lege, I had the honor of occupying for four years; and it was there that the first attempt was made, in this country, to teach this science upon a systematic and extended plan. Subsequently he was himself, for a time, similarly employed in the University of Louisville; a school which owes much of its former renown to his labors, talents, and reputation. S. D. GEOSS. Philadelphia, July 1, 1857. CONTENTS. PART I. GENERAL PRINCIPLES OF PATHOLOGICAL ANATOMY. CHAPTER I. INFLAMMATION. Preliminary Observations.—Fluids and Solids.—Different kinds of Sympathy.—Disease, func- tional and organic.—Inflammation, how modified by Temperament, Age, Sex, Habit, Climate, Season, the nature of the exciting cause, and the character of the tissue; acute and chronic ; does not occur with equal frequency in all parts of the body ; common and specific.—Nature, symptoms, and seat of ordinary Inflammation ; Redness, Heat, Pain, and Swelling ; Derange- ment of the Vital Actions ; Structure of the Capillaries ; joint agency of the Vascular and Nervous Systems; altered Sensibility; preternatural influx of Blood; Congestion; Theo- ries of Boerhaave, Cullen, Vacca, and others. Terminations and Conditions of Inflam- mation .......... Page 33 CHAPTER II. EFFUSION OF SERUM. Occurs, to a greater or less extent, in almost every Inflammation.—Oedema, Anasarca, and Dropsy.—Color, consistence, quantity, and chemical composition.—Usually the result of a mild degree of Inflammation.—Conclusion ...... 59 CHAPTER III. LYMPHIZATION. Always the result of Inflammation.—Physical properties of Lymph.—Quantity.—Varieties of Form.—Chemical Constitution.—Period at which the Deposition commences.—Has a tend- ency to become organized.—How this is effected.—Analogous Tissues.—Use of Lymph as a means of Restoration.—Adhesive Action ...... 63 CHAPTER IV. SUPPURATION. Definition.—Organs in which it is most easily effected.—May take place without Solution of Continuity.—Varieties of Form.—Abscesses.—Physical and Chemical Properties of Pus.— Distinguishing Tests.—How produced ... 72 X CONTENTS. CHAPTER V. HEMORRHAGE. Ihe subject still involved in obscurity.—Causes.—Opinions of Morgagni and Bichat; Exhalant Vessels.—Aptitude of different Structures.—Nomenclature.—Predisposition.—Hereditary Proclivity.—Hemorrhage sometimes vicarious.—Active and passive.—Critical.—Quantity of Blood effused.—Changes and final Disposition .... Page 82 CHAPTER VI. SOFTENING. One of the most unequivocal signs of inflammation.—Structure most liable to be affected by it.—In what anatomical element is the lesion seated?—Causes.—Degrees of softening 87 CHAPTER VII. GANGRENE. Definition.—Parts most apt to suffer.—Color and Consistence.—Extent.—Manner in which Nature guards against the occurrence of Hemorrhage.—Causes, of two kinds.—Malignant Pustule.—Gangrene from the use of Ergot.—From the exhibition of Tartar Emetic.— Senile Gangrene.—Opinions as to its cause ...... 89 CHAPTER VIII. ULCERATION. Definition ; intricate Nature—Most common in the Skin, Cellular Tissue, and Mucous Mem- branes.—Maybe slow or rapid.—Manifests a tendency to extend towards the nearest surface. —Produced by Inflammation.—Influenced by an impoverished state of the Blood.—Ulcers sometimes heal; the process by which this is accomplished.—Ulceration a sanative effort 95 CHAPTER IX. GRANULATION. Importance of the Subject.—Nature of Granulations.—Difference in regard to their Vascularity and Sensibility.—How modified by Texture.—Are Secreting and Absorbing organs 98 CHAPTER X. CICATRIZATION. Nature of the Process.—Different Steps.—Do Ulcers ever heal from the Centre ?__Process of Cicatrization influenced by the Formand Situation of the Sore.—Meaning of the term Cica- trice.—Reproduction of the original Tissues.—Transformations of Cicatrices 101 CHAPTER XI. INDURATION. Definition.—Color, Size, Weight, and Degree.—Period necessary for its production.—Causes 104 CHAPTER XII. HYPERTROPHY. Meaning of the term.—Liability of different Structures.—Causes.—May be general or local — Color, Weight, and Volume of the Part affected . . ,„8 CONTENTS. XI CHAPTER XIII. ATROPHY. Definition.—May be General or Partial.—Causes : want of Exercise; Diminution of the Nerv- ous Influence ; Deficient supply of Blood; Inflammation . . . Page 111 CHAPTER XIV. FISTULES. Definition.—Distinction into Complete and Partial.—Most common Situation.—Nomenclature. —Length and Diameter.—External and Internal Orifices.—Direction.—Lined by Adventi- tious Organized Membrane.—Nature of the Discharge.—State of the adjoining Tissues.— Causes ........... 114 CHAPTER XV. TRANSFORMATIONS. The Body in a constant state of Mutation.—Number of Transformations: the Cellular, Mucous, Cutaneous, Fibrous, Cartilaginous, Osseous and Adipose . . . .117 CHAPTER XVI. PNEUMATOSIS, OR COLLECTIONS OF AERIFORM FLUIDS. Definition.—Frequency.—Names by which it is known.—Form and Extent.— Physical and Chemical Properties.—Causes.—Effects on neighboring Organs.—Most frequent in the Fe- male.—Duration.—May be expelled or absorbed ..... 122 CHAPTER XVII. POLYPES. T.Iost common Situation.—Not peculiar to the Human Subject.—Number, Size, and Form.— Structure and Varieties.—Vesicular, Fibrous, Vascular, and Granular.—May degenerate in different ways.—Period of Life most liable to their Formation.—Effects on contiguous Struc- tures.—True Character.—Are always covered by a Mucous Membrane . . 128 CHAPTER XVIII. HYDATIDS. Where found.—Classification of Hydatids.—The Cysticercus, Polyeephalus, Diceras, Echino- coceus, and Acephalocystis.—Their Origin and Organization.—The manner in which they are nourished.—The Changes which they experience by Age, and the Alterations they induce in the Organs in which they are developed ..... 135 CHAPTER XIX. SEROUS CYSTS. Have the form of Shut Sacs.—Organs in which they are most frequently found.—Classification : the Simple, Multilocular, and the Included.—Nature of the Contained Fluid.—Are either new Products, or formed out of the pre-existing Textures.—Are liable to Inflammation and its Consequences ......... 143 XII CONTENTS. CHAPTER XX. HETEROLOGOUS FORMATIONS. Preliminary Observations.—Classification ; Tubercle; Melanosis; Scirrhus; Encephaloid ; Col- loid ; Epithelial Cancer.—I. Tubercle.—Definition.—Great frequency.—Occurs nearly in all Tissues, and at all Periods of Life.—Is common in the lower Animals.—Chemical Composition. —Varieties of Form.—Concrete and semi-concrete Tubercular Matter.—Notions respecting its Origin, Development, and Organization.—Softening and Excavations.—II. Melanosis.—His- torical Sketch.—Occurs in Man and Animals.—Chemical Analysis.—Color and Consistence. —Varieties of Form.—Tissues most liable to suffer from Melanotic Diathesis.—States of the System which predispose to its formation.—III. Scirrhus.—Difficulty of the Subject.— Definition.—Varieties of Form.—Chemical Constitution.—Barely appears before the age of thirty.—Most common in Glandular Organs.—Is apt to Ulcerate and involve the general System.—IV. Encephaloid.—Is intimately allied to Scirrhus.—Terms by which it has been designated.—More frequent in some Structures than in others.—Varieties of Form.—Color, Consistence, and Composition.—Organization and Mode of Origin.—A Disease of early Life. —Involves the whole System.—Termination.—V. Colloid.—First described by Laennec.— Different Names. — Is a distinct Formation. — Composed of two Elements. — Microscopical Characters. — Cellular Tissue, Vessels, and Nerves. — Chemical Constitution.—Varieties of Form.—Most common Situation.—Most frequent from Thirty-five to Fifty.—Mode of Origin and Progress.—VI. Epithelial Cancer.—Its Nature, Organization, and Tendency Page 147 PART II. SPECIAL PATHOLOGICAL ANATOMY. CHAPTER I. BLOOD. Lesions of the Blood.—Nature and Formation of the Buffy Coat.—Cupped Appearance of the Blood.—Want of Coagulability.—Relative Quantity of Fibrin in Healthy andDiseased Blood. —Alterations of the Hematosine.—Lesions of the Serum, in Inflammation, Dropsy, and other Maladies.—Changes of the Blood, from Acceleration of the Circulation and Division of the Pneumogastric Nerves.—Appearances in Cholera, Fever, Chlorosis and Scurvy . 197 CHAPTER II. CELLULAR TEXTURE. Lesions.—Acute Inflammation.—Suppuration.—Gangrene.—Chronic Inflammation.__Indura- tion.—Serous Infiltration.—Emphysema.—Degenerations.—Foreign Substances.__Guinea Worm ........... 218 CHAPTER III. ADIPOSE TEXTURE. Lesions of the Adipose Tissue.—Wounds.—Liability to Inflammation and local.—Adipose Diathesis.—Atrophy .—Hypertrophy, genera 223 CONTENTS. xiii CHAPTER IV. MUSCULAR SYSTEM. I. Muscles.—Reunite when divided.—Inflammation.—Suppuration.—Mortification.—Chronic Irritation.—Softening.—Induration.—Ossification.—Fibrous and Fatty Transformations.— Heterologous Deposits.—Hypertrophy.—Atrophy.—Parasitic Animals.—Sanguineous Effu- sions.—II. Tendons.—Reunite when divided.—Inflammation.—Ossification.—Atrophy.__ Diseases of the Sheaths of the Tendons.—III. Aponeuroses.—Acute and Chronic Inflamma- tion.—IV. Synovial Burses.—Diseases.—Fibro-cartilaginous Concretions.—Hypertrophy.— Hydatoid Bodies ........ Page 227 CHAPTER V. ARTERIES. Lesions.—Wounds.—Inflammation.— Suppuration.—Ulceration.— Gangrene.— Softening.— Induration.—Hypertrophy.—Morbid—Deposits.—Contraction.—Aneurism . . 238 CHAPTER VI. VEINS. Lesions.—Acute Inflammation.—Suppuration.—Ulceration.—Chronic Inflammation.—Dilata tion.—Obliteration.—Calcareous Deposits.—Phlebolites.—Admission of Air . 257 CHAPTER VII. LYMPHATIC VESSELS AND GANGLIONS. I. Lymphatic Vessels.—Liability to Inflammation and Suppuration.—Tubercular Deposits.— Dilatation.—Aneurism of the Thoracic Duct.—II Lymphatic Ganglions.—Lesions.—Inflam- mation and its ordinary Consequences.—Hypertrophy.—Encephaloid Disease.—Tubercle.— Ossification.—Melanosis ........ 262 CHAPTER VIII. JOINTS. I. Articular Cartilages.—Lesions.—Reparation.—Inflammation.—Softening.—Suppuration.— Ulceration.—Ossification.—II. Synovial Membranes.—Diseases : Inflammation.—Effusion of Lymph and Pus.—Ulceration.—Chronic Irritation.—Loose Cartilages.—Chalky Concre- tions.—III. Ligaments.—Adhesive Inflammation.—Atrophy.—Calcareous Concretions 269 CHAPTER IX. OSSEOUS SYSTEM. I. Bones.—Diseases.—Reparation.—Inflammation.—Suppuration.—Ulceration.—Gangrene.— Softening.—Rachitis.— Fragility.—Hypertrophy.—Atrophy.— Hydatids.—Aneurism.—Car- cinoma.—Melanosis.—Tubercle.—II. Periosteum.—Its Fibrous Structure liable to the same kind of Diseases as the Fibrous Membranes generally. — Hypertrophy.—Ossification.—Is seldom, if ever, affected by the Heterologous Formations.—III. Medullary Membrane.— Diseases few, but important ........ 276 XIV CONTENTS. CHAPTER X. CUTANEOUS SYSTEM. I. Skin.— Reproductive Power of the different Lamella; of the Skin.— Diseases.—(i.) Unclas- sifiable Lesions. — Keloid. — Eiloid. — Lepoid. — Melanosis. — Encephaloid. — Scirrhous Tumors.— Hypertrophy.—Corns.—Warts.— Horny Excrescences. — Gangrene.— Sebaceous Tumors.—Hemorrhages.—(n.) Classifiable Lesions.—1. Exanthematous Diseases.—2. Pus- tular.—3. Papular.—4. Bullar.—5. Tubercular.—6. Scaly.—7. Syphilitic Diseases.—8. Stains. —II. Nails. — Reproductive Power. — Inordinate Length.—Absence.— Malformation.— Vicious Situation.—Onyxitis.—III. Hairs.—Similarity to the Nails.—Polish Plait.—Regene- rating Power.—Hypertrophy.—Female Beards.—Softening.—Fragility.—Changes of Color. —Accidental Development of Hair ...... Page 302 CHAPTER XI. NERVOUS SYSTEM. I. Lesions of the Brain.—Wounds.—Encephalitis.—Suppuration.—Abscesses.—Gangrene.— Softening.—Chronic Inflammation. —Induration.—Ulceration.—Sanguineous Effusions.— Hypertrophy and Atrophy.—Tubercles.—Melanosis.—Encephaloid.—Cartilaginous Forma- tions.—Calcareous Deposits.—Cysts and Hydatids.—II. Lesions of the Cerebral Envelops.— Inflammation of the Dura Mater.—Suppuration.—Fibrous Tumors.—Bony Deposits.—Hy- pertrophy of the Glands of Pacchioni.—Arachnitis.—Hydrocephalus.—Tubercles.—Diseases of the Pia Mater.—III. Lesions of the Spinal Cord.—Inflammation.—Heterologous For- mations.— Hydro-rachitis.—IV. Lesions of the Nerves.—Restorative Power.—Neuritis. —Suppuration.—Ulceration.—Hypertrophy and Atrophy.—Diseases of the Nervous Ganglia 338 CHAPTER XII. EYE. I. Lesions of the Lachrymal Apparattis.—Lachrymal Gland.—Ducts and Sac.—II. Lesions of the Ball of the Eye.—The Conjunctiva.—'Pterygium. — Lachrymal Caruncle. — Acute Corneitis.—Ulceration and Ossification of the Cornea.—Fleshy Excrescences.—Alterations of Form.—Diseases of the Sclerotica.—Choroid Tunic. — The Retina.—Amaurosis.—Optic Nerve.—Membrane of Demours.—Hsemophthalmus.—Lesions of the Iris.—Alterations of the Pupil.—Capsule of the Crystalline Lens.—Liquor of Morgagni.—Varieties of Cataract. —Vitreous Humor.—Heterologous Formations ..... 371 CHAPTER XIII. EAR. Malformations of the External Ear.—Polypous Growths—Lesions of the Tympanum.__Bones of the Ear.—Eustachian Tube.—The Labyrinth and Vestibule.—Diseases of the Auditory Nerve...........387 CHAPTER XIV. THYMUS GLAND. Weight and Size.—Development and Decay.—Hypertrophy.—Thymic Asthma.—Inflamma- tion.—Ulceration.—Scirrhus.—Tubercular Deposits.— Ossification.—Steatomatous degenera- tion ........ oQ1 CONTENTS. XV CHAPTER XV. THYROID GLAND. Acute Inflammation. — Suppuration. — Goitrous Enlargement. — Sanguineous Effusions.— Atrophy.—Tubercular Deposits.—Scirrhus ..... Page 393 CHAPTER XVI. RESPIRATORY APPARATUS. I. Lesions of the Air-Passages.—Inflammation of the Larynx.—Membranous Croup.—(Ede- ma of the glottis.—Ossification of the Laryngeal Cartilages.—Polypous Growths.—Warty Excrescences.—Tubercles and Hydatids.—Tracheitis.—Stricture.—Dilatation.—Inflamma- tion of the Bronchiae. Dilatation.—Contraction.—Flattening.—II. Lesions of the Lungs. —Acute Inflammation. — Hepatization.—Abscess. — Gangrene. — Chronic Pueumonitis. — Carnification.—(Edema.—Emphysema.—Apoplexy. —Encephaloid Disease. — Melanosis.— Serous Cysts.—Hydatids.—Calcarerous Concretions.—Hypertrophy.—Atrophy.—Tubercular Phthisis.—III. Lesions of tlie Pleura.—Acute Inflammation.—Formation of Matter.—Gan- grene.—Chronic Pleuritis.—Ossification.—Accumulation of Gas.—Ulceration.—Tubercular Deposits .......... 397 CHAPTER XVII. HEART AND ITS MEMBRANES. I. Lesions of the Pericardium,.—Inflammation.—Hydro-pericardium.—Formation of Matter and Deposits of Lymph.—Effusion of Blood.—Accumulation of Air.—Serous Cysts.—Con- genital Absence.—II. Lesions of the Heart.—Situation, Weight, and Dimensions.—Acute Carditis.—Collections of Pus.—Ulceration.—Inflammation seldom or never ends in Gan- grene.—Softening.—Induration.—Cartilaginous and Osseous Degenerations.—Scirrhus and Encephaloid.—Fatty Transformation.—Sanguineous Effusions.—Serous Cysts.—Hydatids.— Atrophy.—Dilatation.—Aneurism.—Hypertrophy.—Malformations.—III. Lesions of the En- docardium.—Acute Inflammation.—Thickening.—Wart-like Excrescences.—Fibro-Cartila- ginous, Cartilaginous, and Osseous Transformations.—Fibrinous Concretions . 448 CHAPTER XVIII. NASAL, MAXILLARY, AND FRONTAL CAVITIES. I. Nasal Cavity.—Deviations from the Normal Standard.—Nasal Septum.—Inflammation of the Schneiderian Membrane.—Epistaxis.—Different kinds of Polypes.—Obstruction of the Mucous Follicles.—II. Maxillary Si?ius.—Purulent Accumulations.—Ulceration of its Lin- ing Membrane.—Polypous Growths.—Carcinoma.—Exostoses.—III. Lesions of the Frontal Sinus ........... 473 CHAPTER XIX. MOUTH, PHARYNX, AND (ESOPHAGUS. I. Diseases of the Lips.—Carcinoma, Encysted Tumors, and Congenital Fissure.—Malforma- tions of the Jaw.—II. Glossitis.—Ulceration, Hypertrophy, and Cancer of the Tongue.— Congenital Deficiencies.—III. Salivary Glands.—Parotitis.—Atrophy and Hypertrophy.— Scirrhus.—Calcareous Concretions.—Ranula.—Fatty Degeneration.—Morbid Alterations.— IV. The Teeth.—Caries.—Gangrene.—Inflammation of their Internal Membrane.—Fun- gous Tumors.—Exostoses.—Denuding Process.—Deposits of Tartar.—Congenital Vices.—V. XVI CONTENTS. Tlie Gum.__Liability to Inflammation.—Epulis.—Ulcerative Absorption.—Mortification.— Alveolar Abscess.—VI. Diseases of the Tonsils.—VII. Tlie Soft Palate and Uvula.—VIII. The Pharynx.—Diphtheritis.—Polypes.—Sacculated Condition.—IX. Oesophagitis.—Ulce- ration .—Softening.—Stricture .-Scirrhus.—Laceration.—Congenital Malformations Page 478 CHAPTER XX. STOMACH AND BOWELS. I. Consistence and Color of the Gastro-Enteric Mucous Membrane ; how modified by Age, Diges- tion, and other circumstances.—II. Inflammation.—Anatomical Characters of the Acute Form of the Disease.—Increased Vascularity.—Dryness.—Thickening.—Softening.—Deposi- tion of Lymph.—Formation of Vesicles.—Effusion of Blood and Serum.—May pass into Gan- grene or become Chronic.—III. Softening; of two kinds, from Inflammation, and the Ac- tion of the Gastric Juice.—IV. Diseases of tlie Stomach.—Ulceration.—Hypertrophy and Atrophy.—Formation of Pouches.—Cartilaginous Degeneration.—Carcinoma.—Laceration. —V. Lesions of the Duodenum.—VI. Affections of the Small Bowels, properly so called. Ulceration of the isolated Crypts and of the Glands of Peyer.—Typhoid Fever.—Infan- tile Cholera.—Tubercular Deposits.—Melanosis. — Intussusception. —Hernia.—Abnormal Pouches.—Repair of Wounds.—Atrophy and Hypertrophy.—Earthy Concretions.—VII. Lesions of the Large Bowel.—Ulcers.—Wart-like Vegetations.—Singular Contraction of the Colon.—VIII. Vermiform Appendage.—IX. Bccto-Anal Region.—-Carcinoma.—Fissure of the Anus.—Enlargement of Pouches.—Organic Stricture of the Rectum. — Polypes.— Hemorrhoids.—Fistule.—Prolapse of the Bowel.—Congenital Vices.—X. Intestinal Worms. —Lumbricoides.—Oxyuris.—Tricocephalus.—Tsenia Solium.—Taenia Lata . . 500 CHAPTER XXI. PERITONEUM. Is liable to different forms of Disease.—Acute Inflammation.—Deposition of Lymph.—Effusion of Serum, Pus, and Blood.—Softening of Subserous Cellular Tissue.—Parts of the Membrane most apt to suffer.—Development of Vesicles.—Chronic Irritation.—Agglutination of the Bowels and formation of False Passages.—Ascitic Effusions.—Generation of Gas.—Tubercles. —Carcinomatous Growths ••-..... 585 CHAPTER XXII. BILIARY APPARATUS. I. The Liver.— Weight, Color, and Analysis.—Lesions.—Inflammation.—Suppuration and Ab scess.—Gangrene.—Softening.—Induration.—Hypertrophy and Atrophy.—Cirrhosis.__Tu- bercles.—Carcinoma.—Melanosis.—Hydatids.—Adipose Transformation.—The Liver Fluke and other Worms.—Cartilaginous Degeneration.—Osseous Concretions.—Sanguineous Effu- sions.—Erectile Tumor.—Restorative Powers of the Liver.—II. The Gall-Bladder. Inflam- mation.—Ulceration and Rupture.—Atrophy and Thickening of its Coats.—Diseases of the Biliary Ducts.—Alterations of the Bile.—Gall-stones . . . 594. CHAPTER XXIII. SPLEEN. Relations, Weight, and Size.—Acute Splenitis.—Anatomical Characters.—May pass into Sup- puration or into Gangrene.—Softening.—Induration and Hepatization.—Hypertrophy and Atrophy.—Tubercles.—Calcareous Concretions.—Fibro-Cartilaginous and Osseous Matter.— Hydatids and Serous Cysts.—Sanguineous Deposits.—Laceration . aiq CONTENTS. XVH CHAPTER XXIV. PANCREAS. Is liable to pretty much the same Diseases as the Salivary Glands.—Rarely the seat of Acute Inflammation.—Atrophy.—Hypertrophy.—Is sometimes affected with Scirrhus.—Encepha- loid.—Melanosis.—Fatty Transformation.—Serous Cysts.—Tubercular Deposits.—Sangui- neous Effusion.—Earthy Concretions ...... Page 626 CHAPTER XXV. URINARY APPARATUS. I. Supra-renal Capsules.—II. The Kidneys. — Observations on their Congenital Vices.— Lesions of their Fibrous Covering.—Pyelitis, Acute and Chronic.—Nephritis, Acute and Chronic.— Abscesses.— Softening.— Induration. — Gangrene seldom or never observed.— Bright's Disease.—Scirrhus and Encephaloid.—Tubercles.—Melanosis.—Erectile Tissues.— Serous Cysts.— Hydatids.—Fibro-Cartilaginous, Osseous, and Fatty Degenerations.— En- largement and Atrophy.—Rupture.—Renal Calculi.—The Strongylus.—III. The Ureter.— Liable to Deposits of Tubercular Matter.—Effusion of Lymph, Thickening and Attenuation of its Parietes, with Contraction or Enlargement of its Cavity.—IV. The Urinary Bladder.— Is rarely affected with acute Inflammation, Suppuration, Softening, or Gangrene.—Hyper- trophy of the Mucous and Muscular Tunics.—Developments of Cysts.—Ulceration.—Ence- phaloid Disease. — Tubercle. —Neuralgia.—Rupture.—Worms.—Morbid Urine.—Urinary Deposits.—Calculous Concretions.—V. The Prostate Gland.—Is liable to various forms of Disease.—Inflammatory Abscess, Chronic Enlargement, Tubercles, Melanosis, Encephaloid, and Calculi . . . . . • • • • .631 CHAPTER XXVI. MALE ORGANS OF GENERATION. I. The Testicle.— Weight and Volume.—Diseases of its Vaginal Tunic—Inflammation.—Hy- drocele.—Hsematocele.—Earthy Concretions.—Orchitis.—Malignant Affections of the Testi- cle.—Tubercles and Hydatids.—Hypertrophy and Atrophy.—II. The Spermatic Cord.— Encysted Dropsy.—Varicocele.—Neuralgia.—III. The Seminal Vesicles.—Their Lesions, few in number and still involved in obscurity.—Tubercles.—Earthy Concretions.—IV. The Scrotum.—Carcinoma.—Excessive Enlargement.—Is sometimes affected with a peculiar Sloughing Ulcer.—Contains Foreign Substances, such as Teeth, Hair, and pieces of Bone. —Earthy Concretions.—V. The Penis. — Gonorrhoea. — Gleet.—Chordee.— Organic Stric- ture.— Abscess along the Course of the Urethra.—Malformations of this Tube.—Imperfora- tion.—Morbid Erection of the Penis.—Degeneration of the Pectiniform Septum and Fibrous Sheath.—Carcinoma.—Syphilitic Ulceration.—Herpetic Affections.—Warty Excrescences.— Phymosis and Paraphymosis.—Sometimes Seat of Calculous Concretions . . 683 CHAPTER XXVII. FEMALE ORGANS OF GENERATION. I. The Uterus.—Observations on its Weight and Volume.—Liable to Malformations.—Retro- version.—Prolapse and Inversion.—Is apt to suffer from Inflammation, both of its Lining Membrane, its serous Covering, and its proper Tissue.—Remarks on Uterine Phlebitis.— Softening.—Induration.—Atrophy.—Fibrous Tumors.—Different Species of Polypes.—Cal- careous Concretions.—Transformation of the Uterine Tissue into Cartilage and Bone.— Malignant Diseases.—Encephaloid and Scirrhus.—Tubercular Deposits.—Rupture.—Hemor- rhage.—Accumulation of Air.—Hairs.—Obstructions of the Mouth of the Womb.—Hydatids. 2 XV111 CONTENTS. —Uterine Moles. II. The Ovaries.—Their Disorders are numerous and important.—Osseous Transformations.—Serous Cysts and Hydatids.—Scirrhus.—Occasionally contain Teeth, Hair, and Fragments of Bone.—Hemorrhage.—Remarks on the Corpora Lutea. III. The Fal- lopian Tubes.—Are seldom affected with Disease. IV. Tlie Vagina and Vulva.—Liable to the same kinds of Maladies as other Mucous Structures.—Polypes of the Vagina.— Varices.—Enlargement of its Mucous Follicles.—Vices of Formation.—The Great Labia.— Polypes.—Clitoris.—Nymphae, and Orifice of the Urethra. V. The Mammary Gland:— Is often the seat of Acute and Chronic Inflammation.—Its Diseases, in many respects, resemble those of the Testicle and Ovary. VI. Placenta and Umbilical Cord.—Inflamma- tion.— Suppuration.— Softening.— Cartilaginous Degeneration.—Ossification.—Fatty De- generation.—Hypertrophy.—Tubercles.—Sanguineous Effusions . - Page 707 LIST OF ILLUSTRATIONS. 1. Natural ear of a rabbit 2. Inflamed ear of a rabbit 3. Change in the capillary circulation in inflammation 4. Inflamed serous membrane 5. Inflamed web of a frog's foot 6. Reticulated arrangement of the corpuscles in inflammatory blood 7. Plastic corpuscles and filaments in recent lymph exuded on the pi 8. Recent lymph, forming false membrane 9. 1 > Nuclei and cells developing themselves into fibres 11. A perfect fibrous tissue 12. Newly-formed vessels in plastic lymph 13. False membrane of the pleura 14. Vessels in a clot of blood 15. Natural appearance of pus-corpuscles; and after application of acetic acid 16. Pus-corpuscles, magnified 400 diameters 17. Mucous pus-globules . 18. Gangrene .... 19. Senile gangrene 20. Structure of a granulation 21. Structure of a cicatrice of the skin . 22. Burn of the neck 23. Cellular cysticerce 24. Magnified head of same 25. Portion of human muscle with the same inclosed 26. Vesicular cysticerce . 27. Magnified head of same 28. Dicystis 29. Magnified head of same 30. Speckled cysticerce 31. Fischerian cysticerce . 32. Granular polycephalus 33. Small body attached to the inner surface of the animal 34. Rough diceras 35. Echinococcus . 36. Acephalocyst . 37. Young acephalocysts 38. Tubercle-corpuscles 39. Vessels in and around tubercles 40. Fibrous stroma of scirrhus XX LIST OF ILLUSTRATIONS. FIG, 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. Cancer-cells . Encephaloid cells > Stroma of medullary carcinoma Colloid tumor External appeai-ance of the same Stroma of colloid Epithelial cancer Epithelial cells Epithelial papilla Buffy and cupped blood Filaria medinensis . Fatty tumor . Spiral trichina Separate cyst of the same . The same magnified Fibroid bodies of a ganglion Fibroid bodies of a synovial burse Deposition of calcareous matter Atheromatous deposits Hypertrophy of the aorta Sacculated aneurism Cylindroid aneurism Varicose artery Dissecting aneurism Arterio-venous aneurism Anastomotic aneurism Aneurism of the aorta in progress of obliteration Obliterated aneurism of the hepatic artery Fibrinous phlebitis . Varicose veins Obliteration of the vena cava Phlebolites .... Dilated lymphatics . Hypertrophy of the lymphatic glands Melanosis of a lymphatic gland Cretaceous degeneration of lymphatic glands Osseous anchylosis of the knee Loose articular concretions . Attached articular concretions Exuberant callus of a broken femur Fracture of the arm-bone of a chicken Appearance of bone after amputation Chronic abscess of the tibia Caries of the tibia Caries of the head of the humerus Necrosis of the thigh bone . Madame Supiot Rickets General hypertrophy of bone—internal structure General hypertrophy of bone—external appearance LIST OF ILLUSTRATIONS. XXI FIG. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. 141. 142. Hypertrophy involving both the thickness and length of bone Exostosis of the thigh-bone Ivory-like exostosis . Absorption of the humerus Atrophy of bone Atrophy of cellular structure of the thigh-bone Enchondromatous tumor of the ribs Encephaloid disease of the thigh-bone Change of bone produced by carcinoma Colloid tumor Tubercular excavation of the cuneiform bone Keloid growth of the face Horny excrescence of the scalp Section of a horn Sebaceous tumors of the scalp Cyst of a sebaceous tumor . I Itch insect Onyxitis of the great toe Osseous deposits upon the dura mater Carcinoma of the dura mater Bifid spine .... Bifid spine .... Section of a neuroma Hypertrophy of a nervous ganglion Granular conjunctivitis . . Pterygium Encanthis Corneitis Ulcer of the cornea Conical cornea Staphyloma . Staphyloma of the sclerotic coat Ossification of the choroid . Cellular hydatid Iritis Prolapse of the iris . Encephaloid of the eye Gelatinoid polype of the ear Goitre Cellular structure of a goitrous thyroid gland Ossified thyroid gland ffidema of the glottis False membrane of croup False membrane of the bronchial tubes Ossification of the cartilages of the larynx Polype of the larynx Uniform dilatation of the branchiae Sacculated dilatation of the bronchiae Obliteration of the bronchia? Obliteration of the branchiae 2* XX11 LIST OF ILLUSTRATIONS. FIG. 143. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154. 155. 156. 157. 158. 159. 160. 161. 162. 163. 164. 165. 166. 167. 168. 169. 170. 171. 172. 173. 174. 175. 176. 177. 178. 179. 180. 181. 182. 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193. Microscopic appearances in pneumonia Red hepatization of the lung Chronic pueumonitis Vesicular emphysema Interlobular emphysema Pulmonary cavities . Pulmonary cavities intersected by cord-like bodies Cicatrization of tubercular cavities Cicatrization of tubercular cavities False membrane of the pleura Ossification of the pleura Pericarditis .... Cyst in the left ventricle of the heart Hypertrophy of the left ventricle Rupture of the heart Ossification of the mitral valves Fibrinous concretion of the heart Gelatinous polypes . Nasal polype, containing nbro-cartilaginous concretions Epithelial cancer of the lower lip Glossitis Hypertrophy of the tongue . Salivary calculus I Caries of the teeth .... Chronic inflammation of the dental periosteum Fungous tumor of a tooth do. do. Fusion of teeth Malformation of the fangs of a tooth Epulis Hypertrophied tonsils False membrane of the oesophagus Stricture of the oesophagus . Dilatation of the oesophagus Ulcerated scirrhus of the oesophagus Ulcer of the stomach Cauliflower cancer of the stomach Section of a scirrhous stomach Scirrhus of the pylorus Ulceration of the glands of Peyer Enlargement of the mucous follicles Follicular ulceration of the large bowel Intussusception of the small bowel Sacs of the bowel Wound of the bowel; eversion of the mucous membrane Ligation of the bowel Cicatrization of the bowel after ligature Wound of the bowel LIST OF ILLUSTRATIONS. XXU1 FIG. 194. 195. 196. 197. 198. 199. 200. 201. 202. 203. 204. 205. 206. 207. 208. 209. 210. 211. 212. 213. 214. 215. 216. 217. 218. 219. 220. 221. 222. 223. 224. 225. 226. 227. 228. 229. 230. 231. 232. 233. 234. 235. 236. 237. 238. 239. 240. 241. 242. 243. 244. Cicatrization of the mucous membrane Attachment of the omentum to the bowel, external to the wound > Cicatrization of the mucous membrane Artificial anus Diverticulum of the small bowel Ulceration of the large bowel Wart-like vegetations of the mucous membrane of the large bowel Pouches of the rectum Organic stricture of the rectum Polype of the rectum—external appearance Polype of the rectum—internal appearance External hemorrhoids Internal hemorrhoids Minute structure of an internal hemorrhoidal tumor Partial prolapse of the rectum Complete prolapse of the rectum Ascaris lumbricoides Organs of the female ascaris Organs of the male ascaris . Penis of the ascaris lumbricoides Head and mouth of the ascaris Lumbricoid worm in the eye of a button Ascaris vermicularis Trichocephalus dispar Taenia solium Taenia lata . . . False membrane of peritonitis Cartilaginous and osseous concretions of the peritoneum Hypertrophy of the omentum Cirrhosis of the liver Hypertrophy of the hepatic acini Nutmeg appearance of the liver Scirrhus of the liver Melanosis of the liver Distoma hepaticum . Taenia in the liver Osseous concretions of the liver Atrophy of the gall-bladder Dilatation of the biliary ducts Calculi in the gall-bladder . Tubercles of the spleen Granular degeneration of the kidney—incipient Granular degeneration of the kidney—more advanced Granular degeneration of the kidney—still more advanced Serous cysts of the kidney Cysts of the kidney . Cysts of the kidney—external appearance Cysts of the kidney—internal appearance Encephaloid of the kidney . Tubercular excavations of the kidney PAGE 557 558 XXIV" LIST OF ILLUSTRATIONS. FIG. 245. 246. 247. 248. 249. 250. 251. °52 253. 254. 255. 256. 257. 258. 259. 260. 261. 262. 263. 264. 265. 266. 267. 268. 269. 270. 271. 272. 273. 274. 275. 276. 277. 278. 279. 280. 281. 282. 283. 284. 285. 286. 287. 288. 289. 290. 291. 292. 293. 294. 295. Calculi of the kidney and ureter . ,, Large strongyle < , < Horseshoe kidney , Dilatation of the ureter and pelvis of the kidney Hypertrophy of the muscular fibres of the bladder Bar-like formation at the neck of the bladder Sac-like pouches of the bladder Extrophy of the bladder Female dactylius aculeatus Male dactylius aculeatus £ The same magnified . Epithelium . Granular cells from the bladder Casts of uriniferous tubes Blood-corpuscles in an aggregated state Blood-corpuscles in a separate state Pus-corpuscles Spermatozoa Lithic deposit Oxalic deposit Triple phosphate Uric calculus Section of the same Oxalic calculus Section of the same Hemp-seed calculus , Phosphatic calculus Ammoniaco-magnesian calculus Fusible calculus Fusible calculus—internal structure Cystic calculus Cystic calculus—internal appearance Hypertrophy of the prostate Lobulated hypertrophy of the prostate Hypertrophy of the middle lobe Irregular hypertrophy of third lobe Prostatic calculus Hydrocele of the vaginal coat Haematocele of the scrotum Acute orchitis Abscess of the testicle Tubercles of the testicle Cystic testicle Calcareous matter in the testicle Fibrous tumor of the vaginal tunic Tubercular matter in the seminal vesicles Earthy concretions in a seminal vesicle Chimney-sweeper's cancer . Hypertrophy, or elephantiasis of the scrotum Stricture of the urethra, with false passage LIST OF ILLUSTRATIONS. XXV FIG. 296. Urinary fistules in the perineum 297. Epispadias . 298. Venereal ulcer on the penis 299. Warts on the penis 300. Phymosis 301. Paraphymosis 302. Double uterus 303. Bipartite uterus 304. Bicorned uterus 305. Double cavity of the uterus 306. Retroversion of the uterus 307. Anteversion of the uterus 308. Inversion of the uterus 309 ) >• Enlargement of the mucous follicles 310. J 5 311. Fibrous tumor in the cavity of the uterus . 312. Fibrous tumors of the uterus—internal and external 313. Fibrous polype of the uterus 314. Uterine polype attached to the base of the organ . 315. Uterine polype hanging from the vulva 316. Incipient cancer beginning in the body of the uterus 317. Carcinoma of the uterus beginning at the mouth and neck of the 318. Laceration of the womb 319. Hydatids of the uterus 320. Exterior of a fibrinous mole 321. Mole cut open, showing its structure 322. Mole with the cavity communicating externally 323. Vascular mole 324. Ovarian cyst 325. Teeth and pieces of jaw-bone 326. Hair from an ovarian tumor 327. Corpus luteurn of menstruation 328. Corpus luteum of pregnancy 329. Dropsy of the Fallopian tube 330. Foetus in Fallopian tube 331. Enlarged mucous crypts ? 332. Prolapse of the vagina 333. Hypertrophy of the clitoris and nymphae . 334. Vascular excrescences around female urethra 335. Adenoid tumor of the mamma 336. Cystic disease of the breast 337. Scirrhus of the breast 338. Scirrhus of the mamma, showing retraction of the nipple 339. Fungus haematodes of the mamma 340. Encephaloid of the mammary gland, of the haematoid variety 341. Fibro-cartilaginous degeneration of the placenta 342. Twisted and knotty umbilical cord organ J PART I. GENERAL PRINCIPLES OF PATHOLOGICAL ANATOMY. PATHOLOGICAL ANATOMY. CHAPTER I. INFLAMMATION. Preliminary Observations.—Fluids and Solids.—Different kinds of Sympathy.—Disease, func- tional and organic.—Inflammation, how modified by Temperament, Age, Sex, Habit, Climate, Season, the nature of the exciting cause, and the character of the tissue; acute and chronic ; does not occur with equal frequency in all parts of the body ; common and specific.—Nature, symptoms, and seat of ordinary Inflammation ; Redness, Heat, Pain, and Swelling ; Derange- ment of the Vital Actions ; Structure of the Capillaries ; joint agency of the Vascular and Nervous Systems; altered Sensibility; preternatural influx of Blood ; Congestion ; Theo- ries of Boerhaave, Cullen, Vacca, and others. Terminations and Conditions of Inflam- mation. The human body is composed of solids and fluids, which are inti- mately blended together, and mutually dependent upon each other for their origin and preservation. Both classes are resolvable into a num- ber of proximate constituents, differing widely in their color, their consistence, and their chemical properties. Of the fluids, the blood is by far the most important, as it is out of it that the solids are formed, and by it that they are nourished and sustained. The quantity of this liquid, on an average, is about eighteen pounds; but it is liable to vary not only in different persons, but likewise in the same individuals at different periods. Not only its amount, but also its quality, is much influenced by the kind of food and drink, the exercise, the climate, and mode of life, to which the individual is subjected. It is not my design, in this place, to say anything of the chemical constituents of the blood, further than to declare that this fluid contains all the ele- ments of the solid parts of the body, that the latter are constantly permeated by it, and that there can be no secretion, whether healthy or morbid, that is not derived from it. The diseases to which it is liable will be made the subject of separate consideration. The solids consist of what are called the tissues; of which the num- ber1 has been variously stated by different writers, scarcely any two agreeing on the subject. Without occupying the attention of the reader with any discussion of this sort, which would be out of place here, I shall merely remark concerning them that they all differ from 34 INFLAMMATION. each other in their appearance, their composition, their structure, and the purposes which they are designed to fulfil in the economy. With the exception of the muscular and nervous fibres, they all seem to be derived from the cellular element, a substance which enters so largely into the composition of the animal machine, cementing together its various parts, and forming myriads of meshes for the reception of its nutrient and recrementitious particles. Combined in various ways, these tissues constitute the different organs, whether parenchymatous, pulpy, glandular, or erectile. The parenchymatous structure is well exemplified in the lungs, which are composed of a soft, spongy, cellular substance, freely pervaded by vessels. Of the pulpy texture, a good illustration is afforded by the brain : here there is very little cellular matter, and the consistence of the organ appears to depend principally upon the presence of a large proportion of albumen. The glandular structure is still imperfectly understood. The liver, which forms the type of this system, is made up of myriads of rounded or polygonal cells, around which the capil- lary vessels circulate. The erectile texture, the most perfect example of which occurs in the penis, is composed mainly of arteries and veins, closely interwoven with each other, and susceptible of temporary erec- tion, from the influx of blood. The tissues, whether they be regarded individually, or as united together to form compound organs, are differently supplied with vessels, nerves, and lymphatics; and, consequently, although they are all important, each in its own way, to the well-being of the general system, some are much more so than others. Whole limbs, containing every variety of texture, may be removed, even in the human subject, without being necessarily followed by the dissolution of the economy; whereas, scarcely a single one of the internal organs, properly so called, with the exception of the spleen, can be extirpated without the destruction of life. Connected together by vessels and nerves, as well as, in some instances, by continuity of surface, there subsists between the various parts of the body the closest fellow-feeling. In health, this sympa- thetic action is carried on so imperceptibly as to escape the attention ©f the physiologist; but no sooner is the system deranged than it manifests itself at almost every point of the compass, serving at once to show the nature of the lesion, and the particular tissue, or set of textures, which it implicates. Every one is familiar with the powerful sympathy existing between the uterus and the stomach; the stomach and the lungs; the lungs and the heart; the heart and the brain. Nor is this fellow-feeling less marked in some of the other viscera. In duodenitis, nothing is more common than to see the liver disturbed in its functions; or, if the disease continue long, even in its structure. The explanation of this is obvious. The duodenum and the liver are not only near neighbors, but the mucous membrane, which lines the former, is extended into the latter, by means of its excretory ducts into the very centre of each granule. There is thus a direct continuity of structure, in consequence of which disease cannot exist long or in any considerable degree, in the one without being propagated to the DISEASE: WHAT IS IT? 35 other. So, also, with the urethra and urinary bladder; the vagina and uterus; the fauces and tonsils; the larynx and trachea; the nose and frontal sinuses; the Eustachian tube and middle ear. All these cases are examples of what has been termed continuous sympathy. In other cases, again, this sympathy displays itself in parts very remote from the one originally affected. In mumps, that is, in in- flammation of the parotid gland, a not unfrequent occurrence is a swelling of the testicle, proceeding sometimes to such an extent as to destroy the structure and function of the organ. In what manner, or in accordance with what law of the animal economy, this associa- tion is established, it is impossible to say, as there is no similarity of texture any more than a direct nervous connection. The parotid is supplied with filaments from the ascending cervical nerves, and with branches from the fifth cranial; the testicle, with filaments from the spermatic plexus, formed by the sympathetic. Thus, then, there is no immediate tie between these organs, and yet, as has been stated, they often display the strongest fellow-feeling. The sympathy existing between the uterus and the breast, and which is so conspicuous both in the healthy and diseased states of these parts, has been endeavored to be explained by the anastomosis of the internal mammary and epigastric arteries; but it need scarcely be remarked that this mode of accounting for the phenomenon is far-fetched and unsatisfactory, the vessels ad- verted to having by no means the intimate connection which some have ascribed to them. The same difficulty occurs when we attempt to ascertain the cause of the well-known sympathy between the cere- bellum and genital organs. In regard to all of these organs, all that we know is, that there is such a bond of connection, and this, surely, for all practical purposes, is sufficient. Writers long ago noticed the sympathy between parts of the same structure, situated remotely from each other. In gout, a disease which is seated in the fibrous textures of the extremities, it often happens,. especially when the attack is violent, that the pericardium is involved; the affection being transferred from its original situation to the chest. This is effected by what is called metastasis, a term which only expresses our ignorance. The transfer must take place solely on account of the similarity of structure, not through any direct commu- nication ; for every anatomist knows that there is no connection what- ever between the fibrous envelops of the voluntary muscles and the fibrous covering of the heart. The serous and synovial membranes, the cutaneous and mucous tissues, strongly sympathize with each other, no doubt from the anatomical elements which enter into their composition being so much alike. The liver and the skin are inti- mately associated by fellow-feeling J but how this is brought about we have no means of determining. I have thus briefly adverted to the relationship subsisting between the principal organs of the body, and endeavored to account for it upon anatomical principles. Much time might be occupied in the dis- cussion of the subject; but I am not certain that it would result in much good. AVhat is most worth knowing, is soonest learned, and least subject to dispute. The relationship here described should be 36 INFLAMMATION. carefully studied, as it will be impossible, without an extensive acquaintance with it, to comprehend some of the most extraordinary phenomena observable at the bedside of the sick. Having made these remarks, we may now proceed a step further, and inquire what constitutes disease; for everybody knows what is meant by health. Disease may be defined to be a departure from the sound state, whether this departure consist simply in a derangement of function or structure. So long as the solid and fluid materials of the body act in concert, there cannot, of course, be any lesion; health, in all its vigor and perfection, must be the result: but when the blood and the tissues are arrayed, as it were, against each other, the har- mony of the system is interrupted, and unnatural action is set up, or, in other words, there is disease. This deranged action, it need scarcely be stated, may be limited, or it may involve a considerable number of organs and tissues at the same time. Of the essence of disease, very little is known; indeed, nothing at all; nor can the utmost ingenuity hope to remove the veil which still envelops the subject, until the physiology and pathology of the vascu- lar and nervous systems shall be better understood. The proximate cause of morbid action, and the immediate cause of life in the healthy state, are as inscrutable to the human mind as the cause of gravitation, of attraction, and repulsion. All we can boast of is, that we know something of their effects; beyond this, it is extremely problematical whether we shall ever be able to penetrate. With this, indeed, every philosophical inquirer after truth should be contented, remembering that the secrets of nature are not easily detected, and that to God alone belongs the knowledge of the intrinsic property of things. It has been already intimated, that diseases are functional or organic. As it is of the latter class that we shall more particularly treat in the following pages, it will be proper that we should speak of them some- what at length. Before proceeding further, however, it behooves me to explain what I comprehend by the term organic. By pathological anatomists, the word is generally employed to denote some permanent change in the textures of an organ ; but, in the present sense, I would not only include under it all such lesions, but also every temporary alteration which the tissues experience when in a state of disease. The term organic will thus have a wider latitude; and, as expressing the same thing, we shall often have occasion to use the word structural. If this acception be adopted, it may perhaps be doubted whether, under any circumstances, there can, strictly speaking, be a functional dis- ease, or, in other terms, a mere aberration of the physiological state of a part, without some change in its anatomical elements. The ques- tion, at all events, is not settled. Bearing in mind the above definition, it may be assumed, as a gene- ral proposition, liable to few exceptions, that all organic diseases whatever be their seat or extent, are the result of inflammatory action^ either of an acute or a chronic kind. To some, this proposition may be startling; nevertheless, if it be carefully examined, it will be found I doubt not, to be grounded on fact. The truth of this remark will appear more evident as we proceed. MODIFIED BY AGE, SEX, CLIMATE. 37 The second proposition that may be stated is, that every inflamma- tion, irritation, or morbid action, is originally of a local nature; that is, it always makes its impression in the first instance upon some par- ticular part, texture, or organ. After the malady has continued for a longer or shorter period, it may extend to and implicate other structures. If, for instance, the mucous membrane of the stomach be fretted, the morbid action accruing from this cause will be confined at first to that lining; or, in more comprehensive terms, the disease will be strictly local; by degrees, however, as the disorder progresses, the submucous cellular tissue becomes affected; and spreading still further, it next invades the muscular fibres of the organ, and, finally, the peritoneal covering. It is in this manner that most affections, which are originally local, extend their sphere of action so as to become general, whether they be considered simply in reference to one organ, to several, or to a great number of them. Inflammation of particular organs and textures is usually designated by adding the Greek term itis to the anatomical name of the part affected, as gastritis, laryngitis, pleuritis. In some instances the old nomenclature is retained. Thus inflammation of the tonsils is called quinsy; of the eye, ophthalmia; of the urethra, gonorrhoea; of the parotid gland, mumps. In regard to its progress, intensity, and mode of termination, inflam- mation is greatly modified by temperament, age, sex, habit, climate, and season, by the nature of the exciting cause, and, above all, by the character of the tissue in which it is developed. The time of life which seems to be most obnoxious to this disease, is from the first to the tenth year, nearly one half of the entire mortality occurring during this interval. Affections of the cutaneous, mucous, and lymphatic systems, are particularly rife during this period, and carry off an im- mense number of children. Scarcely less common is inflammation of the arachnoid membrane. Pleuritis, pneumonitis, cerebritis, and hepatitis, with carditis, phlebitis, and arteritis, are comparatively in- frequent before the age of manhood; from thence on, however, they are by no means unusual, and prove a fruitful source of destruction. Diseases of the genital organs are rarely observed before the age of puberty; indeed, anterior to this period, these structures seem to lie in a dormant state. Once roused into action, however, they deeply sympathize with the other viscera, and hence the frequency of organic maladies of the uterus, the ovaries, breasts, and testicles, towards the decline of life. Affections of the urinary bladder are comparatively rare in the young, whilst they are very common in the old. Considered in reference to secc, some organs and tissues are more liable to be affected with inflammation than others. Cerebritis and splenitis, as well as carditis and arteritis, are infinitely more common in men than in women, probably, from the organs of the former being more exposed to perturbating agents, both of a physical and a mental kind. On the other hand, it is a well-established fact that the female sex is much more obnoxious to inflammation of the peritoneum, of the veins, and lymphatics, than the male. The seasons of the year in which inflammation is most prevalent 38 INFLAMMATION. are winter and spring; it is also more common in moist than in dry situations, and in cold and hot climates than in such as are temperate. In northern latitudes, the parts most frequently involved are the lungs, the air-passages, and the fibrous textures; in tropical, the mucous membrane of the large bowel, the liver, and the skin. The above are circumstances in the history of inflammation which, of course, we can only glance at; the subject is one of vast interest to the practitioner, and the attentive study of it cannot fail to be of the greatest benefit to him. The rapidity with which this disease may run its course is subject to a considerable number of circumstances, amongst which the most important are the nature of the exciting cause and the structure of the part affected. As a general rule, it may be stated that the more liberally an organ is supplied with vessels and nerves, the more easily will it be disorganized. Thus, an inflammation of the mucous mem- brane of the bowels will usually terminate much more rapidly either in health, or in death, than the same disease seated in a fibrous mem- brane, a tendon, ligament, or bone. When an acute inflammation, after having existed for some time, does not terminate in the usual manner, it is said to become chronic. Paradoxical as it may at first sight appear, there are some varieties of this disease that assume a chronic form at the very moment of their outset. The irritation which accompanies the tubercular deposition, and some species of pure uncomplicated pneumonitis, are of this de- scription. Considered in regard to its degree of intensity, inflammation presents a great variety of forms, from the slightest possible derangement to the most intense morbid action. In this respect, therefore, the disease may be said to be mild, moderate, or violent. For the purpose of designating the first of these conditions, some writers are in the habit of employing the term sub - acute; a word which seems to me to be ill-chosen, and consequently conducive to error. The terms mild, slight, or moderate, are free from this objection, and will, therefore, be retained in the following pages. Inflammation is sometimes latent, or, in other words, there is an entire absence of the symptoms by which it is ordinarily characterized. Examples of this variety of morbid action are found in certain forms of pneumonia, arachnitis, and typhoid fever. In the latter affection the glands of Peyer are often very much diseased, and even extensively ulcerated, without any of the usual manifestations of inflammation. Again, inflammation may be intermittent, as in certain forms of neu- ralgia, in chilblain, and, perhaps, in ague. This disease does not occur with equal frequency in all the organs and tissues of the body. There are some parts, in fact, in which it has been doubted whether this affection ever takes place. Such are the nails, the epidermis, and the hairs. These structures are supposed, by general anatomists, to be destitute of vessels, and, therefore in- capable of performing any vital action. This, however, is merely a conjecture | the fact remains to be proved, and, for my own part I feel quite certain that these textures are susceptible of inflammation' PHENOMENA. 39 although much less frequently, as well as in a much humbler degree, than the more highly organized tissues. The cellular, mucous, serous, and dermoid textures are particularly prone to inflammation. It is here that the disease can be studied with the greatest advantage, both as it respects its phenomena and modes of termination, inasmuch as it is usually well-marked, intense in degree, and rapid in its progress. The synovial membranes, the fibrous enve- lops, the bones, ligaments, and cartilages, with the muscles and their tendons, inflame with difficulty; but when the disease has once fastened itself upon them, they readily yield to its influence, the sufferings being often excessively severe, and the consequences very serious. The blood- vessels, nerves, and absorbents are all more or less liable to phlegmasia. The conservative power of these structures, especially of the former, is remarkable, and is strikingly evinced in cases of gangrene, where, as will be hereafter shown, they frequently retain their vitality amidst the half putrefied mass. Of the organs, properly so called, some are more ready to take on inflammation than others. Those which are most frequently affected, at least in this country, are the lungs, spleen, liver, uterus, and brain. The heart, ovaries, thyroid body, pancreas, prostate gland, testicles, and kidneys are comparatively rarely the seat of this disease. Respecting specific inflammation, some parts, again, are more prone to this disease than others. Thus, erysipelas commonly attacks the skin; anthrax, the subcutaneous cellular tissue; rheumatism, the fibrous envelops of the extremities; tubercle, the lungs; scirrhus, the glan- dular organs. In the skin, numerous varieties of inflammation, both of an acute and chronic kind, are observed that never occur in any other of the elementary textures and systems of the body. To this category specially belong the different species of eruptive and scaly diseases, which have their seat, for the most part, in the superficial portion of the dermis, the network of Malpighi, and the cuticle. Phenomena and Nature of Inflammation.—The nature of inflamma- tion, its seat, and the phenomena which characterize it, have always attracted much attention, and been a source of much discussion. Theory after theory has been framed, each in its turn to live for a while, and then to give way to some other, either more ingenious, or fostered and protected with more talent and pertinacity by its author. To review the various notions that exist on this subject would be a task as irksome to the inquirer as it would be unprofitable to the student of pathological anatomy. At every step the mind would be bewildered with idle conjecture, and at the close of the investigation it would be no better off, so far as real and substantial information is concerned, than at the outset. We can only express our regret that so much time has been misspent, so much talent wasted, in the con- struction of hypotheses, which, although sometimes plausible, do not, in the majority of instances, embrace a single well-ascertained fact to repay us for the trouble of examining them. Pathological anatomy is emphatically a science of observation and induction: in pursuing this inquiry, I shall, therefore, limit my remarks to a simple analysis of what is known respecting it; referring such of my readers as are 40 INFLAMMATION. fond of speculative reasoning to the various works that have been published on the subject within the last two centuries. He will there find a melancholy illustration of the fact that genius, however often it has wandered in quest of truth, has rarely succeeded in detecting it. The phenomena usually enumerated as marking inflammation are discoloration, heat, pain, and swelling. These signs, however, are not always present; nor are they the only circumstances which occur in inflammation in this disease: in every case there is a perversion of the vital actions, attended with an altered state of the nutritive and secretory functions. To affix to these several conditions their respective value, it will be necessary to allot to each of them a considerable share of attention. Most writers, until recently, attached too much importance to some of them, and too little to others; whilst they entirely over- looked the fact that they are always greatly modified by the nature of the tissue in which the malady, of which they are the indices, is located. If we regard the four phenomena, discoloration, heat, pain, and swelling, referred to above, as being essential to the process, it will be at once perceived that there can be but few inflammations; and we shall, there- fore, be obliged, in describing diseases, to invoke other names, such as irritation and fever; a blind adherence to which has unfortunately tended too much to retard the progress of pathological science. Boer- haave enumerated one hundred and fifty varieties of fever: had he enumerated a thousand more he would have been much nearer to the truth, for he might then have specified nearly every form of inflam- mation, whether occurring in the external parts of the body, or in the interior organs. The word " fever" is a conventional one, and is em- ployed to designate, not the nature or seat of a disease, but simply the phenomena which it manifests. So also with the term irritation. Mr. Travers and others have written extensive treatises on this sub- ject; but have they pointed out anything concerning the essential character of this disease ? have they told us anything of the peculiar condition of the nervous and vascular systems which accompanies it? So far as I am acquainted with their labors they have not; and yet men continue to talk about irritation, with its numerous varieties, as if they had the most perfect knowledge of its nature, seat, causes, and symptoms. A course such as this cannot but have a most dangerous tendency in practice; for what one physician describes as a fever, an- other will consider simply as an irritation, a third as an inflammation, and in this way no principles can ever be introduced as standards of treatment. The practice of medicine must continue to ebb and to flow with every tide of professional opinion. The time, however, cannot be far off, when the term fever must be entirely discarded from our books, and diseases named according to the tissues they implicate. Then, and not till then, can it be expected that the laws of deranged action will be properly interpreted, or fully comprehended. All diseases, I feel confident, will ultimately be found to have "a local origin and habitation;" and if this opinion shall ever be proved to be true, the whole class of febrile maladies, with its hun- dred varieties and subdivisions, will cease to have a place in our medical treatises. The artificial nosology of Sauvao-es of Hoffmann REDNESS. 41 Cullen, nosack, and a host of minor worthies, has had its day; its authority is at an end; its sceptre is departed; philosophy has usurped its place, and derides its aid. For the great changes which have been effected, and which are still going forward, in relation to the doctrine of morbid action, we are mainly indebted to a profound cultivation of pathological anatomy, which, since the time of Bichat, a period of less than sixty years, has advanced with such rapid strides, and reduced the healing art to a degree of certainty, which could scarcely have been anticipated. The discoloration of an inflamed part presents various shades, from the slightest rose to the deepest purple. There are some tissues which naturally contain little blood, or which convey only serosity, and these, of course, are never much discolored when affected with disease. The tendons, ligaments, and cartilages are seldom reddened, no matter what may be the intensity of the inflammation. In the fibrous mem- branes, such as the pericardium, the dura mater, and sclerotic coat of the eye, the discoloration is usually of a lilac or purple hue, with a shade of blue. In the mucous lining of the alimentary tube, the red- ness, in the early stage of the disease, is bright and florid, like that of arterial blood; but, as it progresses, it often assumes a dark violet, or black appearance, especially when it is about to pass into gangrene. A striking exemplification of the truth of this remark is afforded by the mucous membrane of the fauces in the malignant form of scarla- tina. In the beginning of this disease, the tonsils and adjacent parts are of a bright red, which is often, in the course of a few hours, con- verted into a deep purple. In the skin, the redness is sometimes of a scarlet color; at other times it has a yellow tinge, with various shades of mahogany. The yellow color is most commonly witnessed along with derangement of the liver; hence the frequency of its occurrence in the latter stages of erysipelas and anthrax. In inflammation of the pleura and peritoneum, the redness is, at first, of a lilac hue; after- wards of a scarlet, brownish, or violet. In the arachnoid there is rarely, if ever, any perceptible discoloration. Inflammation of the spleen and liver is attended with a purple hue: when the brain is affected, the color is generally rosaceous, cineritious, or like the lees of wine. The salivary glands are usually of a pink complexion; the kidneys, of a deep violet; the testicles and ovaries, of a reddish yellow. In the lungs the color varies from the slightest rose to the deepest purple. The redness is generally greatest at the centre of the inflamed part, from which it gradually diminishes in intensity until it reaches the natural standard of the tissue or organ in which it is located. It may be superficial or deep-seated; circumscribed or diffuse; arborescent or capilliform; punctated or blotch-like. In some instances, as in the lining membrane of the arteries, the color is uniform, having the appearance as if it were dyed into the part. Whatever form it may assume, the immediate cause of it is an unnatural influx of blood into the capillaries, the red globules being admitted in much greater numbers than in the sound state. So long as the circulation in these vessels is carried on vigorously, the redness in many of the tissues will be of a 42 INFLAMMATION. bright scarlet tint; but no sooner does the blood begin to stagnate than the part assumes a darker hue, probably from some chemical change which the fluid experiences under such circumstances. When a part is inflamed, is there really a preternatural development of heat t Mr. John Hunter thought there was not; and, in corrobora- tion of this opinion, he adduces some experiments which he performed on the inferior animals. He made a wound in the right side of the chest of a dog, and, pushing the thermometer in contact with the diaphragm, ascertained that the temperature of the part was 101°. A large dossil of lint was then put into the opening, and its surface covered over with adhesive strips. On the following day, when the parts were in a state of inflammation, the foreign substance was re- moved, and the instrument being again introduced, the heat was found to be exactly the same as before, namely, 101°. Similar experiments were made on the rectum and vagina of an ass, with the same results. There would thus seem to be no real increase of temperature. As a general rule, this is no doubt the case. Nevertheless, it has been clearly ascertained that, under certain circumstances, the reverse obtains. The difference is certainly not so great in the external as in the internal parts of the body. Yet even here there is reason to believe that the temperature of the inflamed structure is frequently higher, by several degrees, than that of the blood. In the natural state, the average heat of this fluid, as I have ascertained by numerous experi- ments, is 96°, whereas, in disease, the thermometer sometimes falls as low as 92°, or rises as high as 104°.l Every one knows how extremely hot the breath is in inflammatory affections of the throat, which can only be explained on the assump- tion that there is a partial increase of temperature. That the heat of the body, like every other physical endowment, is liable to be modified, is a fact which has been clearly established by the researches of physio- logists. Sir Everard Home states that the oviduct of a frog ready to spawn, is two degrees hotter than the heart; and it has been ascer- tained by Professor Dunglison,2 that, during labor, the temperature of the uterus sometimes rises to 106°. A similar phenomenon has been observed to occur in plants. M. Huber3 found that, when the heat of the atmosphere stood at 21° of the centigrade thermometer, the instru- ment surrounded with spadices of the arum cordifolium, during the process of fecundation, rose as high as 42°. From the foregoing facts, it clearly appears that there is occasionally a considerable extrication of heat, even when there is no inflammation, or when there is merely a slight approximation towards it. The subject of animal heat is still enveloped in doubt: that it is dependent, however, in great measure, upon the nervous system, appears suffi- ciently obvious; and if this point be conceded, no difficulty will be in the way of accounting for the alterations of temperature which 1 See The Western Medical Gazette, vol. i. 2 American Med. Intelligencer, Feb., 1839. 3 Ellis on Respiration, p. 204; also, Mayo's Physiology, p. 79, 4th ed. PAIN. 43 occur in different conditions of the body. A deranged state of the nervous function would, of course, be accompanied by a correspond- ing modification of the heat of the part, whether this was higher or lower than the natural standard; and this, indeed, is precisely what happens when inflammation is seated in parts remote from the central organ of the circulation. In cases of erysipelas, furuncle, and anthrax, the thermometer has been observed, in numerous experiments made since the time of Mr. Hunter, to rise as high even as 107°. Similar results have been noticed in tetanus and acute rheumatism. The temperature of a scrofulous tumor has been found raised as much as 5J° above the general heat of the body. There can, therefore, be no doubt whatever, as was before intimated, that, in certain cases of in- flammation, whether occurring in the interior organs or in the external parts, there is a real augmentation of temperature, over and above what is observed at the heart, the great fountain of the circulation. In some parts of the body, such as the ligaments, bones, cartilages, fibrous membranes, and tendons, the extrication of heat must necessarily be very slight. Pain is one of the most important symptoms of inflammation. Like redness, it varies in degree according to the nature of the affected part. As a general rule, it may be stated, that it is most keenly felt in those structures which are most liberally endowed with vessels and nerves. There are some tissues which, in the healthy state, are perfectly void of sensation, but which are exquisitely sensitive when laboring under disease. Thus, for example, a sound bone may be sawed, rasped, and even burnt, without the animal evincing the least uneasiness; but no sooner does it become inflamed than it gives rise to the most excru- ciating torture, leading often rapidly to hectic, with its whole train of evils. Similar phenomena occur in the fibrous membranes, the tendons, ligaments, and cartilages. In regard to the different viscera, it is a singular fact that they generally experience much more pain when their coverings are affected than when their proper structure is in- volved. In hepatitis, the inflammation often proceeds to a most de- structive extent before the individual is aware of his danger. Cerebritis is seldom so painful a malady as arachnitis; and a pleuritis, it is well known, is invariably attended with more suffering than a pneumonitis. The degree of suffering evinced by the mucous membranes, in a state of inflammation, is subject to much variety. In some situations the pain is excessive, whilst in others it is literally absent, the disease proceeding in its work of disorganization without giving the indi- vidual, so to speak, the slightest intimation of it. In pulmonary phthisis, nothing is more common than to find ulcers in the ileum and colon, sometimes of great size, where there was no sign whatever of their presence during life. It is a singular fact, in relation to this subject, that the pain is usually much greater when the inflammation is seated at the extremities of the mucous membranes, or at their junction with the skin, than when it involves the intermediate points. The difference may be explained by the difference of organization. The mucous lining of the intestinal tube, and of the air-passages, which often manifests very little sensibility when inflamed, receives 44 INFLAMMATION. its nerves almost entirely from the ganglionic system; whereas the reverse is the case with the conjunctiva, the fauces, the urethra, and urinary bladder, the vagina and rectum, these parts being liberally supplied by filaments derived from the cerebro-spinal axis. The pain varies not only in degree, but also in its character. In the cellular tissue it is acute and pulsatile; in the pleura, sharp and lancinating; in the lungs and glandular viscera, obtuse and heavy; in the skin, prurient and smarting; in the bones, dull and gnawing. Sometimes the pain is persistent, sometimes intermittent, sometimes periodical; but, what is more remarkable than all is, that it is not unfrequently felt at parts very remote from the one originally and mainly affected. We have a familiar instance of this peculiarity in the hip-joint disease of children, in which the earliest symptom com- plained of is pain in the knee. In hepatitis, the right shoulder is often the seat of the suffering; in cystitis, the head of the penis. We are sometimes enabled to account for this by the direct nervous com- munication, but more frequently the matter is entirely inexplicable. When inflammation is about to pass into suppuration, the pain usually becomes throbbing, and the patient is seized with shivering, with fever, and, in some instances, with delirium. After this process is fairly established, it almost always diminishes in intensity, or even wholly subsides. Pressure generally increases the pain, and in some cases the slightest touch of the finger produces intolerable suffering. The proximate cause of this symptom has been variously accounted for. It is usually supposed to be owing to the unnatural influx of blood, the increased size of the capillaries, and to the quantity of effused fluids, which compress, it is said, the delicate nervous filaments of the part concerned. This seems to me, however, to be taking only a partial view of the case. To complete the theory, it is necessary to assume that the nervous filaments themselves are affected, altered, or deranged, independently of the causes just adverted to; and in this idea there is nothing in the least repugnant to the laws of pathology. What the precise nature of the change is we cannot define; nor is this a matter of much importance. The effect of augmented circulation in producing augmented sensi- bility, is strikingly evinced in what occurs in inflammation of the hand. If the part be allowed to hang down, severe throbbing pain is instantly felt, which is as instantly relieved, in many cases, by putting the limb in an elevated position. Cold applications, by constringing the vessels, lead to the same result, and hence their beneficial effect in the treatment of external inflammation. The fourth and last symptom of inflammation, to be noticed, is swelling. This is occasioned partly by the enlargement of the vessels, but chiefly by the effusion of serosity, lymph, blood, or pus, into the cellular tissue. In its degree it varies according to the laxity and vascularity of the part concerned. It is always well marked in the subcutaneous cellular substance, whilst the skin itself is generally little, if at all, affected by it. Inflammation of the serous and fibrous textures, the ligaments, tendons, muscles, cartilages, and bones, is usually unattended with swelling. The same remark is applicable to SWELLING. 45 the internal viscera. The mucous membranes are rarely the seat of tumefaction, this symptom being noticed chiefly in the vulva, at the mouth of the larynx, and in the conjunctiva of the eye. Although the swelling generally comes on gradually, yet, in some instances, it proceeds with astonishing rapidity, at the same time that it spreads over a large extent of surface. The sting of the bee, wasp, hornet, and yellow-jacket, and the bite of the rattlesnake are often attended with the most frightful tumefaction, which makes its appear- ance sometimes in a few minutes, and speedily diffuses itself over an entire limb, or even the whole body. From the hasty survey which has been taken of these symptoms, we are authorized to conclude that they are by no means entitled to the stress which has been generally placed upon them by writers. In many instances there is an entire absence of at least one or two of them, and yet the part is absolutely in a state of high inflammation. How often does it happen that enteritis is lighted up, and goes on to destructive disorganization, without even the slightest indication of its presence ? In arachnitis, the only symptom, frequently, is severe cephalalgia, with delirium and partial paralysis. The patient dies, and, on examination, the membrane is found to retain its natural thinness, and to be as free from injection as in the sound state. In such a case, should there be but little effusion of serum and fibrin, a superficial observer might conclude that there had not been any inflammation, or that what he saw was the result solely of irritation. The injurious tendency which such a mode of procedure would exert on the practice of medicine is too obvious to require any comment in this place. In reasoning on this subject, the physician should constantly bear in mind the important fact, that the symptoms which have been enumerated above, although they are frequently all present, are not necessarily so, and that the absence of some of them is not a sufficient proof that inflammation does not exist. By such course alone can he expect to escape error. Besides these phenomena, there is always, in well-established in- flammation, a perverted state of the vital action. In none of the tissues is this state, perhaps, ever entirely absent; and yet, as might be ex- pected, it is much more conspicuous in some than in others. It is sometimes, indeed, the only symptom present, or the only one which can be recognized. In gastritis, the only manifestation of which is frequently irritability, without heat or pain, or uneasiness on pressure, the digestive function is entirely suspended, gastric juice is no longer secreted, and the organ is oppressed by the mildest articles of food. In the duodenum the process of chylification is interrupted, retarded, or perverted; in the liver, bile is either no longer deposited, or it is furnished in small quantity, and vitiated in quality. In high degrees of inflammation of both kidneys, there is sometimes a total want of urine, and the individual dies under all the symptoms which charac- terize the retention of that fluid in the bladder. It should be observed here, that, as a general rule, this derangement of the functional action is always greatest when the irritation is at its height, and that, from this period on, it gradually diminishes until the disease subsides. 46 INFLAMMATION. When the office of an organ is to receive some external impression, it does either not so at all, or only very imperfectly. The inflamed eye is no longer able to take cognizance of light; the Schneiderian membrane does not notice odors; and the ear is incapable of distin- guishing sounds. When the brain is affected, the intellectual faculties are deranged, and the individual raves with delirium, or lies, like an automatic mass, dead to all surrounding impressions. The function of absorption is often very much impaired in this disease. A solution of strychnine applied to an inflamed serous membrane, as the pleura, will not result in any injury to the animal, or only in a very long time after the contact has been effected. In some experi- ments made by Gendrin, prussic acid was applied with impunity to the conjunctiva of the eye, the Schneiderian membrane of the nose, and the mucous lining of the vagina, which had been previously inflamed by hot oil and tincture of cantharides. Notwithstanding, however, the results of these experiments, correctly stated, no doubt, by the French philosopher, experience daily teaches us that, whilst some substances are rejected by the organs and tissues, when in a high state of inflammation, there are others, the absorption of which is still, to a certain extent, carried on. In the stomach, for example, mild diluent drinks, such as gum-water, flaxseed tea, or arrowroot, are rapidly conveyed into the circulation, and are usually more or less employed by practitioners. If the quantity given, however, be so great as to oppress the affected organ, absorption will cease, and the fluid will be ejected. In the serous cavities nearly the same cir- cumstance is observed. When the fluid that is effused in these situa- tions exceeds several quarts, the absorbents appear to be incapable of taking it up, and the surgeon is obliged to evacuate it. Acetate of morphia applied to a piece of skin that has been inflamed by a blister, will tranquillize the system nearly in as short a period as when it is introduced in the ordinary way. Not less remarkably altered is the nutritive function. If an organ remain for a considerable time inflamed, the particles which are re- quisite for its growth and nourishment are withheld, and, in conse- quence, it gradually sinks into a state of atrophy. In more rapid cases the part retains its natural bulk, but undergoes a change of color and consistence, from the imperfect admission of blood, and from some derangement of the molecular structure. This state is remarkably conspicuous in several of our organs and tissues, and will be described hereafter under the name of softening, mollescence, or ramollisse- ment. The next subject which we have proposed to discuss is the seat of inflammation. That this is in the capillary vessels is a fact concern- ing which there exists no dispute. Of the nature of these vessels themselves, however, different views have been expressed by anatomists and it will, therefore, be necessary, before proceeding farther, to exa- mine briefly their situation, structure, and functions; for in this way alone can we expect to throw any real light upon the nature of the present disease. The capillaries are those minute tubes which are everywhere in- ALTERED ABSORPTION AND NUTRITION—SEAT. 47 terposed between the arteries and the veins. It was at one time imagined that they formed a distinct set of vessels by themselves, per- fectly independent of the rest of the vascular system, an opinion which has been abundantly disproved by the researches of modern anatomists. It is now well known that they not only communicate directly with the arteries and veins, but likewise that they are, as it were, merely so many prolongations of them. The walls of the capillaries, as may be imagined, must be extremely thin, delicate, and transparent, otherwise it would be much easier to discern them. Bichat states that they are formed entirely out of the inner arterial and venous membrane, the other tunics being excluded, as he alleges, from their composition. An opinion precisely similar to this is advanced by Beclard. He asserts that the parietes of the capillaries are scarcely to be distinguished from the substance of the organs in which they are situated, and thence draws the inference that they are rather formed out of this substance than that they possess walls of their own, acknowledging, however, at the same time, that it is not impossible that the internal tunic of these vessels is uninter- ruptedly continued from the arteries to the veins. More recent investigations, by means of minute injections, and of powerful micro- scopes, have satisfactorily demonstrated' that the capillaries are not mere channels in organs, but are, indeed, possessed of parietes, con- sisting of an exceedingly fine structureless membrane, in which here and there elongated nuclei are imbedded, and which is continuous with the fibrous portion of the internal tunic of the larger vessels. Where, however, the arterial capillaries terminate or the venous begin, is for the most part still a matter of conjecture. With regard to their caliber, the capillaries are divisible into two classes. The one embraces those minute tubules which, though invisi- ble to the naked eye, are found, when examined with the microscope, to be capable of carrying a continuous stream of blood, so as to give the part in which they are located a red appearance; the other in- cludes those delicate vessels, the cavity of which is so small as to admit only a single globule at a time, and which it is extremely difficult to detect even with a good magnifier. By reflecting for a moment on the size of the red particles of the blood, estimated by most writers to be about the three thousandth part of an inch, the reader will be struck with the great tenuity of these vessels. That the capillaries do not abound equally in all the organs and tissues, was rendered sufficiently obvious in speaking of the pheno- mena of inflammation. The parts which form the basis of the skeleton, together with the tendons, the cellular substance, the epidermis, nails, and hairs, have, comparatively, few of these vessels after the body has attained a certain degree of development. In the early stages of life, however, several of these structures are highly vascular, and can be readily injected. The serous membranes appear to possess yery few capillaries; in the healthy state, in fact, none can be discerned in them; yet, when inflamed, they are rendered highly vascular, and thousands of minute vessels, which before were invisible, are now perfectly dis- tinct, giving the affected part a beautiful reddish aspect. The capil- 48 INFLAMMATION. laries abound in the mucous membranes, the skin, the liver, spleen, lungs, and kidneys. They are also very numerous in the heart, the muscles of voluntary life, in the brain, and in the pia mater. Thus situated, and thus constituted, the capillaries form by far the most interesting as well as the most voluminous portion of the vas- cular system. To it are confided the important functions of nutrition, secretion, calorification, and, perhaps, also, at least in part, that of ab- sorption. Whilst the larger vessels perform the office merely of sangui-ducts, it is in the capillaries that the fluid and solid materials are brought into those intimate relations which precede the conver- sion of the one into the other, and which are necessary to their vitality and support. In inflammation the capillaries play a most important part; blood is sent into them in unnatural quantity; their action is perverted, and, in consequence, various fluids are poured out which are foreign to the normal condition of the economy. These, however, are not the only structures that are affected. It is highly probable that the nervous filaments are equally engaged in the morbid enter- prise, though this is a point concerning which our information is ex- tremely slender. The fact is certain that neither of these tissues can be long involved without the other participating in the derangement. The joint agency of the nervous and vascular systems, in the pro- duction of inflammation, has been happily illustrated by the researches of modern physiologists. It has been ascertained, for example, that, when the ophthalmic branch of the fifth pair of nerves is divided in the cranial cavity of a rabbit at the Varolian bridge, inflammation is speedily lighted up in the surface of the eye, which eventuates in opacity of the upper segment of the cornea. What is still more re- markable is, that, when the nerve is cut on the petrous portion of the temporal bone, so as to involve the destruction of the ganglion of Gasser, the resulting irritation is not only more violent in degree, but much more deeply seated, as well as more deplorable in its effects, the consequence being nothing less than a complete disorganization of the organ. Analogous effects follow the division of the pneumogastric nerves. When these cords are cut high up in the neck, the lining membrane of the air-passage assumes a dark color, the lungs are engorged with black blood, and an abundance of serosity is poured out into the parenchymatous texture, as well as into the pulmonary vesicles and the minute branches of the bronchise. The pleura generally partici- pates in the irritation, and there is almost always more or less inflam- mation of the stomach, with a suspension of the secretion of the gastric juice. Animals in which the brachial plexus of nerves has been tied are \ seized, in a short time, with inflammation of the integuments of the remote parts of the limb, which gradually progresses until all the soft structures are invaded by gangrene. A friend of mine removed a section of the peroneal nerve on account of a neuroma; the wound was long in healing, and two of the small toes sloughed before the patient recovered. These facts enable us to explain certain circum- stances that have been long noticed by practitioners in particular AGENCY OF VASCULAR AND NERVOUS SYSTEMS. 49 morbid states of the system. A part affected with palsy is much less capable of withstanding the ordinary impressions of physical agents, than one receiving its customary supply of nervous influence. A burn in a paralytic person creates much more serious mischief than in one that enjoys perfect health; and the same is true in regard to blisters and other irritants, the injudicious application of which often leads to the destruction of large portions of the skin and subjacent cellular tissue. There is little doubt that the inflammation of the bladder, which always supervenes upon serious injury of the spinal marrow, is caused in the same way; that is, by the interruption of the natural supply of the nervous influence. In whatever manner parts are deprived of their nervous influence, it is presumable that they are brought under relations somewhat analogous to those of a frozen limb. The temperature is lowered, the sensibility impaired, the process of nutrition perverted; in a word, the natural connection between the vessels and nerves is broken up, and hence that series of phenomena known under the name of inflam- mation. Let us pursue this subject a little further. The very first step in the process of inflammation is an altered sen- sibility of the part, produced by some hurtful agent, which the system makes an effort to dislodge. To effect this, the local impression is reflected upon the cerebro-spinal axis, and through this again upon the heart, which, being sympathetically incited to increased action, sends more blood to the part concerned than it is accustomed to receive, at the same time that the capillaries are perceptibly dilated. Those who maintain that the capillaries possess an inherent contractility, by virtue of which they aid in the circulation, may probably be disposed to deny the agency of the heart in bringing about this preternatural determination of blood; but if they will only carefully study the subject, they will, I am sure, arrive at a different conclusion. That these vessels do contract and dilate, no one will dispute; for expe- riment has fully decided this point; all that I contend for is, that the capillaries have no vermicular movement, and that they are, there- fore, incapable of carrying on the circulation without the direct in- fluence of the heart. In the inceptive stage of inflammation, this sympathetic action of the heart is no doubt so slight as frequently to escape the attention of the observer; but, as the disease progresses, it assumes a more distinct character, and can always be easily recognized. The phenomena above alluded to, namely, the preternatural influx of blood, and the dilatation of the capillaries, can be easily detected by exciting irritation in the mesentery of a rabbit, the tail of a tad- pole, the fin of a fish, or the web of a frog's foot, parts which are per- fectly transparent, and therefore well calculated for the purpose. On viewing these structures with a microscope, in the sound state, numer- ous channels will be observed filled with blood, the red globules of which roll along in the most regular and beautiful order. If they be now irritated with spirits of wine, hot water, or diluted acid, the little rivulets will be found to become dilated, from the manner in which the blood is crowded into them by the heart, which, in order to remove the local obstruction, is excited into sympathetic action. 4 50 INFLAMMATION. In a few minutes hundreds of vessels, which were previously invisi- ble, will be seen shooting out in different directions, and connecting themselves with the sides of those that appeared in the first instance. These are not new channels, but old ones appertaining to the second class of capillaries, which are rendered evident by the intromission of red particles, which are either excluded in the healthy state, or pass along in so slow and gradual a manner as to elude the eye ot the beholder. The dilated condition of the vessels is well seen in the accompany- ing cuts from Hunter. They represent the two ears of a rabbit, one in the natural state, the other inflamed, from having been frozen and thawed. They were injected at the same time, and consequently with the same degree of force. Fig. 1 is the natural ear; Fig. 2 the in- flamed ear. The vessels in the latter are not only much larger than in the former, but also apparently more numerous; the main artery in the one is likewise greatly increased in size, while in the other it is hardly distinguishable. Fig. 2. Natural ear of a rabbit. Inflamed ear of a rabbit. Such are the initial steps of inflammation. If the process be now checked by the removal of the exciting cause, the phenomena referred to gradually disappear, and the part recovers its natural tone and condition. If, on the other hand, the inflammation be allowed to proceed, another series of changes may be witnessed surpassing, if possible, in point of interest, those just described. The circulation gradually ceases, and a perfect state of stagnation occurs in the inflamed part. STATE OF CAPILLARIES. 51 The capillaries become filled with red corpuscles, which adhere to the walls of the vessels, and subsequently constitute a dense uniform mass of thickened blood of a bright or sometimes dark red color, opposing an effectual barrier to artificial injection. With these altera- tions the healthy functions of the part are suspended. It is red, hot, painful and tumid; and serum, lymph, or pus, may fill its interstices. An exact copy of a portion of the web in the foot of a young frog, after a drop of strong alcohol had been placed upon it. The view exhibits a deep-seated artery and vein, somewhat out of focus; the inter- mediate or capillary plexus running over them, and pigment cells of various sizes scattered over the whole. On the left of the figure, the circulation is still active and natural. About the middle it is more slow, the column of blood is oscillating, and the corpuscles crowded together. On the right, congestion, followed by exudation, has taken place, constituting inflammatary action in the part. a. A deep-seated vein, partially out of focus. The current of blood is of a deeper color, and not so rapid as that in the artery. It is running in the opposite direction. The lymph space on each side, filled with slightly yellowish blood plasma, is very apparent, containing a number of colorless corpuscles, clinging to or slowly moving along the sides of the vessel. 5. A deep-seated artery, out of focus, the rapid current of blood allowing nothing to be perceived but a reddish-yellow broad streak, with lighter spaces at the sides. Opposite c, laceration of a capillary vessel has produced an extravasation of blood, which resembled a brownish-red spot. At d, congestion has occurred, and the blood corpuscles are apparently merged into one semi-transparent, reddish mass, entirely filling the vessels. The spaces of the web, between the capillaries, are rendered thicker and less transparent, partly by the action of the alcohol, partly by the exudation. This latter entirely fills up the spaces, or only coats the vessel.—Bennett. In violent cases the blood breaks through the diseased vessels, and forms slight ecchymoses, as in Fig. 4, from Hunter, representing a magnified portion of inflamed serous membrane. The same appear- ances are seen in the inflamed web of the frog, in Fig. 5, from Marshall Hall. Occasionally, again, the blood escapes from the vessels, and, forcing its way along the cellular tissue, forms new channels, through which it afterwards continues to circulate. Immediately around the seat of greatest intensity of the morbid action, the vessels are distended and the blood circulates but slowly through them. At a more remote point, phenomena somewhat dif- ferent may be witnessed. An active determination towards the inflamed 52 INFLAMMATION. part fills the vessels; but the blood moves in continuous streams and with extreme rapidity; and unable to traverse the stagnated masses, Fig. 4. Inflamed serous membrane. is sent onwards through new channels: so that, whilst in the centre of the morbid action, stagnation occurs, and around this a sluggish circulation exists, in the neighborhood of the lesion an increased activity is the result. The arteries that lead to the part are distended and pulsate strongly; but not, as has been asserted, with preternatural frequency. A circumstance that has been recently much dwelt upon is the appearance of the blood in inflammation. If a drop of this fluid from an inflamed part be examined with the microscope, the red corpuscles may be observed to run almost immediately into clusters of piles or rouleaux, as represented in Fig. 6. The same appear- ance is observed in the blood of pregnant women; it does not occur, however, within the walls of the vessels, but only in the blood when coagulating. Many authors regard an increase of the white corpus- cles as a constant phenomenon in the blood of an inflamed part; but this fact may still be regarded as undecided. Inflammation, it will thus be seen, is a gradual process, which is preceded and accompanied by certain stages, running insensibly into each other. Contrary to what might be inferred from analogy, it has been ascertained that more time is usually required for this process to be developed in highly vascular organs, as the lungs and peritoneum, than in parts in which the circulation is more tardy and less perfect as the liver and kidney. It is worthy of remark, however, that when the disease is once fairly established, it progresses much more rapidly in the former than in the latter of these structures. Having thus finished the notice which it was proposed to take of the anatomical characters of inflammation, it will only be necessary in concluding this part of the subject, to allude to the principal cir- cumstances which are capable of producing congestion and discolora- tion of the different organs and tissues, immediately prior to, during Inflamed web of a frog's foot. CONGESTION AND DISCOLORATION. 53 Microscopic diagram showing the reticulated arrangement of the cor- puscles in inflammatory blood. In the upper part, normal ordinary aggregation is shown in contrast.— Wharton Jones. Edinburgh Me- dical and Surgical Journal, October, 1843, p. 309. or subsequently to, the extinction of life. In a practical point of view, not less than in a pathological, this is a matter of no trifling moment, yet one concerning which there still prevails a great deal of misapprehension in the minds of medical men. Coyigestion and Discoloration.—The causes under the influence of which congestion and discoloration may be produced before death, are referable, first, to mechanical obstruction, interfering with the free return of the venous blood; and, secondly, to the effects of stimu- lating agents, introduced into the body either as food, drink, medicine, or poison. The latter of these will be examined in another place, and it will therefore only be necessary, on the present occasion, briefly to inquire into the character of the former. Whatever has a tendency to interrupt the passage of the blood to or from the heart, must be a cause of congestion in the organ where the accumulation takes place. The obstruction, which may exist in any part of the body, may be produced by a great variety of circumstances, as the presence of a tumor, some morbid deposit, or the obliteration of a large vessel. But the more common source of it, perhaps, is organic lesion of the heart, particularly of its valves, of the auriculo-ventricular apertures, or of the mouth of the aorta or pulmonary artery, opposing the progress of the blood, and throwing it back upon other viscera, which thus receive an undue supply of it. That congestion may be, and often is, produced in this manner, is too well known to admit of dispute; but it is by no means so clear that it does not, inasmuch as it is of a permanent nature, give rise to results very different from those we are now con- templating,—in a word, that it does not lead to inflammation, or to what Andral has termed active hypersemia. However this may be, it seems to me that pure, uncomplicated congestion, in whatever parts of the body occurring, must uniformly depend upon one or other of the following circumstances: 1. Obstruction of the heart and great vessels, by the formation of fibrinous concretions during the last struggles of life. 2. Partial paralysis of the heart, disqualifying it, to a greater or less extent, for carrying on the circulation. 3. Asphyxia, whether induced by actual strangulation, the inhalation of deleterious gases, or difficult dissolution in ordinary sickness. The congestion produced by the first two classes of causes is gene- rally partial, and is almost always limited to the more dependent situa- tions ; that, on the contrary, which results from asphyxia usually per- vades the whole body, and is particularly conspicuous in the skin, the conjunctiva, the mouth and lips, in the lungs, the heart, and the great vessels, which are often distended, to their very utmost, with black fluid blood. In either case, the resultant discoloration is of a dull bluish tint, as well as much more uniform than in inflammation. 54 INFLAMMATION. The causes which operate in the production of congestion and dis- coloration after death, are the gravitation of the blood, and the trans- udation of this fluid, or of some of its component elements, through the parietes of the vessels. It is well ascertained that, with the cessation of life, the blood, in obedience to the laws of gravity, gradually subsides to the more de- pending structures, distending their vessels, both large and small, and imparting to them its peculiar color. Under ordinary circumstances, these appearances are most conspicuous in the posterior parts of the body; but observation has fully shown that they may be produced in any situation, laterally, in front, or behind, simply by placing the sub- ject in a particular position, and keeping it there until it is deprived of its warmth. The congestion thus arising is limited, in great degree, to the veins, which are often as thoroughly distended as if they had been filled with injecting matter; they spread out in an arborescent manner, and are generally traceable to large trunks, which are them- selves frequently quite full of blood. Their contents are of a dark modena color, perfectly fluid, or partly fluid, and partly coagulated, and easily pressed from one place to another; the reverse of which, as before stated, is the case when the congestion depends upon inflammation. At what period the injection begins has not been accurately determined; there is reason, however, to believe that it frequently commences several hours, or even days, prior to dissolution. In the generality of instances, as is well known, the approaches of death are gradual; one organ fails, as it were, after another, and whilst some parts are still actively engaged in the discharge of the duties which nature has assigned to them, others have either ceased to act, or have become so crippled as to be able to perform their functions only in a tardy and imperfect manner. Under such circumstances, observation warrants the presumption that the blood, from the feeble impulse exerted upon it by the heart, the central organ of the circulation, accumulates in the more dependent parts of the body, in a mode calculated to pro- duce local congestion, with a corresponding augmentation of color, long before the solids and fluids are consigned to the influence of de- composing agents. The structures which are more particularly liable to be affected by this kind of injection, are the posterior portions of the lungs, of the liver, and of the kidneys, for the reason not only that these organs are highly vascular in the normal state, but that the individual usually lies upon his back, both after, and for some time previously to, death. For the same reason, the skin of the back parts of the neck, trunk, and extremities is always much more loaded with blood than at the sides or in front, where the cutaneous vessels are comparatively empty. The accompanying discoloration varies with the nature of the affected tissues, from slight rose to deep red, as in the most intense inflamma- tion. Ordinarily, however, it is very faint, as well as more uniform and diffuse than in disease, and much more easily removed by pres- sure and ablution. The second cause capable of imparting an abnormal color to the animal textures after death, is the transudation of the blood through CONGESTION AND DISCOLORATION. 55 the parietes of the vessels. It is a law of the healthy economy that the vessels shall retain the fluid which is destined to pass along them without suffering permeation; but no sooner is the vital principle withdrawn than the body is brought under the influence of surround- ing agents, which speedily change the relations of its various com- ponent elements, and impress upon them a total alteration of charac- ter. Amongst these, the most important, in connection with the present topic, is the percolation of the blood through its vessels, and its diffusion through the solids, by which the latter are rendered un- naturally red and moist, as if they had been steeped in some coloring liquid. The redness thus produced, as it almost always depends upon putrefactive decomposition, rarely appears within the first four-and- twenty hours after death, unless there is a very high degree of sum- mer heat conjoined with atmospheric humidity. Nor does it occur with equal facility or frequency in all parts of the body ; the structures which are soonest and most extensively affected are the endocardiac lining and the internal tunic of the arteries and veins, where it is often mistaken for that of inflammation. To this, however, it bears only a very remote resemblance. It is usually a mere scarlet stain, as if it were attached to the free surface of the membrane, over which it is generally uniformly diffused, without any particular alteration in the subjacent parts, or any deposit upon the interior of the tube. Some- times the redness occurs in bands, patches, streaks, points, or arbore- scent lines, with intervals retaining the ordinary appearance. The latter variety is frequently observed along the course of the larger veins of the stomach and bowels, in warm, wet weather, when the ex- amination is delayed beyond thirty-six hours. Similar phenomena are occasionally witnessed, under like circumstances, in the skin of the back part of the body, particularly in those regions which are sub- jected to pressure. Finally, as the process of decomposition advances, the discoloration, losing its scarlet character, assumes a muddy, brown- ish aspect, with various tints of green, and, at the same time, pervades, to a greater or less extent, all the softer textures of the body. These changes take place, all other things being equal, much sooner in warm than in cold weather, and in full, plethoric individuals, than in such as die in a state of general anasmia. Exposure to the air is another cause of cadaveric coloration, which demands brief consideration in reference to the present subject. This variety of redness, which generally begins to appear within a very short time after the removal of the organs from the body, always proceeds with great rapidity in warm weather, especially when the part is brought under the direct influence of the solar rays. The structures in which it is most commonly observed, are the spleen, liver, kidney, and heart, the internal tunic of the arteries and veins, and the mucous membrane of the alimentary tube. In nearly all these situations, the color is of a bright scarlet, like that of arterial blood, and uniformly diffused over the whole, or the greater portion of the organ in which it occurs. In the stomach and bowels, it occasionally presents itself in small florid specks, as if the surface of the lining membrane had been spinkled with vermilion. Absorption of the 56 INFLAMMATION. oxygen of the air, arid the admixture of this gas with the blood, are the causes, undoubtedly, under the influence of which this species of coloration is established. Hence, by exposing the affected organ, for a few minutes, to a gentle stream of water, or immersing it in diluted vinegar, it almost instantly changes its florid appearance, and assumes a dark purple hue, similar to that of venous blood. Such are the varieties of congestion and discoloration, resulting from causes which exert their influence during the last moments of existence, or within the first few days after death. ^ Although, in general, easily distinguishable from those of inflammation, yet it must be confessed that the diagnosis is sometimes extremely difficult, if not impossible, so closely do they run into each other. Under such cir- cumstances, a careful analysis of the symptoms of the case, with the effects of the remedies employed, and an attentive consideration of the ordinary products of morbid action, are absolutely indispensable to a correct appreciation of the nature and character of the supposed lesion. Should there be merely some degree of redness, with rami- form injection, traceable to some large venous trunk, unaccompanied by effusion, softening, opacity, induration, thickening, or ulceration, the presumption is strong that these appearances are the result solely of congestion, produced by some one or more of the causes previously pointed out. If, on the other hand, the discoloration and vascularity are associated with some, or all, of the anatomical characters here indicated, it must be concluded that they are dependent upon inflam- matory irritation, since they afford the best possible evidence of the existence of that lesion. Theories of Inflammation.—After what has been stated, it will not be expected that much should be said respecting the various theories, or, rather, hypotheses, that have been projected in relation to the proximate cause of inflammation. A few only of the more prominent will be noticed. The first which I shall mention is that of Boerhaave, which supposes that the disease essentially consists in an obstructed state of the capillaries, produced by some morbid lentor of the blood, or by the entrance of the red globules into vessels not fitted to receive them. This opinion rested on the belief that the sanguineous particles are remarkably complicated in their structure, each red one consisting of six serous, and each serous of six lymphatic ones, for the convevance of which three kinds of tubules were imagined, as channels of com- munication between the arteries and veins. By getting into a wron^ vessel, the globules might very readily produce obstruction, and thus excite inflammation. The late Dr. Cullen, of Edinburgh, not less distinguished for his eloquence as a teacher than his ability as a writer, conceived the idea that inflammation was merely a sort of spasmodic contraction of the small vessels, interrupting the passage of the blood. This state he supposed, was sometimes the effect of direct debility ; and he imagined moreover, that there was frequently a peculiar condition of the whole vascular system, which predisposed to this affection, and which received from him the name of the phlogistic diathesis. This theory notwith- standing the favorable manner in which it was for a long while'reo-arded THEORIES OF INFLAMMATION. 57 has the disadvantage of being unsupported by a sihgle fact. So far from the vessels being contracted in inflammation, it is now well ascer- tained, as was before mentioned, that they are invariably dilated, and that, in consequence of this, they always admit an unusually large amount of blood, which could not happen were the reverse of this the case. Dissatisfied with the crude conjectures of Boerhaave, Cullen, and other writers, another theory was proposed by Dr. Yacca, an eminent Italian pathologist, soon after the middle of the last century. In his treatise on inflammation, published at Florence, in 1765, he maintains the opinion that this disease invariably results from sanguineous con- gestion, attended with more or less debility of the affected part. The first step in the process is relaxation of the capillary vessels, which allows them to be abnormally distended by the blood that passes through them. To th'is increased quantity of fluid he ascribes the redness, heat, pain, and turgescence, which are always more distinctly marked in proportion to the dilatation of the minute arteries and veins, the violence of the exciting cause, and the natural vascularity of the part concerned. Since the time of Yacca, the theory of diminished power of the vessels has been warmly advocated by a considerable number of pa- thologists, especially by Dr. Wilson Philip, Dr. Hastings, and Dr. Thomson. The experiments which were performed by these distin- guished writers, although they are at variance as respects some trifling points, all tend to show that inflammation essentially consists in a weakened action of the capillaries, by which the balance between them and the large vessels is destroyed, and congestion is the result. Op- posed to these views, again, are those of Mr. Hunter and Dr. Gendrin. These pathologists have both minutely investigated the subject of in- flammation in all its departments, and they adopt the belief that the primary cause of the disease is an increased action of the vessels. Amidst such discrepancy of opinion, it might seem, at first sight, extremely difficult, if not impossible, to arrive at any satisfactory conclusion. To me, both views appear to be correct, but not in the sense advocated by their respective authors. In the early stage of the disorder, we have every reason to believe, from the phenomena which are exhibited under the microscope, that the vessels have an augmented action; subsequently, however, when the disease is fully established, the capillaries are partially paralyzed, the blood ceases to circulate, the function of nutrition, secretion, and absorption, is inter- rupted, and everything indicates the diminished power of the part. Dr. Bennett, of Edinburgh, has recently attempted to show that inflammation is merely a deviation from healthy nutrition. As in the natural state, the sanguineous liquor, as it is termed, exudes through the capillaries into the interstices of the tissues, furnishing materials for the development of the various textures, so in inflam- mation the fluid in question passes from the dilated vessels of the affected part, and forms germs for the development of morbid cells, which may lead to the production of pus, to an analogous substance, or to a cancerous growth. Inflammation, according to this view, is 58 INFLAMMATION. synonymous with abnormal nutrition, in which the cardinal symptoms of the disease, namely, heat, pain, redness, and swelling, are merely consequences of the antecedent engorgement and concomitant effusion. The theory of Dr. Bennett does not, in my judgment, throw any new light upon this intricate and mysterious subject, but leaves it precisely where it was. It has been long known that in every well-established inflammation there is " perverted action," with altered exudation, and no pathologist ever supposed that the phenomena usually enumerated as characterizing the process were anything more than effects, conse- quences, or manifestations of the morbid action which precedes and accompanies it. Liebig ascribes the essential cause of inflammation to an unusually rapid union of the oxygen of the arterial blood with the tissues of the inflamed part; Henld to a paralysis of the capillaries; Macartney to a sense of injury felt by the organic nerves; Wharton Jones to an unnatural attraction of the red globules for each other, and for the sides of the minute vessels, which is favored by the increased quantity of fibrin and albumen; Williams to the production of a greater num- ber of white globules, obstructing the vessels by their adhesive pro- perties ; whilst quite recently Yirchow supports the theory of a local lesion of nutrition, and combines with this the "attractive theory," to explain the stagnation of blood, but not the inflammation. Terminations of Inflammation.—Finally, inflammation ends in dif- ferent ways. When it gradually subsides, without any untoward occurrence, it is said to terminate in resolution. In some cases it re- lieves itself by an effusion of serum and lymph, by suppuration, by hemorrhage, and by softening. At other times, the part loses its vitality; and it is then said to end in gangrene. Philosophically speaking, some of these states are merely conditions, not terminations of inflammation. Thus, suppuration is absolutely, from first to last, a phlegmasial process; and so of softening, the effusion of serum, and the deposition of lymph. It is therefore rather in compliance with professional usage than with the sound principles of pathology, that we should continue to employ this vague expression. With respect to acute inflammation, the following terminations may be recognized: 1, resolution; 2, effusion of serum; 3, deposition of lymph; 4, suppuration ; 5, hemorrhage ; 6, softening; 7, gangrene. These different terminations constitute merely so many degrees of in- flammation. Thus, suppuration indicates a higher grade of action than lymphization, and a milder one than hemorrhage, softening, or gangrene. We might thus construct a sort of phlegmasial scale, the index of which would be the product of the disease, or the mode in which it terminates. The various depositions which attend the inflammatory process are an effort of nature to relieve the morbid action; or, what is the same thing, to unload the vessels, and remove oppression. "It is" to use the language of Professor Paine,1 of New York, "nature carrying on the work of depletion in the very instruments of disease, whilst, 1 Medical and Physiological Commentaries, vol. ii. p. 330. New York 1840. EFFUSION OF SERUM. 59 as in the effusion of lymph, she may simultaneously accomplish an- other great final purpose." Effusions seem to relieve vascular dis- tension upon the same principle as the abstraction of blood by the lancet, by purgatives, and by other evacuants. Catarrhal affections of the nose often speedily disappear the moment there is a free discharge of mucus; a deposit of serum may put a sudden stop to a pleuritis; and a violent enteritis is sometimes cured in a few hours by a copious hemorrhage from the bowels. The manner in which suppuration modifies and arrests inflammation has long been familiar to patholo- gists. Chronic inflammation has fewer terminations or conditions than the acute. The principal ones may be thus stated: 1, ulceration; 2, granulation; 3, cicatrization; 4, induration. Besides these conditions, chronic inflammation may occasionally be attended with hemorrhage and softening, or even terminate in gangrene. These occurrences are, however, extremely rare, and are seldom witnessed except when there is a sudden supervention of acute disease. Let us now proceed to describe these different states in the order in which they are here enumerated. CHAPTER II. EFFUSION OF SERUM. Occurs, to a greater or less extent, in almost every Inflammation.—(Edema, Anasarca, and Dropsy.—Color, consistence, quantity, and chemical composition.—Usually the result of a mild degree of Inflammation.—Conclusion. An effusion of serum, to a greater or less extent, occurs in almost every inflammation. There are some varieties of this disease in which, indeed, it forms the chief if not the only symptom. It is seen most frequently in the interstices of the cellular tissue, on the surface of the serous membranes, in the parenchymatous texture of the lungs, in hydatids, and serous cysts. There are some structures which, from their dense and compact nature, do not seem to admit of this infiltra- tion. Of this description are the liver, kidney, womb, prostate gland, and spleen, together with the tendons, aponeuroses, ligaments, car- tilages, and bones. Very little serum is effused by the brain, spinal cord, nerves, vessels, and mucous membranes. With respect to the latter, the parts most frequently and extensively affected, are the mar- gins of the glottis, the conjunctiva, the prepuce, and the nymphse. Considered in reference to the subcutaneous cellular tissue, the effusion occurs much more frequently in the inferior extremities than in the superior; in the genital organs than in the trunk; in the eyelids than in the face, head, or neck. The lymphatic ganglions and the inter- fibrillar substance of the muscles are often the seats of considerable 60 EFFUSION OF SERUM. serous infiltrations, especially in weak cachectic subjects, or those who are worn out by severe and protracted diseases. Large quantities of this liquid are "frequently discharged bv the mucous membrane of the bowels, in diarrhoea and cholera. In the skin the most striking ex- emplification of this effusion is seen in the vesication of an ordinary blister, in burns and scalds, and in the elevation of the cuticle which announces mortification. . Yarious names are employed to designate these effusions. When the fluid is poured out into the interstices of the subcutaneous cellular tissue, it forms a smooth, pale, glossy swelling, which pits on pressure, and is seldom painful, unless there is considerable inflammation. _ This is called oedema. When this affection occurs in the extremities, it generally varies with the position of the body, being very slight or entirely absent when the limb is elevated, and most prominent when it is dependent. The reason of this is obvious. In many cases the fluid is not formed in these parts, but gravitates thither from other regions, making passages for itself through the cellular tissue. As meaning the same thing, the term anasarca is sometimes used. The word, however, is generally employed in a more comprehensive sense, to designate the effusion of serum into the meshes of the cellular tissue, in whatever part of the body this structure exists. When the collections occur in the serous sacs, they are called dropsies. These, again, are named according to the particular cavities in which they are found. Thus, an accumulation of water in the arachnoid is de- nominated hydrocephalus; in the spinal canal, hydrorachitis; in the pleura, hydrothorax; in the pericardium, hydropericardium; in the peritoneum, hydroabdominalis; in the vaginal tunic, hydrocele: and hydrarthrosis, in the articulations. The color and consistence of the effused fluid are liable to consider- able diversity. In some situations, as in the arachnoid membrane and subcutaneous cellular tissue, it is clear and limpid, like the purest spring water; in others, it is more or less viscid, of a pale yellowish tint, and mixed with flakes of fibrin. A lemon-colored serum is not of unfrequent occurrence in the chest, the vaginal tunic of the testicle, and in the articulations of the extremities. Occasionally the fluid is of a pale reddish color, from the admixture of hematosine, and cases are witnessed where it has the aspect and consistence of coffee-grounds. The latter variety is particularly common in inflammation of the peri- toneum, caused by strangulation. In jaundice, it sometimes contains a yellow coloring matter, like that of the bile; it has also been found impregnated with cholesterine and uric acid. Of the chemical composition of this fluid very little was known until within the last thirty years. The progress of animal chemistry has taught us that the serous effusions consist mainly of water, albumen, extractive matter, fats and salts. When the inflammation is of an active grade an organizable fibrinous substance is present; sometimes even in considerable quantity. The proportion of albumen is subject to much variety, being very abundant in some situations, and almost entirely wanting in others. The principal saline ingredients are soda and potash, in the form of muriates and sulphates, with phosphate of CHEMICAL AND PHYSICAL PROPERTIES. 61 lime, iron, and magnesia. The specific gravity of the effused liquids is generally less than that of the serum of the blood, and their coagula- bility is always in direct ratio to the amount of albumen. In the fluid of hydrocephalus and spina bifida the quantity of this substance is frequently so small as scarcely to be rendered visible by heat, alcohol, or acids. From all, then, that we know concerning this matter, it may be legitimately inferred that it is perfectly identical with the serum of the blood from which it is derived, differing from it only in specific gravity, and in the relative proportion of its constituents. The amount of fluid varies from a few drops to several gallons. The rapidity with which it is poured out, even in large quantity, is sometimes surprising. In persons bit by venomous serpents, the whole body often attains an enormous size in the course of a few hours from this source, and some of the internal organs are literally inundated. Usually, however, the effusion takes place more gradually, and never to any considerable extent until the inflammation has attained a certain point. In the serous membranes, for example, which afford this fluid in great abundance, one of the first things that happen, when they are irritated, is the suspension of the natural secretion, which is restored and augmented only after the violence of the inflammatory impulse has somewhat abated. If this should not occur, lymph, not serum, will be furnished, either alone or combined with pus or blood; or the individual, the subject of the disease, will perish from its effects; or the part will fall into a state of sphacelus. Causes.—It has been already hinted that serous effusion is the result of inflammation, usually of a very mild grade. That this is true, as a general rule, cannot be doubted; the exceptions, if there be any, are certainly \ery rare, and have not yet been satisfactorily pointed out. A few facts, clearly and concisely stated, will materially assist in de- termining this problem. It has been alleged, in the first place, that serum is occasionally effused when there is an obstacle simply in the circulation, without any concomitant inflammatory action. It is a matter of common observation with the physician, that anasarca of the lower extremities often arises from obliteration of the femoral, external iliac, and ascend- ing hollow veins; and the face, neck, and arms are frequently loaded with serum from compression of the vessels which return the blood to the right side of the heart. When the portal vein, or any one of its principal branches, is obstructed, abdominal dropsy, or ascites, follows.* Contraction of the right auriculo-ventricular orifice, or dis- ease of the valves of the pulmonary artery, impeding the passage of the blood, and compelling it to regurgitate into the inferior cava, produces the same result, together with oedema of the legs and feet. These examples will be sufficient for the subject which they are intended to illustrate. Let us now endeavor to ascertain how far they are de- pendent upon inflammation, or whether they are the result merely of mechanical obstruction. It is frequently extremely difficult to ascertain the condition of the seat of the effusion by anatomical in- spection. In ascites how often does it happen that there is the most copious accumulation of water, caused obviously by inflammation, 62 EFFUSION OF SERUM. and yet, on examination after death, there is scarcely a single trace of the latter malady. That there are cases, then, of serous effusions, m which the ordinary phenomena of phlegmasia, particularly the dis- coloration, entirely vanish on the approach of death, or during the last struggles of life, cannot be doubted ; indeed, it is not improbable that there are instances in which this disparition occurs long before the individual expires. The absence of redness, therefore, does not prove that there was no inflammation; for the existence of this lesion is sufficiently evinced by the presence of the watery accumulation, and the opacity of the affected membrane. Should there be, in addition, specks, patches, or bands of fibrin, all doubt on the subject must vanish. Such, then, being the difficulty of recognizing the presence of in- flammation, where every symptom during life gives indubitable evi- dence of its existence, can it be wondered at that, in the instances above referred to, pathologists should still consider the effusion of serum as the result merely of mechanical obstruction ? The question may now be asked, can such an obstruction exist, to any considerable extent, without producing a state of parts analogous to, if not really identical with, inflammation ? I answer, no. Let it be supposed that the obstacle exists in the ascending hollow vein. This vessel is destined to return the blood from the inferior extremities, the pelvis and abdo- men, to the right side of the heart. But, failing in this, from the difficulty adverted to, the blood is interrupted in its passage upwards, and congestion of all the vessels, both large and small, is the result. This congestion is not transient, but permanent; and it is scarcely reasonable to presume, judging from our knowledge of the circulation, that this state could exist long without producing an altered condition of the sensibility of the parts affected, attended with more or less redness, and effusion of serosity. The peritoneum and cellular tissue of the limbs are the structures which bear the onus of the obstruction, and these, it is well known, are parts which are most liberally supplied with serous capillaries. But, it may be said that the effusion may result from perverted action, from irritation, or disturbed function: all this may be true, and yet not in the least invalidate our position. Everybody knows that in inflammation there is perverted action, or deranged function, with irritation, or altered sensibility. These terms, therefore, if they mean anything at all, only denote certain conditions, not the cause of these conditions; as redness, heat, pain, and tumes- cence are not inflammation, but only so many symptoms of it.* The preceding remarks are equally applicable to those watery effu- sions of the serous textures, which occur in association with organic diseases of the glandular and parenchymatous viscera. A large scirrhous tumor of the liver, seated so superficially as to encroach upon and fret its serous investment, is often attended with ascites although the portal circulation is in nowise obstructed or embarrassed. In the same manner hydrothorax is sometimes induced by tubercles of the lungs; hydrocele by carcinoma of the testicle; hydrocephalus by heterologous growths of the brain. In all these instances the effusion of water is the result, unquestionably, of inflammation lighted LYMPHIZATION. 63 up in the serous covering of the respective organs, by the morbid deposit acting as a foreign substance. The dropsical accumulations which supervene upon scarlet fever, measles, and other eruptive dis- eases, can be traced, in most cases, directly to phlegmasial irritation of the serous membranes. Taking into consideration the preceding facts, and the reasoning founded upon them, the conclusion is obvious that the effusion of serosity, no matter in what part, organ, or region it occurs, is invaria- bly the result of a process analogous to, if not strictly identical with, inflammation. This process, I repeat it, is often very imperfectly marked, both during life and after death, so that the ordinary pheno- mena of phlegmasia are in nowise manifest to our senses. CHAPTER III. LYMPHIZATION.' Always the result of Inflammation.—Physical properties of Lymph.—Quantity.—Varieties of Form.—Chemical Constitution.—Period at which the Deposition commences.—Has a tend- ency to become organized.—How this is effected.—Analogous Tissues.—Use of Lymph as a means of Restoration.—Adhesive Action. If there be still some doubt as to the question, whether the effusion of serum is invariably of inflammatory origin, there can surely be none respecting that of fibrin. So true is this, in reference to the latter product, that it may be assumed as a law, than which there is none more satisfactorily established in pathological science. Yet, as in the former case, examples not unfrequently occur where the fibrin consti- tutes the only sign observable after death, of the previous existence of inflammation. In arachnitis, large quantities of this matter are often poured out, without our being able to detect the slightest red- ness, opacity, or thickening of the serous membrane. Nevertheless, it would be absurd to say that, because some of the ordinary pheno- mena are wanting, there had been no inflammation. Lymph is a vital, organizable substance, separated from the blood by a process of secretion, similar in kind to, but different in degree from, that which presides over the elaboration of serum and pus. In its physical properties it is liable, like other morbid products, to be modified by adventitious circumstances, and hence it does not always exhibit the same appearance. In general, it is transparent, and of a white, yellowish-white, or opaline tint; but it may be opaque, cineri- 1 As this term is not to be found in any of our pathological treatises, it is necessary to observe, that it is employed here in the same sense as " effusion of lymph" or " depo- sition of fibrin." We say a part is in a state of suppuration when it is secreting mat- ter ; with the same propriety we may say that a structure is in a state of lymphization, when it is pouring out lymph or fibrin. 64 LYMPHIZATION. tious, milky-white, or reddish. In jaundice, I have seen it of a pale yellowish hue, from the presence of the coloring matter of the bile. At first it is very soft, semi-liquid, or almost diffluent and so viscid that it may be drawn out into thin filaments; but it gradually increases in consistence, assumes a retiform arrangement, and feels very much like a mass of cobwebs moistened with water. When squeezed, it yields a small quantity of fluid identical with the serum of the blood. If the circumstances under which it is deposited are favorable, it is either absorbed, or a part of it remains, becomes organized, and is ren- dered capable of being converted into a great variety of tissues, such as the cellular, serous, fibrous, cartilaginous, and even the osseous. The period necessary for these transformations varies from a tew days to many months. Under the microscope lymph does not always present the same cha- racters. It is, in general, found to be composed of a large number of globules, cells, and granules, lying in a transparent matrix. The globules or exudation-corpuscles resemble, at first, the ordinary chyle- corpuscles or white corpuscles of the blood, but in their development may give rise to all the different forms of plastic cells described by authors, or they may degenerate into granular masses, and perhaps also into pus-cells. The matrix is generally hyaline and indistinctly fibrillated, or may consist of distinct fibres, or of networks of delicate fibrils inclosing nucleated cells of different size. From these elements tissues are formed in the same manner as the textures are originally developed. Sometimes exudation-corpuscles and cells are entirely absent in lymph, and the whole mass consists of a fibrillated texture or of a fibrous blastema; or it may coutain large, irregular, flaky masses. The granules exist in lymph in uncertain proportion, and are, in fact, not always of the same nature; some appertain to the organization, others to the breaking up of the inflammatory product. An element repeatedly met with in inflamed tissues is the granule cell, or inflam- matory globule of Gluge. It is a large distinct cell made up of numerous granules, and generally has a distinct cell-membrane. This cell-wall may burst, and the granules be dispersed in the inflamed parts. It is highly probable that these granule-cells are owing to a fatty degeneration of pre-existing cells. They are not met with merely in inflammatory lymph. Basing their views on these varying minute appearances, some patho- logists maintain the doctrine of an essential difference in the character of the effused lymph, and thus seek to explain the different terminations of inflammation. Rokitansky, for example, divides fibrous exudations into the plastic and croupous. The latter, consisting almost entirely of nucleated formations and corpuscles, occurs more especially in mucous membranes, and is distinguished for its tendency to extend over large surfaces, and to corrode, when it breaks up, as it is very prone to do, the tissues with which it is in contact. He mentions, in addition to the plastic, an albuminous, serous, and hemorrhagic exudation. Mr. Paget makes a similar division. He distinguishes two forms of inflammatory lymph, the fibrinous and corpuscular. The fibrinous has the general properties of the fibrin of the clot of the blood, soon coao-u- CHEMICAL AND PHYSICAL PROPERTIES. 65 lating into a solid form. Microscopically, this fibrinous lymph is cha- racterized by the small proportion of exudation-corpuscles. It is tough and semitransparent, and occurs chiefly in acute inflammations of serous membranes, especially in vigorous persons. It is prone to organize into tissue, and leads to adhesions and indurations, hence it frequently exhibits the cells and fibres of developing structure. In the corpuscular lymph the exudation-corpuscles are in great abund- ance, and little healthy fibrin is present. This variety of lymph tends to suppurative inflammation. It is generally seen in patients of defi- cient vital powers. Between these two forms numerous intermediate stages are observed. Thus it would seem that the state of the blood exerts a strong influ- ence on the production of the different varieties of inflammatory lymph. The fact, also, of the various forms of fibrinous coagula in the heart, showing, at times, a firm fibrillated structure; at others, a granular mass with numerous corpuscles, and corresponding with the lymph out of the bloodvessels, and more or less with the general condition of the body, renders it highly probable that the form of exudation is pre-de- termined by the state of the blood. Possibly, also, although in a less degree, the seat and intensity of the inflammation may aid in pro- ducing different blastema. It remains for future research to establish these observations on more positive grounds; especially ought we to investigate the chemical relations of the exuded lymphvto the circu- lating blood. We shall have occasion, when speaking of suppuration, to return to this question. Fig. 7 displays a portion of recently-effused lymph, opaque, white- colored, friable, and magnified about 380 diameters, from traumatic inflammation of the peritoneum of a horse. It is composed of globules, smaller molecules, and granular matter in a hyaline matrix. In the lower part of the figure the granules and molecules are shown as float- ing in serous fluid. In Fig. 8, the structure of the effused matter is Fig. 7. Fig. 8. Fig. 7. Plastic corpuscles and filaments in recent lymph exuded on the pleura, a. The corpuscles unchanged by acetic acid.—Bennett. • Fig. 8. Recent lymph, forming false membrane. somewhat different. It forms, in fact, a sort of false membrane, mag- nified 800 diameters. Numerous corpuscles are seen, more or less globular, and having the character of primary cells; the intervening 5 6Q LYMPHIZATION. texture is formed of most delicate fibrils. A few minute granules are interspersed through the tissue.1 The chemical composition of lymph proves it to be similar to the buffy coat of the blood. The researches of Lassaigne have thrown addi- tional light on this interesting subject, by showing that the false membranes of the serous and mucous cavities are composed mainly of fibrin, with a small quantity of soluble albumen and a yellow-colored serum, containing all the organic and saline elements of the blood. Immersed in alcohol, or a strong solution of corrosive sublimate, the effused matter becomes dense and firm, and assumes a whitish, shrivelled aspect. In water it is gradually decomposed, and broken up into small, dirty, rotten-looking fragments, which readily yield under the pressure of the finger. Lymph is effused under a considerable variety of forms, depend- ing upon the peculiar shape of the part which supplies it. In the sub- cutaneous cellular tissue it usually occurs in small amorphous masses, or in disseminated globules. In the larynx and trachea, it accurately moulds itself to those cavities. In the peritoneum, it forms bands, occasionally of considerable length, which extend from one coil of bowel to another; in the pleura it is commonly laminated. To these statements there are, of course, numerous exceptions, which will be adverted to in other parts of this treatise. The quantity of fibrin poured out is subject to much diversity. In general it is furnished most abundantly by the serous sacs; yet, under certain circumstances, large quantities are effused by the mucous mem- branes of the respiratory and intestinal tubes, as well as by that of the oesophagus and uterus. Happily, however, this substance rarely re- mains long in these outlets; otherwise the most serious consequences might ensue. As it is, in the trachea it often produces death, by pre- venting the ingress of the atmosphere; the lachrymal passages, and many of the minute bronchial canals are sometimes obliterated by it; in the urethra it lays the foundation of permanent stricture; and in the chest, by tying down and compressing the lungs, it may give rise to atrophy, or otherwise embarrass the respiratory function. Considerable quantities of fibrin are not unfrequently found on the inner surface of the arteries, the largest sized trunks of which are occasionally obliterated by it. The muscles, fibrous membranes, tendons, ligaments, cartilages, and bones yield very little when in a state of inflammation. The skin, veins, and absorbents furnish it also very sparingly. A good deal is generally effused in phlegmasia of the subcutaneous cellular tissue, around abscesses, and upon the walls of fistulous passages. With respect to the parenchymatous and glandu- lar organs, the effusion of fibrin may be said to be in direct proportion to the amount of cellular substance which enters into their composi- tion, being always very small when their structure is dense and com- pact, and more or less copious when it is soft and lax. The period at which the deposition of lymph commences is influenced by different circumstances, the principal of which are referable to the 1 Gulliver, Appendix to Gerber's General Anatomy, PI. p. 59. ORGANIZATION. 67 intensity of the inflammation and the nature of the affected structure, tissue, or organ. If an incision be made into the skin of the finger, its surface will become covered with plastic matter within less than an hour after it has ceased to bleed; and the flaps of the stump in ampu- tation often become thoroughly glazed with lymph nearly in the same time. Some years ago I had occasion to operate upon a gentleman on account of internal strangulation of the bowel. Some adhesions were found between the intestinal convolutions, but they were slight. The man died precisely four hours after the operation; and, on laying open the abdomen shortly afterwards, I discovered a thin film of lymph spread over nearly the whole of the small bowel, and also over a large part of the parietal portion of the peritoneum. In a young man who died under my care of a gunshot wound, which penetrated the liver and diaphragm, I found both the pleura and peritoneum exten- sively coated with this substance nine hours after the reception of the injury. In many cases there is reason to believe that the effusion takes place almost at the very onset of the inflammation, and that it proceeds, with greater or less rapidity, until the disease either abates, passes into suppuration, assumes a chronic form, or destroys life. If this substance remains undisturbed, it manifests a disposition to become organized. The period within which this happens varies from a few hours to several weeks. The serous membranes are the struc- tures in which the organization is accomplished with the greatest ease and rapidity; while in the mucous it either does not take place at all, or very imperfectly, and only after a long time. It is likewise effected with great facility in the skin, in the cellular tissue, and in fractured bones. The organization of the effused substance is greatly influenced by the state of the constitution, by the nature of the pre- existing texture, and, above all, by the amount of its own inherent vitality. When this is of a low grade, the lymph either dies, and thus becomes a source of mischief, or it becomes vascularized, and under- goes a slow conversion into an analogous tissue. How this vascularization is effected is an interesting subject of in- quiry, and one which has excited much discussion among pathological anatomists. That it is produced in one of two ways, is sufficiently ob- vious ; either by the vessels of the natural tissues shooting into it, or spontaneously by powers residing within itself. Proofs are not want- ing in support of both views. In removing, for example, a recently formed adventitious membrane, we not unfrequently find its adherent surface marked by numerous bloody points, caused evidently by the rupture of the elongated capillaries of the inflamed normal membrane. What renders this supposition the more probable, is the fact that the free surface of the serous membrane—for it is to this class of textures that these remarks are more particularly intended to apply—is studded with very minute granulations, which are highly vascular, and accu- rately correspond in their situation with the red dots observable on the attached surface of the new membrane. These granulations become gradually more and more distinct, both on the original and on the adven- titious structure; and, by means of a magnifying-glass, very delicate slender vessels, arterial as well as venous, may be seen passing from the LYMPHIZATION. substance of the one into that of the other. As the penetrating vessels increase in volume and number, the lymph adheres more firmly to the inflamed surface of the natural membrane, until at length the circulation between them is fully established, being carried on with the same free- dom and vigor as in other regions of the body. The second opinion—that, namely, which supposes the lymph to possess a self-vascularizing power—ranks amongst its advocates some of the most distinguished pathologists of the last and present centuries; and the facts which they have adduced in favor of their position go fai, it must be confessed, in leading us to doubt whether this substance, in whatever form it may appear, is ever vascularized in any other way. They have shown, most conclusively, as it seems to me, that portions of exuded lymph contain vessels, and perform the functions of nutri- tion, secretion, and absorption, before it is possible to trace the slightest vascular connection between them and the surrounding textures. In the pleura, it has often occurred to me to see as many as three, four, five, and even six distinct layers of this substance, arranged so as to intercept cavities of various sizes, filled with serum, flakes of fibrin, pus, and even blood. In some of the cases, the circumstances were such as to render it perfectly certain that the development of these ad- ventitious membranes must have taken place with so much rapidity as to preclude the idea that their vascularization could be effected through the agency of the subjacent serous structure. There is, therefore, reason to believe that lymph possesses, in many instances, an inherent self-creating power, in virtue of which it forms blood which gradually prepares its own vessels. What the precise nature of this vitalizing influence is, we cannot, of course, determine: the difficulty, surely, cannot be solved by invoking, as has been done by Andral, the agency of the electric fluid. Of the intimate character of this fluid we know as little as of life itself; and the notion just alluded to is, therefore, ill calculated to enlighten us on a subject concerning which we must necessarily remain forever ignorant. The traces of the organizing process are seen in numerous cell- Fig. 9. mmm\ h%:'M\\ ''■'■ Fig. 10. Fig n w A\ \. mi . S* ^\o. ., I'S ■M. ■ &.-- ■ ■=* .' "A '■ .- \»- ■■'• \'!'.U: *•■ "V ^ ^ *%k, '-*;- ,vi if fill --...- ■* f i 'f r - "1 \ ':.:i..i''i ill i i- ': I i r' ■: l y? ::■■. ''^Nr.--;'^'-' \'-N ^i ''•'■ '£' [!■" v - ■I i) i ■V;.^^iiL. :i-X. * a f / Figs. 9,10, from Bennett, show nuclei and cells developing themselves into fibres: whilst Fig. 11 shows a perfect fibrous tissue. formations of every conceivable shape and size. From these cells are formed the tissues, in exactly the same manner as in perfectly normal structures. The greatest tendency of lymph is to develop itself into TISSUES RESULTING FROM IT. 69 fibrous tissue. It always assumes the character of the structure in which, or near which, it is effused. Thus, in and around a bone, osseous tissue is formed from the inflammatory lymph. These transforma- tions may occur even before bloodvessels in the part are organized. It is certain that these are not the only necessary organizing element, and it is impossible to avoid the conclusion that coagulating lymph is susceptible of spontaneous development, and endued with a certain amount of vitality. It derives assistance and nourishment from the original structures, but it is capable of effecting its organization by its own inherent life-power. If possessed of a feeble vitality it will break down and become effete. The study of the development of normal tissues, especially since the introduction of the cell doctrine, has taught us how structures are organized; and why should not the same laws govern the development of lymph when effused by the inflammatory process ? It may, in fact, be fairly presumed that all constituents of the body can be formed in coagulating lymph. That vessels can be there created is certain. Independently of the facts already adduced, the experiments of John Hunter and Everard Home, in which the vessels formed in a clot of blood were successfully filled with injecting matter, place this subject in a most incontrovertible light. Shroeder Vander Kolk,1 detected, with the aid of a magnifying power, numer- ous vessels, finer than the most delicate hair, and terminating in a cul-de-sac, in a piece of false membrane floating about in the midst of a serous fluid; it was still soft, gelatinous, and entirely free from adhesions. Fig. 12. Fig. 13. Newly-formed vessels in plastic lymph. False membrane of the pleura. The arrangement of the newly-formed vessels is represented in the annexed sketches, from plates by Hunter and Lobstein. Fig. 12 is a portion of coagulating lymph attached by a narrowneck to the peri- toneal coat of an inflamed intestine. The vessels have a ramiform disposition, and freely anastomose with each other. Fig. 13 is a piece of false membrane of the pleura. The vessels are large, numerous, and farther advanced than in the other sketch. Fig. 14 affords a good illustration of the vessels of a coagulum of blood, as seen by Hunter and Home. Nothing is known, with any certainty, concerning the nerves of this organized matter. They have been detected only a few times in 1 Observationes Anatomico Patbologicse et Practici argumenti, p. 20. 70 LYMPHIZATION. adventitious membranes;1 that they exist, however, may be legiti- mately inferred from the fact that they are capable of executing the highly important function of nutrition, secretion, and absorption, which, but for this circumstance, they could not possibly accomplish. My opinion is, that plastic lymph, in whatever part of the body it occurs, in its progress towards organization, either generates its own nerves, or receives them from the neighboring tissues, in the coats of the vessels. I am the more inclined to adopt this view from the analogy afforded by some of the primitive textures, as the osseous and car- tilaginous, which, there is reason to believe, obtain their nervous sup- ply in this way. Absorbent vessels also exist; but their presence, like that of the nerves, has hitherto been a matter rather of inference than of actual observation. Shrceder Vander Kolk1 has, however, satisfactorily demonstrated them in the false membranes of pleuritis. His preparations are injected with quicksilver, and are said to exhibit the characteristic knotty arrangement observable in the lymphatic vessels of the natural tissues. Plastic lymph, organized in the manner now described, forms the basis of all the analogous tissues, and the bond of union of divided parts. It may become the seat of inflammation, both acute and chronic; pour out serum, lymph, pus, and even blood; and undergo the same transformations precisely as the natural textures. It is likewise the source of what is termed induration, and probably, also, in a modified form, of scirrhus and tubercle. The analogous tissues formed, as just stated, out of the plastic element of the blood, are nearly as numerous as the natural, to which, as their name imports, they bear the closest resemblance in the threefold respect of physical, chemical, and vital properties. The following arrange- ment embraces the different kinds of textures pertaining to this class which have hitherto been described by authors: cellular; serous; mucous; cutaneous; vascular, including the erectile; adipose; horny, including the cuticle, hair, and nails; fibrous; fibrocartilaginous; cartilaginous; osseous. These tissues will be described in their ap- propriate place. In the mean time, it may be remarked concerning them, generally, that they do not occur with equal facility; that they are more prone to form in the old than in the young; and that whilst some most closely resemble the tissues from which they have received their names, the likeness of others is faint and imperfect. 1 By Vircliow. See Wurzb. "Verhard, i. 144. 2 London Medical Gazette for Jan., 1843. TISSUES RESULTING FROM IT. 71 It has been already intimated that coagulating lymph performs a most conspicuous part in the reunion of divided parts. Without the assistance of this substance, no wound, however trifling, could possibly get well. The little incision made in the operation of venesection would either prove fatal, or become a source of permanent incon- venience and suffering. Ulcers would not heal, and fractured limbs would dangle about "in wild uncertainty." Formerly surgeons seemed to be entirely ignorant of the utility of this substance as a means of repairing injuries, whether occurring in the soft or hard parts of the body. It remained for Mr. Hunter to exhibit the subject in its true light, by which he created an epoch in the history of the science, amongst the most interesting that have occurred. As admitting of the most easy examination, attention may be here directed to the part which this substance performs in the reparation of wounds of the cutaneous and cellular tissues. If these structures be simply incised, the edges of the cut surface, if kept in close apposi- tion with each other, are united by what was formerly denominated first intention, or, since the time of John Hunter, union by adhesive inflam- mation. In a case of this description, the first thing that nature does is to set up a new action in the part—that is, the wound becomes red, painful, hot, and tumid—phenomena which clearly indicate that her workmen are busily engaged in repairing the injury which has been sustained. Plastic lymph is now thrown out, by which the contiguous surfaces of the incision are gradually and effectually agglutinated together. Whilst this secretion is in operation, the vessels of the part are elongated, and, passing through the bond of union thus set up, they finally inosculate with each other, transmitting thereby the blood through the new substance, which, at the same time, increases considerably in firmness and density. Similar changes take place with respect to the nerves and absorbents. Thus the effused lymph becomes a living intermedium; and it is in this way that the restora- tion of divided parts, no matter what may be their structure, is ef- fected. That the process, however, may go on kindly, it is essential that the concomitant inflammation shall not transcend certain limits; otherwise there will be suppuration instead of lymphization. It is upon a knowledge of this property of coagulating lymph that are founded some of the most astonishing improvements that have been achieved by modern surgery. Amongst these the most remarka- ble are the operations for tying arteries, in cases of aneurism, so much perfected, if not devised, by John Hunter; and for repairing mutilated organs by transplanting parts from one region of the body to another. Much good has also resulted in respect to the treatment of incised wounds, whether produced by accident, by the removal of a tumor, or the amputation of a limb. In all these instances it is customary, in every part of the civilized word, except, perhaps, France, to en- deavor, if possible, to bring about union by the first intention; the surgeon well knowing that if this can be effected he will save himself much trouble, and the patient no little suffering and inconvenience. The effusion of lymph is a means employed by nature to obviate accidents. A convincing proof of this is witnessed in cases of tuber- 72 SUPPURATION. cular phthisis. In this disease, abscesses generally form in the supe- rior lobes of the lungs; these are sometimes seated quite superficially; at other times they are exceedingly capacious, and extend in different directions until they make their way completely through the pulmo- nary tissue, and even the pleura. But does the softened tubercular matter usually escape into the cavity of the chest? By no means. Long before the event alluded to takes place, inflammation is set up in the surrounding serous membranes, followed by a copious secretion of lymph, by which an effectual barrier is opposed to the extravasa- tion of the purulent fluid. Similar phenomena occur in ulcerations of the bowels, and in abscesses of the abdominal and pelvic viscera. CHAPTER IV. SUPPURATION. Definition.—Organs in which it is most easily effected.—May take place without Solution of Continuity.—Varieties of Form.—Abscesses.—Physical and Chemical Properties of Pus.— Distinguishing Tests.—How produced. A third mode by which inflammation relieves itself is suppuration. This consists in the formation of purulent matter, and constitutes, strictly speaking, merely the third stage of inflammation, inasmuch as pus is never deposited when there is an entire absence of this state. That this position is correct, will hardly be doubted. Hunter, it is true, is of opinion that collections of extraneous matter, as he terms them, may form in various parts of the body, without any antecedent inflammation; but in this notion he has not been followed, so far as I know, by any respectable authority since he promulgated it. Indeed, if any one will take the trouble to peruse the chapter which this great pathologist has published on this subject, he will be struck, at almost every line, with the vagueness of his expressions and the inconclusive- ness of his reasonings. In what is called a cold abscess, the formation of which is sometimes the work of months, inflammation is just as much concerned as in a phlegmonous boil that is developed in two or three days. The only difference is, that, in the one the process goes on slowly, almost imperceptibly; while in the other it proceeds rapidly, and is accompanied with symptoms so well marked as not to be mis- taken. The formation of purulent matter does not take place with equal facility in all the organs and textures. Of the viscera, those which are most prone to take on suppurative action are the liver, lungs, and brain; of the tissues, the cellular, the cutaneous, mucous, and serous. In the fibrous textures, the cartilaginous, tendinous, and osseous, this fluid forms with difficulty, and is seldom of a thick, consistent nature. ACUTE ABSCESS. 73 Of the mucous system some portions are more liable to be affected with suppuration than others. Thus, it is much more common to find pus in the colon than in the stomach or ileum, in the vagina than in the uterus, in the urethra than in the urina^ bladder, in the nose than in the mouth, in the fauces than in the • oesophagus, in the bronchia than in the larynx. So, likewise, in the serous system, suppuration is more frequent in some situations than in others; as, for example, in the pleura, the vaginal tunic of the testicle, and the lining membrane of the larger joints. In the subcutaneous cellular texture, pus is most readily formed in those parts which are remote from the central organ of the circulation. The bloodvessels do not often suppurate, except when wounded; and the same, so far as we know, is the case with the absorbents. The lymphatic ganglions, how- ever, are very frequently affected in this way, especially those of the axilla, the groin, the mesentery, and the base of the lower-jaw, in persons who are predisposed to scrofulous disease. The nervous tissue seldom suppurates, and still more rarely the muscular. From all these facts we may deduce the axiom, that those structures are most prone to form matter which contain the largest amount of loose cellular sub- stance, and, conversely, that those which possess this tissue sparingly always suppurate with difficulty, requiring in general a much longer period, and elaborating a less perfect fluid. It is well known that pus may be formed without any solution of continuity. This mode of suppuration, in fact, is very common, not only in all the serous cavities, but throughout nearly the whole of the mucous system. It is not, however, confined to these textures. In the cellular substance, in the lungs, brain, liver, and other viscera, nothing is more frequent than suppuration, without any breach what- ever, in the first instance, of continuity. Pus, when first effused, generally appears in the form of distinct globules, which are dispersed through the affected structure, and can be easily recognized by their pale yellowish color. As the purulent particles increase in number, they gradually become confluent by the absorption of the part concerned, and in this way the matter is at length collected into an abscess. Abscesses.—Abscesses are usually divided into three classes, the acute, the chronic, and the metastatic. This arrangement is founded on their mode of origin, and is of great pathological as well as prac- tical interest. The period required for the formation of an acute abscess, often termed phlegmonous, depends a good deal upon the constitution of the patient, the nature of the exciting cause, the degree of inflam- matory action, and the anatomical elements of the part affected. In the lungs, brain, spinal cord, and spleen, death usually takes place before the matter has time to concentrate itself into a focus; and hence, in examining persons who have died of acute diseases of these organs, it is extremely rare to meet with an abscess even of small size. On an average, the period necessary for the formation of visceral col- lections of this kind may be stated at from twelve to fifteen days; whereas in the subcutaneous cellular substance, abscesses often make 74 SUPPURATION. their appearance in less than a week, sometimes, indeed, in less than forty-eight hours, from the commencement of the inflammation. When the abscess is superficial it always manifests a tendency to extend to the cutaneous surface, where it ultimately points and breaks. The period required to effect this depends very much upon the activity of the absorbent vessels, and the nature of the parts by which the fluid is covered. The process itself is denominated ulcera- tive absorption, and is always greatly promoted by the pressure of the confined matter. Its progress may be temporarily resisted by aponeurotic and other structures, but it ultimately surmounts every obstacle, though, perhaps, at the expense of much suffering. When the pus is long retained, it may commit extensive mischief by burrow- ing among neighboring parts, as is exemplified in whitlow, erysipelas, and abscess round the anus. Visceral abscesses, on the other hand, usually discharge their con- tents into some hollow organ, or they burst into a splanchnic cavity. This is the ordinary tendency of purulent collections of the liver and spleen; sometimes, however, they pursue a more tedious and devious route, through the walls of the abdomen. Abscesses of the lungs usually open into a neighboring bronchial tube, from which the matter is afterwards expelled by coughing. In the kidney, the purulent fluid may escape along with the urine, or it may be retained, and ultimately find an outlet through the bowel, the external surface, or the perito- neal cavity. In the brain, as there is no vent for the pus, the abscess almost always proves fatal. The purulent matter is sometimes inclosed by a layer of plastic matter. This substance, which is furnished by the neighboring vessels, and which presents itself in the form of a distinct sac, cyst, or bag, technically called the pyogenic membrane, varies in its properties in different cases and even in different parts of the same preparation. In recent cases, it is always much softer than in those of long standing, owing to the new product not having had time to become thoroughly organized and converted into a complete membranous pouch. In thickness it varies from the fourth of a line to a quarter of an inch, or upwards. Its consistence is often equal to that of a fibrous membrane, though generally it is much more easily torn. Externally it is rough, flocculent, and firmly united to the surrounding tissues, which are at the same time preternaturally dense and vascular. The inner surface of the sac is either smooth and glistening, or villous and granulated, of a pale ash, or reddish color, and constantly bathed by purulent fluid. The manner in which this cyst is organized does not differ from that of the adventitious membranes generally. Its vessels are usually very numerous; and, although they are extremely minute, may be readily injected with fine size. The presence of absorbents is rather inferred from one of the functions of the sac than established by actual demonstration. That the contents of an abscess may be removed by the powers of the system, is well known to every surgeon- the pro- cess, indeed, often occurs spontaneously; at other times means are employed to excite and promote it. No nerves have been traced into it; although it is certain that it must be well supplied with them. ACUTE ABSCESS. 75 Thus, we perceive that this pseudo-membrane is a highly organized structure, capable of performing important functions, and of awakening important sympathies in the system. It not only completely isolates the abscess from the surrounding parts, but it secretes, and often absorbs, the matter which it contains. It has been thought that its formation always precedes that of the pus, and that it thus becomes the immediate secerning tissue. This opinion, however, is only par- tially correct. After it is organized, the pouch must necessarily secrete its own contents; but at an early period the matter is fur- nished by the vessels of the adjacent tissues, with which it is in immediate contact. We must, therefore, suppose that the membrane is formed subsequently to the abscess which it is destined to circum- scribe. When an acute abscess is formed with great rapidity, as when it is seated beneath the skin, the matter is either extensively diffused through the interstices of the cellular tissue; or it is circumscribed by a deposit of lymph, which is generally absorbed as soon as the fluid ceases to be secreted. It never presents itself, as in other cases, in the form of a distinct membranous pouch. Acute abscesses offer much variety with respect to their volume. In general, their dimensions are in direct ratio to the spongy and vascular structure of the affected part. Thus, abscesses of the gland- ular organs, with the exception perhaps of the liver, are seldom so large as those of the groin, axilla, lumbar region, or the retro-peri- toneal cellular substance, where they may attain a magnitude capable of holding several pints or even quarts. The number of acute abscesses is also liable to considerable variety. While in some cases there is only one, in others, as in some of the deep-seated viscera, there may be as many as a dozen, twenty, forty, or even fifty. In smallpox, the number of little abscesses on the surface of the skin is often immense. Their contents are generally of a healthy or laudable character, and vary from a few drops to several ounces, pints, or even quarts; occasionally they are mingled with clotted blood, shreds of cellular tissue, or the debris of the organ in which the abscess is situated. The formation of this variety of abscess is generally attended by well-marked symptoms. The pain loses its intensity, and changes to a throbbing or pulsatile sensation; the swelling becomes soft, but more prominent; the surface assumes a purple or livid aspect; fluctuation is perceived; the tumor points, the skin is attenuated, and the ulcera- tive absorption still continuing, an aperture takes place, which allows the contents to escape. Matter issues through the opening for some time afterwards; but the cavity of the abscess gradually contracts, and its sides are ultimately united either by granulation or direct adhesion. The same mode of cure is employed by nature when the matter is absorbed. An abscess is said to be chronic or cold when the matter forms very slowly, and the morbid action which precedes it is so mild as to escape recognition. There is usually no pain, heat, or redness of the affected part, and hence the disease often exists for months before it attracts 76 SUPPURATION. attention. On this account the term cold abscess has properly been ap- plied to it. In its quantity, the matter varies from a few ounces to several pounds; it is generally of a whitish, yellowish, or greenish color, of a thin, whey-like consistence, free from odor, and intermixed with small caseous flakes, not unlike particles of soft-boiled rice. If it be allowed to stand for some time, it separates into two parts, one of which is serous, the other fibrinous, or, more properly speaking, tubercular. The fluid, in fact, is essentially scrofulous, and bears the greatest _ resem- blance to the pus of a pulmonary cavern. An abscess of this kind has always a distinct cyst, of a dense fibrous texture, which is closely connected with the surrounding tissues, and is often several lines in thickness. Owing to this circumstance, the matter manifests little tendency to make its way to the surface; instead of this, it extends in different directions, forming frequently long and tortuous tracks before the superincumbent integuments are destroyed by ulcerative absorp- tion. If the cyst be punctured, and its contents evacuated, the accu- mulation will be as great .as ever in the course of five or six days. When the matter passes from one part to another it constitutes what is called a congestive abscess. Chronic abscesses are most common in the subcutaneous cellular tissue, the lymphatic ganglions, and the dorso-lumbar portion of the spine. They are usually situated about the chest, in the neck, groin, axilla, the loins, and the circumference of the pelvis. There is seldom more than one, but occasionally two, or even three are observed in the same subject. They are generally of an irregular figure, and frequently present themselves at a distance of many inches from the original seat of their formation. Of this an example is fur- nished by psoas abscess, which always begins in disease of the spine, and often extends to Poupart's ligament or even beyond it. This variety of abscess is always connected with a scrofulous state of the constitution; and, although there is generally an absence of the ordinary phenomena of inflammation, there can be no doubt that the influence of this process is essential to its production. The disease may last for several years before it finally disappears, or destroys life. As long as the abscess remains closed, the constitution does not seem to be disturbed by its presence; but no sooner is it opened than im portant sympathies are awakened, and the resultant irritation may be so violent as to prove fatal in a few days. The metastatic abscess is most common in the internal viscera, be- neath the peritoneum, and in the joints. It is also observed, though not so frequently, in the subcutaneous cellular tissue and in the mus- cles. The causes under the influence of which it is developed, are, injuries of the head, extensive wounds, compound dislocations, com- minuted fractures, and capital operations. It also occurs during the puerperal state, and as a consequence of phlebitis, erysipelas, typhoid fever, pneumonia, and other diseases. It most frequently affects the lungs and liver, then the spleen, and lastly, the brain, heart, and kid- neys. It always selects the most vascular portions of these organs, and hence their periphery suffers much oftener than their centre. In regard to their number, metastatic abscesses vary in different NATURE OF PUS. 77 instances. It is seldom that we find only one; most generally there are as many as twenty, thirty, fifty, or even a hundred. Sometimes, indeed, the surface of the affected organ is completely studded with them, more than a thousand having been observed in a single case, principally in the deep-seated viscera. The size of this abscess is also very various. Some do not exceed that of a hemp-seed or garden pea; but others are as large as a hazelnut, a marble, a pigeon's egg, or an orange. When very numerous, they are usually proportionably small. In their figure they are generally oval, spherical, or angular; some- times remarkably irregular. When seated near each other, they occa- sionally become confluent, like the pustules of smallpox. The contents of a metastatic abscess are seldom of the nature of well-elaborated pus; on the contrary, they are almost always of a semi- concrete consistence, of a dirty grayish, cineritious, or drab color, and composed mainly of a plastic lymph. This is particularly true of re- cent cases; in those of longer standing, the contents are more decidedly purulent, but even then they are often blended with grumous blood and flakes of fibrin. The textures immediately around the abscess may be natural, or variously altered in their appearance and consistence. In most cases they are engorged with blood, heightened in color, softened, or con- verted into a pulpy diffluent substance. The coats of the vessels are inflamed, thickened, and infiltrated with serosity, while their canals are filled with pus, semi-fluid blood, or fibrinous concretions. The capillary veins usually participate in the inflammation. The period which intervenes between the occurrence of the exciting cause and the actual development of the abscess varies from five to fifteen days. The matter generally forms in a very rapid and stealthy manner, unaccompanied by pain, heat, or redness of the part which it selects for its seat. The most prominent symptoms are, violent rigors, usually paroxysmal in their character, delirium, stupor, prostration, and general insensibility. The development of this abscess has been variously explained. The ancients were of opinion that it was the product of metastasis; or, in other words, that the pus was absorbed from the part originally affected, and transported to some other situ- ation, where it was collected into a focus. This view is still enter- tained by many pathologists; but it has been conclusively proved, by a number of well-attested facts, that the abscess is the result of phle- bitis, and that it often exists independently of the suppurative process in the organs and tissues which sustained the primary mischief. It is an interesting observation in connection with this subject that in the circulating fluid none of the corpuscles of pus can be detected. Masses of coagulated fibrin have, on the other hand, been repeatedly observed. Nature of Pus.—The subject of abscess necessarily brings us to the consideration of the physical, microscopical, and chemical properties of pus. When genuine, or, as it is not improperly called, healthy, pus is of a pale yellowish tint, opaque, homogeneous, of a sweetish taste, without any particular smell, and of the consistence of thin cream. It is heavier than water, in which it is partly dissolved, emits a faint, mawkish odor on being heated to the natural temperature of the body, 78 SUPPURATION. resists putrefaction with remarkable pertinacity, and is coagulated by heat, alcohol, and muriate of ammonia. Pus freezes less rapidly than water, and when thawed it does not regain its original properties. The specific gravity of pus is liable to considerable variation. It is less than that of blood, and greater than that of serum. According to Gueterbock, it ranges from 1030 to 1033. In seven distinct exa- minations of pus, taken from abscesses in different situations—as the thigh, arm, axilla, back, pleura, and the lung in pulmonary phthisis— Dr. John Davy found the specific gravity as low in one as 1021, and in another as high as 1042. This great disparity is mainly attributable to two circumstances, the unusual quantity of the solid ingredients, and the variable density of the liquid part. Pus, when microscopically examined, is found to be composed of numerous small corpuscles suspended in a thin transparent fluid. These little bodies, which have received the name of pus-globules, are generally of a spherical form, and vary in size from the 3o1ootn t0 the 3^Bth of an inch in diameter. They are mostly very granular, and possess a delicate cell-wall, which becomes distinct on the addi- tion of water. They are nucleated; some containing one well-defined nucleus; others two, three, or more small nuclear bodies. Acetic acid has the effect to render them apparent; the cell-contents and wall be- come transparent under its influence, especially if the acid be undiluted. Fig. 15 exhibits pus-corpuscles in their natural state. Fig. 15. Fig. 16. Fig. 16. a. Natural appearance of Pus-Corpuscles, b. Appearance after application of acetic acid.—Lehmann. Fig. 17. Pus-Corpuscles, magnified 400 diameters. These corpuscles float in the purulent liquor, but they are not the only solid elements observable. Purulent matter exhibits, besides these, granules, shreds of fibrin, and exudation-corpuscles of varying shape; also, at times, small homogeneous, non-nucleated corpuscles, termed " pyoid" by Lebert. The mode of formation of these pus-corpuscles is still involved in obscurity. It is supposed by some pathologists that the grouping to- gether of granules in the blastema forms a nucleus, and that a cell-^wall becomes subsequently developed around one or several of these. Others maintain the opposite view, and regard the growth of a pus- corpuscle as gradual, from a very small vesicle up, the nuclei appear- VARIETIES OF PUS. 79 ing last. Some of the most recent observers trace the pus-globules to a degeneration of the ordinary cells observed in coagulating lymph. The corpuscles of pus may break up into masses of fine granules, or undergo fatty or calcareous degeneration. If these changes occur, va- rious crystals, masses of cholesterine and oil-globules may be seen in the purulent fluid. The chemical constitution of pus has been examined by a great num- ber of experimentalists. The results of their investigation tend to show that pus contains most of the elements of the blood. The following analysis is by Gueterbock, from the pus of an abscess in the human breast. Water ........ 86-1 Fat, soluble only in boiling alcohol . . . . 1*6 Fat and osmazome, soluble in cold alcohol . . . 4-3 Albumen, pyine, pus-globules, and granules, soluble neither in hot nor in cold alcohol . . . . . .7*4 Loss ...... 0*6 100- Lehmann has investigated the chemical composition of the different elements of pus with great care. Normal pus he found to contain from 14 to 16$ of solid constituents, of which from 5-6$ belonged to mineral or inorganic substances. The most usual insoluble salts of pus are the phosphates of lime and magnesia, and the sulphate of lime; the principal part of the soluble salts is furnished by chloride of sodium. The quantity of fat in pus Lehmann found to vary from 2-6$; the quantity of albumen in the serum from 1*2 to 3*7$. Casein and the coloring matter of the blood do not occur in normal pus. A substance which usually enters into the composition of pus is pyine. Gueterbock, who discovered it, considers it a peculiar animal principle. Its exact nature is not understood. It is supposed by some to be an oxide of protein, by others a form of fibrin. It can be precipitated from pus by acetic acid, or by alum. It is soluble in water, but insoluble in alcohol. With regard to the composition of the compound part of the pus- globules we possess no positive knowledge. The cell-walls, contents, and nuclei, react like protein bodies, and are probably of an albu- minous nature. The cell-walls are dissolved by acids, but resist the action of alkalies. Varieties of Pus.—Pus is liable to be modified in its properties by the presence of extraneous substances, such as grumous blood, fibrin, cholesterine, or the debris of the organs and textures in which it is formed. In common phlegmon, it often contains shreds of cellular tissue, of a dirty grayish color, not unlike wet tow. The brownish matter found in certain abscesses of the liver probably derives its color and consistence from the intermixture of the softened and broken- down hepatic parenchyma. In suppuration of the different glands, the pus is not unfrequently mingled with the product of their secre- tion. Thus, in the kidney, it may blend itself with the urine, in the liver with the bile, in the mamma with the milk, in the testicle with the semen. Purulent matter is sometimes very fetid, probably from the extrication of sulphuretted hydrogen. 80 SUPPURATION. The different varieties of pus have received different names. When the fluid is of a whitish color, creamy in its consistence, and composed of a great number of globules, it is said to be healthy, pure or lauda- ble, in reference to the process by which it is produced, which is of a healthy, sanative, or restorative nature. It is usually met with in suppurating wounds, in healing ulcers, and in acute abscesses. Its properties have been already sufficiently described. Sanious, serous, ichorous, or sanguinolent pus is thin, almost trans- parent, and of a yellowish, oily, or reddish color, and is generally so acrid as to erode the parts with which it comes in contact. It is a product of unhealthy inflammation, and is principally observed in caries of the bones, in irritable ulcers, and in open cancers. This variety of pus is frequently blended with grumous blood, flakes of fibrin, and the debris of the affected tissues. Fibrinous pus consists of common pus in combination with plastic lymph. It is of a whitish, grayish, or cineritious color, and of a semi- liquid, concrete, or lardaceous consistence. Under the microscope, it displays the globules of healthy pus, with numerous other cells and fibres of irregular shape. It is commonly found in the joints, the splanchnic cavities, in metastatic abscesses, and in carbuncular inflam- mation. Its presence denotes a high degree of morbid action. Scrofulous pus is mostly seen in pulmonary caverns, cold abscesses, scrofulous disease of the joints, and chronic inflammation of the lym- phatic ganglions. It usually separates into two parts, of which one is thick, straw-colored, and inodorous; the other thin, ropy, and mixed with small, opaque, curdy flakes. When scrofulous pus is long retained it may acquire a disagreeable, nauseous smell, not unlike the pollen of the chestnut; at other times it is excessively fetid. The attendant action is usually very languid. There is a variety of pus to which, owing to its admixture with mucus, the term mucopurulent is applied. It is usually a product of a high degree of inflammation of the various outlets of the body, par- ticulary the nose, eye, bronchial tubes, and genito-urinary apparatus. The mucus which proceeds from these surfaces in the healthy state is composed of a transparent fluid, and of abraded epithelium cells, flat, and irregularly sided, with a central nucleus. In addition to t'hesej the microscope detects numerous granular masses and spherical glo- bules, similar to those of pus; the whole being sus- pended in a viscid, transparent, ductile fluid. These different appearances are well depicted in Fig. 18. Under inflammation, the epithelium cells are cast off so quickly that they have not time to become flattened out, and the globules are not only greatly augmented in number, but they acquire somewhat of the character of those of pus. Mucous pus-giobuies. Certain kinds of pus are contagious. Of this description is the matter of smallpox,'varioloid gonorrhoea, and chancre. In what particular element of the fluid the virus or specific secretion is contained, or whether it exists as an entity is undetermined. The vitality of the organ by which it is elaborated TESTS OF PUS; ITS MODE OF FORMATION. 81 is not necessary for the preservation of its peculiar effects. Once secreted, it becomes independent of its source, and retains, for a con- siderable period, the power of contaminating the parts to which it is applied, producing a disease of the same character. Various chemical agents, however, as the alkalies and acids, have the property of neu- tralizing or destroying it, so that, if inoculation be afterwards attempted, no effects will follow. If the pus of a chancre be examined with the microscope, it will often be found to contain animalcules, particularly the vibrio lineola. Pus is merely an altered state of the blood, the product of a peculiar secretion, not unlike that in kind, though more intense in degree, which is concerned in separating the nutritious elements from the vital fluid. How it is deprived of the coloring matter it is not easy to determine; it is one of those hidden and mysterious circumstances, concerning the efficient cause of which it would be absurd to speculate. Nor is it easy to establish whether the secreted fluid undergoes the peculiar change which gives to it its purulent character, inside or outside of the vessels. Gendrin believes the change to take place in the blood-globules within the vessels; some modern pathologists, however, regard the metamor- phosis as due to alterations of the elements of exuded lymph. Tests.—Various attempts have been made to discover some test by which pus might be distinguished from other secretions, especially from mucus, which it is known to resemble more closely than any other. An ingenious test was proposed by Dr. Young, of England. It is founded on the globular particles of the fluid, and consists in putting a portion between two pieces of plate glass, holding it near the eye, and looking through it at a distant candle. If the matter be purulent, it will be encompassed by a bright halo of colors, not unlike those of the rainbow, the light being at the centre, and the tints so much the more intense as the particles are more numerous and more equably diffused. Gueterbock, who has examined this fluid with great care, finds the only distinction between it and mucus to be, that the pus- globules always sink in water, while the mucus floats. A test more accurate is the agitation of the suspected fluid with liquor potassae. If it be pus, a dense gelatinous mass is formed. Again, the serum of pus is highly albuminous, mucus is not. Finally, mucus treated with acetic acid coagulates into a thin membranous formation; pus does not: treated with ether, mucus yields mere traces of fat, while this principle may be extracted from purulent fluids in considerable quantities. Much has been said about the difference between the mucus-corpuscle and pus-corpuscle. But no such difference exists in reality. Perfectly healthy mucus contains no corpuscles, and it is only when the mucous surfaces have become irritated or inflamed that corpuscles are observed in the viscid fluid. These corpuscles are undeveloped epithelial cells, lymph-corpuscles and pus-corpuscles; in fact, they are the products of the morbid action. The so-termed increased mucous secretions, the result of irritation, are thus, in reality, more or less muco-purulent; an admixture of ropy mucus with the elements of inflamed membranes. The distinctions, therefore, between mucus and pus, formerly so much dwelt upon, have lost most of their practical value. 6 82 HEMORRHAGE. CHAPTER V. HEMORRHAGE. The subject still involved in obscurity.—Causes.—Opinions of Morgagni and Bichat; Exhalant Vessels.—Aptitude of different Structures.—Nomenclature.—Predisposition.—Hereditary Proclivity.—Hemorrhage sometimes vicarious.—Active and passive.—Critical.—Quantity of Blood effused.—Changes and final Disposition. In the pathology of hemorrhage there is much that remains to be elucidated. This is not surprising, when we consider the ignorance which still exists in relation to the capillaries in which this lesion is, for the most part, located. We have no means, except by analogy and induction, of ascertaining the habits, if I may so express myself, of these small tubes whilst engaged in the discharge of their various functions. We are acquainted, however, with certain facts, and these, scanty as they are, must guide us in the discussion of the subject. Although inflammation is not unfrequently attended by a discharge of blood, this is by no means the only condition in which this phe- nomenon is observed. In many instances it would seem to be the result purely of over-distension of the capillaries, from obstruction in the heart or large vessels, by which the sanguine fluid is pre- vented from pursuing its accustomed route with its accustomed freedom. It is not necessary, however, in order to bring about this congestion, that the system should be in a state of plethora; most commonly, indeed, the reverse is the case, the quantity of blood being unusually small. In some diseases, again, such as scurvy and typhus, in which hemorrhagic effusions are by no means infrequent, it is exceedingly probable that the blood itself is morbidly affected, by which it is enabled the more readily to percolate through the relaxed parietes of the minute vessels, carrying with it its different component elements. Formerly the idea prevailed that all sanguineous effusions invari- ably depended upon rupture of the bloodvessels. Nor is this notion, even at the present day, fully eradicated from the minds of some physicians and pathologists. Morgagni seems to have been the first to throw out the hint that hemorrhages might be the result merely of a process of exhalation, without the slightest appreciable lesion of the vessels from which it emanates. This opinion, so well calculated to elucidate this interesting piece of pathology, was afterwards embraced by Bichat, who has fully discussed it in his great work on the tissues. He explains the phenomenon through the instrumentality of a set of open-mouthed vessels, known under the name of the exhalants. Of these he has described not less than three distinct orders, the excre- HOW EFFECTED. 83 mentitious, nutrient, and recrementitious. The existence of such vessels was long ago admitted by Boerhaave and Haller; and, since their time, they have formed a favorite subject of speculation with many highly respectable anatomists. Unfortunately, however, much labor has been wasted which might have been turned to more profitable account; for it is now well known that there are no exhalants, in the true sense of that term; none, at all events, have ever been demon- strated. How, then, if the open-mouthed vessels, so minutely described by Bichat and others, have no existence, are we to explain the exhalation of blood? Are. we to suppose, with Mascagni, that the arteries are everywhere furnished with pores through which the contained fluids merely percolate? That there are apertures in the tunics of the vessels, of some kind or other, is a circumstance concerning which there can no longer be any dispute. It has been satisfactorily proved by experiments, repeated a thousand times, and modified in every possible way, that all animal tissues are permeable to fluids and gases; which could not be the case if they were destitute of pores. What the nature of these openings is, it is not my design to inquire, nor is it material that it should be known. The fact that they exist is sufficient for my purpose. Assuming, therefore, that all vascular canals are porous, the most plausible theory that suggests itself is that all hemorrhages, not de- pendent on rupture, are caused by a sort of endosmose, diapedesis, or transudation, by which the elements of the blood are forced through the coats of the vessels, and made to occupy situations in which they are not naturally found. The process, however, is not a mechanical, but a vital one, and consequently very different from the transudation of the blood which takes place after death from decomposition. How far this process differs from that of ordinary secretion, or what the precise conditions are on which it depends, are circumstances which it is not in our power to explain. Analogically, it may be inferred that the vessels are in a state of morbid activity, whereby fluids are suffered to escape that were appointed to be retained; or it may be supposed, as we have reason to believe is often actually the case, that the capilla- ries, being in a state of debility and relaxation, have their pores rendered unnaturally patulous, and thus allow the blood to have a more ready egress. Nor is it probable that the change, whatever it may be, is confined to the minute vessels. To give rise to the phe^ nomenon in question, the nervous system must be involved, so as to promote, if not excite, the perverted action. The idea of Morgagni and Bichat, that hemorrhage proceeds from exhalation, embraces no error, other than that it ascribes this process to a set of vessels which, so far as is at present known, have no real existence. In all other respects, the term exhalation expresses the same thing as that of exosmose, transudation, oozing, or diapedesis. The theory propounded by Morgagni and Bichat will not appear so difficult, if we take into account the results of some recent experi- ments in relation to the subject of venous absorption. The doctrine that this function is exclusively executed by the lymphatics, has been 84 HEMORRHAGE. completely subverted by the researches of Magendie and other' phy- siologists. If, then, it be admitted, as certainly it must, that the veins absorb or imbibe fluids, it does not require much stretch of the imagi- nation to conceive that the arteries, which so much resemble them in structure, should exhale blood, especially when they are in a state of disease. This process, indeed, takes place, apparently, even within the limits of health, as in the uterus, where it constitutes the menses. Having made these remarks, it may now be stated that, so far as the immediate causes of hemorrhage are concerned, it may result, first, from exhalation: and, secondly, from direct injury of the vessels. In regard to the former of these divisions, enough has been said to render it unnecessary to add anything more in this place; as respects the latter, I shall only observe, that the most frequent source of hemor- rhage is a rupture of the vessels, in consequence of disease of their tunics, or from the violence with which the blood is impelled into them by the action of the heart or by extraneous force. Liability of different Structures.—The structures in which hemorrhage is most frequently observed are the mucous, the cellular, and the serous. Almost every organ and texture of the body, however, is liable to be thus affected. Of the mucous system, some portions are much oftener involved than others. It is asserted by some that all parts of the alimentary tube are equally subject to this effusion, which, however is a mistake. Beyond all doubt hemorrhage is most common in the large bowel; next, in point of frequency, in the stomach ; and, finally, in the inferior third of the ileum. The jejunum and duode- num, together with the oesophagus, mouth, and fauces, are rarely affected. A discharge of blood from the nose and bronchial tubes is not an infrequent event, while it is very unusual in the larynx and the trachea. In regard to the genito-urinary division of the mucous sys- tem, considerable difference obtains in the two sexes. In the male, the urethra and bladder are oftenest involved; in the female, the uterus and vagina. Of the serous membranes the parts most liable to sanguineous effu- sion are the pleura and pericardium. The cutaneous texture is very rarely affected, except in scurvy and typhus fever. With regard to the viscera, the brain and lungs are much oftener the seat of hemor- hage than any other. Indeed, it is doubtful whether some of them, owing to the peculiarity of their structure, are susceptible of this le- sion. Be this as it may, effusions of blood, whether from rupture or otherwise, are exceedingly uncommon in the liver, spleen, kidney, pancreas, uterus, ovary, and testis. In the fibrous, cartilaginous, liga- mentous, and osseous textures, they seldom, if ever occur. Eruptions of blood have received different names, according to the parts in which they occur; but these it is not necessary to Spe- cify. They have sometimes been described under the term apoplexy. This word was originally restricted to hemorrhagic effusions of the brain: at the present period, however, it is employed in a wider sense, being applied to all extravasations of blood, no matter where occurring. Causes.—The predisposition to hemorrhage in different organs varies VICARIOUS. 85 remarkably in the different periods of life. During childhood epis- taxis is most common ; between twenty and thirty-five, there is an ex- traordinary proclivity to hemorrhage of the lungs and rectum; about the age of forty, bleeding of the uterus is most usual; from fifty to sixty, apoplexy and hsematuria are most frequent, especially in men of irregular, dissolute habits. The exciting causes of hemorrhage are extremely numerous, but, as they do not particularly concern the pathological anatomist, they need not be enumerated here. A plethoric state of the system, especially in the young, and a nervo- sanguineous temperament, are circumstances which powerfully pre- dispose to its occurrence. Climate also appears to determine some difference in the eruption of blood in different situations. In cold regions, for example, hemorrhage is most frequently observed in the nose, bronchial tubes, and urinary bladder; in tropical, in the rectum and uterus. It is also supposed to be more common in the female than in the male; but upon this subject we have no positive information. Hereditary.—One of the most remarkable circumstances in the history of this lesion, is its hereditary tendency. The facts which are in our possession, in relation to this subject, are too numerous and well authenticated to admit of the slightest doubt, in the mind even of the most skeptical. Almost every practitioner must have noticed cases of this description. Dr. Krimer, a German physiologist, records a curious instance in which this hereditary proclivity displayed itself in the male descendants of a family in four successive generations; and two similar cases have been reported by Dr. J. N. Hughes, of Kentucky.1 What is more singular than all, is, that the disease may cease in one generation and reappear in another. In a most remarkable case of this mode of transmission, mentioned by Dr. Riecken,2 the parents, who both attained to old age, had never been subject to hemorrhage. The couple had twelve children—five boys and seven girls—of whom three of the former and one of the latter died of the lesion in question. The youngest daughter, who never suffered from the affection, married a stout, healthy man, by whom she had six children—four boys and two girls; two of the former of whom fell victims to hemorrhage. Vicarious.—Not less singular is that variety of hemorrhage to which the term vicarious has been applied. As its name imports, it is sup- plemental of a similar natural or morbid state in a remote organ, and is most frequently observed in young females, in consequence of the tardy appearance of the menstrual flux, or of its suppression after it has been established. In the great majority of cases, it is located in the mucous membrane of the nose, and recurs with considerable regularity every lunar month, until the obstruction, of which it is the result, has subsided. Occasionally the blood oozes from the skin, the eye, ear, lung, anus, umbilicus, and even the nipple, either simultane- ously or successively. What particular changes, if any, the capilla- ries, which are the seat of these vicarious effusions, undergo, is not 1 Transylvania Journal of Medicine, vols. iv. and v. 2 Edinburgh Medical and Surgical Journal, No. 108 ; also, Cyclop. Pract. Med., vol. i. p. 480. 86 HEMORRHAGE. ascertained: we only know that they are the chief agents which are concerned in their production: beyond this all is doubt and uncer- tainty. That they are effected under the immediate influence of the functional operation of the minute vessels, as has been suggested by some, appears not improbable; but this, I apprehend, does not explain the matter, or bring us any nearer to the truth than we were before. Classes. — Hemorrhages are usually divided into two classes, the active and passive; the former occurring in strong, robust persons, the latter in such as are naturally feeble, or who have become so by dis- ease, impoverished diet, or excessive evacuations. This distinction, however, is not of much value in a practical point of view, as it is often extremely difficult to refer the cases that are met with to the one or the other of these forms; nor is it of any importance in reference to the proximate causes of the disease, inasmuch as they are usually the same in both varieties. Again, hemorrhages have been divided into acute and chronic; an arrangement which is, perhaps, on the whole, the less objectionable of the two. Hemorrhages are not always announced by precursory symptoms. In some cases the individual experiences obscure pains in different parts of the body, with a sensation of weight and fulness in the organ from which the effusion is about to occur, and chilliness of the ex- tremities, particularly the feet. The blood, which often escapes with great rapidity, oozing out at innumerable points, is generally of a florid hue, and, although it readily coagulates, seldom separates into serum and crassamentum, as when it is drawn from a vessel at the arm. Sanguineous effusions sometimes occur as a critical discharge, espe- cially in cases of protracted fever. Nature, in such cases, seems to make an effort to get rid of the original disease, by establishing an efflux in some remote part, which, in most instances, is the nose. Nevertheless, as the occurrence is not constant, it can be regarded in the light merely of an accidental circumstance, produced by some disruption in the balance of the circulation. The quantity of blood varies, in different cases, from a few drops to several quarts. Generally speaking, it will be likely to be much greater when it proceeds from the rupture of a vessel than when it is the result of exhalation. In no part of the body is hemorrhage so apt to be profuse as in the mucous system. In the uterus, the bronchial tubes, the stomach, and intestines, an immense quantity of blood is frequently discharged in the course of a few minutes. _ Changes in the Effused Blood.—When blood is effused, one of four circumstances happens in regard to its final disposal. In the first place, it may be entirely rejected, as generally happens when the' hemorrhage occurs in the oesophagus, the stomach, or bowels. In all these situations, as well as in the urinary, genital, and respiratory passages, the blood is voided either in a pure state,' or blended with such substances as may happen to be lodged there at the time. Secondly, the .fluid may be absorbed. This frequently takes place in the subcutaneous cellular tissue, and sometimes, also, in the brain lungs, and other viscera. Thirdly, the blood may remain, and become SOFTENING. 87 organized; or, fourthly, it may act as a foreign substance, and induce fatal inflammation. The above account would be imperfect were we to pass by the changes which are wrought in the color and consistence of the effused blood. When it is poured into the pulmonary organs, it is usually quite fluid, and of a bright florid hue, from the influence of the atmo- sphere. In the stomach, on the contrary, it is generally more or less coagulated, and of a black color, from the action of the acid and gas- eous contents of the organ. In most of the other viscera, properly so termed, it is of a dark complexion, and, for the first day or two, of a fluid consistence. Subsequently, by the action of the neighboring absorbents, the coloring and serous portions of the blood are, in great measure, removed, and the consequence is that it not only becomes lighter but likewise more dense and firm. At a still more remote period, the clot becomes organized, and not unfrequently also encysted. To these important changes, with wrhich every one should be acquainted, we shall revert when treating of cerebral apoplexy, a disease in which they are generally most conspicuous. CHAPTER VI. SOFTENING. One of the most singular effects of inflammation is softening of the affected parts. The term which is here used to designate it is synony- mous with that of mollescence, so much in vogue among the French pathologists. Next to redness, softening may be regarded as decidedly the most unequivocal sign of the existence of phlegmasial irritation. Softening does not occur with equal frequency in all the organs and tissues of the body, yet there is perhaps not a single one that is not sometimes affected with it. The parts in which it is most common, as well as most strongly marked, are the brain, the spinal cord, the mucous membrane of the alimentary tube, the spleen, and liver. It is occasionally seen in the tendons and cartilages, where it forms the principal, if indeed not the only, character of inflammation, both the redness and turgescence being, in most cases, entirely wanting here. The bloodvessels, the serous and fibrous textures, the ligaments, the voluntary and involuntary muscles, and the external teguments are among those parts of the body which are least liable to be affected with this disease, owing, no doubt, to the peculiarity of their nervous and vascular endowments. In the bones, softening is by no means uncommon, and may pervade nearly the entire skeleton. When this is the case, the other organs and textures of the body usually partici- pate in the lesion, although so slightly, perhaps, as to be scarcely observable in making the dissection. 88 SOFTENING. The interesting question here arises—what is the particular anato- mical element in which the lesion now under consideration resides? As might be expected, observations have been made with a view of deciding this point, and the result would seem to be, that, in nearly all cases, the structure most at fault is the interstitial cellular. In the liver, for example, the diminution of cohesion is never so strongly marked in the granulations as in the cellular substance by which they are surrounded. So likewise in the muscles, the fleshy fibres fre- quently retain their healthy consistence long after the connecting tissue is converted into a soft shreddy mass. In the stomach and bowels, also, the mucous membrane is never softened by inflammation without the cellular structure beneath participating in it. These changes are, probably, brought about by a degeneration of the effused lymph and of the tissues themselves. If the softened part be examined with the microscope it will be found to consist of granules, either diffused or amalgamated in masses, and of the debris of the softened organs. The most common cause of softening, as has been already stated, is inflammatory irritation, generally acute, but sometimes of a slow, chronic, character. It may also be the result of causes which exert their influence after death. In making examinations, nothing is more common than to find the posterior parts of the lungs much softer than the anterior, simply, it would appear, from the stagnation of the blood; and, in the stomach, mollescence, it is well known, is frequently produced by the action of the gastric juice. These facts should be borne in mind by the pathologist; otherwise he will be in danger of confound- ing these phenomena with such as are caused by inflammation. There is a species of softening, particularly frequent in the brain and spinal cord, supposed to proceed from ossification, obliteration, or mechanical obstruction of the arteries. That mollescence may be brought about in this way is fully established; at the same time it must be confessed that it is far from being certain, that, when the nutrition of an organ is thus interrupted, the changes which it experiences are not of a character which assimilate it to inflammation. This opinion will not appear implausible when it is recollected that there is always more or less effusion of serosity, of lymph, or even of purulent matter. There can, indeed, strictly speaking, be no such thing as dry softening; and whenever, therefore, the fluids here referred to are found, there is reason to believe that they are poured out as an effect of inflammatory irritation. The degree and consistence of a softened organ cannot be very well defined in a general way, and the consideration of it must, therefore, be postponed until we come to speak of mollescence of individual structures. In its color it may vary from a milky white, as in the brain, to deep red, as in the lung, with every intermediate shade of ash, brown and yellowish. What is singular, the bloodvessels in many cases seem as if they had entirely disappeared, whilst in others they are so weak as to be incapable of withstanding the slightest pressure or receiving the finest injection. GANGRENE. 89 CHAPTER VII. GANGRENE. Gangrene, mortification, or sphacelus, which I shall use as synony- mous terms, may be defined to be the extinction of the vitality of a part of the body, the rest of the organism retaining its life. When this event is about to take place, the affected structure loses its sensi- bility and temperature, the blood ceases to circulate, and all its other functions are suspended. The process by which these changes are accomplished is generally progressive, its rapidity varying with the constitution of the patient, the violence of the exciting causes, and, above all, the nature of the suffering structure. Thus, gaugrene, in some cases, takes place in the course of a few hours, whilst, in others, it does not make its appearance for several weeks or months from the commencement of the inflammation. Much diversity prevails amongst the different organs and tissues in regard to their liability to become affected with this lesion. The cellular, cutaneous, and mucous may be enumerated as the textures which are more frequently seized with mortification than any other; .and it is worthy of remark that these are parts which are extremely well supplied with blood, especially the two latter. Nevertheless, in the skin and cellular substance, this event takes place most frequently in situations which are remote from the central organ of the circula- tion, as on the hands, feet, and posterior portions of the trunk. In the mucous system, the parts most liable to mortification are the gums, the inside of the cheeks, the tonsils, the colon, the inferior third of the ileum, the urinary bladder, and the lining membrane of the vulva. The serous membranes, muscles, ligaments, tendons, aponeu- roses, and cartilages are rarely affected; and the same remark holds good in reference to the arteries, veins, and absorbents. The three latter of these structures, indeed, possess a most astonishing conserv- ative power, and hence it is not uncommon to find them retain their integrity in the midst of the sphacelated part. In malignant scarlet fever, attended with mortification of the tonsils and upper part of the neck, I have seen the common carotid continue in the perform- ance of its function, and the individual recover, notwithstanding the detachment of immense sloughs of the skin and cellular substance; and similar phenomena have often been witnessed in gangrene of the inferior extremities. It seems doubtful from the cases on record whether sphacelus has ever been actually observed in the uterus, kidneys, ovaries, supra- renal capsules, the thyroid body, the testicles, pancreas, and salivary 90 GANGRENE. glands. The occurrence, at any rate, is extremely rare, and further observation is necessary to settle the question. Gangrene of the lungs is by no means so uncommon as was formerly supposed; it is also sometimes observed in the liver and spleen, and, more rarely, in the brain and spinal cord. The nerves are seldom affected; the heart, perhaps, never, although cases have been recorded in which the reverse is said to have been true. The bones are often destroyed by gan- grene, especially those of the inferior extremities, from causes which seem to;be originally seated in their own structure, or in the fibrous membrane which surrounds them. The color of the mortified part varies with the nature of the affect- ed tissue. In the lungs it is frequently greenish, black in the spleen, cineritious in the cellular tissue, livid in the skin, brownish or pale yellow in the mucous membranes, and like the lees of red wine in the brain and spinal cord. This statement, of course, is liable to nume- rous exceptions, to which particular reference will be made in their appropriate places. Ligaments, tendons, and fibrous membranes rarely undergo much change of color, unless there is at the same time an abundant effusion of sero-sanguinolent fluid, in which case they occa- sionally have a reddish, macerated appearance. It need scarcely be remarked that the consistence of a mortified part must depend, in great measure, upon the mode of aggregation of its anatomical elements, and upon the amount of blood by which they are nourished. In gangrene of the lung, which contains a large quantity of cellular substance, pervaded by myriads of the finest capillaries, the affected part is generally very soft—sometimes, in fact, a mere diffluent putrilage—in which it is impossible to discern the slightest trace of the primitive structure of the organ. Nearly simi- lar phenomena are occasionally observed in gangrene of the brain, spleen, and liver. In mortification of the cellular tissue, especially in the carbuncular variety, the loss of cohesion is likewise very consider- able ; so that this substance can be torn and cut with much more facility than in the normal state. The harder solids, as they are de- nominated, on the contrary, undergo very little change of consistence, as is exemplified in tendon, ligament, and bone. Much of this loss of cohesion is owing to chemical decomposition. The period at which this begins is greatly influenced by the structure of the affected part, the quantity of effused fluid, the season of the year, and the nature of the dressings. There are several species of gangrene, where the affected part is perfectly dry, hard, and shrivelled, approaching to the condition of a rotten pear. In other cases the mortified mass is remarkably soft and boggy, exuding, on being divid- ed, a large quantity of thin, turbid, sanious matter. It is on the ab- sence of this fluid, on the one hand, and on its presence, on the other, that is founded the distinction, made by some writers, into dry and humid gangrene. The exhalation which arises during the progress of the decomposition, and which gives to gangrene its characteristic fetor, has not, I believe, been thoroughly investigated by any chemist; probably it is of the nature of hydrogen gas, holding in solution a certain quantity of carbon, sulphur, and phosphorus. CAUSES. 91 Gangrene may affect a single tissue, or appear simultaneously in a considerable number. This latter occurrence is well exemplified in severe inflammation of the lower extremity, Fig. 19. Commencing in the subcutaneous cellular tissue, it gradually extends to the skin, the Fig. 18. Gangrene after compound fracture; still spreading; no line of demarcation. aponeurosis, muscles, periosteum, and bones, which, together with the vessels and nerves, it sometimes converts into one common sphacelated mass, of a dark livid color. In a case of this description, should the patient's constitution be good, the gangrene, after having proceeded a certain distance up the limb, manifests a disposition to stop, or, more properly speaking, the surrounding structures make an effort to resist its further encroachment. This attempt is generally indicated by the appearance of a red line, for which the surgeon always anxiously looks, as it forms a circumvallation around the dead parts, and shows that the morbid action is arrested. The next step which nature takes in the enterprise is to set up ulcerative action, by which the mortified mass, now called a slough, is gradually detached, the structures that give way first being the cutaneous and cellular, then the muscular and fibrous, then the nervous and vascular, and finally, the ligamentous and osseous. The action by which this important change is effected is confined exclusively to the living parts, and the rapidity with which it takes place is influenced by a great variety of causes, which it would be needless here to enumerate. One of the most interesting phenomena, in connection with this sloughing process, is the manner in which nature guards against the occurrence of hemorrhage. Long before death has accomplished its work, the blood in the vessels of the affected limb begins to coagulate, and, by the time the parts are ready to be detached, the inspissated fluid is firmly glued to the inner surface of the tubes by adhesive inflammation. The arteries and veins, however large, are thus, as it were, hermetically sealed, so that, on amputating the limb, particularly when the plug extends high up into the sound parts, there is fre- quently not the slightest hemorrhage. Causes.—The causes of gangrene may be divided into two great classes, into those, namely, which act directly upon the part, and those which exert their deleterious influence through the constitu- tion. Of the former, it is not necessary to say anything here, further than that they are either of a mechanical, chemical, or physical charac- 92 GANGRENE. ter: of the latter, however, as they involve some highly interesting circumstances in relation to the operation of internal poisons, it will be proper to give a more comprehensive account. Among the internal causes of gangrene, are organic diseases of the heart, leading to deficient circulation in remote parts of the body, imperfect supply of the nervous influence, habitual intemperance in eating and drinking, want of nutritious diet, and the inordinate use of spurred rye. That an impoverished state of the blood, with lesion of the in- nervation, is a frequent cause of gangrene, is a fact which is now generally admitted by medical men. In the lower orders of society, mortification from this source sometimes manifests itself in the mucous membrane of the mouth and vulva, in the groin, axilla, and feet. The influence which a diseased state of the blood exercises in the pro- duction of this lesion is well exemplified in scurvy. Persons who labor under this affection are extremely prone to inflammation from the slightest accident, frequently followed by gangrene. The ex- haustion, also, which exists during protracted fevers, is well known not only to favor the development of inflammation, but to give this disease a peculiar tendency to mortification. Malignant pustule, as it is termed, a disease which is not uncom- mon in certain provinces of France and Germany, and which will be noticed more particularly hereafter, seems to be often produced by causes which exert their influence through the medium of the cir- culating fluids. In the experiments of Hamont and Leuret, blood taken from the veins of an affected animal and transfused into those of a sound one, readily induced this singular malady. Even the flesh appears to be strongly impregnated with the septic agent, numerous examples being on record where death was occasioned by using it as food. There is a species of gangrene which is very rare in this country, but sufficiently common in certain districts of France, Switzerland, and Germany, where it sometimes prevails endemically. Many of the inhabitants of these countries, it is well known, use rye almost ex- clusively as an article of food. In very moist seasons, this grain often contains a large quantity of blighted matter, which has received the name of ergot, secale cornutum, or cock-spur, and which, when em- ployed for a considerable length of time, is supposed to give rise to the disease in question. The attention of the profession was first called to this affection by M. Dodard, a French physician, in 1076: it was examined with considerable accuracy by M. Noel, surgeon to the Hotel Dieu, of Orleans, and has since his time been frequently made the subject of investigation; but for the latest and most correct account of it we are indebted to M. Tessier. This species of gangrene is, in every respect, a most singular affection. In the cases described by M. Noel, it always began in the toes, whence it gradually extended along the foot and leg, until, in some instances, it reached the upper part of the thigh, or even the trunk. In the majority of the patients, the gangrene was preceded by redness, pain, and burning heat, which subsided, in the course of four or five days, CAUSES — ERGOT—EMETICS. 93 leaving the parts cold, hard, dry, insensible, and as black as charcoal. * After some time, sloughing commenced, and, if the system was not too much exhausted, nature alone was frequently sufficient to effect the separation of the affected limbs. In one of the cases, both thighs were detached at the ileo-femoral articulation. In a second series of cases, delineated by Gassoud, the disease is described as occurring in the feet, legs, hands and arms. The symp- toms which accompanied it varied in different individuals. In some, there was considerable swelling, with great pain and heat; in others, the tumefaction was combined with redness, and the patient labored under fever and delirium; in others, again, the suffering was entirely local, and was sometimes intermittent, sometimes constant. The sepa- ration of the black mortified mass commonly took place spontaneously, and was often attended with the most excruciating pain. Neither in these, nor in the cases mentioned by Noel, was there any of the fetor which is so generally present in ordinary gangrene. M. Bossau, how- ever, met with some instances of this affection in which the parts exhaled an insupportable stench; but it is worthy of remark that, in most of them, the gangrene was not of the dry kind. The disease, it would seem, attacked, indiscriminately, men, women, and children. For a long time doubts were entertained whether ergot was really the cause of this disease. With a view of settling this point, M. Tessier, an eminent French physician, was requested by the Royal Academy of Medicine of Paris to investigate the matter experimentally. The subjects of his researches were ducks, turkeys, and pigs. With- out going into details, which would be foreign to my design, it may be briefly stated that these animals were rigidly subjected to the use of spurred rye; that most of them died between the tenth and twenty-fourth day; and that distinct marks of sphacelus were per- ceived in different parts of the body, both externally and internally. How, it may now be asked, does ergot operate so as to produce this singular effect? On this point we are still in complete ignorance. The only idea I can form of the influence of this substance is, that it exerts its deleterious impression, in the first instance, upon the blood, and, through it, upon the capillaries, causing inflammation in them, followed by gangrene. This opinion, indeed, seems to be fully borne out by the phenomena which precede this event, not only in the human subject, but likewise in the inferior animals. That the blood and its vessels are alone implicated, is not probable: the nervous system is, no doubt, also seriously involved: all that is contended for is, that these are the parts which receive the primary impression, what- ever that may be. A remarkable case of gangrene of all the extremities, resembling mortification from ergotism, occurred in this city in 1655, in the prac- tice of Dr. Bernard Henry, in a female forty-two years old, the mother of nine children, of intemperate habits, and formerly the subject of syphilis. The disease was preceded by pain and stinging sensations in the hands and feet, which, together with the tip of the nose and the skin over both patellae, became gradually black, cold, dry, and shrivelled, the mortification extending finally beyond the middle of 94 GANGRENE. the arms and legs. There was no ossification of any of the arteries, and the principal lesion seemed to be contraction of the left auriculo- ventricular orifice. This form of gangrene is sometimes seen in the inferior animals. In Chester County, Pennsylvania, it prevailed extensively among the horned cattle in 1819, and, in the following year, in Orange County, New York. In these instances the disease seems to have proceeded from the use of the green grass, the poa viridis, the seeds of which were affected with ergot.1 It is a curious fact that violent vomiting and purging, induced by drastic cathartic medicine, will sometimes give rise to a bad form of inflammation, rapidly followed by gangrene. The parts most liable to suffer in this way are the nose, ears, lips, cheeks, chin, toes, and fingers; those outskirts of the body which do not possess a very active circulation, especially in persons of a feeble constitution, or impaired health. The mortification i s gene- rally preceded by severe pain, and by deep purple discoloration of the af- fected surface. Closely allied to the disease now described is senile gangrene, or mor- tification of the toes and feet, so ably portrayed by Mr. Pott, of England. Occurring most commonly in old persons, it is met with at all periods of life, sometimes even as early as the third year. Both sexes are liable to it, but males suffer more frequently than females, probably because they are more intemperate and exposed to greater hardships. Senile gangrene is generally slow and insidious in its origin, com- mencing sometimes without the slightest pain, uneasiness, or swelling. The lower extremities, especially the feet and legs, are the parts of the body most frequently involved in its progress. The hands and arms may also suffer; but it is rare that the nose, ears, lips, cheeks, and trunk are implicated. When the disease affects the lower limb, it generally makes its appearance first on the inside of one of the smaller toes by a circumscribed bluish spot, which is more or less painful, and is soon followed by a separation of the cuticle, leaving the skin beneath of a dark red color. In some instances the gangrene begins at a number of points at once, and when this is the case it is usually more rapid in its march, as well as accompanied with more urgent symptoms. In its progress, it gradually involves the whole foot, and not unfrequently the leg, and even the thigh, the soft parts of which are converted into a black, bluish, or brownish mass, often extremely offensive to the smell. The sloughing process generally goes on rapidly, and the bones occasionally drop off at the joints. Senile gangrene of the foot. 1 Domestic Encyclopedia, vol. ii. p. 52, and vol. iii. p. 196. ULCERATION. 95 The cause of this variety of gangrene is ossification of the arteries, with inflammation of their lining membrane leading to an effusion of plastic matter, and the formation of coagula, fibrinous concretions, and other extraneous products in their interior. A mechanical obstruc- tion is thus occasioned, which embarrasses, interrupts, or totally sus- pends the circulation of the affected part, and gives rise to the cold, dry, withered, and mummified condition which characterizes the dis- ease. The obstruction, there is reason to believe, usually commences in the capillaries, from which it gradually extends to the larger ves- sels. How the inflammation which precedes and accompanies the obstruction originates, is not determined. The predisposing causes are various; but are referable mainly to organic disease of the heart and great vessels, vitiation of the fluids, particularly the blood, and impairment of the vital powers. CHAPTER VIII. ULCERATION. Definition I intricate Nature—Most common in the Skin, Cellular Tissue, and Mucous Mem- branes.—Maybe slow or rapid.—Manifests a tendency to extend towards the nearest surface. —Produced by Inflammation.—Influenced by an impoverished state of the Blood.—Ulcers sometimes heal; the process by which this is accomplished.—Ulceration a sanative effort. Ulceration may be defined to be the molecular death of a part, or mortification in miniature, attended with the disintegration and gradual removal of the affected parts. It is synonymous with what was anciently called erosion, and with what some modern pathologists denominate ulcerative absorption. Of the intimate nature of this lesion nothing is known with any certainty, beyond the fact that it is essentially connected with inflammation. Although there are few parts which are not susceptible of ulceration, yet that this occurrence is much more frequent in some textures than in others, is a fact of which every one is convinced by daily observa- tion. The cutaneous, mucous, and cellular tissues are much more frequently affected than all the rest put together. This is well ex- emplified in the numerous blotches which so often cover the body, and in the erosions which are so frequently noticed in the bowels, mouth, throat, vagina, and larynx. The heterologous formations, the bones and teeth, with the articular cartilages and their synovial cover- ings, come next in order. The serous membranes, properly so called, the fibrous and muscular structures, rarely suffer from ulceration; and the same is true of the internal viscera, excepting the uterus. Nature seems also to have endowed the vascular system with a remarkable power of resisting this process. Vessels, even of large size, are occa- 96 ULCERATION. sionally completely exposed from the destruction of the surrounding parts, and yet entirely escape the disease. It is remarkable that parts even of the same structure will take on ulceration much more readily in some situations than in others. This is well exemplified in the digestive mucous membrane. Thus, for one erosion in the stomach, we find at least a thousand in the ileum and the colon; and so also, though not in the same ratio, with the skin of the upper as compared with that of the lower extremity. Newly-formed parts are extremely prone to ulceration. A cicatrice is rapidly destroyed by this process, because it is much more feebly organized than structures that have existed longer. The same thing happens in the callus of a fractured bone. Ulceration occasionally proceeds with great rapidity, destroying as much of the body in a few days as nature can repair in as many months. It is sometimes limited to one texture; at other times invades a considerable number. In the bones, although it usually progresses very slowly, it is often remarkably destructive, whole pieces of the skeleton being, in some instances, literally eaten away. In the skin and mucous membranes it may persist for years, without greatly impairing the health of the individual. In the articular cartilages, although it may be equally protracted, it generally induces anchylosis, or death from constitutional irritation. Ulceration always manifests a tendency to extend towards the nearest surface. This is a law which is attended with the most salutary effects; for, if there were no such provision, the individual, the subject of this process, would often fall a victim to its ravages. This tendency is well exemplified in the tibia. Ulceration, commencing in the interior of this bone, generally works its way through the part which is covered merely by the skin and periosteum, nature thus greatly economizing her time, and saving the surrounding structures from much mischief. Another beautiful illustration of this law is afforded by the liver. When an abscess is seated in this organ inflammation is gradually set up in its peritoneal covering, followed by an effusion of lymph, by which the viscus is glued to the stomach, the colon, or duodenum. Ulcerative action now begins, and steadily proceeds until a communication is established between the adherent parts, affording a ready outlet for the purulent fluid. In this manner nature effects, in a few days, what, if the opening were made through the skin and muscles, it 'would require wreeks to accomplish. The great cause of ulceration is inflammation conjoined with pressure. In many instances, however, it follows suppuration and gangrene. Nor is pressure always essential to the process. In many situations, indeed, as in the cutaneous and mucous textures, ulceration occurs without the slightest aid from this source. On the other hand, there are examples in which pressure appears to be the principal agent, as in caries of the bones produced by the presence of a large aneurismal tumor. The same disease disproves the idea, formerly so current, that ulceration can never happea without the formation of pus. Were any further illustration necessary of the fallacy of this opinion, we mio-ht refer to ITS NATURE. 97 the cornea and mucous textures, where this process often occurs unac- companied by the slightest effusion of matter. The question here comes up, what is the nature of this concomitant inflammation ? Is it of that description to which Mr. Hunter has applied the term adhesive ? or does it possess a character altogether peculiar to itself? The latter supposition is certainly the most plausible as well as most in accordance with our knowledge of the subject. Every practitioner is acquainted with the fact that an inflammation, apparently of the same kind and degree, produced by the same cause, and affecting the same tissue, will, at one time, end in ulceration, at another pass off without any such occurrence. This can only be explained on the assumption that the inflammation which precedes and accompanies the ulcerative process is of a specific character, or, in other words, that it is modified by circumstances, either local or constitutional, or both conjoined, which the pathologist cannot appre- ciate. This opinion is the more plausible, as there are some erosions which invariably result from particular causes, and none other. The venereal ulcer has its peculiar features, not less than the tubercular, the herpetic, or the scirrhous. All these are specific affections, induced by specific agents, accompanied by specific inflammation, and followed by specific results. An impoverished state of the blood powerfully predisposes to ulcer- ation, and is probably, of itself, sufficient, in many cases, to produce this result. In extreme anaemia, where there is always great deficiency of fibrin and albumen, sores are very liable to form in various parts, especially in those which are remote from the central organ of the circulation, from the slightest congestion of the capillary vessels, with- out any positive evidence of inflammatory disturbance. A blister applied to the calf of the leg, or even the trunk, will, under such cir- cumstances, often speedily degenerate into a foul, sloughy, or irritable ulcer. In typhoid fever, similar sores frequently occur on the hips and buttocks; and in scurvy nothing is more common than ulceration of the mucous and cutaneous tissues. In both these diseases, the blood undergoes important alterations, which lead to disorder of the nutritive function and lesion of the innervation, followed by local con- gestions in remote and dependent parts of the body, where the circu- lation is naturally weak and languid. In all cases of protracted anaemia the muscles become thin and flabby, the solids are poorly nourished, hemorrhagic and serous effusions occur, wounds heal slowly and imperfectly, and old cicatrices often break out into open sores. This was strikingly exemplified in Lord Anson's voyage to the Pacific Ocean, in which many of his crew suffered severely with the scurvy. It was remarked that those who had had sores before they embarked were attacked with ulceration in the same parts, and that, if their bones had been formerly fractured, they became disunited by the ab- sorption of the callus. Ulceration of the cornea and other textures has been found to ensue in animals fed on sugar, starch, and other non-azotized articles of food, the protracted use of which greatly im- poverishes the blood, and thus brings the system into a condition similar to that which exists in scurvy, chlorosis, and typhoid fever. 7 98 GRANULATION. The ulcerative process is usually accompanied with more or less pain. In many cases, especially in the bones and cartilages, it is of a dull aching or gnawing character, as if insects were feeding on the part. Occasionally, it is entirely absent, or the patient experiences merely a slight degree of uneasiness. In some instances, it is con- tinued ; in others, intermittent; in others, periodical. Along with this symptom, there is often irritative, or hectic fever, with rapid emacia- tion, and great failure of the powers of the system. The inflammation which precedes the ulceration always continues until the process is completely arrested, and the ulcerated structures are either absorbed, or, as is far more usual, ejected. Ulcers often heal. This takes place much more readily in some tissues than in others; but the process by which it is accomplished is the same in all, namely, by granulation. The different steps of this pro- cess, together with various other circumstances connected with ulcera- tion, will be described in detail under the head of the different organs and tissues. Ulceration may be regarded as, in some degree, a salutary process, or as a means employed by nature to rid the animal economy of ex- traneous materials. It has been already seen that collections of puru- lent fluids have a disposition to escape by the nearest and easiest route; and this is uniformly effected by the agency of ulceration. A ball lodged under the skin is removed in the same way; or it travels from one region to another, and is finally cut out at a considerable distance from the place where it was originally situated. It is use- ful also in the expulsion of tubercular matter, in the exfoliation of bones, and in the sloughing of soft parts. In other cases, again, as in old drunkards, the process seems to be designed to relieve the system of hurtful fluids, by establishing extensive sores on the legs, attended with a perpetual flow of irritating matter. Thus we see that ulceration, although apparently a very unpleasant, is in many instances a most fortunate event, and one for which the practitioner often anx- iously looks. CHAPTER IX. GRANULATION. Importance of the Subject.—Nature of Granulations.—Difference in regard to their Vascularity and Sensibility.—How modified by Texture.—Are Secreting and Absorbing organs. Leaving the subject of ulceration, I now come, by an easy transi- tion, to speak of that of granulation. This process, like that of union by the first intention, is one of the grand operations employed by nature for the cure of wounds, and the filling up of ulcers. To the surgeon, a knowledge of this process is of indispensable importance; STRUCTURE. 99 whilst to the inquisitive physiologist it discloses a series of changes, which, in point of interest, are not surpassed by any in the animal frame, whether in a sound or diseased state. A granulation is a small, vascular body, generally somewhat mam- millated in shape, more or less red, sensitive, and capable of secreting pus. It consists, in the first instance, essentially of coagulating lymph; and the process by which it is formed is very similar to that which is concerned in union by the first intention. Let me be understood. An individual receives a wound involving the skin and cellular tissue. The edges, instead of being brought into contact, are allowed to re- main apart. Immediate adhesion being thus prevented, another pro- cess, more complex and tardy, is instituted. The sore now becomes painful, and, in short, exhibits all the ordinary phenomena of inflam- mation. A thin, watery fluid oozes from its surface; and, after some hours—generally from six to twenty-four—it is found to be slightly incrusted with lymph, by which its interstices are filled up, and the whole is made to assume a smooth, uniform appearance. The layer thus formed is of a whitish color, somewhat ropy in its consistence, homogensous, and easily wiped away. If it be allowed to remain, in the course of a short time, varying from one to two days, sooner or later, according to the activity of the sore, the exudation becomes organized, partly by the subjacent old vessels extending into it, or, if we adopt the opinion of some, by the formation of new ones, which inosculate with those of the divided parts, and partly by structural changes which take place in the elements of the exudation. „The sur- face of the sore is now of a red color, readily bleeds if it be touched, and is elevated into a great number of little rounded bodies, closely aggregated together, which are the rudimentary granulations. An- other layer of plastic lymph is next effused, the vessels are still further elongated, and thus incrustation after incrustation is formed and or- ganized, until the cavity is finally filled up. In these layers of plastic lymph organization by cell development may be observed independ- ently of bloodvessels, and fibro-areolar tissue is generally abundantly formed from the cells of the granulation. The changes which the granulation cells undergo is-'best studied in the deeper seated layers, in which the cells are seen elongated and changing into fibres. Not only does each granulation receive one or more arterial and venous branches, but, in all probability, also a small nerve and an ab- sorbent. Such, at least, must be our conclusion when we reflect that this little body not only bleeds when roughly handled, but that it often becomes highly sensitive, and that it readily absorbs such substances as are placed in contact with it. Anatomists have not, however, as yet succeeded in detecting either nerves or absorbents in granulations. Some of the power of absorbing substances may be owing to the blood- vessels of the part, as physiology teaches us that such absorption fre- quently takes place from vascular surfaces. The vascularity of these little bodies is much greater, I am disposed to think, than is usually imagined. That they are liberally supplied with vessels is at once indicated by their florid complexion, by the astonishing rapidity of their growth, by the facility with which they 100 GRANULATION. bleed when touched, and by the fact that they become hard and tumid if filled with injecting matter. The arteries, the precise number of which is not known, having entered the base of each elevation, soon separate into arborescent branches, which freely anastomose with each other, as well as with those in the granulations immediately around. Accompanying these arteries are corresponding veins, which carry away the blood which is not required for the nourishment of the part, the effusion of lymph, and the secretion of pus, with which the abraded surface is usually covered. Both classes of vessels are generally vari- cose, and much convoluted, as in Fig. 20, from Mr. Liston: a, repre- senting the free surface of the injected granulations; b, the attached surface. Fig. 20. Structure of a granulation. Granulations are often very sensitive. This, however, is not the case everywhere, or under all circumstances. In the cutaneous and cellular tissues, the granulations are, all other things being equal, incomparably more sensitive than in the tendons, aponeuroses, and ligaments. The same thing is true with respect to the granulations of the bones, except when they spring from the cancellated structure, in which case they are frequently so tender that it is impossible to touch them without inducing severe pain. These little bodies are also more sensitive when there is much inflammation, and in persons of an irritable and worn-out constitution than in such as are healthy and ro- bust. In some instances, especially in old ulcers of the leg, they are more than triple the ordinary size, extremely pale, cold, apparently infiltrated with serosity, and so completely insensible that they may be cut without the least pain. Granulations are absorbing as well as secreting bodies. These pro- perties, however, are not equally well marked in all the tissues. A great difference, for instance, exists in this respect between the granu- lations which arise from the skin and those which arise from the bones the former absorbing and secreting with great rapidity, while the lat- ter perform these offices very slowly and imperfectly. ' A knowledge of this fact is of no little value in the practice of surgery as it enables us, on the one hand, to avoid stimulating dressings, and, 'on the other CICATRIZATION. 101 the application of such substances as have a tendency, when absorbed into the system, to give rise to dangerous results. Not a few cases are on record where arsenic, corrosive sublimate, and other articles of the materia medica, placed in contact with a granulating sore, have destroyed life. The extract of belladonna, used in this way, will pro- duce temporary amaurosis, mercury will salivate, and opium, it is well known, will occasion sleep nearly as soon as when introduced into the stomach. Thus, granulations are a very interesting and important set of tex- tures, extremely complex in their structure, and performing the triple office of pouring out lymph, secreting pus, and absorbing such sub- stances, to a greater or less extent, as are brought in contact with them. The facility with which they are developed is much greater in some tissues than in others, depending on the degree of laxity and vascu- larity of the part from which they spring. The concomitant inflam- mation appears also to be of a mixed character, as it is attended with the simultaneous effusion of lymph and purulent matter; and it is im- portant that the phlogistic action should not transcend certain bounds, otherwise the process will be interrupted, retarded, or wholly sus- pended. The skin and cellular substance appear, of all the tissues, to be most susceptible of granulation. Mucous membranes, aponeuroses, ligaments, tendons, cartilages, and bones, together with the internal viscera, excepting, perhaps, the brain, rarely heal in this manner, and then only after a long time. CHAPTER X. CICATRIZATION. IT^ture of the Process.—Different Steps.—Do Ulcers never heal from the Centre?—Process of Cicatrization influenced by the Form and Situation of the Sore.—Meaning of the term Cica- trice.—Reproduction of the original Tissues.—Transformations of Cicatrices. The subject next in order is cicatrization. The remarks which I shall offer respecting it must necessarily be brief, as a great deal of what might be said will more appropriately fall under the head of the different organs and tissues. Cicatrization is the process which nature employs to heal wounds and ulcers. It is the finishing stroke, if the expression be allowable, of granulation, the labor necessary to polish the surface of the sore, to contract its diameter, and to bring it as nearly as possible to a level with the surrounding structures. This process, although it is not limited to the skin, as might be inferred from reading some modern treatises on surgery, is yet most advantageously studied there, as it 102 CICATRIZATION. enables us, as it were, to follow nature in the different steps of her enterprise. The first step in the healing of an ulcer is the subsidence of the inflammation, which becomes gradually less and less, until the sur- rounding parts regain their natural color, form, and consistence. The sore at the same time sensibly diminishes in diameter, by the contraction and coalescence of its granulations ; and its surface, instead of being rough and uneven, assumes a smooth, glassy appearance, its centre, however, being still considerably depressed ; or, if the granula- tions have been very exuberant, unnaturally elevated. Cicatrization is now observed to begin; the first indication of it being a thin, deli- cate, bluish pellicle, placed along the margin of the breach, where it soon unites with the old skin by an interchange of tissue, of vessels, and nerves. If the part be inspected at a later period, the substance that was thus deposited and organized, will be found to have increased in thickness and density, and to be gradually extending itself towards the centre of the ulcer by the addition of new matter. It is in this manner, by this successive experipheral action, that the denuded sur- face is eventually covered over. But do ulcers and wounds never heal from the centre ? This is a topic concerning which pathologists have expressed different senti- ments, some maintaining the affirmative, others the negative side of the question. From an inspection of numerous cases, I am convinced that the process of cicatrization takes place only in the way in which I have here described it. To this remark there is only a single exception. In extensive wounds, especially of the lacerated kind, it often happens that portions of the original skin remain, forming so many little patches in the midst of the abraded surface. In such cases, the cicatrization goes on simultaneously around these parts and along the principal edges of the solution of continuity. There is, however, no new law in operation here, since the old skin is the starting-point of the new in both instances. The process of cicatrization is much influenced by the form and situation of the sore. Circular-shaped breaches of continuity heal much slower, cozteris paribus, than such as are longitudinal, for the obvious reason that it takes the new skin a much longer time to reach the centre in the former than in the latter. A sore in the leg cicatrizes with more difficulty than one on the trunk; and a callous ulcer than a soft one. When the cure is completed, a cicatrice is left, or, as it is called in familiar language, a scar. This is always much smaller than the original sore, and still further diminishes by the contraction of the new skin. When the breach of continuity has been of great extent, as when it has been produced by a burn, this contraction is often a source of great mis- chief and deformity. At first, the cicatrice is ex- tremely vascular, soft, and of a bluish color; after- wards the vessels decrease in size and number, and the part becomes dense, bloodless, and whiter than the original skin. This is well seen in persons who have had confluent smallpox, and in those who have CICATRIZATION. 103 been covered with venereal blotches. The vessels of the cicatrice are curiously interlaced, and anastomose freely with each other, so as to form a very fine and delicate network, as in Fig. 21. Are the original textures, in the formation of cicatrices, always regenerated? and, if so, in what respect, if any, do they differ from them ? Cartilages and muscles are said to be the only parts not sus- ceptible of reproduction. But even this is extremely doubtful; at any rate I am certain that I have seen muscles, which were almost entirely torn asunder, unite through the medium of fleshy matter. Some time since, I had under my charge a healthy lad, eleven years old, who had a large piece of the great pectoral and broad dorsal muscles torn away by a steam-engine, in which the breach of conti- nuity was repaired by a substance perfectly identical with the original. The granulations were unusually florid, highly sensitive, and grew with astonishing rapidity. In old subjects, it is probable that the junction is effected by tendon. The cartilages of the ribs generally unite by osseous matter, as certain pieces of the skeleton, such as the patella, the olecranon process, and the neck of the femur do by car- tilaginous. In most instances, however, the reproduction is imperfect. This is the case even with the skin. The cutis is never so strong or so capable of resisting the effects of disease as in the normal state; it is not pro- vided with sebaceous follicles, the mucous network is but imperfectly regenerated, and the epidermis drops constantly off in thin, dry, furfu- raceous scales. No hairs are to be seen on the scar; for, as their roots have been destroyed, they cannot, of course, be reproduced. The same imperfect development is observed in the cicatrization of the mucous and some other tissues. Cicatrices, like other analogous tissues, may undergo various changes. Of these the most frequent and important are, inflamma- tion, inordinate contraction, hypertrophy, and malignant degeneration. All newly-formed parts are liable to inflammation, the effects of which they are much less capable of resisting than the primitive tissues, owing to the fact of their possessing a much lower grade of vitality. Hence, even when the morbid action is not very high, it may readily lead to softening, gangrene, or ulceration. In protracted anasmia, and in nearly all other diseases attended with an impoverished condition of the blood, cicatrices of the skin are extremely prone to suffer; their vessels become congested, their surface is discolored, and their tissues are invaded by ulceration or gangrene. Inordinate contraction (Fig. 22) is most common in cicatrices pro- duced by burns. These injuries are often followed by the most un- sightly deformity, owing to the atrophy of the newly-formed tissues, and the property which they possess of diminishing their diameter. In this manner the chin may be drawn down upon the sternum, the hand bent upon the wrist, the arm pinioned to the side, and the leg flexed upon the thigh. Even the bones may be curved, and forced from their natural position, so great is this contractile power. A cicatrice may become hypertrophied, or grow into hard knobs or ridges. The best form of this occurs in burns, in consequence of 104 INDURATION. some defect in the modelling process. The ridges have a rough, un- even surface, and a dense, fibrous structure; they creak under the knife, and the section ex- Fig. 22. hibits a white, gristly ap- pearance. The cuticle is thick and dry, and scarcely any cellular tissue exists in it in a free state. Old scars, whether pro- duced by a burn, cut, or laceration, or whether the skin alone is injured, or other structures along with it, become occasionally the seat of malignant growths. The disease usually ap- pears in the form of a little excrescence, which is dry and covered with cuti- cle, but which soon be- comes moist, and partially ulcerated, secreting a thin, fetid, semi-purulent fluid. The excrescence is gradu- ally converted into a more solid tumor, which may acquire the volume of a pullet's egg, and display all the characteristics of scirrhus, encephaloid, or epithelial cancer. Ultimately ulceration sets in, fungous granulations spring up, and the patient dies from the irritation and discharge. The disease rarely returns if thoroughly extirpated. Burn of the neck. Deformity caused by contraction of the cicatrice. CHAPTER XI INDURATION, Definition.—Color, Size, AVeight, and Degree.—Period necessary for its production.—Causes. By this term is designated that peculiar pathological condition of an organ which is characterized by an increase of its consistence, whether arising from the deposition of a new product, from a deficiency of the natural secretion, or simply from the transformation of its ele- mentary tissues. This definition does not, of course, include the induration produced by the heterologous formations, such as tubercle, encephaloid, and scirrhus, with the latter of which the present disease is unfortunately too often confounded. INDURATION. 105 Induration is an extremely common lesion, and may occur in any tissue of the body, but is most frequently seen in the spleen, liver, lymphatic ganglions, and subcutaneous cellular substance; next to which, the lungs, heart, brain, ovaries, breasts, and prostate gland are the most common seats of it. No age, sex, or condition of life is exempt from it; and it has been witnessed even as an intra-uterine affection, or within a few days after birth. Like many other diseases induration may exist alone, or in association with other alterations; it may affect a part of an organ, its whole substance, or only one of its anatomical elements. The color of the affected part usually partakes, to a greater or less extent, of the natural complexion of the organ. The most ordinary tints are red and gray, with numerous intermediate shades of white, yellow, brown, and black. As a general rule it may be stated, that the intensity of the color is in proportion to the vascularity of the affected part, and the violence of the exciting cause. Thus, in acute pneumonitis, the induration—hepatization—is almost always charac- terized by deep redness, often verging on purple, whilst, in the chronic form of the disease, it is commonly of a dirty pale color, grayish, or dappled. When the induration occurs in structures that are naturally light, as in the subserous, submucous, and subcutaneous cellular tissue, there is always more or less concomitant opacity. The size of a part in a state of induration may be natural, augmented, or diminished. An increase of bulk is by far the most frequent, and is sometimes very considerable in induration of the liver, spleen, and lymphatic ganglions. A diminution of size is by no means unusual, but cannot be regarded as a necessary consequence of the disease; the same remarks are applicable to the weight of the affected organ, which is much more frequently above than below the normal standard. There are other physical changes attendant on this patho- logical condition, which need only be alluded to in this place, such as diminished humidity, altered sonorousness, and loss of elasticity. These changes are strikingly exemplified in inflammation of the pul- monary tissue, which becomes dry, hard, increpitous, sinks in water, and emits a dull sound on percussion of the chest. The degree of induration is liable to considerable variety, depending upon a number of contingent circumstances. Parts that are naturally soft and flaccid are often, when thus affected, rendered quite dense, firm and unyielding. Of this the lung affords a remarkable illustra- tion. In the sound state this viscus is soft, spongy, and elastic, but, when in a state of induration, it is sometimes almost incompressible, and cuts like old cheese, occasioning a peculiar grating sound under the knife. Considered in a general point of view, induration may be said to present three degrees, which it is of some importance to distinguish. In the first, the part still retains its moisture, and feels only a little unnaturally dense; in the second, it is already firm, dryish, and con- siderably altered in color; in the third, its consistence is so much increased as to resemble the white of a hard-boiled egg, old cheese, or 106 INDURATION. fibro-cartilage, every trace of its original softness, juiciness, and pliancy being gone. As to the time requisite for the production of these several degrees of induration, no definite rule can be established, as it is influenced by a variety of circumstances, the consideration of which must be deferred until we come to speak of the special pathology of this affection. In the great majority of instances, however, the process is remarkably slow; weeks, months, and even years elapsing before it reaches its full development. In other cases, on the contrary, it forms with great rapidity, a few days being sufficient for the alteration of a tissue from its normal consistence to that of a firm, dense mass. Thus, if we consider the disease in reference to the period necessary for its development, it may be said at one time to be chronic, at another acute, the former being much the more frequent. The causes of this pathological state are referable, for the most part, to inflammation, followed by an effusion of coagulating lymph into the interstitial substance of the affected organ. In the lungs there is frequently, in addition to this, more or less blood poured out, which, combining with the natural structures, gives them a red color. It is thus that red hepatization is established. In chronic cases, on the other hand, the induration is commonly effected by the lymph alone; and hence it is that the organ is usually of a much lighter hue. In the hardening of the subcutaneous cellular tissue of infants, a disease of pretty frequent occurrence in certain districts of Europe, the effused matter is generally impregnated with two coloring principles, the one of an orange red, the other of a bluish shade. From the foregoing considerations, it is certain that one variety, at least, of induration is dependent upon inflammatory irritation. In a second series of cases, the lesion, if such it may be called, appears to arise from a deficiency merely of the natural secretion. To this cate- gory belongs the induration of the various organs and tissues observ- able in old people. As we advance in life, the whole body experiences an astonishing change in its consistence; many of the vessels are ob- literated, the juices are dried up, the solids are rendered hard and rigid, and, as a natural consequence, the movements are difficult and imperfect. An increase of consistence from this cause is generally most considerable in the cellular tissue, the mamma?, ovaries, prostate gland, the muscles of voluntary life, and the bones, the latter of which sometimes acquire a degree of hardness equal to that of ivory. The proximate cause of this condition is probably a diminution of the vascularity of the affected part, attended with a deficiency of the nor- mal secretion, and perhaps, also, a partial absorption of its more tender anatomical constituents. The part thus becomes hard, dry, and, where the circumstances are favorable, shrivelled and corrugated. In a third series of cases the induration is traceable to a real trans- formation; that is, some of the effused material becomes organized into dense tissue, whilst, on the other hand, some of the anatomical elements of the affected part may disappear, leaving nothing but the original framework. Examples of this description are occasionally seen in the liver, spleen, and lungs, around hydatids, serous cysts, CAUSES. 107 tubercles, and other tumors. The irritation caused by the presence of these adventitious growths produces a partial absorption of the natural structures, leaving those which remain in a dense and indu- rated state. Similar effects are sometimes brought about by pro- tracted compression, whether occasioned by bands of false membrane, or by large accumulations of fluid. Of this a striking illustration is furnished by the lung. In chronic pleuritis, attended with copious effusion, this organ is often reduced to the size of a small cake, by the approximation simply of its solid textures, which are thus rendered unnaturally dense and hard. If the compression is not kept up too long, these textures may be made, in time, to resume their natural bulk, form, and consistence; and so the respiratory function be gra- dually restored. This variety of induration is almost constantly asso- ciated with atrophy. Such are the several forms of induration which are noticed in the different organs and tissues of the body, and the causes under the in- fluence of which they are produced. Let us next proceed to inquire, whether parts thus affected can regain their natural consistence, and, if so, under what circumstances ? The former of these queries can be easily answered; the latter properly belongs to therapeutics, and need not, therefore, be particu- larly discussed on the present occasion. That induration is suscept- ible of being cured, daily observation abundantly testifies. This re- mark is especially true in relation to the chronic form of the lesion ; in the acute it is not so common, the disease usually reaching a fatal height before the system can properly react; yet even here recovery is far from being infrequent. As the induration of which I am now speaking is caused by the deposition of a new product, it is obvious that whatever has a tendency to remove this, must be instrumental in bringing about the restoration of the affected part. It is with a view of accomplishing this object that the practitioner resorts to the exhi- bition of iodine and other kindred articles, when the disease is located in some internal organ; or that he uses friction and other stimulating means, if it be seated externally. In either case he is desirous of pro- ducing the same effect, namely, the absorption of the effused substance, the incorporation of which with the natural textures gives rise to the lesion under notice. The time required for effecting this object cannot be specified, as it must be influenced by a great variety of circum- stances which it would be out of place here to consider. In acute cases, the induration frequently subsides in the course of a few weeks, even when it involves a very large extent of surface and a multipli- city of tissues; in chronic, on the contrary, the process is usually very tardy, months elapsing before it is completed. In the meantime, the function of the part is imperfectly executed, and the longer the case is protracted the greater will be the danger that the organ will never recover its original consistence. Under such circumstances the affected textures frequently undergo the fibro-cartilaginous, cartilaginous, and osseous transformations; and, it is even thought by some, that they are apt to degenerate into malignant disease. This, however, is doubtful; at all events, I have never seen a case in confirmation of it. 108 HYPERTROPHY. CHAPTER XII. HYPERTROPHY. Meaning of the term.—Liability of different Structures.—Causes.—May be general or local.— Color, Weight, and Volume of the Part affected. The word hypertrophy was originally restricted to those preter- natural enlargements which are so frequently found in the heart and thyroid gland. As understood at the present day, however, it has a much more extensive application, being employed to designate an im- portant class of lesions, the essential character of which consists in an abnormal development of the weight and volume of the various organs of the body without, in many instances, any accompanying alteration of their organization and structure. With the exception of the serous membranes, the ligaments, and ten- dons, there is not a single organ which is not occasionally found in a state of hypertrophy. Nevertheless, there are some structures in which it occurs more frequently than in others, and amongst these may be particularly specified the heart, adipose tissue, spleen, thyroid gland, lymphatic ganglions, breast, bones, and bloodvessels. Hypertrophy is seldom seen in the brain, spinal cord, and nerves. It rarely com- mences in people below middle age, and from forty to fifty may be mentioned as its favorite time of invasion; but it is often observed in persons much younger than this, as in those who are not more than five, ten, or fifteen. Indeed, it would seem occasionally, as is the case of the thymus gland, to come on soon after birth, if not before. As to the causes which are concerned in the production of hyper- trophy, some are of a general, others of a local character. Of the former, very little can be said to be known with any degree of cer- tainty, as the affection in question sometimes occurs in spite of the most abstemious course of living. In polysarcy, the body has been known to attain the enormous weight of upwards of seven hundred pounds, without the individual being at all remarkable as a large eater. In such cases,—which depend chiefly upon an inordinate de- velopment of fatty matter,—there would seem to be a peculiar diathe- sis, almost everything that the person consumes being converted into adipose substance. Of general hypertrophy a most extraordinary example is recorded in the first volume of a French periodical, entitled The Hebdomadary Journal of Medicine. The individual was a girl, twenty-nine years of age; during the last eleven of which she had suppression of the menses, embarrassed respiration, numbness of the limbs, and frequent attacks CAUSES. 109 of headache, with progressive development of the cutaneous, adipose, cellular, and muscular tissues. At the period here specified, the face was enormously enlarged, the tongue almost filled the mouth, the neck was extremely thick, and the breast reached nearly to the chin. The circumference of the trunk was five feet two inches, just equal to the height of the body, and the extremities, both upper and lower, were of prodigious size. This extraordinary bulk was not caused by the excessive accumulation of the subcutaneous fat alone, as all the external muscles appeared prominent and well-defined. The heart was hypertrophied in the same proportion, and struck with unusual vio- lence against the side of the chest. The brain likewise participated in the abnormal growth, and the girl finally became idiotic. In this case the symptoms above referred to are obviously insufficient to account for the origin of the excess of nutrition, and we must therefore sup- pose that the individual labored under some constitutional peculiarity. Local hypertrophy may occupy an entire organ, or, as more fre- quently happens, be confined to particular sections of it; it may exist alone, or in connection with other lesions. The local causes which manifest their effects in the production of hypertrophy are, first, chronic inflammation; secondly, mechanical obstruction; thirdly, inordinate exercise. Each of these topics we shall endeavor briefly to illustrate. That chronic irritation may produce hypertrophy is a fact of'which every pathologist must have witnessed frequent examples. Who has not seen the lymphatic ganglions of the groin preternaturally enlarged from irritation of the head of the penis, of the mesentery from ulcera- tion of the ileum, and of the bronchiae from disease of the lungs ? En- largement of the liver and spleen, sometimes to a very great extent, arises undoubtedly from this cause. In chronic dysentery, not only the mucous and submucous cellular textures become hypertrophied, but the affection often extends to the muscular tunic, which occasion-* ally attains an extraordinary degree of development. The follicles and villosities, which are hardly perceptible to the naked eye in the healthy state, are also rendered extremely prominent, the former being some- times of the size of a mustard-seed, the latter more than a line in length. A similar development is frequently observed in the coats of the urin- ary bladder, in consequence of chronic inflammation. Hypertrophy may be caused, secondly, by some mechanical impedi- ment interfering with the due performance of the functions of an or- gan. This is frequently seen in the heart, where, in consequence of disease of the valves, preventing the easy passage of the blood, the viscus is obliged to undergo increased action, and so becomes more or less enlarged. In the muscular fibres of the stomach, the same change is often witnessed from obstruction at the pylorus, and in those of the urinary bladder, from stricture of the urethra, or hypertrophy of the prostate gland. Hypertrophy may, in the third place, occur solely from the increased action of an organ in the discharge of its normal functions. Of this variety examples are found in the muscular system of animal life, in the lungs, and in the kidneys. In every part of the frame, the muscles 110 HYPERTROPHY. are proportionate, in size and structure, to the efforts required from them; and it is a law of nature that, whenever they are frequently called into action, their fibres become considerably augmented in thick- ness, and capable, consequently, of much greater exertion. _ Thus the blacksmith, who constantly uses his arms in striking with his hammer, has much larger and stronger muscles than the dancing-master, who merely employs his legs. The same is true with regard to the lungs and kidneys. When one of these organs is imperfectly developed, compressed by effused fluid or some morbid growth, or, as in the case of the latter, entirely absent, the other is sure to become preternatu- rally expanded, thereby compensating for the deficiency. There are some viscera which are subject to temporary hypertrophy. Of this description are the uterus and mammary gland. During pregnancy and lactation these organs increase very much in bulk, but again dimi- nish soon after parturition and weaning. The color of a hypertrophied organ is subject to considerable diver- sity. Most generally, perhaps, it is somewhat heightened, especially when the affection is wholly physiological. Occasionally it is very much diminished; and cases are often observed where it is apparently quite natural. The consistence may likewise be normal, diminished, or increased. These three conditions do not, however, occur with equal frequency. An increase of density is by far the most common, and is particularly conspicuous in hypertrophy of the heart, mammary gland, the muscular fibres of the stomach and colon, the lymphatic ganglions, cellular tissue, bones, liver, spleen, and kidneys. A dimi- nution of consistence is extremely rare, and cannot be viewed as a necessary consequence of the lesion. An increase of weight of the affected organ follows, as a necessary consequence, in all cases where the lesion is not conjoined with atrophy. An augmentation of volume is by no means constant. Thus, in hyper- • trophy of the heart and bladder, there may be great development of the muscular fibres, with marked diminution of the size of their cavi- ties. A change of form always arises when the hypertrophy is par- tially circumscribed, or limited to a particular point, as in the bones, skin, heart, bronchial tubes, and bloodvessels. Hypertrophy essentially consists in an augmentation of the nutritive function. AVhen in a state of unusual activity, the quantity of blood which an organ receives is considerably increased, in consequence of which it assumes a deeper color than one that is less exercised, at the same time that it augments somewhat in density. The elementary particles are increased in number, or such as already exist are aug- mented in size; it is in this manner that the change under consider- ation is brought about. In that variety of it which results from chronic irritation, it is not unlikely that there is often superadded to the alter- ation just mentioned a deposit of new substance in the spaces of the connecting cellular tissue, leading thus to a real change of structure. The effects of hypertrophy on surrounding parts will be pointed out when we come to speak of this lesion as it occurs in different tissues of the body. ATROPHY. Ill CHAPTER XIII. ATROPHY. Definition.—May be General or Partial.—.Causes : want of Exercise; Diminution of the Nerv- ous Influence ; Deficient supply of Blood ; Inflammation. Directly the reverse of the lesion now described is atrophy, an affection of frequent occurrence, and of great practical interest. Like hypertrophy, with which it often coexists, it may pervade the entire organism, or be limited to a single viscus, or even to one of its ele- mentary constituents; and as the one essentially consists in an increase of the nutritive function, with a corresponding augmentation of bulk, so the other must be regarded as depending on imperfect exercise of the same function, with a corresponding diminution of the affected part. General atrophy, commonly called marasmus, emaciation, or con- sumption, frequently arises from organic disease of the lungs, heart, and stomach, and from morbid enlargement of the mesenteric ganglions, preventing the passage of the chyle from the intestinal tube into the thoracic duct. Occasionally, however, this lesion of the nutritive function exists in a very high degree without any ostensible cause. Who does not recollect the extraordinary individual who was ex- hibited in this country, some years ago, under the sobriquet of the "living skeleton?" Calvin Edson, for such was his name, weighed only fifty-eight pounds. He was forty-two years old, five feet two inches high, and formerly weighed one hundred and thirty-five pounds. During the last sixteen years of his life he had been gradually wasting, without any apparent disease, his appetite and health being as good as usual. In another instance of extreme atrophy of the general system, in a young Frenchman named Seurat, who was shown in London, not long ago, the lesion seems to have been connected with imperfect alimentation, as the individual did not, on an average in the twenty-four hours, take more than three or four ounces of food, with a little wine. All animals have a period of growth, maturation, and decay. In the human subject, the body, after having reached the age of forty, begins to exhibit traces of decline, which from this time on become gradually more and more conspicuous, until the machine is literally worn out, and man " goeth to his long home." Examined at this period, the whole mass of the brain is generally found diminished in size, the nerves have lost their moisture, and the ganglia connected with them are condensed, and considerably shrunk in volume. The respiratory system experiences similar changes: the lungs are dryish, 112 ATROPHY. inelastic, and increpitous, their volume is sensibly lessened, the walls of the air-cells are attenuated, and whole lobules are sometimes deprived of their vesicular structure. The muscles of voluntary life are pale, flabby, and diminished in bulk; the arteries, veins, and absorbents shrink in their diameter, and a large proportion of the more minute ones, becoming useless, are obliterated, and lost; the lymphatic gan- glions are hard, small, and many of them entirely disappear; the bones are spongy, brittle, and extremely prone to fracture; the ligaments are unusually slender; the articular cartilages are dry, and attenuated; and the salivary glands, together with the liver, pancreas, spleen, and kidneys, are indurated, and considerably reduced in size. In the male sex, after the functions of the testicles have ceased, absorption frequently commences in these bodies, which shrink, become soft, pulpy, and are sometimes not larger than a French bean. The cells of the penis are augmented, and their fibrous parietes very much attenuated, in some instances even partially absorbed. In the female, the ovaries are pale, shrivelled, and frequently transformed into a condensed grayish substance; the mammae are soft and flabby, with scarcely a trace of their original structure; and the uterus is hard, firm, and diminished in volume. Along with the changes of texture here described, are to be observed certain alterations in the various fluids. The digestive function being less vigorously executed than in youth and manhood, there is a less perfect elaboration of the chyle, followed by a deteriorated state of the blood which is prepared from it. Nor does the difficulty end here. On reaching the lungs, the vital fluid, in consequence of the deranged state of the pulmonary tissues, is but partially acted on by the atmo- sphere, and is thus rendered unfit for the proper nourishment and stimulation of the various organs and textures of the body. The jelly, which exists in such great abundance in young persons, totally disappears in decrepitude, its place being usurped by albumen and fibrin. The various secretions are likewise modified, and everything indicates that the blood has undergone important changes, both in its physical, chemical, and vital properties. Such is a rapid sketch of senile atrophy, a state which strongly illustrates the effects of the wear and tear of the animal machine. Local atrophy may affect an entire organ, a portion of an organ, or one or more of its anatomical elements, exist as the only lesion, or be associated with other diseases. The causes which give rise to this affection are, first, cessation of the function of an organ; secondly, diminution of the nervous influence; thirdly, deficient supply of blood; and fourthly, inflammatory irritation. It appears to be a law of the animal economy, that when an organ is of no further use, it gradually falls into a state of decay. Of this class of structures are the umbilical vesicle and the pupillary mem- brane of the foetus, the former of which, after having subserved the purpose of its formation, disappears at the close of the third month, the latter between the seventh and eighth. The kidneys are preceded in the embryo by two jelly-like parts, to which the term Wolffian bodies has been applied, as they were first pointed out by Dr. Wolff, CAUSES. 113 a German anatomist. These bodies, which exist not only in the mammalia, but likewise in birds and amphibia, acquire their greatest bulk about the middle of utero-gestation, after Avhich they gradually diminish by absorption, and at length entirely disappear. The guber- naculum, which is visible in the tenth week of embryotic life, is a thin membranous process, which guides the testicle to the internal ring, and is finally converted into cellular substance. These are in- stances of atrophy from the cessation of the functions of an organ in the foetus. After birth changes not less remarkable are to be observed; such, for example, as the wasting of the thyroid body, the supra- renal capsules, and the thymus gland. From the same cause the alveolar processes of the jaws disappear after the removal of the teeth. In the female, the ovaries shrink after the decline of the menses; and, in conformity with the same law, the testicles often diminish remarka- bly in size in monks, who lead a life of celibacy, in the strict observance of their vows. Atrophy may result, secondly, from a diminution of nervous in- fluence, a circumstance not surprising when it is recollected how much the action of the capillaries is under the control of the cerebro- spinal axis. Whole limbs sometimes waste from this cause; in other cases, the lesion is more limited, and implies a very partial disorder of the nerves. It has been observed that, when atrophy is caused by disease of the brain, it occurs much more slowly than when it is occasioned by an affection of the nerves of the part. The reason of this difference is not very obvious. The most remarkable examples of atrophy of the extremities are those which result from pressure on the axillary and sciatic plexuses. A few years ago I had under my care a young man who had received a dislocation of the humerus fifteen months before, which was per- mitted to remain unreduced. The head of the bone rested on the brachial nerves, and, although the limb retained a considerable degree of motion, the muscles were exceedingly soft and wasted in comparison with those of the other arm. Professor Lobstein,1 of Strasburg, men- tions a somewhat similar case, which he observed in a man fifty-four years of age. When a child, he was thrown down in the street, and, soon after, the right limb became very feeble, soft, and reduced in size. On dissection, all the muscles were found extremely pale, and as thin as membranes; the gastrocnemius and soleus weighed less.than three ounces, whilst those of the sound limb weighed nearly eight, the tendo-achillis of the former being only two lines in thickness, of the latter, five. The right hip-bone was considerably reduced in size and thickness, and the corresponding femur weighed only three ounces, two drachms and a half, whilst that of the opposite side weighed nearly double. The nerves themselves, as well as the bloodvessels of the diseased extremity, did not seem to be perceptibly altered. Another cause of local atrophy is a deficient supply of sanguineous fluid. When any part is deprived of its usual quantity of blood, it very soon becomes enfeebled, its substance is rendered pale and flabby, 1 Traite d'Anatomie Pathologique, t. i. p. 90. 8 114 FISTULES. and it at last loses the power of action, although every other condition for its performance may remain unimpaired. Thus the testicle wastes after tying the spermatic artery; and, for the same reason, the muscles of the lower extremity frequently shrink after securing the principal vascular trunk of the thigh. Atrophy of the heart is sometimes pro- duced by ossification of the coronary vessels, and a case is recorded in which the spleen, from the obstructed condition of its artery, was not larger than a filbert. In old age, as was before intimated, many of the capillaries are obliterated; and it is not improbable that to this circumstance is owing that diminution of the size of our organs, which constitutes senile atrophy. To the same cause is to be attributed the wasting of the lung and heart, from the accumulation of fluids in the pleuritic and pericardiac cavities. Finally, a fourth cause of atrophy is inflammation. The irritation excited by the presence of biliary concretions in the gall-bladder is sometimes followed by complete wasting of that organ. Hepatitis often gives rise to atrophy of the parenchymatous structure of the liver, and orchitis, especially when supervening on mumps, is not un- frequently succeeded by impotence. How the lesion is produced, in these cases, it is not easy to determine. It is probable that the chief fault is in the arterial capillaries, which cease to perform their accus- tomed functions, and thus allow the absorbents to carry off more than the usual amount of organic matter. CHAPTER XIV. FISTULES. Definition.—Distinction into Complete and Partial.—Most common Situation.—Nomenclature. —Length and Diameter.—External and Internal Orifices.—Direction.—Lined by Adventi- tious Organized Membrane.—Nature of the Discharge.—State of the adjoining Tissues.— Causes. A fistule is a narrow track, straight or tortuous, of variable depth, having generally two distinct orifices, lined by an adventitious mem- brane, and bathed with a thin, gleety fluid, intermixed with the natural contents of the part, organ, canal, or cavity affected. The disease, which is always of a consecutive nature, occurs in different regions of the body, and is developed under the influence of various causes. Although the abnormal track has usually two openings, one of which is superficial, and the other deep-seated, yet this is by no means constantly the case. Hence the distinction of fistules into complete and partial. The terms recent and old, used by some writers refer merely to the duration of the disease. The lesion may occur in almost any situation, but originates most ORIFICES. 115 frequently in the anus, the perineum, the face, groin, and mammary gland. Fistule of the neck, thoracic cavity, the biliary apparatus, the stomach, colon, and small bowel, kidney, pancreas, and urinary blad- ders comparatively rare. It takes place in both sexes, and at every period of life; but children and young persons suffer much less fre- quently than the old and middle-aged. The nomenclature of fistule is quite extensive, and probably more intricate than that of any other lesion. The names are derived either from the parts in which the abnormal passage is situated, as anal, peri- neal, broncho-pleural, and recto-vaginal; or from the nature of the discharge, as salivary, urinary, and sterooraceous. Fistules vary much in their extent. The longest tracks are those which occur along the spinal column, in connection with psoas abscess. In this affection the matter, which is of a scrofulous character, generally points in the groin, just above Poupart's ligament, in the upper part of the thigh, or, lastly, in the ileolumbar region, where it ultimately escapes by ulcerative absorption. The channel which is thus estab- lished varies in length from six to twelve inches, and is always lined by a well organized adventitious membrane, which continues to secrete, for a long time, the same kind of fluid as that which was discharged in the first instance. Tracks of considerable length are sometimes met with in the internal organs, as between the kidney and lung, between one coil of intestine and another, or between the urinary bladder and the cutaneous surface. In other situations, on the con- trary, the passage is remarkably superficial, being hardly two or three lines from the surface, or from the cavity with which it communicates. In their diameter these anormal tracks are not less variable than in their length. Sometimes they are so small as scarcely to admit the finest bristle; while at other times they are sufficiently capacious to receive a goose-quill, or even the end of the finger. The narrowest tracks usually occur in the lachrymal passages, the salivary glands, the anus, and the perineum. It is not often that the fistule is of the same uniform diameter throughout; on the contrary, it is almost always larger at one point than at another. The external orifice, generally of a rounded or oval shape, may be so narrow, on the one hand, as to be hardly perceptible, or, on the other, so large as to admit the end of a probe, a goose-quill, or a finger. It may have sharp and well defined margins, or be surrounded by a soft, spongy, florid rim; or, lastly, it may be depressed or infun- dibuliform. The number of external orifices varies in different cases. In general, there is only one, or, at most, two or three; but occasion- ally, though rarely, there are as many as six or a dozen. When the number is very considerable the affected surface commonly presents a cribriform appearance. The internal orifice may be of the same size as the external, or it may be smaller or larger. In its shape it is usually irregularly rounded, and it is seldom that it is found multiple, even when the number of external openings is considerable. In its direction the passage may be perfectly straight; but in a great majority of cases it is more or less flexuous, serpentine, oblique, or 116 FISTULES. winding. Occasionally it forms nearly a right angle with the surface on which it opens. When several tracks exist they often run together, and open by one common orifice upon the reservoir with which they communicate. Nature.—A. fistule, in its recent state, is nothing more than a raw surface, studded with granulations, and secreting purulent matter. It is, in fact, an ulcer, an open sore, a solution of continuity, which must un- dergo a process of reparation before it can be justly entitled to its dis- tinctive appellation. The track, however, soon becomes smooth, and is speedily coated with an adventitious membrane, varying in thickness from a mere film to half a lme, a line, or even the sixth of an inch. This new layer, at first soft and easily detached, gradually augments in density, and is at length inseparably united to the parts which it serves to line. Its color, like its consistence, is influenced very much by its age, and by the nature of the secretion or excretion which passes over it. At an early period it is red, pink, or rose; but in cases of long standing it is either white, gray, or slightly bluish. The free surface of the membrane is smooth and polished ; or it is rough, mammillated, or studded with villi of various shapes and sizes. The other surface is attached by means of short cellular substance to the parts upon which it lies. Bands of lymph sometimes extend from one side of the abnormal channel to the other, as in the bridle stricture of the urethra; but this is rare. The membrane above described is formed from the plastic lymph of the blood, and is of the same nature as the pyogenic membrane of a chronic abscess. Around the anus, in the perineum, and in some other regions, it bears no little resemblance to the mucous tissue, but differs from it in having no follicles and no distinct epithelial layer. It is liberally supplied with vessels, nerves, and, probably, with absorb- ents, is the seat of a constant secretion of gleety or other matter, and is liable, like all new textures, to inflammation and its consequences. In ancient cases it occasionally acquires a dense, fibrous, or even fibro- cartilaginous consistence. The nature of the discharge in this disease varies with the situation of the abnormal passage. In general, it is thin and gleety, as in chronic gonorrhoea, and mingled with the natural secretions, or excretions of the reservoir with which the fistule communicates. AVhen the lining membrane, however, labors under inflammatory irritation, the dis- charge is either entirely suspended, or it is bloody, purulent, or muco- purulent. The parts in which the abnormal track is situated are variously affected. In some cases they are nearly natural; but in general they are firm and callous, from the effusion and organization of plastic lymph, which, being often present in large quantity, completely obliter- ates the meshes of the connecting cellular tissue. Finally, the causes which give rise to fistules are either mechanical or vital. To the first class belong wounds, contusions, and lacerations; to the second, ulceration, gangrene, and the formation of abscesses. There is a variety of fistule which may be regarded as a remnant of embryotic organization. Its most frequent situation is the antero- DIFFERENT KINDS- CELLULAR. 117 lateral part of the neck. Like the ordinary fistule, it may terminate in a cul-de-sac, or it may have two orifices, of which the external is sometimes scarcely visible. The abnormal passage itself is usually very narrow, and seldom extends beyond two or three lines in depth. CHAPTER XV. TRANSFORMATIONS. The Body in a state of constant Mutation.—Number of Transformations: the Cellular, Mucous, Cutaneous, Fibrous, Cartilaginous, Osseous and Adipose. If we trace the human body through the various stages of its existence, it will be found that it is incessantly undergoing changes, by which the nutrition of its elementary constituents is modified, until they are at length converted into totally different structures. During infancy and adolescence, entire organs, now no longer of any use in the economy, change their characters, and are either completely absorbed, or revert to their primitive condition. Thus the thymus gland, which at birth is so large as to cover the whole of the anterior surface of the pericardium, and which consists of a considerable number of distinct lobes, gradually shrinks into cellular tissue, and finally, about the age of thirty, entirely disappears. The term transformation is employed to designate those changes which a pre-existing tissue undergoes, as it is being converted into another that is totally different from it, but which has its analogue in the animal economy. Viewed in this light, the number of transformations is really very small, and may be stated as follows: 1. The cellular. 2. The mucous. 3. The cutaneous. 4. The fibrous. 5. The cartilaginous. 6. The osseous. 7. The adipose. To each of these transformations it will be necessary to devote separate consideration; premising that they occur most frequently in old age, and that they are all effected under the influence of inflammatory irritation. How far the latter proposition is true, will appear by and by. 1. The cellular transformation, on the whole, is much less frequent than some of the others. The best illustrations of it are to be found in the peritoneum, the adventitious membranes, the gall-bladder, and the ligaments. The gubernaculum also affords a good example of it. This band, which is intrusted with the office of conducting the testicle from the lumbar region to the scrotum, is of a fibrous nature, which it retains until it has effected the purpose of its creation, when it gra- dually shrinks into cellular substance. During its descent, the organ in question likewise drags along with it a portion of peritoneum. This process forms an elongated cul-de-sac, somewhat like the finger 118 TRANSFORMATIONS. of a glove, which occupies the inguinal canal, lying in front of the spermatic cord, to which, and to the testicle, it closely adheres. When the descent is completed, the canal is by degrees closed up, and the portion of peritoneum alluded to degenerates into cellular tissue, whilst that over the testicle remains still a serous cavity. The ligaments, especially the capsular, are sometimes converted into cellular substance. The metamorphosis is most marked in young per- sons affected with unreduced luxations of the hip and shoulder-joints. In such cases it is not rare to find the ligaments of a dull white color, deprived of their fibrous arrangement, and transformed into lax cellu- lar structures. The same thing is occasionally observed in the ex- tremity of an obliterated artery, and in the coats of the gall-bladder, when it is obliged to suspend its functions from some permanent ob- struction of its excretory duct. The adventitious serous membranes, particularly the band-like, are often transformed into cellular tissue, more frequently in the pleuritic and pericardiac cavities than in any other situations. 2. Considering the close connection between the mucous and cuta- neous tissues, their similarity of organization and of function, it is not surprising that the one should be convertible into the other. With regard to the former, which serves to line the various outlets of the body, it has only to be exposed to the atmosphere and to repeated fric- tion, and, sooner or later, it will be transformed into skin, or, at least, into a substance so nearly resembling it, that it would be difficult to point out any difference between them. The process by which this is accom- plished is gradual, and requires some time for its completion. The first thing that is noticed in the exposed membrane is a change of color, which progressively diminishes in intensity, until at length it approaches that of the external cutaneous surface. Whilst this blanch- ing is going forward, the part loses its accustomed sensibility, aug- ments in thickness and density, and becomes covered with a horny lamella, corresponding with the epidermis. Its absorbing powers are also much lessened, and, instead of mucus, it pours out a thin, watery fluid, analogous to the cutaneous perspiration. This transformation, however, is at best imperfect; and it remains to be shown whether it really consists of the same number of layers as the natural skin. 3. The cutaneous texture is the only one, it appears to me, which is, strictly speaking, susceptible of the mucous transformation. In order to bring this about, the process above described should be, as it were, reversed; that is, the skin should be inverted, and excluded from the influence of the atmosphere. Soon after this is done, the epidermis is observed to drop off, and the true skin assumes a deep, florid aspect, becomes extremely sensitive as well as somewhat rouo-h, and deposits a thin, ropy, whitish fluid, in all respects similar to mucus'. Analogous phenomena are often witnessed in corpulent persons, espe- cially in infants, who suffer from chafes in the neck, groin, and' arm- pit, from neglect of cleanliness. -f. Cases occasionally occur in which an opportunity is afforded for observing what is termed the fibrous transformation. The tissues most liable to be thus affected are the cellular, serous, and vascular, together OSSEOUS. 119 with the muscular and pseudo-membranous. In whatever situation it occurs, it is in the cellular element that it probably always begins, from which it gradually extends to and involves other textures, its progress being slow or rapid, according to the nature of the affected part, and the intensity of the exciting cause. In some instances this transformation would seem to be of a phy- siological kind, taking place in parts that have ceased to perform their functions. Of this description are the vessels which are concerned in carrying on the foetal circulation. These vessels, during intra-uterine life, are of the same structure precisely as the rest of the vascular system, of which they form so many appendages; but no sooner is the child detached from its mother than they are rendered useless, and ■instead of continuing hollow, which could answer no good purpose, they are gradually closed, and converted into dense, fibrous cords, in which it is impossible to recognize the slightest trace of the original structure. The process which is thus at work is of an inflammatory character, and serves the double purpose of obliterating these super- annuated vessels, and metamorphosing their tunics. 5. Next to the osseous, there is no transformation of such frequent occurrence as the cartilaginous. This usually appears in the form of thin plates or nodules, which possess many of the properties, both physical and vital, of the tissue from which they obtain their name. Of all the textures, the subserous cellular seems to be the one that is most subject to this species of transformation. It is also frequent in the fibrous envelops of the spleen, especially in the inferior animals, in the placenta, the gall-bladder, the parietes of accidental cysts, in adventitious membranes, and in the walls of abscesses and of tuber- culous excavations. It is rare in the submucous cellular tissue. The new substance cuts precisely like a piece of costal cartilage, and passes by insensible gradations into the circumjacent cellular tissue, which is generally unnaturally thick and indurated. Recent researches have shown that it is generally in reality devoid of all the elements of cartilage. It mostly consists of very dense fibrous tissue, and might, therefore, not inappropriately be classed with the fibrous trans- formations. 6. The most common transformation, by far, is the osseous. Al- though it has been described as occurring in all the tissues, even the nervous and muscular, it is now well ascertained that it is confined ex- clusively to the cellular, fibrous, fibro-cartilaginous, and cartilaginous, the frequency with which it takes place being in the order here enu- merated. The new substance, which often bears but a very faint re- semblance to natural bone, makes its appearance under three principal varieties of form, the lamellated, tuberoid, and spicular. Of these the first is the most common. It is usually met with in the subserous cellular tissue of the chest, abdomen, cerebro-spinal canal, and testicle, where it occasionally forms patches of considerable size, of a pale yellowish color, and from the third of a line to the twelfth of an inch in thickness. It is also seen in the walls of accidental serous cysts, in the interior of fibrous tumors, in the thyroid gland, and in the coats of the arteries. When the patches are numerous, they sometimes 120 TRANSFORMATIONS. coalesce, and thus form a sort of osseous membrane. In this manner I have often seen the largest arteries converted into hard, rigid tubes; and I have a specimen of diseased thyroid gland, which is reduced to a perfect bony shell, the interior being occupied by a soft, cretaceous substance. The second variety, the tuberoid, is most common in the brain, the parenchymatous organs, and in the interior of serous cavities, whether natural or accidental. The number of concretions, although sometimes considerable, is generally small, not exceeding ten or fifteen. In the lungs, however, as many as five or six hundred have been found in a single subject. Varying in size between a clover-seed and a walnut, they are usually about the volume of a cherry-stone, of an irregularly spherical shape, more or less brittle, and of a pale straw color: in some instances, they are perfectly smooth, and of a pearly opaline lustre. Whether occurring alone or in groups, they are either inclosed by distinct cysts, or they lie in immediate contact with the tissues or cavities in which they are formed. Instead of occurring in plates or granules, the accidental substance occasionally appears in the form of little spicules, resembling so many stalactites. Varying in length from a few lines to an inch or more, they are rarely thicker than a crow-quill, and are most commonly met with in the subserous cellular tissue of the brain and spinal cord, in the periosteum, and in the cellular tissue between the muscles. This variety, on the whole, is much less frequent than either of the other two. With respect to its consistence, the osseous tissue, if it be really entitled to this appellation, is subject to much variety. In the great falx of the dura mater, I have frequently found it as dense and solid as the petrous portion of the temporal bone; in most other situations, however, it is much softer, and often remarkably brittle. Chemically examined, it is found, like the natural osseous tissue, to be composed of the phosphate and carbonate of lime, in combination with animal matter. The relative proportions of these constituents are extremely variable, and it not unfrequently happens that one of them is totally absent. In fact, in the majority of cases, this so termed osseous trans- formation does not present the usual uniform characters of true bone. It is rather a calcareous degeneration, or a deposit of chalky particles, with an absence of the natural elements of bone. This is especially observed in the ossification of arteries, and in that of the valves of the left side of the heart; it is also seen in the parietes of serous cysts. At other times the character of the ossified parts, even in the struc- tures mentioned, is that of imperfect bone. A transformation pre- senting the well-marked minute features of osseous tissue is seen in the dura mater and arachnoid membrane, and, in advancing age, in the cartilages of the ribs and joints. In fibrous tumors, sheaths, and cellular tissue bone is generally not very perfectly formed. When ossification takes place in the above structures, it will be found to present a series of successive stages, corresponding to those observed in the ossification of parts of the foetal skeleton. The first change which this substance experiences is a diminution of its natural ADIPOSE. 121 transparency, accompanied with a slight degree of thickening of the part, and a deposition of turbid, cream-like matter, which is diffused through its areolar texture. As the morbid process advances, the part becomes more and more opaque, is rendered flexible and elastic, assumes a grayish color, and grates under the scalpel. It is now distinctly fibro- cartilaginous; it is next converted into cartilage, and finally into bone, the particles of osseous matter being deposited at different points, which gradually augment in diameter, and at length, running into each other, thus completely change the primitive character of the part. The period required for the perfection of each of these changes can- not be determined. Such, in a few words, is the process which nature ordinarily employs to accomplish this transformation; I say ordinarily, for there are cases, as every one knows, in which the process is much less compli- cated, and in which the osseous matter is deposited without any ante- cedent alteration in the structure of the part. Accidental ossification is frequently witnessed in old age. There are very few persons, beyond the fiftieth year, in whom the arteries, together with the costal and laryngeal cartilages, are not thus affected. In other cases, it is directly chargeable to inflammation, sometimes of an acute, but mostly of a chronic nature. The ossification of the pleura in pulmonary phthisis, of the vaginal tunic in old hydroceles, and of the arachnoid in chronic hydrocephalus, is justly referable to this cause and to no other. So also with regard to the ossification of the periosteum during the formation of callus, of the walls of old abscesses, and the linings of tubercular excavations of the lungs. 7. The most remarkable transformation, perhaps, of all, is the adi- pose, in which, by the aid of the microscope, the tissues are seen to undergo a real fatty degeneration. In the majority of cases, indeed, it is a true replacement of tissue by oil. By some the alteration is sup- posed to consist essentially in the superaddition of fatty matter to the existing tissues, whilst others consider it as the result of a true trans- formation, the same in principle as the fibrous, cartilaginous, or osseous. Whatever doubts may still exist upon the subject, it seems to me that both views are, to a certain extent, correct. At all events, my own observations have fully convinced me that there are cases in which the fatty matter is literally infiltrated into the interstices of the different organs, imparting to them a greasy color and consistence. On the other hand, I am equally certain that a transformation, properly so called, of this kind takes place in different structures, especially in the liver, kidneys, pancreas, heart, and muscles, parts in which it is most frequently witnessed. An organ that is thus affected is generally of a pale straw-color, is diminished rather than increased in consistence, is easily torn, receives the impression of the finger, greases the scalpel which is used in cutting it, is of lighter specific gravity than in the natural state, and contains from one-third to one-half its own weight of yellow concrete oil. Such being the changes which ordinarily attend this transformation, the question next presents itself, how are they brought about ? In the liver of the inferior animals, as will be shown in another place, this degeneration can often be produced at will, 122 PNEUMATOSIS. simply by subjecting them to rest in a dark apartment, and cramming their stomachs with rich, stimulating food, which, by creating obstruc- tion in the portal circle, in all probability induces inflammation in the hepatic tissues. In the human subject it is occasionally connected with general hypertrophy of the adipose tissue, and instances are observed in which it appears to depend upon the want of exercise of the affected part. The latter opinion is entitled to consideration chiefly from what occurs in the muscles of the inferior extremities of old persons who have long labored under paralysis. In such cases, the muscles often assume a pale color, are remarkably soft and flaccid, and exude a clear, oily fluid on pressure, their fibres, however, re- maining perfectly distinct. But are these effects really attributable to the repose in which these parts, under the circumstances referred to, are placed ? Would it not be more philosophical^ in the absence of more satisfactory evidence, to conclude that something was due to the want of nervous influence, and to the altered state of the circulation thence arising ? Be this as it may, I feel disposed to think that the transformation in question is uniformly the result of a low and imper- ceptible grade of inflammatory irritation. The subject, however, re- quires further investigation. CHAPTER XVI. PNEUMATOSIS, OR COLLECTIONS OF AERIFORM FLUIDS. Definition.—Frequency.—Names by which it is known.—Form and Extent.— Physical and Chemical Properties.—Causes.—Effects on neighboring Organs.—Most frequent in the Fe- male.—Duration.—May be expelled or absorbed. The term pneumatosis is employed to designate a class of affections which consist in the introduction, development, accumulation, or ex- halation of air, gas, wind, or aeriform fluids in the various organs, tissues and cavities of the body. Collections of this kind were noticed by different observers at a very early period of the profession, and are much more common than is generally supposed. They occur in various parts of the body, exhibit much variety as to degree and extent, give rise to very serious and sometimes even fatal effects, and are frequently so obscure in their character as to be mistaken for other affections. Various epithets, derived for the most part from the anatomical name of the affected organ, tissue, or cavity, have long been employed to designate these gasiform collections. Thus, when the disease is seated in the chest, it is denominated pneumo-thorax; in the abdomen, tym- panitis; in the uterus, physometra; in the heart-bag, pneumo-peri- EXTENT, PROPERTIES, AND CAUSES. 123 cardium; in the scrotum and vaginal tunic,penumatocele; in the general cellular tissue, emphysema. The form in which the effused air or gas*appears is liable to con- siderable diversity, dependent chiefly upon the nature of the part affected. In the cellular substance it presents itself in the shape of a tumor, not prominent and circumscribed, but more or less diffused, soft, elastic, and emitting a peculiar crepitating or crackling sound on pressure. In the lung, where it constitutes one variety of emphy- sema, it occurs in narrow, bluish bands, or patches, from a line to half an inch or even an inch in breadth. When the aeriform fluid escapes into the cellular structure between the pleura and the lung it forms movable vesicles, blebs or bubbles, of a whitish, pearly appearance, and about the size of a currant or small bead. Similar phenomena take place in the vessels of the pia mater, in the cellular tissue between the pia mater and the arachnoid, and in the submucous cellular sub- stance of the intestinal tube. In the first of these situations the air usually forms a congeries of transparent vesicles, which are rendered beautifully distinct by their contrast with the blood which not unfre- quently separates them partially from each other. In the serous membranes the fluid is either extensively diffused, or it is confined by bands of plastic lymph to particular portions of these sacs, forming, so to speak, circumscribed windy bags. In its extent the accumulation may vary from a few globules to many cubic inches. In the splanchnic cavities, particularly that of the abdo- men, it may be so great as to lead to very serious distension of the walls by which they are inclosed, or of the organs which are contained in them. The bowels are sometimes puffed out many times beyond their natural dimensions; their muscular fibres are paralyzed; the function of defecation is suspended; and life is destroyed by the effects of the compression of the diaphragm and adjoining viscera. In the subcutaneous cellular tissue the quantity of effused fluid is sometimes very great, extending over an entire limb, one side of the trunk, or even the entire body. In the lung, submucous cellular tis- sue, and bloodvessels, the development is generally very small, some- times hardly perceptible. Considerable quantities of gas are occasion- ally collected in the uterus, in the cellular substance of a mortified limb, and in the interior of a sphacelated hernia. The physical and chemical properties of the aeriform fluid are influ- enced by a number of circumstances, of which the most important are, the period during which it is retained in the system, the absence or presence of disease in the part affected, and the nature of the concomi- tant effusion, whether this be serous, purulent, or bloody, alone, or in a state of combination. In the lungs and subcutaneous cellular tissue, where the extravasation is most commonly the result of some injury, the fluid is generally inodorous, perfectly transparent, and in all re- spects similar to the atmosphere from which it is originally derived. In the pleura and pericardium, in the uterus, in certain abscesses, and, above all, in the intestinal canal, it is often remarkably fetid, and charged with various kinds of gases—oxygen, hydrogen, nitrogen, and carbonic acid—the relative proportions of which vary much in differ- 124 PNEUMATOSIS. ent cases and in different circumstances. When the hydrogen predomi- nates the fluid may be so thoroughly impregnated with it as to be in- flammable ; while, on the other hand, if there be a great redundancy of carbonic acid, it may be incapable of sustaining combustion, and readily extinguish a lighted taper. In the alimentary tube the fluid frequently contains a considerable quantity of sulphuretted hydrogen, and the same substance occasionally exists, though more sparingly, in the gaseous accumulations of the uterus, pleura, pericardium, and peri- toneum. The air which is developed in scrofulous abscesses is some- times remarkably fetid, probably from the same cause. Considered in relation to the causes by which they are produced, and the morbid condition of the parts in which they are developed, aeriform accumulations may arise in a variety of ways, and under very different circumstances. Hence the several kinds of pneumatosis may with great propriety be arranged under the following heads: 1. Pneu- matosis from the presence of a wound, laceration, or perforation; 2. Pneumatosis from the operation of chemical agents; 3. Pneumatosis from exhalation, or the influence of a true vital process. 1. Pneumatosis from external injury is most frequently noticed in the subcutaneous cellular tissue, where it sometimes occupies a great extent of surface, and forms, as was previously intimated, a soft, elastic swelling, emitting a peculiar crackling sound on pressure. The air, in consequence of the permeable nature of the structure in which it is lodged, may be readily pushed from one place to another, and often travels with great rapidity to points very remote from the one origin- ally affected. Whether it experiences any changes in its chemical or physical properties in its passage, or during its sojourn, our informa- tion does not enable us to determine. Another form of this variety of pneumatosis occurs in the pulmonary tissue, usually from the rupture of the air-cells, and the consequent diffusion of the atmo- sphere through the connecting cellular substance. The appearance which the extravasated fluid presents here has been already pointed out. The air may remain in its original situation, or it may escape into the mediastinal cavity, and thence spread over the cellular tissue of the neck, head, and upper extremities. To the same class of affec- tions belong the collections of aeriform fluids in the pleuritic cavity, from the ulceration of a bronchial tube. On this occurrence, which is by no means unfrequent, the air rushes into the cavity in question, where, if there be no adhesions of the contiguous serous surfaces, or considerable accumulation of serum, pus, or lymph, it may lead to se- vere compression of the pulmonary tissues, and so cause great embar- rassment in the respiratory function. In perforation of the intestinal tube, whether occasioned by a wound or by ulcerative absorption, large quantities of air sometimes find their way into the peritoneal cavity, producing more or less distension of the abdomen, and a hollow, drum- like sound on percussion. Finally, the air may be introduced directly from without through the natural inlets of the body, as the intestinal tube, the vagina, and the uterus. A considerable quantity of air constantly finds its way into the stomach along with our alimentary substances, and it is well CAUSES. 125 known that many individuals possess the faculty of swallowing this fluid at pleasure. In the vagina, air may be drawn up into this tube while in a relaxed state, and afterwards explode with a considerable noise. The air may be retained for some time, or it may pass off soon after it has collected; it may be confined to the vagina, or it may as- cend into the uterus, especially if the orifice and neck of that organ are unobstructed. Well-marked and even large accumulations of air are occasionally met with in the urinary bladder, probably from the direct introduction of the fluid through the urethra, though it may be difficult, especially in the male, to explain the manner in which this is effected. 2. The second class of causes, capable of producing pneumatosis, are of a chemical nature. Of this, the best examples are afforded by the uterus and vagina, in consequence of the retention of some extraneous substance, either solid, semi-solid, or liquid, as a piece of placenta, a portion of the foetal membranes, a blighted ovum, a clot of blood, a mass of lymph or mucus, or the menstrual fluid. Whenever any sub- stance of this kind is prevented from passing off, from the want of expulsive power of the womb, or the existence of some mechanical obstacle at the mouth or neck of that organ, it must necessarily un- dergo putrefactive decomposition, and thus give rise to the extrication of gas or air, usually more or less fetid in its character, and sometimes even inflammable. The quantity of gas evolved may be very con- siderable, or so trifling as to be scarcely perceptible; and the process upon which its elimination depends may continue in operation for several weeks, months, and even years. Very considerable accumulations of gas sometimes take place from the partial decomposition of sero-purulent fluids. This phenomenon is most frequently noticed in the thoracic cavity, as a complication of chronic pleuritis; but may also occur in the pericardium, peritoneum, and even in the vaginal tunic of the testicle. To the same class of affections may be referred the aeriform fluids met with in scrofulous abscesses and in the sero-purulent collections of the larger joints, particularly that of the knee. Another good example of this class of causes is afforded by what occurs in mortification. No sooner is a part, in a high state of in- flammation, deprived of its vitality than it yields to the influence of the physical agents by which it is surrounded. Decomposition is speedily set up, and gas, usually of a highly offensive character, con- tinues to be evolved until nature succeeds in casting off the slough. This variety of pneumatosis is frequently observed in sphacelated hernia, and sometimes, though more rarely, in mortification of the pleura and peritoneum. The aeriform fluids which are developed in the stomach and bowels are generally produced under the influence of chemical decomposition. The food of man is extremely various in its nature, consisting as it does of a vast number of articles, both vegetable and animal; and hence it is not surprising that the gas which is extricated during digestion and the sojourn of the refuse matter in the intestinal tube, should often deviate in a remarkable manner from the normal standard. 126 PNEUMATOSIS. Van Helmont long ago ascertained that the air contained in the large bowel is not unfrequently inflammable, while that in the stomach and small bowel rarely, if ever, possesses this property. The experiments of Jurine, Magendie, and Chevreul, show that the gas of the alimentary canal, in a state of health, is composed of azote, oxygen, hydrogen, and carbonic acid, the latter of which generally exists in greatest abundance in the colon and rectum, where there is also frequently a small amount of sulphuretted hydrogen. What changes, if any, this fluid experiences when there is derangement of the digestive function, has not been determined. We only know that, under these circum- stances, it is often evolved in immense quantities, and with a rapidity truly astonishing. 3. It has been contended, thirdly, that the extrication of air, gas, or aeriform fluid, is occasionally the result of vital causes, or, in other words, of a process of secretion not unlike that of serosity, lymph, or pus. It is undeniable that pneumatosis often takes place in situations, and under circumstances, which altogether preclude the idea of its being derived in any other manner. The occasional existence of pneumo-thorax, of emphysema of the subcutaneous cellular substance, of pneumo-pericardium, of physometra, and of pneumatosis of the peritoneal cavity, has been attested by numerous pathologists. John Hunter, in his observations on digestion, long ago asserted, as an incontrovertible fact, that " air is either formed from the blood, or let loose by some action of the vessels, both naturally, and from disease;" and he has adduced the generation of wind within the cavity of the uterus as an evidence of the power possessed by the living organs of separating gaseous fluids from the blood. Since the time of this illustrious physiologist, numerous observations and experiments have been published, strongly corroborative, if not, in fact, conclusive, of this view of the subject. Krimer states that, having exposed the aorta of an animal whose circulation had been previously rendered exceedingly languid by the free use of digitalis, he included a portion of it, entirely emptied of its contents, between two ligatures, and on opening it some time afterwards found it full of air. Similar results may be produced by tying a loop of intestine. Gendrin1 ascertained that, if inflammation of the villous coat of the bowel be excited by the application of diluted ammonia, boiling water, or alcohol, and the part isolated by ligatures, the inclosed portion will be found, on the subsequent day, in two cases out of five, to be distended by an'inodor- ous gasiform fluid. Similar experiments have been performed with the same results, by Sebastian, Siemens, and other pathologists. The effects which gasiform accumulations exert upon the surround- ing structures vary very much according to their extent and situation. In the alimentary tube, where they are more common than in any other part of the body, they often give rise to serious inconvenience, and sometimes even to loss of life. One of their earliest effects here is debility of the muscular fibres, which may finally end in complete paralysis, followed by excessive distension of the abdomen, and ina- 1 Hist. Anat. des Inflammations, t. i. p. 582. EFFECTS. 127 bility to evacuate the feces. When the accumulation is excessive, or protracted, the coats of the canal may become softened and even lacerated; an occurrence of which many examples are on record. Large collections of gas occasionally take place in the bowels from the presence of organic disease, spasmodic stricture, or hardened feces; and in such cases death may happen from over-distension of the ali- mentary tube, producing pressure upon the diaphragm to such a degree as to arrest respiration. In the pleural sac the effused fluid may not only compress the lung, but even displace the heart. When the pericardium is distended, the contained organ will necessarily suffer more or less functional dis- turbance, though the air is probably in most cases speedily absorbed. In the uterus the accumulation of gaseous fluid may be mistaken for pregnancy, since it gives rise to more or less enlargement of the abdomen, and sometimes even to considerable swelling of the mam- mary glands. In general emphysema the movements of the body are impeded, and the patient occasionally perishes from the pressure excited by the effused fluid upon the vital organs. Pneumatosis may occur in several situations at the same time, or, as it leaves one part of the body, it may make its appearance in another. It may exist as a separate and independent affection, or it may be complicated with other diseases, of which irritation and inflammation, with the various products of the latter, are the most common. Spontaneous pneumatosis may occur in both sexes, and at any period of life, but is most frequent in women, about, or soon after, the decline of the menses. Various diseases predispose to it and persons of a weak, nervous habit are more liable to suffer from it than such as are strong and robust. The affection may be developed with great rapidity, but generally takes place gradually, and may last for a num- ber of hours, several days, or even a much longer period. In some instances the generation of gas assumes an intermittent type, recurring in regular paroxysms once every twenty-four hours, or once every other day, like an intermittent fever. There seems occasionally to be a sort of flatulent diathesis; that is, the patient suffers habitually from windy accumulations of the stomach and bowels, so that he seldom knows what it is to be entirely free from colicky pains. It has also been supposed that pneumatosis may be hereditary, but of this we have no positive evidence. Finally, the effused air may be discharged as fast as it is extricated; remain for some time, and then escape; or be retained permanently, as it were, and give rise to the bad effects already pointed out. Un- der favorable circumstances it may be absorbed, particularly when it is diffused through the cellular substance. 128 POLYPES. CHAPTER XVII. POLYPES. Most common Situation.—Not peculiar to the Human Subject.—Number, Size, and Form- Structure and Varieties.—Vesicular, Fibrous, Vascular, and Granular.—May degenerate in different ways.—Period of Life most liable to their Formation.—Effects on contiguous Struc- tures.—True Character.—Are always covered by a Mucous Membrane. A polype is a morbid growth, organized, vascular, and presenting itself in the form of a pendulous tumor, more or less firm, rarely ex- ceeding the volume of a hen's egg, varying in structure and other pro- perties in different parts of the body, and generally attached by a short neck or pedicle to the surface of a mucous membrane. The term is of Greek derivation, and was no doubt originally employed on oc- count of the resemblance which this excrescence was supposed to bear to certain zoophytes. It is evidently not very appropriate, but as its import is fully understood by pathologists it would only occasion confusion to change it. Although all parts of the mucous system, with the exception, per- haps, of the gall-bladder, the ureters, and Fallopian tubes, are liable to these growths, yet there are some in which they are more frequently observed than in others. Their most common situation is unques- tionably the nose; next in order is the uterus; then comes the maxil- lary sinus; then the rectum; and, finally, the vagina. In the aliment- ary canal, apart from the portion of it just specified, they are most frequent in the pharynx and the colon. They are occasionally met with in the larynx and trachea, frontal and sphenoidal sinuses, the gums, external ear, urinary bladder, lachrymal sac, urethra, and vulva; but their occurrence here is extremely rare. Polypes are not peculiar to the human subject. They have been noticed in a number of the inferior animals, particularly the horse, ass, cow, and dog, in which their occurrence is by no means infrequent. Their most common situation in these quadrupeds, as in man, is the nose, uterus, and maxillary sinus. The number of these bodies is much influenced by their structure, and by the nature of the cavity in which they are developed. The harder varieties are almost always solitary, while the softer are fre- quently multiple, or, what is the same thing, occur in groups or clus- ters, to the number sometimes of six or even a dozen. Cases, indeed, have been recorded in which there were as many as twenty or thirty. This, however, is rare. The nose is the part in which they are most numerous, though even here there is often not more than one. In the VESICULAR SPECIES. 129 uterus, maxillary sinus, vagina, and alimentary canal; in fact, in most of the situations above specified they are usually solitary. In the rectum, however, as many as four have been observed in the same subject, and in the vagina they are sometimes quite numerous. Tumors of this kind occasionally co-exist in different parts of the body, particularly in the nose and uterus. In their size polypes vary from that of a pea to that of an almond, a walnut, and even the fist. The soft varieties are usually much smaller than the hard, which now and then acquire an enormous volume. In the uterus a fibrous polype has been known to be as large as a child's head, or to measure from ten to fifteen inches in length by six or eight in breadth. In the nasal fossa, where they must necessarily be comparatively small, they frequently extend down into the pharynx, depressing the arch of the palate, and touching the root of the tongue. In the uterus they gradually pass into the vagina, and ultimately pro- trude at the vulva, from which they may descend many inches between the thighs. In the stomach they have been found more than eight inches in length by upwards of an inch in diameter. In the maxillary sinus, notwithstanding the firm and resisting character of its walls, they often acquire an immense size, especially when of a malignant nature. The form of these vegetations, like their number, is greatly influ- enced by the cavity in which they are situated, and by the pressure which is exerted upon them by the surrounding structures. In the nose and uterus they are generally conical or globular, with a tolerably distinct pedicle, while in many other parts, as the stomach, pharynx, and bowels, they are cylindrical, or of the shape of a leech or earth- worm. In the maxillary, frontal, and sphenoidal sinuses they become usually pretty accurately moulded to the form of the cavity in which they are developed, whatever may have been their original appear- ance. In a uterine polype in my private collection, the tumor bears a striking resemblance to a mushroom; the pedicle, which completely closes the orifice of the organ, is about an inch long, and terminates in a bulbous expansion, nearly fifteen lines in diameter. When of a globular figure, the polype commonly adheres by a tolerably broad base; but if conical or cylindroid, it is almost always provided with a well-marked pedicle, narrow neck, or footstalk, which is from half an inch to an inch or even two inches in length by several lines in diameter, rounded, and often of unequal thickness in different por- tions of its extent. Sometimes the pedicle is very much elongated, constituting what some of the French writers have denominated the " pendulous polype." Occasionally, two or three tumors grow from a single stalk, and in some instances, though they are rare, the free ex tremity of the polype has a bifid, grooved, fissured, knobby, or tuber culated arrangement. In relation to their structure, polypes may be referred to four prin- cipal species, the vesicular, fibrous, vascular, and granular. To these some writers have added several others, as the sarcomatous, lardace- ous, cartilaginous, osseous, and mixed; such a distinction, however, is obviously improper, inasmuch as all these formations are the result 9 130 POLYPES. entirely of secondary changes, produced in these bodies by irritation, diseased action, or perverted nutrition. The vesicular, gelatinoid, or cellular polype is most frequently ob- served in the nose, though it is also occasionally met with in the other mucous cavities. It is of a soft, spongy consistence, homogeneous, frequently semi-transparent, and usually of a grayish, yellowish, violet, or pale greenish color. The surface of the tumor may be perfectly smooth and uniform, but more commonly it is somewhat rough, lobu- lated, or divided into ridges; vessels, sometimes of considerable length and volume, often ramify over it in different directions, without appa- rently entering its interior. This variety of polype occurs either singly or in clusters, and consists essentially of a loose delicate cellular tissue. When punctured, a yellowish, whitish, or lactescent serosity escapes, slightly coagulable by heat, alcohol, and acids, and which, when examined microscopically, shows nucleated cells lying in a trans- parent or slightly granular blastema. Its form, which is commonly conical or globular, is greatly influenced by the cavity in which it is situated; it is generally supported by a well-marked neck or pedicle; grows with considerable rapidity; is devoid of sensibility; readily breaks under pressure; and is always hygrometric, expanding when the atmosphere is moist, and decreasing when it is dry. The vesicular polype bears no little resemblance, both in its color and consistence, to the common oyster, or a lump of hardened jelly. When extirpated it is very apt to be reproduced. The fibrous polype is so named from its structure, which strongly resembles that of a fibrous tumor. Its most common seat is the uterus, but it likewise occurs in the maxillary sinus, in the nose, in the ali- mentary canal, and, perhaps, also, in some of the other mucous passages. It is distinguished by the extreme firmness of its texture, which equals that of tendon, fibrous membrane, or even fibro-cartilage. It exhibits a faintly striated, linear, or thread-like arrangement, and is composed of distinct filaments, which interlace with each other in various direc- tions, and inclose a glutinous substance, the quantity of which is usually in an inverse ratio to the density of the morbid mass. A polype of this kind is more or less elastic, slightly, if at all, com- pressible, opaque, and of a pale reddish, lilac, or grayish color. Some- times it has a marbled or mottled appearance, and occasionally it is almost as white as a fibrous membrane. It is generally supported by a tolerably broad base, instead of a narrow, rounded pedicle; possesses very little or no sensibility; has few bloodvessels; is covered by a reflection of the mucous membrane; grows very tardily, though it often acquires a large bulk; and is much more apt than the other species to degenerate into malignant disease. Different sections of it often exhibit different structures, and in a few instances it is found to contain one or more cavities, which are either empty, or filled with grumous blood, milky fluid, gelatinous matter, or fat and hair. The fibrous polype always occurs singly; never in groups or clusters, as is the case with the vesicular and granular. The third species of polype is the vascular, which, in comparison with the vesicular and fibrous, is extremely rare. It is occasionally GRANULAR SPECIES. 131 found in the nose and maxillary sinus, but is most common in the rectum, external ear, vagina, and uterus. It is of a soft spongy con- sistence, bleeds readily when touched or irritated, and is composed of a great number of vessels, which, intersecting each other in different directions, are supported by a cellular tissue in varying quantity and forms of development, and surrounded by a delicate mucous membrane. Its color is usually florid, deep red, or purple, especially when it is handled, compressed, or exposed to the air. In its size it varies from that of a cherry to that of a hickory-nut, a hen's egg, or even a moderate-sized fist. It rarely, however, acquires much bulk; and its growth, notwithstanding its vascularity, is usually slow, so that a number of years may elapse before it leads to much incon- venience. The vascular polype is generally attached by a small pedicle, and is almost always of a conical, globular, or ovoidal form. A tolerably large artery, accompanied by one or two'moderate-sized veins, usually passes along the pedicle, and ramifies through the substance of the tumor, which it pervades in every possible direction. Hence it is usually erectile during life, and more or less flaccid after death. The granular polype, probably the least frequent of any, is chiefly found in the uterus, though it also occurs in the nasal fossa?, the larynx, and the urinary bladder. Appearing almost always in clusters, which are sometimes spread over a considerable extent of surface, it varies in size between a currant and a grape, and is suspended by a rounded, delicate pedicle, often not thicker than a hempen thread, and from an inch and a half to two inches in length. It is of a pale rose, whitish, or grayish color, homogeneous, granular, soft, inelastic, and looking, when cut, somewhat like glandular flesh, the incision being occa- sionally followed by the exudation of a very small quantity of serous fluid. The polype is very easily detached from the surface on which it grows; is covered by an exceedingly delicate membrane; increases very slowly in size; and is apt, if repeatedly irritated, to take on malignant action. No vessels are apparent to the naked eye, and, unless ulcerated, or otherwise diseased, it does not evince any sensi- bility. The different forms of polypous tumors, of which I have now give'n a brief description, may, in consequence of disease, to which, in com- mon with other morbid growths, they are more or less liable, undergo various transformations. The most common of these are the carci- nomatous, lardaceous, fibro-cartilaginous, cartilaginous, osseous, and earthy. None of these, with the exception of the first two, pervade the entire tumor, but occur in isolated masses, with intervening portions of sound substance. The fibrous polype is by far the most liable to take on malignant disease; and next to this is the granular. As to the other varieties, they are rarely, if ever, affected in this manner. When the tumor assumes this kind of action, it usually grows with great rapidity, extending in all directions, and breaking down everything before it. It is of a deep red, brown, or livid color, is traversed by large, tortuous 132 POLYPES. vessels, and is extremely prone to bleed upon the slightest touch, or under the most trifling irritation. Its sensibility is much augmented; pains dart through it in various directions; the whole system deeply sympathizes; the countenance exhibits a sallow cadaverous aspect; the general health is rapidly undermined, and the patient, worn out by suffering, sinks into the grave; the tumor, in the meanwhile, having opened at various points, and thrown out fungous excrescences. Examined at this stage of the malady, the morbid mass is found to be of a soft, brain-like consistence in some parts, lardaceous, scirrhous, hsematoid, fibrous, or fleshy in others; the whole presenting a strange combination of disease, in which the surrounding structures, bones, cartilages, muscles, nerves, and vessels are often inseparably blended. The period of life most liable to these morbid growths varies accord- ing to their structure, and the nature of the cavity or canal in which they are developed. In the rectum, they are most common in children under ten years; in the uterus, between thirty and forty; in the nose, in young adults ; in the larynx, in advanced life. From the fact that they have occasionally been observed within a few weeks or months after birth, it is probable that they may sometimes be congenital. It would also appear that the disease may occur in several members of the same family, whence it has been inferred that it might be hereditary; of which, however, there is not, as yet, sufficientkevidence. We have no statistical facts which enable us to determine whether one sex is more liable to these formations than the other; the prob- ability, however, is, that they are more frequent in women than in men. We are equally ignorant respecting the influence exerted upon their production by temperament, occupation, climate, and season. The pathological effects of polypes on contiguous structures vary according to the volume, form, and situation of the tumor. As long as they are inconsiderable they cause little trouble or inconvenience, except, perhaps, in the uterus, where even a small body of this kind may occasion profuse and repeated hemorrhage. In proportion as they increase in size they manifest a disposition to press upon the walls of the cavities in which they are confined, or, if these cavities have a natural outlet, to pass beyond them, and encroach upon the circum- jacent parts. Thus, in the nose, they frequently extend backwards into the fauces, and forwards into the anterior nares, while above they may press upon the turbinated bones, laterally upon the upper jaw, and inferiorly upon the roof of the mouth. In the maxillary sinus, after having filled that chamber, they usually encroach upon the_ eye, lachrymal sac, nose, mouth, and face, thrusting them out of their natural position, and thus causing not only much deformity, but more or less functional disturbance. A polype of the nose produces mechanical obstruction, attended with difficulty of breathing and a change of voice, which is often hoarse or croaking, as if the individual was laboring under cold. In the larynx, excrescences of this kind occasion dyspnoea, alteration or extinction of the voice, suffocative paroxysms, and a sense of uneasiness and of constriction in the region of the part affected. In the rectum, a polypous tumor has been known NATURE AND MODE OF FORMATION. 133 to cause fatal obstruction, from retention of the feces.1 In the bladder, the disease is attended with frequent micturition, along with tempo- rary inability to void the urine, and is liable to be followed by the worst consequences. In the uterus, the most important effect by far is excessive loss of blood. The hemorrhage, which is often very copious, recurs upon the slightest exertion, and usually persists, with various intermissions, until the foreign body is removed or expelled. The quantity of blood lost may amount to many ounces or even pounds. It may be dis- charged in a fluid state, or be retained for a time, and then come away in clots. A polype may also occasion prolapse of the womb, or even inversion, especially if it be attached to the fundus of the organ, and be of great weight, so as to lead to constant dragging and expulsive efforts. " The presence of a small polype does not prevent conception, although it renders the continuance of utero-gestation very doubtful, inasmuch as it frequently causes abortion." I have already referred to a tumor of this nature, of the shape of a mushroom, which so com- pletely closed the mouth of the womb as to cut off all communication between the interior of that viscus and the vagina. In regard to their origin, polypes cannot be viewed, strictly speak- ing, in the light of new formations, but rather as the result of a species of hypertrophy of the mucous membrane, either alone, or conjointly with the textures over which it lies, and to which it is more or less intimately attached. That this is the case may be easily proved by an examination of the anatomical elements of which these tumors are composed. Thus, the granular polype, as it is called, evidently con- sists of an enlargement of one or more of the mucous follicles, which everywhere exist in the mucous membranes, though much more numerously in some situations than in others. These little bodies are particularly abundant at the neck of the uterus, and hence the reason probably why this species of tumor is almost exclusively confined to this organ. When these glands are irritated or inflamed, their outlets become obstructed, either by the adhesive process, or from the reten- tion of inspissated mucus, in consequence of which they augment in size, and gradually assume a pediculated appearance. In the mean- time the mucous membrane of the uterus is prolongated over their outer surface, so as to give them a complete investment; vessels ex- tend into them from different points of their circumference, and thus they continue to grow until they exhibit the peculiar form, color, con- sistence, and structure which characterize them. In its mode of development this variety of polype closely resembles that of an en- cysted tumor of the skin, which is caused by the obstruction of a sebaceous follicle, and the consequent accumulation and retention of its contents. The principal difference between them is, that the latter is not pediculated, owing to the resistance which it everywhere meets with from the cutaneous tissues, while the other, projecting into an open space, may readily expand in every direction, and by its weight and dragging produce the footstalk by which it is usually suspended. 1 Meckel's Neues Archiv., B i.; Voigtel, Handbuch der Pathol. Anatomie, B. ii. p. 649. 134 POLYPES. The vesicular polype is probably, at least in most cases, nothing but a species of hypertrophy of the mucous membrane, with infiltration and induration of the submucous cellular substance. In the vascular variety of the disease there is a predominance of the vascular elements; the bloodvessels are increased in size, and protruded underneath the villous membrane, forming a soft, spongy, and erectile tumor, of a red, florid or purple color, and the seat of frequent hemorrhages. The mucous follicles have nothing to do with its production, and the cellu- lar substance enters but sparingly into its composition; barely sufficient to connect the arterial and venous ramifications, and to form a frame- work for their distribution. In the fibrous polype there is a prolonga- tion or hypertrophied state of the fibrous tissue of the part. In the uterus, where this species of the disease is remarkably frequent, it is not unlikely that a portion of the proper tissue of that organ is the structure originally concerned; in the nose, gums, and maxillary sinus it is probably the periosteum. Dr. Da Costa informs me that he has repeatedly, in addition to fibrous tissue, found smooth muscular fibres and fibre-cells in polypes of the uterus, especially well marked in those that appeared fleshy to the naked eye. From the preceding account of the different species of polypes it will be perceived that all these vegetations are covered with a mucous membrane, which is merely a prolongation of that of the cavity or canal in which the foreign body is developed. This investment varies very much in its physical properties, according to the structure, size, and age of the tumor. In the fibrous polype it is usually of consider- able thickness, opaque, rough, mammillated, tough at some points, and remarkably brittle at others; while in the vesicular, granular, and vas- cular it is comparatively thin, semi-transparent, or perfectly pellucid, smooth, glossy, and of tolerably uniform consistence throughout. In recent cases, and occasionally even when the tumor is of long standing and of considerable bulk, the membrane by which it is covered is a mere film, requiring the greatest care to demonstrate it. I am in pos- session of a polype of the rectum, evidently belonging to the vascular variety, which is studded all over with the finest villi, much more minute than those of the small bowel. In the carcinomatous form of the disease, the investing membrane is often remarkably thickened, highly vascular, rough, pulpy, and exceedingly fragile. Polypes are well supplied with blood. In many cases, indeed, the vessels are not only quite apparent, but large, tortuous, and even vari- cose. The veins evidently predominate, both in volume and number, and their parietes are often so thin and brittle that they are scarcely able to sustain the pressure of the column of the contained blood. The largest usually ramify over the surface of the morbid product, immediately beneath the mucous membrane, to which they frequently impart a beautiful striated appearance. The arteries are comparatively small, and pervade the substance of the tumor in every direction con- veying to it the materials which are required for its growth and nou- rishment. Both classes of vessels are derived from the structures to which the polype is attached, and not from any formative or creative power of the abnormal body itself. No nerves or absorbents have been HYDATIDS. 135 detected in these excrescences, but that they exist in them, and are de- rived in the same manner as the bloodvessels, does not admit of doubt, though we have no means of demonstrating the fact. CHAPTER XVIII. HYDATIDS. Historical Outline.—Where found.—Classification of Hydatids.—The Cysticercus, Polycepha- lus, Diceras, Echinococcus, and Acephalocystis.—Their Origin and Organization.—The man- ner in which they are nourished.—The Changes which they experience by Age, and the Alterations they induce in the Organs in which they are developed. The combined researches of naturalists and pathologists have shown that many of the higher orders of animals, as well as some of the lower, are infested with a class of beings, which are generally known, at the present day, by the name of hydatids. The term hydatid was formerly given to every encysted tumor containing a transparent fluid. It has, however, become customary to restrict it to those sacs which inclose entozoa, and it is in accordance with this view that I shall use the term. Their most common residence is in the serous cavities, the alimentary canal and the passages which open into it, the cellular tissue, among the muscles, and in the proper substance of the different organs. They have been found in nearly all classes of ani- mals, in birds, reptiles, and fishes, as well as in a great many of the mammalia. Whether they exist in insects, has not been ascertained. No period of life is exempt from them. Portal mentions an instance of their having been detected in the foetus. They are most common, however, in adults and old people. So far as can be ascertained, these parasitic beings possess no genital organs, no apparatus for respiration, no trace of a circulation, and ap- parently no nerves. They can live and propagate their species only in the interior of other animals, and their existence is usually very brief, most of them perishing within the first year or two after they are developed, often much earlier. A few of them only are capable of performing distinct movements under the influence of external stimulants. In describing these singular animalcules, I shall divide them into five genera: 1, the cysticercus; 2, the polycephalus; 3, the diceras; 4, the echinococcus; and, 5, the acephalocystis. Differing from each other in many essential points, it will be necessary to devote to each of these genera separate consideration. It may be premised, however, con- cerning them, that they all consist of a thin, pellucid vesicle, varying in size between a clover-seed and an orange, which is filled with a clear, watery fluid, and surrounded by a dense, fibrous capsule, upon which they depend for their nourishment and support. 136 HYDATIDS. The cysticercus is nearly cylindrical in shape, terminating behind in a caudal vesicle, whence its name. The whole animal is somewhat wrinkled, and its head, which strongly resembles that of the tape-worm, is furnished with hooks and suckers. This genus is more frequently met with in the inferior animals than in man, and is particularly com- mon in the liver and brain of the sheep. Its size rarely exceeds a small walnut, and in most cases it is not near so large. It generally exists singly in the inclosing cyst, which is almost always thin, deli- cate, and transparent, except in old cases, or where the hydatid has lost its vitality, when it is apt to be thick, dense, semi-cartilaginous, or even bony. The body of the animal itself may degenerate and become covered with a chalky crust. In the sheep, in which this Fig. 24. Fig. 25. Fig. 23 exhibits the natural form of the animal: a. The head; b. The neck, and c. The dilated vesicular tail. Fig. 24 shows the head in a magnified state: d. The proboscis ; e, e, e. The suctorious disks. Fig. 25. A portion of human muscle with the cysticercus inclosed : a, a. The cyst cut open; b, b. The parasite ; c. The muscle. genus often acquires a large size, the caudal vesicle presents an infinite number of minute elevated lines, running nearly at right angles with the body of the animal. Five species of the cysticercus have been recognized by authors, the cellular, vesicular, dicystic, speckled, and Fischerian. The cellular cysticerce (Figs. 23, 24, and 25) is met with mainly in the hog, in which it occasions the disease commonly known under the Fig. 26. Fig. 27. The natural form of the parasite. The head, as it appears under the microscope : a. The flattened promontory; 6, b. The hooklets ; and c, c, c The suckers. Fig. 23. VESICULAR—POL YCEPH ALUS. 137 Fig. 28. name of measles, or what the German writers call finnen. It has been rarely observed in the human subject. The body is conoidal, from four to ten lines in length, and composed of a thin, transparent mem- brane, without any perceptible fibres: the caudal bladder is of an oval shape, and the head, which is tetragonal, is furnished with four suckers, together with thirty-two hooks divided into two rows. The vesicular species (Figs. 26 and 27), which is also very rare in man, having been found only in a single instance in the choroid plexus of an apoplectic subject, has hitherto been chiefly observed in the ox, sheep, swine, goat, stag, and gazelle. The peritoneum, pleura, and arachnoid are the situations in which it delights to dwell. Its head, which is almost tetragonal, is armed with a cylindrical and slightly curved snout; the neck is quite short, the body small, and the caudal vesicle nearly spherical. The third species (Figs. 28 and 29) is the dicystis, or, as this term literally signifies, the double-bladder hydatid. Laennec is the only person who has observed this worm. He found it in the lateral ventricles of a man who had died of apoplexy. It consists of two large vesicles, of which one is caudal, whilst the other, which is annulated and of a conical shape, forms the body. Both are traversed by a wide canal, which terminates anteriorly in a cul-de-sac. The head has four suckers, and a certain but indeter- minate number of hooks. The speckled cysticerce (Fig. 30) has a head with one sucker and six hooks; the body is conical, nearly transparent, and from four to eight lines long; the caudal bladder is spherical and irregularly dotted with very small white points. It has been met with only in one instance, byTreutler, in the choroid plexus of a young woman. The Fischerian species (Fig. 31) has a rounded, slender, annulated body, and a large head furnished with an indeterminate number of hooks and suckers. The caudal bladder, which is pear-shaped, is about the fourth of an inch long, and terminates in a small point, which adheres to the organ which the animal inhabits. It is said to have no inclos- ing cyst. Dr. Fischer, of Leipsic, after whom it is named, detected it twice in the choroid plexus of the human subject. The second genus, the polycephalus, is extremely rare, and has not, up to the present time, so far at least as I am aware, been found in man. It is composed of a semi transparent cyst, speckled with minute, opaque whitish spots, and is of a somewhat oval figure ; it is generally very small, and is provided, as the derivation of the name indicates, with a great number of heads. The situations which it generally occupies Fig. 28 is the dicystis of the natural ize. Fig. 29 the magnified head. 138 HYDATIDS. in the inferior animals are the brain, liver, and intermuscular cellular tissue. Two species have been noticed by authors, the cerebral and the granular (Figs. 32 and 33), which, however, as they never occur in the human subject, need not be described. Fig. 32. Fig. 33. Fig. 34. Fig. 32 exhibits the granular polycephalus imbedded in the liver of the sheep: a. The hepatic tissue; 6. A portion of the cyst; c. The parasite cut open. Fig. 33 is a small body attached to the inner surface of the animal. The diceras, a genus established by Sulzer, infests the alimentary canal of animals, and also occasionally that of the human subject. The German author here mentioned first observed it in the alvine evacuations of a young woman after having taken some purgative medicine. This genus, which embraces only one species, the rough diceras (Fig. 34), is distinguished by its flat, oval body, which is about a line and a half long, and terminated in a point posteriorly, and by the rough, bifid horn which surmounts its head, and from which the animal derives its name. It is loosely inclosed by a capsule. As yet it has not been discovered in the substance of any of the viscera. Of the diceras, I have never seen any specimens, and suspect it to be very uncommon. Eudolphi, indeed, appears altogether to doubt its existence; a view which has since become the most prevalent. The fourth genus (Fig. 35), the echinococcus, was first suggested by Rudolphv, but is not admitted by Cuvier. Occurring principally in the brain, liver, spleen, and omentum, it consists of a capsule, Fig. 35. analogous in structure to that of the acephalocyst, attached to fthe inner surface of which are numerous animalcules, of an ovoidal shape, extremely fine, granulated, and provided with four suckers and a crown of booklets. The echinococcus is occasionally found In the human subject. Zeder discovered some in the brain of a young woman, occupying the third and fourth ventricles; they were about twelve in number, pyriform, and quite small. Miiller has described an instance in which they were voided with the urine, by a man laboring under renal disease. But the most extraordinary case, perhaps, on record, is that published by Rendtorf. The sac containing the hydatids was developed in the brain; it was of large size, and weighed upwards of two pounds. The walls of ACEPHALOCYSTS. 139 the right ventricle, in which it was situated, were so attenuated as to be scarcely a line and a half in thickness. The Fi§- 36- moir on Vesicular Acephaiocyst. Worms." Occurring both in the human subject and in many of the inferior animals, the individuals of this class of parasites infest some organs much more frequently than others. They seem to have a remarkable predilection for the liver, owing, probably, to some peculiarity of structure favor- able to their development. The brain, ovary, uterus, mammary gland, spleen,'and kidney are also sometimes their seat; in fact, they have been found in every part of the body, except the alimentary canal and urinary bladder. Varying in size between a mustard-seed and a large orange, they are generally of a spherical figure, and composed of a white, semi-opaque, pulpy vesicle, filled with a clear, limpid fluid. This vesicle, which forms the hydatid, properly so called, is from the sixth of a line to the eighth of an inch in thickness, is often separable into two or more layers, and is so exceedingly delicate as to yield under the slightest pressure of the finger. So weak, indeed, is it, that it is frequently incapable of withstanding the pressure even of its own contents, as I have had repeated opportunities of witnessing, after the partial removal of the inclosing cyst. On being ruptured, it shrinks into a soft, irregular, puply mass, of an opaline color, which readily swims in water, and bears the greatest resemblance to the white of a hard- boiled egg. M. Collard states that it consists of two principal ingre- dients, one of which is essentially albuminous, whilst the other, the precise nature of which is not known, has a considerable analogy with mucus. To the inner surface of the vesicle now described are often attached extremely minute bodies (Fig. 37), not bigger than the finest grain of sand, of a grayish color, and a spherical shape, which are young hydatids. In some instances they are connected with the exterior of the parent sac; but this is very rare. It has been made the basis, 140 HYDATIDS. however, of the division of acephalocysts into two species, the endo- genous and exogenous, the former being most common in the human subject, the latter in the ox and other ruminant animals. The animalcules at first line the inner layer of the vesicle. In what manner, or how soon after their formation, they are cast off, are circumstances in their history concerning which we are ignorant. All that is known with any certainty is, that they may often be seen floating about in great numbers, while Young acephalocysts. , ° . , °, -, , , ' ,, they are scarcely the two-hundredth part of an inch in diameter, which would lead us to infer that they are generally detached at a very early period of their existence. When the hydatid, as often happens, consists of several coats, the generation sometimes takes place between them, or even in their substance. In whatever way it is accomplished, a small opaque elevation, easily distinguishable by the eye, usually indicates the spot where the young have been de- veloped. It sometimes happens, though not very often, that a large acephalo- cyst contains several that are smaller, one within the other, all of the same shape and structure. As many as three, four, and even five, have been found thus inclosed, like so many pill-boxes. This arrange- ment, which occurs much oftener in the human subject than in the inferior animals, is explained by the endogenous mode of generation previously adverted to, by which one acephalocyst, after having arrived at maturity, produces another, each successive one being smaller than its parent. The inclosing cyst of this species of hydatid is usually semi-trans- parent, very strong and dense, and has no connection whatever with the parasite within. In fact, there is commonly interposed between them a soft, pulpy, dirty-looking substance, arranged in a thin, un- equal lamella. The thickness of the outer capsule varies a good deal with the size and age of the tumor: it can occasionally be separated into several layers, and may be said to possess all the properties of the fibrous tissue, without any of its linear disposition. It is probable that these acephalocysts of Laennec are nothing but echinococci, whose bodies have become hydropic, so that these two genera may possibly soon be cast into one. Such is a rapid sketch of the most common genera and species of hydatids. Let us now inquire briefly into their origin and organiza- tion, the manner in which they are nourished, the changes they experi- ence from age, and the alterations they induce in the tissues in which they are developed. The origin of hydatids is involved in doubt and conjecture. An idea was at one time entertained that they were the result of inflam- mation. Recent researches tend to show that they are the ov,a of worms, probably of the taenia, which reach a certain stage of develop- ment, and then become encysted, or may themselves become hydropic. In dogs and rabbits fed with these cysticerci and echinococci, tasnia STRUCTURE AND NOURISHMENT. 141 were subsequently found; and, on the other hand, the embryos of taenia have been seen perforating the intestinal walls, in order to reach the parenchymatous structures in which they were destined to become imbedded. AVhilst the formative process is going forward, the parasite takes care to isolate itself from the parts in which it is developed, bjr means of a capsule, which surrounds and protects it from injury. This cap- sule, formed out of plastic lymph, is furnished with appropriate vessels as well as, in all probability, with nerves and absorbents. Many of these vessels, which are so large that they can be readily injected, are spread out in beautiful arborescent lines. So far as I have had an oppor- tunity of examining them—and I have often done this in the acephalo- cyst of the hog—they appear to be derived principally from the sur- rounding textures. Nevertheless, there are certain situations in which they are plainly the result of new formation, as in the ventricles of the brain, the serous sacs, the ovaries, and the uterus. Nowhere can any of their branches be traced from the outer covering into the walls of the hydatid itself. The proper hydatid contains, as was before stated, a thin, aqueous fluid, which, so long as the animal remains healthy, is generally per- fectly clear and limpid, like the purest spring-water. Under opposite circumstances, it is frequently turbid and discolored, or entirely replaced by purulent matter, blood, or other substance. Be this as it may, the fluid is usually remarkably saline in its taste, possesses little or no odor, and rarely, if ever, coagulates by exposure to heat, alcohol, corrosive sublimate, or the dilute acids. In several experiments which I made on the contents of some very large acephalocysts of the liver of the hog, heat produced not the slightest change; and similar results ensued in a trial which I made on a hydatid taken from the liver of a man forty years old. These results accord with the researches of Marcet, Cruveilhier, and other writers; and they point out the great resemblance of this fluid to that of hydrocephalus, in its want of coagulability, in consequence of the almost total destitution of albu- men. How are hydatids nourished? or, rather, whence do they derive the materials necessary for their support? It has been already seen that they are completely isolated from the tissues in which they are developed by means of a capsule which has no immediate connection with them, and the inner surface of which, moreover, particularly in the acephalocystic genus, is generally lined by a thin, pulpy, fragile lamella, which adds still further to the isolation. This intervening substance is supposed by Dr. Hodgkin to be a sort of excrementitious secretion from the hydatid itself: I, on the other hand, would rather con- clude, in the absence of facts, that it is an important structure, designed to assist in the elaboration of a fluid for nourishing the parasite. This fluid, which is probably of a sero-albuminous character, and is fur- nished by the vessels of the inclosing capsule, is filtered through the soft, pulpy matter here adverted to, and is finally imbibed by the proper cyst of the hydatid, which it thus enables to live and to exe- cute its humble functions; those, namely, of secreting a thin, watery 142 HYDATIDS. liquid, and of propagating its species. All this, of course, is conjec- tural ; nevertheless, the argument might easily be sustained by analogy, the only kind of proof that can be adduced in illustration of an inquiry environed by so many difficulties. Many hydatids appear to be short-lived. This is especially true of the acephalocysts of some of the inferior animals, as the sheep and swine, in which they are said to be produced in the spring, and to perish the following winter. In others, again, as well as in the human subject, they last for years, and often acquire a large bulk. Their ex- istence is greatly influenced by the nature of the tissues in which they are developed, as well as by their number and size. Not unfrequently an old hydatid is destroyed by its young, which press upon and finally rupture it. In a second series of cases, death comes on without any assignable cause; the contained fluid gradually disappearing, and the proper cyst, as well as the inclosing capsule, becoming collapsed, opaque, corrugated, and of a yellowish amber color. In a third series the parasite is attacked with inflammation. When acute, this disease sometimes ends in a species of gangrene; but more generally in sup- puration. Of both these terminations I have had occasion to observe a considerable number of instances. In the former case, the fluid is of a turbid appearance, and the cysts, both proper and adventitious, are converted into a soft, brownish mass, which is sometimes quite offensive. In the latter, that is, when the inflammation ends in sup- puration, the contained liquid is often entirely absorbed, its place being occupied by a yellowish, gold-colored pus, of a thick, plastic consist- ence, slightly saline to the taste, and of a faint animal odor. This occurrence is most frequently witnessed, according to my experience, in old acephalocysts, and in most of the cases that I have examined the internal membrane was either wholly destroyed, or broken up into fragments, mixed with the abnormal secretions. When the inflammation is chronic it is not uncommon for the in- closing capsule to become thickened, indurated, and fibrous, from the deposition of lymph. Occasionally it puts on exactly the appearances of the interior of a large aueurismal sac; cases have also been ob- served where it was rendered cartilaginous, and even bony. The ossi- fication usually begins by a few central points, which gradually aug- ment in diameter, until, in some instances, they coalesce with each other, and form considerable sized patches. A hydatid has been known to be the seat of apoplexy. The only instance of this kind that I remember to have read of, is that men- tioned by Dr. Hodgkin, in his morbid anatomy of the serous mem- branes : it occurred in a man forty years old. The hydatid was seated in the neighborhood of the spleen, and was externally of a dark color, which arose from a thin layer of blood interposed between the proper and the inclosing cyst. Hydatids may prove mischievous in two ways; first by their great number, and, secondly, by their large size. In either case they are apt, sooner or later, to excite inflammation in the parts in which they are situated, which may terminate in suppuration, softening, gangrene, induration, or, finally, in ulceration. The hardest structures are some- SEROUS CYSTS. 143 times incapable of withstanding their progress. Thus, a case is re- corded in which they perforated the scapula. When seated in the abdominal viscera, they are often passed by stool, ejected by vomiting, or discharged externally through a fistulous aperture. In the lungs, hundreds are sometimes coughed up by the same patient; in the kid- neys they have been known to be voided with the urine, either entirely, or in small fragments. In the brain, they may become a source of epilepsy, paralysis, or destructive softening; while, in the serous cavi- ties, their escape is occasionally attended with fatal inflammation. CHAPTER XIX. SEROUS CYSTS. Have the form of Shut Sacs.—Organs in which they are most frequently found.—Classification : the Simple, Multilocular, and the Included.—Nature of the Contained Fluid.—Are either new Products, or formed out of the pre-existing Textures.—Are liable to Inflammation and its Consequences. Much more simple in their structure, as well as much less obscure in their mode of origin, than hydatids, are those membranous pouches which have received from morbid anatomists the name of serous cysts. Deriving their generic distinction from their contents, which are usually of an aqueous character, they constitute a class of adventitious textures, which, like those naturally existing in the splanchnic cavities, form perfectly shut sacs, rough and adherent on one surface, smooth and in contact with a fluid on the other. Their shape is globular, ovoidal, pear-like, or pediculated, and in size they observe every intermediate degree between a grain of mustard and a large melon. As far as can be ascertained, they are, with few exceptions, the result of an entirely new formation, dependent upon the effusion and organ- ization of plastic lymph. With the mechanism of this creative pro- cess, as with that of hydatids and other accidental growths, we are altogether unacquainted; nor is it possible always to appreciate the different morbid lesions which precede and accompany it; that it pro- ceeds, however, under the influence of causes which excite inflamma- tion in the normal tissues, is a fact borne out both by observation and analogy. Like hydatids, with which they are often confounded, serous cysts are found either upon the free surfaces in the natural cavities, or in the proper substance of the organs. They have been observed in al- most all classes of animals; and, although no period of life can be said to be exempt from them, yet they are much more frequently seen in the old than in the young, and, according to my own experience, in the female than in the male. They may be considered as living at the expense, and in the interior, of other structures, more perfectly organ- 144 SEROUS CYSTS. ized than themselves, v/hich afford them protection and the means of subsistence. Their occurrence is extremely common, both in man and in ruminating animals; and it has even been contended that they occasionally manifest a hereditary tendency, the greater portion of a large family having been known to be thus affected during several successive generations. They have been found in nearly every struc- ture and cavity of the body, but particularly in the ovaries, the liver, kidneys, the mammae, and the testicles. They are also not infrequent in the brain of old persons; but they are seldom seen in the spleen, heart, lungs, and pancreas. In the vessels, the fibrous membranes, ligaments, cartilages, and mucous outlets, they have not, I believe, been noticed. Structure.—Viewed in reference to their structure, these adventitious sacs may be divided into three classes, the simple, multilocular, and included. Before we proceed to speak of these in detail, it will be proper to offer a few remarks concerning their contents. Like the natural serous membranes, the sacs in question, when once formed, or even whilst they are in progress of development, enjoy a life of their own, and are susceptible of various morbid actions, either set up in their substance or propagated to them from the surrounding normal textures. So long as they remain healthy, or in the exercise of the functions which nature has assigned to them, the fluid which they secrete, and which occupies their interior, is of a thin, watery con- sistence, clear and limpid, somewhat saline in its taste, and more or less coagulable by heat, alcohol, and acids. As to quantity, it ranges according to the size of the morbid growth, from a single drop to many ounces or even quarts. When affected with disease, the con- tents of the cysts are variously altered, often presenting appearances which are not to be observed under similar circumstances in the normal serous textures. The most interesting of these changes will be adverted to in another paragraph. The simple cyst, the type of the whole series, consists of a thin, deli- cate sac, generally of a globular figure, the interior of which is occu- pied, in the healthy state, by a pellucid fluid possessing all the proper- ties of the serum of the blood. Composed of a single lamella, it is usually perfectly transparent, is seld'om bigger than an orange, and is supplied with very long, slender vessels, which are evidently derived, in all cases, from the circumjacent parts. It is from these vessels, which are often extremely numerous, and spread out in a most beauti- ful arborescent manner, that the cyst obtains its nutriment and the materials from which it prepares its contents. They are probably accompanied by nerves and absorbents; but these, if they exist, are so excessively minute as to elude our closest scrutiny; and hence no anatomist has ever succeeded in tracing them. The parts in which this variety is most frequently developed are the internal organs of reproduction in the female, particularly the ovaries and the fimbriated extremities of the Fallopian tubes, the liver, and the brain, in the lateral ventricles of which, along the choroid plexus of old subjects, they often occur in clusters of ten, twenty, or thirty at a time, the largest not exceeding a common currant. SEROUS CYSTS. 145 Advancing a step higher in the scale of complexity, we come to the second division of the subject, the multilocular cyst. The principal difference between this and the preceding variety consists in the cellu- lated structure which is to be found in the former, and in the entire absence of it in the latter. This arrangement, from which the present accidental growth derives its name, is produced by a variable number of membranous processes, which are attached to the inner surface of the main cyst, and extend inward so as to intersect each other in different directions. In this way numerous compartments are formed, of vary- ing size and shape, which sometimes communicate together, at other times are perfectly distinct. The most curious circumstance connected with these chambers is, that they often contain different kinds of sub- stances. Thus, one may be occupied by perfectly limpid serum, a second by pure blood, a third by pus, and a fourth, perhaps, by fatty, melicerous or atheromatous matter. The reason of this cannot be easily explained; we might naturally expect to find it in some difference of structure; but, in the majority of cases, no such difference exists; and we are therefore forced to conclude that the phenomenon depends merely upon a modification of secretion. This variety of cyst is most commonly found in the cerebral sub- stance around old apoplectic effusions. It is also frequently seen in ovarian tumors, and in the subcutaneous cellular tissue; in parts which are constantly subjected to pressure, as the shoulders of porters and the knees of chamber-maids. In its shape, the multilocular cyst is generally irregular, its walls are of unequal thickness, and its internal processes are often rough and uneven. The third variety, the included, much less frequent than either of the others, is characterized by the circumstance of the main cyst, which is commonly of an irregular shape, containing clusters of smaller ones attached to different points of its inner surface. The number of included vesicles is sometimes truly surprising, many hundreds being found in the same specimen, from the volume of a grain of mustard to that of a hickory-nut; they are mostly of a globular form, and are composed each of a single lamella, which is continuous with, and appears to be merely a reflection from, the original sac, which not unfrequently contains several series of these junior cysts. On cutting into them, they are found to be occupied, in the great majority of instances, by a serous fluid, in others by a matter resembling the white of eggs, thin starch, or a solution of gum Arabic; or all these substances may occur at the same time, filling different cavities. When the interior vesicles are large or numerous, they sometimes completely distend the main cyst, rendering it rough and protuberant, and occasionally even bursting it; after which, being no longer re- pressed, they often grow with extraordinary rapidity. These cysts are apt to be confounded with hydatids; but may be readily distinguished by the fact of their being all intimately con nected with the parent sac, by the circumstance of vessels passing from the one to the other, and by their not containing any parasitic forma- tions. The parts in which these cysts are most frequently met with, and in which they acquire the largest size, are the ovaries and the 10 146 SEROUS CYSTS. broad ligaments of the uterus. In most cases they are, as was pre- viously stated, of a globular form; but it is by no means unusual for them to present a pediculated appearance, especially the binary and tertiary orders. Thus, there are three distinct varieties of serous cysts, all referable to three general modes of formation, the first being the most simple, the third the most complicated, the other being intermediate between them. In other words, the first consists of a simple sac, filled with a serous fluid ; the second, of a sac which is intersected by more or less numerous processes; and the third, of a sac which contains clusters of smaller ones, precisely of the same shape and structure as itself. It has been seen that these different classes of cysts are the re- sult, in most instances, of an entirely new formation, dependent upon a perverted state of the nutritive function. In other cases, they appear to be formed out of pre-existing textures, sometimes of a serous, at other times of a mucous nature. To the former category belong the cysts which are so often found in the ovaries, in consequence of the enlargement of the vesicles of De Graaf; to the latter, those which are developed in the kidneys and in the female breasts, from obstruc- tion of the excretory ducts. In these situations it is not uncommon for the adventitious growth to receive an accidental covering from the organ in which it is located. In the ovaries, for example, we accord- ingly find that the cyst is usually provided with very thick, dense parietes, separable into three distinct layers, the internal of which consists of the capsule of the vesicle of De Graaf, the second of the albugineous coat, and the third of the peritoneal covering of the organ. The same thing is sometimes observed in the spleen and liver. It is worthy of remark that, when the cyst is formed out of pre-existing mucous membrane, as in the instances above referred to, it generally, in the course of a short period, assumes all the properties of the serous textures. Serous cysts, whether of new formation, or constructed out of the pre existing tissues, are liable to inflammation, and, when thus affected, they may present all the phenomena which characterize this disease in other parts of the body. The contained fluid, in such cases, is generally thick, turbid, and discolored, owing to the presence of sub- stances which do not naturally belong to it. Occasionally it has the aspect and consistence of coffee-grounds, thin treacle, or tar; and the instances are by no means unusual in which it possesses all the pro- perties of genuine pus. A fatty matter has also been found in it, as well as a substance resembling cholesterine. The cyst itself may be variously affected. Generally speaking, it is opaque, grayish, dense, and fibrous, being thicker and stronger at some points than at others. The examples are rare in which the cyst is eroded, or transformed into cartilage or bone. The alterations which it creates in the parts where it is situated need not be particularly described, as they do not differ from those induced by hydatids. HETEROLOGOUS FORMATIONS. 147 CHAPTER XX. HETEROLOGOUS FORMATIONS. Preliminary Observations.—Classification; Tubercle; Melanosis; Scirrhus; Encephaloid ; Col- loid ; Epithelial Cancer.—I. Tubercle.—Definition.—'Great frequency.—Occurs nearly in all Tissues, and at all Periods of Life.—Iscommon in the lower Animals.—Chemical Composition. —Varieties of Form.—Concrete and semi-concrete Tubercular Matter.—Notions respecting its Origin, Development, and Organization.—Softening and Excavations.—II. Melanosis.—His- torical Sketch.—Occurs in Man and Animals.—Chemical Analysis.—Color and Consistence. —Varieties of Form.—Tissues most liable to suffer from Melanotic Diathesis.—States of the System which predispose to its formation.—III. Scirrhus.—Difficulty of the Subject.— Definition.—Varieties of Form.—Chemical Constitution.—Rarely appears before the age of thirty.—Most common in Glandular Organs.—Proximate cause.—Opinions of Adams, Car- michael, Hodgkin, and others.—Is apt to Ulcerate and involve the general System—IV. Encephaloid.—Is intimately allied to Scirrhus. —Terms by which it has been designated.— More frequent in some Structures than in others.—Varieties of Form.—Color, Consistence, and Composition.—Organization and Mode of Origin.—A Disease of early Life.—Involves the whole System.—Termination.—V. Colloid.—First described by Laennec.—Different Names.—Is a distinct Formation.—Composed of two Elements.—Microscopical Characters. —Cellular Tissue, Vessels, and Nerves.—Chemical Constitution.—Varieties of Form.—Most common Situation.—Most frequent from Thirty-five to Fifty.—Mode of Origin and Progress. —VI. Epitlielial Cancer.—Its Nature, Organization, and Tendency. By the term heterologous are understood certain morbid products, of a solid or semi-concrete consistence, which have no resemblance whatever, or, at most, only a very remote one, to the natural, normal, or pre-existing tissues of the body. It is of Greek derivation, literally signifying unlike, dissimilar, or without analogy, and is employed by many as synonymous with the word heteroclite, first devised, I believe, by some of the German anatomists. The number of heterologous products has been variously stated by writers, but it admits of much doubt whether there are really more than six, namely, the tubercular, scirrhous, encephaloid, col- loid, melanotic, and epithelial. To these might, perhaps, be added the parasitic animals which are developed in different parts of the body, such as worms and hydatids, and the calcareous concretions which are found in certain cavities and canals, as the urinary bladder, ureters, intestinal tube, and veins. Cirrhosis, sclerosis, and some other morbid appearances, comprised under the present head by Laennec and Beclard, are evidently foreign to it, and must therefore be excluded. Any arrangement, however, that may be offered in the present state of the science must, from the very nature of the subject, be imperfect, and susceptible of further improvement. Indeed, I am not certain that the term heterologous, as applied to. these formations, 148 TUBERCLE. is not altogether ill-chosen, and out of place, since most of them are found, when carefully investigated, to have a very close resemblance, in many of their most essential features, to the normal tissues of the body. Although the heterologous formations, properly so called, are not of equal frequency, yet they all have one common tendency, namely, to destroy, sooner or later, the structures in which they are located. Hence the propriety of the term malignant, under which some of them have long been noticed by authors, and from which arrangement, from some unaccountable circumstance, tubercle has hitherto been excluded. Not only, indeed, is this disease malignant, but, if we reflect upon the rapidity of its progress, and its extraordinay fatality, it must unques- tionably be regarded as the most malignant of all the heteroclite form- ations of which we have any knowledge. The period during which the morbid deposits remain, varies from a few months to several years; a circumstance which, together with the several changes which they themselves undergo, and which they exert upon the structures in which they are located, will be fully adverted to in the following sections. These morbid products occur at all periods of life, in both sexes, and in nearly all the organs and tissues of the body. Their origin, although still enveloped in obscurity, is probably of an inflammatory nature, attended with an altered condition of the blood, and an aberra- tion of the nutritive function. SECTION I. TUBERCLE. Of all the heterologous formations, the most interesting, unquestion- ably, is the tubercular, whether it be viewed in reference to its fre- quency, the obscurity which still envelops its nature, or the great attention which it has always elicited from the medical philosopher. Occurring at all periods of life, from the most tender infancy to the most decrepid old age, it is the cause, in all probability, of nearly one-third1 of all the deaths that annually happen throughout the world. If this be true, as the data which we have, though still very imperfect, would lead us to infer, it will be readily granted that a knowledge of this disease must be of vast importance to the practi- tioner, and worthy of his most profound investigation. The term tubercle was anciently applied, in a very vague manner, to almost every kind of tumor, no matter what was its situation, form, consistence, or composition. The confusion concerning the character of this and other morbid products, thus introduced in the infancy of the science, prevailed during more than twenty centuries, and is still, 1 The greater part of this mortality is caused directly by pulmonary phthisis ; the rest by tubercles of the lymphatic ganglions, the spleen, the serous membranes, and the bones. • SITUATION. 149 there is reason to believe, sufficiently common. The definitions which have been given of this term are almost as numerous as the authors who have written upon the disease. It is of Latin derivation, and literally implies a little swelling. In the sense in which I shall here use it, it denotes a small, solid tumor, of an irregularly spherical figure, more or less opaque, of a pale yellowish color, seldom exceeding the volume of a pea, and composed of a peculiar substance, which, sooner or later, undergoes a process of decomposition. This definition, how- ever, does not embrace more than two of the varieties of form in which the tubercular matter is deposited; and it is rather in compli- ance with the established custom of pathological writers, than the rules of sound criticism, that I restrict the meaning of the word within these narrow limits. Situation.—There is hardly an organ in the body in which tubercular matter is not occasionally deposited. Nevertheless, it is much more common in some situations than in others. The lungs, lymphatic ganglions, the spleen, peritoneum, the mucous follicles of the aliment- ary canal, the liver, the spongy texture of the bones, and the adven- titious membranes of the splanchnic cavities, are particularly distin- guished by the frequency with which this disease originates in them. Of these parts, again, the summits of the lungs and the lymphatic ganglions, especially the bronchial and mesenteric, are most liable to suffer; for the reason, probably, that they naturally possess a very languid circulation, and are therefore proportionably prone to inflam- matory congestion. The matter may be deposited upon the free surface of the different membranes, both natural and adventitious, in the cellular tissue, and in the parenchymatous substance of the various organs. In the lungs it is much more frequently witnessed in the air-cells than in the connecting cellular tissue. In the lymphatic ganglions, where tubercular disease is nearly as common as in the lungs, it is always deposited in the interstitial substance. In the liver and kidney the matter may occur upon the surface of these organs, or in their inte- rior ; in the former case it is developed in the parenchymatous tex- ture, in the latter generally in the mucous lining of the excretory canals. In the brain, where there is scarcely any cellular tissue in a free state, the heteroclite substance is deposited in the cerebral texture. The site of tubercular disease is influenced, in a very considerable degree, by the age of the individual. This is a circumstance which, from its practical bearing, is deserving of further attention. The three following tables afford an account of the localization of this heterologous deposit in children and in adults. The first is constructed from the excellent memoir of Dr. Lombard, of Geneva, and is founded on 100 careful autopsic inspections. 150 TUBERCLE TABLE I. Bronchial ganglions Lungs . Mesenteric ganglions Spleen Kidneys Intestines Nervous centres . Cervical ganglions Cerebral envelops Pancreas 87 times. 73 i 31 i 25 i 11 t 9 i 9 i 7 t 6 i 5 i Gastro-hepatic ganglion . Subperitoneal cellular tissue Inguinal ganglions . Subpleural cellular substance Lumbar ganglions . Urinary bladder Omentum Gall-bladder . False membranes of the pleura 5 times. 5 " 3 " 2 " 1 « 1 " 1 " 1 " 1 « The second table is by Rilliet and Barthez,1 and shows the compara- tive frequency of tubercular deposits in different organs, in three hundred and fourteen children between the first and fifteenth year. TABLE II. Lungs . in 265 cases. Liver 71 cases Bronchial ganglions . 249 U Large intestines 60 " Mesenteric ganglions . 144 a Membranes of the brain 52 " Small intestines 134 a Kidneys 49 " Pleura 109 if Brain 37 " Spleen 107 u Stomach . 21 " Peritoneum 86 it Pericardium and heart 10 " The third table is compiled from the treatise of Louis, and refers to 358 cases of tubercular disease after the age of fifteen. A compa- rison of this with the materials furnished by Lombard and by Rilliet and Barthez, will show the occurrence of the morbid deposit in dif- ferent organs in the two periods of life. TABLE III Lungs Small intestines . Large bowel Mesenteric ganglions Cervical ganglions Lumbar ganglions Prostate gland Spleen Ovaries Kidneys . about 357, or in all except 1 \ _\ 1 Carbonate of lime j Oxide of iron, a trace 100 Lombard discovered in crude tubercle ninety-eight parts of animal matter, and only two parts of salts. Chalky tubercle, on the con- trary, contained ninety-six parts of salts, and scarcely four of animal matter. These results have been confirmed by the analysis of L'Heri- tier, who found in hardened tubercle from five to nine per cent, of animal substance, and from ninety-one to ninety-five of carbonate and phosphate of lime. The animal matter consists, according to some chemists, of combinations of proteine. Thus, Vogel states tubercle to consist of fibrin, albumen, casein, fat and extractive matters, a sub- stance resembling pyine, and different salts. The discrepancies in the results of the above analyses may be accounted for by supposing that the chemical constitution of tuber- cular matter varies, as no doubt it does, not only in the different stages of its existence, but also in different individuals, in different situations, and in different parts even of the same organ. It is reasonable to con- clude, also, that it is modified, more or less, by the state of the solids and fluids, or, in other words, by the cachexy, or constitutional pecu- liarity leading to its formation. In all these respects tubercular matter bears the closest resemblance to serum, lymph, and pus, which are often remarkably altered in their chemical and physical properties by the nature of the affected tissue, the state of the system, and the concomitant inflammation. In the inferior animals, the composition 98 0.15 1.85 VARIETIES OF FORM. 153 of this substance presents, perhaps, still greater variety than in the human subject. In the ox, there is always an unusual predominance of earthy salts, and hence the extraordinary brittleness which cha- racterizes the morbid product. In the turtle I have seen the tuber- cular substance of the color and consistence of calcareous moss, or what, in mineralogical language, is termed tufa. In the sheep, horse, and some other quadrupeds, on the contrary, the animal matter is gene- rally much greater than the saline, especially in the early stage of the disease. Varieties of Form.—Tubercular matter presents itself under four distinct varieties of form, the miliary, encysted, infiltrated, and lamel- lated. Of these the first and last are the most frequent, both in man and in the inferior animals, and they all depend upon the condition of the organs and tissues in which they are developed. The miliary variety, so called from its resemblance to a millet-seed, is by far the most common of all, and is the one from which the deposit derives its distinctive name.1 It is usually of a rounded shape, but may be more or less flattened, ovoidal, or angular, according to the degree of compression exerted upon it by the parts in which it is situated. In its volume it varies from a pin-head to that of a pea. In the brain and liver it is sometimes as large as a cherry, a marble, or even a billiard-ball. It is opaque, inelastic, and of a pale yellowish color, either uniformly, or lighter at some points than at others. In some instances, it is grayish, reddish, deep-brown, blackish, speckled, bluish, opaline, or of a whitish pearly tint. Its consistence also is liable to much diversity. Thus it may be hard and dense like fibro-carti- lage, caseiform, curdy and friable, soft, or almost semi-liquid. On account of the difference of color which these tubercles assume, as well as of their difference of consistency, some pathologists have described two varieties: the semitransparent grayish bodies or gray tubercle, in contradistinction to the larger or more friable yellowish masses or yelloiv tubercle. Both present, as will be shown hereafter, the same structure. The yellow tubercle contains, however, more oil, forms larger masses, and has a greater tendency to soften. The gray may become converted into the yellow tubercle. The number of miliary tubercles varies from one to many thousand. In their early state they are perfectly isolated; but, as they augment in volume and number, they gradually approach each'other, and ulti- mately coalesce, resembling, in this particular, the pustules of confluent smallpox. In this manner large masses are frequently formed, varying in density from the consistence of recent lymph to that of fibro-carti- lage, and presenting an ovoidal, globular, polygonal, or stellated con- figuration. Tumors of this description seldom exceed the dimensions of a walnut; but they may attain the bulk of an orange, the fist, or even of a foetal head. This variety of the tubercular deposit, although most common in the lungs and lymphatic ganglions, is often observed 1 It has become customary of late to restrict the term miliary tubercle to very small isolated bodies. In my description, however, of this form of the deposit I include, also, the large masses which are formed by the union of the smaller. 154 TUBERCLE. in other organs, especially the spleen, the serous membranes, the isolated follicles, the Peyerian glands, the kidney, and the liver. _ It also occurs in the spongy tissue of the bones, in the brain, testicle, prostate gland, pancreas, thymus gland, the uterus and ovaries. The mtliary tubercle is occasionally surrounded by a distinct capsule, constituting what is called the encysted variety. The envelop varies very much in its structure and appearance in different cases. On the peritoneum it generally presents itself in the form of a thin, transparent film, of excessive tenuity; more commonly, however, it is of a dense, fibrous nature, from the sixth of a line to a line in thickness, and of a pale grayish color; sometimes pink, violet, or mottled. Externally it is firmly attached to the parts in which it is developed, and from which it is often separated with difficulty. The tubercular matter itself is commonly of a grayish-yellow tint, opaque, interspersed with dark points, and closely adherent to the inner surface of the cyst. Both structures have probably a contemporaneous origin. This, how- ever, is still a mooted question. In old tubercles the cyst is sometimes ossified. This variety of tubercle is very rare. The situations in which it is most commonly found are the peritoneum, lungs, spleen, brain, bones, and bronchial lymphatic ganglions. A third variety of tubercular matter exists in the form of infiltration. It is often found around tubercular excavations, sometimes in con- siderable patches, of a grayish, or yellowish aspect, more or less dense, crisp, and firm, like cartilage. In its texture it is apparently homogeneous, presenting, when divided, a smooth, polished surface, in which it is impossible to discern the slightest trace of the original structure. The deposit has occasionally the aspect and consistence of jelly, and then constitutes the gelatiniform infiltration of Laennec. This form of tubercular secretion is exceedingly rare, and is prin- cipally observed in the lungs in connection with miliary tubercles, the intervals of which it occupies. The heteroclite matter is of a pale reddish, or grayish tint, verging on greenish. In its consistence it varies according to the period at which it is inspected; at first it is soft, semi-concrete, and almost tremulous; but at a more advanced stage it is denser and changes into the ordinary infiltrated tubercle. After an indefinite time both varieties of infiltration experience the same transmutations as the common miliary tubercle, the commence- ment of the degenerating process being announced by the formation of one or more opaque, yellowish points in the interior of the morbid mass. The fourth variety is the stratiform, in which, as the name imports, the tubercular matter is deposited in the form of a layer, generally upon the free surface of the mucous membranes. Next to the miliary variety, this seems to be the most common in which this substance presents itself. It is occasionally met with in the bronchial tubes, but much oftener in the ureter and pelvis of the kidney, the uterus, and the seminal vesicles. The layer varies in thickness from that of a sheet of paper to a line, a quarter of an inch, or even half an inch, according to the capacity of the canal or reservoir in which it is situated. It is opaque, curdy, friable, and of a grayish, cineritious, GRAY GRANULATION. 155 or yellowish tint; it is generally very easily detached from the surface on which it lies, and seems to possess little or no plastic force. It is, in fact, essentially an effete, or excrementitial substance. When the matter is poured into the seminal vesicles, the uterus, ureter, or pelvis of the kidney, the lamellated arrangement is only well marked so long as the deposit is scanty; as soon as it becomes abundant, it assumes an amorphous, nodulated form, and may completely fill the containing cavity. The same arrangement occurs in the bronchial tubes, where the matter sometimes extends into the air-cells, forming small cauli- flower-shaped expansions. This variety of the tubercular deposit is not peculiar to the human subject. It has been repeatedly observed in the lower animals, as the cow, sheep, and rabbit, and I have myself seen it in the green turtle. The new substance, in this instance, occupied the bronchial canals, being arranged in long, cylindrical masses, and in thin, yellowish patches, of an irregular shape, and from five or six lines to several inches in diameter. In some of the tubes it was firm, tenacious, and separated with difficulty from the mucous surface; in others, it was remarkably brittle, dry, putty-like, and apparently unadherent. Many of the air-vesicles were entirely filled with it. There is a form of tubercle which has attracted much notice, and which is known under the name of the gray granulation. It is of a very dense texture, grayish, or colorless, semi-transparent, rounded, ovoidal, or flattened, and from the size of a small pin-head or millet-seed to that of a currant, a pea, or a common cherry. When divided, it is perfectly homogeneous, and exhibits an opaline, shining, or vitreous appearance. It is sometimes invested by a delicate film-like cyst, and always greatly resembles, when first deposited, a globule or small mass of lymph. The number of grayish granulations varies exceedingly. There may be only a few, perhaps, indeed, not more than one or two, or there may be hundreds, and even thousands, according to the size of the affected organ. There is, in fact, no limit in this respect. It is seldom that these little bodies coalesce, unless they exist in vast num- bers, when they may unite, and form masses or nodules, equal, in some instances, in volume to a hen's egg, or even to a large apple. Whether isolated, or grouped, they always adhere with considerable pertinacity to the tissues immediately around them, and are frequently encircled by clusters of red vessels, some of which occasionally extend into their substance. After they have existed for an indefinite period, they generally lose their grayish, opaline tint, and assume the appearance of common tubercles. The change usually begins in the centre, in the form of an opaque, yellowish point, which progressively increases until the whole body is completely softened, or converted into a curdy, friable substance, not unlike semi-concrete cheese. The gray granulation 1s most commonly met with in the lungs, and on the free surfaces of the serous membranes, both natural and adven- titious. It also occurs, and that with considerable frequency, in the mucous follicles of the alimentary canal, in the glands of Peyer, in the larynx and trachea, in the spleen, liver, kidney, and brain. Its exist- 156 TUBERCLE. ence has been attested in the bones, and in the lymphatic ganglions. It occasionally forms with great rapidity, especially in the brain and arachnoid membrane, where the resultant irritation may prove fatal in a few weeks. In the peritoneum, hundreds may be developed in a few days, from the volume of the smallest pin-head to that of a millet- seed. They may occur alone, or, as is almost always the case, be associated with the yellow miliary tubercle. So constant, in fact, is this coexistence that it may be assumed as a law liable to few excep- tions. In 358 subjects, Louis met with only five examples of granulations without yellow tubercles, and two of tubercles without granulations. Considerable discussion has been occasioned respecting the true character of these gray granulations, or, as they are termed, after the pathologist who first described them, "Bayle's granulation." Some have denied their tubercular nature altogether; others, Laennec in- cluded, regard them as nascent tubercles; to me they appear merely as a variety of the ordinary gray tubercle, an opinion which I have long taught in my lectures. The gray granulation seems to be modified by the action of the affected part, the state of the blood, and the condition of the general health. If serum, lymph, and pus are modified in this manner, as we know they are, why should tubercle not be ? That they are liable to assume the characters of the common yellow tubercle is certain, but death may, and often does, take place before any such change is effected. The gray granulation may precede the yellow tubercle, or it may be deposited simultaneously with it. Under whatever circumstances it is found, it is endowed with much greater power of resisting the influ- ence of such agents as have a tendency to destroy it. It is evidently the product of a more healthy action; it indicates a better state of the solids and fluids; in a word, it is a more plastic, organizable sub- stance than common tubercle. How formed.—When first effused, tubercular matter is perfectly soft, fluid, or semiliquid. By degrees, however, as its more attenuated particles are removed, as they always promptly are by the absorbent vessels of the surrounding tissues, it becomes dryer, denser, more opaque, and more solid, and may ultimately acquire the consistence of fibro-cartilage. This constitutes the second stage of the disease, or that of crude tubercle. The period required for this change has not been ascertained. The probability is that it is short. In acute phthisis the tubercles may reach the,ir full development in three or four weeks; while, in the peritoneum, there is reason to believe that they often attain this stage much sooner. In some parts of the body, as, for example, in the peritoneum, we can detect nature, as it were, in the very act of her work, beino- able to trace this substance distinctly as it passes from the fluid to the solid state. In chronic inflammation of this membrane, I have repeatedly seen tubercles in every possible stage of development; some, evidently deposited only a day or two before the individual expired, being soft, viscid, and perfectly transparent; others semi-concrete, yellowish, and consequently more or less opaque; and, lastly, another set perfectly ORIGIN. 157 dense and firm, organized, and covered by an accidental serous mem- brane, of the most delicate texture. Thus, the conclusion is obvious, that all tubercular matter, whatever be its form, site, or extent, is, in the first instance, of a liquid nature, and that it becomes solid, concrete, or crude only by the removal of the serosity which is always poured out along with it. It has been a subject of speculation how a tubercle, originally not larger than a pin's head, may increase to the size of a pea, a cherry, or even an almond. The most plausible hypothesis ascribes the en- largement to juxtaposition, or to the superaddition of one particle to another. The cause which provoked the original deposit continuing in operation, leads to irritation in the surrounding parts, in conse- quence of which new molecules are effused around those already formed, and which thus serve as their nuclei. The process is thus not unlike that of amorphous crystallization. It is upon this circum- stance that many pathologists have founded an argument against the vitality of tubercle, forgetting that lymph, the basis of all new growths, is deposited precisely in the same manner. All tubercular matter, whatever be its site, form, or consistence, is a direct product of the blood, elaborated by a process of secretion similar to that which presides over the separation of serum, lymph, and pus. The effusion is always effected under the influence of in- flammatory irritation, and is preceded, in almost all cases, by the tuber- cular dyscrasia or cachexy. All the solids are enfeebled, and the blood itself is singularly changed in its properties. Even at a comparatively early period it is already quite thin, impoverished, and deficient in globules; its color resembles that of pale claret; and the clot is un- usually small and dense. Thus a predisposition is established, which may be excited into action by a thousand extraneous circumstances, and without which there would rarely, if ever, be any deposit of this kind. In the former editions of this work I expressed the opinion that tubercles are always of inflammatory origin, specific in its character, and a more thorough examination of the subject since has only tended to confirm this conclusion. The concomitant action is usually very languid, or so mild and imperceptible that extensive mischief is often done before the patient is aware of it. In this respect, the develop- ment of tubercles resembles that of a strumous abscess, which is rarely characterized by any of the ordinary phenomena of phlegmasia. The doctrine of the inflammatory origin of this disease is counte- nanced, if not actually established, by the following circumstances:— First, by chemical analysis. Experiments show them to afford albu- men, gelatin, and fibrin; substances which, whether they occur alone, or in combination with each other, are always to be regarded, when found upon the surfaces or in the interstices of the organs, as the result of inflammatory irritation. Secondly, tubercular matter bears a very great resemblance to spoiled, degraded, or cacoplastic lymph, which is an acknowledged product of inflammation. Thirdly, the deposit is often excited by cold, especially when con- 158 TUBERCLE. joined with moisture, and by unwholesome, indigestible, or innutritious food. Dyspepsia frequently leads to the same result. By the former are produced internal congestions; by the latter, a poor and impover- ished state of the blood, so favorable to the development of tubercle. Fourthly, in many cases the disease is attended or preceded by hypergemia, or active congestion. This often happens in the lungs, the pleura, peritoneum, and lymphatic ganglions. Fifthly, the doctrine of the inflammatory origin of this deposition derives great plausibility from what occurs in the inferior animals, from mechanical irritation. In the experiments of Cruveilhier, Kay, and Saunders, well-characterized tubercles were produced in a very short time, simply by dropping mercury into the trachea. Similar effects are frequently witnessed in miners, needle-grinders, and weavers, who habitually inhale gritty or irritating matter. Persons of this description are peculiarly prone to phthisis. Sixthly, there is no appreciable deposit, or effusion in any of the shut sacs, cells or cavities of the body, which is not, strictly speaking, the result of inflammatory action, though this may be too slight to attract attention, or to be attended by the ordinary phenomena of that process. May become organized.—Are tubercles ever organized ? Concerning this question, which has been greatly agitated within the last twenty years, much diversity of sentiment still prevails among pathological anatomists. While many deny that these little bodies are susceptible of this process, on the ground that they are mere morbid secretions, and consequently essentially non-vascular bodies, others maintain that they are supplied with vessels, and endowed, like hydatids, serous cysts, and adventitious textures generally, with an independent vitality. Laennec, it is well known, maintained the independent vitality of tubercle, but failed to adduce any evidence of its organization. Lugol positively asserts that he has, in numerous instances, detected blood- vessels in this deposit. In a valuable paper, in the twentieth volume of the Medico-Chirurgical Transactions of London, Dr. P. N. Kino-ston gives an account of seven cases, in which great numbers of pulmonary tubercles, of the ordinary kind, presented, under the microscope, red vessels, which extended into their interior, and anastomosed, not only with each other, but with the vessels of the adjacent tissues. In one of the cases red vessels were seen in the deposit in the bronchial and mesenteric ganglions. Professor Macartney and Dr. Carmichael, of Dublin, also maintain the independent vitality of tubercle. The former states that he has demonstrated the presence of vessels by in- jection. In a lung which Dr. Bayless injected, at my request, ten years ago, with size colored with vermilion, a number of tubercles ex- hibited the clearest possible evidence of vascularity. On cutting into a mass of this kind, a tubercle, about the size of a duck-shot, and of a light grayish color, was divided, from the centre of which the arti- ficial fluid, which was still warm, ran in a small jet or stream, precisely as blood flows from a divided vessel. Louis,1 although he does not 1 Pathological Researches on Phthisis, case 29th, p. 331. ORGANIZATION. 159 believe in the organization of this substance, on one occasion observed vessels in it. He injected the pulmonary artery, and found ramifica- tions of it in some of the gray semi-transparent masses. Another proof, but of a more indirect character, of the organiza- tion of tubercle, is furnished by the fact that these bodies are often of a yellowish tint in jaundice. This is obviously owing to the ad- mixture of the coloring principle of the bile with the blood, both of which are simultaneously circulated through the heteroclite mass. Again, it may be presumed that tubercles are organized from the transformations they undergo. The process of softening which gene- rally begins in their centre, beyond the influence of external agents, admits of explanation in no other way. Finally, tubercles, as will presently be seen, are occasionally con- verted into cretaceous, sandy, or earthy concretions; which could hardly happen if they were not organized products. In this trans- formation, which may begin at any part of their interior, the animal matter is gradually absorbed, and its place occupied by chalky matter, or phosphate and carbonate of lime. I have never been able to trace any nerves or absorbents into these bodies, nor am I aware that this has been done by others ; neverthe- less, as these structures are everywhere necessary to organization, it is perfectly philosophical to infer their existence. That tubercles are invariably organized, or provided with ves- sels, nerves, and absorbents, no one acquainted with the subject will assert. There are some situations, indeed, in which it would be impossible for the process to be established; as, for example, when the strumous matter is spread over the free surface of the mucous membranes, whether in the bronchial tubes, the uterus, seminal vesicles, or the excretory ducts of the kidneys. Here the heteroge- neous nature of the contents of these reservoirs alone would be an insurmountable barrier to the organization, to say nothing of the peculiar modified character of the morbid secretion itself. I say pecu- liar modified character, because it is well known that the chemical and physical properties of tubercular deposits are widely different in the localities here specified from what they are in other parts of the body. They usually have a deeper yellowish color, are much more curdy and friable, and contain a much greater amount of earthy in- gredients. Upon this point it is hardly conceivable that there should be two opinions. Thus, then, it may be stated, as a general proposition, that, when the tubercular matter is deposited upon the larger mucous surfaces, it is not susceptible of organization ; whilst, when it is effused into the cavities of the cellular tissue, into the air-vesicles of the lungs, and into the intermolecular spaces of our organs, it may, and often does, become " part and parcel" of the living frame. Within the last fifteen years I have examined not less than ten or a dozen specimens of or- ganized tubercles of the kidney, spleen, peritoneum, and lungs, mostly of young subjects. The tubercles were of the miliary kind, and numerous vessels, loaded with florid blood, could be seen shooting into them in every direction, many of them penetrating a considerable 160 TUBERCLE. distance into their substance. Their vascular supply would thus seem to be derived from the tissues in which they are deposited; and this, in the generality of cases, is no doubt true; nevertheless, there is reason to believe that they occasionally possess a self-organizing power, analogous to that of the adventitious membranes of the splanch- nic cavities. If, under favorable circumstances, plastic lymph is capable of generating its own vessels, why should not tubercle be? Although the vessels thus formed must be very small and few in number, they are probably sufficient, in many instances, to preserve the vitality of the tubercle without the aid of the circumjacent textures. Generally, however, such aid is not long withheld; for, as the newly-created ves- sels extend from the central to the peripheral portion of the hete- rologous deposit, they speedily communicate with the arteries and veins of the affected organ. It is in this manner that the organization of tubercle may be supposed to be accomplished, and in proportion to its perfection will be its power of resisting destruction. In making these remarks, I do not wish to be understood as assert- ing that I have seen the vessels which are here supposed to form the proper circulation of tubercle; their existence is altogether assumed from the analogy afforded by encephaloid growths, and the adventi- tious membranes. Actual observation will, perhaps, never avail us much in determining the question, since the subject is beset with difficulties scarcely to be found in any other morbid deposit. But I do assert, unhesitatingly, that I have repeatedly traced vessels into such tumors from the tissues around them, and that, upon dividing them, the section thus made has frequently exhibited small florid dots of blood. But it may be objected that these vessels have never been injected. Granting this to be true, and what, it may be asked, does it prove? Are we reduced to the necessity of denying the vitality of a structure, because we cannot succeed in throwing foreign substances into its vessels ? Microscopical Characters.—Of late years the microscopical character of tubercular matter has been studied with great care. It consists of granules, nuclei and cells lying in a transparent matrix. Most of the granules are very minute, and afford an albuminous reaction; some are fatty, and dissolved by ether. In the yellow variety of tubercle fatty granules generally abound. The free nuclei, or tubercle- corpuscles, constitute a large portion of each tubercular mass. In shape they are very irregular, some being round, others oval, p. 3g oblong, or almost shapeless. They inclose fine, granu- lar contents, but commonly no nuclei. Their size varies from l-3500th to l-2500th of an inch in diameter, and they are regarded by Lebert and his school as the cha- racteristic corpuscles of tubercle. Large cells with seve- ral nuclei are occasionally found in tubercular masses, especially in the air-vesicles of the lung, adhering to the walls, or in their interior. These cells, or the "com- Tubercie-corpus- P™1"1 corpuscles of tubercle," were first described by cies.-After da- Virchow in 18ol. rlheir exact nature is not determined; costa. by many they are considered as abnormal epithelial cells. SOFTENING. 161 Besides these elements, we may find in tubercular masses, oil drops, crystals of cholesterine, and large irregularly-shaped flaky bodies, probably of an albuminous nature, elastic fibres, and epithelial cells, in various stages of fatty degeneration. To morbid changes in the epithelium, several distinguished pathologists have, indeed, attributed the formation of the tubercular corpuscles and deposits. Changes.—When tubercular matter has arrived at the crude stage, it may remain stationary for an indeterminate period. The circum- stances which favor its preservation are dependent partly upon its own intrinsic powers, and partly upon the condition of the surrounding tissues. The state of the general health, also, nx> doubt, exerts an im- portant influence. When tubercles exist in excess they may, so to speak, produce their own destruction, by the pressure which they exert upon each other, and upon the parts in which they are developed. In what is called "galloping" consumption, the period of latency may not ex- ceed five or six weeks. In the ordinary form of the disease, however, the interval is much longer, and may extend to several years. The changes which a crude tubercle may undergo are three: soften- ing, absorption, and the chalky or cretaceous transformation. Of these the first is incomparably the most frequent, and is always accom- panied by more or less destruction of the surrounding tissues. Softening constitutes the third stage of tubercle. By some this change of consistence is supposed always to begin at the centre of the morbid mass; while others, on the contrary, maintain that it may commence at any part, indifferently, at the centre or at the circum- ference. Careful examination leads me to conclude that the process may take place in the latter way, but, in the great majority of cases, it unquestionably begins in the interior of the morbid deposit. In fact, so common is this that it may be regarded as the law, the other as the exception. The softening sometimes occurs simultaneously at several points, and is then usually very rapid. As it advances, the tubercular substance presents a moist, macerated, and unctuous cha- racter, and is gradually transformed into true scrofulous pus. When the degeneration involves the entire mass, it is usual to find two dif- ferent kinds of matter in the little abscess which now occupies its place. Of these one is thick, straw-colored, and inodorous, like lauda- ble pus; the other thin, whey-like, and mixed with small, opaque, cheesy flakes. Agreeably to the doctrine which it has been my endeavor through- out this chapter to enforce, that tubercles are organized structures, the softening of these bodies may be supposed to be analogous to slow suppuration, by which they are gradually broken down and dissolved. They contain, in fact, within themselves the germs of their destruc- tion ; they possess only a low grade of vitality; their power of resist- ance is comparatively feeble; and hence they readily yield to what- ever has a tendency to disturb their molecular arrangement. After they have existed for an indefinite period, they create more or less irritation in the textures immediately around them. This irritation is speedily propagated to the tubercles themselves, which, as they have little plastic force, soon yield to the invasion, the rapidity of their 11 162 TUBERCLE. softening being always in direct proportion to the intensity of the ex- citing cause, and the density of the morbid mass. Those, on the other hand, who believe that tubercles are inorgan- izable products, maintain that their softening is effected solely by the agency of the surrounding tissues. According to this theory, they produce, like any other extraneous bodies, an irritation—an afflux of blood—followed by a secretion of purulent matter; which, insinuat- ing itself into the heterologous deposit, thus causes its disintegration. This theory, however, is opposed by the fact, previously adverted to, that the softening generally begins at the centre of the morbid product, where the surrounding tissues can exert no influence. The softening takes place much more rapidly in some organs than in others, in which it does either not occur at all, or only after a long period. In the lungs, where the process has hitherto been chiefly studied, it may take place as early as the end of the first month from the time of the deposition, though generally not until much later. Upon this subject, however, it is obviously impossible to lay down any definite rule, as the production of the phenomenon in question must necessarily be influenced by a great variety of causes, such, particularly, as the extent of the disease, the state of the patient's health, and the density of the heterologous deposit. Occasionally the softening goes on simultaneously over a large extent of surface, so as to break down one-third, a half, or two-thirds of an organ; but this is rare, and is confined exclusively to acute cases. In the lungs, the degeneration usually begins at the summit, and gradually extends to- wards the base, as is shown by the fact that if these viscera be ex- amined in this direction, we successively find, at various heights, excavations and tubercles in different stages of softening, the more solid being almost always lowest in the scale. Before the changes, of which we have now spoken, take place, the morbid deposit appears to create little disturbance in the general economy, and may exist, some- times to a very considerable extent, without giving rise to symptoms indicative of its presence. After having become perfectly soft, the tubercular matter is either absorbed, or, if it be favorably situated, it works its way out. In the lungs, it usually breaks into the bronchial tubes, leaving thus, not unfrequently, a considerable number of excavations, cavities, or fistulous apertures. In these organs the caverns are rarely entirely empty before the end of the third or the beginning of the fourth month, counting from the time of the invasion of the disease. In recent cases, the walls of the chamber are soft, and lined by a thin layer of lymph; in the more ancient ones, the false membrane is dense, grayish, and from one-fourth to one-third of a line thick. These excavations are most common in the lungs: they are some- times found in the brain, liver, spleen, kidney, and bones; but so sel- dom that our knowledge concerning them here is still very imperfect. In the kidney I have met with them repeatedly. In the long bones they occasionally communicate with the medullary canal, or some contiguous joint, establishing thus an analogy with tubercles of the lungs opening into the bronchial tubes; in the short bones, as those SOFTENING. 163 of the spine, it is not uncommon for them to make their way to the surface by long, tortuous passages, which it is always difficult, and frequently impossible to heal. The size of these caverns is variable. We frequently find them as large as a hen's egg, and, in some instances, even of the volume of the fist: generally, however, they are much smaller, not exceeding the dimensions of a hazel-nut, an almond, or a walnut. The lesions which are observed in the tissues around these cavities, and the changes experienced by the vessels, will be more fully described in the chapter on tubercles of the lungs, to which I must also refer for an account of the process of cicatrization, as it takes place much oftener in those organs than in any other parts of the body. It is very probable that crude tubercles, after a certain period, may be absorbed, and disappear. This conjecture, at all events, is coun- tenanced by what is occasionally witnessed in the human subject, in which, after the symptoms of pulmonary phthisis are apparently well developed, they gradually vanish, and the patient regains his accus- tomed health. In scrofulous affections of the lymphatic ganglions of the neck and mesentery, especially of young children, there is every reason to believe that the tubercular matter is often removed in this manner. In the bones, too, the probability is that it is not always followed by softening. Finally, tubercles may undergo the cretaceous, sandy, or calcareous degeneration. This increase of consistence is most liable to occur in those cases wherein these bodies contain a great disproportion of curdy, friable substance, and in which they have established a sort of tolerance in the surrounding tissues. The transformation, although noticed in various situations, is most frequent in the summits of the lungs and in the bronchial lymphatic ganglions. The animal matter of which crude tubercles naturally consist appears to be abstracted, and its place supplied by the earthy salts, especially the phosphate and carbonate of lime, which have been shown by Thenard, Lombard, and L'Heritier, to form from ninety- three to ninety-eight per cent, of the entire mass. Thus it would seem that in cretaceous and common tubercle the proportions of the ingredients are merely reversed. Advanced age greatly favors this transformation, which, however, sometimes occurs in very young sub- jects and even in children. When the tubercles are very numer- ous, or unusually voluminous, they must necessarily exert injurious pressure upon the parts in their immediate vicinity, and thus embarrass, if not entirely in- terrupt, their functions. The proper tissues of the organs are more or less strangulated, and many of the vascular ramifications are obliterated by absorp- (5 4k Vessels in and around tubercles. 164 MELANOSIS. tion or adhesive inflammation. Even the larger trunks are sometimes very much encroached upon by these bodies. It is in consequence of this obstruction that a sort of supplemental circulation is sometimes established, the object of which is to compensate for the otherwise in- sufficient nourishment of the affected tissues. The new vessels are arranged in arborescent lines, or in the form of a delicate and beautiful network around the tubercular deposits, to the development and vitality of which they no doubt • materially contribute. They are often very numerous, and may be readily filled with fine injection. Fig. 39, from Lobstein, is an excellent illustration of these vessels from a case of granulations of the peritoneum. SECTION II. MELANOSIS. One of the most singular, and, at the same time, one of the rarest of the heterologous formations, is the melanotic, for a correct knowledge of which we are indebted to Laennec. The first account of this disease was given by this distinguished pathologist in 1806, in the Bulletins de la Faculte" de Mddecine de Paris. The term employed to designate this morbid product is a Greek compound, literally signifying black disease, and is synonymous with what has since been called black cancer. The account which Laennec has left of this accidental product, and which may be considered as one of the most accurate and graphic that has ever been furnished, describes it as a homogeneous substance, very similar in its structure and consistence to a bronchial gland, of a deep black color, opaque, humid, and slightly unctuous to the touch. This substance, after a while, has a tendency to become soft; the pro- cess by which this is effected generally commencing in the centre, and gradually proceeding towards the circumference, until it is entirely broken up and dissolved. When this is accomplished, nature sets up an eliminating effort, the surrounding parts take on inflammation, and the heterologous matter is finally expelled, thus leaving a correspond- ing cavity, which either continues open, is lined with lymph, or else completely obliterated. No age seems to be exempt from this disease, though it is, without doubt, much more frequent in the old than in the young. Nor is it confined exclusively to the human subject. It has been frequently seen in the horse, ox, dog, cat, rabbit, rat, and mouse. What is remark- able, it is much more common in white than in colored horses; and the same is true, I have reason to believe, in regard to cattle. It has been seen in certain birds, as the heron. The composition of melanotic substance has been examined by different chemists, both in England and on the continent of Europe; but the most complete investigation which has been made, is that of COMPOSITION. 165 Dr. Barruel, of Paris. According to this chemist, melanosis of the human subject is essentially composed of the coloring matter of the blood, united with fibrin, and of three distinct fatty substances. Of these, the first is soluble in alcohol at a moderate heat, and susceptible of crystallizing in small brilliant scales; the second is soluble only in boiling alcohol, soft, and amorphous; the third is fluid at the ordinary temperature of the atmosphere, of a reddish-brown color, and contains a considerable quantity of phosphate of lime and iron. The result of this analysis is fully confirmed by that subsequently obtained by Dr. Hecht,1 from a specimen of melanosis of the lungs. Dr. Henry, of Manchester, found that a stream of chlorine, passed through a solution of this substance, destroys its black color, and throws down light yellowish flakes. Boiling produces no change, not even when a small quantity of caustic potash is added. Acids do not alter it, except the nitric, which turns it yellow. Corrosive sublimate, the nitrate of mercury, and the muriate of tin precipitate it, the super- natant fluid being left quite clear. To these analyses it may not be improper to add the results obtained by Dr. Foy, of Paris, from a melanotic tumor of the horse. They are as follows:— Albumen Fibrin . A highly carbonized principle Water . Oxide of iron . Sub-phosphate of lime Muriate of potash " soda Carbonate of soda " lime " magnesia Tartrate of soda. probably altered cruor 15.00 6.25 31.40 18.75 1.75 8.75 5.00 3.75 2.50 3.75 1.75 1.75 100.40 The pure substance of melanotic tumors freed from the other organic substances which generally accompany it, has had the name of " melanine" given to it, and is identical in chemical composition with the pigmentary substance of the choroid coat and iris. It is in- soluble in water, alcohol, diluted acids, and only sparingly soluble in alkalies, unless very concentrated. It is opaque, and without any marked taste or smell, and is composed of carbon, hydrogen, nitrogen, and iron, in almost similar proportion as found in hematin, except- ing that it contains less iron. When placed in contact with white linen, it readily communicates to it its peculiar tint; but the stain that is thus produced is easily removed by ablution. Exposed to the atmosphere, it becomes dry, brittle, and pulverizable, and a long period elapses before it undergoes decomposition. By burning, it is converted into a dark, carbonaceous substance, and emits a strong empyreumatic odor. The color of melanosis is considerably influenced by accidental cir- 1 Lobstein, Traite" d'Anat. Patholog., t. i. p. 463. 166 MELANOSIS. cumstances, as the quantity of cruor and cellular tissue entering into its composition. It may be said always to incline to black ; but not unfrequently it presents various shades of brown and yellow, which are usually most conspicuous when this substance is stirred in a small quantity of water. In its consistence, melanosis varies from the fluidity of ink to the density of fibro-cartilage. The minute texture of melanosis has been carefully investigated by Miiller,1 who finds it to consist of a fibrous network, and of numerous meshes, occupied by free, unadherent pigment cells, the largest of which are more than 0.00108 of an English inch in diameter; the smaller vary from 0.00105 to 0.00039, or even less. They are of a pale yellow color, dark, or dark-brown, and of a rounded, oval, or irregular figure; some are elongated, and a few are actually caudate, terminating at one or both extremities in a point, or in a fibril. The pigment cells are not present in all specimens, and the smaller ones are supposed to be young cells set free by the rupture of the old. They are filled with yellowish or blackish granules, and a few of the larger ones occasionally contain, independently of these bodies, a nucleus with its nucleolus. In some of his examinations, Miiller found the granules free, and dispersed through the meshes of the fibrous network. It is probable that, in these instances, the cells were dis- solved, or broken down, so as to allow their contents to escape. These colored granules may be found in the cells of other structures, both normal and abnormal. They are seen in the lung-pigment and frequently in elements of cancerous tumors. Their occurrence in this latter class of growths has made several pathologists doubt the exist- ence of melanosis as a separate disease, and especially as distinct from cancer; but such is not the view that I believe the most correct. How these pigment-cells of melanosis are formed is matter of doubt. Virchow considers them as transformations of blood-corpuscles within cell- walls. Varieties of Form.—With respect to form, there are six varieties under which this matter is deposited, the tuberoid, lamellated, dot- like, infiltrated, ramiform, and liquid. The tuberoid variety, as the name indicates, occurs in distinct masses, varying in diameter between a currant and a walnut, of a dull sooty color, and of a spherical, ovoidal, or conical shape. By the agglomera- tion of a number of such bodies, large tumors are sometimes formed, with a rough, lobulated surface, which always attain their greatest development in the cellular and adipose tissues. In the human sub- ject, their size seldom exceeds that of the fist; in the horse, on the con- trary, they have been found to weigh from twenty to forty pounds. _ A thin, transparent covering, evidently formed out of the natural tissues, invests these tumors, and gives them the appearance of being encysted. Vessels and nerves are occasionally seen ramifying over their surface, or penetrating their substance, and in many cases they are intersected by fibrous filaments, which are either derived from the general envelop, or they are the remains of the lacerated 1 Op. cit.,p. 56. FORM—DIATHESIS. 167 cellular substance into which the heterologous matter is originally deposited. These circumstances have led to the opinion—at first sight plausible enough, yet wholly erroneous—that the black matter of these tumors is organized. Of the vessels which are distributed to the melanotic mass, the veins greatly predominate; they are often very large and tortuous, and are liable to give way under the most trifling causes. Both arteries and veins are incapable of being in- jected, the matter used for this purpose being always extravasated in the substance of the morbid deposit. When the tumor is developed on the serous surfaces, it frequently presents a pedunculated appearance, like certain polypes of the uterus, and vagina. In such cases it is always surrounded by a distinct cyst, of which it is difficult to say whether it is a new formation, or simply an extension of the natural membrane. There is another variety of melanotic tumor in which the covering seems to be formed by con- densed fibrin, effused, in all probability, as a consequence of the irrita- tion excited by the presence of the foreign matter. Sometimes the cyst is of considerable thickness, firmly connected with the circumjacent tissues, and furnished with minute vessels; generally, however, it is remarkably thin, soft, flocculent, and without the least visible trace of organization. This variety of melanosis occurs most commonly in the liver and brain. It is extremely rare in the human subject, but I have noticed it repeatedly in the liver of the ox. The lamellated variety is observed chiefly in the inferior animals; it is extremely rare in the human subject. It is confined exclusively to the serous membranes, where it is usually deposited into the con- necting cellular tissue, in small, irregular patches, of a black brownish color. More rarely the matter is poured out upon the free surface of these textures. When this happens, the layer is seldom more than the fourth of a line in thickness, of a soft, pulpy consistence, and covered with a thin, transparent pellicle of new formation. The peritoneum is the most common seat of the lamellated variety of melanosis; and here it is often difficult to distinguish it from the spurious form of the dis- ease, caused by the deposition of blood, and the subsequent changes which this fluid undergoes from contact with the acid contents of the alimentary tube. In some instances the serous membranes present a stained appearance, as if the heterologous matter had been effused into their intermolecular spaces. Such spots are not infrequent in the peritoneum of those who die of ascites. In the punctiform variety the melanotic matter appears in small points, thousands of which are sometimes scattered over the surface of the affected organ, giving it a singularly speckled aspect. This form of the disease, which may-be easily imitated by dusting a piece of white paper with soot or powdered charcoal, is most common in the lungs, liver, and subserous cellular tissue of the alimentary tube. I have also repeatedly seen it in the skin of white horses. When the points are very close, the affected part may present the appearance of being infiltrated. Ramiform is the term used when the adventitious matter is contained in the vessels deposited upon their surface, or effused among their tunics. This variety is chiefly met with in the 168 MELANOSIS. liver and the lymphatic ganglions, either alone, or in association with the infiltrated and tuberoid forms. Finally, melanotic matter may present itself in a fluid slate. This form, however, is exceedingly rare, and is noticed chiefly in the serous cavities, the lungs, and the urinary organs. A considerable number of examples of collections of liquid in the peritoneal cavity, of the color and consistence of ink, are on record. It must be confessed, however, that it admits of much doubt whether the effused matter was usually anything more than blood, altered in its composition by the agency of the absorbent vessels. Instances in which melanotic fluid was ex- pectorated, though rare, are mentioned by different writers; and ex- amples are on record in which it was voided along with the urine. Black, inky-looking matter has often been discharged by vomiting and stool. A case has been published in which a cyst, developed in one of the kidneys, contained eight ounces of this liquid. The tissues most prone to the melanotic deposition are, beyond all comparison, the cellular and adipose. Large masses of this substance are often met with under the skin, particularly of the trunk, in the mediastinal cavities, in the folds of the mesentery and omentum, and around the kidneys. In horses, the subcutaneous substance of the buttock, anus, vulva, and tail, is a very common seat of the disease. Of the different organs, the liver, lungs, spleen, eye, kidneys, and ovaries, may be enumerated as being most frequently affected. The lymphatic ganglions, especially those of the bronchias, are also very liable to it. The bones, fibrous and serous membranes, the pancreas, arteries, and salivary glands, are seldom implicated; while the brain and spinal cord, the nerves, the veins, the muscles and their tendons, the cartilages, the synovial and mucous membranes, the uterus and mammary glands, the thyroid and thymus bodies, the prostate, testicle, seminal vesicle, and supra-renal capsule, enjoy almost an entire im- munity from its invasion. I have seen melanosis of the heart; but this is the only portion of the system of involuntary muscles in which this disease has been found. The system is not unfrequently affected with a genuine melanotic diathesis, the disease in question occurring either simultaneously, or in tolerably rapid succession, in a great number of organs and tissues. Of this a remarkable example came under my observation in 1855, in a man, aged fifty-eight, a pilot on the Ohio and Mississippi rivers. He had been an invalid for upwards of twelve months, during eight of which he had been constantly confined to his bed. His principal symptoms were, progressive emaciation, a frequent, irritable pulse, night-sweats, harassing cough, occasional discharges of blood from the bowels, and a frequent desire to void his urine. Towards the last, oedema of the extremities supervened, aphthae formed in the mouth, and he finally died completely exhausted. An examination of the body, made by Prof. T. G. Eichardson and myself, disclosed the existence of numerous tubercles in the subcu- taneous cellular substance, chiefly on the abdomen, chest, and shoulders, of a black or grayish color, movable, firm, of a rounded or ovoidal shape, and from the size of a small pea to that of the kernel of a CAUSES. 169 prune. A few of the larger tubercles projected into the skin, impart- ing to it their peculiar tint. The lymphatic ganglions of the groins and axillae were enlarged and melanotic. The omentum and peritoneum presented thousands of black shot-like tubercles, interspersed, here and there, with whitish ones, very vascular, and of larger volume. The spleen was sound; but the liver and gall-bladder, the pancreas, stomach, small and large bowel, the kidneys and supra-renal capsules, the urinary bladder, prostate gland, and seminal vesicles, the lungs and pleurae, the bronchial ganglions, the thyroid gland, and the heart, were all more or less extensively involved in the melanotic disease. No examination was made of the brain, voluntary muscles, and bones, except the ster- num, which was natural. The vessels were free from the characteristic deposit. One of the most remarkable features in the above case was the ex- istence of numerous white and grayish tubercles in the midst of the black, indicating that the former were of younger growth, and that they had not yet been impregnated with the melanotic matter; or, what is the same thing, that the older the tubercles were the darker was their color. Melanosis may exist alone, or be combined with other heterologous formations. Of these the most common is the scirrhous; the rarest, the tubercular. The tissues immediately around the melanotic deposit are often very much contaminated. Sometimes they are only hardened, or perhaps softened; at other times they are extensively infiltrated with the morbid matter, and of a deep black color. When the tumors are developed in the muscular substance, the fibres are merely pushed aside by them, without being contaminated by the disease. The nerves and bones likewise remain intact. Melanotic tumors, after having acquired a certain size, generally remain stationary, giving rise to little or no inconvenience, save what results from their bulk and consequent pressure. At times, however, they manifest a disposition to ulcerate, and, when this happens, an intractable sore is left, with hard, ragged edges, from the surface of which there is a constant discharge of black, inky matter, mixed with blood, pus, or a thin, fetid, ichorous fluid. When removed, the most remarkable feature of these tumors is their tendency to reappear in the neighborhood of the cicatrice, or in some other situation. The melanotic matter is always deposited in the liquid form. Indeed, we can scarcely conceive of the possibility of its being secreted in any other way. In the course, however, of a short time after the effusion has taken place, the matter becomes inspissated, by the gradual absorp- tion of its more attenuated particles; and in this manner it finally acquires the hardness and density of a solid substance. What cor- roborates this view, is the fact that thin, liquid melanotic matter is sometimes found in the splanchnic cavities without any breach of the serous membranes, and that it frequently exudes in this form from the surface of carcinomatous and other tumors, in a state of ulceration. Of the causes of this disease, and of the states of the system which predispose to it, nothing is known with any degree of certainty. That the melanotic matter is derived immediately from the blood, both 170 SCIRRHUS. anatomical examination and chemical analysis abundantly show; but how far, or in what respect, this fluid is altered before the deposition is effected, are points in the history of this disease concerning which pathology and physiology are equally silent and undetermined. If we remember that melanosis is essentially composed of the same ele- ments as the coloring matter of the skin and of the choroid coat of the eye, we may be allowed to suppose that this substance, existing in an unnatural quantity in the blood, is deposited by an aberration of the nutritive functions of the vessels, into organs and tissues in which it is not found in the normal state. By some, however, melanotic matter is regarded as effused blood, which has undergone a peculiar pigmental transformation. It is said to be most common in individuals of a melancholic temperament. In the inferior animals, especially in horses and asses, it often betrays an hereditary tendency, and the same circumstance has occasionally been witnessed in the human subject. Melanosis, even when in a state of suppuration, does not seem to be communicable by immediate contact. Gollety-Latournelle re- peatedly attempted to propagate the disease from infected mares to healthy horses during coition, but without success. Gohier inoculated horses, asses, and dogs with matter of this kind, without, in a siugle instance, inducing the disorder. SECTION III. SCIRRHUS. Scirrhus may be defined to be a hard, crisp, opaque substance, of a light grayish color, with dull yellowish, fibrous intersections, or- ganized, liable to lancinating pain, occurring for the most part after the middle period of life, and passing sooner or later into ulceration. The disease, like tubercle, has its regular period of growth, maturation, and decay ; like it, it is merely a local manifestation of a constitutional disorder; and, like it, its tendency is ultimately to destroy, not only the tissues in which it is deposited, but also the life of the individual. To comprehend, in the fullest manner, the circumstances which modify its physical characters, the disease should be studied in its various stages and in different organs of the body. Varieties of Form.—Scirrhus occurs as a solitary tumor, or in dis- seminated masses, as an infiltration, or as a lamella, of variable extent and thickness. Of these varieties the first is by far the most com- mon ; both the others, especially the second, are infrequent. In the tuberoid variety, the heterologous substance forms small cir- cumscribed nodules, the number of which, as in the liver is some- times very great, and the consistence of which varies between fresh pork and fibro-cartilage. Their size and shape are much influenced by the nature of the tissues in which they are developed, and by the STRUCTURE. 171 resistance which is offered ta their progress. Single tumors of this kind are rounded, ovoidal, or conical; when, on the contrary, several are agglomerated together, they are generally very irregular, angular, and more or less tabulated. In their size they vary between a mus- tard-seed and an adult fist, their average being that of an almond, a lemon, or an orange. In the infiltrated form, the morbid matter is diffused through the interstices of the affected organ, which it converts into a substance similar to itself. It is extremely infrequent, and occurs chiefly in the lungs, liver, uterus, kidneys, and bones. The primitive texture, whatever it may be, gradually loses its normal color and consistence, but its volume is seldom much augmented or diminished. Finally, the adventitious matter may appear in the form of a lamella, layer, or stratum, either beneath or upon the surface of the serous and mucous membranes. This variety is most frequently met with in the submucous cellular tissue of the oesophagus, stomach, and bowels. In these situations it is not unusual to find large patches of this descrip- tion, of a pale bluish tint, crisp, from one to six lines in thickness, and of a dense, fibro-cartilaginous consistence. The lining membrane, together with the muscular tunic, sooner or later participates in the disease ; and the part of the tube corresponding with the seat of the lesion becomes hard, rigid, and contracted. Structure.—A scirrhous tumor creaks under the knife, is opaque, firm, inelastic, and of a white bluish color, with various shades of gray, rose, and drab. These tints are most conspicuous when there is an admix- ture of bile, blood, or pus, as sometimes happens when the heterologous matter is very old. Thin slices of it are found to be semi-transparent, flexible, and elastic; when dried, they exhibit nearly all the properties of the horny tissue. Fibrous intersections, generally of a slightly yellowish color, are seen to pervade the diseased mass, starting from the centre as their common nucleus, and radiating thence towards the circumference. These lines are merely the remains, in most cases, of the cellular substance of the affected part, and are often so arranged as to resemble very closely the fibrous structure of an unripe pear or turnip. A creamy-looking fluid is occasionally incorporated with the heteroclite mass, and constitutes the most decided evidence of its car- cinomatous nature. Scirrhous growths, especially such as occur in the female breast, occasionally contain hydatids. A more common appearance is the development of cysts, filled with a thin, grayish, gummy substance. Clotted blood is likewise present in some instances. By some writers, scirrhous tumors are said to be always furnished with a distinct cyst; as a general rule, however, this is not the case, and this forms one of their characteristic features. When they are very large and old, the cellular tissue around them is generally a good deal condensed, but seldom to such an extent as to entitle it to the appellation of a cap- sule. Distinct vessels are very rarely perceived in them; nor is it possible to discern any nerves. Scirrhus is susceptible of considerable variation of structure, de- pending chiefly upon the quantity of the adventitious matter, its vas- 172 SCIRRHUS. cularity, its mode of aggregation, and the pressure which is exerted upon it by the surrounding parts. A knowledge of this fact has led to the establishment of several subdivisions or varieties, of which I shall specify only a few of the more common and important, as the mammary, pancreatic, lardaceous, and reticular. The mammary form of scirrhus exhibits an appearance similar to a section of the female breast, or a boiled udder. The tumor has a tabulated arrangement, and is intersected in various directions by fibrous bands of a dull white, bluish-gray, or pale straw color. It is ordinarily solitary, and rarely acquires much bulk. The pancreatic variety derives it name from its resemblance to the pancreas. It is firm, dense, inelastic, and composed of numerous lobules separated by bands of cellular tissue, and resolvable into granules, or smaller bodies. The tumor in its bulk may equal an orange, or a large fist; it is occasionally inclosed in a distinct capsule, and usull}' selects the breast or lymphatic ganglions for its seat. The lardaceous variety is met with chiefly in the lungs, uterus, and mammary gland. The adventitious matter is diffused through the tissues of the affected organ, which it compresses, alters, and finally transforms into a substance similar to itself. It cuts with con- siderable crispness, and closely resembles a section of the rind of fresh pork, having little or none of the fibrous arrangement of ordi- nary scirrhus. The extent of the deposit is generally inconsiderable; in some instances, however, it affects one fourth, a half, or even two- thirds of an organ, the weight of which is always increased, while its form and dimensions commonly remain unchanged. However this may be, it may continue in a crude state for many years; at length, however, it takes on softening, and then pursues the same career as ordinary cancer. One of the most common varieties of scirrhus is the reticular, the ordinary seat of which is the mammary gland, though it may also occur in other parts, as the stomach, lymphatic ganglions, lip, eye, heart, and anterior mediastinum. It is distinguished by its white or bluish reticular figures, by its large bulk, and by its tendency to assume a tabulated form; its consistence ranges between scirrhus and encephaloid. This form of cancer is composed of gray globules, im- bedded in the meshes of a fibrous network, which is not seen until after their removal by scraping or maceration. The reticular figures, which give this variety of scirrhus its distinctive features, are white, or yellowish-white, and of a very irregular shape; sometimes they have an arborescent arrangement, at other times they appear in spots. They are peculiar formations, not dilated vessels with hypertrophied walls, such as are sometimes seen in the ordinary form of the disease, but they are produced by the inlaying of white grains in the gray mass. Chemical Constitution.—The chemical composition of scirrhous matter has been examined by different chemists; one of the most complete analyses is that published by Foy, and which is as follows:— COMPOSITION—AGE — MINUTE TEXTURE. 173 Albumen . 42.00 White fatty matter . 5.00 Red fatty matter . . 3.25 Fibrin . . 5.85 Water . . 5.00 Oxide of iron . 1.65 Subphosphate of lime . . 16.60 r Soda . Carbonate of 1 Lime (_ Magnesia Hydrochlorates of I g°^SSa Tartrate of soda . 5.00 6.60 0.85 4.10 3.25 0.85 100.00 Hecht1 found seventy-two grains of scirrhous breast to contain— Albumen.......... 2 grains. Gelatine..........20 " Fibrin...........20 " Fluid fatty matter........10 " Water...........20 « Seventy grains of scirrhous uterus were found, by the same chemist, to be composed of— Gelatine . Fibrin Fatty matter Water 15 grains. 10 " 10 " 35 " 70 By comparing the analysis of Hecht with that of Foy, it will be perceived that it exhibits striking peculiarities, consisting mainly in the presence of a considerable quantity of gelatine, in the small proportion of albumen, and in the entire absence of inorganic salts. It will also be noticed that the results obtained by Hecht in his two examinations differ remarkably from each other. Thus, in his first analysis, albumen is enumerated as one of the ingredients, while in the second none of this substance appears to have been detected ; there was also a greater proportion of fibrin and gelatine, and a much smaller quantity of water. Miiller agrees with Foy in stating that scirrhus rarely, if ever, contains any gelatine, while Morin and Collard de Martigny unite with Hecht in asserting that it is an invariable elementary principle of this deposit. On the whole, it may be fairly inferred, from the preceding statements, that the intimate composition of scirrhous matter varies considerably not only in different parts of the body, but likewise in different stages of the disease, and probably, also, in different parts of the same preparation. Period of Life.—Scirrhus rarely appears before the age of thirty, in which respect it differs strikingly from encephaloid. It is much more common in women than in men, and its favorite period of attack is from the fortieth to the fiftieth year. It rarely occurs before the period of puberty. My son, Dr. S. W. Gross, has recently reported a well marked case of cancer of the liver, in a child under three months of age. The lymphatic temperament is supposed to predispose to it, and in some instances it seems to be connected with a hereditary taint, being transmitted from parents to their offspring. In the uterus and mammary gland, it has been repeatedly observed in several members of the same family. Seat.—Scirrhus sometimes attacks a considerable number of organs 1 Lobstein, Traite d'Anatomie Pathologique, t. i. p. 405. 174 SCIRRHUS. Fig. 40. in the same individual, either simultaneously, or successively. In females, it is not uncommon to find both the breast and the uterus involved at the same time. It occasionally co-exists with encephaloid, tubercle, melanosis, and hydatids. The parts of the body most liable to scirrhus are such as have a glandular structure. In females, it is most common in the breast and uterus; in males, in the penis. In both sexes the lips, stomach, rec- tum, and liver may be mentioned as frequent seats of it. The spleen, lungs, and kidneys are seldom affected. It is also extremely rare in the bones; and it is doubtful whether it ever occurs in the cartilages, in the serous, synovial, and fibrous textures, and in the muscles of voluntary life. Organization.—The mass of scirrhus consists of two distinct sub- stances, a firm fibrous, and a softer granular. The former is of a whitish, cineritious or pale yellowish color, and is composed of a very irregular network, the meshes of which have no determinate shape or size. It constitutes the bed in which the granular element is deposited, and is seldom very apparent until the latter has been scraped away or removed by maceration. When this has been done, its filaments are found to intersect each other in every di- rection, as is seen in Fig. 40, and to form the cells, meshes, or cavities, just alluded to. The fibrous element is not always a new product, but merely the remnant of the tissues in which the morbid matter is seated. In scirrhus of the mammary gland, it seems to consist mainly of the pre-existing areolar substance and the lactiferous tubes, the former of which is very much condensed, while the latter are hypertrophied and filled with a colorless, whitish or yellowish matter. In scirrhus of the liver, ou the contrary, the fibrous structure is generally of new formation, just as much so as the cells it serves to inclose. The softer part of scirrhus inclosed in the meshes of fibrous tissue consists mainly of cells and free nuclei lying in a transpa- rent, slightly granular matrix. The cells are generally large, possessed of delicate but distinct cell-walls, are not very granu- lar, and inclose one or several distinct nu- clei. Their shape differs; some are round, others oval, others again caudated; their size varies from the T^w to B J „ of an inch in diameter. The nuclei in the cells are always large, and generally of an oval Fibrous stroma of scirrhus. Fig. 41. Cancer-cells from the bladder, inclos- ing one or more large nuclei.—After Da Costa. CAUSES — HYDATIDS. 175 shape; they frequently contain one or several distinct nucleoli. Some- times many free nuclei are dispersed through the uniting substance. Furthermore, in many cancers, both cells and nuclei rapidly change, and we may observe, in addition to the structures described, oil-drops, granules, crystals, and cells in different stages of degeneration. The differently shaped cells, with large, distinct and regular nuclei, are almost always present in cancerous tumors. They abound in en- cephaloid, and have been regarded by many pathologists as the charac- teristic cells of cancerous tumors. Although so frequently found, cancerous tumors are met with which do not contain any of these so- called "cancer-cells." Concerning the proximate cause of scirrhus, nothing is known with any certainty, notwithstanding the numerous attempts that have been made to investigate it. We may, perhaps, assign it to a specific change of the blood, or to a general cachexy, which determines the local mani- festation of the disease. This latter may sometimes supervene upon external violence,'such as a blow, kick or bruise. The deposit itself, I believe to be nearly always preceded by inflammatory irritation of the part. The precise nature of this action cannot be defined: all that can be said about it is, that it is of a specific kind, and that it gives rise to the effusion of a fluid analogous to the fibrin of the blood, and not very dissimilar, consequently, from the matter of tubercle. The cancerous matter is deposited into the cellular structure of the organs, which it gradually transforms, effaces, or destroys. That this is the case, is sufficiently evinced by what happens in the liver, kidney, and pancreas. Cases occasionally occur in which it can be discovered in different stages of its development, so as to enable us to determine the manner in which it is effused. Thus, in the liver, the scirrhous mat- ter generally appears in very minute, circumscribed points, correspond- ing with the granulations which are so abundantly found there in the natural state. At first, there is merely a change of color, the granu- lations exhibiting a pale grayish aspect, without the slightest deformity or change of volume. At a somewhat later period, the little tumors are observed to be of a white milky hue, hard, dense, crisp, opaque, irregularly spherical, and perfectly devoid of the original structure. Now these alterations, it is quite evident, can only be accounted for on the assumption that, in proportion as the heterologous matter is deposited into the cellular texture of the acini of the liver, their pro- per parenchymatous substance, whatever it may be, together with their vessels, is obliterated by absorption, the pressure which the accidental secretion produces being fully adequate to bring about this result. Similar phenomena may be witnessed during the development of scir- rhus in other organs. From the foregoing remarks, then, it may be concluded, first, that the deposit of scirrhus is preceded by inflammation; secondly, that it has a great predilection for the glandular viscera; thirdly, that it rarely occurs under the age of forty; fourthly, that the matter of which it consists, when first deposited, strongly resembles that of tubercle; and, lastly, that this matter is deposited always into the cellular tissue 176 SCIRRHUS. of our organs, in such a manner as to transform their proper paren- chymatous structure. Changes.—After having existed for some time, varying from a few months to several years, the scirrhous matter manifests a disposition to become soft, the process by which this is effected commencing, like that of tubercle, at different parts of the diseased mass, from which it extends in various directions, until the whole or the greater portion of it is broken up and dissolved. Some authors have contended that the liquefaction invariably begins in the centre; but that this is not true, my own experience abundantly attests. The process, in fact, may commence at any point, at the centre or at the periphery, or simul- taneously in both these situations; and, as it advances, the superincum- bent integuments crack at one or more places, through which the soft- ened matter, now of the aspect of encephaloid, jelly, syrup, gum, or honey, is ultimately discharged. Ulceration, however, often occurs in scirrhous tumors long before the internal disorganization in ques- tion is accomplished. A scirrhous ulcer possesses certain features which may be con- sidered as characteristic. Generally, it is remarkably irregular in its shape, with a surface that is either cracked, fissured, or fungous, of a dark, reddish color, and of a peculiar glossy, cedematous aspect. Soft cauliflower excrescences sometimes sprout from it, so sensitive as to bleed on the slightest touch, or even of their own accord. The edges of the sore are of a reddish-gray color, elevated, everted, irregularly serrated, and harder in some places than in others, emitting more or less sanies on pressure. A deep excavation is occasionally formed, presenting the appearance as if a portion of the diseased mass had been lifted out of its bed. In cases which run their course very rapidly, the surface of the ulcer is frequently covered with a soft, grayish putrilage, of the most intolerable odor. The fluid which bathes the surface of the ulcer is generally of a thin, bloody, ill-conditioned nature, with an odor approaching that of ammonia. It is always highly irritating, and the quantity discharged is sometimes surprisingly great. It always blackens silver, and im- parts a green color to syrup of violets. Potash produces no change; but, on the addition of sulphuric acid, a peculiar gas is evolved, having many of the properties of sulphuretted hydrogen. This gas appears to exist in union with ammonia, and gives the fluid its peculiar fetid odor. In this advanced stage of the disease, the skin around the ulcer is of a purple color—from the overloaded state of its capillaries—hard, puckered, somewhat tender on pressure, and easily eroded by the irritating discharges. By degrees, the ulcer spreads both in depth and diameter until at length the whole mass is involved in the dis- organizing process, and the patient sinks under the exhausting hectic, caused by the profuse local discharges, and by the violent constitu- tional irritation. The lymphatic ganglions in the neighborhood at this advanced stage are almost constantly enlarged and indurated, and the tumor, instead of being movable and circumscribed, as it was in ENCEPHALOID. 177 the early period of its growth, forms a hard, solid, undefined mass, firmly adherent to the surrounding structures. Finally, scirrhus, after having attained a certain age and bulk, is occasionally assailed by destructive inflammation, followed by slough- ing of the whole of the heterologous matter. I have witnessed this mode of termination only in one instance. The patient was an elderly lady, who had a medium-sized scirrhous tumor in one of the mam- mary glands, of several years' standing. Without any obvious cause inflammation set in, and in a few weeks the whole mass was lifted from its bed, as neatly as if it had been dissected out with the knife. Subsequently the disease showed itself in the axillary lymphatic gan- glions, and made rapid strides towards a fatal termination. SECTION IV. ENCEPHALOID. Intimately allied to scirrhus, in its mode of origin, yet differing from it widely in many of its essential features, is encephaloid, one of the most formidable and destructive of the heterologous formations. As the term indicates, this morbid growth bears a great resemblance to the cere- bral tissue, not only in appearance, but also in chemical composition. Most writers designate this disease by a different appellation, accord- ing to the peculiar notions which they entertain of its composition and structure. Thus it has been called medullary sarcoma, fungus hsema- todes, soft cancer, medullary fungus, and cerebriform cancer. The term encephaloid seems, on the whole, the least objectionable, and I shall therefore retain it on the present occasion. Encephaloid, compared with some of the other heterologous forma- tions, is a very frequent disease, occurring in both sexes and at every period of life. It is not peculiar to the human subject, but is occa- sionally witnessed in the inferior animals, especially the horse, ox, and dog. It may exist alone, or be associated with tubercle, scirrhus, melanosis, hydatids, and other growths. Varieties of Form.—The foreign matter is deposited in the different organs in three distinct varieties of form, the tuberoid, the stratiform, and the infiltrated. In the tuberoid variety the heterologous matter appears in the form of a circumscribed tumor, from the size of a pea to that of an adult head. In its shape it is generally irregularly rounded, ovoidal, or even quite flat, according to the amount of pressure exerted upon it by the surrounding parts. It is composed of different lobules, which are enveloped by a thin covering, and separated from each other by delicate membranous partitions. The outer, covering, evidently derived from the neighboring cellular tissue, is usually not more than half a line in thickness, easily torn, semi-transparent, and of a light rose color. From its inner surface are detached numerous processes, 12 178 ENCEPHALOID. which, dipping into the morbid growth in various directions, form so many cavities for the reception of the new deposit. These septa, which are sometimes remarkably rough and shreddy, always become more obvious after the pulpy mass is squeezed out. The cells which they form by their intersections are subject to much variety, and hence the peculiar tabulated shape which characterizes the morbid growth when occurring in parts that offer little or no obstacle to its extension. Although the covering of encephaloid tumors is ordinarily derived from the pre-existing structures in their immediate vicinity, yet cases occasionally occur in which it is evidently of new formation. In such cases, the external envelop is generally very thin, or, indeed, almost film-like, easily lacerated, and of a grayish color, with rough, shreddy surfaces. The interior septa are likewise less perfect, and the whole mass is commonly so soft as to yield to the slightest force. The external envelop and its internal septa are abundantly sup- plied with vessels, which, pervading the morbid mass in different directions, assist in its growth, and in maintaining its vitality. These vessels, which always consist of a much greater number of veins than of arteries, are often remarkably large, convoluted, and easily traced to the neighboring trunks; their walls are exceedingly brittle, and hence the most trifling accident is liable to be attended with effusion of blood. Hence, too, the dark clots which are so frequently met with in encephaloid tumors. The cerebriform substance itself is easily squeezed out of its cavities, owing to its imperfect adhesion; and, in- terspersed through different parts of it, are frequently observed, besides the sanguineous depots just adverted to, small cells filled with purulent matter, serum, or thin, sanious, and offensive fluid. I have seen as much as half a pint of reddish serosity flow from a single cavity of this kind, the inner surface of which had a peculiar honeycomb-like appearance. When developed beneath the pleura and peritoneum, these tumors generally assume a pear-shaped appearance, the footstalk, by which they are attached, being often quite slender. In their volume they vary between that of a pea and a walnut; they are of a dirty straw color, and of a semi-concrete consistence. Although usually isolated, they sometimes occur in groups, and are always distinctly encysted, the capsule which covers them being either of new formation, or, as more frequently happens, derived from the serous membrane beneath which they are developed. This variety of encephaloid is uncommon. The stratiform variety is exceedingly rare; I have met with it only in a few instances. It is found chiefly in the submucous cellular tis- sue of the stomach and rectum, and beneath the serous membranes especially the pleura and peritoneum, in irregular patches, from the diameter of a pin-head to that of an American dollar. The deposit is generally of a whitish, cream-like color, tolerably hard and dense, and from the fourth of a line to the twelfth of an inch in thickness. Seve- ral such patches occasionally run together, forming an irregular layer of considerable extent, over which the serous membrane is indurated and puckered. VARIETIES OF FORM. 179 The encephaloid matter sometimes occurs as an infiltration. This variety, which is likewise very uncommon, is seen principally in the uterus, liver, and lungs, where it forms small, irregular masses, of a semi-concrete consistence. In the situations here referred to, the heterologous substance usually partakes more or less of the color of the parts in which it is deposited, and is often distinguished with dif- ficulty from tubercular infiltration. Structure.—The color of the heterologous substance, although gene- rally inclining to cineritious, runs through various shades of white and red, having either the yellowish aspect of cream, the complexion of jelly, or the black appearance of the crassamentum. In the tuberoid species, it is not unusual to see different sections of the morbid mass exhibit different shades of color, one part being pale, another cine- ritious, and a third of a deep brown, from the intermixture of clotted blood. It is seldom that the tumor has the pure white aspect of the medullary substance of the brain. The consistence of this morbid growth is also subject to much variety. Though in general pretty nearly that of the foetal brain, it is some- times as soft as cream, and at other times as hard as fibro-cartilage. Like tubercular matter, it has been supposed by some to be ori- ginally deposited in a concrete state; but such an opinion is alto- gether untenable, for it cannot be supported even by a single argument from analogy. The error into which some anatomists haye fallen, may be explained by the fact that the heterologous matter varies in its physical and chemical properties, not only in different organs of the body, but often, also, in different sections of the same mass. Thus, we frequently find encephaloid tumors hard and lardaceous in one part, semi-concrete and medullary-looking in a second, pulpy and cineritious in a third. That these differences of consistence, as well as of color, are the result, at least in some degree, of changes effected in the morbid substance after the deposition has taken place, cannot be doubted. It may therefore be assumed that this matter, like the tubercular, is never poured out in any other than a fluid state, what- ever may be its consistence at the time it is examined, whether con- crete, pulpy, or semi-liquid. The structure of encephaloid, as just stated, is not always the same; on the contrary, it is often very much diversified, and is therefore usually arranged under different heads, as constituting so many varieties. Of these, the most common is the hozmatoid, or that form now generally known under the name of fungus hsematodes. In this variety the morbid structure bears a close resemblance to the placenta, or to a mass of coagulated blood; it is of a brownish, mahogany, or pale brick color, extremely friable, and composed of small, intertwined vessels and cellular tissue, or of an amorphous, or laminated substance, not unlike the crassamentum, or a recent fibrinous concretion. In some instances the heterologous deposit has a granular appearance. It is always contained in distinct cells, of a rounded or oval shape, from the size of a billiard-ball down to the head of the smallest pin. These cells generally communicate with each other, and are formed by ISO ENCEPHALOID. a fibrous network, either of new development, or composed of the pre-existing textures. This variety of encephaloid is generally tabulated, and may consist almost entirely of hsematoid substance ; it is compressible, and slightly elastic, has a solid feel, offers little resistance to the knife, and the cut surface has a uniform red or mottled appearance, like a section of the placenta or a calf's liver. The outer surface of the tumor may be perfectly smooth, or rough and shaggy; the latter character being often rendered very conspicuous after maceration for a day or two in water. The haematoid tumor is exceedingly vascular, and frequently attains a very large bulk. It is sometimes invested by a distinct capsule, either of new formation, or, as is more generally the case, derived from the surrounding parts; and interspersed through it are occasionally clots of extravasated blood, or cells filled with various kinds of matter. The most common seats of this growth are the mammary gland, the lymphatic ganglions, the extremities, the eye, brain, and liver. In the latter organ it sometimes exists in consider- able numbers, from the volume of a grain of mustard to that of an orange, and composed entirely of a red, bloody, semi-concrete sub- stance, easily enucleated from the containing bed. The cerebriform matter may be quite hard, inelastic, or nearly so, white, and perfectly uniform when cut, like the interior of a potato. When this is the case, it constitutes what has been called the solanoid variety of cancer. The morbid growth may also resemble the struc- ture of the kidney, and is then termed nephroid. " When the fibrous intersections are distinct, broad, and fascicular, the divided mass has more the appearance of a cut turnip, and is therefore called napiform." Miiller has described a variety of encephaloid under the name of hyaline, in reference to its transparent, vitreous appearance. This cha- racter, however, is not constant, and the term fasciculated is therefore preferable. This form of the disease is not very common, and is usually distinguished with difficulty from the reticulated variety of scirrhus, described in another page. It resembles, in its general features, the nephroid variety of cancer. The tumor is highly vascular, and is composed of extremely pale, transparent fibres, which follow no fixed direction. The fibres are often arranged in tufts, which, being inter- twined with each other, give the morbid mass a tabulated aspect, both externally and internally. Encephaloid tumors, apparently quite similar in their physical and chemical properties, frequently exhibit, on microscopical inspection, marked peculiarities. They generally, however, show corpuscles and a stroma. The corpuscles or cancer-cells are exactly like those found in scirrhus, and like these their shape varies materially. Some are round, others ovoid, caudate, or with several prolongations. Nearly all contain large, distinct oval nuclei, many even nucleoli; both of which may be found lying free in the basis-substance. The'cells or nuclei may sometimes be observed to be filled with granules of oil or even with pigment. The caudate bodies contain either a granular substance without any evident nucleus, or a nucleus with one or more nucleoli. MICROSCOPICAL CHARACTERS. 181 Their sides are prolonged into fibrils, or filaments, as represented in Fig. 42. The cellular elements are suspended in a liquid, slightly granular, homogeneous blastema, which with the corpuscles forms the ordinary Fig. 42. Elongated and caudate cells from an encephaloid tumor. cancer juice. At times there is a firmer stroma for the cells, of indis- tinctly fibrillated, or even of distinct fibrous structure, forming a net- work in which the cancerous elements are deposited. The growth of the stroma of cancer, and its exact shape have been recently carefully investigated by Eokitansky,1 who states that in the firmer varieties of it two interlacing networks may be seen. One (Fig. 43) consists of tubes of a hyaline substance studded with cells, elongated nuclei, and long-drawn fibres, all lying parallel to the longitudinal axis of the stroma. The other (a) is formed of more opaque and granular hollow beams or tubes, with fenestrated gaps. These hollow beams, it is probable, contain cancerous elements. They gradually become more densely fibrillated, and from their sides spring hollow villous excrescences (Fig. 44) which may continue to grow and lead to a form- ation of the network, or may, by themselves giving off many and fresh dentritic vegetations, assume a villous form, such as is best seen in the variety of encephaloid called villous cancer. Other elements met with in encephaloid tumors are granules, oil, pigment, and bloodvessels. The latter are generally very numerous, and mostly of new formation. Encephaloid matter, freed from the cellular structure in which it is contained, and before it has passed into its crude state, is of a viscid, jelly-like consistence, emits a pecu- liar spermatic odor on being heated, and readily coagulates in alcohol, in the acids, and in a solution of corrosive sublimate. It is miscible with water, and gradually liquefies when exposed to the action of the air. 1 See Path. Anat., pp. 97, 264, and Reports of Vienna Academy, 1852. 182 ENCEPHALOID. Encephaloid is endowed with a high degree of vitality, arising from the peculiarity of its organization, one of its chief characteristics being Fig. 43. Fig. 44. Figs. 43 and 44 represent so many stages of the development of the stroma of medullary carcinoma. After Eokitanskt. its excessive vascularity, which is much greater than that of any other heteromorphous deposit. It is not improbable, though the circumstance is not demonstrable, that the tuberoid variety, at least, always possesses a double circulation, one being derived from its own intrinsic powers, and consequently proper to the morbid mass, while the other is common to it and to the surrounding structures. How- ever this may be, its vascularity is unquestionably the main cause of its rapid growth and of the extraordinary bulk which it so often attains. For the same reason it is very prone to bleed; the new vessels, which are usually very imperfectly organized, being exceedingly liable to be ruptured on the slightest injury. Nerves probably exist in consider- able abundance in encephaloid, though it is a singular fact that this disease is generally much less painful than scirrhus. Chemical Constitution.—The chemical characters of this substance have been investigated by Hecht, Morin, Collard de Martigny, Mau- noir, Wiggers, and Foy; the latter of whom has published the sub- joined quantitative analysis:— 2.75 4.00 1.00 2.70 2.00 0.35 100.00 Albumen . 47.00 White fatty matter 7.50 Red fatty matter 5.35 Osmazome 4.00 Fibrin 6.50 Water 8.00 Oxide of iron . 1.35 Sub-phosphate of liir te 6.30 ("Soda . Carbonates of \ Lime . {. Magnesia . Hydrochlorates of { g^SSE Tartrate of soda . SITE — INFLUENCE OF SEX. 183 Compared with the analysis of scirrhus by the same chemist, the chief peculiarities here are the presence of osmazome, and the lesser quantity of inorganic salts. The fibrin exists nearly in the same pro- portion, while the amount of albumen and fatty matter is considerably greater. Foy and Maunoir have never found any gelatine in this substance; and Miiller also observes that, except in one case of encepha- loid of the kidney, he never detected any notable quantity of that principle even after subjecting the morbid matter to the most protracted boiling. On the other hand, Hecht, Morin, Wiggers, and Collard de Martigny, all agree in enumerating gelatine among the constituents of this morbid product. The first of these chemists appears to have found it entering very abundantly into the composition of crude speci- mens, and albumen into that of softened, while fat occurred in neither.1 Phosphuretted fat has been discovered once in this species of growth by Wiggers; cholesterine by Gugert; and casein by Miiller. Age, Sex, and Site.—Encephaloid has been found in various organs at every period of life. It occasionally makes its appearance soon after birth, and it has also been seen as an intra-uterine affection.2 On the other hand, it may manifest itself at a very advanced age. The following table, compiled for me by my friend Dr. Cassot, tends to show that the disease is most frequent between the twenty-first and fiftieth years. It is founded on an analysis of one hundred cases, in nine of which, however, the age is not mentioned. TABLE I. Years. No. of cases. Tears. No. of cases 1 to 3 . . . . 8 50 to 60 . 7 3 " 7 4 60 " 70 . 4 7 " 14 5 70 " 75 . 2 14 " 21 9 Age not specified 9 21 " 30 20 --- 30 " 40 14 100 40 to 50 . 18 In the eye encephaloid occurs most frequently in childhood. I have seen at least a dozen cases at this period, and there is reason to believe, from the testimony of numerous observers, that at least five-sixths of those who die of this disease in this organ are cut off at this age. On the other hand, encephaloid of the liver, lungs, brain, testicle, mammary gland, ovary, uterus, bones, and lymphatic ganglions is more frequently noticed in adolescence, manhood, and old age, than at any other time of life. The relative frequency of the disease in the two sexes has not been ascertained. Of the cases analyzed b;y Dr. Cassot, sixty-two were males, and thirty-six were females; in two, the sex is not specified. In my own practice I have seen the disease oftener in men than in women, but this may have been a mere coincidence. Of the influ- ence of temperament, climate, and occupation in the production of encephaloid, our knowledge is altogether theoretical. The same remark is true in regard to the hereditary transmission of the disease. 1 Cyclopaedia of Surgery, vol. i. p. 595. 2 Am. Journ. Med. Sci., vol. v. p. 204. 184 ENCEPHALOID. The site of encephaloid is a circumstance deserving attention. The parts most frequently affected are the eyes, bones, testicles, liver, lym- phatic ganglions, and subcutaneous cellular tissue. Scarcely a single organ, however, is entirely exempt from its attack. It has been noticed even in the veins, especially in those of the liver, kidney, and uterus; and in many instances it is ingrafted upon polypous and other growths. The following table, constructed by Dr. Cassot, gives a view of the localization of the disease in different structures in 100 cases. TABLE II. 3 times. Groin .... 3 times. 10 " 3 " Thigh .... Knee .... 8 " 8 " 4 " 3 " 1 " 6 " 5 " 1 " 6 " Leg . Surface of the body Fauces and larynx Lungs and thoracic cavity Liver and abdominal cavity Uterus and pelvic cavity 4 " 1 " 1 " 4 " 9 " 3 " 1 " 1 " 1 " Scrotum and testicle . 14 " 100 It is very common to observe the successive or simultaneous deve- lopment of this disease in a number of organs or parts. Thus, it has been seen in various degrees of development, in the cellular tissue, bones, muscles, serous and mucous membranes, heart, lungs, thyroid gland, liver, spleen, pancreas, kidneys, supra-renal capsules, gall-blad- der, and other structures. Tendency to reappear.—Another remarkable feature of encephaloid is its disposition to reappear after extirpation, either at the original seat, in the structures immediately around, or in remote parts. This is not surprising when we consider that the disease is of constitutional origin, and that the deposits to which it gives rise are merely so many local manifestations of its presence in the system. In what degree the blood is disordered in this affection, or in what respect it favors the hetero- logous formation, we are entirely ignorant. An interesting case of encephaloid, well calculated to illustrate this renovative tendency, came under my observation in 1855. The patient, aged twenty-eight, was a married woman, and the mother of three children. Four years previ- ously, a tumor began to form on the upper and outer part of the right thigh, and gradually increased until, in the course of ten months, it had attained the size of a large goose egg, when it was removed. The wound healed rapidly, but the tumor soon reappeared, and at the end of four months, when it was again excised, it had attained fully one-half of its previous bulk. In less than fifteen months two more operations were performed. The woman now came under my care, somewhat shattered in health, but without any apparent constitutional or lym- phatic involvement, the tumor being hardly as large as a common orange. The knife was again used, the wound healing kindly as before. Shortly afterwards, however, the tumor returned a 'fifth time, when a sixth operation was performed, followed by death in a few weeks. A somewhat similar case has been observed by my friend Skull . Eye . Face . Neck . Shoulder Interscapular region Axilla. Forearm Hand . Mammary gland . Chest . Abdomen CHANGES. 185 Professor Buchanan, of Nashville, and is related in the eighth volume of the Western Journal of Medicine and Surgery. Changes.—Encephaloid disease, after having attained a certain de- velopment, may remain temporarily stationary, unaccompanied by any local suffering, until the part receives some injury, when it often grows with frightful rapidity. When seated in the subcutaneous cellular tis- sue, the tumor that is thus formed is at first quite movable, smooth on the surface, and devoid of sensation; but gradually, as the enlargement progresses, it becomes fixed, irregularly tabulated, elastic, and painful. If allowed to proceed, the diseased mass has a tendency to open and protrude, generally by ulceration, sometimes by sloughing, and occa- sionally by the bursting of an abscess in its interior. However this may be, the exposed surface is highly sensitive, and presents a dark reddish fungous appearance, being extremely vascular, very prone to hemorrhage, and constantly bathed with a thin, fetid, irritating sanies, the quantity of which is sometimes very profuse. In many instances the vessels of the morbid growth give way, causing an effusion of pure blood; and this may be so obstinate and copious as gradually to destroy the patient. Occasionally there is a discharge of thin, glairy fluid, resembling the white of an egg. Such sores, besides being always highly disagreeable, never heal, from the inability of the parts to form healthy granulations. Sometimes the ulcerated mass sloughs as completely away as if it were dissected out; but these cases are uncommon, and are soon followed by a reproduction of the heterologous substance. Obstinate hemorrhage is most apt to occur in such tumors as are of the class to which pathologists have applied the term fungus haematodes. In the eye and breast, for example, much more frequently than else- where, the morbid growth, if permitted to go on unrestrained, is ex- tremely prone to bleed. The reason of this is obvious. The diseased mass is always composed, at least in part, of a vascular, erectile tissue, interspersed with encephaloid matter, and hence, as soon as ulceration sets in, hemorrhage, occasionally to an alarming and even fatal extent, is the consequence. The eroded surface, in these cases, is pale, livid, or of a mahogany color, and studded with large fungous excrescences, so grouped together as to resemble a cauliflower. In this advanced stage of the disease, there is a rapid failure of the strength, the flesh wastes, the appetite declines, the patient is harassed with hectic fever, and the countenance assumes a peculiar yellowish, cadaverous hue. The lymphatic ganglions in the neighborhood, meanwhile, become enlarged, and converted into a substance resem- bling that of the original tumor. Two modes of explanation may be offered to account for this phenomenon. The one supposes that these bodies are affected merely sympathetically, causing their vessels to pour out encephaloid matter; the other, that this substance is carried to them by absorbent vessels coming from the affected part. Although this enlargement of the lymphatic ganglions seldom occurs before ulceration sets in, yet I have known it to exist at an early period after the development of the heteroclite mass, a good while, in- deed, before the skin covering it manifested any disposition to give way. 186 COLLOID. SECTION V. COLLOID. A morbid product, consisting of a dense, fibrous, areolar structure, and of a soft, transparent, glue-like matter occupying its cells, was first described by Laennec, in the early part of the present century, under the appellation of colloid. It is also known by the term gelati- niform cancer, alveolar carcinoma, and gum cancer. By some this heterologous formation is regarded merely as a modification of the carcinomatous products already described; but, however this may be, I am satisfied, from careful personal examination, that it possesses sufficiently distinctive features to entitle it to separate consideration. Structure.—Colloid is composed of two distinct elements, bearing to each other the relation of containing and contained parts, and differing, consequently, very widely in their physical and chemical properties, as well as in their origin and mode of arrangement. The first may be con- sidered as the fundamental structure, the stroma, base, or framework, inasmuch as it gives form and solidity to the whole mass. It is made up of a fibrous tissue, hard, firm, slightly elastic, and of a dull whitish, or pale grayish color, the band-like filaments of which intersect each other in every direction, so as to inclose areolae, cells, or spaces, cal- culated to contain the jelly-like matter that is deposited within them. The vacuities thus formed present every intermediate size, between a grain of sand and a common marble. In a specimen in my possession the smallest cells are hardly as large as the most delicate pin-head; some are as big as peas, and a few are of the volume of a Lima bean. In their figure they are rounded, ovoidal, or angular; many of the most capacious are multilocular, or divided by thin fibrinous septa into different compartments. In regard to their number, the loculi are too variable to admit of any definite statement. Hundreds fre- quently exist upon a surface not more than an inch square, and, in masses of large size, the probability is that there are myriads, many of them being so minute as to be invisible with the naked eye. The cystiform structure now described is easily recognized in all specimens of the disease, and constitutes, in fact, one of its distinguish- ing anatomical peculiarities. The cells are lined by a thin, transpa- rent membrane, more delicate than the pulmonary pleura, smooth on its inner surface, and intimately attached by the other to the surrounding parts by short, dense, cellular substance. This lamella is evidently of a serous nature, but differs from a natural sac of that name in being perforated at one or more points, so that a probe may be readily passed from one cell into another. In the large cavities the inner surface of the cyst has sometimes a wrinkled or corrugated appear- ance, especially when it is partially collapsed. Yery few, if any, of the loculi, so far as my observation extends, are completely shut, and hence a colloid tumor may be said to bear a very close resemblance MICROSCOPICAL CHARACTERS. 187 Colloid tumor. Fig. 45. External appearance. Fig. 46. Internal structure. From a preparation in my collection. to a sponge, the cells of which communicate everywhere with each other. The vesicular and tuberoid arrangements of colloid are ex- hibited in Figs. 45 and 46. Microscopically examined, col- loid substance appears homoge- neous, sometimes slightly granu- lar; occasionally it forms large irregular plates. In this basis- structure are imbedded nucleated corpuscles, and, as first pointed out by Miiller, large parent-cells, inclosing several smaller cells. Oc- casionally cancer-cells, as seen in scirrhus or encephaloid, are mixed with the morbid mass; yet colloid matter may be found without any of the elements regarded as charac- teristic of cancer. Peculiar concentric corpuscles are met with in the gelatinous infiltration of the spleen, heart, and thymus. The stroma of colloid consists of a delicate fibrous tissue, inclosing the peculiar jelly- like mass, or of a firmer multilocular fibro-membra- Fig- 4?. nous structure, as seen in Fig. 47. At times the col- loid material occurs as an infiltration into tissues. The grand constituent of this morbid growth is an unorganizable product, the consistence of which varies from that of soft jelly, or a solution of starch, isinglass, or arrowroot to that of cus- tard, half dissolved glue, or semi-concrete albumen. It is generally of a pale straw color verging on green, perfectly clear, trans- parent, slightly tremulous, and somewhat tenacious or clammy. In the older cells it is sometimes as firm as moist cheese or the white of a boiled egg, opaque, and of a light yellowish hue, interspersed with dark points. It has also been found of a reddish color, similar to that of currant jelly, and a variety of it has been described which is of pearly whiteness, with a granular fracture and feel, and the chemical constitution of caseum. Whatever, however, may be its appearance or consistence, it has seldom any adhesion to the containing cyst, and is therefore always easily enucleated: it is only when the matter is very Stroma of colloid, 188 COLLOID. hard, or intermixed, as it sometimes is, with flakes of lymph, that it is detached or scraped away with difficulty. Yery little cellular substance enters into the composition of colloid. Whenever it occurs in a free state it is very short, firm, and of the same color as the fibrous septa which it serves to unite to each other and to the lining membrane of the cells. The vascular system of this morbid product has not been so thoroughly investigated as it deserves to be. That it is usually well developed, however, is apparent, not only from the large size and great number of the vessels themselves, but from the extraordinary bulk to which this cancerous formation occasionally attains. In the specimen previously referred to, vessels were seen in every direction, some of them remarkably tortuous, and from two to three inches in length by a line and a half or more in diameter. Always limited to the fibrous septa and the cysts inclos- ing the jelly-like matter, they exhibit the same arborescent arrange- ment as in the natural structures. Their walls are quite thick in pro- portion to their calibre, and hence they are much less liable to rupture than the vessels of encephaloid, which are generally very thin and fragile. They commonly observe a tortuous, straggling arrangement, and, as they pass along to their points of destination, they deposit numerous twigs, which, penetrating the fibrous tissue in every direc- tion, finally terminate in the walls of the cysts inclosing the jelly-like matter. Nothing is known, with any certainty, respecting the relative size and number of the arteries and veins of colloid, or the manner in which they are arranged in regard to each other. Colloid is doubtless furnished with nerves and absorbents; but no one has yet succeeded in determining their origin and mode of distri- bution, the relation which they bear to the arteries and veins, or the manner in which they terminate in the cysts and membranous septa. Analysis.—No satisfactory analysis has yet been made of colloid. The jelly-like matter, when freed from membranous tissue, yields no trace of real gelatine, nor does it contain any casein. In the pultaceous variety, however, as it has been called, the contents of the cells have been found to consist of the latter substance. Occasionally albumen is present, and fresh specimens sometimes yield a little osmazome. By protracted ebullition Miiller obtained a small quantity of matter, which, though somewhat allied to the salivary principle, he considers as of a peculiar nature: it was not affected by any chemical reagent, not even by tannin, and its existence was established only by evapo- rating the fluid in which the heterologous substance had been boiled. 100 parts examined by Lebert and Wurz yielded— Carbon .......... 48.09 Hydrogen .......... 7.47 Oxygen.......... 37.44 Nitrogen.......... 7.00 Not one of the other nitrogenized principles met with in healthy or in abnormal structures contain as small a proportion of nitrogen. The jelly-like matter retains its natural transparency, color, and con- sistence^ for a long time in spirits of wine. In my private collection is a section of a colloid tumor, which has been in"alcohol since Janu- VARIETIES OF FORM. 189 ary, 1840, without having apparently undergone the slightest change of any kind. Varieties of Form.—Colloid occurs in three varieties of form, in dis- seminated masses, as a distinct, solitary tumor, and as an infiltration in the substance of the part affected. Concerning the relative frequency of these varieties of form we have no positive information, but the pro- bability is that the last is the most common. Disseminated masses of colloid are met with in the greater and lesser omentum, the mammary gland, the testicle, and in osteo-sarcomatous tumors. They are of a rounded form, compressible and elastic, smooth, and of a pale greenish, whitish, pearly, or grayish color; they are generally about the size of currants, grapes, or marbles, and their interior is often divided into two, three, or even four lodges or com- partments. Their number varies in different instances from one to several hundred. Small bluish veins are sometimes observed on their surface. When occurring as a solitary tumor, the colloid matter is collected into rounded masses of various sizes, agglomerated together, and united by dense cellulo-fibrous tissue. The number of tubercles may range from half a dozen or less to several thousand. The surface of the morbid mass is tabulated, botryoidal, or mammillated, according to the volume and arrangement of the component cysts. Occasionally it bears a strong resemblance to the exterior of a pudding-stone. The color varies with the nature of the contained matter; a pale geeenish is the most usual tint; but it may be pink, bluish, yellowish, or pearly white, or all these shades may coexist in different sections of the same preparation. In its weight it ranges from a few ounces to several pounds; in its volume, from an orange to a fist, a cocoa-nut, or even an adult head. When cut, it emits a sound not unlike fibro-cartilage ; it has a dense, solid feel, when deprived of its jelly-like matter, but as long as the vesicles are distended, it is rather soft, distinctly elastic, and even fluctuating, particularly over the larger cysts. A thin, delicate capsule, composed of condensed cellular tissue, occasionally invests the morbid mass, and isolates it from the surrounding parts. This form of the disease is most common in the peritoneum, the greater and lesser omentum, in the ovary, and in those affections of the bones known under the names of osteo-sarcoma and spina-ventosa. In the third variety, the adventitious substance is diffused through the tissues of the affected organ, which it gradually subverts, so that in time it loses all trace of its primitive organization. The cysts are usually very small, frequently not larger than grains of sand or mustard seeds, and the jelly-like matter, generally of a pale bluish tint, also exists more sparingly than in the other forms of the disease. When an organ, as, for example, the stomach, is transformed into this substance, it almost always retains its shape, however much it may be changed in its size and consistence. The most common seat of the infiltrated variety of colloid is.the stomach, but the disease has also been observed in the small bowel, rectum, omentum, and the inferior extremity of the uterus. Quantity.—The quantity of the heterologous matter is extremely vari- 190 COLLOID. able, and is greatly influenced by the nature of the part in which it is deposited. In the bones and on the free surfaces of the serous mem- branes it often aquires considerable bulk, owing to the slight resistance opposed to its extension. I am now speaking, not of individual tuber- cles, but of aggregated masses, formed during the progressive develop- pment of the disease. The former, as was before stated, are generally very diminutive, while the latter frequently equal the volume of an orange, a fist, or even of the head of an adult. Mr. Walshe1 alludes to a colloid tumor of the omentum as large as a cocoa-nut, contained in the collection of King's College, London; Andral2 describes one, removed by Eoux from a man fifty years of age, which weighed nearly nine pounds, and Yelpeau has seen large masses of this kind in the extremi- ties. The most immense colloid tumor, however, of which I have any knowledge, fell under my observation in January, 1840, in a man forty-nine years old, whose body I examined along with the late Dr. Mason, of Cincinnati. It extended from the pelvis to the liver and diaphragm, surrounded the colon and part of the stomach, and con- cealed from view nearly the whole of the abdominal viscera. Its thick- ness was from two and a half to three inches; in length it measured nearly one foot, and in breadth more than eight inches. Its weight was estimated at twenty-five pounds. It was composed of thousands of agglomerated masses, from the size of a grain of mustard to that of a hickory-nut, and seemed to have been developed in the peritoneum, or in the great omentum, the latter of which was completely effaced. The liver was smaller than natural, probably from the pressure ex- erted upon it by the tumor, but in other respects it was perfectly sound, as were likewise the other viscera, both abdominal and thoracic. The disease was first noticed in July, 1837, as a small, hard, circumscribed tumor, just above the pubes. Large colloid tumors are sometimes developed in the bones, and also, though more rarely, in the ovary. In the alimentary canal the disease frequently occupies a large extent of surface. In the stomach, for which, in common with scirrhus and encephaloid, it seems to have a marked predilection, it often spreads over one-third, one-half or even two-thirds of its walls, transforming them into thick, solid masses of a dense, gristly consistence. In the rectum, colon, and small bowel, its limits are generally more circumscribed. Seat.—The seat of colloid appears to be much more limited than that of the other cancerous productions. The structures which are most liable to it are the alimentary canal, particularly the stomach and rectum, the omentum, ovary, lower jaw, and bones of the extremities. It has also been noticed, though rarely, in the mammary gland, uterus, and testicle. It sometimes affects several organs simultaneously, or in more or less rapid succession, as in the interesting case reported by the late Professor J. C. Warren, of Boston, in which colloid tubercles, from the size of a small granule to that of a pea, existed in immense numbers in almost every part of the body, especially in the bones, 1 Cyclopaedia of Surgery, vol. i. p. 602. 2 path# Anatomy, p. i. p. 208. EPITHELIAL CANCER. 191 voluntary muscles, heart, mesentery, liver, and kidneys. They were of a whitish aspect, and gelatinous consistence. The disease may co- exist with scirrhus and encephaloid, but I do not know that it is ever associated with melanosis or hydatids. Period of Life.—The period of life most obnoxious to this disease is from thirty-five to fifty. It has been observed in a patient of sixty- eight ; and, on the other hand, it has been noticed several times in sub- jects under twenty ; indeed, it is altogether probable that it may occur at a much earlier period. It has been witnessed in both sexes, but whether it is more frequent in one than the other, is not determined. The disease occurs in quadrupeds. I have met with two well-marked examples of it in the superior maxillary bone of the ox, the animals being otherwise perfectly healthy. How this disease originates, or what its causes are, we are entirely ignorant. Its progress is usually slow, except when the tumor is very vascular, when it is apt to grow with great rapidity. It manifests no disposition to ulcerate, as is the case with scirrhus and encephaloid; is never the seat of hemorrhage or much pain; the general health usually holds out well; and the countenance rarely acquires that sallow, cadaverous hue so common in ordinary carcinoma. SECTION YI. EPITHELIAL CANCER. A form of morbid growth, which has only recently been carefully studied, is that known under the names of epithelial cancer, epithe- lioma, or cancroid. It occurs especially on the skin and on mucous membranes, although it may invade more deeply seated tissues; for it has been found in lymphatic glands, muscles, and bones, and even in internal organs, as the liver and lungs. The most common seat of these epithelial cancers is the lower lip; next in frequency follow the cheeks, the tongue, the external organs of generation, the oesophagus, larynx, pharynx and trachea. They are met with as cauliflower excrescences on the neck of the uterus and in the vagina. On the scrotum they constitute the so-called chimney- sweep cancer. The external appearance of these tumors on mucous membranes is generally that of an exuberant warty growth, of a pale whitish or red color. On the skin they are either smooth, or, more usually, present a peculiar tuberculated form, with ulcerations and dark red crusts on their exterior. The affected part seems enlarged and feels hard; if cut into, the section exhibits a firm whitish mass, and generally also en- larged papillae; occasionally a soft juicy substance may be pressed out of the morbid structure. When the disease affects the cheeks the en- larged papillae are not commonly met with, but they are very distinct in 192 EPITHELIAL CANCER. Fig. 48. epithelial cancer of the lip and penis. These papillae are of various length, shape, and thickness. Some are single, others united. On the penis they form a distinct outer growth resting on a white thick sub- stance, which consists of the changed cavernous bodies. Epithelial cancers soften and ulcerate; the sores thus formed are of irregular shape and covered with a creamy substance, or a dark red crust. The ulceration may give rise to complete destruction of the morbid tissue, and a hard cicatrice may be subsequently formed, although this is an unusual termination. The ulceration gradually extends beyond the tissues primarily diseased, and leads to disastrous consequences. Thus, cases have been seen in which the femoral artery was laid open by ulceration extending from the affected in- guinal glands. The ravages of this form of disease are well seen in the accompany- ing cut (Fig. 48). The affection be- gan in the skin of the nose, whence it gradually spread to the cheeks, eye- lids, and forehead, involving soft structure, cartilage, and bone, until the patient, after many years' suffer- ing, was worn out by hectic irritation. Minutely examined, these growths consist mainly of cells like pavement epithelium. The cells are large and flattened, angular, rounded, or with prolongations; a few are shrivelled and bent up. They usually contain one or two distinct nuclei, which are small in comparison with the size of the cell, although larger than those in healthy epithelium. They either lie in superimposed layers, held to- gether by an intercellular substance, or by a delicate fibrous tissue, or they are found inclosed in peculiar cysts, apparently fibrous, although probably formed from compressed cells, and almost characteristic of these epithelial formations (Fig. 49). In some cases round cells with distinct large oval nuclei, such as are ordinarily met with in cancerous tumors, are observed. Mixed up with the cells are a great many free nuclei, granules, and occa- sionally crystals of cholesterine, pig- ment-cells and blood globules. The natural structure of the part is for the most part destroyed. The enlarged papillae consist of loose fibrous tissue »L?^fc^JSot^dratiST; and. bloodvessels very densely coated Dr. da Costa. with layers of epithelial cells and free Epithelial cancer in a state of ulceration. From a specimen in my collection, presented me by Professor Buchanan, of Nashville. Fig. 49. EPITHELIAL CANCERS. 193 Fig. 50. nuclei. Fig. 50 represents one taken from an epithelial cancer of the lip. Epithelial cancers occur more frequently in the male than in the female. They are rarely seen before the age of thirty. Their most frequent cause is probably continued local irritation. Those on the lip are some- times produced by smoking very short pipes. A case is reported by Dr. Da Costa, as occurring on the abdomen in the person of a shoemaker, which could be clearly attributed to a small board worn whilst working. Yery frequently they seem to originate in warts. Several cases have been collect- ed which tend to prove that they are at times found where an hereditary predis- position to cancer exists. Epithelial cancers are generally very slow in their growth. The duration of the tumor up to the time of operation, noted by Dr. Da Costa,1 was in twenty-two cases as follows:— 22 years. a. Papilla taken from an epithelial cancer, magnified 250 diameters ; b. Sepa- rate epithelial cells.—After Da Costa. 3-6 months. 1 year. 2 years. 3 years. 4 years. 7-9 years. On the lip 1 1. 4 2 1 1 Face 3 1 1 — 1 — Gums — — ■ — — — 1 Tongue — — — 1 — — Trunk — — — — — 2 Extremities — — 1 — — — Another peculiarity of these cancers is, that they do not often return when completely extirpated, and that they are rarely found except in the parts primarily involved. Thus, out of eighteen post-mortem exa- minations made by Lebert and Mayer, the disease could not in one single instance be found in any other part of the body. This fact, taken in connection with their frequent local origin, their greater cura- bility, and the absence of the ordinary elements of cancer, has led many to deny altogether their carcinomatous nature, and to group them, under the term epithelioma or cancroid, as a class distinct from cancer; others, again, believe that the majority of these tumors are simple epi thelial formations, but that cancerous structures may combine with them. The whole question of the true relation of these tumors to the ordinary forms of cancer, is as yet far from being satisfactorily settled. 1 Remarks on Epithelial Tumors in Philadelphia Medical Examiner, April, 1852. 13 PART II. SPECIAL PATHOLOGICAL ANATOMY. PART II. SPECIAL PATHOLOGICAL ANATOMY. CHAPTER I. OF THE BLOOD. Lesions of the Blood.—Nature and Formation of the Buffy Coat.—Cupped Appearance of the Blood.—Want of Coagulability.—Relative Quantity of Fibrin in Healthy and Diseased Blood. —Alterations of the Hematosine.—Lesions of the Serum, in Inflammation, Dropsy, and other Maladies.—Changes of the Blood, from Acceleration of the Circulation and Division of the Pneumogastric Nerves.—Appearances in Cholera, Fever, Chlorosis and Scurvy. Although I do not feel disposed to attach that great importance to the blood which the advocates of the old humoral pathology did, yet it cannot be denied that it is the most essential fluid in the animal economy, inasmuch as it furnishes the various materials which dis- pense vitality and nourishment to the different tissues, as well as vigor to its several organs, serving thus, in the expressive language of our medical ancestors, as the pabulum of life. From it all the solids are formed, and all the other liquids secreted; and hence it may justly be considered as the basis of every part of the complicated fabric, as, without it, it would be impossible for any growth, whether healthy or morbid, to take place. Pervading every portion of the body, and penetrating every fibre, however minute, or however con- stituted—acquiring constantly new properties as it passes through the lungs, and losing them again as it meanders through the rest of the system—it is in the highest degree probable that, whilst it thus fertilizes the various structures, it may convey to them alike the elements of general health and of general disease. So long as it pre- serves its integrity, the impression which it makes upon the solids 198 BLOOD. must of necessity be of a salutary kind, calculated to stimulate the whole machine, and to rouse it to the proper performance of its functions. On the other hand, any departure from this state, although so slight as to escape our notice, must be followed, it is reasonable to presume, by a corresponding derangement of the system. In inflam- matory affections, it undergoes most important changes, exhibiting frequently, as will be seen by and by, a peculiar buff-colored aspect; in dropsy, it is thin and pale, like weak claret; in plethora, on the contrary, it is thick, remarkably tenacious, firm, and of a deep red complexion. If it be imperfectly elaborated, a morbid diathesis is established, which often lays the foundation of mortal maladies, and which is transmitted, in many instances, from the parent to the off- spring. In this way "God visits the iniquity of the fathers on their children, down to the third and fourth generation," as is exemplified in the hereditary predisposition to arthritic, syphilitic, and tubercular diseases, mental imbecility, and a host of other disorders, as afflicting to the patient as they are generally perplexing to the practitioner. The blood is a fluid of a dark reddish color, slightly saline to the taste, and of a specific gravity varying between 1.045 to 1.075. It consists of a fluid called sanguineous liquor, in which the corpuscles are suspended. The liquor is composed largely of water, and con- tains in solution salts, albumen, extractive matter, fat, and fibrin. This latter element is spontaneously coagulable, and plays the most important part in the formation of the blood-clot. I shall first describe the lesions in which the individual constituents of the blood are con- cerned, and secondly the alteration in reference to the entire mass. The most remarkable change which the fibrin of the blood expe- riences, and one which we have the most frequent opportunities of observing, is that inflammatory condition which gives rise to what has been termed the buffy coat, or, from its frequent occurrence in acute disease of the serous membrane of the chest, the pleuritic crust. In general, it presents itself in the form of a thin lamella, of a pale straw color, which is spread over and closely adherent to the upper surface of the crassamentum, looking a good deal like a sheet of tallow. In some instances, it is of the color of a lemon-rind, nearly white, or greenish. The latter appearance is especially conspicuous in the blood of pregnant females, and has sometimes been considered, though erroneously, as an indication of that particular state. The formation of the buffy coat is always consentaneous with the process of coagulation, appearing at first like an opaque, viscid film, of a reddish opaline tint, and of a consistence equal to that of mucus, which is either diffused over the whole surface of the fluid, or occurs in small insulated spots, looking like so many little islands in the midst of a body of water. Whilst warm, this substance is remarkably tenacious, and may be drawn out in the form of little filaments, which, on cooling, assume a whitish aspect. When fully formed, which, however, it is not under some hours, the buffy coat is dense, elastic, slightly diaphanous, strongly adherent to the cruor, which it covers, smooth on its free surface, and rough on the other. Now and then BUFFY COAT—HOW MODIFIED. 199 it is remarkably soft, and reticulated, or like the interior of a honey- comb, from the development and rupture of little air-vesicles. If the buffy coat be carefully separated from the crassamentum, washed in cold water, and then immersed in strong alcohol, its elastic properties will be greatly augmented, and the membrane will present very much the appearance of a half-tanned hide, or of the proper uterine tissue during pregnancy. It is essentially composed of fibrin, along with a considerable but variable amount of albumen and serum, or what has been termed the sanguineous liquor, which may be squeezed out by pressure. The greatest analogy is thus seen to exist, both as regards appearance and chemical composition, between the buffy coat of the blood, as exhibited in certain diseased states of the system, and the substance that constitutes the adventitious membranes of the serous cavities. Considerable diversity prevails in respect to the thickness of the buffy coat, depending on the intensity of the disease, and the nature of the affected part. Most commonly it does not exceed the eighth of an inch; but, in some rare instances, I have known it to be from three to six lines. As a general rule, it may be stated to be greater in plethoric subjects than in such as are weak, and in inflammation of the joints, serous membranes, and parenchymatous organs, than in the same disease in other structures. The consistence of the buffy coat is also liable to vary. In typhus, scurvy, and chlorosis; in short, in all cachectic states of the body, it is generally soft and brittle, thin, iridescent, and of a dirty yellowish color. On the contrary, in simple inflammatory affections, it is usually highly tenacious, thick, and of a uniform opaline tint. This peculiar appearance of the blood occurs in all inflammatory disorders, and, in fact, in almost every condition of the system in which there is a predominance of vascular action. It is usually found in the acute stages of pneumonitis, hepatitis, scarlet fever, smallpox, goutj rheumatism, and, perhaps, invariably in pleurisy ; at least, I do not remember ever to have bled a patient laboring under this affec- tion in whom the blood was not more or less buffed. It is also very generally met with in pregnant women, in dropsy, in chronic diseases of the chest and abdomen, in scurvy, in chronic gout and rheumatism, and in those who are subjected to frequent venesection. In chronic in- flammation, in whatever tissue or organ seated, the buffy coat usually continues for a long time, especially if the disease be attended with much constitutional disturbance, reappearing at almost every repeti- tion of the bleeding until the malady wholly subsides. The same phenomenon is witnessed -in those affections in which the primary morbific impression seems to be made on the circulating current, as smallpox, for example, the virus of which is evidently absorbed by the vascular system. At the commencement of this disease, the blood is usually covered with a tolerably thick crust, but this crust seldom exists, or, at most, only in a very slight degree, prior to the establish- ment of the eruptive fever. When the exanthem is moderate, the quantity of buffy matter is commonly very small; in nearly all cases 200 BLOOD. it continues until the scabs are perfectly dried, and occasionally even a few days later. The relative frequency of the buffy coat in various diseases is ex- hibited in the following table, compiled from Andral:— Diseases. No. Perfect Imperfect Absence of of cases. buffy coat. buffy coat. buffy coat. Acute amygdalitis 12 9 1 2 132 35 25 63 10 3 — 7 11 7 1 3 Cerebral congestion 103 14 12 77 Pleuritic effusion, recent and chronic 27 7 9 11 Intermittent fever 32 5 — 27 Typhoid fever .... 187 10 30 147 Cerebral hemorrhage . 22 2 — 20 Hypertrophy of the heart 72 11 — 61 Albuminuria .... 6 — — 6 Pneumonitis .... 230 215 15 — Acute rheumatism 134 125 5 4 Chronic rheumatism 50 11 — 39 11 — — 11 9 — — 9 Pulmonary tubercles . . 203 140 13 50 Persons sometimes labor under intense inflammation, and yet the blood does not exhibit the buffed appearance until after they have been bled several times. The reason of this is not very obvious; but we may suppose that the system, in these cases, is so surcharged with blood, or that the heart and vessels are so exhausted that the usual nervous energy upon which the slow coagulation of this fluid depends is not imparted. At other times, the reverse of this obtains, the blood which flows first exhibiting the buffy coat, whilst that which is drawn towards the close of the operation will have little or none of it. This phenomenon is particularly apt to take place when the blood is allowed to issue slowly from a small orifice. The manner in which the formation of the buffy coat may be modi- fied by the state of the nervous system, is well illustrated by a case related by Hewson.1 A young, robust man was bled during an attack of inflammatory fever. On opening the vein, the blood merely trickled down the arm, owing, apparently, to the fright of the patient; but, in a few seconds, it began to run quite freely. Three ounces were then received into a second cup, and a like quantity was immediately caught in a third. The individual now became faint, and was laid on the floor, when a few drachms more were taken in a fourth cup. Of these four measures of fluid, that which was removed last coagulated in three minutes, the first in twelve minutes, and the second in about twenty-two minutes. Neither of these had any inflammatory buff; but the blood received into the third cup began, in five minutes, to appear transparent on the surface; and, although it did not fully coagulate for upwards of half an hour, it had a remarkably thick, tough crust. The formation of the buffy coat appears to be due to a loss of affinity 1 On the Blood, vol. i. p. 82, et seq. BUFFY COAT — CAUSE. 201 between the fibrin and the red particles, in consequence of which the latter, during the process of coagulation, gravitate towards the bottom of the crassamentum instead of remaining entangled in it, as they always do in the natural state. In this manner the top of the crassamentum becomes covered with a colorless layer, the thickness and density of which vary according to the repulsive power between the two element- ary constituents here referred to, the intensity of the disease, the state of the patient's system, and the degree of contraction of the inspissated mass. The reason why this separation does not occur while the blood is still contained in its vessels, is the constant motion to which it is subjected, and which is incompatible with the coagulating process. There are certain external circumstances which greatly conduce to the formation of the buffy coat, of which the most important are a narrow receiver, and a large orifice, capable of furnishing from two to three ounces of blood in a minute. If the receiver be broad and shallow, and the stream small, coagulation will occur before the red particles have time to detach themselves from the fibrin, or to gravi- tate towards the lower portion of the crassamentum. If blood be drawn simultaneously from both arms, it will generally be perfectly uniform, both as respects the quantity of the serum and the density of the cruor. Should the blood, however, run dispropor- tionably slow on one side, there will be no appearance of inflamma- tory crusts, whilst it will readily form on the blood which issues from the other, for the obvious reason that, in the former case, the liquid will concrete before the red globules have time to disengage them- selves from the fibrin; whereas, in the latter, the fluidity will be suffi- ciently protracted to admit of this occurrence. It will be seen, from the foregoing remarks, that we cannot, as a general rule, consider the inflammatory crust as depending uniformly upon the shape of the receiver, the size of the orifice, or the volume of the stream, since all these circumstances merely modif}^ but can never produce the buffy coat, unless the fluid is susceptible of it, or has undergone those changes which are necessary for its development. Nevertheless, it should be borne in mind, when we wish to draw any legitimate conclusions in relation to the inflammatory crust, that it is all-important that the blood should not be exposed to too low a tem- perature, that the reciever should be rather narrow and deep, and, lastly, that the orifice in the vein should be large enough to furnish at least two ounces of fluid in a minute. To effect this, the incision should be about a line and a half in length, and the blood should run in a full, continuous jet. When the middle of the buffy coat is depressed/ or scooped out, as it were, it is said to be cupped (Fig. 51). This appearance is gene- rally limited to the upper surface of the crassamentum; but I have occasionally witnessed it also upon the lower surface, though never to the same extent. It is very common in nearly all diseases of a highly inflammatory character, such as pleurisy, peritonitis, rheu- matism, and gout. Venous blood is not alone susceptible of being buffed and cupped: the same phenomena are observed in arterial blood, and the only reason, perhaps, why they are not so familiar to us, is 202 BLOOD. owing to the less frequent performance of arteriotomy than of venesec- tion. The manner in which this Fig. 51. cupped condition of the blood disappears, is well exemplified in acase which, a few years ago, came under the notice of my friend, Dr. Charles Woodward, of Cincinnati. He attended a married lady under a violent attack of pleuritis, for which she was bled several times. The blood which was taken on the first day of the treatment was deep- ly buffed and cupped. Twenty- four hours after the same appear- ances were exhibited, except that the clot was not quite so much depressed in the centre; in twelve hours more, the fluid was still buffed, but no longer cupped; Buffy and cupped blood, from a preparation in my and, at the fourth Operation, per- coiiection. formed three days after the first, it was neither buffed nor cupped. This cupped state of the blood, as just hinted, is generally indica- tive of the highest degree of inflammatory action, yet, strange as it may seem, it is not unfrequently found in very opposite conditions of the system, as in persons who are greatly exhausted by hemorrhagic and other profuse discharges, and who do not evince the slightest symptoms of phlegmasia. Most commonly, it occurs in connection with inflammation of the serous membranes and the parenchymatous organs; being seldom present in inflammation of the mucous and der- moid textures. Although it is not consistent with the plau of this work to enter into any therapeutic considerations, yet I cannot dismiss this branch of the subject without briefly inquiring how far the buffy coat should be regarded as an index to the abstraction of blood. It has been al- ready seen that this phenomenon occurs under very opposite states of the system, in the most debilitated as well as in the most robust, in the highest degrees of disease as well as in the lowest, and in indi- viduals who are in the enjoyment, apparently, of the most perfect health. The blood, in the advanced stages of pregnancy, is almost always covered with a layer of fibrin; and the same thing is generally observed in persons that have suffered from profuse hemorrhages of the stomach, lungs, or other organs. In individuals subjected to a course of mercury, the blood drawn from the arm is frequently as much buffed as in the most violent attacks of gout or pleurisy, not- withstanding the great reduction of the vital powers. The same effect may be produced simply by taking severe exercise. Thus, if a horse be bled immediately after he has run round a race track, the blood, in consequence of the hurried state of the circulation, will exhibit the buffy coat, whereas that previously abstracted will be perfectly free WANT OF COAGULABILITY. 203 from it. Similar appearances have been repeatedly witnessed in the human subject. If these circumstances be coupled with the fact, that the buffy coat may be entirely absent, even in the most intense in- flammation, the conclusion is obvious, that the phenomenon in ques- tion can neither be regarded as a certain test of morbid action either in the solids or in the vital fluid, nor a safe index of the propriety of bloodletting. The fibrin is sometimes remarkably destitute of coagulating power. This is strikingly evinced in persons who are suddenly destroyed by lightning and electricity; a violent blow on the stomach, or severe injury of the brain; by the bite of venomous serpents; by acid vege- table poisons, such as prussic acid ; excessive bodily fatigue; and even violent agitation of the mind. It is also frequently witnessed in Asiatic cholera, in scurvy, and in malignant fevers. Occasionally, too, it is present, and yet the individual is apparently in the enjoy- ment of good health. Under such circumstances, the most trifling injury may prove fatal, since the only means by which hemorrhage can be successfully combated is taken away, the blood refusing, in spite of all our efforts, to coagulate. Mr. Wardrop, of England, in a short but valuable treatise on blood-letting, published some years ago, has cited a number of cases of this kind, several of which came un- der his own immediate observation. In one of the instances alluded to, the patient died from hemorrhage, induced by the introduction of a seton in the side; in another, from a slight wound of one of the fingers; in a third, from the extraction of a tooth; in the fourth, from a superficial wound in the palm of the hand; and, in the fifth, from a bite of the tongue. In 1839, I lost a male infant, five months and a half old, from hemorrhage caused by the division of the gum over the central inci- sors of the upper jaw; the bleeding came on in less than twenty-four hours after the operation, and, resisting all the means which I could employ for its suppression, proved fatal at the end of the fifth day. A few days before death hemorrhagic spots appeared in various parts of the body. The child had been born of healthy parents. I recol- lect a case of fatal bleeding from the extraction of a tooth. The patient was a servant girl, fifteen years old, of delicate constitution, who had never menstruated, and had been in bad health for about four months previously to her death. During the last six weeks she had been taking a variety of the most powerful emmenagogues, without any apparent benefit. In this state, Dr. Barnes was requested to ex- tract the second molar tooth on each side of the lower jaw. Five days after the operation, the patient was attacked with profuse hemorrhage from the wounded sockets and surrounding structures, which persisted, notwithstanding the employment of the most energetic measures, un- til a short time afterwards, when she died perfectly exhausted. In compressing the parts with a piece of cork, the bleeding could be tem- porarily arrested, but the blood would soon ooze out from the mu- cous membrane of the cheek. The late Dr. J. A. Swett/of New York, has recorded a case in which 1 New York Journ. Med. & Surg., July, 1840, p. 174. 204 BLOOD. this tendency existed in all the children, eighteen in number, of the same family. All but one had died from this cause, and he was suf- fering under profuse hemorrhage of the nose and rectum. Twelve sisters died before the age of twelve from bleeding of the uterus ; two of the brothers had fallen victims to traumatic hemorrhage. Mr. Wardrop gives a curious case in which this peculiarity was hereditary. The patient was a boy, and the hemorrhagic tendency displayed itself when he was scarcely two months old. On several occasions, he nearly lost his life from the most insignificant wounds. His brother, twenty-two years old, was frequently afflicted in the same way. Of his five uncles, not one was free from this predisposition: three died after a division of the frsenum of the tongue, one from the extraction of a tooth, and the other, although he suffered from the same disease, finally died from some other cause. His two aunts ex- hibited no signs of this diathesis; but, what is singular, all the male branches of their families, excepting one, were thus affected. A still more remarkable case has been recently reported by Dr. Hughes, of Kentucky.1 The predisposition here was associated with a rheumatic diathesis, and was satisfactorily traced as far back as five generations. It was confined exclusively to the male branches of the different families ; but the females, nevertheless, invariably transmitted it to their offspring. Many of the individuals died in infancy and childhood, death resulting in some from the cut of the lancet; in some from accidental wounds; in some from internal hemorrhage; and in two simply from the application of blisters, the vesicles being filled with blood instead of water. To what is this want of coagulating property of the blood to be ascribed? That it is owing, at least in part, to an insufficient supply of nervous power, upon the presence of which the vitality of the fluid in question essentially depends, is exceedingly probable. The direct influence of the nervous system on the blood was long ago con- tended for, and has been happily elucidated in modern times. It has been satisfactorily ascertained, that, whenever the pneumogastric nerves are tied in animals, the blood loses its property of coagulating, the coloring matter at the same time separating from the fibrin. But the influence of the nervous system is nowhere more strikiugly evinced than in the effects produced by a severe blow on the coeliac ganglion. Here death is caused with the same rapidity as by light- ning and the most subtle poisons; the blood, as was before stated, exhibiting precisely similar appearances, being unusually black, dis- solved, and incapable of separating into serum and crassamentum. It has been shown by AndraP and Gavarret, that in all acute in- 1 Transylvania Journal of Medicine, vol. v. For a similar case, related by the same gentleman, see op. cit., vol. iv. p. 518. 2 Andral considers the average proportion of fibrin in healthy blood as 3 to 1000. It may be found, however, as low as 2..r> or 2, and as high as 3.5 or even 4. The mean proportion of the globules he fixes at 127 parts in 1000 ; the extremes in the physio- logical condition of the system being 140 and 110. The solid materials of the serum are estimated at 80 parts in the 1000. and of these from 68 to 70 are pure albumen. The water of the blood is fixed at 790. See Pathological Hematology, translated by HEMORRHAGIC DIATHESIS. 205 flammations a peculiar condition of the system is engendered, in consequence of which the blood is suddenly surcharged with fibrin. It does not matter what may have been the previous health, the super- vention of an attack of this kind involves necessarily, in every case, an increase of this substance above the natural standard. This law obtains in animals, as the dog, horse, cow, and sheep, as well as in man. In the human subject, when the inflammation is fully estab- lished, the fibrin varies in quantity between 6 and 8 ; in some cases it rises as high as between 8 and 9; and occasionally, though rarely, it reaches 10^, or even 12J. The elevation dates from the very com- mencement of the morbid action, and may therefore be regarded as the pathognomonic sign of it. The only exception to this, so far as at present ascertained, is in utero-gestation, in which, both in the human subject and in the inferior animals, the blood, especially as the period of confinement approaches, always contains a redundancy of this substance, and displays a remarkable tendency to assume the character of inflammatory blood. It has been supposed that the tying of the pneumogastric nerves in the neck has the effect of diminishing the quantity of fibrin in a very notable manner. Dupuy having performed this operation, drew a certain amount of blood from the carotid artery, and ascertained that it contained twenty one grains of fibrin. In a few hours after, the same amount contained only nineteen grains ; at the end of six- teen hours, eighteen grains; and, at the end of forty hours, twelve grains. In a little more than two days from the operation, the horse died in a state of asphyxia, when the same quantity of fluid, still taken from the carotid, had only seven grains of fibrin.1 The ques- tion naturally presents itself, was the progressive diminution, here spoken of, produced directly by the division of the pneumogastric nerves, or indirectly by disturbing the process of sanguification ? In all probability the section of the nerve had nothing to do with it; for it is not at all unlikely, though this is not stated, that the animal at each bleeding lost more blood than was necessary for the purposes of the experiment; and, if this be admitted, the facts observed by Dupuy, though he accounted for them in a very different way, will be found to tally with the results of the experiments of Dr. Andrews, alluded to in another part of this chapter. A marked diminution of fibrin is occasioned in cases of scurvy, purpura, typhus, and in inveterate syphilis. The blood-corpuscles are very liable to changes of different kinds. They may increase or diminish in number, or undergo dissolution, and thus permit the haematin to escape. In many maladies, this seems to disengage itself from the globules in which it naturally resides, and to percolate through the vessels into the different cavities of the body, or into the interstices of some of the organs. This separation fre- quently occurs in scurvy, in malignant dysentery, and in typhus Drs. Meigs and Stille, p. 30, Philada., 1844; also Ilrrherches sur les Modifications du Sang dans les Maladies, par Andral et Gavarret, Annates de Chim. et de Phys., t. lxxv., Nov. 1840. 1 Andral, Anat. Path., t. i. p. 204. 206 BLOOD. fever, and is probably the cause of the passive hemorrhages and petechial spots which are so commonly met with in these affections. To the same circumstance is to be attributed the stained condition of the endocardium and the inner membrane of the vessels, which usually takes place within a short time after death, especially in warm weather, and which has sometimes been mistaken for the effects of inflamma- tion. A diminution of the red corpuscles, either from their destruc- tion, or from their not being formed in adequate numbers, often exists. This diminution, as might be anticipated from its apparent cause, is usually connected with those conditions of the system which are cha- racterized by great debility, whether occasioned by impoverished living, protracted indisposition, or profuse hemorrhagic discharges. It is very constantly met with in chlorosis, in ascites, in organic affections of the stomach, and duodenum, in persons who are frequently bled, and in females who suffer habitually from menorrhagia. It would appear that women have always, comparatively speaking, fewer blood corpuscles, and less haematin in their blood than men, a fact which was first ascertained, I believe, by Lecanu, and which, he thinks, is attributable to their monthly evacuations. The following comparative view is the mean of his analysis made with blood drawn from ten adults of both sexes:— Female. Male. Water........804.37 789.32 Albumen.......69.72 67.50 Saline and extractive matter . . . 9.95 10.69 Red globules......115.96 132.49 1000.00 1000.00 In the above diseases, the countenance is remarkably blanched from the want of haematin, the different tissues are literally exsanguineous, the nutritive function is badly executed, and there is great failure of the strength, with a disposition, in many cases, to cellular infiltration of the extremities. This state of things often persists for months, and occasionally, as in chlorosis, even for years. The blood, under such circumstances, is absolutely impoverished, being scarcely fit, from the absence of red particles, for the purposes which nature has assign- ed to it. Acute maladies produce, in effect, the same results, with this difference, that these two important elements of the vital fluid are usually much more quickly regenerated, especially when the individual has the benefit of free exercise and animal food. There are some maladies, such as cholera, typhus, and plague, in which the blood is unusually black. The cause of this is not very obvious, but it may be supposed that several circumstances are neces- sary to its production. Amongst these, the most important, without doubt, is the partial abstraction of the vital principle of the blood, producing thereby a general impairment of the various functions of the system. In no organ is this disordered action carried to so great a degree as in the lungs, where, although the atmosphere still comes in contact with the delicate air-cells, the sanguineous fluid, from its exhausted condition and destitution of saline principles, is no longer susceptible of being properly arterialized. That this is true, is abun- HEMATOSINE. 207 dantly established by pathological anatomy, physiological experiments, and chemical analysis; for, as will be seen hereafter, the blood, in the diseases referred to, is generally extremely black, dissolved, highly carbonized, and sometimes almost entirely drained of its salts. In cholera especially, these states of the blood are amongst the most uni- form occurrences; and it is to them that are to be mainly attributed the livid color of the skin, the embarrassed breathing, and the rapid exhaustion which those who are the subjects of the malady generally exhibit. To this general statement several other facts, strongly corroborative of what has just been said, may now be added. In the first place, we may notice the effects that result from a division of the pneumo- gastric nerves, which are the governors, if such an expression be allowable, of the respiratory organs. This experiment is invariably followed by a suspension of the arterializing process, in consequence of which the blood, both in the veins and arteries, is always found of a black color after death. The same effect has been observed to be produced by merely tying these nerves. The blood also flows of a dark color when the carotid artery is opened after the phrenic nerves have been secured: the lungs, however, in this case, are not found heavy and engorged, as in the former. These facts, together with many others of a similar character that might be cited, clearly demon- strate the dependency of the arterializing process upon the nervous influence. If we abstract this agent, the vital fluid becomes darker and darker, until at length the lungs are rendered utterly incompetent to make any salutary impression upon it. These changes, secondly, are generally produced more rapidly in proportion to the abstraction of the salts of the blood. The truth of this remark is strikingly corroborated by what occurs when saline fluids are injected into the veins of cholera patients, an operation which was performed successfully in several instances, both in this country and in Europe, during the prevalence of this disease. In the collapsed stage of this disease, when the individual is actually in a state of asphyxia, the skin cold and livid, the respiration labored, and the pulse imperceptible at the wrist, no sooner are the watery and saline materials restored, than the whole aspect of things is changed; the heart begins to act with increased vigor, warmth is diffused through- out the body, the breathing becomes easier, the strength returns, and the surface recovers its accustomed hue. Blood drawn from the arm, under these circumstances, will exhibit, if not its usual appearance, a very close approximation to it. Thus, then, there are at least two elements concerned in the production of the black color of the blood, namely, a partial abstraction of the vital principle, and a diminished amount of saline matter. Whether these are the only ones, I cannot pretend to decide; nor can we expect to be able to remove the veil which still enshrouds the subject, until animal chemistry shall have made further discoveries. No speculation on the part of the morbid anatomist, however ingenious, can be entitled to any confidence, or throw any real and substantial light upon the question at issue. The increase of the white corpuscles of the blood and the decrease of 208 BLOOD. the red give rise to a disease called leucocythcemia, or leucaemia. It may be detected by a microscopic examination of the blood and by the peculiar milky appearance of the sanguineous liquor when freed of its fibrin. Upon post-mortem examination soft clots are met with in the heart and the larger veins, consisting almost entirely of white globules. The liver, lymphatic glands, and spleen are generally found enlarged: the latter organ almost always. The serum, like the cruor with which it is so intimately combined, is liable to various alterations, carried, frequently, to such a degree as to entitle them to be termed morbid. Thus it has been found to have the aspect and consistence of milk; to have streaks upon its surface like cream; to have oil in it; and, finally, to be remarkably destitute of saline and animal principles. These changes may occur exclusively in the serum; but there is reason to believe that, in the great majority of instances, the fibrin and blood corpuscles also change their relations. The occurrence of milky serum is probably more common than the silence of the profession in regard to it would lead us to infer. It is usually met with in inflammatory disorders, and seems to be con- nected with deficient assimilating power of the digestive organs. In a case of milky serum, which fell under my observation in 1832, the patient, a young man, thirty years of age, had long been addicted to the intemperate use of ardent spirits, and at the time here specified he labored under symptoms of pleuritis, accompanied with headache, want of appetite, and considerable constitutional disturbance. The blood, as it issued from the vein in the arm, had a singularly dirty, turbid appearance, not unlike a mixture of chocolate and milk. It had scarcely been*drawn ten minutes before it began to assume a white creamy aspect; and it finally formed a layer on the surface of the clot about the eighth of an inch in thickness. In the course of an hour some of this fluid was skimmed off and put in another vessel, in which it was allowed to remain for half a day. On examining it, at the expiration of this time, I found it to be slightly concrete, of the specific gravity of 1.026, remarkably unctuous, and of a strong saline taste. It readily coagulated on the addition of alcohol, corrosive sublimate, and the mineral acids, as well as on exposure to heat; and, on being viewed with the microscope, exhibited no appearance what- ever of globules, circumstances which justify the conclusion that it was essentially composed of albumen. The cruor was somewhat more abundant than usual, and the quantity of serum of course less. It is worthy of remark, that, upon a repetition of the bleeding, twenty- four hours afterwards, the blood presented precisely the same charac- ters as before. Milky serum may also be occasioned, as already stated, by an increase of the white corpuscles, and especially by an inordinate amount of fatty matter. This may be discovered by treating the serum with ether. Becquerel and Kodier have shown that an increase of the phosphuretted fat generally occurs whenever the blood becomes strumous, whilst cholesterine is found in large proportion in old per- sons, in obstruction to the flow of bile, and in inflammation. To the same class of cases ought to be referred, I apprehend, those MILKY SERUM. 209 in which the serum is said to have contained oil, of which several well-marked examples have been recorded by Dr. Traill, of Liverpool, in the twenty-fourth volume of the Edinburgh Medical and Surgical Journal. In the last specimen which he has described, the serum was of a light straw color, cream-like in its consistence, and at first appa- rently homogeneous. On being kept, however, for a short time, it coagulated, and was poured with difficulty from the bottle in which it was contained. On analysis, it yielded a large proportion of albumen and oil, the latter of which was so pure as almost to burn when ex- posed to the flame of a lamp. It has been made a matter of inquiry to ascertain, if possible, the cause of this milky state of the serum. By some it has been attri- buted to the admixture of fatty matter; by others, to the presence of crude chyle. That it is connected with deficient assimilating power appears altogether probable, both from the nature of the diseases in which this peculiar state of the serum is found, and from the resem- blance which this substance bears to the fluid just referred to. Chyle, it is well known, varies in appearance as the food has or has not con- tained fatty matter: in the former case, its color is milk-white; in the latter, it is nearly transparent. Soon after being drawn, it coagulates, and subsequently separates into three parts, one solid, which rests at the bottom of the vessel, and looks like fibrin; another liquid, which is analogous to serum; and a third, which forms a thin layer on the surface of the others, and is of an oily nature. If to this remarkable similarity between these two fluids we add the fact, that nearly all the cases in which milky serum has been observed were characterized by derangement of the chylopoietic viscera, it renders it more than prob- able, I think, that the appearance under consideration is owing to defi- cient assimilation, by which a larger amount of fatty substance is retained in the circulation than in the normal state. Where the fault actually resides, whether in the mesenteric glands, in the thoracic duct, or in the lungs, or in all these organs, is a question which, in the pre- sent state of the science, it is impossible to determine. It is seldom that we find this state of the blood associated with the buffy coat. It has long been a matter of observation, that, in high degrees of inflammations, the watery part of the blood is more viscid and of a deeper yellowish color than usual, presenting frequently the aspect and consistence of synovial liquor. This appearance is less evident when the clot does not float in, or occupy the centre of the fluid. It has been shown that the serum in these disordered conditions of the system contains at least twice as much albumen as in the healthy state; a circumstance which readily accounts for its remarkable vis- cidity, its astonishing coagulable properties, its increased specific gravity, and its deep yellowish color. In dropsical and cachectic persons, on the contrary, the serum is generally much thinner, and of a paler hue, than in such as are strong and plethoric. Its specific gravity is also much less, and there is a sensible diminution of albumen. Similar alterations take place in persons who are in the habit of being frequently bled. The effects thus produced, though long known, have been placed in a very strik- 210 BLOOD. ing light by the researches of Dr. Andrews, of England.1 The animal selected for the experiments was the calf, which was bled from a large orifice in the jugular vein, till symptoms of syncope were in- duced. The operation was repeated at intervals of twenty-four hours, during which the calf was generally once fed upon a mixture of meal and water. The appearance of the blood thus drawn was greatly altered at each successive abstraction. At the first operation, the cruor was very large, and a considerable portion of haematosin was collected from it; but, as the venesection was repeated, it gradually diminished in bulk, whilst its consistency augmented till the fourth bleeding, when it presented the appearance of a small contracted ball immersed in a great quantity of serum. This experiment was frequently repeated on different animals, and uniformly with the same results; whence it maybe fairly inferred that an increase of serum, with a corresponding diminution of crassa- mentum, is a very constant, if not an invariable effect of the repeated abstraction of this fluid from the system. Dr. Andrews farther ascer- tained that there is a perceptible decrease of albumen and salts at each bleeding; he states, however, that the diminution is very variable, and that it seldom exceeds one and a half per cent., even after the fourth operation. In the globules a still greater diminution occurs, being not unfrequently reduced to less than one-half their original number. These experiments are unquestionably of a highly interesting nature, and their results are well calculated to lead to useful precepts in practice. Organic disease of the kidney is another of those conditions in which there is a deficiency of albumen with a consequent diminution of specific gravity. The reason of this is obvious. In nearly all cases of this disorder, the serum is of low specific gravity, and deprived of its animal principles, while the urine, which is loaded with them, is readily coagulable by heat, alcohol, and acids. Jaundice is another disease in which this fluid is morbidly affected, its most prominent change being its deep orange color. How far, or in what respects, the saline ingredients of the serum are liable to be altered, are points concerning which there is no accurate information. That they frequently exist in excess, as well as in defect, does not admit of any reasonable doubt. The ill effects resulting from the long continued use of salt provisions are familiar to every army and navy surgeon. Irritable ulcers, itch, and tetter, with other highly distressing and troublesome disorders, are often directly chargeable to such a mode of life. An increase of the salts has been observed in inflammation of several organs, and in high inflammatory fevers. On the other hand, in scurvy, Asiatic cholera, and in the malignant fever of tropical climates, it is extremely probable that there is generally a great de- ficiency of saline ingredients. In these disorders the blood remains dark even in an atmosphere of pure oxygen ; but, on the addition of a solution of muriate of soda, it instantly assumes a florid hue ; and 1 London Medical Gazette, vol. xv. p. 592. GENERAL DISEASES OF. 211 this takes place even when the solution is very weak. Frequent bleeding, as has been already seen, has also the effect of sensibly di- minishing the saline matter of the blood. That the blood, considered as a mass, may be variously affected, is equally true as of its several constituents. All such changes, what- ever they may be, should be carefully studied, as they correspond with so many particular morbid states of the system. Numerous cases have been published, in which the blood not only contained the different elements of the secreted fluids, but likewise a variety of other accidental products, such as pus, entozoa, and encephaloid matter. In whatever way these substances may gain admission into the vessels, or in whatever mode they may be there developed—and concerning which I do not feel disposed here to speculate—it is certain that, by combining with the blood, they not only vitiate it, but sometimes completely alter its physical, chemical, and vital properties. There can, indeed, be hardly any doubt that the elements of what are termed the heterologous formations may be found in the circulation, and that they are deposited subsequently in the various organs and tex- tures, like other substances, by a sort of perverted action, induced by their presence. The ill effects of contaminated blood on the solids are well illustrated in the operation of transfusion. This operation, devised by Lower, in 1665, consists in transferring the blood of one animal into the veins of another, and has been performed, with complete success, upon the human subject. That no detriment, however, may accrue from it, it is neces- sary that the fluid thus used should be of a healthy character, otherwise it will act as a poison. The truth of this assertion has been fully estab- lished by experiment and observation. Thus, a man, a flayer by occu- pation, whose case is described by Gendrin, was affected with putrid fever, attended with excessive prostration of strength, gangrenous pustules, and hemorrhagic exudations from the mouth and nostrils. His breath, fecal discharges, and whole body exhaled a most offensive odor; and the blood which was taken from the arm was unusually black, scarcely coagulated, and displayed a remarkable tendency to decom- position, being already quite fetid at the end of three hours and a half. Under these circumstances the vein was re-opened, and an ounce of blood being drawn, it was introduced into the cellular tissue of the groin of a cat. The animal was soon seized with copious vomiting, followed by dyspnoea, thirst, and extreme prostration, and, in less than seven hours, it died in convulsions. On inspection, the different viscera were found in a state of congestion and ecchymosis; the heart was soft and flabby; the blood was everywhere black and uncoagulated; the left pleuritic sac contained several ounces of sero-sanguinolent fluid ; and the whole body, emitting a nasty, fetid odor, speedily began to putrefy. A small quantity of blood, taken from the same patient, was next injected into the femoral vein of a dog. Similar phenomena ensued as in the preceding case, the animal soon dying from the effects of the morbid fluid. The same writer details some experiments which he performed with the blood of persons affected with confluent small- pox. In a very short time the most violent effects arose, and the 212 BLOOD. dogs, the subjects of the investigations, usually died in from twenty to thirty hours, in consequence, apparently, of inflammation of the principal internal viscera. To these experiments may be annexed the extraordinary case re- lated by Du Hamel, of a butcher, who died of malignant pustule, four days after having held in his mouth the knife with which he had slaughtered an over-driven ox. Another person lost his life by acci- dentally pricking his hand with a bone of the same animal; and two women suffered severely merely from some drops of blood falling on them. Not less conclusive are the results of the experiments of Dupuy and Lauret. These physiologists found that, on introducing blood taken from a horse affected with malignant carbuncle, into the veins and cellular tissue of another, they could readily induce the disease. Glanders have been communicated in a similar manner; and Dr. Hertrizch, of Berlin, asserts that hydrophobia can be readily produced by inoculating a sound animal with the blood of one that is rabid. A peculiar disease of the dog, called mange, has been transferred in the same way. These facts are highly interesting, inasmuch as they throw light on another subject, namely, the propagation of exanthematous affections by artificial means. As the blood, in the examples above quoted, was capable of trans- mitting similar affections, no doubt can be entertained that it was really contaminated ; and there is, moreover, the strongest ground for believing that fatal disturbance is often induced in this way, where we are little prepared to expect it, for aught we can discover in this fluid. The experiments, indeed, of Christison, Coindet, and others, of inject- ing poisonous substances into the veins of animals, conclusively show that, although the smallest quantity will frequently destroy life, yet the most delicate chemical tests will be insufficient to detect their presence in the vital current. Inordinate acceleration of the circulation appears to be often fol- lowed by serious alterations of the blood. It was long ago noticed that violent muscular exertion will vitiate this fluid, render the per- spiration strong and offensive, change the qualities of the urine, and terminate, if long continued, in intense fever, and even death. Dupuy has ascertained by experiments that the fibrin is either very sensibly diminished or otherwise altered, in animals that are subjected to ex- cessive exercise; and Chaussier asserts that transfusion of the blood, under such circumstances, will be speedily followed by the develop- ment of gangrenous pustules and malignant fever. The deleterious effect on the blood produced by over-driving animals is well illustrated by the case narrated by Du Hamel, detailed in a preceding paragraph, and is still further exhibited in an instance which occurred in our own country. The case to which I refer is this: Some years ago, a number of fattened cattle were driven into one of the New England cities, and having been pressed too hard in a sultry day, were so over- heated that some of them became quite exhausted. In this condition they were slaughtered, and the consequence was, as is stated by the MORBID CHANGES—CAUSES. 213 reporter of the case, Dr. Fountain,1 that nearly all who partook of their flesh were seized with typhus fever. In Asiatic cholera, in fevers, and other maladies, the blood, contem- plated as a mass, is very materially altered; but whether primarily or consecutively, is a question by no means decided. In the first of these disorders, the fluid is drained of its water, and, consequently, contains a disproportionate amount of albumen and blood-corpuscles; its color is excessively black, both in the veins and arteries; it co- agulates very imperfectly; is greatly augmented in specific gravity; and the saline matter occasionally wholly disappears. Its fibrin may remain unaltered. Sometimes the serum contains even an increase of phosphates and salts of potassa.2 One of the most extraordinary cir- cumstances connected with the blood of cholera subjects is the presence of urea; this substance, however, is not always found, and it is usually most abundant where there is marked and long-continued suppression of urine. The great diminution of the serum of cholera blood is easily ac- counted for by the rice-fluid discharges, which are often so excessively copious in this disease, and which are essentially composed of the same elementary principles, namely, water, animal matter, and neutral salts. According to the analysis of Lecanu, it contains neither caseum, nor bile, nor albumen, except in the form of flakes suspended in the ejected liquor. The blood of fever patients has recently attracted a considerable share of attention among practical writers; but as yet our knowledge in relation to this subject is both limited and imperfect. In those who died of typhus at Brest, in 1757, the blood is said to have been grumous, black and decomposed, particularly in the portal vessels; and Dr. Tweedie, in his Clinical Illustrations of Fever, states that the cras- samentum of the blood in this class of diseases, instead of forming a firm coagulum, is unusually soft, scarcely of the consistence of half-boiled currant-jelly, preternaturally small, and so destitute of cohesive power as to break on the slightest touch. In the typhus fever of Philadel- phia, Dr. Gerhard3 found the blood drawn during life, even at an early stage of the disease, of a very dark color, free from buffy coat, and with a large, soft coagulum. At a more advanced period, it exhibited the dissolved appearance described by various authors as characteristic of typhus or putrid fever. The blood, contained in the heart and arteries, was still more strikingly altered. In one case it is said to have been of the color and consistence of molasses, with minute fatty globules floating in it. In typhoid fever the most frequent alterations in the character of the blood are, the imperfect formation of the buffy coat, the peculiar state of the clot, and the diminution of the natural proportion of fibrin. In one hundred and eleven bleedings, of which accurate notes were 1 Transactions of the Medical Society of the State of New York, vol. ii. p. 219. Albany, 1837. 2 Lehmann's Chem., vol. i. p. 637. 3 Amer. Journ. Med Scien., vol. xx. p. 298. 214 BLOOD. kept by Eaciborski,1 the buffy coat was entirely absent in forty-six, or existed merely in small, viscid, semi transparent patches. The clot in all was more or less dark, frothy, and so soft as to break down under the slightest pressure, or even under its own weight. The serum was always diminished in quantity, and, without being actually turbid, was never so clear as in recent inflammation. In all these bleedings, which were performed upon twenty-one patients, the buffy coat was not perfect in a single one. The results of these observa- tions are confirmed by the researches of Louis, Chomel, Bouillaud, Andral and Gavarret. All these writers testify to the black, grumous, and imperfectly coagulated condition of the clot, and the infrequency of the buffy coat. When present, the latter is usually very thin, soft, gelatinous, or infiltrated, and of a grayish, greenish, iridescent, semi- transparent appearance. The blood in the cavities of the heart is either entirely fluid, or it presents itself in the form of dark coagula, or, finally, it is converted into whitish or yellowish concretions. The proportion of fibrin is never augmented above the natural standard; on the contrary, it is generally very considerably diminished, espe- cially in severe cases. The globules are less numerous than in healthy blood, but, in proportion to the quantity of fibrin, they always exist in a redundant state. The globules are stated by some to be less, by others more numer- ous, than in healthy blood. They are generally increased at the com- mencement of the disease aud subsequently diminish. In the yellow fever of Philadelphia, in 1797, Dr. Push2 found the blood frequently quite dissolved, dark, grumous, and occasionally like the washings of flesh. In some of the cases the serum had a yellow color; and, towards the close of the disease, it was very com- mon to see the cruor more or less sizy. This appearance, it would seem, generally portended a favorable issue. Similar states of the blood have been noticed by Ariquila, Bally, Palloni, and others, in the epidemic yellow fever of Spain ; and, more recently, by Dr. Cop- land and Dr. Stevens, in the same disease, as it occurred in the AVest Indies. These authors describe the blood of yellow fever patients as semi-concrete, of a dark color, very poor in regard to its fibrinous and saline constituents, and extremely prone to decomposition. A state very analogous to this is observed in the plague, in epidemic peri- tonitis, and in the worst forms of erysipelas. On the other hand, in the elaborate work of my friend Dr. La Roche on yellow fever, it is mentioned that the blood, in the early stages, has been frequently found to be of a bright florid hue. This is ascribed by him to an increase of saline matter. The dissolved htemato-globulin and the coloring matter of the bile account for the red or yellow color which the serum sometimes presents. In the latter stages of the disease and after death, urea has been detected in the blood by Chasaniol. Yet experiments performed by Prof. Pogers, of this city, did not prove this substance to be present. 1 Gazette Medioale, Feb., 1839. 2 Medical Inquiries, vol. ii. p. 13. IN ANAEMIA. 215 According to his observations, the blood drawn during the second stage of the disease contained the constituents of bile and an increased quantity of salts, but no urea.1 Our knowledge of the alterations which the blood experiences in those who die of plague is still extremely defective. This disease is usually very rapid in its march, and is characterized by the develop- ment of buboes, livid patches on the skin, great congestion of the viscera, and effusions in the internal cavities. According to Dr. Bu- lard,2 of Turkey, the blood occasionally remains perfectly fluid, and never exhibits the buffy coat; it is unusually cohesive as it flows from the vein, and not unfrequently emits a peculiar odor. It was analyzed in three cases, and found to contain in 100 parts the follow- ing ingredients:— fWater.........35.576 ! Fibrin......... .624 Coloring matter, with some fibrin, albumen, [ and fatty substances ...... 3.800 Clot 1 j fWater.........54.420 | Albumen and coloring matter ..... 4.704 o j Extractive..........252 | Chloride of potassium and sodium .... .408 Carbonate of soda and fatty matters .... .216 l_ Distinct traces of sulphurous acid. In plethora the blood is unusually florid, the serum is more or less discolored, and the clot, which rarely exhibits the buffy coat, is large, and of moderate firmness. The fibrin is not sensibly augmented; it remains within the natural limits, and does not even tend, in the greater number of cases, to mount to the highest standard. The serum is much diminished in quantity, but its organic materials do not pre- sent any particular change of proportions. The globules alone are in excess, and it is this circumstance which establishes, as far as it re- spects the blood, the character of plethora. In thirty-one bleedings performed by Andral,3 the globules stood at 141 as the average, at 131 as the minimum, and 15-1 as the maximum. Plethora may also occur simply by an increased quantity of the whole blood without one element existing in greater abundance than another. In anozmia, the reverse of plethora, the clot is very small, and floats in an abundant, colorless serum. Instead of being soft, as might be expected, it is exceedingly dense, coherent, and often covered by cha- racteristic buff. This state of the clot is the more marked in propor- tion as the ana3mia is more thoroughly established. In confirmed cases the blood may even be cupped, as was pointed out long ago by Bor- sieri. The fundamental character of anaemia consists in a diminution of the globules, which often fall far below the normal limits. Thus Andral4 found, as the average of the proportion of the globules, in sixteen cases of incipient anajmia the cipher 109, and in twenty-four cases of confirmed anaemia the cipher 65. In the spontaneous form 1 La Roche on Yellow Fever, vol. i. p. 174. 2 British and Foreign Med. Rev., vol. viii. p. 551. 3 Op. cit., p. 40. * Op. cit., pp. 43-52. 216 BLOOD. of the disease the fibrin and solid matters of the serum may retain their normal relations; but when it supervenes on copious hemor- rhages they are generally sensibly diminished. In a female, who had experienced repeated attacks of monorrhagia, the blood contained only 21 in the thousand of globules, 1.8 of fibrin, and 61 of solid matters of the serum, the proportion of water being 915. In chlorosis, which may be viewed as the most perfect type of anaemia, the blood always experiences great changes, both as it re- gards its color, its consistence, and the relative proportion of its ingre- dients. It is almost always remarkably impoverished, and it is to this circumstance that is to be ascribed the blanched appearance of the skin and the diminished temperature of the body, which form such prominent features in its history. In the violent degrees of this malady, the crassamentum is soft and small, the serum thin and copi- ous, and the corpuscles and hsematin so diminished as scarcely to leave a stain when dropped on white linen. Jaundice is another disease, in which, as was formerly stated, the blood is more or less altered in its properties. Not only the coloring prin- ciple of the bile, but even the resin of this substance has been detected in the circulation ; and, as a necessary consequence, especially when the disease is of long continuance, every tissue of the body assumes a yellowish tinge, as well as, in many cases, the different secretions. In four subjects that I have had occasion to dissect within the last five years, all the soft parts, together with the whole of the osseous and cartilaginous systems, were of a deep orange complexion, from this cause. Even the brain participated in the change; for its substance was by no means of so clear a white as in the healthy state. When the bile is thus introduced into the general circulation, it appears to act as a sort of narcotic, inducing drowsiness and irritability. In other cases it generates fever, with headache, nausea, and loss of appe- tite. The presence of this fluid may be easily detected in the serum of the blood by adding to it an equal quantity of sulphuric acid, diluted with twice its bulk of water. The serum will thus change its yellow straw color for the characteristic green tint of bile. But in no deranged condition of the body is the blood more remark- ably altered than in scurvy. The relation of the different constituents of the blood in this disease has not, as yet, been satisfactorily determined: it is always unnaturally black, greatly deficient in cohesive power, and manifests but little disposition to separate into serum and crassa- mentum. In the latter stages of the malady, it has frequently the aspect and consistence of thin tar, treacle, or even of ink, the fibrin looking like wool floating in a dark, muddy substance, sometimes of a greenish tint. The blood that oozes from the mucous surfaces, in the form of spontaneous hemorrhage, exhibits similar appearances, showing, most conclusively, that it has undergone essential changes, both in its chemical properties and in its vital affinities. The blood is generally considerably altered in pulmonary phthisis. Among the changes which occur in the progress of this affection the most conspicuous is an impoverished condition of this fluid, which is thin, light colored, and deficient in globules. The diminution of the PHTHISIS — CARCINOMA. 217 globules is apparent at the very commencement of the morbid deposit, and reaches its minimum when the lungs are filled with cavities. The fibrin is not changed as long as the tubercles remain crude, or as long as there is no inflammation in the parts around them. The very moment, however, the softening process begins, it increases in quantity, and so continues until the disease arrives at its third stage, when it attains its maximum. Andral weighed the fibrin obtained from thirty tubercu- lar patients in thirty-three different bleedings. In seven of these the tubercles were crude, in nine they were softening, and in fourteen they were converted into abscesses. The seven patients of the first series were bled, altogether, nine times; in seven times the fibrin was found normal;- and twice it exceeded the physiological standard, giving the numbers 4.8 and 5.1. It is worthy of note, however, that in each of these two cases there was an inflammatory complication. In ten bleedings performed on the nine patients of the second order, that is, when the tubercles were in a state of softening, the fibrin wras in excess in all, excepting one, sometimes very slightly, hardly reach- ing 4, and sometimes varying between 4 and 5. In the fourteen cases of the third class, this substance was in excess twelve times, and that in a much greater degree than in the second series. The minimum was 4.0 ; the maximum 5.9. The clot in the early stage of phthisis is generally rather small and dense, but does not exhibit any other peculiarities. When softening sets in, or cavities begin to form, it diminishes very sensibly, and is almost always covered with a buffy coat. In the advanced stage of phthisis, the latter phenomenon is nearly as constant as in pneumonia, or acute articular rheumatism. Modern research has not thrown much light on the condition of the blood in carcinoma. From facts, however, collected by Andral on the subject, he is led to infer that here, as in tubercle, the fibrin does not increase until the matter is advancing to, or has actually reached, its stage of softening and destruction. The globules offer nothing remarkable, except the progressive numerical diminution they undergo in consequence of the defective nutrition and profuse hemor- rhages so generally attendant upon the disease. To the instances now cited, numerous others might be added, equally striking and satisfactory, in which the vital fluid is most seriously altered, and transformed into substances very different, in their cha- racter, from those observable in the healthy state of the economy. But to do this would far transcend the limits of the present work, if, indeed, it would not be equivalent to writing a treatise on individual maladies. From the facts that have been presented upon the subject, it cannot be doubted, by any one who duly and impartially contemplates it, that the blood is a fruitful source of disease, or, in other words, that it is susceptible of various morbid impressions, of which, in many instances, it is the primary and original seat. Considering the vast surface from which the chyliferous vessels imbibe nutritious matter, and the heterogeneous nature of man's food and drink, it is highly probable that the elements of disease may thus readily find their way into the current of the circulation, and establish a prejudicial action 218 CELLULAR TISSUE. in the solids, by which they, in turn, are disordered, and thrown into commotions incompatible with the harmony and well-being of the general system, or of some of its numerous members, tied together as they all are, figuratively speaking, by the closest consanguinity. CHAPTER II. CELLULAR TEXTURE. Lesions.—Acute Inflammation.—Suppuration.—Gangrene.—Chronic Inflammation.—Indura- tion.—Serous Infiltration.—Emphysema.—Degenerations.—Foreign Substances.—G-uinea Worm. Notwithstanding its apparently unorganized character, the cellular substance possesses the formative power in a very eminent degree. When destroyed, it is speedily regenerated; and in many instances, it supplies the loss of those textures that cannot be perfectly repro- duced, as the muscular and tendinous. Every growth, in fact, whether normal or accidental, probably begins in the cellular substance. The cellular tissue, diffused through every part of the body, and cementing together its various anatomical elements, is prone to nume- rous diseases, both of a primary and consecutive nature. Many of these lesions are of a highly interesting character, as affording an admirable insight into some of the most striking processes employed by the animal economy in repairing injuries, and in throwing off from the system such materials as have a tendency to impede the exercise of its normal functions. The principal morbid affections of the cellular tissue, which demand the special attention of the morbid anatomist, may be comprised under the following heads: 1, acute inflammation; 2, chronic inflammation ; 3, induration ; 4, morbid growths; 5, serous infiltration; 6, hemorrhage; 7, emphysema; 8, foreign bodies; and '.), the development of parasitic animals. 1. In acute inflammation, the cellular tissue is of a light reddish color, soft, spongy, and inelastic; its cavities are filled with an opaque, gelatinous fluid; and all the vessels ramifying through it are distended with blood. The nerves, too, are increased in their dimensions; and, when the irritation has been violent, it is not unusual to find small extravasations, produced by a real rupture of some of the capillaries. If the part affected contains much adipose matter, this will be variously modified, according to the degree of the inflammation; when moderate, the fat is commonly absorbed; if intense, it is broken down, mixed with the effused blood, and converted into a yellowish, pap-like sub- stance, nearly destitute of its original features. These appearances, which denote a high degree of morbid action, always decrease towards the periphery of the inflammation; the redness also gradually declines ACUTE INFLAMMATION. 219 in intensity; the vessels are less minutely injected; and the tissue, although somewhat oedematous, preserves its accustomed elasticity and expansibility. After some time, varying from three to eight days, softening takes place towards the centre of the inflamed mass, and the cells of the tissue become loaded with globules of pus. Subsequently the walls of these interstices are broken down, and the purulent matter is col- lected into one or more cavities. The swelling, in the mean time, becomes more circumscribed, the surrounding oedema diminishes, and the neighboring cells being agglutinated together by lymph, an effectual barrier is thus presented to the extension of the pus. The cellular substance immediately around the matter is of a dense, compact texture, forming a firm, resisting sac, the inner surface of which, at first red and rough, gradually assumes a smooth, velvety aspect, not unlike raucous membrane. Such are the ordinary characters, and such the usual termination of circumscribed phlegmonous inflammation of the cellular tissue. Another variety, much more formidable than the preceding, because much more destructive in its results, is the diffuse, so termed from its spreading tendency. In whatever manner this disease arises, whether from external violence, phlebitis, poisoned wounds, phlegmonous erysipelas, or any other cause, it always attacks a large extent of surface, often invading a whole limb, or even a considerable portion of the trunk. In most cases it terminates in suppuration, and sometimes even in sloughing. The matter, which is generally of an unhealthy, sanious character, is not contained in a sac, nor is it restricted by an effusion of fibrin, as in the phlegmonous form, but is extensively diffused, and often causes great havoc in the adjacent structures. When diffuse inflammation occurs in debauched, worn-out indi- viduals, as it is apt to do when it presents itself in the form of carbuncle, it not unfrequently terminates in gangrene. This disease, which is usually located in parts remote from the centre of the circulation, is characterized by a soft, doughy, undefined swelling, with deep-seated, burning pain, an oppressive sense of weight, and vesication of the cuticle. In a short period, the swelling assumes a dark, brownish, violet or purple color, and imparts a peculiar, boggy feeling, as if the subjacent textures were floating in a fluid. Numerous apertures now appear in different parts of the skin, giving vent to a thin, acrid sanies. If the cellular substance thus affected be examined after death, it will be found to have very much the appearance of wet tow, being of a deep ash-color, soft, inelastic, extensively detached, and bathed in a bloody and offensive fluid. These changes are not always confined to the subcutaneous cellular tissue, in which they more commonly commence. Not unfrequently, long, sinuous tracks are formed between the muscles, and gangrenous shreds are seen hanging from aponeurotic sheaths, tendons, ligaments, and bloodvessels. Sometimes, though rarely, the disorganizing process extends to the periosteum, involving both it and the subjacent bone in the destruction. Excessive pain and great consti- tutional disturbance—at first of an inflammatory, and afterwards of a typhoid character—are the usual attendants of this formidable malady. 220 CELLULAR TISSUE. 2. In chronic inflammation, the cellular tissue no longer tears with the same facility as in health; it is dense, hard, and crisp; admits of little extension, and is nearly destitute of elasticity. When _ the disease is protracted, the tissue gradually assumes an opaque, milky color, and its cavities are distended with sero-fibrinous matter, so as to be no longer permeable to blood, air, pus, or water. These altera- tions, which give the seat of the disease a tumid and constricted feature, are well characterized in the callous edges of old ulcers, in chronic erysipelas, in the hard swellings so often witnessed in gouty and rheumatic affections, in pelagra, elephantiasis, and in the indura- tion of the cellular substance of new-born infants. This disease seldom produces healthy pus; on the contrary, the matter is commonly of a sanious, sero-purulent, or sanguinolent nature. Occasionally small abscesses are scattered through the affected tissue, containing a yellowish, turbid serum, or thick curdy matter, not un- like that of a strumous lymphatic ganglion. In the subcutaneous cellular substance, these deposits are often inclosed by a thick layer of lymph, by which their contents are kept within their proper sphere. During the development of this sac, the circumjacent tissue is red and indurated; but, as soon as the membrane is organized, as often hap- pens when the irritation is protracted, these phenomena generally disappear, and the parts gradually resume their normal properties. The sac often acquires great thickness and density, layer after layer being deposited upon its internal surface, as is the case with the ad- ventitious membranes in other situations, when they participate in the inflammation of the surrounding structures. This affection is rarely attended with much pain; indeed, were it not for the hardened and inflexible state of the affected part, the patient would experience but little inconvenience. 3. Induration of the cellular tissue constitutes a peculiar disease in children, described by writers under the several appellations of oedematous hardening, scleroma, and skin-bound. It is comparatively rare in this country and in Great Britain; but, on the continent of Europe, especially in the foundling hospitals of Paris, it is extremely prevalent and fatal, hundreds of infants dying from it annually. Many children, it would seem, come into the world with this affection, or are attacked within the first twenty-four hours after birth. Its pro- gress is usually very rapid, most of the little patients being cut off in the course of three or four days. The disorder sometimes affects the whole body; more commonly, however, it is restricted to particular regions, as the abdomen and inferior extremities. The skin is of a brownish color, interspersed with yellowish looking patches, and its texture is remarkably hard and firm, almost like leather. The subcutaneous cellular tissue is very dense and granular, communicating, when cut, the sensation of fibro- cartilage, calf's-foot jelly, or half-dissolved glue. Frequently it is of a bright lemon-color, and contains a large number of dark yellow granules, which are nothing but diseased adipose vesicles. The infil- trated matter is sometimes firm and concrete; but, in the early stages SEROUS INFILTRATIONS — HEMORRHAGE. 221 of the disorder it is commonly thin, and straw-colored, like serum, and readily coagulates by heat, alcohol, or dilute acid. The greatest induration is usually met with on the outer surface of the leg, and on the dorsal aspect of the hand and foot. Associated with these morbid appearances are various lesions of the internal organs. The lungs are hard, increpitous, marbled, and congested; the oval foramen and arterial duct often remain patulous, or are but partially closed ; the liver is extremely vascular, and the gall-bladder is distended with vitiated bile; the mesenteric glands are enlarged and injected; the gastro-enteric mucous lining is more or less inflamed; and the whole venous system is remarkably engorged with blood. Various opinions have been suggested respecting the precise nature of this affection; the most plausible being that which ascribes it to inflammatory irritation, either of an acute or chronic character, which determines an effusion of sero-fibrinous matter into the meshes of the cellular tissue, closing up its cavities and hardening its texture. 4. The cellular tissue is liable to various morbid growths, deposits, and transformations. Amongst these the most common are cysts, melanosis, and fungus hasmatodes, neither of which will require par- ticular notice in this place. Fibrous, cartilaginous, and bony forma- tions are most prone to occur in the sub-serous cellular tissue of the chest, abdomen, and scrotum, in small grains, patches, or irregular incrustations. Such degenerations are extremely rare in the cellular tissue under the skin, and still more, if possible, in that of the mucous membranes. 5. Serous infiltrations of the cellular tissue are very common in per- sons of deteriorated constitution, and in those who have become exhausted by protracted diseases, profuse hemorrhages, and other affections impairing the vital powers. In poisoned wounds, the effu- sion is generally very rapid, large in quantity, and highly acrid in quality. Various terms have been employed to designate this con- dition of the cellular tissue. Thus, when it is restricted to a particular region, as, for instance, the eyelid, leg, or scrotum, it is named oedema; whilst, when it is more extensive, or diffused over the greater part of the body, it is called anasarca. Neither of these appellations, it is obvious, is well chosen, as the one literally signifies merely a swelling, the other dropsy of the flesh. The interstices of the cellular tissue in this disorder are very much enlarged, and the skin over the part, which has generally a singularly glossy and tumid appearance, readily pits upon pressure. The effused fluid, which is of a sero-albuminous nature, is coagulable by heat, alcohol, and acids, and occasionally un- dergoes spontaneous concretion. These serous infiltrations, in what- ever part of the body they occur, ought to be regarded as the result of capillary congestion, depending upon inflammation, debility, or me- chanical obstruction. 6. Hemorrhage always arises from a rupture of the bloodvessels, produced by external violence, or by some internal cause, the precise nature of which is not so well understood. In the former case, the fluid, although sometimes widely diffused, generally forms an elastic, 222 CELLULAR TEXTURE. Fie 52. circumscribed tumor, technically denominated an ecchymosis ; in the latter, it is more commonly seen in small patches of a dark purple color, which have received the name of suggillations, death-marks, or cadaveric lividities. These spots, which are always most conspicuous on the pos- terior parts of the body, are very distinct in persons who die from petechial fevers, the plague, and the scurvy, and can be readily distinguished from ecchy- moses by the entire absence of all signs of violence. Suggillations, however, do not always arise exclusively in the manner here indicated.. In many instances, if not in most, they result entirely from an accumulation of blood in the capillary vessels of the skin and cellu- lar tissue, without any extravasation whatever. These facts should be borne in mind, as they have a most im- portant bearing upon legal medicine. For the want of correct information upon this subject, errors the most serious have sometimes been committed by physicians. 7. Emphysema may be produced by a great variety of causes, but the most common are penetrating wounds of the chest and rupture of the air-cells of the lungs, from violent coughing, or ulceration, and injury of the lining membrane of the windpipe. It has been sup- posed that it sometimes arises spontaneously, as the re- sult of a process of secretion from the bloodvessels; and, in a considerable number of cases, it has been met with as an attendant on gangrene. The infiltration is sometimes very great, the air occupying nearly the whole of the cellular tissue. The distended parts have a bloated aspect, pit under the finger, and emit, when pressed, a peculiar crepitating sound, not unlike the lungs. 8. Foreign substances are sometimes found in the cel- lular tissue. In most cases they excite inflammation in the contiguous parts, and are finally discharged by suppuration. Not unfrequently, however, especially when they get admission through the alimentary tube, they become encysted, the cellular tissue around them being condensed, and converted into a sac. At other times, again, after traversing the body in different directions, they are arrested, and work their way out through the skin, generally at the back of the hand and foot, though in this respect there is no invariable rule. It is thus that bullets and needles often pervade the subcutaneous cellular tissue, starting, perhaps, at the trunk, and gradually reaching the most distant parts of the extremities, and this, too, frequently without producing any serious mischief. Not long ago, a case occurred in one of the Parisian hospi- tals, where the cellular substance was literally loaded with needles, and yet the patient lived several years in tolerable comfort. a. Head; b. Cau- dal extremity. ADIPOSE TEXTURE. 223 9. The cellular tissue is occasionally the residence of parasitic animcds, developed either in its substance, or introduced from without. Of these, the only one requiring notice is the Filaria medinensis (Fig. 52), the little dragon, or Guinea-worm. This animal, which is extremely simple in its structure, generally occurs immediately beneath the skin. The legs and feet are the parts which it more commonly infests, but it has also been observed in the scrotum, the anus, and in different parts of the head and trunk. It is of a white color, about the thick- ness of a violin-string, and, when full-grown, from five to ten inches in length; its diameter being nearly equal from one end to the other, except towards the tail, which is somewhat tapering and curled. The countries in which these worms most frequently occur, are Egypt, Arabia, Guinea, Persia, and Abyssinia. Several of them have been known to coexist in the same patient; and occasionally they have been found from three to four feet in length. CHAPTER III. ADIPOSE TEXTURE. Lesions of the Adipose Tissue.—Wounds.—Liability to Inflammation.—Hypertrophy, genera and local.—Adipose Diathesis.—Atrophy. Wounds of the adipose tissue present nothing unusual in their mode of healing: they commonly unite without difficulty, in fact, not unfrequently by the first intention. When the divided parts are kept asunder, the fatty matter is'gradually absorbed, and the restoration in finally effected by the granulating process, as in similar injuries of other textures. It has been questioned by some, whether the adipose tissue is sus- ceptible of inflammation, the opinion having probably arisen from a belief, at one time very current among physiologists, that this sub- stance is not endowed with a sufficient degree of vitality for this pro- cess to take place. In endeavoring to solve this problem, we must bear in mind the distinction between the adipose tissue, properly so called, and the fat. The one, as is well known, is an organized substance, provided with bloodvessels, nerves, and absorbents, and, therefore, liable to inflammation; the other, on the contrary, is inorganic, and on this account is insusceptible of any morbid action whatever. In acute inflammation, the adipose tissue assumes a dark reddish aspect, and always manifests a peculiar tendency to slough, in consequence, it would seem, of its vascular and nervous endowments being too feeble to offer the necessary resistance. In peritonitis, we often see the fatty omentum inflamed in one part, and gangrenous in another, even where there is little effusion of lymph or serum. The adipose tissue is liable to hypertrophy. This may be general 224 ADIPOSE TEXTURE. or partial. Various attempts have been made to estimate the standard amount of fat; but, as the quantity varies in different individuals, and even in the same person, under different circumstances of health and disease, it is obvious that there must be great difficulty in arriving at a satisfactory conclusion. The majority of anatomists, however, agree in the opinion that, in an adult of ordinary size, it forms about one- twentieth part of the entire body. Thus, a man weighing one hun- dred and sixty pounds, would have about eight pounds of fat. But, in case of obesity, it often greatly exceeds this quantity; and, on the other hand, in emaciation it often falls far below it. In general hy- pertrophy, the quantity of fat is sometimes enormous, amounting to five or six times the weight of the entire body. The celebrated Pritchard, of Kentucky, who exhibited himself at Litton's museum, in Cincinnati, in 1834, weighed five hundred and fifty pounds. The Canadian giant, as he was called, whom I saw in this city, in 1829, weighed six hundred and eighteen pounds. He wras six feet four inches in height, and the circumference of each leg, around the calf, was nearly three feet. The most remarkable feature in the case was, that this enormous deposit of fat, making him so much larger than ordinary men of the same stature, was confined chiefly to the abdomen and lower extremities, the thorax, shoulders and arms being little stouter than in other persons. Daniel Lambert, of England, who died at the age of forty, weighed seven hundred and thirty-nine pounds; and a German journal relates the case of a man who weighed eight hundred pounds, the fat of the abdomen being nearly fourteen inches thick. An account of a somewhat similar case has been published by Dupuytren. The individual, a poor beggar-woman, measured five feet one inch in height, and five feet two inches in circumference. The thoracic and abdominal cavities were enormously loaded with adeps; on the mammas, the subcutaneous layer was seven inches in thickness. But the most extraordinary example of this affection, of which I have any knowledge, occurred some years ago in the State of New York in a girl who weighed three hundred and sixty-four pounds, though only ten years and a half old. There would thus seem to be, from the above detail of cases, some- times a real adipose diathesis, nearly all the materials entering the circulating mass being converted into fat. Various articles of food and drink have a tendency to bring about this state of the system. Malt liquors, taken to excess, and the moderate use of wine and ardent spirits, are, perhaps, the most powerful means for producing general hypertrophy of the adipose tissue. But, whatever may be the exciting causes of these depositions, it is certain that indolence and freedom from care are necessary, if not essential, to the process. Castration is generally followed by considerable obesity; and the same thing has long been observed in women who have been deprived of the ovaries, or in whom these organs are diseased or imperfectly developed. Simi- lar phenomena have been noticed in animals, after the removal of the spleen; though the obesity, in these cases, is generally only temporary, the body gradually returning to its former weight and spareness. Whether the same changes have ever been witnessed in the human ADIPOSE DIATHESIS. 225 subject, as the result of the loss of this organ, has not been ascertained. In birds, considerable accumulations of fat sometimes occur in a very short time. Thus, when the ground is loaded with insects Fig- 53. and other nutritious sub- stances, robins and thrushes will occasionally fatten to such an extent, in the course of twenty-four hours, as to be almost unable to get out of the way of the sportsman. Partial hypertrophy of this texture is well exemplified in adipose tumors. (Fig. 53.) Generally developed under the skin, these tumors not unfrequently occur within the abdominal cavity, in connection with the perito- neum. Their size, though commonly small, is some- times enormous. Dr. Bray, of Evansville, Indiana, re- moved one, some years ago, weighing nearly forty pounds. In their shape, these tumors are usually somewhat globular, but as their bulk augments they are apt to become elongated, and to assume a pyriform, gourd-like, or pediculated configuration. Their surface is irregularly tabulated, and they are composed of various sized masses, of a rounded, or ovoidal shape, in all respects similar to those of the adipose tissue in the normal state. They are surrounded by a thin but firm capsule of cellular substance; and their supply of blood is by no means so liberal as might be supposed from their size, and the rapidity of their growth. These tumors sometimes occur in considerable numbers in the same individual. In a gentleman, thirty-eight years of age, who attended my lectures in 1844, I counted upwards of two hundred, from the volume of a small pea up to that of a large marble; they had a doughy, inelastic feel, and were nearly all of a globular shape. They were seated principally on the forearms, the inside of the thighs, the loin, abdomen, and pectoral muscles, the latter of which were lite- rally covered with them. None existed on the head, neck, and upper part of the back. They were first noticed in 1828; the general health was good, and no cause could be assigned for their occurrence. Dur- ing two severe attacks of acute disease, attended with great emacia- tion, many of them entirely disappeared. To ascertain the true cha- racter of these tumors, I was permitted to remove one, about the size of a filbert, and found it to be composed entirely of fatty matter. Sometimes, again, these fatty tumors betray an hereditary tendency. 15 Fatty tumor. From a preparation in my cabinet. 226 ADIPOSE TEXTURE. In a case recently communicated to me by Dr. Charles Maer, of Tama- qua, Pennsylvania, the disposition has evinced itself in three succes- sive generations. The grandfather had two fatty tumors on the back of the neck. Five of his sons have similar tumors on various parts of the body; the largest number on any one of them being eight, three on the posterior part of the neck, one on the right arm, one on the chest, one on the right shoulder, one on the left groin, and one on the right thigh. A grand-daughter has a fatty tumor on the side of her neck. The adipose tumor occasionally, though rarely, inflames and suppu- rates. The matter is of a thin, sanious character, and mixed with globules of fat. It is seldom collected into a distinct abscess. In my private collection is a fatty tumor containing a deposit of bony matter. In abdominal obesity, the encumbered organs are often literally buried in beds of fat. The tumors are generally more pediculated than those which are developed under the skin, and they may grow either on the omentum, from the epiploic appendages, or beneath the peritoneum, giving that projecting rotundity to the abdomen which is vulgarly distinguished by the name of "pot-belly," and which is so well described by Prince Henry, in his address to Falstaff, as "a huge hill of flesh," " a globe of sinful continents." Large quantities of fat occasionally envelop the kidney. In a specimen which I took from an old man a few years ago, the mass amounted to three pounds; and Dr. Horner refers to one, removed from a bullock, which filled a common sized wash-tub. In the chest large masses of fat sometimes surround the pericardium, compressing the heart and great vessels, and thus inducing palpitation, and even fatal syncope. Atrophy of the adipose tissue, which is far more common than its preternatural accumulation, may arise from one or other of the follow- ing causes: defective or unwholesome diet; organic lesions of the lungs, heart, stomach, or bowels ; protracted abstinence, as in fasting, sickness, and the periodical sleep of hibernating animals; excessive loss of blood; immoderate indulgence in ardent spirits; long watching; exposure to intense heat; severe study, and great bodily fatigue. The latter is well exemplified in the case of grooms, and in persons who make long journeys on horseback. Captain Eiley, of Ohio, who was shipwrecked on the coast of Africa, and captured by the natives, was reduced from two hundred and forty to ninety-two pounds, from ex- cessive exercise, partly on an old camel, partly on foot, across the sandy desert. There seems to be sometimes a great diminution of this substance without our being able to assign any satisfactory cause; as, for example, in the case of the celebrated Calvin Edson, who, although apparently in good health,-was literally nothing but skin and bone, his entire weight not exceeding fifty-eight pounds. Men of anxious mind and fretful temper seldom get fat. With what justice does Shakspeare, in one of his most magnificent plays, make Ccesar say— " Let me have men about me that are fat; Sleek-headed men, and such as sleep o'nights. Yond' Cassius has a lean and hungry look : He thinks too much ; such men are dangerous."1 Julius Caesar, act i., scene 2. MUSCULAR SYSTEM. 227 The removal of the fat, by whatever cause induced, is probably effected by the conjoined agency of the vessels and lymphatics; but upon this subject physiologists are by no means agreed, some ascribing it exclusively to the former, others to the latter, of these vessels. It would be interesting to know in what form this substance is absorbed, whether as oily matter, or after undergoing chemical decomposition. Facts are not wanting in support of both these views; but it must be confessed, that, whilst the one is plausible, the other is much more in accordance with the laws and operations of the living system. The adipose vesicles, in this affection, diminish in size; and, as their walls are brought in apposition, an erroneous opinion has hence arisen that they are sometimes entirely obliterated. The adipose tissue is occasionally the seat of melanosis, occurring either in minute inky spots, or in small, spherical tubercles, of a con- crete or semi-fluid consistence. Most commonly it is seen in the fat of the orbit, the anus and rectum, in the mesentery and omentum, and around the kidneys. It has also been noticed in the subcutaneous adeps, but much less frequently than in the other situations. Fatty transformations are not uncommon. How they are produced, is still a problem. It is not unlikely, however, that they are partly, if not mainly, the result of a tardy inflammatory action, causing a perversion of the nutritive function, by which fatty particles are de- posited in place of the healthy tissues, and the nitrogenous basis of these converted into oil. These changes, which have hitherto been noticed chiefly in the heart, liver, and voluntary muscles, will be de- scribed in their appropriate places. CHAPTER IV. MUSCULAR SYSTEM. I. Muscles.—Reunite when divided.—Inflammation.—Suppuration.—Mortification.—Chronic Irritation.—Softening.—Induration.—Ossification.—Fibrous and Patty Transformations.— Heterologous Deposits.—Hypertrophy.—Atrophy.—Parasitic Animals.—Sanguineous Effu- sions.—II. Tendons.—Reunite when divided.—Inflammation.—Ossification.—Atrophy.— Diseases of the Sheaths of the Tendons.—III. Aponeuroses.—Acute and Chronic Inflamma- tion.—IV. Synovial Burses.—Diseases.—Fibrocartilaginous Concretions.—Hypertrophy.— Hydatoid Bodies. SECTION I. MUSCLES. The voluntary muscles unite, when divided by adhesive inflamma- tion, with nearly the same facility as the cutaneous and cellular textures, the period required for the reparation varying according to the extent 228 MUSCLES. of the injury and the nature of the constitution. If the edges of the wound be allowed to remain apart, the restoration is effected through the medium of granulations, the growth of which is often rapid and luxuriant. As the healing advances, these bodies contract in volume, and are ultimately converted, by a modelling process, into real muscular tissue, or, at all events, into a substance so closely resembling it as to render it difficult to distinguish them from each other. I cannot understand upon what grounds the partial regeneration of the muscular tissue has been denied. That the bond of union is occasionally of a fibrous, ligamentous, or even a fibro cartilaginous character, as has been contended, cannot be doubted; but that such is not the course which nature generally pursues, even in old persons, observation fully convinces me. The principal lesions of the voluntary muscles are inflammation, change of consistence, ossification, atrophy, and the fatty transforma- tion. Inflammation of the muscles is by no means so common as in some of the other textures. It is not improbable that it sometimes com- mences in their own substance; much more frequently, however, it is communicated to them from the contiguous parts, as the intervening cellular structure and their aponeurotic coverings. The disease here, as elsewhere, may be acute, as when it is caused by wounds or external injury, or chronic, as when it is associated with gout and rheumatism. In either case, it is generally limited to particular muscles; though, in a few rare instances, it affects a whole group, either simultaneously or successively. As comparatively few opportunities have occurred for studying this lesion, it is not surprising that a good account of its anatomical characters should still be a desideratum. The initial step in the acute form of the disease, as well, perhaps, as in the chronic, consists in an engorged state of the vessels of the con- necting cellular texture, which, in consequence, loses its natural white- ness, and assumes a faint red complexion. The fleshy fibres are at the same time increased in density, though as yet they have experienced no change of color. Gradually, however, their vascularity is augmented, the affected part becomes rigid, and their contractile power is so much impaired that motion is not only difficult but painful, the muscle, the subject of the disease, being the seat of constant spasmodic actions. At a more advanced period, when the disease has reached a higher grade of intensity, the connecting cellular tissue is swollen, and infil- trated with serosity, intermixed with globules and shreds of lymph. The muscular fibres are of a deep mahogany hue, soft, flaccid, easily torn, and scarcely distinguishable from the surrounding parts. The discoloration, although sometimes uniform, and diffused over a large extent of surface, more commonly occurs in irregular patches, with intervals of sound substance. In violent cases, it is not unusual to find small ecchymoses, caused by the rupture of some of the capillary vessels. The muscle, at this advanced stage, is totally changed in its character, and there is generally more or less effusion of serum, lymph, and blood, between it and the circumjacent structures, with inflamma- tory appearances of its aponeurotic sheath. The ordinary stimulants MORTIFICATION — INFLAMMATION. 229 no longer exert their accustomed influence, the fleshy fibres remaining rigidly fixed, even under galvanism. It is seldom that inflammation of the muscles passes into suppura- tion. The occurrence is most frequently witnessed in erysipelas, car- buncle, pyaemia, and other violent forms of inflammation, running rapidly through their different stages. The pus, which is usually of a fibrous character, is originally deposited in small disseminated glo- bules, which give the affected part a singularly speckled appearance. In rare instances it is collected into distinct abscesses. Not less rare is mortification of the external muscles. This termi- nation has hitherto been observed chiefly in erysipelatous and carbun- cular inflammation, in old worn-out subjects. It is easily recognized by the altered color of the fleshy fibres, which are usually of a dark, cineritious aspect, by their softness and lacerability, and by their gangrenous odor. The sloughs are detached in ragged shreds, bathed by a thin, dirty, sanious, and offensive fluid. The injured muscle is never entirely regenerated; and the sphacelus, if extensive, generally proves fatal. In chronic inflammation,the muscular tissue loses its florid complexion, and assumes a pale yellowish appearance, not unlike that of an autumnal leaf. Its consistence is also increased; and the fleshy fibres, which are often very much thickened, are so firmly glued to each other as to render it difficult to separate them. This form of myositis, as before intimated, occasionally terminates in suppuration. Another effect, which is still more rare, is ulceration. This is sometimes observed in phagedenic sores of the leg, extending successively through the skin, cellular substance, aponeurosis, and, finally, the muscular texture. The most remarkable circumstance about these erosions is the disap- pearance of the fleshy fibres. When the constitution is good, the restorative process generally goes on kindly, and the ulcer is soon filled with healthy granulations. The muscles are occasionally in a state of softening. The loss of cohesion is generally limited to particular muscles, or even to particu- lar portions. The exciting causes of the affection are still involved in obscurity; though it is not impossible that it mainly depends upon irritation and loss of nervous power. In proof of the correctness of this view, it may be stated that the lesion is usually connected with inflammatory appearances of the collateral tissues, or with general or partial paralysis. A flaccid condition of the muscular system often coexists with what is termed the tubercular cachexy, and with a watery and impoverished state of the blood. By whatever cause it is induced, the fleshy fibres are unusually pale, bordering on a light fawn tint, flabby, and easily lacerated, the slightest pressure being sufficient to convert them into a soft, pulpy mass. It is highly probable that most of the muscles thus affected are in a state of fatty degeneration. Induration of the muscular tissue, arising from an effusion of plas- tic matter into the interstitial cellular substance, is frequently seen in the neighborhood of fractured bones, around scirrhous tumors, and in the legs of persons affected with elephantiasis, gout, and rheumatism. Under the influence of these causes, the muscular fibres are rendered 230 MUSCLES. hard and firm, and, in some instances, almost cartilaginous. The color. in the early stage, is simply brown; subsequently it acquires a pale reddish tint, and at a still later period the part exhibits a grayish leaden aspect, with here and there a spot retaining a portion of its, natural complexion. It has been doubted, even by high authority, whether the muscular texture is ever the seat of ossification. I am myself inclined to think that the primitive locality of the deposit is the interstitial cellular substance, whence it gradually extends to the fleshy fibres, blanching and extenuating them, or even wholly destroying them by absorption. This degeneration, though commonly confined to individual muscles, as those of the loins, shoulder, and calf of the leg, occasionally affects a great number of them. A striking example, in which the muscular system exhibited the ossific diathesis, is recorded by Dr. David L. Eogers, of New York. The subject was a boy, aged thirteen years, whose health had always been good until about six months before his death. The sterno-cleido-mastoid, great and small pectoral, trapezius, rhomboid, subscapular, broad and long dorsal, together with the mus- cles about the great trochanter, were all transformed, either partially or wholly, into bony layers. The scapula was fixed to the ribs and studded with bony excrescences. The great and small pectoral muscles were united into one, and attached to the ribs by osseous matter. The tendinous parts of the muscles were free from disease, and there was no ossification of the vascular system. In several situations spicules of bone, from one to two inches long, projected from the affected mus- scles. The mesenteric glands were increased in size, and a large ab- scess existed on each side of the chest. The abdominal and thoracic organs appeared to be healthy. Ossification of particular muscles is sometimes witnessed as an effect of long-continued pressure. In recruits, the deltoid and pectoral mus- cles of the left side occasionally experience this transformation in a considerable degree, from the irritation produced by carrying the musket. A small, red, painful swelling is formed, which, if neglected, terminates in a mass of bone, from four to seven inches in length, and from two drachms to upwards of an ounce in weight. This ossific tendency is occasionally exhibited in early life, and constitutes a very serious disease, in which not only the muscles, but also the ligaments and tendons are implicated. In gouty and rickety subjects, whitish stone-like concretions are occasionally found in the muscles: they are usually of a spherical shape, with a volume seldom exceeding that of a pea, and consist principally of phosphate and carbonate of lime, cemented together by a minute quantity of animal matter. The muscular tissue is -occasionally transformed into the fibrous. The degeneration sometimes involves whole muscles, which, when the change is completed, scarcely retain a single vestige of their original features, save their shape, and even this is often materially altered. The deltoid and sterno-mastoid appear to be more frequently affected in this way than any other parts of the muscular system. The cause of this transformation admits of easy explanation. Whenever a muscle FATTY DEGENERATION—MELANOSIS. 231 is placed in a state of total inactivity, it experiences a modification of nutrition, by which, without any appreciable irritation, it gradually loses its fleshy character, and is converted into a fibrous substance, the economy making an effort to rid itself of it, as a useless structure. This view derives confirmation from what occurs in the inferior animals. In some species of quadrupeds, for example, parts that are distinctly muscular in early life, are subsequently, by some change in the function of nutrition, transformed into another texture, better adapted to the wants of the system than one which is simply contractile. Another lesion to which the muscles, in common with several other organs, are liable, is the fatty degeneration. In this affection the muscles generally retain their original form and volume, though in some in- stances they are partially shrivelled and disfigured. They are of a pale straw color, or even entirely white, unctuous to the touch, and rather diminished than increased in consistence. Notwithstanding this, how- ever, the linear arrangement of their fibres is not only recognizable by the eye, but can be easily traced with the scalpel. On pressure, a clear oily fluid oozes out, which greases the finger, or whatever else is brought in contact with it, and is of an unusually inflammable nature. Muscular tissue, which has undergone the adipose degeneration, con- sists of an oily liquid, probably elaine, gelatine, adipocire, solid fat, and a substance resembling boiled flesh. These materials, the quantity of which is variable, are not deposited between the muscular filaments, as has been conjectured by some, but form actually a part of their component principles. Under the microscope, indeed, the whole fibre is seen filled with granules in part between the transverse striae, in part replacing them. It is worthy of remark, however, that the inter- stitial cellular element is always considerably altered, being of a whitish color, very soft, and lacerable. The fatty transformation is most marked in the muscles of the loins, hip, thigh, and leg of old persons affected with paralysis. It is like- wise observed in the heart, and in some rare instances, in the muscles around unreduced luxations, large exostoses, and old deep-seated ul- cers. When the change is complete and extensive, it occasionally in- volves the corresponding tendons and aponeuroses, which, in conse- quence, lose their polished, satin-like lustre. It rarely happens that we have an opportunity of observing tuber- cles in the muscular tissue. AVhen present, they are generally connected with a strumous diathesis, and coexist in other parts of the body. Otto states that he has several times seen tubercles in the muscles of the neck and thigh of scrofulous monkeys; Andral has noticed similar bodies in the muscles of the hog. In the case to which the latter writer refers, they occurred in association with small transparent hyda- tids, evidently of the cysticercic kind. Melanosis is sometimes seen in the muscles in the form of an infiltra- tion, which imparts its peculiar stain to the muscular fibres, converting them into a soft, pulpy substance, in which it is impossible to recognize the slightest trace of the primitive structure. Occasionally, again, the black matter is encysted, presenting an irregularly spherical mass, of pretty firm consistence, the volume of which varies from that of a pea 232 MUSCLES. to that of a foetal head. This morbid formation is sometimes directly chargeable to external injury; at other times, it takes place without any assignable cause. It always betrays a malignant character, pro- ceeding, if allowed to remain, to ulceration, and returning, sooner or later, when extirpated. Scirrhus, encephaloid and colloid are also extremely infrequent. Indeed, so seldom do these heteroclite formations occur in the muscular sys- tem, that it has hitherto fallen to the lot of few pathological anatomists to observe them. In the interesting case of colloid described by the late Professor Warren, of Boston, an immense number of tumors of this kind, varying in size from that of a pea to that of a small granule, hardly visible without the aid of a microscope, existed in the voluntary muscles, especially in those of the thigh and abdomen. It appears extremely doubtful whether any of the heterologous formations are, in reality, ever seated in the muscular substance itself. In all probability they are originally developed in the interstitial cel- lular tissue, whence, as they augment in volume, they encroach upon the fleshy fibres, which they displace, alter, or destroy. On this point, however, I am not prepared to give a positive opinion. Hypertrophy of the voluntary muscles is extremely infrequent, and has hitherto been noticed chiefly in the tongue, where, as will be shown hereafter, it is occasionally congenital. As occurring from the influ- ence of inordinate exercise, and the unusual influx of blood, the best example is that which takes place in the muscles of the arm of the blacksmith, and in the leg of the rope dancer. Muscles that have ex- perienced this change, whether it be the result of accident, or purely physiological, are of a deep red color, firm, tough, and comparatively little compressible, with a bulk greatly exceeding what is observed in the normal state. A more common affection is atrophy, or unnatural diminution of volume. It may arise either from general disease, such as phthisis, carcinoma, or dropsy, or from local difficulty, as inflammation, palsy, or defective nutrition. Indeed, whatever has a tendency to impair the function of innervation, retard the circulation of the blood, or produce permanent inactivity, maybe considered as so many causes of atrophy of the voluntary muscles. Hence this lesion is generally associated with palsy, whether proceeding indirectly from disease of the cerebro- spinal axis, or directly from injury of the nerves supplying the affected part. The muscles around luxated joints, especially those of the hip and shoulder, are often atrophied, simply, it would appear, from want of exercise. The extent to which the wasting of the muscles proceeds is various. Frequently they are reduced to mere membranous bands, pale, flaccid, and almost devoid of irritability; in some rare instances, their fibres are entirely absorbed, a dense cellular substance being all that is left in their place. In persons dying of protracted diseases, I have re- peatedly observed a dark bluish color in particular muscles, especially those of the abdomen, accompanied with remarkable flaccidity and facility of laceration. These changes are very common in negroes; and, from having often noticed them within a few hours after death, I PARASITES. 233 Fie. 54. Fig. 55. Fig. 54. Cysts of the spiral trichina in situ, natural size. Fig. 55. Separate cyst, containing the trichina magnified. am disposed to think that they are not altogether cadaveric. Dropsical and consumptive subjects, more frequently than any other, present these appearances. The voluntary muscles are occasionally infested by parasitic ani- mals, the principal of which are the cysticercic hydatid, and the spiral trichina. The former are seldom seen in the human subject, but are very common in the swine, sheep, and other quadrupeds, in which, particularly in the first, they often exist in immense numbers, rendering the flesh completely unfit for use. The spiral trichina (Figs. 54, 55, 56), discovered by Mr. Richard Owen, the distinguished English natural- ist, is a very delicate, minute, coiled-up, entozoon, about the twenty-fourth of a line in length, and the seven-hundredth part of an inch in diameter. It is of a cylindri- cal shape, and terminates obtusely at both extremities, which are of unequal size, the larger being furnished with a transverse linear orifice, which evidently answers the purpose of a mouth. The alimentary canal, as described by Dr. Farre,1 is bounded by two slightly irregular lines running paral- lel to each other, for the distance of rather more than one-fifth of the length of the body, where they terminate in a transverse ridge, presenting a minute concavity towards the large ex- tremity. From this point on, the canal exhibits a sacculated arrange- ment, the little dilatation appearing as if bound down by a line ex- tending along the surface of the tube in the direction of its axis. This sacculated appearance is gradually lost towards the smaller end, where the part assumes a zigzag or spiral course, and terminates in a small slit, regarded as the anus. No nervous system has been discovered. In the female Dr. Farre has pointed out a collection of ten or twelve granules, about one-fifth of the length of the body from the blunt ex- tremity, which he considers as the ovary. It is a singular fact that this worm is always inclosed by a distinct cyst, which is the reason, probably, why it so long escaped the observation of anatomists; since its occur- rence is rather frequent than otherwise. This cyst, which is supposed by some to be merely condensed cellular tissue, is formed out of the plastic lymph of the blood, and is scarcely one-fortieth by one hundredth of an inch in diameter. It is of a whitish appearance, and of an oblong shape, with one extremity so con- tracted as to form a short, imperfect neck. Amongst a collection of trichinas, it is by no means uncommon to find some which have lost their vitality nifle(^. ^j^e&^b or been entirely removed by absorption. In such Tail; c. Body. Fig. 56. 1 Library of Practical Medicine, by Dr. Tweedie. Amer. edit. 234 TENDONS. cases, the inclosing cyst is usually collapsed, more or less opaque, or even ossified, like that of a dead hydatid. It is probable that these parasitic animals enjoy but a very brief existence. The length of time that they retain their vitality after removal from the body of the patient in which they are found, is variable. Mr. Owen mentions the fact of life having been discovered two weeks after death. Generally there is only one animal in each cyst, but occa- sionally, though very rarely, two and even three have been found. The inclosing cyst lies parallel to the fleshy fibres, in the connecting cellular tissue of which it is developed. The trichina is almost wholly confined to the muscles and tendons of voluntary motion. It has also been met with in the little muscles of the ossicles of the ear, but it has never been seen in the substance of the heart or in the fleshy fibres of the alimentary canal. Their number is sometimes prodi- gious. Dr. Bowditch states that he has counted upwards of fifty in a superficies of a quarter of an inch square, and he supposes that the muscular system of a person of moderate stature might contain as many as 7,680,000. Their development seems to be uninfluenced by age, sex, constitution, or any particular form of disease, though they have hitherto been most frequently observed in chronic organic affec- tions. They have, however, been seen in persons who were killed apparently in perfect health. Of their mode of origin, growth, and nourishment, nothing is known. Muscular apoplexy appears to be most common in scorbutic subjects, or in persons of a weak and lax fibre, with a thin and watery state of the blood. It has likewise been noticed in persons affected with in- termittent fever, delirium tremens, and phlegmonous erysipelas. No muscles, not even the heart, are exempt from it, but the straight muscles of the abdomen are, perhaps, more frequently and extensively affected than any other. The number of apoplectic depots is extremely variable. In some instances there are only a few, whilst in others there are several dozens. They are at first of a dark color and soft consistence, but they gradually become lighter and more solid, resem- bling, in these respects, apoplectic depots of the brain. In volume, they range between a pea and a hen's egg. The muscular texture immediately around them is more or less lacerated, and infiltrated with blood. SECTION II. TENDONS. The extremities of a divided tendon readily unite through the in- tervention of lymph, which gradually assumes all the properties of the original texture. During the first few days, the matter is very soft, and of a red color, from the admixture of the blood poured out in the operation. By and by, it augments in density, becomes slightly OSSIFICATION. 235 elastic, and adheres more or less tenaciously, not only to the cut ends of the tendon, bu*t likewise to its fibrous sheath, which is discolored for some distance from the wound. In a few weeks, the extra vasated blood is entirely absorbed, and the new substance, now of a pale grayish complexion, is diminished in thickness, but increased in firm- ness, and inseparably coherent with the original structure, to the pro- perties of which it ultimately assimilates itself. When these bodies are destroyed by gangrene, it is probable that they are never entirely regenerated. From what is known concerning the organization of the tendons, it might be inferred that they are not very prone to inflammation; and such, indeed, experience has shown to be the fact. The disease, in most cases, arises spontaneously from the influence of the syphilitic poison, the operation of mercury, or from the effect of atmospheric vicissitudes. Its march, under these circumstances, is generally of a chronic nature, the most important alterations which it induces being hypertrophy and induration of the affected part. Conjoined with these changes are usually certain morbid appearances of the fibrous sheaths, such as infiltration of their external cellular texture with a greenish jelly-like fluid, thickening and opacity of the lining mem- brane, and effusion of yellow turbid synovia. Purulent matter is sometimes poured out; and the tendinous structure may be so much altered as to become unfit for its functions. The process of acute inflammation is most distinctly seen in wounds, sprains, and whitlow. The tendon loses its natural polish, and assumes a faint reddish color, from the engorged state of its capillaries. At a more advanced stage, lymph is poured out, either alone, or mixed with serum and blood ; in violent cases, suppuration occasionally sets in, but this is rare. When the inflammation has attained its height the tendon is of a pale ash color, soft, pulpy, and considerably thick- ened. Inflammation readily deprives the tendons of their vitality; a cir- cumstance which is not surprising when we consider their feeble and imperfect organization. Whole cords are sometimes destroyed by this disease, and ultimately cast off in the form of sloughs; the work of separation, however, is usually very tedious, and resembles a good deal the exfoliation of a necrosed bone. In this state, the tendons lose their pearly lustre, assume a dull grayish aspect, and become thick and doughy; the individual fibres, however, retaining, in some degree, their original consistence. This occurrence most frequently happens in the fingers and palms of the hand in what is called whitlow; one of the most painful and distressing affections to which these tex- tures are liable. Ossification of the tendons is much less common in man than in the inferior animals. Birds are very liable to it; it is also frequently observed in the horse, sheep, goat, and ox. The change is most com- mon in the tendons of the foot in old subjects, where they slide over, and rub upon the bones. Atrophy is likewise very rare, and is only observed in connection 236 APONEUROSES. with great wasting of the muscular texture. Inordinate enlargement occurs principally as an effect of chronic inflammation. I am not aware that any of the heterologous deposits ever take place either in the tendons, or in any of the other structures included in the present chapter. The sheaths of the tendons, like other serous structures, are sub- ject to dropsical accumulations. The bags thus formed are generally of an ovoidal shape, and vary in size from that of a pea to that of an apricot. Their contents are usually of a glairy viscid character, like the white of eggs, though, in this respect, there is considerable diversity in different cases. Sometimes, along with the fluid, the sac contains a number of loose bodies, similar to the concretions found in the movable joints and synovial burses. Fig. 57. They are of a pale yellowish color, tough consistence, shaped like gourd-seeds, and of variable size, from that of a grain of wheat to that of a bean. This disease constitutes what, in surgi- cal language, is called a ganglion. A dif- ference of opinion has existed in regard to its nature, the question being, whether it is of new formation, or merely a saccu- lated expansion of the serous lining of the tubular structure in question. For Fibroid bodies of a ganglion. From a my OWU part, I have nO hesitation in Say- preparation in my collection, ing that the former opinion is entirely gratuitous. The disease occurs most fre- quently at the wrist, along the extensor tendons. Females are more subject to it than males, especially such as are much engaged in hard manual exercise. SECTION III. APONEUROSES. The aponeuroses, possessing the same organization as the periosteum, dura mater, and pericardium, are liable to the same diseases. Acute inflammation is very rare, and is observed principally as the result of external violence, whitlow, and anthrax. Gout and rheumatism are supposed to have their seat exclusively in the fibrous envelops of the extremities; but of the truth of this opinion many physicians still entertain serious doubt. My own idea is, that the "aponeurotic, liga- mentous, tendinous, and bursal textures are all implicated nearly in the same degree, the diseases here referred to sometimes beginning in one, sometimes in another, but sooner or later attacking the whole of them. Upon this subject, however, we stand in need of further and more substantial information. SYNOVIAL BURSES. 237 In chronic inflammation, which is much more common than the acute, the aponeuroses become thickened, preternaturally hard, and of a pale yellowish hue, interspersed with grayish, leaden colored, or brownish patches. Spicules of bone sometimes sprout from them; they may acquire quite a large size, and exhibit the appearance of so many sta- lactites. Another effect of chronic irritation, likewise very rare, is extreme attenuation of these membranes, constituting real atrophy. This result is generally produced by the pressure of a tumor, which, exerting its detrimental influence for some time, by degrees causes the absorption of the aponeurotic fibres. Inflammation of these structures manifests little disposition to pass into suppuration, gangrene, or ulcer- ation; and the heterologous deposits are almost entirely unknown in them. SECTION IV. SYNOVIAL BUJtSES. The synovial burses are liable to inflammation, suppuration, thicken- ing, and cartilaginous degeneration. One of the earliest effects of acute inflammation is an increase of vascularity, the redness here, as in the other serous structures, appear- ing, at first, in separate lines, which at length coalesce, and thus assume an arborescent arrangement. In some instances, the redness has a dotted form, or there are small ecchymoses, caused by the rupture of some minute vessel. The synovial membrane loses its transparency, and presents an opaque, milky aspect, being as yet little or not at all thickened. When the disease is at its height, the natural secretion is partially suspended, which, however, lasts only for a short time, when it not only augments in quantity, but is likewise changed in quality. Instead of being thin, oily, and transparent, it takes on the appearance of a brownish, turbid serum, mixed with flakes of lymph, pus, or even small clots of blood. The tumor which is thus formed is sometimes as large as a cocoa-nut, but generally it does not exceed the size of a walnut, an orange, or a goose's egg: in most cases it is rounded, elastic, and painful on pressure, the skin covering it being red and hot. The fluid, whatever may be its nature, may open externally, or the sac may burst, and the fluid be effused into the surrounding cellular tissue. I have repeatedly found these tumors filled with a substance of the color and consistence of currant jelly. When the disease is chronic, the effused fluid is sometimes loaded with loose concretions, of a dense semi-cartilaginous consistence. (Fig. 58.) They are of a light yellowish color, and of a flat oval form, not unlike melon-seeds. Their numbers are occasionally quite great, upwards of fifty having been extracted from a single burse. How are these bodies produced? It has been inferred that they are merely 238 ARTERIES. masses of plastic lymph originally poured out in soft amorphous flakes, which by degrees become Fig. 58. firm, and assume a deter- Fibroid bodies of a synovial burse. than half an inch in thick- ness, with a small central cavity filled with synovial fluid. In the horse it is often converted into a hard gristly substance; and the same phenomenon is occasion- ally witnessed in the human subject. Cases occur where it partakes of an osseous character. Not unfrequently the inner surface of the sac exhibits a honeycomb appearance, the shreds of lymph intersect- ing each other in various directions. In many instances, however, though the inflammation may have persisted for a long time, the mem- brane retains nearly its primitive structure. Bodies closely resembling hydatids are sometimes found in the synovial burses. In one case, upwards of one hundred and forty of these substances, varying from one to three lines in diameter, nearly transparent, and of a lenticular shape, were counted; they were situ- ated in a large pouch between the great trochanter and the tendon of the great gluteal muscle. CHAPTER V. ARTERIES. Lesions.— Wounds.— Inflammation.— Suppuration.— Ulceration.— Gangrene.— Softening. — Induration.—Hypertrophy.—Morbid—Deposits.—Contraction.—Aneurism. The arteries are liable to wounds, inflammation, suppuration, ulcera- tion, contraction, and dilatation, hypertrophy, and different morbid deposits. ARTERIES. 239 1. Wounds.—When an artery is divided, the immediate effect is an impetuous flow of blood, attended by a forcible retraction of the vessel within its sheath, and a slight annular contraction of its extremity. The canal of the sheath is now closed by the formation of a coagulum, blood being at the same time effused into the surrounding cellular substance. The next step in the process is the concretion of the fluid within the divided vessel, generally as high up as the nearest collateral branch. The stopper thus formed is commonly of a slender, conical shape, with the apex directed towards the heart. It is seldom suffi- ciently large to constitute a perfect plug for the vessel, nor does it at first adhere very firmly to its internal surface, excepting at its base, where it is also closely united with the outer coagulum. The connec- tion between the two clots, and the relation which they sustain to the orifice of the divided artery, have been felicitously compared to the mouth of a bottle, closed by its stopper, and covered with sealing-wax. Soon after these coagula have formed beneath, around, and within the divided artery, the different tunics, taking on inflammation, pour out plastic lymph, which serves still further to seal up the orifice of the vessel, and to strengthen the connection between it and the clotted blood. The absorbent vessels of the parts are also actively engaged in carrying away, at first, the more attenuated, and afterwards the more solid elements of the coagula in which these changes occur, until the whole mass is finally transformed into a dense grayish cord, in which it is difficult to discern any trace of the original textures. The period required for the perfection of these changes varies in different cases, depending upon the volume of the vessel, the nature of the wound, and the constitution of the patient. Such, in a few words, is the process employed by nature in arresting hemorrhage from a divided artery. Similar phenomena, very nearly, take place when a vessel of this kind is tied with a ligature, except that there is no external coagulum. The internal clot is also generally more complete; and, as the serous and fibrous membranes are usually cut through, the inflammation is apt to run much higher, the different coats being often rendered extremely vascular and pulpy. The liga- ture is either removed by absorption, or, as is more frequently the case, it remains until the outer tunic is destroyed by ulcerative action; which, when the artery is small, usually happens in eight or ten days, but, when large, not under several weeks. In whatever way an artery be obliterated, the collateral vessels, as they are termed, are always permanently enlarged, compensating thereby for the lost power on the part of the main trunk. Thus, by the anastomoses of the vascular system, and by the happy contrivance here alluded to, the Creator has provided the means of carrying on the circulation, even after the stoutest branches are completely closed up. When an artery is wounded longitudinally, or to a small extent obliquely, either an aneurism is formed, or the breach is repaired by adhesive inflammation. The same consequences follow when an artery is punctured with a sharp-pointed instrument, or if it be divided trans- versely through one-fourth of its circumference. If the vessel be cut across one-half or two-thirds, cicatrization will be impossible; the in- 240 ARTERIES. jured tunics will either yield to their native power of retraction, or they will be destroyed by ulceration. In either case, the final restora- tion is effected in the same manner nearly as when the vessel is cut across in the first instance. When an artery is forcibly lacerated, it is much less apt to bleed profusely than one that is divided by a transverse cut. Cases occur where whole limbs, involving, of course, the largest arteries, are torn from the body, and yet scarcely any blood is lost. The retraction and annular constriction are always much greater here, and the coagula also much larger, as well as more rapidly formed, than under opposite circumstances; and these occurrences, added to the ragged state of the inner and middle coats, and the exhausted condition of the patient, as must always happen in such severe accidents, afford a speedy and effectual barrier to the emission of blood. 2. Acute Arteritis.—Acute arteritis is generally induced by external injury, or by an extension of disease from the adjoining structures. Nevertheless, it occasionally exists as an idiopathic affection, or comes on without any assignable cause. Pestricted in the majority of in- stances to one or more of the larger trunks, it not unfrequently involves the smaller branches, and sometimes even the capillaries. Occasionally the disease appears to pervade nearly the whole arterial system. When arising spontaneously, the disease usually begins in the in- ternal membrane and subserous cellular tissue, from which it gradually spreads to the other tunics; the reverse happening when it is induced by external violence. The anatomical characters of acute arteritis are redness, opacity, rugosity, and softening of the lining membrane, with an engorged, lacerable, and thickened state of the outer and middle tunics. When the inflammation is severe, the parietes of the affected artery are generally remarkably pulpy, and so much diminished in consistence as to be easily torn or divided by the ligature. The nutrient vessels are loaded with blood, and often exhibit a real varicose aspect, their ultimate twigs ending apparently in the subserous cellular substance. With regard to the redness of the internal membrane, it is liable to considerable diversity; generally speaking, it occurs in small patches, which are diffused over a considerable extent of surface, and which vary in diameter between that of a split pea and a five cent piece. In intensity it ranges from a light pink to a deep scarlet, through numerous intermediate shades of lilac and purple. In some instances the redness is uniform. With this change of color are always associated important alterations of texture. The inner membrane, as was before intimated, losing its smoothness and polish, assumes a rough, fleecy aspect, and, owing to the softened state of the subserous cellular tissue, is easily detached from its natural connections. Glo- bules of lymph, either alone or blended with pus, occasionally adhere to its inner surface; and, in the larger arteries, it is not uncommon to meet with well developed pseudo-membranes, similar in all respects to those of the serous textures of the splanchnic cavities. The other tunics are also seriously affected. They become moist, tumid, friable, and transformed frequently into a reddish, homogeneous mass, almost SUPPURATION. 241 devoid of cohesive power. Their elasticity, naturally so great, is par- tially lost, and in many instances they are freely infiltrated with serosity, sanguinolent fluid, or even pure pus. Patches of a scarlet, purple, or brownish color, caused by the im- bibition of blood, are sometimes observed on the inner coats of the arteries after death, and have been supposed, though erroneously, to be a result of inflammatory irritation. They are most conspicuous on the under surface of the vessels, or where there is the greatest amount of blood accumulated, and they are frequently witnessed in persons who die of pulmonary phthisis, putrid fever, apoplexy, and malignant cholera. The redness thus produced exhibits the appearance as if it were dyed into the very substance of the lining membrane, and it com- monly exists in stripes, small specks, or geometrical figures, having an abrupt termination; that, on the other hand, which results from irritation generally loses itself by insensible degrees, nor is it diffused over so large an extent of surface. But, however this may be, no difficulty can possibly arise upon the subject, when it is remembered that the inflammatory discoloration is constantly associated with im- portant lesions of the arterial tissues. The cadaveric redness always appears much sooner in warm than in cold weather, and may be pro- duced at pleasure by steeping a vessel for twenty or thirty hours in fluid blood, at a moderate degree of heat. 3. Suppuration.—Although suppuration is seldom spoken of as an attendant on arteritis, yet I am inclined to believe that it is more frequent than is commonly imagined. The matter being generally effused upon the inner surface of the vessel, is swept away by the cir- culating current as fast as it is secreted, which is the reason, doubt- less, why it is not oftener noticed after death. Sometimes, however, it is entangled in the substance of the false membranes, infiltrated into the arterial tunics, or collected into small points between the inner and middle tunics. Arteritis is much less liable to terminate in suppuration than phlebitis, in which respect the one resembles inflammation of the serous membranes, the other of the mucous. 4. Gangrene.—The arteries may be said to be almost insusceptible of gangrene. Their conservative energies, as stated elsewhere, are surprisingly great, and hence they often escape destruction in the midst of parts that are perfectly deprived of vitality. In such cases, their outer surface becomes incrusted, at an early period of the dis- ease, with a thin layer of fibrin; and, long before the dead textures begin to separate, the blood coagulates in their interior, thus opposing an effectual barrier to the occurrence of hemorrhage. 5. Ulceration.—Ulceration, as a consequence of arteritis, whether acute or chronic, is seldom witnessed. Manifesting a peculiar predi- lection for the larger trunks, it commonly commences in the serous membrane, from which it gradually extends to the middle and outer tunics until it leads to complete perforation. Such a termination, however, is extremely rare. The ulcers, which are very irregular in respect to their form, vary much in their size, number, and general characters. At times they are very small, scarcely exceeding the diameter of a mustard-seed; but they may be as large as a split pea, 242 ARTERIES. a five cent piece, or even a guinea, according to the size of the affected tube. Their margins are usually ragged, irregular, and considerably elevated, but seldom injected; their bottom, which is rough and uneven, is commonly formed by the middle tunic, the fibres of which frequently present a shreddy, lacerated appearance. In many instances, the ero- sions look like so many fissures, cracks, or chaps, with sharp, promi- nent, and irregular borders. This form of the disease is ordinarily dependent upon the presence of calcareous matter. The number of ulcers is seldom considerable, though in a few rare cases the inner surface of the larger trunks has been found completely checkered with them. When confined to the internal tunic, they sometimes admit of cicatrization. 6. Softening.—Softening of the arteries is a common occurrence, especially in the smaller branches. It is often witnessed in organic diseases of the principal viscera, and is a frequent attendant upon acute inflammation, cancerous affections, and the application of the ligature. In chronic enlargement of the liver and spleen, the arteries which supply these viscera are often so much changed in their struc- ture that they can be torn, or their coats separated from each other, with the greatest ease. In puerperal fever, the arteries of the uterus are occasionally converted into soft, pulpy, friable, and inelastic cylin- ders, incapable of withstanding the slightest resistance; and similar phenomena are frequently witnessed in the cerebral arteries in mol- lescence of the brain and around apoplectic effusions. In the chronic form of the disease, the larger trunks are more commonly involved. This disease is characterized, as the name indicates, by a diminution of the cohesive power of the vessel, the coats of which are rendered friable, spongy, and inelastic. When acute, it is generally accompa- nied with slight tumefaction, engorgement of the capillary vessels, and effusion of serosity or sanguinolent fluid into the interstitial cellular tissue. In the chronic form, however, the coats of the vessel retain their normal thickness, or they may even be diminished in size, and exhibit a dry, shrivelled appearance. The degree of mollescence of the arteries varies from a slight diminu- tion of the natural consistence of the part affected to that of a soft, pulpy, friable substance. In mild cases, or in the incipient stage of the disease, the morbid alteration is often so inconsiderable as to be altogether overlooked. At a subsequent period, however, or when the lesion is fully developed, the diminution of consistence is so great as to be recognized at first sight. The part affected has a tumid, in- filtrated appearance, and is converted into a semi-pulpy, friable, and disorganized substance, which readily yields under the pressure of the finger or the handle of the scalpel. This degree of softening is chiefly witnessed in acute inflammation of the parenchymatous organs, attended with effusion of serum, lymph, pus, or other fluid. It also occurs in erysipelas and gangrene, as well as after the application of the ligature in persons whose constitution has been impaired by old age or the effects of disease. In the chronic form of the disease, the arterial tunics are rather friable than softened; there being no tumefaction, engorgement of the capillary vessels, or infiltration of ULCERATION—INDURATION. 243 any kind. They are, in fact, affected with a sort of dry softening, without any other appreciable lesion. They are of the natural thick- ness, but so brittle that they are incapable of withstanding the slightest force. This form of mollescence is principally observed in encepha- loid disease, in osteo-sarcoma, in hypertrophy of the liver and spleen, in softening of the bones, and in chronic enlargement of the joints. In the first of these affections, it is evidently the cause of the frequent hemorrhages of whicH it is the seat after the establishment of ulcera- tion. The extent of the softening is extremely variable. It may be limited to a small portion, comprehend the whole circumference of the affected vessel, or be diffused over a surface several inches in length. It may be confined to a single artery, or occur in a great number. It has been described as pervading nearly the whole of the arterial system, especially that portion of it which is conneccted with the left ventricle. Finally, it may be limited to the individual tunics, or it may affect them all at the same time. The disease, however, is most common in the internal and middle coats, or, rather, in the cellular tissue by which these two layers are united to each other. In idiopathic softening the external tunic often escapes entirely, even when there is great loss of cohesion of the other layers. The color of the softened part is also liable to vary. When the dis- ease is the result of acute inflammation, as when it is caused by the application of a ligature, the most common discoloration is the red, which is usually most conspicuous in the lining membrane, to which it may be entirely limited, or it may extend to the other tunics. The redness may be circumscribed or diffused, and vary in degree from a light rose to lilac, scarlet, modena, or even purple. In the chronic form of the affection, the softened part presents a pale yellowish, gray- ish, or dull whitish tint, its natural color being little altered; except, perhaps, in the middle tunic, which is sometimes of a brownish or dull mahogany hue. Softening of the arteries is sometimes associated with the formation of fibrinous concretions in the interior of these vessels, with atheroma, and with the fibrous, cartilaginous, or osseous degeneration. It always impairs the elasticity of the coats of the affected vessel, diminishes their power of resistance, and predisposes to laceration, dilatation, aneurism, and even perforation. 7. Chronic Arteritis.—Chronic arteritis is probably a much more common affection than the great silence of the profession respecting it would lead us to infer. Like the acute form of the disorder, it is much more frequently observed in the large than in the small arteries, and hitherto has been noticed chiefly in persons who have died of lesion of the heart, or who have been constitutionally affected by mercury, syphilis, or scurvy. The most prominent feature of chronic inflam- mation is thickening of the several coats of the artery, which, in pro- tracted cases, may amount to such a degree as to encroach materially upon its caliber. The nutrient vessels are not much injected, and the redness, so conspicuous in the acute variety of the disease, is rarely present in this. The lining membrane, on the contrary, is of a yel- 244 ARTERIES. lowish, dusky, brownish, or grayish tint, interspersed frequently with bluish spots, which thus give it a mottled appearance. All the tunics are abnormally thickened, dense, and brittle, possessing little elasticity or cohesive power. The morbid process is supposed to commence on the outer coat and gradually to extend inwards. Patches of fibrin are often observed upon the inner surface of the vessel; and, in many instances, the lining membrane is considerably puckered, cracked, or even forced out of its natural situation. The various deposits pre- sently to be noticed, are probably all caused by chronic inflammation. 8. Induration —Induration of the arteries, as a pure uncomplicated affection, is rare. It is usually associated with hypertrophy, or with the fibrous, cartilaginous, atheromatous, or osseous degeneration, and is most common in the aorta and its primitive branches. It is very rare in the arteries of the superior half of the body. Old age is the period of life most liable to this alteration, which may affect a single vessel, a considerable number, or even the whole of this division of the vascular system; it may involve all the tunics, or it may be limited to one or more of the individual membranes. An artery, in a state of induration, is preternaturally fragile, devoid, in part, or entirely, of elasticity, and capable of withstanding an un- usual degree of lateral pressure. The connecting cellular tissue is remarkably friable, and hence the different tunics may generally be easily peeled from each other. The color of the affected part varies in the different layers; in the serous, it is commonly pale yellowish, interspersed with grayish or reddish brown; in the middle, the more frequent tint is light mahogany, or pale maroon; while in the external there is rarely any perceptible alteration from the natural appearance. The lining membrane is often puckered, many of the nutrient vessels are obliterated, and, when the induration is combined with hypertrophy or some of the deposits about to be mentioned, the caliber of the affected tube may be sensibly diminished in size. 9. Transformations.—Occasionally we find deposits resembling cartil- age, either alone, or, as is more generally the case, in association with calcareous or atheromatous matter. Most commonly they are limited to the inner membrane of the arteries, in the connecting cellular sub- stance of which they appear to be developed in the form of irregular isolated patches, of a whitish, yellowish, or grayish aspect. Not un- frequently, however, they implicate all the tunics, occupying the vessel to such an extent as to convert it into a firm, inelastic tube. AVriters are by no means agreed in regard to the question, whether this matter is originally deposited in a cartilaginous form, or simplv in that of fibrin. The result of my own researches would lead me to adopt the former opinion. The most common affection of the arteries, by far, is the deposition of calcareous matter. It is particularly frequent in old people, after the sixtieth year; but no period of life, except early infancy, is exempt from it. The arteries most commonly implicated are, according to my observations, the thoracic aorta, the femoral, popliteal, tibial and fibu- lar, splenic, spermatic, iliac, cardiac, and radial. The deposit is very frequent in the cerebral arteries of old persons, and thus often lays. TUBERCULAR DEPOSIT. 245 Fig. 59. the foundation of the apoplectic effusions so common at this period of life. The carotid, subclavian, brachial, hypogastric, hepatic, mesenteric, and gastric arteries are seldom ossi- fied. In the pulmonary artery this degeneration is extremely rare. Instances occur where there seems to be a peculiar ossific diathesis, almost all the arteries in the body being rendered bony. Of this I witnessed an extraordinary example in 1834, in a man sixty-five years old, in whom not only the larger trunks, but all the mus- cular twigs, were transformed into rigid, inelastic cylin- ders, blunting the knife at every incision. The calcareous matter exists in various forms; some- times in small grains and nodules; sometimes in scales, plates, and patches; and sometimes in complete rings, which encircle the vessel, and convert it into a firm, in- flexible tube, totally devoid of its normal attributes. These appearances are exhibited in Fig. 59. In the incipient stage of their development, these deposits often consist of minute isolated specks, of a light straw color; and not unfrequently they are associated with other secretions, especially the atheromatous and carti- laginous. In whatever form the matter shows itself, the coats of the arteries always experience important modi- fications, becoming preternaturally hard and brittle, and either thickened or attenuated. These changes are generally most conspicuous in the two inner membranes, which assume a dense, corrugated appearance, and are extremely liable to break and ulcerate, thus frequently obliging the outer tunic to sustain the whole force of the circulating torrent. The serous lining is often remark- ably thick, dense, opaque, and transversely wrinkled. Destitute of the usual structure of bone, the calcareous deposit differs still further from this texture in not pos- sessing vitality, and in being always secreted in the form of a homogeneous mass, without any definite arrange- ment. The component elements of this substance vary in different specimens, even from the same individual; but, in most cases, the proportion of animal matter is small. In the experiments of Brande, one hundred parts were found to consist of sixty-five of phosphate of lime, and thirty-five of albumen, with some traces of gelatine; whereas in those of Vauquelin the animal matter formed only about one-fourth, the remainder being made up of the phosphate and carbonate of lime and soluble salts. Lassaigne found that one hundred parts of an ossified artery contained fifty parts of animal matter, forty-seven and a half of phosphate of lime, two of car- bonate of lime, and a few traces of sulphate of lime. The results of these experiments are extremely interesting, because they serve to show, as was before intimated, that the calcareous deposit varies in its composition in different individuals, at different periods of life, in Deposition of calcareous mat- ter. From a spe- cimen in my col- lection. 246 ARTERIES. different parts of the arterial system, and even in different portions of the same vessel. Various opinions have been entertained by pathological anatomists respecting the precise seat of this deposit; some placing it in the sub- stance of the lining membrane, others in the middle coat, others in the cellular texture, by which these two layers are connected together. The latter of these views is borne out by the analogy which is ob- served in the subserous cellular tissue in other parts of the body; but, independently of this, I am disposed to adopt the opinion from personal observation, too carefully conducted, and too often repeated, to permit me to entertain any doubt upon the subject. At the same time, it must be admitted that this matter may occasionally be poured out into the substance of the different tunics, otherwise we could not account for the deposit being entirely limited, as it sometimes is, to the exte- rior of the arteries. The exciting cause of these formations is chronic inflammation, seated in the cellular element of the arterial structures. Another deposit to which the arteries are subject is the athero- matous. This affection, I have reason to believe, is extremely rare in the native inhabitants of our country, but appears to be very common in Europe and in our foreign emigrants. It usually begins in the cellular substance which connects the inner and middle tunics, in small isolated points, not larger than the head of a pin, of a pale yellowish, white, or brownish color, somewhat greasy to the touch, and of a semi-concrete friable consist- ence. As these points or dots augment in size, they push the lining membrane beyond its natural level, and if they are at all numerous, or if se- veral of them are seated to- gether, their tendency is to become confluent, and to form irregular patches, which may involve the whole circumference of the tube, and extend several lines or even inches up and down. I have never seen this deposit arranged in streaks or lines, such as we observe in the degeneration which precedes the formation of bony matter, nor have I found it entirely limited, as it is said occasionally to be, to the inner coat. After having remained stationary for an indefinite period, this hete- rologous product manifests a disposition to soften, and is ultimately converted into a friable, curdy substance, possessing apparently all the properties of scrofulous pus. When the disease has reached this point, the lining membrane is frequently elevated into small pustules or little abscesses, which, when ruptured, leave a corresponding number Atheromatous deposits. From a preparation in my collection. HYPERTROPHY. 247 of ragged and irregular ulcers, the base of which is formed by the substance of the middle coat; this lesion is frequently associated with the fibrous or calcareous formation, and with more or less opacity, thickening, and corrugation of the lining membrane. Though the quantity of new matter is seldom very great, yet its tendency uni- formly is to impair the elasticity of the arterial tunics, and to dispose them to laceration. The disease is most frequently witnessed in stru- mous subjects, after the thirty-fifth year. Atheromatous deposits, examined with the microscope, are found to consist of albuminous and earthy particles, of crystalline plates of cholesterine, of an imperfect fibrous texture, and of oil-globules. The fatty matter is often so plentiful as to impart a greasy stain to paper when dried on it by heat. Atheroma would thus seem to consist in a fatty transformation of a fibrinous exudation, having its primary seat under the inner coat of the artery. Mr. Gulliver was the first who broached this view, which he has since confirmed by repeated investi- gations of the subject. I was formerly of opinion that these deposits were of a tubercular nature, but in consideration of the numerous minute examinations now on record, this opinion seems to me no longer tenable. The most frequent seat of atheromatous deposits is the aorta, par- ticularly the thoracic portion, in the neighborhood of the origin of the great cervical trunks. The affection is common in advanced age, but is not noticed in infancy and childhood. A somewhat similar change, but involving more especially the coats of the vessels and leading to their atrophy, occurs in the fatty degeneration of the smaller arteries, whose tissue is seen destroyed, and replaced by shining oil-globules. This change is most frequently met with in the cerebral vessels, and predisposes to their rupture. Much less frequent than the deposits now described are the me- lanotic and encephaloid. These, in fact, are among the rarest affec- tions of the arterial tissue. When occurring in this situation, the melanotic matter is usually effused into the subserous cellular sub- stance, in the form of minute dots, or in that of small irregular patches. The encephaloid matter, on the contrary, although it is occasionally seated in the same locality, more frequently occupies the interior of the artery, assuming an arborescent arrangement, and filling up its caliber. 10. Hypertrophy.—Hypertrophy is well exemplified in the arteries of the uterus during gestation, and in the growth of various tumors, especially such as attain a great bulk. In these states of the system they often become extremely capacious, elongated, and tortuous, being coiled up like varicose veins. The object of this augmentation of volume is to allow a larger quantity of blood to flow into the growing part; and hence, in the instance of the uterus, we find that, as soon as the child is expelled, the dilated and thickened arteries gradually revert to their former dimensions. Hypertrophy of these vessels is generally associated with hypertrophy of the veins, and is, in most cases, purely physiological, there being no discernible lesion whatever 248 ARTERIES. of their tunics. Figure 61 is an admirable specimen of hypertrophy of the aorta near the heart. The tunics of the vessels are enormous- ly thickened, in addition to which the inner and middle are greatly corrugated, or ele- vated into irregular ridges. 11. Contraction.—Contrac- tion of the arteries, either alone or associated with,dila- tation, occasionally exists as a congenital defect; but, in the great majority of in- stances, it is the result of in- flammation, most commonly of the chronic kind, giving rise to fibrinous concretions, atheromatous deposits, or calcareous degeneration. In this way, the caliber of the vessel is sometimes com- pletely obliterated, and its texture transformed into a dense ligamentous cord, the circulation being carried on by enlarged collateral chan- nels in the same manner as when an artery is secured by ligature. Hitherto, this lesion has been observed more particularly in the larger trunks, especially in the aorta, but no part of the arterial system is exempt from it. In- deed, there would occasionally seem to be a peculiar predisposition to this contraction, the capacity of almost every vessel in the body being sensibly affected by it. The pulmonary artery, although seldom impli- cated, is sometimes remarkably contracted, as in the case observed by Dr. Knox, of Edinburgh, in which it was reduced to the size of a small goose-quill. 12. Dilatation or Aneurism.—Dilatation of the arteries, constituting what, in surgical language, is termed aneurism, is one of the most fre- quent lesions to which these interesting structures are liable. Varying in size and shape, under different circumstances, the enlargement exists sometimes at one point, sometimes at several, and sometimes is more extensively diffused, occupying the whole circumference of the tube. In the majority of instances, the disease is seated in the larger trunks; but occasionally it attacks the smaller branches, and not unfrequently even the capillaries. Aneurismal enlargements may be divided into five principal varieties, the sacculated, cylindroid, varicose, dissecting, and anastomotic. To these may very properly be added another, namely, the arterio-venous, or that form of the disease which has been described under the name of aneurismal varix. When a tumor of this kind is composed of all the arterial tunics it is called a true aneurism; if, on the other hand, it consists only of Hypertrophy of the aorta, a. The heart, b. The aorta. From a preparation in my collection. SACCULATED ANEURISM. 249 Fie;. 62. the external coat, the inner and middle being ruptured, ulcerated, or destroyed, it is denominated a false aneurism. Of these two varieties, the latter is by far the more common. Cases occasionally occur, though rarely, where, in consequence of the laceration of the fibrous membrane, the internal coat is protruded across the crevice, in the form of a hernia, which gradually encroaches upon the cellular mem- brane, and thus dilates it into a distinct pouch. a. In the sacculated aneurism (Fig. 62), the coats of the artery are dilated into one or more pouches, oc- cupying only a limited portion of its circumference. It occurs most fre- quently in the great trunks, particu- larly the thoracic aorta, and occasion- ally affects all the principal branches of the body. Pelletan examined an individual, in whom he discovered upwards of sixty of these dilatations; and a still more extraordinary exam- ple has been reported by Cloquet. In this case, the number of tumors was upwards of two hundred. The subject was fifty years of age. They affected almost every artery in the body, even the aorta and its principal divisions, but they were most numer- ous in the extremities. The axillary, humeral, radial, and ulnar arteries, the femoral, popliteal, tibial, and pero- neal, were closely studded with them. In volume they varied between that of a millet-seed and .a large pea. In other respects, the coats of the vessels were perfectly healthy. There would thus seem to be occasionally a real aneurismal diathesis. Much diversity obtains in relation to the dimensions of these sac-like projections; in some instances, as has just been seen, they are re- markably small, whilst in others they acquire the magnitude of a large egg, the fist, or even of a mature foetal head. The manner in which they are attached is also subject to considerable variation, but generally it is by a narrow footstalk or a tolerably broad base. The orifice of communication between the sac and the artery varies in different preparations. When the tumor arises by a narrow foot- stalk the opening is usually proportionably small, with smooth and well-defined margins. When, on the other hand, it is attached by a broad base, the aperture is always much larger, and its edges are also more irregular, sometimes, indeed, quite shreddy and ragged, as if they had been torn. The situation of the orifice is commonly towards the centre of the sac, but it may be at one side, or even at one of its extremities. The form of the opening is extremely variable, and admits of no specific description. In the early stage of the disease, and in nearly all cases where the tumor is small, the orifice is of a rounded or circular configuration, while in cases of an opposite cha- Saccnlated aneurism: a. Artery ; 6. Aneu- rismal pouch. From a specimen in my collec- lection. 250 ARTERIES. Fig. 63. racter it is generally more or less irregular. The internal and middle tunics may terminate abruptly at the margins of the opening of com- munication, or they may extend into the cavity of the sac, and thus serve to give it a partial lining. b. The cylindroid aneurism (Fig. 63) is of an elongated spherical shape: the dilatation, which is pretty nearly uni- form, embraces the entire circumference of the vessel, varying in length from a few lines to several inches. The coats are generally thickened, and the inner surface of the tube is rough, uneven, and covered with thin, irregular layers or patches of fibrin. In some instances, the dilatation is truly enormous. In a specimen of cylindroid aneurism of the arch of the aorta in my cabinet, the tumor measures upwards of ten inches in circumference, by five and a half in length. It formed an im- mense ovoidal swelling in front of the neck, which extended nearly as high up on the left side as the angle of the jaw; whilst below, it pressed upon and destroyed the inner half of the clavicle, part of the first rib, and a small portion of the breast bone. Almost all the arteries in the body are sometimes affected with this species of enlargement. c. The varicose aneurism (Fig. 64) consists, as its name imports, in an' enlarged and nodulated state of the artery, similar to that of a varicose vein. The dilatation ordinarily embraces a considerable portion of the length of the vessel, the coats of which are at the same time very thin and brittle, preternaturally light, and readily collapse when divided. In this variety of the disease, the artery is remarkably elongated, tortuous, and convoluted; the lesion seldom occurs in the larger trunks, but is most fre- quently observed in the secondary and ternary divisions, as the splenic, carotid, humeral, femoral, tibial, radial, temporal, and occipital. d. The dissecting aneurism, which is entirely limited to the aorta and the large trunks which arise from it, or in which it terminates, consists in a sepa- ration of the middle and external tunics of the affected vessel, preceded by ulcer- ation, fissure, or rupture of the lining membrane, caused by the force with which the blood is impelled against it by the contraction of the left ventricle of the heart. Such, at any rate, is the account usually given by pathologists of the nature of this affection; but the observations and dissections of Dr. Pennock, confirmed by a careful personal examina- tion of nearly all the published cases of dissecting aneurism, render it Cylindroid aneurism. From a preparation in my collection. Fig. 64. Varicose artery. From a specimen in my cabinet. DISSECTING ANEURISM. 251 exceedingly probable that it is generally situated between the lamina of the middle tunic, and not between the latter and the external. The manner in which the lesion takes place is easily understood. In the natural state the different coats are so intimately connected to- gether that it is almost impossi- ble, even by the nicest dissection, to detach them from each other ; but when they are altered by dis- ease, or by some of the degenera- tions to which they are so liable, the connecting cellular tissue is rendered soft and friable, and their separation may then be ef- fected with the greatest facility. In this condition, moreover, the tunics themselves are frequently very much changed, so that they are scarcely able to resist the slightest impulse. Now, if under these circumstances the lining membrane gives way, whether from ulceration, erosion, or rup- ture, the blood will insinuate itself into the accidental opening, which is thus gradually enlarged, at the same time that the fluid is forced on between the layers of the weakened middle tunic, dissect- ing them from each other as with a knife, and forming thus either a blind pouch, or a distinct canal, open at both extremities, or at some intermediate point. The detachment is not of the same extent in all cases. It very rarely, in fact, embraces more than one-fourth, one-half, or two-thirds of the circumference of the tube, while in length it may vary from six, eight, or ten lines to as many inches. Occasionally it reaches nearly from one extremity of the aorta to the other, being perhaps prolonged at the same time into the carotid, subclavian, and iliac arteries. The new channel is seldom of uniform size, but is apt to be larger at some points than at others; it runs parallel with the old canal, lying either in front or on one side of it, and is always lined by an adventitious membrane, thicker than the corresponding membrane of the aorta, of a fibro-serous nature, semi-transparent, and of a light maroon, yellowish, or grayish-brown color. The septum between the two tubes is composed of the internal membrane and of one or more of the lamellas of the middle tunic, which are usually considerably hypertrophied, and much firmer than in the natural state. The accidental channel presents itself either in the form of a pouch Fig. 65. The appearances presented by the dissecting aneu- rism are depicted in Fig. 63, from Pennock: a. Semi- lunar valves; b. External vessel laid open in its entire extent, so as to expose the aorta at c ; d. Val- vular opening in the coats of the aorta, showing the communication of this vessel with the artificial chan- nel, 6 ; the probe e passes through the abnormal opening: / shows the foramina between the aorta and the outer canal. 252 ARTERIES. or cul-de-sac; or, after descending some distance, it communicates with the old canal by a distinct rent. The inlet of the factitious route is generally a mere slit or fissure, with thin, ragged edges, from six lines to an inch and a quarter in length, and directed transversely, obliquely, spirally, or longitudinally. The inferior opening, or outlet, is also liable to much diversity, both in regard to its size, shape, and incli- nation;'but generally it is considerably smaller than the upper, from which it may be situated from five to eight or even ten inches. The apertures of communication between the old and new channels are generally multiple. When this is the case, they are commonly nothing but the orifices of pre-existing vessels, the relations of which have been changed by the abnormal separation. The external tunic may be variously altered, but in a majority of cases it is comparatively sound. In some cases the new vessel compresses the old, changing its direc- tion, and assuming its functions. The blood, however, never passes entirely along the collateral route, and hence the original vessel always preserves its tubular form. The dissecting aneurism appears to be most common in women, after the fiftieth year. In six cases, where the sex is mentioned, I find that the patients were all females, four of whose ages, respectively, were fifty, sixty, seventy-five, and one hundred. In seven cases, of which I have been enabled to obtain the particulars, the heart was hypertrophied in all, in some enormously; there was also more or less disease of the mitral or semilunar valves, or of both; and the aorta was either ossi- fied, sacculated, or the seat of atheromatous deposits. Death in several of the cases was caused by a rupture of the aneurism, and an escape of blood into the pericardial sac. Spontaneous aneurism is most frequent between the ages of thirty and fifty. Before twenty and after sixty the disease is very rare. The dissecting aneurism is exclusively confined to old people. Men are much more liable to ordinary aneurism than women, for the reason, doubtless, that they are much more frequently exposed to the exciting causes of the malady, as violent muscular exertion and all kinds of hardship, whereas females always lead a more sedentary and tranquil life. Spontaneous aneurism is most common, first, in the aorta, next in the popliteal artery, then in the femoral, and lastly, in the carotid, subcla- vian, axillary, external iliac, and innominate. The arteries of the leg and foot, the head, and the superior extremity rarely suffer in this way. Aneurism of the pulmonary artery has been observed only in a few instances. The reason of this comparative exemption exists in the fact that the vessels here mentioned are so seldom assailed by the fibrous, fibro-cartilaginous, osseous, and other degenerations so common in the aorta and in the arteries of the thigh and neck. Most of the species of aneurism here enumerated are dependent, directly or otherwise, upon an altered or modified state of the arterial tissues. The internal and middle tunics are commonly most affected; indeed, it is rare to find them perfectly free from disease. The cal- careous, cartilaginous, or atheromatous deposits, noticed in a previous ARTERIO-VENOUS ANEURISM. 253 page, are usually present; and oftentimes the aneurismal pouch is ex- clusively formed of the outer coat, the other two being entirely de- stroyed. In the sacculated variety of the disease, as well as in some of the rest, one of the earliest effects consequent on the development of the tumor, is the deposition of the fibrin of the blood, as this fluid sweeps over its inner surface. This deposition, which generally occurs in concentric layers, is sometimes remarkably abundant. Its thick- ness varies from six to eight lines, according to the age and size of the sac, but it may exceed two inches. The oldest lamellee, or those lying directly in contact with the inner surface of the tumor, are gene- rally of a whitish, grayish, or yellowish color, remarkably hard, dry, and brittle; whereas those which are of recent formation are always of a darker hue, soft, and elastic. e. The last form of dilatation to be noticed is the arterio-venous (Fig. 66), or, as it is generally denominated, aneurismal varix. Although this lesion is most apt to happen at the bend of the arm, where the median basilic vein lies over the humeral artery, yet it may occur in any part of the vascular system in which two considerable sized trunks of this kind are contiguous. In most instances, it follows upon the operation of venesection, but occa- sionally it arises spontaneously, or, more properly speaking, as an effect of ulcer- ation. When produced by a sharp-pointed instrument, as, for instance, the lancet, the superficial wound generally heals by the first intention; but that between the two vessels remains permanently patent, and thus allows the blood to flow readily from one to the other. By degrees the channel here established augments in diameter, and the two ves- sels are either effectually agglutinated together, or their connecting cellular substance is injected with blood, so as to form a sort of globular pouch. The artery and vein, in the mean time, be- come sensibly altered, both as respects the size of their caliber and the texture of their parietes. The former, which now receives black blood, is gradually dilated into a soft, thin flexuous tube, which ultimately acquires all the pro- perties Of a Vien. These Changes, which Arterio-venous variety of aneurism ; a. are always most distinctly marked in the The artery; b- The vein; c-Th" "1,,1]ins be" immediate neighborhood of the preter- natural aperture, frequently extend as low down as the first large collateral branch, and their invariable effect is to obscure the pulsation in the corresponding part of the limb. The vein also loses, in some measure, its normal characters. It becomes large and tortuous, both 254 ARTERIES. above and below the seat of the injury, acquires an extraordinary degree of density, and is no longer either so extensible or elastic. The cause of these textural changes is chronic inflammation, leading, in the one case, to partial atrophy, in the other to partial hypertrophy; or, in other words, what one vessel loses, the other gains. This species of aneurism, which is generally of slow formation, seldom acquires any great bulk. It may be as large as an egg, but ordinarily it does not exceed the volume of a common plum. It communicates to the hand a sort of jarring sensation, and to the ear a peculiar hissing sound, not unlike what would result from the prolonged articulation of the letter E, which are the pathognomonic signs of its existence. /. The anastomotic aneurism (Fig. 67), usually described by the Ger- man pathologists under the name of telangiectasy, is composed of a con- geries of convoluted capillary arteries and veins, Fig. 67. dilated into a soft pulsating tumor, generally of a i^sgr-ir—..-—^=rspw bright florid tint, but occasionally of a bluish, W^^W^^^M^ mulberry, or purple color. In some instances, it ?~^/%&l&-(*f&\ appears as a congenital disease, constituting what '&in%iti'i'Mr$f&W ^s caUed a ncevus maternus. When of long stand- 0%%H^-/^V^l] m»' tne vessels are often dilated into small sacs, '&&■!'$'£'p/vjl and s0 f°rm a truly erectile tissue, analogous to ^wM$:$'M$$l ^at °f ^e penis, nipple, or wattles of the turkey- ^f,M'^S^if!iii cock. Although every part of the capillary Anastomotic aneurism. system is probably susceptible of this singular dilatation, yet the most frequent situations of anastomotic aneurism are the head, hands, and feet. In a few rare instances, it has been observed on the gums and inside of the cheeks. There is a form of hemorrhoidal tumor, which, as will be subsequently shown, is probably merely a variety of anastomotic aneurism. This species of aneurism often acquires a considerable magnitude: Its progress is not always rapid; occasionally, indeed, it remains sta- tionary for years. Ultimately, however, ulceration sets in, and in this way the tumor becomes the seat of frequent hemorrhages. Duration and Termination.—The duration of aneurism is influenced by so many extraneous and intrinsic circumstances that it is impos- sible to lay down any specific rules in regard to it. In a majority of cases it does not exceed six or eight months, while in many it termi- nates much sooner, and in a few it may continue from one to two or three years. The disease proves fatal much earlier in old persons than in the young or middle aged, and in false than in true aneurism. Aneurism by anastomosis may last for many years before it bursts, and the same remark is true of the varicose and arterio-venous forms of the affection. The occupation of the patient, the situation of the tumor, the state of the arterial tunics, and the energy of the circula- tion, are the circumstances which mainly influence the duration of the disease. An aneurismal tumor, after having attained a certain size, manifests a disposition to burst, which it does either as an effect of ulceration, or of inflammation and gangrene. In either case, life is destroyed in the same manner, namely, by hemorrhage, which may be sudden REPAIR. 255 and copious, or slight and gradual, according to the extent of the accidental opening. In the neck, groin, and extremities, the tumor generally breaks upon the surface; in the chest and abdomen, into the serous cavities, or into some of the adjoining viscera. Aneurism of the arch of the aorta usually bursts into the pleura, pericardium, trachea, bronchial tubes, oesophagus, or posterior mediastinum. Eup- ture into the substance of the lungs is very rare. Sometimes a communication is established between the tumor and the heart, or between it and the pulmonary artery. The tumor has also been known, though very rarely, to burst into the spinal canal, one or more of the bodies of the vertebras having been previously destroyed by ulcerative absorption. Aneurism of the abdominal aorta may burst into the peritoneal cavity, stomach, bowels, or urinary bladder. Repair.—Aneurism does not necessarily prove fatal. Nature occa- sionally sets up a process of reparation, and of this there are not less than five different modes, all founded, however, upon the same principle. a. The most common process is the formation of fibrinous concre- tions, by which the whole interior of the sac, with the exception of a small narrow channel, is gradually filled up; the affected artery itself re- maining pervious, and carrying on the circulation. (Fig. 68.) Of this va- riety of cure many examples are on record. The most interesting speci- men of the kind that has fallen under my observation was presented to me by a former pupil, Dr. Shumard. The tumor, which involved the hepatic artery of a young bullock, was of the volume of a large goose egg, of a globular form, and occupied by an immense number of concentric la- mellae, of a dense, firm texture, of a pale grayish tint, and strongly united to each other and to the inclosing sac by short cellular substance. The affected artery was perfectly free, and the blood passed readily from one orifice of the vessel to the other, across a sort of groove or channel in the upper part of the tumor. These appearances are well seen in the annexed cut (Fig. 69). In some instances the aneu- rismal sac is completely filled by the fibrin, the artery is obliterated, either partly, or in the whole of its length, and the circulation is entirely arrested. b. Separation may be effected by the development of inflammation, accompanied by the coagulation of the blood both in the sac and in the artery, and followed by profuse suppuration. Ulcerative absorp- tion takes place, and the matter is discharged along with the contents of the tumor, the sides of which gradually approach each other, and finally unite by granulations. c. Tumors are sometimes developed in the course of the affected artery, and by pressing upon it, either on the cardiac or capillary side of the aneurism, may lead to the coagulation of the contents of the Aneurism of the aorta. The greater part of the cyst filled with clot. Aperture of commu- nication small. 256 ARTERIES. latter, and the occurrence of a spontaneous cure. The same effect may be produced by the aneurism itself, especially when of large size, overlapping and blocking up the connecting artery. Fig. 69. An aneurismal tumor obliterated by the deposition and organization of fibrin. From a preparation in my collection. d. A fourth mode is by gangrene, commencing either in the sac itself, or in the structures immediately around it. The blood coagu- lates here as in gangrene of other parts of the body, the contents of the sac are discharged along with the sloughs, an abundant suppura- tion is established, granulations spring up, and the affected artery is not only obliterated but ultimately transformed into a dense ligament- ous cord. This mode of reparation, like the last two, is very infre- quent, for the patient usually dies either from the violence of the morbid action, or from the effects of hemorrhage. e. A rare process of reparation consists in a clot of blood, detached by a blow, contusion, or violent concussion, finding its way into the opening of communication between the aneurism and the artery, and thus effectually intercepting the circulation in both. Soon after the circulation within the aneurismal pouch is fairly arrested, whether by the formation of fibrinous concretions, the inva- sion of gangrene, or the effusion of purulent matter, a process of absorption commences, leading to important changes in the debris of the tumor. The internal concretions are transformed into pale, whitish, yellowish, or grayish lamellae, while the cyst by which they are sur- rounded assumes the character of a dense, fibrous membrane, altogether unlike the coats of the artery with which it is connected, and of which it originally formed a part. Whether the tumor is ultimately entirely absorbed, or whether a portion of it remains, and gives rise to the little nodules occasionally seen on the exterior of larger vascular trunks is a question which we have no means of determining. The general opinion is, that these bodies are nothing but aneurismal sacs, which have been filled up by lamellated coagula, and the volume of which has been diminished by absorption. Effects on Neighboring Parts.—The influence which aneurism exerts upon the adjacent structures varies according to the size and situation VEINS. 257 of the tumor. As long as the sac is small the effects will be propor- tionably slight, if not imperceptible; but as it augments in volume, it will necessarily produce more or less pressure upon the parts with which it lies in contact, and thus lead to changes of a marked and serious character. In the neck the tumor may embarrass the circu- lation of the jugular vein, and thereby cause cerebral congestion, headache, vertigo, and intumescence of the face. By compressing the trachea and oesophagus it may occasion difficulty of respiration and deglutition. In aneurism of the thoracic and abdominal aorta, the heart, lungs, and other organs are liable to be displaced, deformed, partially atrophied, and more or less changed in their structure. The thoracic duct and vena cava are sometimes very much compressed, and partly, or even entirely obstructed. The common carotid and subclavian are occasionally obliterated by the pressure of an aneurism of the aorta. In aneurism of the popliteal artery the pressure of the tumor often intercepts the passage of the blood in the branches below, so as to lead to gangrene of the whole limb. The bones in the neighborhood of the aneurismal tumor frequently experience important changes. The pieces most liable to suffer are the vertebrae, ribs, sternum, and clavicle, which may be eroded, ulcer- ated, excavated, atrophied, or even in great measure destroyed. The cartilages, fibro-cartilages, ligaments, and aponeuroses seldom undergo much alteration, no matter how great or protracted the pressure exerted by the tumor. The muscles are wasted, changed in color, and trans- formed into thin, elongated, ribbon-shaped bands; the nerves are stretched and flattened; the cellular tissue is infiltrated with serum and lymph; and the skin, gradually attenuated, is ultimately invaded by ulceration or gangrene. In cases of long standing, the soft parts around the tumor are sometimes very much condensed, and a sort of adventitious cyst is formed, similar to what is observed in certain va- rieties of chronic abscess. CHAPTER VI. VEINS. Lesions.—Acute Inflammation.—Suppuration.—Ulceration.—Chronic Inflammation.—Dilata- tion.—Obliteration.—Calcareous Deposits.—Phlebolites.—Admission of Air. 1. Acute Phlebitis.—Acute inflammation of the veins is much more frequent than in the arteries; the reverse being the case in respect to the chronic form of the disease. It usually implicates a large extent of surface, often affecting a number of veins simultaneously, and, what is remarkable, always tending to spread in the direction of the heart. The 17 258 VEINS. Fig- 70. anatomical characters of this disorder are swelling, < ^ opacity, and pulpiness of the internal membrane, with uniform redness, varying from light pink to deep florid. The middle and outer coats soon be- come deeply injected, and their proper substance, although at first preternaturally soft and humid, is at length rendered so dense and firm that the vein feels like a hard, contracted cord. The cavity of the inflamed vessel is filled with clotted blood, some- times blended with pus or lymph, and in many cases it is lined by a false membrane, susceptible, under certain circumstances, of organization. Instances occur in which the pus is infiltrated into the sub- stance of the vein, or collected into small abscesses beneath the lining membrane. The pus generally resembles that of a phleg- monous abscess, and sometimes completely fills some of the larger veins of the womb and surround- ing parts. In a case mentioned by Wilson,1 the uterine and iliac veins were greatly thickened, and the abdominal cava contained upwards of four ounces of purulent matter, which was prevented from reach- ing the heart, partly by the contraction of the vessel near its entrance at the diaphragm, partly by a mass of pseudo-membrane. Suppuration is also liable to occur after venesection, amputation, compound fractures, and the application of the ligature. In the umbilical vein it often follows the tying of the cord, causing erysipelatous inflamma- tion, which in a few days destroys life. 2. Ulceration.—Ulceration of the veins occurs much less frequently than in the arteries. Commencing most commonly at one or more points of the inner membrane, it gradually extends to the other tunics, which it sometimes completely erodes. The immediate effect of this accident is an effusion of blood, which may be so great as to produce fatal results. The ulcers, which affect various forms, are occasionally quite numerous, and spread over a large extent of surface. 3. Chronic Phlebitis.—The characters of chronic inflammation of the veins differ considerably from those of the acute form. The coats are usually much thickened, hypertrophied, and so dense that the vessel, when cut across, preserves its cylindrical figure, like an artery. The redness is of a brownish tint, interspersed with numerous shades of gray, violet, or purple; and the inner membrane, which is rou^h and shrivelled, can be easily raised in large opaque shreds. In some in- stances, the vein is dilated, or contracted, obstructed with clotted blood lined by lymph, or filled with pus. There are certain states of the system in which the veins seem to attain a very great size, carrying an inordinate amount of blood. This hypertrophy, for so it may be termed, is very conspicuous in chronic Fibrinous phlebitis, a. The femoral vein, oc- cluded by solidified con- tents. At b, the saphena enters ; and consolida- tion ends abruptly there. 1 Transactions of a Society for the Improvement of Medical Knowledge, vol. lii. p. 65. OBLITERATION. 259 affections of the joints, in vascular and malignant tumors, and in the veins of the uterus during the latter months of pregnancy. It is always conjoined with hypertrophy of the arteries, and forms one of the most serious obstacles to the cure of various diseases. 4. Dilatation.—Dilatation (Fig. 71) is most frequently observed in the veins of the testicles and lower extremities, in persons whose employ- ment compels them to stand for a long time in one position. It has also been Fig- 71. observed in the superior extremities, and, in a few instances, I have wit- nessed it in the superficial veins of the abdomen. Of the deep-seated veins, those most frequently affected are the subclavian, jugular, azygos, and he- morrhoidal. The vessels, in this dis- ease, become preternaturally large, elongated, knotty, irregular, and tor- tuous, winding in a serpentine man- ner underneath the skin. Their coats are either of the normal structure, or they are thick and rigid, or thin and expanded, or, finally, they are weak in some places, and hypertrophied in others. When laid open, they are found to be rough and irregularly sacculated, strong bands being some- times stretched across their interior, which divide the vessel into little cells, filled with coagulated blood. The valves, although they gene- rally retain their normal texture, are sometimes thickened, indurated, displaced, or ruptured. This varicose state of the veins is usually attended by chronic inflammation, and often leads to great and irrepa- rable mischief. In many cases, the vessels are converted into hard, rigid cylinders, or their tunics are invaded by ulceration, followed by perforation and profuse hemorrhage. 5. Obliteration.—Obliteration of the veins is by no means uncommon, and is almost always the result of inflammation. Sometimes it is caused by the pressure of a tumor forcing the sides of the vessel closely in contact, and so converting it into a dense ligamentous cord. The largest veins are sometimes thus obliterated. Many years ago I exa- mined, along with Professor Drake and Dr. Eives, the body of a man, aged forty, in whom the descending cava was closed by a plug of plastic lymph, from the second lumbar vertebra as high up as the liver. The vessel retained its normal size, and the morbid substance, which was of a pale straw color, and of the consistence of semi-concrete albumen, adhered firmly to its inner surface, having evidently been deposited a long time previous to death (Fig. 72). A similar substance was found in the portal and right renal veins, together with several of the smaller veins of the left lung. All the abdominal viscera showed signs of chronic disease, and, during the last two years of his life, the 260 VEINS. Fig. 72. Obliteration of the hollow vein by fibrinous concretion. From a specimen in my cabinet. a. Broad ligament of uterus ; 66. Uterine veins containing phlebo- lites ; e. Phlebolite sawed open, ex- hibiting its concentric arrangement. individual suffered, at intervals, from ascites. In another case, which I saw eighteen months ago, a similar substance was found in the ex- ternal iliac and femoral veins, together with some of the smaller vessels of the pelvis. The most prominent symptom here, as far as the veins were concerned, was oedema of the cor- responding extremity. 6. Calcareous Deposits.—Calcareous deposits within the coats of the veins are much more rare than in those of the arteries, this circum- stance depending upon their difference of or- ganization. Instances of this occurrence, how- ever, are mentioned by various authors in the walls of the great hollow vein of the abdo- men, in the femoral vein, and in the external saphenous. Whether the venous tissues are liable to the atheromatous degeneration, so common in the arterial, is questionable; at all events, I am not acquainted with a single re- corded instance of it, nor have I met with it in my own dissections. A sort of fatty sub- stance is occasionally found. Andral once saw a tumor of this description, about the size of a walnut, which exhibited all the anatomical characters of the adipose texture. It was de- veloped in the substance of the great portal vein, the cavity of which it almost filled. 7. Phlebolites.—Loose concretions, phlebo- lites or vein-stones, varying in size from a currant to a pea, are occasionally found in the interior of these tubes (Fig. 73). Com- monly of a yellowish, brownish, or bluish color, they are of a hard and brittle consist- ence, and of an oblong, oval, or spherical form, with a smooth, even surface. When divided by the saw, they are found to be made up of several thin but distinct lamellae, dis- posed concentrically around a small, delicate nucleus, frequently consisting of fibrin. The number of these calculi is extremely variable; there are rarely more than two or three, though occasionally as many as ten, twenty, and even thirty, are observed. They are generally met with in the smaller veins; more frequently, perhaps, in the spermatic, uterine, vaginal, vesical, hemorrhoidal, and splenic, than in any other. In the saphenous and its branches, they often exist in connection with varicose enlargement. According to the analysis of Gmelin, subsequently confirmed by that of INTRODUCTION OF AIR. 261 Dr. Prout, vein-stones are composed principally of phosphate and car- bonate of lime, with a small amount of animal matter, probably albu- men, and a trace of oxide of iron. A difference of opinion still prevails respecting their mode of origin. Some suppose that they are developed in the substance of the veins, whence they make their way into their interior by destroying the lining membrane; others, on the contrary, believe that they are formed directly from the fibrinous matter of the blood itself. The rounded shape and polished surface of these bodies, with the fact that the inner coat is often perfectly sound, strongly cor- roborate the latter conjecture. I have repeatedly seen them in the very centre of fibrinous clots, and been able to trace their progress, some portions being of an earthy nature, while others presented all the characters of the plastic substance of the blood blended with more or less haematosine. 8. Introduction of Air.—It has long been known that air thrown suddenly and in large quantity into the venous system, is often fol- lowed by fatal effects. This circumstance, although long ago men- tioned by Wepfer, Chabert, and other writers, appears to have been almost entirely forgotten, until it was again brought before the pro- fession by the researches of Bichat, Nysten, Magendie, and Piedagnel. The experiments of these distinguished philosophers clearly prove that the insufflation of air into the veins produces instantaneous death, and that, on dissection, traces of this fluid can be detected in different parts of the hody, particularly in the right cavities of the heart. As an accidental occurrence, this effect is sometimes witnessed in surgical operations, involving the jugular, subclavian, or axillary veins, and as such it was first noticed by M. Beauchene, of Paris, in 1818, in cutting out a tumor from the neck of a young man. The dissection was nearly finished, when the patient suddenly became faint, and expired in forty-five minutes from the commencement of the opera- tion. On examining the body, an aperture was found in the internal jugular vein, from which the air had evidently descended along the superior cava to the right chambers of the heart, thereby causing death. Since that period, similar results have been observed by many other surgeons. It is a singular fact that the effects from this cause are much Jess violent, if the air be introduced gradually and in small quantity into the veins. The only difficulty, indeed, that is produced in this case is a momentary excitement of the action of the heart. If the insuffla- tion, however, be repeated for several days, at intervals of six or eight hours, the powers of this organ will become very much weakened, and the pulmonary tissues so far deranged as to give rise to severe cough, frothy expectoration, and considerable embarrassment of the respiratory function. When the air is suddenly injected, the animal is instantly seized with partial syncope, utters cries expressive of suffering, and quickly expires. In the human subject, the accidental introduction of this fluid is sometimes attended with a peculiar hissing noise, like that which is heard when the air rushes into an exhausted receiver. In other cases, symptoms of apoplexy ensue; the counte- nance is of a livid complexion; the respiration deep and stertorous; 262 LYMPHATIC VESSELS AND GANGLIONS. the pulse slow, laborious, and almost imperceptible; the surface is bathed with cold perspiration, and the patient is perfectly insensible. The question may be asked, in what manner does air, when intro- duced into the venous system, operate so as to produce these deleteri- ous effects ? This question, as might be anticipated, has been variously answered by different writers. By some it is maintained that the fluid acts principally, if not entirely "upon the brain, causing symptoms of violent congestion, loss of sensibility, and spasmodic rigidity of the muscles; an explanation which is favored, in some degree, by the experiments of Nysten and Magendie, in which they induced apoplectic phenomena, by injecting air into the carotid arteries of animals. Others, on the contrary, believe that the primary obstacle is in the lungs, since these organs have been found in a condition similar to what is observed in asphyxia. Piedagnel and Leroy, from having seen these structures in a lacerated and emphysematous state, suppose that death is caused solely by this lesion. But the grounds for these opinions are by no means conclusive; and we are at last compelled to resort to the explanation, long ago suggested by the French physiolo- gists, that the fatal effects in question are the result of the sudden distension of the right cavities of the heart, whereby the powers of that viscus are partially paralyzed, and the circulation materially impeded. This view is strongly corroborated, in the first place, by the fact, already adverted to, that if the air be introduced into the veins in a slow and gradual manner, little or no functional derange- ment will manifest itself in either of the above organs; secondly, by the almost total failure of the pulse in cases of an opposite description; thirdly, by the remarkable insensibility of the patient; and, fourthly, by the circumstance that the foreign fluid is usually found in greatest abundance in the right chambers of the heart. CHAPTER VII. LYMPHATIC VESSELS AND GANGLIONS. I. LympJuztic Vessels.—Liability to Inflammation and Suppuration.—Tubercular Deposits.— Dilatation.—Aneurism of the Thoracic Duct.—II Lymphatic Ganglions.—Lesions.—Inflam- mation and its ordinary Consequences.—Hypertrophy.—Encephaloid Disease.—Tubercle.— Ossification.—Melanosis. SECTION I. LYMPHATIC VESSELS. As the lymphatics are so extremely delicate, it is by no means easy to detect in them those various alterations of structure to which they are liable. The following remarks, therefore, embracing a rapid out- SUPPURATION. 263 line of the principal lesions of this system of vessels, will have special reference to the left thoracic duct, in which it is alone possible, in the generality of cases, to detect any deviation from the normal standard. 1. Bichat long ago affirmed that the lymphatics are much more frequently affected with inflammation than the veins, an opinion which has been amply corroborated by the observations of more recent writers. In the early stage of the disease, the lining membrane is of a light reddish tint, opaque, slightly thickened, and preternaturally dense, yet so friable as to allow itself to be peeled off readily in small pellicles. As in the veins, the discoloration occurs at first in minute, circumscribed patches; after some time, however, it becomes uniform, deeper, and gradually invades the other tunic, the vessels of which, very much injected, may be seen ramifying in every direction, forming a network so delicate as to render it difficult to distinguish it with the naked eye. Flakes of lymph are sometimes found adhering to the inner surface; and, in violent cases, it may even be bathed with pus. Under these circumstances, both tunics are of a deep red, violet or purplish color, soft, and spongy, and the surrounding cellular tissue is swollen and infiltrated with serous and other fluids. The proper nutrient vessels, also, are excessively engorged with blood, and are no longer permeable to injecting matter. When the superficial lymphatics are affected, they can be easily traced underneath the skin, like small red cords, tense, nodulated, and painful to the touch, accompanying the principal veins, and going as far as the first conglobate glands, rarely beyond them. This appear- ance, which is well seen in dissecting wounds, in punctures, and in poisoned wounds, is often attended with considerable swelling and oedema of the connecting cellular texture. Such is a succinct outline of the anatomical features of acute inflam- mation of the lymphatics. Of those which mark the chronic form of the disease, nothing need be said in this place, as they have not been properly investigated. That they are very analogous to those charac- terizing chronic inflammation of the veins, is highly probable; at least, such must be our conclusion, when we reflect upon the similarity of structure and function of these two systems of vessels. 2. It has been already stated that suppuration sometimes takes place in these vessels, and it may now be added that they occasionally con- tain pus, the result obviously of absorption. Mascagni states that it is by no means uncommon to find purulent matter in the pulmonary lymphatics in phthisical subjects; and it is well known that the same occurrence has been repeatedly seen in those of the womb and inferior extremities in women dead of phlegmasia dolens. It is still undecided whether acute inflammation ever terminates in gangrene; but there is reason to believe that such an event is not only extremely rare, but that it never occurs as an idiopathic affection. 3. The lymphatics sometimes contain tubercular matter, but the occurrence is rare; it is noticed chiefly in those of the lungs, groin, and pelvis, in union with similar deposits elsewhere. A calcareous,chalky, or bony substance has also been found in them. Occasionally, again, their coats are partially ossified. 264 LYMPHATIC VESSELS AND GANGLIONS. 4. A remarkable dilatation of the lymphatics is sometimes observed, giving them a tortuous, varicose arrangement. (Fig. 74.) This lesion is well illustrated by a case men- Fig. 74. tioned by Dr. Carswell. The sub- ject of it was a young man, twenty- six years of age, who died with two swellings, one in each groin, nearly as large as an orange, for which he had worn a double truss from his boyhood, under the supposition that they were of a hernial character. On examining the patient after death, the tumors were found to consist of an enormous dilatation of the lympha- tics of the inguinal glands. When cut into, instead of presenting a solid, compact structure, they had the ap- pearance of a coarse sponge, the size of all the vessels being augmented, most of them being from one to three lines in diameter. The same Dilated lymphatics. phenomenon was seen, only more strikingly, in the absorbents of the pelvic and lumbar regions. None of them were less than two, and many of them from three to four lines in diameter, whilst the thoracic duct itself was fully three times the natural dimensions. Soemmering has seen the lymphatics of the intestines varicose in hernia; and the same condition was witnessed by Bichat in those of the serous mem- branes in dropsy. Dr. Albers, of Bonn, has reported a case of what he terms aneurism of the thoracic duct. The patient, a man fifty-one years old, died of abscess of the liver. On examining the body, a knotty, elastic tumor was found, about the size and shape of a fig, and resembling very much a hydatid. Its walls were preternaturally thick and firm, and, on cutting through them, a director could be easily passed up and down the canal, thus showing that it was connected with the duct in question. The swelling was filled with thin, flaky lymph, and its inner surface was perfectly smooth and uniform. Baillie states that he has seen the thoracic duct varicose, and nearly as large as the subclavian vein. 5. The thoracic duct is sometimes obliterated. This may depend either upon a thickening of its tunics, the presence of a foreign body, or the reciprocal adhesion of its valves. However produced, this oc- currence almost always impairs the nutritive function, though, owing to the numerous anastomoses of these vessels, and to their continua- tion with the veins, this process is perhaps never entirely interrupted, the chyle finding its way along collateral channels, just as the blood does after the tying of an artery. LYMPHATIC GANGLIONS. 265 SECTION II. LYMPHATIC GANGLIONS. The lymphatic ganglions are liable to inflammation, suppuration, gangrene, hypertrophy, carcinoma, tubercles, melanosis, and ossifica- tion. 1. In acute inflammation, the lymphatic glands are, at first, of a pale flesh color, hard and dense to the touch, considerably swollen, and cannot be torn with the same facility as in the normal state. When cut into, numerous minute points, of a brownish tint, and evidently the orifices of divided absorbents, may be observed ; and, in many instances, blood is extravasated into the connecting cellular tissue, in circumscribed specks, not larger, frequently, than the head of a small pin. The covering of the glands, of a light reddish hue, is every- where crowded with injected vessels, radiating in beautiful dendritic lines. At a more advanced period, these bodies acquire a dark violet color, become soft and spongy, from the infiltration of thin bloody matter, and, on being torn, their substance looks very much like that of the spleen. In this affection, ganglions, naturally not larger than the kernel of an almond, may acquire the magnitude of an orange, or even of the fist; as is exemplified in cases of buboes, and in lymphatic swellings in the axilla, or about the neck. The tumefaction arises, apparently, from the internal connecting cellular tissue, or from thickening of the external coat of the absorbents, as these tubes are still pervious to mercurial injection. This disease may affect a singe gland, extend to several, or involve a whole chain or group. Maceration in water for a few days in hot weather deprives the in- flamed ganglion completely of its red color, and converts it into a soft grayish mass, which easily yields to the pressure of the finger. Boiling has the effect, at first, of rendering it dense and slightly elastic, and afterwards, friable and granular. 2. This disease occasionally terminates in suppuration, the period at which this event happens varying from a few days to a fortnight. The pus may be either diffused through the proper parenchymatous structure, converting it into a dirty, grayish mass, or it may be dis- seminated in distinct globules, or, finally, be collected into an abscess, which may be so large as to occupy the whole gland, the only thing that remains being its external envelop. The quantity of matter is sometimes very great; and, in the majority of cases, it is of a thin greenish character, intermixed with hard, cheesy flakes. The glands most liable to suppuration are those of the groin, axilla, neck, and jaw. 3. Acute inflammation sometimes ends in gangrene. When this takes place, the substance of the gland is of a dirty grayish color, 266 LYMPHATIC GANGLIONS. soft, pulpy, and bathed in a foul, fetid sanies, occasionally so acrid as to prove highly irritating to the surrounding parts. This termination of acute inflammation is well exemplified in cases of syphilitic buboes, occurring in debauched and worn-out habits. In such patients im- mense sloughs are sometimes formed, the gangrene gradually spread- ing from the affected glands of the groin to the adjacent textures. 4. In chronic inflammation, the lymphatic ganglions are hard, firm, not easily lacerated, and of a light brownish color, interspersed with streaks and specks of gray, which have the effect of giving them a mottled aspect; their substance is infiltrated with lymph; and, on being cut, they creak slightly under the knife, the section presenting a homogeneous aspect. The fibrous envelop is very dense and thick; and both its own vessels and those which are distributed to the proper parenchymatous tissue are tortuous, knotty, and dilated. The absorb- ents entering into the composition of these bodies are also more or less enlarged, though occasionally their cavity is so much diminished as to render it impossible to inject them. The disease sometimes passes into suppuration, the parenchymatous structure being entirely destroyed, the thickened and indurated capsule being the only part that is left. The pus in such cases is semi-concrete, and often remarka- bly offensive, apparently from its long sojourn in the parts. 5. Chronic inflammation leaves these glands sometimes in a state of hypertrophy, as in Fig. 75. In this condition, they may be perfectly white or grayish, or else they may acquire a light brownish or yel- lowish tint; their consistence, also, is frequently much augmented, and cases occasionally occur in which they are of a dense, gristly hardness, like scirrhus. The glands most liable to be thus affected are the me- senteric, bronchial, internal Fis- 75. iliac, inguinal, and cervical. I have a preparation, taken from a child three years of age, in which the mesenteric ganglions, all matted into one general mass much larger than a foetal head, are of a bluish gray color, homogene- ous, and of the consistence of fibro-cartilage, each one grat- ing sensibly under the knife. Many of them are as large as Hypertrophy of the lymphatio glands. From a sped- an Orange, and they all have men in my collection. a very thick, indurated cap- sule, very much of the same tint as the altered parenchymatous substance. Hypertrophy of the lymphatic glands may arise from irritation, seated originally in their own tissue, or it may proceed from irritation propagated to them from the surrounding parts. In the glands of the mesentery, it is commonly caused by irritation of the bowels, especially the ileum; in the groin, by that of the penis; in the axilla, by that of the breast; in the neck, by exposure to cold; at the TUBERCLES. 267 jaw, by disease of the gums, teeth, or tonsils. Great mischief is some- times occasioned by this morbid development. An instance is men- tioned in which the bronchial glands were so much enlarged as to induce fatal suffocation; and the internal iliac glands have repeatedly caused death by preventing the descent of the child's head during parturition. AVhen those of the mesentery are enlarged they may obstruct nutrition, and produce excessive emaciation, followed at length by loss of life. At the jaw, they sometimes produce perma- nent anchylosis ; and at the transverse fissure of the liver, an enlarged lymphatic ganglion has been known, more than once, to cause jaundice, by compressing the hepatic or choledoch duct. 6. It has been already mentioned that the lymphatic ganglions sometimes acquire the hardness and density of scir- rhus, and it may now be added that they occasionally Fig- 76. contain encephaloid. When thus affected, they are metamorphosed into a soft brain-like substance, in- closed by a strong membranous cyst, with irregular fibrous filaments intersecting it in different direc- tions. Grumous matter is sometimes found in such tumors, and now and then one part is medullary, an- other fibrous, another scirrhous. Serous cysts are also occasionally seen. In a case of encephaloid of the axil- lary ganglions, which I observed in a man fifty-six ^lano^ of a iym- J ° „° \ . . . p ,, . < . , phatic gland. From a years of age, there was a single cavity of this kind preparation in my coi- which fluctuated under the finger, and contained up- lection. wards of eight ounces of sero-sanguinoient fluid. 7. Melanosis of these glands is extremely rare. (Fig. 76.) I have noticed it in a few instances in the lymphatic glands of the groin and axilla, and these are, I believe, its most frequent seats. It occurs either as an infiltration, or as an irregular tumor, solid, inelastic, and of variable size. 8. Tubercles are frequently observed in the lymphatic glands, occur- ring either in small isolated granules, in considerable clusters, or in the form of infiltration. They are generally associated with tubercles of the lungs, and are most common in children between the ages of three and ten. Louis considers this morbid change as peculiar to phthisis; and he even goes so far as to affirm that it never exists, after the fifteenth year, without pulmonary consumption. This, however, is not true. It is but recently that I examined the body of a man, aged thirty, who died of psoas abscess, in whom, although the lungs were perfectly sound, the lumbar, pelvic, and mesenteric glands were most extensively tuberculized. Nor is this the only instance which I have seen of this disease unconnected with pulmonary phthisis. The deposition of tubercular matter is much more common in the bronchial glands than in any other. In 100 children, in which these organs were carefully inspected, Dr. Lombard found them affected in 87. Age seems to exert a considerable influence in respect to the frequency of this deposition in different parts of the system. In adults, the mesenteric glands are more commonly affected. In 100 phthisical subjects, Louis found these bodies tuberculized in 23, or in the pro- 268 LYMPHATIC GANGLIONS. portion nearly of one to four. When suffering under this disease, the glands exhibit different appearances, according to the progress it may have made. Generally speaking, they are enlarged in their size, of a dense gristly texture, white externally, and of a light rosy tint in- ternally, either uniformly, in streaks, or in patches. The tubercular matter itself is of a singularly yellowish color, especially if it has existed for some length of time, and often contains particles of curdy pus. 9. Finally, the lymphatic glands are occasionally ossified, as in Fig. 77, and still more frequently they are transformed into a soft whitish substance, like chalk. These changes most Fig. 77. commonly occur in the conglobate glands at the root of the lungs, in persons cut off by pulmonary phthisis; but sometimes they are witnessed in other situations, as in the groin, mesentery, and pelvis. Not long ago, I met with a case in which a considerable _ , number of the absorbent glands of the neck Cretaceous degeneration of the lym- . n <-> phatic glands. were ossified. They were perfectly hard, like bone, of a light brownish color, irre- gularly rounded, and from the size of a pea to that of a hazel-nut. Occasionally the lesion seems to be confined entirely to the cellulo- fibrous envelop of these bodies, their parenchymatous structure either remaining sound, or else containing tubercular or calcareous matter. In the bronchial glands, it is not unusual to find hard sabulous con- cretions, matted together by cellular tissue; similar substances, only of a more regular shape, I have several times seen in the lumbar and pelvic glands. In most of the cases which have come under my notice they were perfectly spherical, smooth, uniformly hard, and very few of them larger than a currant; they occurred in the midst of the parenchymatous texture, to which they adhered by dense cellular tissue, and which was, in other respects, entirely natural. These morbid changes may be considered as resulting from a slow chronic inflammation, similar to that which accompanies ossific depo- sition in the arteries. Ordinarily, the metamorphosis begins at one or more points, whence it gradually spreads in different directions, until it embraces the whole gland. When purely ossific, it is sup- posed by some to be preceded by cartilage, but this admits of doubt. ARTICULAR CARTILAGES. 269 CHAPTER VIII. JOINTS. I. Articular Cartilages.—Lesions.—Reparation.—Inflammation.—Softening.—Suppuration.— Ulceration.—Ossification.—II. Synovial Membranes.—Diseases : Inflammation.—Effusion of Lymph and Pus.—Ulceration.—Chronic Irritation.—Loose Cartilages.—Chalky Concre- tions.—III. Ligaments.—Adhesive Inflammation.—Atrophy.—Calcareous Concretions. SECTION I. ARTICULAR CARTILAGES. Cartilages, both articular and non-articular, are susceptible of reparation, inflammation, suppuration, softening, ulceration, and ossi- fication. 1. When divided by a sharp instrument, or torn asunder, as in fractures, cartilages readily unite, the edges of the wound being at first rounded off, and afterwards joined by a dense fibro-ligamentous sub- stance, whiter and more opaque than the original structure. In some instances, the reparation is effected through the medium of osseous matter; but this is rare. In this respect, the articular cartilages differ remarkably from the costal, which, when cut or broken, always unite by bony matter, the reparative process being exactly analogous to that which nature employs in the cicatrization of fracture. The difference in these two cases depends, no doubt, upon some difference of struc- ture, though it is by no means easy to determine why it is that an organ, which naturally contains less earthy matter than another, should, when injured, be more easily united by bone. The reverse, one might suppose, would be the more natural method. Is cartilage ever regene- rated ? Laennec and Beclard think it is; and careful observations, made since their time, fully authorize us in answering this question affirmatively. The reproduction, however, is generally very imper- fect, and serves, therefore, as a very indifferent substitute for the original structure. 2. Inflammation of the cartilages may occur as a primary affection; but more generally succeeds to disease of the osseous, synovial, or ligamentous texture. Its progress is usually slow, and its characters are, for the most part, very obscure. In young persons there is some- times a considerable degree of redness, the vessels of the joint being enlarged and continuous with those of the subjacent bone; but in old subjects this phenomenon is rarely present, the only evidence of the disease being a softened, spongy, and tumid condition of the cartilages. 270 ARTICULAR CARTILAGES. The inflammation is accompanied by severe pain, deep-seated, and of a dull, aching nature; and is soon followed, if its course be not arrested, by ulceration or destructive mollescence. 3. Genuine suppuration of the movable cartilages is seldom, if ever, met with, the purulent matter which is found in the diarthrodial joints being generally poured out by the synovial or bony texture. Pus has been observed in the pubic and sacro-iliac symphyses, but the occurrence is extremely rare. Even in ulceration of this tissue, the formation of purulent fluid is by no means a constant accompaniment. 4. Softening of the cartilages seems to be the result commonly of severe inflammatory action, by which their structure is converted into a semi-transparent, pulpy substance, not unlike thick starch. This change, which is sometimes effected with great rapidity, is generally connected with caries of the articular surfaces of the bones, and seems to be somewhat analogous in its character to gangrene of the soft parts. In gouty affections, the articular cartilages of the fingers and toes are often softened and either partially or entirely removed; similar effects are occasionally witnessed in scrofulous disorders of the spinal column, and of the joints of the hip and knee. During the latter stages of utero-gestation, the fibro-cartilaginous substance of the pubic symphysis is sometimes remarkably softened and relaxed, allowing the two contiguous bones to ride upon each other. A case of this kind came under my notice not long since. The lady was in her fifth pregnancy, and the separation, commencing about a month before her lying-in, was so great that she could scarcely walk, or turn in bed, without the greatest suffering. The parts were almost as tender as a boil, and more than five weeks elapsed after her confinement before they regained their healthy character. This affection, which on the whole is rather uncommon in the human subject, seems to be natural to some of the inferior animals, as the rabbit and Guinea-pig, its ob- ject, in them, being evidently to facilitate the parturient efforts. An analogous lesion is sometimes observed in the sacro-iliac junction; but the softening and concomitant separation are always much less. 5. Ulceration of the cartilages, although it occasionally exists as a primary lesion, in most cases depends upon disease of the adjoining- tissues, as caries of the extremities of the bones, or inflammation of the synovial membranes. It may take place at any period of life, or in any articulation; but it is in the hip and knee that it is most gene- rally met with, in persons between twenty and thirty years of age. In general, the disease is confined to a single joint; but occasionally two or three are affected in the same individual, either simultaneously,'or in succession. Its causes are referable to local injury, atmospheric vicissitudes, or to a strumous, gouty, or syphilitic taint of the consti- tution. Ulcers of the cartilaginous tissue vary much in their size and form. Sometimes they are small and deep, like excavations ; more commonly, however, they are superficial, and occupy a pretty large extent of surface. In the primary variety of the disease, in which the erosion always begins towards the centre of the free surface of the cartilage, ULCERATION. 271 the ulcer is sometimes smooth, narrow, and of a light grayish color, as if a portion had been scooped out with a knife; but more generally it is broad, irregular, and of a dull yellowish cast, involving a large amount of structure, and extending into the adjacent bone. The edges are often irregular, never elevated or undermined; there are no ves- sels to be observed, no granulations, frequently no pus; and the syno- vial membrane either retains its normal characters, or is vascular, opaque, and slightly thickened. The primary ulcer often spreads with great rapidity, producing complete denudation of the bones in the course of a few weeks. This is especially apt to occur in wounds of the large joints, attended with loss of substance, or the ingress of the atmosphere. AVhen the ulcers begin in the synovial membrane, or in the articu- lar extremities of the bones, they are called secondary, and always pos- sess certain traits by which they may be distinguished from the pre- ceding. These differences, however, do not consist so much in anything that relates to the shape, size, or depth of these ulcers, as in the changes which are wrought in the adjoining structures. When the disease ■depends upon inflammation of the synovial texture, it commonly com- mences at the circumference of the cartilage, from which it slowly extends towards the centre of the articulation, destroying, as it pro- ceeds, the lining membrane. Should the ulceration, on the other hand, have its origin in the bone, the cartilage will be gradually detached from its connection, partially absorbed, or broken down into a soft, pulpy, gelatinous, or lardaceous mass. This form of the disease is commonly associated with a stru- mous diathesis, and is most apt to < Fls- '8- occur in the ileo-femoral articula- tion of young children. There is a peculiar fibrous con- dition occasionally observed in the diarthrodial cartilages, apparently the result of incipient ulceration. The cartilage seems to be denuded of synovial membrane, and is everywhere studded with villosi- ties, spicules, or bristles. The affec- tion is most common in old peo- ple, and is probably caused by in- flammation, attended with slow, ulcerative action, or partial ab- sorption. 6. The cartilages sometimes os- sify, especially in persons far ad- vanced in life. In the diarthrodial joints this event is rather uncom- mon, and is witnessed chiefly in disease of the spine, the hip, and knee (Fig. 78). In these situations, the cartilages become not only bony, but are sometimes converted into a substance similar to ivory. The most frequent seat of ossifica- 272 SYNOVIAL MEMBRANE. tion is the sacro-iliac junction, which is so often affected in adults that it is regarded by many as a natural occurrence. Several specimens of this kind are preserved in my private collection. In two of these, the cartilaginous layers are entirely replaced by osseous matter, which has connected the contiguous bones into one common mass. SECTION II. SYNOVIAL MEMBRANE. Synovial membrane readily unites when torn or divided, and is highly susceptible of inflammation. 1. All the joints are liable to inflammation of their lining membrane, but that of the knee is perhaps more frequently affected than all the others put together. The disease is most apt to occur when the body has attained its full vigor, and may be produced by a great variety of causes, such as external violence, cold, the long-continued use of mer- cury, gout, rheumatism, or syphilis. The anatomical characters of acute synovitis are, redness, opacity, thickening, and diminished density of the affected membrane, with alteration of secretion, and infiltration of the surrounding cellular substance. In the early stage of the disease, the redness is commonly very slight, the capillaries being disposed in delicate lines, separated by large intervals. After some time, however, the vessels assume an arborescent form, and the color becomes more intense, occurring either in a uniform manner, or in minute patches, resembling so many ecchy- moses. As these changes proceed, the membrane loses its smoothness and transparency, augments slightly in thickness, and becomes so soft that it may be easily scraped off with the finger-nail, or the edge of the scalpel. The natural secretion, which is at first increased in quantity, thin and limpid, is soon rendered thick and turbid, and often contains flakes of lymph. At a more advanced stage, the secretion is entirely changed in its character, being puriform, sero-sanguinolent, or puru- lent. Occasionally clots of pure blood are contained in the joint; and, in many instances, the free surface of the membrane is covered with minute shreds and globules of lymph, which have the effect of giving it a rough, tomentose aspect. The surrounding cellular tissue is distended with serum, and the vessels penetrating it are engorged with blood, which is so firmly impacted into them that it cannot be easily forced out. The quantity of lymph thrown out in this disease is sometimes very great, filling up nearly the whole of the affected joint. It is generally of a pale straw color, grayish, or lilac, and often adheres very intimately to the inner surface of the articulation, being spread out in the form of an adventitious membrane. I do not know that vessels SYNOVIAL MEMBRANE. 273 have ever been traced into this substance, but that it is susceptible of organization is fully established. 2. Suppuration of the synovial membranes is very apt to take place in scrofulous persons, in whom the matter is generally of a thick, flaky character, like that of a psoas abscess. In most cases, the pus is re- markably viscid and ropy, from the admixture of synovial fluid: not unfrequently it is of a dark grumous appearance, and more or less offensive. When the accumulation is small, it may be absorbed, but more commonly it works its way out through the joint by ulceration, and destroys the patient by constitutional irritation. 3. The synovial membranes are liable to ulceration. This occurs particularly where they are reflected over the peripheral portions of the joints. The edges of the erosions are always very thin, and their size seldom exceeds that of a ten cent piece. It is difficult to say, in these cases, whether the ulceration begins in the membrane itself, in the subjacent cellular tissue, or in the substance of the cartilage. However this may be, the latter of these textures is always, sooner or later, involved in the process, and in this way small superficial abra- sions are often converted into deep cavities. 4. In chronic synovitis, in which the vascularity is much less than in the acute, the membrane often presents a remarkably dull, mottled appearance. Its substance is sometimes very much thickened, either by an effusion of sero-albuminous matter into its molecular texture, or.by the formation of adventitious membranes; and not unfrequently, especially in cases of long standing, it is converted into a soft pulpy mass, of a light brownish color, intersected by numerous whitish shreds. Cases occur in which the synovial membrane is covered with multitudes of small pendulous excrescences, not unlike warts, melon- seeds, or the epiploic appendages of the large intestine. In chronic inflammation the fluid which is thrown out is either thin and glairy, sero-oleaginous, or puriform ; rarely purulent. The quan- tity varies from one to five ounces, and in some rare cases it has been known to amount to more than a quart. This affection, which is dis tinguished by the term "dropsy," is rarely attended with much pain. 5. The movable joints are liable to the formation oifibrocartilaginous osseous concretions, similar to those occasionally found in the peritoneal and pleuritic cavities. In their size they vary from a mustard-seed to that of a small bean; but they may acquire the volume of a marble, an almond, and even the patella. Their number also varies. Com- monly there is only one; occasionally, however, there are three or four, and cases are mentioned where there were as many as eighteen, twenty, twenty-five, and even sixty. Generally of an oval shape, they are sometimes lenticular, spherical, or angular, concave on one side, and convex on the other. They have a whitish pearly appearance, are perfectly smooth and even polished, and consist either of a single mass, or of several lobules, connected together by dense gristly matter. They may be tough and striated, like the ligamentous tissue, or hard, like bone; but in a majority of cases they are distinctly fibro-cartilagi- nous. When very ancient, they have usually a bony nucleus at the centre. These bodies are invested by a reflection of the synovial mem- 18 274 SYNOVIAL MEMBRANE. brane, beneath which they are developed, and to which they are origi- nally attached by a slender pedicle, which is ultimately ruptured by the friction of the articular surfaces between which they are situated. The joints most liable to them are the ginglymoid, particularly the knee, elbow, and temporo-maxillary. The annexed cut, Fig. 79, affords a good idea of the shape and size of these bodies. It was taken from a collection of thirty-eight osseous concretions kindly presented to me by Dr. John T. Berry, of Union- town, Kentucky, having been removed by him from the knee-joint of a colored man upwards of thirty-five years of age. They are of a whitish color, rough on the surface, of various configuration, and from the volume of a pea up to that of a pullet's egg. The sac in which they were inclosed extended from the superior border of the patella to the junction of the lower with the inferior third of the thigh, covering half of its entire surface. The next cut, Fig. 80, exhibits these bodies as they lie in the joint attached to the synovial membrane. Fig. 80. Loose articular concretions. Attached articular concretions. From a specimen in my collection. 6. The diarthrodial joints are occasionally the seat of goutv con- cretions, which, from their color and softness, have received the" name of chalk-stones. They are composed of urate of soda, a peculiar fatty matter, phosphate and carbonate of lime, and a minute quantity of carbonate of magnesia. In an old man, whom I examined some years ago, I found these concretions in nearly all the principal joints of the body, in small amorphous masses, of a whitish color, and of a soft, unctuous consistence. Sometimes they are perfectly smooth and round; more commonly, however, they are rough and irregular, grooved or nodulated. In most cases they are small, though they have been ob- served of the size of an egg. These bodies are almost always con- nected with a gouty diathesis. A LIGAMENTS. 275 SECTION IIT. LIGAMENTS. The diseases of the ligaments are few and infrequent, owing, no doubt, to their very imperfect vascular and nervous endowments. The most important morbid changes are inflammation, atrophy, gouty con- cretions, and lardaceous degeneration. When a ligament is cut, it readily unites by adhesive inflammation, the process being exactly analogous to that which occurs in the resto- ration of a fractured bone. The vessels of the part, becoming enlarged, throw out lymph, which forms a capsule around the divided extremities, and thus keeps them in contact. The same kind of matter is after- wards effused between the ends of the ligament; and, in proportion as this becomes organized, and assumes the properties of the original texture, the outer capsule, just referred to, is diminished, until at length it is wholly absorbed, leaving merely a slight cicatrice. Doubts have been expressed by some writers whether ligaments are susceptible of inflammation. That they are occasionally the primary seat of this disease, cannot be denied; that they become often affected secondarily, is equally certain. Dissection has fully established the latter point; and, as respects the former, its existence is daily witnessed in gouty and syphilitic disorders of the joints. When laboring under inflammation, the ligaments generally give rise to the most severe suffering, aggravated during the night, and leading to great constitu- tional irritation. This is well exemplified in sprains, which are always among the most painful accidents. The physical properties of these textures do not seem to be much altered in the early stages of the inflammation: they retain their white argentine aspect, and here and there may be discovered a straggling capillary. Subsequently, they become more vascular, and their substance is infiltrated with serous, albuminous, or sero-sanguinolent fluid. If the disease continues its ravages, the ligament breaks down into a soft, lardaceous mass, con- taining white silvery shreds, but no trace of vessels. No pus is secreted during these changes; indeed, it is doubtful whether this fluid is ever deposited by this species of tissue, however much it may be inflamed. Atrophy of the ligaments is sometimes produced by the pressure of an aneurismal tumor, or other morbid growth; but more commonly arises through disease of the surrounding textures. When the mus- cles of the shoulder or hip are paralyzed, the capsular ligaments of those joints are not unfrequently so much attenuated and relaxed as % to allow the bones to slip out of their sockets, and this occasionally in a very short period. Similar phenomena are sometimes witnessed in the temporo-maxillary articulation, and in the joints of the fingers and thumb. In these situations, indeed, spontaneous dislocations, from atrophy of the ligaments, are by no means uncommon. 276 BONES. Calcareous concretions, of the same character as those which are de- posited within the synovial sacs, are sometimes found in the ligaments. When this matter is very abundant, as it is apt to be in persons of a gouty diathesis, it has a tendency to fret and irritate the ligaments, and to render them highly sensitive, and liable to hypertrophy. CHAPTER IX. OSSEOUS SYSTEM. I. Bones.—Diseases.—Reparation.—Inflammation.—Suppuration.—Ulceration.—Gangrene. — Softening.— Rachitis.— Fragility.—Hypertrophy.—Atrophy.—Hydatids.—Aneurism.—Car- cinoma.—Melanosis.—Tubercle.—II. Periosteum.—Its Fibrous Structure liable to the same kind of Diseases as the Fibrous Membranes generally. — Hypertrophy.—Ossification. — Is seldom, if ever, affected by the Heterologous Formations.—III. Medullary Membrane.— Diseases few, but important. SECTION I. BONES. The most important diseases of the bones are the following: inflam- mation, suppuration, ulceration, gangrene, softening, fragility, hyper- trophy, atrophy, hydatids, aneurism, carcinoma, melanosis, and tubercle. 1. Repair after Fracture.—The restoration after fracture is effected by adhesive inflammation, analogous, in many respects, to that of the soft parts. The changes which attend it, and which are among the most interesting in the whole range of pathological inquiry, may be referred to four stages, each of which will require separate notice. In the first stage, which extends over a period of about five days, the efforts of nature are altogether of a preparatory character, being limited to the absorption of the blood which was poured out at the moment of the accident. At the expiration of this time, or even before, inflamma- tion sets in; that is, the soft structures around the fracture become hot and vascular, their vessels enlarged and deeply injected, and their cells infiltrated with thick, viscid lymph. The same substance is effused between and around the broken ends, as well as within the medullary canal, and in this manner all the injured parts are temporarily glued together. This substance, which is of a light pink color, and of a soft, gelatinous consistence, is what is named callus, the real nature of which was a source of so many disputes among the ancient pathologists. As the restorative process advances, bony matter is gradually deposited upon the surface of the medullary membrane, until, at length, a dense, solid plug is formed, which fills up the internal canal, and holds the fragments together. Whilst these changes are going on in the interior, the matter which has been effused upon the surface of the broken REPAIR AFTER FRACTURE. 277 pieces also experiences important alterations. At first, as was before intimated, it is perfectly soft and gelatinous; but by degrees it be- comes firm and elastic, like cartilage, and finally assumes all the pro- perties of real bone. This substance is termed the provisional callus. It completely encases the fragments, adhering firmly to their outer surface. The quantity of callus is always in direct proportion to the amount of injury; and hence it is usually greater in an oblique or comminuted fracture than in one that is transverse. In the third stage, the broken bone itself becomes sensibly changed; the lymph which was effused between the fragments, and which until now experienced little alteration, acquires consistence and firmness; numerous vessels are developed in it, and communicate with those of the surrounding structures; and at length, ossification being com- pleted, the two ends of the broken bone are firmly reunited. The period required to effect these changes, is greatly influenced by the age and constitution of the patient, the plan of treatment, and the nature and seat of the fracture; in general, from six to eight weeks may be said to elapse between their commencement and completion. In the fourth and last stage, embracing a period of several months, the provisional callus is gradually absorbed, the soft parts resume their natural state, the prominence formed by the new bone diminishes, and the internal osseous plug is wrought into cells and cavities, by which the medullary canal is at last completely re-established. Thus it appears, as has been already hinted, that the process by which a broken bone is reunited is truly analogous to that which nature adopts in restoring wounds of the soft parts. The only differ- ence seems to consist in the changes which occur in the surrounding parts, and in the formation of the provisional callus. But, in order to render this process effectual, it is necessary that the broken bone should be kept at rest, that it should be provided with a due amount of animal matter, and that the vascular connection between it and the adjacent structures should not be too much interrupted. If these conditions be absent, the restoration will be imperfect, or a false joint will be formed. Fractures of the neck of the thigh bone, the patella, and the olecranon, rarely unite by osseous matter, but in almost all cases through the medium of a white, fibro-ligamentous substance. The causes of this imperfect reproduction consist chiefly in a defect of periosteum, in inefficient nutrition, and in the difficulty which the surgeon experiences in maintaining the fragments in proper apposition. That the union of internal parts greatly depends upon the changes which take place in the surrounding textures, is a fact which has been abundantly verified by observation; and that false joints are often produced by bad and injudicious management is equally true. In the examples, then, before us, it may be supposed that these are the principal, if not the sole agents, which interfere with the restorative process. In the case of the neck of the thigh-bone, the influence of the periosteum in the production of osseous matter is strikingly illus- trated by the fact that, if the fracture be seated partly without and partly within ,the capsular ligament, the former will unite by bone, the latter by fibrous matter. 278 BONES. When & false joint is thus formed, the ends of the broken bone are gradually rounded off, and converted into a smooth, secreting surface, which furnishes a thin, oily fluid, not unlike synovia. The surround- ing cellular substance is at the same time condensed; and in this manner it is, at length, made to answer the purposes of a capsular ligament. The newly-formed bone varies considerably in its properties accord- ing to the period at which it is examined. In recent cases it always contains a large quantity of animal matter, and is therefore compara- tively soft; subsequently, however, it is saturated with earthy salts, and increases greatly in density. In a fractured humerus, one hundred and twenty-eight days after the injury, Dr. Davy found the comparative composition of the shaft and callus to be as follows :— Shaft. Callus. Animal matter . . . . . . . 38.60 38.8 Earthy salts........61.40 61.2 From a specimen where the fracture had occurred long before death, and where the new structures approached the density of ivory, De Claubry obtained the subjoined results:— Original Bone. Callus. Animal matter.......56.284 43.795 Carbonate of lime......3.846 9.785 Phosphate of lime......38.075 44.894 Phosphate of magnesia ..... 1.012 1.526 The new matter is sometimes remarkably exuberant, as in Fig. 81, Exuberant callus of a broken femur. Fracture of the arm-bone of a chicken. From a specimen in my collection. INFLAMMATION. 279 from a specimen in the possession of my friend, Professor Cobb. The fracture, which was oblique, and seated just below the middle of the right femur, had evidently occurred several years before death. The callus is exceedingly porous in its structure, very brittle, and eleven inches in circumference at the widest part, by six inches in length. From its upper extremity are detached two processes, which overlap the superior fragment, and must have considerably impeded the action of the muscles of the limb. The more completely the ends of a broken bone are maintained in contact the more readily and perfectly, all other things being equal, will they be reunited. Osseous reparation, however, is not impossible even when the separation is unusually great. Fig. 82 is the humerus of a turkey, which had been broken near the middle. The union is formed by dense osseous matter, much stronger than the original tex- ture, although the distance between the fragments is nearly one inch. The specimen is in my private collection. 2. Repair after Amputation.—The changes which are wrought in the extremity of a bone after amputation are not without interest. The edges are gradually Fig- 83. rounded off by the action of the absorbents, and new matter is deposited by which the end is covered over, and the medullary canal, as it were, hermetically sealed. Fig. 83, from a specimen in my cabinet, affords a good illus- tration of these appearances. The bones, sawed off three inches and a half below the knee, are connected by a narrow ledge of matter, or a kind of exostosis, and coated with a thin osseous plate. In some instances the osseous stump is remarkably atrophied and reduced in size, probably from the con- stant pressure of the artificial leg. 3. Inflammation.— Osteitis was formerly supposed to be of very rare occurrence; there APPearaaces of h™r stumP aft<* 1 x it i i • • amputation. From a specimen in is reason to believe, however, that it is not my collection. only a frequent malady,but that it is present, in some form or other, in almost every affection of the osseous tissue, whether primary or secondary. The bones most commonly affected are those of the extremities, especially the tibia, which, from its exposed situation and consequent liability to injury, seems to be particularly prone to it. The inflammation may be primarily seated in the osseous structure, or it may be propagated to it from the soft parts: in either case, the periosteum and medullary membrane are apt, sooner or later, to become implicated in the disorder. The malady is generally slow in its progress, and hence a considerable period often elapses before there are any appreciable alterations of tissue. At first, the bone is simply enlarged; but, in a short time, it loses its density, becomes infiltrated with sero-sanguinolent fluid, and assumes a bright reddish hue, the capillaries being very numerous, turgid, and distinct. As the disease advances, the osseous fibres separate from each other, and the widened 280 BONES. intervals are filled with a soft gelatinous substance, mixed with which it is not unusual to find small clots of blood. These changes are generally attended by an absorption of earthy matter, which has the effect of rendering the bone soft and spongy, at the same time that it causes an actual diminution of weight. This, however, is not an in- variable phenomenon, since cases occasionally occur where the phos- phate and carbonate of lime are deposited in inordinate quantity, by which the osseous tissue is made preternaturally brittle. When the inflammation is superficial, it usually extends, as was before remarked, to the periosteum, which becomes hot, red, and swollen; in a word, manifests all the signs of ordinary inflammation. When the medul- lar}^ membrane is implicated, it becomes bloodshot, and the adipose matter is either rapidly absorbed, or it is transformed into a soft dif- fluent mass, of a light reddish color, and of a peculiarly offensive odor. When the ossific inflammation is fully established, the engorged capillary vessels refuse to receive injecting matter, and can be drained of their contents only after protracted maceration. Osteitis may ter- minate in resolution, suppuration, ulceration, or gangrene. 4. Suppuration.—Suppuration of the external substance of the bones is a very common occurrence; but, as it is ordinarily complicated with periostitis, it is difficult to determine which structure is the source of the purulent secretion. It is most frequently observed in connection with some constitutional taint, such as scrofula, syphilis, or the protracted use of mercury; but it may, and very often does, exist as a purely idio- pathic disease. When suppuration takes place in the spongy texture of the bones, the pus is sometimes contained in a delicate vascular cyst, composed of coagulating lymph. Several such collections are occasionally found in a single bone. Thus, in the upper extremity of a carious tibia I discovered three distinct abscesses, the largest of which did not exceed a common almond, whilst the smallest was scarcely of the size of a pea. They were lined each by a soft, vascular membrane, and the bony texture in the neighborhood was unnaturally hard and white. The subject was a female, forty-five years old, who finally died of pulmonary phthisis. Abscesses of this kind seldom attain any considerable magnitude: their contents are dark-colored, thin, and offensive; and, if seated near the extremity of the bone, the mat- ter usually manifests a tendency to work its way.into the contiguous joint. In abscess the bone is sometimes expanded into an immense shell, capable of holding several ounces, and constituting what was formerly called spina ventosa. Fig. 84 represents this appearance in a striking degree. 5. Ulceration.—Ulceration of the osseous tissue is most generally met with in young persons, being rarely observed in the adult or very aged. The disease, which is usually known under the name of caries, is pre- cisely analogous to ulceration of the soft parts, the most prominent feature of each being a loss of substance through molecular disintegra- tion. It is always preceded, as well as accompanied, by inflammatory action, and may be owing either to local injury or to constitutional ULCERATION. 281 causes, such as syphilis, scurvy, scrofula, or deficient nutrition. It may also result from the pressure of aneurismal tumors, or from the spread of malignant ulcers in the soft parts. Every part of the osseous system is liable to caries; but the pieces most frequently attacked are those which form the walls of the thorax and pelvis, the bones of the tarsus and carpus, the bones of the spine. and the heads of the cylindrical bones of the extremities, especially the lower. Caries often goes on for a considerable period without ulceration of the soft parts; and, in such cases, the diagnosis is usually difficult. In the majority of instances, however, the nature of the complaint is indicated by the dull aching pain, the tenderness on pressure, and the red, inflammatory state of the skin. After some time, the superincumbent parts become loose and boggy, and at length one or more aper- tures appear in them, giving vent to a very fetid, dark-colored, or grayish sanies, Fig. 85. The bone which is thus exposed has a foul and eroded aspect, its texture being softened, and infiltrated with a thin brownish fluid, mixed with blood, or with a yellowish, ropy sub- stance, not unlike ill elaborated pus. The ulcers may occupy quite a considerable extent of surface; but, in most cases, they are small, and of a rounded or oval shape. Their edges are steep, elevated, or abrupt, while their bottom is generally studded with small osseous points, which have the effect of making it rough and irregular. The erosions have sometimes Chronic abscess of the tibia— of large size. Bone much thick- ened as well as expanded round the cavitv. Fig. 85. Caries of the tibia, showing ulcer in the skin. From a specimen in mj- collection. a very great depth, and in the broad bones it is not uncommon to see them involve both tables, giving them thus a singularly cribriform appearance. Occasionally they have a sinuous arrange- ment, the affected surface bearing a close resemblance to the barkof a worm-eaten tree. The osseous texture in the immediate neighbor- hood of these ulcers is always in a state of inflammation; and the 282 BONES. Caries of the head of the humerus. From a prepara- tion in my collection. same may be said of the periosteum, which is either red and thick- ened, greatly indurated, or converted into fibro-cartilage. Cases occur, in which the osseous tissue, although slightly softened, is in reality very porous and brittle, owing to an inordinate deposition of earthy matter. This form of the disease, which seems to affect only the broad bones, is generally attended with little discharge, and hence the ancients were in the habit of calling it " dry caries." Fig. 86 shows the effects of this disease as it occurs in the cancellated structure of the head of the humerus, which I exsected for the relief of the patient. The matter which attends ulceration of the osseous tissue is commonly of a thin, watery, ichorous nature, highly irritating to the soft parts, and of an offensive odor. It always con- tains a large amount of earthy salts, on which account the instruments used in dressing a sore of this kind are usually stained black, espe- cially if made of silver. When granulations sprout up, as is always the case when the ulcer manifests a disposition to heal, the matter becomes less acrid, more copious and consistent, assuming, as the recu- perative process advances, all the properties of laudable pus. 6. Gangrene.—Gangrene may show itself at any period; but, in the generality of cases, it comes on between the fifth and the twentieth year, seldom before, and still more rarely after. The parts of the osseous system most frequently affected are the tibia, clavicle, inferior maxilla, femur, ulna, radius, and fibula, though no bone in the body is, perhaps, entirely exempt from it. Necrosis may be partial or complete, simple or compound ; that is, it may affect merely a part of a bone, or it may pervade its whole structure; again, it may be limited to one bone, or it may attack several pieces simultaneously, or several different parts of the same bone. The causes of the complaint are either local or general, and are not essentially different from those which dead to gangrene in the soft tex- tures. Among the local causes may be enumerated wounds, contu- sions, fractures, and chemical irritants; among the internal, a scrofu- lous or venereal taint of the system, the long-continued use of mercury, and the effects of protracted and debilitating febrile diseases. But the most frequent source, perhaps, of all is exposure to cold. It has been stated that necrosis is sometimes partial, or, in other words, limited to a part of a bone. In such cases, death usually arises from external causes, as a blow, contusion, or denudation, and rarely extends beyond the outer compact structure. Exfoliation is not a necessary consequence of a bone that is stripped of its periosteum. If it be in other respects healthy, and enjoy a vigorous circulation," granulations will spring up and gradually repair the breach. If the denudation, however, be very extensive, even although the bone should be perfectly sound, exfoliation will be very apt to take place, owing to the injury which has been inflicted upon the capillary vessels GANGRENE. 283 of the part. The exposed part, supposing that the disease has been occasioned by a removal of the periosteum, remains white and dry, and after some time exfoliates, or comes away in thin scales, plates, or lamellae. The surface from which the separation has been effected is covered with florid granulations, which by degrees assume the ossific process, and thus finally replace, in part or entirely, the lost substance. The exfoliated bone is either white, grayish, or of a light brownish color, rough, often very porous, and so brittle as to fall to pieces under the slightest pressure of the finger. No vessels can be perceived in it, and the animal matter seems to be almost wholly abstracted. By maceration, its dark color gradually disappears; and by immersion in dilute nitric or muriatic acid for a few days, its texture is completely broken up, and converted into soft, gritty particles. When necrosis pervades the whole thickness of a bone, as it is apt to do when it follows caries, exposure to cold, smallpox, or measles, the process of separation is much more complex and tedious, months often elapsing between the death of the part and its final exit from the body. The first step in the process is the formation of a sort of osseous shell, which is evidently designed to answer as a temporary substitute for the old bone, at the same time that it serves to isolate it from the surrounding parts. Let us inquire how this is effected; how an organ which has so greatly suffered is repaired ? The dead bone acting as an irritant or an extraneous pjg. 87. body, excites inflammation in the circumjacent struc- tures, which become thickened and pour out coagu- lating lymph, similar to that which is effused around the extremities of a fracture. After some time, vary- ing according to the age and vigor of the patient, this substance acquires the properties of cartilage, and this, again, in its turn, is finally replaced by osseous matter, arranged in the form of an irregular shell, from one to three lines in thickness. In this shell one or more holes—sometimes as many as eight or ten—technically termed cloacae, and of a rounded or oval shape, are left, which communicate with the surface of the limb, and form the channels through which the dead bone, now named the sequester, is ultimately expelled. The period at which this takes place varies from six or eight weeks to ten or twelve months. Fig. 87 is a rather common form of sequester of the tibia; the spongy structure is entirely destroyed, and the compact is remarkably hard and firm. The sequester is of the same nature precisely as an eschar or slough of the soft parts. It is a dead effete substance, which must be expelled by ulcerative ac- tion. As long as it is retained it produces more or less irritation in the parts with which it is in contact, and is bathed in thin, fetid, sanious matter, or in thick, white, inodorous pus. Its surface is usually Jrto^Z- rough, excavated, spiculated, or honey-combed; its ration in my cabinet. Ii" 284 BONES. color grayish, brownish, or black. In the cylindrical bones it is almost always dense and dry; in the short, porous, moist, brittle, and easily crumbled. It has been generally supposed that the sequester, during its sojourn among the living tissues, is more or less diminished in size and weight by the agency of the absorbents. The experiments, however, of Mr. Gulliver throw some doubt upon the correctness of this opinion, if, indeed, they do not wholly disprove it. Pieces of bone, carefully weighed before and after exposure, were confined on suppurating sur- faces, inserted in the medullary canal, or worn as setons in the sub- cutaneous cellular tissue, and kept there for months, and in one instance for more than a year, without undergoing the slightest alteration in any respect. A paper, detailing nineteen experiments of this kind, is published in the twenty-first volume of the London Medico-Chirurgical Transactions. As soon as the sequester is removed, whether by nature or art, the temporary shell contracts, and by degrees assumes the form of the old bone which it is designed to replace. Whilst this change is going on externally, osseous matter is deposited upon the inner surface of the shell, as well as upon the extremities of the surviving portions, and in this manner the vacant cavity is finally filled up, the time re- quired being always in proportion to the size of the eschar. The medullary canal, if there was one, is seldom re-established; and the new bone, although it remains for a long period highly vascular, is not able to withstand the effects of inflammation so well as the original. Are bones ever completely regenerated ? Eespecting this occur- rence various opinions have been expressed by pathologists, some denying, others strenuously contending for, the possibility of it. The question, it is obvious, can only be decided by observation; and, if this be taken as our guide, few writers will be able to determine the matter for themselves. Here, as in many other obscure points in pathology, a candid appeal to facts, as they have been recorded by pathologists, will do infinitely more than a thousand conjectures. The testimony of the older writers, unfortunately, is of little avail, as they were in the habit, too frequently, of distorting facts to suit their own theories. The same objection lies against some of the moderns ; still there are many exceptions, and from these we must draw our informa- tion. All parts of the skeleton do not seem to be equally capable of reproduction. The short and broad bones are much more rarely regenerated than the long; and among the latter the occurrence has been much oftener witnessed in the tibia than in any other of the cylindrical pieces. Moreau saw a case of complete regeneration of the clavicle; Chopart, of the scapula; Fowles, of the ulna; and Weide- mann, of the lower-jaw. In 1832, I had an opportunity of seeing an Irish lad, from whom Dr. Cusack, of Dublin, had, four years previously, removed the left half of the inferior maxilla, on account of an osteo-sarcomatous affection. In this case, nature had made an attempt at reproduction, though it was still imperfect at the time I made the examination, the part being replaced by a thick, rounded piece of cartilage, sufficiently strong, however, to subserve the ordinary purposes SOFTENING. 285 Madame Supiot; in a posture quite practicable in the advanced stage of the disease. of mastication. Not long ago, a young man showed me the upper half of his astragalus, which had sloughed away several years before; yet he had the perfect use of his ankle joint, which can only be explained on the ground of a perfect reproduc- tion of the necrosed bone. At the time I saw him, the ulna of the left arm was in a state of gangrenous in- flammation. No doubt, it seems to me, can therefore be entertained, re- specting the possibility of bones being regenerated. 7. Softening.—Softening of the bones, more frequent in the female than in the male, occurs almost ex- clusively in adults, and has been known, in a few instances, to in- volve the whole skeleton. Of this, the case of Madame Supiot, Fig. 88, described in the Memoirs of the Royal Academy of Paris, affords a memorable example, all her bones being so soft that they could be bent like wax, and put in almost any position. More generally, however, the lesion is confined to parti- cular bones, being especially apt to occur in such as are largely sup- plied with spongy matter. The osseous tissue in this affection loses its firmness and consistence, becomes soft and pliant, and may be easily cut with the knife. It is of a pale reddish color, often inclining to yellow, is specifically lighter than the healthy structure, and is infiltrated with a turbid, viscid serum, removable by pressure. Occasionally, the osseous fibres are widely separated from each other, so as to leave large cells, which are filled with a bloody-looking, adipose substance. When this is the case, the bone is sometimes remarkably pliant, bending like semi-concrete wax. Boiling completely dissolves it; and exposure to the air, by abstract- ing its moisture, diminishes its weight. Such are the principal changes observable in the osseous tissue. The periosteum over the affected part is pale and extenuated; the marrow is converted into a reddish, greasy sanies; and the medullary membrane is wasted down to a few soft, cellular shreds. The softening generally involves the whole thickness of the bone; but cases occur in which the outer table remains unchanged, consisting of a thin, brittle shell. The disorder obviously consists either in an inordinate absorption of the phosphate of lime, upon which the solidity of the osseous structure depends, or in a deficient deposition of this matter into its meshes. It has been already mentioned that the bones become specifically lighter in this disease; and Dr. Bostock has as- certained the additional fact that they contain nearly eighty parts of animal substance in the hundred. The experiments of this gentleman were afterwards confirmed by those of Dr. G. O. Rees, of London,1 1 Guy's Hospital Reports, No. viii. p. 191, April, 1839. 286 BONES. who, from a careful analysis of three diseased specimens, taken from the same adult subject, obtained the following results, which he has compared with those furnished by healthy bones:— Diseased. Healthy. Earths. Animal matter. Earths. Animal matter. Fibula . . 32.50 67.50 60.02 39.98 Rib . . 30.00 70.00 57.49 42.51 Vertebra . . 26.13 73.87 57.42 42.58 On examining this table, it will be observed that, in the diseased as well as in the sound state, the fibula contains more earthy matter than the rib, and the rib more than the vertebra. In health, the vertebra and rib approach very nearly in their proportions of animal and saline ingredients, while in softening a considerable difference exists between them in this respect. The causes of this change are not understood. Does it depend upon inflammation? All the phenomena of this affec- tion indicate that it does. If we compare the anatomical characters of osteitis and softening, we shall see that they strikingly resemble each other. I do not, by this, wish to be understood to mean that softening is caused by active inflammation; all I contend for is that the disease in question is the result of a slow chronic irritation, leading to lesion of nutrition in the osseous tissue. It is seldom that this disorder is attended with any pain; and this may be regarded as an- other argument in favor of the opinion that it does not depend upon acute inflammation. 8. Rachitis.—Rachitis differs from softening of the bones, properly so called, in two important particulars; first, it is peculiar to very early life, and secondly, the osseous matter, instead of being absorbed as it is in the latter disease, is not deposited in sufficient quantity originally. In both the result is the same. The affection is occasionally congenital, and sometimes, though rarely, it takes place after puberty. Of 346 cases examined by Guerin,1 three occurred before birth, ninety-eight during the first year, one hundred and seventy-six during the second, thirty-five during the third year, nineteen during the fourth, ten during the fifth year, and five from the sixth to the twelfth. Of these cases, 198 were females, and the remainder, or less than one-half, males. The bones of rickety subjects are remarkably soft, spongy, sec- tile, and compressible; of a pink, red, or brownish color, and consider- ably lighter than in the natural state. They are pervaded by a great number of enlarged vessels, and saturated with a thin, sanious fluid, a considerable quantity of which is also effused upon their outer sur- face and into the medullary canal. The walls of the long bones are rarefied and attenuated, while those of the flat bones are more or less expanded, reticulated, and elastic. The marrow is entirely destitute of its natural properties, and the periosteum is thickened, spongy, and deeply injected. The discolored fluid, so abundantly deposited at this early period of the disease, is gradually replaced by a sort of gela- tiniform substance, which becomes organized and vascular, and finally adheres with great firmness to the parts with which it lies in contact. 1 Memoir on Rachitis, translated by Dr. Colescott, in West. Journ. Med. andSur^., Jan., 1841. INDURATION. 287 Fig. 89. In the second stage, a peculiar spongoid substance is formed be- tween the periosteum and the outer surface of the bones; it is from two to three lines, or upwards, in thick- ness, and often presses so much upon the walls of the compact tissue as to force them in towards the medullary canal, which, in consequence, is con- siderably reduced in size, if not en- tirely obliterated. Simultaneously with these changes the bones are ren- dered so soft that they may be easily cut, bent, and indented with the fin- ger. In the third stage—that of reso- lution—the newly-formed substance acquires a firm, dense, compact tex- ture, and is gradually identified with the pre-existing tissues, which at the same time regain their primitive so- lidity. Owing to the presence of this matter, the bones are much larger than in the natural state, and their consistence, especially in the adult, is nearly equal to that of ivory. The cause of rickets is not ascer- tained. The most ingenious conjec- ture regarding it is that which ascribes it to a deficiency of phos- phate of lime, upon which, as is well known, depends the firmness of the osseous tissue. The probability is that the fault resides both in the blood and in the solids. Its origin appears to be occasionally con- nected with syphilis, scrofula, scurvy, and difficult dentition. From the circumstance of its being sometimes witnessed in several children of the same family, it has by many been considered as hereditary. In the earlier stages of the disease, when the bones are soft, and conse- quently unable to support the weight of the body, or to resist the action of the muscles, there is always more or less deformity, which seldom, if ever, wholly disappears in after life. 9. Induration.—The osseous tissue, like the soft parts, is subject to induration. The lesion is a natural concomitant of the third stage of rachitis, and is not unfrequently witnessed in the cranial bones, in exostoses, and in old fractures. It may occur at any period of life, but is most common in advanced age, and may affect, either separately or conjointly, both the spongy and the compact substance. The indu- ration varies in degree from the slightest increase of the natural con- sistence to a state approaching that of ivory. Hence the term eburna- tion is sometimes applied to it. It is characterized by a remarkable closeness of the osseous tissues, the cells of which are filled with inorganic matter, without any evident morbid condition. The affected bone may retain its natural size, but in general it is somewhat in- Rickets. From a patient at the Blockley Hospital. 288 BONES. creased; in a small proportion of cases it is sensibly diminished. Its weight is usually augmented, its form more or less changed, and its density so great that it is exceedingly difficult to break or saw it. In this respect it offers a striking contrast to fragility of the osseous tissue. The cause of this transformation is quite unknown. 10. Fragility.—The bones are liable to become preternaturally brit- tle, crumbling to pieces under the most trifling accidents. The disease, which is technically called fragility, is most commonly found as an at- tendant on old age, and is seldom restricted to any particular class of bones, though the cylindrical are perhaps the most prone to it. The cause of this singular affection has been a source of much theoretical dis- cussion. The best pathologists, however, agree in referring it to a lesion of nutrition, produced by a diminution of the number and volume of the vessels of the osseous tissue. The validity of this opinion derives great plausibility from a contemplation of the changes which the bones undergo in the different periods of life. In childhood, the osseous tissue is remarkably flexible and pliant, and contains a large amount of animal substance; in old age, on the contrary, it is very dense, hard, calcareous, and extremely liable to break, the slightest exertion or accident being often sufficient to cause this result. The number of fractures sometimes produced in this way, even in young persons, is astonishing. Devergie dissected a female who died under symptoms of fragility, in whose skeleton he found not less than eighty-three fractures. Dr. Gibson1 gives the case of a young man, nineteen years of age, in whom the bones of the arm, forearm, thigh and leg, have all been repeatedly broken, from the most trivial causes. The clavi- cles have suffered still more frequently, having been fractured eight times. Fractures from this cause sometimes occur in the foetus in the womb. Chaussier has related a remarkable example of this kind, in which each of the long bones presented one or more of these lesions, some of which were recent, some were beginning to unite, and some were consolidated. The child survived its birth only twenty-four hours. Bones affected with this disease are sometimes so completely satu- rated with oily matter as to render them unfit for preparations; but, in general, they are dry and brittle, and crumble to pieces under the slightest pressure. In the latter stages of scurvy and scrofula, they often become extremely fragile; and, if they be boiled, they break down into thin, irregular scales, or are almost entirely dissolved. The disease is rarely attended with pain, and the general health is usually remarkably good. When fractures occur, they sometimes rapidly unite; at other times, however, restoration does not take place, or only after a very long period. 11. Hypertrophy.—Hypertrophy of the osseous tissue may be par- tial or general; that is, the abnormal growth may affect either a por- tion or the whole of a bone. The latter, however, is a very rare occurrence, though perhaps not so much so as has been imagined. Cases, indeed, not unfrequently occur, in which the broad bones of the 1 Institutes of Surgery, fifth edition, vol. i. p. 233. HYPERTROPHY. 289 head present an extraordinary degree of development, being more than an inch in thickness, and so hard that it is almost impossible to saw them. Under these circumstances, the two tables are ex- tremely compact, the intermediate spongy structure being totally obli- terated, or, rather, replaced by dense earthy matter. Similar appear- ances are sometimes witnessed in the cylindrical bones of the extremi- ties. In an old femur in my private collection, the medullary canal is scarcely large enough to admit a common-sized quill; the whole shaft consists almost entirely of compact substance, in many places more than six lines in thickness. The bones of the male are always larger and more distinctly developed than those of the female; and the bones of persons who take much exercise, than those who are indolent, or make little exertion. By labor, their weight and dimensions increase; their spongy structure diminishes, whilst the compact becomes harder, of a closer grain, and acquires an almost rock-like solidity; the mus- cular prominences are rendered more conspicuous;—in short, every- thing indicates that they are in a state of general hypertrophy. When thus circumstanced, the osseous tissue usually contains a due propor- tion of animal matter; and hence it is always capable of resisting, in a very eminent degree, the influence of such agents as have a tendency to injure it. The adjoining cuts are excellent representations of general hyper- Fig. 90. General hypertrophy—internal structure. From a preparation in my cabinet. trophy of the femur of a man affected with tertiary syphilis. Fig. 90 is a section of the bone exhibiting its interior structure, which is very much condensed throughout, except at the superior extremity, where General hypertrophy—external characters. there are still some remains of the areolar tissue; the medullary canal is entirely obliterated, and the weight of the bone is nearly twice as great as in health. Fig. 91 shows the external appearance of the bone. The drawings are from a specimen in my cabinet. 19 290 BONES. Fie. 92. The adjoining sketch (Fig. 92) is a specimen of hypertrophy of the bones of the leg and foot, both in thick- ness and length. It is from a drawing by Mr. Heiman, of a preparation in the collection of Professor Buchanan, of Nashville. All the bones are much enlarged, increased in weight, and anchylosed at the ankle, tarsal, and metatarsal joints. The interosseous ligament was completely ossified. The foot and leg had been the seat of ex- tensive ulceration, followed by exfolia- tion from the hypertrophied bones. When the hypertrophy is partial, it constitutes what is called an exostosis, an exuberant growth of bony matter, similar in its structure to the osseous tissue in its normal condition. The • bones most commonly affected by this species of hypertrophy are the femoral, frontal, parietal, and lower maxillary, the relative frequency of its attack be- ing in the order here stated. No part of the skeleton, however, is exempt from it; and, in a few instances, it has been known to affect a large number of pieces at the same time, as if there had been an exostotic diathesis. Great variety prevails in regard to the size and shape of these tumors. In general, they look like small, irregular excrescences, with a rough, scabrous surface; but sometimes, especially when they are seated on the flat bones, they are of a spherical form, and nearly or quite smooth. In other cases, again, they have a mammillated appearance; or they form flat disks, resting upon a short, narrow, pedicle; or, finally, they are rounded, nodular, or knob-like. Their size seldom exceeds a small apple, orange, or potato, though examples are occasionally met with where they are as large as a cocoa-nut or a foetal head. In a specimen in my private collection, the walls of the left maxillary sinus are literally studded with these growths, none of which exceeds a small grain of wheat, which they also very much resemble in shape. Fig. 93, from a specimen in my collection, conveys a good idea of an exostosis of the thigh-bone. Fig. 93. Hypertrophy involving both the thickness and length of the bones. Exostosis of the thigh-bone. From a preparation in my collection. ATROPHY. 291 An ivory-like exostosis, show- ing its internal structure. From a specimen in my collection. In their structure, exostoses present all the varieties of the natural bone upon which they grow, being composed of a soft, spongy texture, inclosed by a layer of solid, compact matter. They may be surrounded by a coat of carti- lage, or have all the firmness and density of ivory, as in Fig. 94. In the healthy state, they are perfectly insensible; but they are suscepti- ble of inflammation, and it is probable that, when laboring under this disease, they experi- ence those changes which have obtained for them the names of fungous, medullary, and cancerous, so much in vogue among surgical writers. These tumors are formed in the same man- ner as the osseous tissue in other parts of the skeleton, passing always through the same stages of ossification. That this is the case, will appear sufficiently obvious if we refer for a moment to the causes by which they are produced. Among these, the most common, perhaps, are the various kinds of external violence, such, especially, as blows or contusions; though many con- tend for a scrofulous, gouty, or syphilitic origin. Induced in any of these ways, there must be local inflammation, either in the bone, or in the periosteum, or in both, one of the effects of which is an effu- sion of coagulating lymph. This, after some time, is converted into cartilage, and this finally into bony matter. Some exostoses are extremely rapid in their growth, and soon attain a very considerable magnitude; most commonly, however, their deve- lopment is gradual, going on for many years without causing any serious inconvenience. They are seldom attended with much pain; indeed, it is only when they are very large, or when they degenerate into cancerous affections, that they become a source of local annoy- ance and constitutional disturbance. Youth seems to be the period in which these growths are most frequent, though adults and old per- sons are not exempt from them. An exostosis occasionally separates spontaneously from its connections. 12. Atrophy.—Atrophy of the osseous tissue is characterized by the partial absorption of its elementary constituents, as is evinced by its lightness and porosity. The lesion may occur in any portion of the skeleton, but the long bones are oftener affected than the short or flat. Like hypertrophy, it may be partial or general; that is, it may involve an entire piece, or be limited to a particular part of it.' Atrophy, moreover, may be concentric or eccentric. In the former variety the bone is diminished in its diameter; in the latter, it retains its original size, but is reduced in weight, and rarefied in its tissue. The causes under the influence of which it may take place are, protracted pres- sure, chronic inflammation, deficient nervous influence, and insufficient supply of arterial blood. a. That pressure, steadily exerted for a considerable length of time, 292 BONES. has a tendency to produce atrophy of the osseous tissue, is familiarly known to pathologists. This is well exemplified in the cranial bones in tumors of the dura mater; in the sternum and dorsal vertebras in aneurism of the aorta; in the ribs in cancer of the mammary gland. In all these instances the compact substance is reduced to a thin, translucent plate, while the spongy texture is either wholly destroyed, or worn down to a few slender threads. The immediate cause of the wasting process here is absorption, acting simultaneously and equally upon the animal and earthy constituents. Absorption of the bone is sometimes carried to a great extent after fracture. Nor is the process always limited to the ends of the fragments; instead of this it occasionally affects nearly their whole length. Of the latter occurrence a remarkable case came under my observation last winter in a man named Bowen, a provision merchant of Boston, aged 53 years. When eighteen years old he received two simple frac- tures of the right humerus, at an interval of three months, one being situated about the middle of the bone, the other an inch and a half higher up. The first was repaired in the usual time, but the second refused to unite, the ends of the fragments becoming rounded off, as in the formation of an artificial joint; the process gradually pro- ceeding, the whole bone was finally absorbed, nothing remain- ing except its condyles and a lit- tle of its head. The period oc- cupied in the absorption was about six years,, the general health being all the while unim- paired. The muscles of the arm are well developed, and, when thrown into powerful action, are capable of diminishing the interval between the shoulder and elbow to the extent of several inches. Although the man is unable to perform any of the usual movements of the member, he can readily raise a weight of upwards of one hundred pounds, and can apply his hand to various purposes. The accompanying cut represents the appearance of the limb during the contraction of its muscles. b. Atrophy from chronic inflammation appears to be infrequent. The best specimen of it that I have seen occurred in a colored woman, \ who died of pulmonary phthisis at the age of forty. The body was much emaciated, and all the tang bones were remarkably reduced in weight, though they had experienced no change in their external configuration. The compact substance was wasted to a mere shell, scarcely thicker than common wrapping paper, and the cells of the spongy texture were increased many times beyond the natural size. The medullary canal was much enlarged, and filled with a greasy, reddish substance, not unlike fresh adipocire. These appearances are well shown in the accompanying cut (Fig. 96), and afford a beautiful illustration of the eccentric form of atrophy. Atrophy is sometimes the result of local injury, as a blow, wound, Absorption of the humerus. ATROPHY. 293 Fig. 96. or contusion. The wasting in this case may be limited to the site of the original mischief, or it may extend to the entire bone, which, however, is rare. In what manner such an injury operates, whether through the agency of inflam- matory irritation, or otherwise, in giving rise to atrophy, is unknown. c. Deficient nervous influence is a frequent cause of atrophy both of the osseous tissue and of the soft parts. In paralysis of the lower extremities. there is generally notable wasting, not only of the muscles, but also of the long bones, which are greatly reduced in weight, rarefied in their texture, and diminished in size. Lobstein1 records a re- markable case of this description, referred to in a previous chapter. The man died at the age of fifty- four, with extreme atrophy of the right leg, which appeared to be consequent upon a fall received when he was a child, and by which the great nerves of the limb were severely injured. All the soft parts were excessively wasted, and the right femur weighed little more than three ounces, while its fellow weighed nearly double. The nerves and vessels were not perceptibly changed. Where atrophy is produced by deficient nervous influence it is generally concentric; that is, the bone is sensibly diminished in size without any evident alteration in its ex- ternal configuration. d. The effect of a diminished supply of blood in inducing atrophy of bone is sometimes very conspicuous in old frac- tures. In injuries of this description there is often considerable wasting of the osseous tissue, in consequence merely of the oblitera- tion of the nutritious artery by the callus. The atrophy is always eccentric, and is usually limited to one-third, one half, or two-thirds of the affect- ed bone, according to the seat of the original in- jury, or, more properly speaking, the quantity of the new matter, and the extent of the vascu- lar obliteration. e. Finally, there is a species of senile atrophy. In old age, the bones are rendered light, porous, and brittle; the compact substance is reduced to a mere parchment-like shell, while the areolar texture is remarkably rarefied or expanded; the muscular prominences are diminished in size; the animal matter is partially absorbed; and many of the vessels are obliterated. These changes are nowhere more conspicuous than in the neck of the femur, which, in consequence, often breaks Atrophv of collular stnicture from the most trifling causes, and which, after of the thigh-bone. Fig. 97. 1 Traite d'Anat. Path., t. i. p. 90. 294 BONES. this occurrence, is seldom, if ever, repaired by osseous matter. Fig. 97 is a section of a well-marked specimen of this kind; the internal structure is very much rarefied; and the head of the bone, flattened and expanded, is approximated to the shaft, from the partial absorp- tion of its neck. 13. Acephalocysts.—The bones are occasionally infested by acepha- locysts. They are of a globular form, and vary considerably both in number, in size, and in the appearance of their contents. There may be only two or three, or they may exist in much greater number. In size they range between a hemp-seed and a pullet's egg. When young, they are perfectly smooth, transparent, and occupied by a light- colored, serous fluid. They are liable, however, as they increase in age, to become indurated, and to have their contents rendered turbid, viscid, and albuminous. The portions of the osseous system most subject to these bodies are, the tibia, particularly its superior extremity, the frontal bone, the ilium, the humerus, the spine, and femur. It is very seldom that they exist simultaneously in several pieces of the skeleton. They are usually developed either in the spongy structure, or in the medullary canal, which they distend in every direction, so as to form a chamber several inches in diameter. The parietes of this cavity are generally very thin, and liable to become perforated by ulcerative absorption. The hyda- tids may be adherent, or they may float about in the serous contents of the osseous cyst. Sex does not appear to exert any particular influence upon the pro- duction of this disease. It is most common in adults, but has been met with in young subjects, and even in children. Its causes have not been satisfactorily investigated; nor are its symptoms such as to enable us, in the present state of our knowledge, to distinguish it from other affections. One of the most singular features of these cysts is their indestructible nature, being almost sure, unless completely destroyed, to be speedily regenerated. 14. Aneurism.—Aneurism of the osseous tissue consists in an extra- ordinary development of the minute vessels, and presents precisely the same anatomical features as aneurism by anastomosis of the soft parts. Confined usually to one bone, it may occur in several, or even in a considerable number. In one case it was discovered in the cranium, sternum, ribs, vertebrae, and innominatum of the same subject. Its favorite seat is the upper extremity of the tibia, just below the knee. It may arise at various periods of life, but is most common in young adults. The tumor varies in volume from a pullet's egg to a cocoa-nut. The disease always begins in the cancellated structure, which is converted into various sized chambers, filled with coagulated blood, disposed in concentric layers, as in old aneurismal tumors. Some of the cells occasionally contain fluid blood, or blood partly fluid and partly clotted; but this is rare. The outer table of the bone is ex- panded, attenuated, and perforated, or so soft, flexible, and elastic that it may be bent like cartilage. In some instances, on the other hand, it is remarkably brittle, and may be crushed like the shell of an egg. The periosteum is thickened and indurated; but the joints in the im- FIBRO-CARTILAGINOUS TUMOR. 295 mediate vicinity of the disease are commonly healthy, even when they are separated from it merely by a thin layer of cartilage. The vessels which ramify through the substance of the bone are tortuous and brittle, increased in size, and open by numerous little orifices into the aneurismal sac in the centre of the diseased mass. The causes of this lesion are involved in obscurity. In some in- stances it has been traced to the effects of a blow; in others, to a fall or jump from a considerable height. Either of these causes, by dis- turbing the vascular action of the bone, might produce the disease. Occasionally it is connected with a gouty or rheumatic diathesis, and then probably depends upon inflammatory irritation. 15. Hozmatoid Tumor.—There is a variety of tumor, closely allied to that just described, which, for the sake of uniformity in medical nomen- clature, I shall term haematoid. It is produced by a deposition of blood in the cancellated structure, forming a firm, oval, and elastic tumor, filled with dark, solid coagula. The best specimen of this disease that I have met with, occurred to me, about ten years ago, in a man aged thirty-five, a portion of whose lower jaw I amputated, on account of what was supposed to be osteo-sarcoma. The tumor, about the size of a common orange, extended from the canine tooth on the right side to the middle grinder of the left, and consisted of a mere osseous shell, without any vestige of the cancellated structure; it was occupied by three red, solid coagula, the largest of which did not exceed the volume of a pigeon's egg. The cavity was only partially filled by the clotted blood, which adhered to the inner surface of the bony wall, and was evidently organized. The tumor had appeared three years before without any assignable cause. Whence was this blood derived? Did it proceed from a rupture of some of the vessels of the bone ? If so, the fact could not be ascertained by the most careful examination. 16. Fibro-cartilaginous Tumor.—The fibro-cartilaginous tumor, the enchondroma of recent writers, may be developed in the cancellated structure, or upon the outer surface of the bones, beneath the peri- osteum. Its figure is globular; its surface rough, or nodulated; its consistence firm, dense, and elastic; its color white, or grayish. When boiled, it yields a peculiar form of gelatine, termed chondrin. The tumor is essentially composed of' a fibrous and a cartilaginous sub- stance. The former constitutes the nidus in which the latter is deposited, and consists of a vast number of oblong or rounded cells, from the size of a clover-seed to that of a pea. These cavities cannot generally be distinguished until the cartilaginous element has been scraped away, or removed by maceration. The morbid mass is strik- ingly conglomerate, and often attains a large bulk. When it originates, as it commonly does, in the central part of the bone, it gradually en- croaches upon the compact tissue, which it expands into a thin, porous shell, either entirely osseous, or partly osseous and partly cartilaginous. Finally, the attenuated lamella gives way at one or more points, and thus allows the morbid growth to protrude beneath the periosteum, which is itself often very much altered in its character. This tumor ordinarily affects only one bone, is not malignant, and is productive of little inconvenience, except from its size. It is peculiar 296 BONES. to early life, is often directly chargeable to external violence, manifests no tendency to degeneration, not even when of long standing, is gene rally slow in its progress, and occasionally appears simultaneously in several parts of the skeleton. Every portion of the osseous system is liable to it; but the pieces most frequently affected are the metacarpal bones, the phalanges of the fingers, the humerus, and the lower jaw. To the tumor now described, especially when it is hard, fibrous, and Fig. 98. Fig. 99. Enchondromatous tumor of the ribs. a. External Encephaloid disease of the thigh-bone. From appearance. 6. Internal structure. From a specimen a specimen in my cabinet. in my cabinet. interspersed with the debris of osseous matter, or red and dense, like half-boiled beef, or fresh pork, the unmeaning title of osteo-sarcoma is usually applied by surgical writers. 17. Encephaloid.—Encephaloid, fungus hsematodes, or cerebriform cancer, generally, if not invariably, originates in the spongy structure, from which it gradually extends to the compact lamella, and finally to the periosteum. It most commonly attacks the upper and lower jaw, and the long bones of the extremities, particularly the femur, humerus, and digital phalanges. No portion of the skeleton, however, is ex- empt from it. The most terrific feature of encephaloid is its tendency to recur in some other part of the body, after it has been dislodged from its original situation. It may occur at any period of life, but young persons are most prone to it. Although encephaloid may occur as an infiltration, it most com- monly presents itself in the form of a tumor, arranged in rounded, SCIRRHUS. 297 tabulated masses, of the color and consistence of the medullary- structure of the brain. Not unfrequently it contains small cavi- ties, filled with clotted blood, dirty looking serum, or soft, gelati- nous, oily, sebaceous, or melliceroid matter. Occasionally one part of the tumor exhibits the brain-like character, while another is strictly hsematoid, or composed of a mixture of blood and encephaloid. In the great majority of cases, however, the two substances are pretty intimately blended together. Vessels, sometimes of considerable volume, may be seen ramifying over the surface of the morbid growth, and dipping into its interior. The outer table of the bone is trans- formed into a thin, parchment-like lamella, perforated in various places, or entirely destroyed by absorption. A section of the tumor usually exhibits, in addition to the appearances just described, osseous fragments, or pieces of fibro-cartilage. The superincumbent integu- ments, traversed by large bluish veins, are at first soft and glossy ; but at length, from the constant and increasing pressure, they ulcerate, and allow the fungous mass to protrude. Some of the more extraordinary alterations which the osseous structure is capable of undergoing in this disease are well seen in the annexed cut, Fig. 100, from a drawing made for me by Mr. Heiman, of Fig. 100. Nashville, from a specimen in the cabinet of Professor Buchanan of that city. The patient was a mulatto girl, about twelve years of age, who had labored for some time under a large tabulated tumor, partly elastic and partly inelastic, situated in the lower part of the leg, and attended with great dilatation and distension of the subcutaneous veins. Amputation being performed, the stump healed kindly, and for several weeks the girl did well; but in a few months she began to complain of pain in her hip and side, and she died in less than a year, apparently from internal malignant disease. A section of the tumor displayed an immense number of osseous spicules, of extraordinary length and deli- cacy, whose intervals were occupied partly by cartilaginous and partly by gelatinous substance, with here and there a cyst containing bloody- looking matter. 18. Scirrhus.—Scirrhus of the osseous tissue is singularly rare. It occurs exclusively in old subjects, and is usually concomitant of the 298 BONES. same disease of the breast or some other organ. Generally limited to a single bone, it may affect several pieces simultaneously, and always begins in the cancellated structure. Its favorite seat is the femur, but it may appear in any part of the skeleton, in the short and flat bones, as well as in the long. The heteroclite matter is deposited under two varieties of form, the infiltrated, and the tuberoid. In the former it is diffused through the areolar tissue, and exhibits the color and consistence of fibro-cartilage, or the rind of fresh pork. In the tuberoid variety the morbid mass is either solitary, or it consists of several agglomerated nodules, from the volume of a hazel-nut to that of an almond. Occasionally three or four distinct tumors are developed simultaneously in the same bone. They are of an irregularly rounded or oval shape, dense and firm in their consistence, and of a greenish, whitish, or yellowish color. The bone is seldom much altered in its size or external configuration, but is liable to be absorbed, and fractured at the seat of the disease. 18. Colloid.—Of colloid of the osseous tis- sue very little is known. It is most fre- quently met within the diseased conditions of the bones denominated osteo-sarcoma and spina-ventosa; which are often almost wholly composed of cells and cavities filled with jelly-like matter. The question, however, respecting the identity of these affections can be determined only by future observation. A case in which a colloid tumor grew from the body of the sphenoid bone, outside the dura mater, came under my notice in 1844, in the medical ward at the Louisville Marine Hospital. The patient died at the age of thirty-nine years from epilepsy, produced by a fall twelve months previously. On examination, Dr. Colescott and myself found, in the situation referred to, a tabulated tumor, of irregular form, and about the size of a pullet's egg, which had flattened the Yarolian bridge, and evidently induced the disease in question (Fig. 101). A section of the morbid mass showed that it was com- posedof several compartments communicating with each other, and occupied by a white, semi-concrete substance, in all respects similar to that of colloid. 19. Melanosis.—Melanosis of the osseous tissue is exceedingly rare. It may appear in small disseminated masses, nodules, or clusters, or in the form of infiltration. It has been observed in various parts of the skeleton, but is most common in the pieces of the extremities, par- ticularly the femur and tibia. Coexisting generally with melanosis in other organs, it is situated either upon the surface of the bone, beneath the periosteum, in the medullary canal, or in the spongy structure, the latter of which it sometimes dyes of a deep black color. In its progress and mode of termination it closely resembles medullary sarcoma. a. Colloid tumor, b. Ethmoid bone. c. Orbitar plate of the frontal bone. From a preparation in my collection. TUBERCLES. 299 20. Tubercles.—Tubercles of the bones are much more common than is generally imagined. The bones usually affected are the vertebrae, the short bones of the hand and foot, and the articulating extremities of Fig. 102. Tubercular excavation of the cuneiform bone. From a preparation in my collection. the long bones. The particular seat of tubercles is the spongy tex- ture, though occasionally they are formed upon the outer surface of the bones, between it and the periosteum. Fig. 102 is a good illus- tration of a tubercular cavity of the internal cuneiform bone of the left foot, which I was obliged to amputate on account of the great extent of the disease. There are two varieties of form in which this matter is deposited. In one, perhaps the more common, the tubercles are encysted, the inclosing membrane, which varies in thickness from a fifth to half a line, being composed of coagulating lymph, very soft at first, but gradually becoming harder and harder, until finally, in some cases, it acquires the character of fibro-cartilage. It is of a dull grayish color, is made up of delicate inelastic fibres, crossing each other in every conceivable direction, and is frequently furnished with small vessels, passing into it from the surrounding structure. The number of tubercles is seldom very great; their size varies from that of a pea to that of a nutmeg; and in most cases they present a yellowish, opaque appearance. When these bodies become softened, the matter will either work its way out, or pass, by a sort of fistulous route, into a neighboring joint, establishing thereby an analogy with pulmonary tubercles opening into the bronchial tubes. Sometimes a spontaneous cure takes place, the heterologous substance being absorbed, and the cyst contracting so as to obliterate its cavity. In the second variety, the tubercular matter is deposited directly in the cells of the osseous tissue, forming grayish, semi-transparent, opaline patches, from the one-sixth of an inch to an inch in diameter. This infiltration is noticed chiefly in the bodies of the vertebrae, and in the bones of the tarsus, where it is frequently pervaded by nume- rous vessels, too delicate to be discerned with the naked eye. The bony tissue immediately around is sometimes deeply injected, but seldom otherwise diseased. In this, as in the preceding variety, the tubercular deposit, after having existed for some time, gradually softens, its vascularity disappears, and the cells in which it was contained are filled with earthy matter. This, however, is not always the case; for now and then the ulcerative process continues until the bone is totally destroyed. 300 PERIOSTEUM. SECTION II. PERIOSTEUM. The morbid relations of the periosteum, although not unlike those of other fibrous textures, are too important to be passed by without some notice. The most common lesion to which this membrane is liable is chronic inflammation, followed by thickening, and a deposit of osseous matter, generally upon the internal surface, but occasion- ally upon the external. Acute inflammation is also frequently observed, and seldom exists without implicating the subjacent bone. Inflammation arises either spontaneously, from external injury, or from the operation of the syphilitic poison. In the acute form of the disease, the membrane becomes reddened, its vessels are loaded with blood, and its substance is sensibly softened as well as slightly thick- ened. Its attachment to the bones is also considerably diminished, so that it can be much more easily peeled off, and the cellular substance on its external surface is generally infiltrated with sero-albuminous matter. These changes are frequently observed upon the fragments of a broken bone, and in incised wounds of the muscles, involving the periosteum. This disease, especially the acute form of it, not unfrequently passes into suppuration. This event is more particularly apt to occur in periostitis of the inferior extremity, caused by cold operating upon a strumous constitution, or by the effects of mercury, or the action of the syphilitic virus. In either case, the suppurative process is remark- ably tardy, and the pus is rarely of a healthy character, but almost always very thin, bloody, and offensive, with flakes of curdy matter. As the fluid accumulates, the superincumbent integuments assume a red, glossy, and swollen appearance; the part is excessively painful; fluctuation takes place, and the abscess breaks at one or more points, the corresponding portion of the bone being frequently destroyed by ulceration. Another termination of acute inflammation is mortification. When this occurs, the normal appearance of the membrane is lost, being changed to a dirty ash color, whilst its texture is softened, easily torn, and bathed in a foul offensive fluid, having the characteristic gan- grenous odor. This termination, it need scarcely be observed, can never take place without the osseous texture participating in it. The best examples of it are witnessed in the periosteum of the alveolar processes of the jaws, from the abuse of mercury, and in that of the tibia from common necrosis. The sloughs, which are always tough and shreddy, are usually thrown off with considerable difficulty, owing to the tardy and imperfect action of the circumjacent structures. When the periosteum labors under chronic inflammation, it is very apt to become thickened from the effusion of plastic lymph. The MEDULLARY MEMBRANE. 301 hypertrophy, for so It may be termed, generally occurs in association with induration, and often involves a considerable extent of surface, forming a diffuse, incompressible swelling, partly fibrous, partly car- tilaginous, and partly osseous. In other cases, the hypertrophy is more circumscribed, and either exhibits the mixed structure just specified, or it is entirely bony. These tumors are commonly of slow formation, and they seldom acquire any great bulk. During the progress of their development, they are the seat of a constant, deep-seated gnawing pain, which is most severe at night, when the body becomes warm in bed. After continuing for an indefinite period they either remain stationary, or they gradually disappear by absorption, or they excite suppuration in the superimposed textures. In old people, it is not uncommon to find this membrane ossified upon its internal surface, or even through its entire substance. When thus affected, the periosteum is of a dull drab color, resists the knife, and is with difficulty detached from the bone which it covers, owing to the partial incorporation of their tissues. When dried, it exhibits very much the appearance of an ossified artery. In the extremities, especially in the thighs, I have frequently seen considerable nodules of bone spring from the outer surface of this membrane, so as to en- croach more or less upon the muscles. In their shape, they are, for the most part, ovoidal, and in their consistence they often equal the petrous portion of the temporal bone. Their color is usually a few shades lighter than that of the osseous texture in the healthy state. The periosteum has been found affected, in a few rare cases, with melanosis; and occasionally, also, with the tubercular deposit. In carcinoma of the bones, the membrane is often implicated secondarily, but it is rarely, if ever, the original seat of this formidable malady. In a number of dissections which I have made of encephaloid disease of the bones and soft parts, I have found the periosteum entirely un- touched, not even thickened or indurated. Hence we may infer that this fibrous lamella possesses an astonishing self-preserving power, much superior to what is enjoyed by most other tissues. SECTION III. MEDULLARY MEMBRANE. Of the diseases of the medullary membrane very little is known. Acute inflammation is extremely rare, and is observed principally in fractures of the long bones. The membrane in this form of the lesion assumes a reddish tint, and the secretion of fatty matter is not only temporarily suspended, but that which existed prior to the occurrence of the accident is generally absorbed. In violent cases, pus is effused, and forms an abscess in the interior of the bone. In necrosis, the medullary membrane, corresponding with the affected portion of bone, loses its vitality, and is gradually broken up into a dark-colored, oily putrilage, of a fetid gangrenous odor. 302 SKIN. Of chronic inflammation of this membrane, I'recollect a beautiful instance in the tibia and fibula of a man sixty years of age, who died from the effects of a sloughing ulcer, brought on apparently by in- temperance. Both bones were in a state of necrosis at their middle; inferiorly they were greatly expanded, but towards the knee they were of the natural dimensions, and contained a red, florid-looking marrow, of preternatural hardness. The discoloration, however, was not uni- form, but in distinct patches, varying in diameter from that of a pea to that of a twenty-five cent piece. The adipose tissue of the bones bears the greatest resemblance to that in other parts of the body, but it is highly probable that it pos- sesses certain modifications of structure, leading to corresponding peculiarities in reference to its diseases. That this is the case I am disposed to believe from the fact that the medullary membrane is not unfrequently the seat of several of the heterologous formations, as the scirrhous and encephaloid, which are never developed in the adeps of the general sj'-stem. Tubercular matter is also sometimes deposited here; and another argument in favor of this view is founded upon the notable difference in the products of the two tissues, that of the bones being always of a thin, oily nature, and composed principally of elaine, while the other is serai-concrete, and formed mainly of stearine. CHAPTER X. CUTANEOUS SYSTEM. I. Sii?i.—Reproductive Power of the different Lamellae of the Skin.—Diseases.—(i.) Unclas- sifiable Lesions. — Keloid. — Eiloid. — Lepoid. — Melanosis. — Encephaloid. — Scirrhous Tumors.— Hypertrophy.—Corns.—Warts.— Horny Excrescences. — Gangrene.— Sebaceous Tumors.—Hemorrhages.—(n.) Classifiable Lesions.—1. Exanthematous Diseases.—2. Pus- tular.—3. Papular.—4. Bullar.—5. Tubercular.—6. Scaly.—7. Syphilitic Diseases.—8. Stains. —II. Nails. — Reproductive Power.— Inordinate Length.—Absence.— Malformation.— Vicious Situation.—Onyxitis.—III. Hairs.—Similarity to the Nails.—Polish Plait.—Regene- rating Power.—Hypertrophy.—Female Beards.—Softening.—Fragility.—Changes of Color. —Accidental Development of Hair. SECTION I. SKIN. I. UNCLASSIFIABLE LESIONS. 1. Keloid, Eiloid, and Lepoid.—Keloid is most common on the neck, shoulder, and front of the chest, where it usually manifests itself by a small reddish point, about the size and shape of a grain of barley, which goes on increasing until it may attain the diameter of an inch LEPOIDES. ' 303 Keloid growth of the face. From a patient at the College Clinique. or more. The centre of the tumor is generally somewhat depressed, its surface wrinkled, and its margin radiated, having some resemblance to the claws of a crab, whence its name. (Fig. Fig-103. 103.) It is hard, re- sisting, and of a pale rose, or deep cherry- red color. Its inte- rior exhibits a gray- ish, fibrous appear- ance, much like scir- rhus of the female breast, the rays shoot- ing out in different directions. Its pro- gress is slow, and it rarely ulcerates, but it is always attended with great itching. Occasionally it disap- pears, leaving merely a white, firm cicatrice. The most remarkable circumstance about this tumor is its disposition to return after removal, and this may happen repeatedly, until the patient is at length worn out by his suffering. The late Dr. John C. Warren,1 of Boston, was the first, I believe, to describe a peculiar form of skin tumor, called eiloid, from its coil- like disposition. In its early stages, it presents the appearance of a small elevation, similar to that from a burn, which goes on gradually increasing, without pain, heat, redness, or ulceration, until it acquires a great size, and affects the patient's health. In a drawing accom- panying the account, the tumor has the appearance of a triple coil of inflated intestine, the rolls lying in close contact, and being each four inches long, arising by a narrow base from the right side of the neck. The patient was a negress, fifteen years of age, whose health was other- wise disordered. Soon after its removal, the tumor reappeared at its former situation: it was again extirpated; and, showing itself a third time, it speedily proved fatal. Of the anatomy of eiloid nothing is known. The morbid growth probably takes its rise in the dermis, but in what particular part has not been ascertained. Lepoid, so called for its bark-like appearance, is a rare affection. Its most common situation is the cranio-facial region, generally the fore- head, cheek, or temple. Its progress is slow, and old age is its favorite period of attack. Consisting in an inflammation of the dermis, it makes its appearance in the form of a small, circumscribed speck, of a dirty color, which becomes covered with a very rough, brownish crust, resembling the bark of a tree. This falling off is soon replaced by another, of the same shape and color. Thus the disease is kept up for many successive years. Ulceration ultimately sets in and the 1 Surgical Observations on Tumors, p. 48. Boston, 1837. 304 SKIN. dermis exhibits a red, glossy surface, spicular, pitted, or granular, which throws out a thin, ill-looking pus. On examining the affected skin, it is found to be almost of a gristly hardness, its internal sur- face being studded with a number of small, whitish, rounded bodies, connected together by a dense, grayish texture. Very little pain attends this affection, and it often continues for many years before it manifests any malignant tendency. 2. Heterologous Products.—Melanosis of the skin may occur alone or in union with other morbid products. The most common form in which it shows itself is in that of small grains, of the size and color of a black currant. These little tumors are usually embedded in the dermoid tissue, and are sometimes quite numerous, giving the cuta- neous surface a singularly tuberculated aspect: they seldom ulcerate, but when they do they always leave an unhealthy, intractable sore. Similar deposits almost always coexist in the subcutaneous cellular tissue, and in some of the internal organs. Encephaloid has never been remarked as a primary disease of the skin, although it frequently extends to it from the subjacent textures, producing a red, spongy, tuberculated sore, more or less painful, and liable to bleed upon the slightest touch. The scirrhous tumor of the skin exhibits, when cut, a grayish, dense, crisp texture, intersected by numerous fibrous filaments, and yielding a small quantity of lactescent fluid on pressure. In size, it varies between a pea and a pigeon's egg: it is rounded, conical, or pedicu- lated, and occasionally rests upon a large flattened base. It often remains stationary for many years; but finally ulcerates, and reappears after extirpation. 3. Hypertrophy.—Hypertrophy of the skin is not uncommon. Oc- curring most frequently in old subjects, it is sometimes congenital, and involves either the whole thickness of the organ, or some of its com- ponent layers. The integuments of the nose are particularly liable to enlarge and thicken; the lesion is also sufficiently common on the neck, breast, arm, and back, forming rough, pendulous folds, several inches in length, which are usually somewhat darker than the skin in the normal state. Hypertrophy constitutes a prominent feature in elephantiasis, in burns, and in chronic ulcers of the inferior extre- mity. The enlargement, in some instances, implicates nearly the whole cutaneous surface, by which the movements of the body are impeded, and the individual acquires a hideous aspect. The hypertrophy may be seated principally in the papilla. The affection is sometimes congenital, sometimes accidental, and is met with in various degrees. When it accompanies or follows burns, blis- ters, and chronic eczema, the bodies in question often attain an extra- ordinary development; their volume is five or six times above the natural standard; they are of a pale brownish color; and they present an uneven, mammillated appearance, not unlike the pile of coarse plush, which is rendered particularly conspicuous when they are plunged into warm water. The dermis, in these cases, is often very much thickened, as well as indurated, and is covered with thin mica- HORN-LIKE EXCRESCENCES. 305 ceous scales, which are easily rubbed off, and are constantly repro- duced. Hypertrophy of the epidermis is well displayed in certain affections of the skin, as corns, warts, and bunions, and, in a more striking de- gree, in ichthyosis and elephantiasis, in which the different cutaneous layers are sometimes of enormous thickness. Corns are hard, dry, insensible callosities, occurring mostly on the lateral and dorsal surfaces of the toes, especially the first and last: they are also sometimes seen on the sole of the foot, between the fingers, and on the flexor tendons in the palm of the hand in working people. They owe their origin usually to inflammatory irritation of the cellular layer of the dermis, eventuating in the effusion of lymph, and the con- sequent thickening and induration of the cuticle. The texture of a corn, especially when old, is lamellated, and almost always more firm at the centre than at the circumference. By cutting away its super- ficial layers, a sort of internal nucleus is exposed, which has a whitish, horny-looking appearance, and often occupies a considerable portion of the substance of the dermis: it is generally more or less moist, and is now and then surrounded by a minute ecchymosis. The form of these callosities, although variable, is usually rounded, and their size rarely exceeds that of a five cent piece. Some corns are movable, others fixed; and cases occur in which they have a sort of radiating root, extending deeply into the subjacent cellular texture. Their remote cause is pressure, commonly that of a shoe, which, if continued for any length of time, inflames the cutis, and renders it excessively painful. The complaint is more frequent in females than in the other sex, and in the rich than in the laboring poor. A wart is a hard, insensible excrescence, of a conical form; its sur- face is hard, tuberous, fissured, and almost indolent; in size, it seldom exceeds a common pea; in color, it is several shades darker than the surrounding skin ; sometimes it is movable, sometimes fixed. Being of a radiated structure, it is composed of elongated, vascular papillae, encased in the epidermis. It is caused by slow, chronic irritation, and often occurs in immense numbers on the hands and face of young persons. In the latter situation, warts are apt, in the more advanced periods of life, to take on carcinomatous action, either spontaneously, or from being frequently irritated. In the young, they often disap- pear spontaneously. 4. Horn-like Excrescences.—The skin is sometimes the seat of horn-like excrescences, occurring principally in those parts of the body where sebaceous follicles abound, as the face and scalp. In seventy-one cases collected by Dr. Villeneuve, twenty-six were seated on the scalp, five on the nose, two on the cheek, one on the lower jaw, four on the chest, four on the back, three on the anus and penis, four on the but- tocks, twelve on the thigh, two on the knee, two on the ham, one on the leg, and three on the foot. They have also been seen on the scrotum, the back of the hand, and on the ear. Although the reverse has been asserted, they appear with nearly equal frequency in both sexes, during the period which intervenes between the ages of forty 20 306 SKIN. l'ic. 104. and seventy. I have met with them in young chil- dren before the tenth year. The size which some of these excrescences attain is surprising. (Fig. 104.) There is one in the British Mu- seum, which is eleven inches in length by two and a half in circumference. From three to six inches is by no means an unusual size. Their direction is generally somewhat spiral, twisted, or bent; and, in their appear- ance, they often bear the closest resemblance to the horn of the sheep, being marked by rough, circular rings with intervening de- pressions, indicative of the successive steps of their de- velopment. In color, they vary from a dingy yellow to a dark grayish. They are of a firm, cartilaginous consist- ence, more or less flexible and conical in their shape, being large at their origin, and tapering toward their terminal extremity; when burned, they exhale a charac- teristic animal odor. Now and then their surface is imbricated, knobbed, or covered with small, pearl-colored scales. Internally they have occasion- ally a lamellated arrangement, as in Fig. 105. These excrescences are generally connected with the seba- ceous follicles, and are often directly traceable to chronic inflammation, such, for example, as is pro- duced by a burn, wound, or contusion. When first observed, they are quite soft, tran sparent, and invested by a distinct cyst, which, extending over their base, is gradually and insensibly lost upon their trunk. In a short time they become hard, assume a darker hue, and thus acquire the properties of the horny tissue. Their growth is always very slow, from three to five years elapsing before they attain any considerable size. When they drop off spontane ously, as they sometimes do, they invariably sprout out anew, pursuing the same course as their predecessors. The same Horny excrescence growing from the scalp. Fig. 105. A section of the horn, showing its lamellated structure. GANGRENE OF THE EXTERNAL INTEGUMENT. 307 thing happens when they are extirpated without the precaution of destroying the matral cyst. Several such excrescences are occasionally observed in the same individual. 5. Gangrene.—The production of gangrene of the external integu- ments is by no means a rare occurrence. It is observed in different situations, and arises from a variety of causes, some of which seem to have a preference, so to speak, for this over other structures. Occa- sionally, therefore, it may occur as an original idiopathic affection; but more generally it is the result of specific inflammation, or of inflamma- tion depending upon external violence. Of the former, we have an example in malignant pustule, in phlegmonous erysipelas, and in com- mon carbuncle. As illustrating the present subject, I shall describe malignant pustule, a disease which owes its origin to the operation of some septic agent, and which is typical of this form of gangrene. Malignant pustule, charbon, or anthracion, although very rare in this country, is often observed in certain parts of France, particularly in Lorraine, Burgundy, Provence, and Languedoc. In the low marshy districts of these regions, the cattle are obliged to subsist upon bad vitiated provender; in consequence of which many of them are seized with dynamic fever, accompanied with gangrene of the skin. In the summer season, indeed, the disease sometimes prevails epidemically. By dissecting animals that perish in this way, or by merely touching their hides or hair, the disease is readily propagated to the human subject. There are numerous facts, also, which prove that malignant pustule may be communicated by introducing the hand into the rectum, vagina, and throat of cattle affected with this malady; and similar results are produced by touching the blood, the secreted fluids, and the excrements, or by injecting the former into the veins. Shepherds, herdsmen, tanners, and butchers are most subject to the disease; and the parts most liable to be affected are such as are habitually uncovered, as the face, neck, and chest, together with the arms and hands, the legs and feet. The anatomical characters of the disease may be divided into three stages, each of which is marked by some peculiarity, worthy of separate consideration. The time which elapses between the inoculation and the develop^ ment of the disease varies from three to eight days. It commences in a small circular prominence, the centre of which soon degenerates into a minute vesicle, about the size of a millet-seed, without heat, tension, or redness. As this vesicle enlarges, it assumes a brownish color, and on being ruptured, discharges a few drops of a yellowish bloody serosity. At intervals, a good deal of itching is experienced, accom- panied with a peculiar stinging sensation. This period lasts from twenty-four to forty-eight hours, and constitutes the first stage of the disease. The second stage, which rarely continues beyond a few days, is characterized by the development of a hard, movable, circumscribed tumor, of a yellowish livid color, with a rough granulated surface. This is shortly surrounded by a purple, glossy-looking areola, on which numerous phlyctenser, containing a reddish serosity, are situated, which 308 SKIN. quickly run into each other. The disease, having penetrated the entire thickness of the dermis, now invades the subjacent cellular tissue, and the centre of the little tumor presents all the features of an eschar. In the third stage, the gangrenous point rapidly extends, and the enlarging areola rises above the eschar, causing its centre to be de- pressed. The surrounding surface is tense, emphysematous, and of an erysipelatous red; the acrid heat and stinging are succeeded by a sense of weight and numbness; the disease burrows deeply into the cellular texture; and the mortified skin is of a blackish color, and a firm, leather-like consistence. From twenty-four to seventy-two hours is the usual duration of this stage, which is commonly attended with high constitutional excitement. The size of the slough, at this period, varies from six lines to several inches. But it is not always that malignant pustule observes this regularity. The different stages often succeed each other in rapid and indistinct succession; the disease having proved fatal in less than twenty-four hours after its commencement. When it terminates favorably, a red inflammatory circle appears, which serves as a line of demarcation between the dead and living parts. From experiments performed in 1816, by M. Berthelemy,1 a pro- fessor in the Veterinary School at Alfort, near Paris, it appears that the ichorous matter furnished by malignant pustule retains for a long time its nocuous properties. Having put some of the fluid in a corked vial, he preserved it for about eleven months, when he inserted a por- tion of it into the skin of a stout, healthy horse. The consequence was a gangrenous tumor, having all the characteristics of malignant pustule, and which, notwithstanding the small quantity of virus, killed the animal in three days. In ordinary gangrene, or in that variety which arises from excessive inflammatory action, the color of the skin changes from a florid red to a darker shade, acquiring, during the progress of the disease, a purple, livid, or blackish hue. Concurrently with this change of color, the affected part undergoes a decided alteration of structure. It feels soft, boggy, and emphysematous, and the cuticle is raised into numerous phlyctenae, filled with bloody looking serosity. When completely deprived of vitality, the skin sometimes becomes a shade o"r two lighter, and is detached in soft, grayish, inelastic strips, which are often bathed with a thin, ichorous, and offensive fluid. " The ash colored slough seems to occur most frequently in skin which is moister, and the black-colored, in skin which is more dry, than com- mon." There is a species of cutaneous gangrene, to which, from the pecu- liarity of its appearance, we may apply the term white. It generally comes on without appreciable cause or preliminary symptoms, in irregu- lar shaped patches, from one to three inches in diameter. The sloughs are of a dead milky color, and of a hard, dryish consistence, yielding little or no moisture on pressure. Any portion of the body may be the seat of this affection; but the arms, back, and chest are the parts 1 Dictionnaire de Medecine et de Chirurgie Veterinaire, t. iii. p. 713. SEBACEOUS FOLLICLES. '309 Fig. 106. most frequently implicated. The true nature of the lesion is still in- volved in mystery. 6. Sebaceous Follicles.—The sebaceous follicles are not often diseased. When inflamed, they augment in volume, their capillaries are injected, and they pour out a preternatural quantity of matter, which, in time, forms an unctuous, tenacious covering, not unlike a layer of semi-con- crete wax. If it be allowed to remain, this substance sometimes ac- quires the appearance of thick, imbricated scales, of a blackish color, which may be mistaken for those of ichthyosis, from which, however, they differ, in being much more easily detached. Under this accidental covering, the skin is of an unusually red color, and the mouths of the follicles are either very much enlarged, or obstructed with hard seba- ceous matter. This disease, which is almost peculiar to youth and adults, may last for years, and the secretion which attends it is occa- sionally of a sero-purulent nature, especially in obstinate cases. Another effect which sometimes results from inflammation of the sebaceous follicles, is the formation of encysted tumors, containing meliceric, atheromatous, or steatomatous matter, or several of these substances con- joined. The mouth of the follicles being obstructed, and the natural secretion going on, their cavity gradu- ally expands, until the sac acquires, in some instances, the volume of an apple, or even of a fist. The parietes of these tumors are occa- sionally quite hard and thick, like the dura mater; and cases are ob- served, though very rarely, in which they are ossified, or transformed into fibro-cartilage. Externally, they are rough, being connected to the sur- rounding parts by cellular tissue; in- ternally, on the contrary, they are generally smooth and glistening. Small sacs are sometimes observed in the interior of these tumors. In their shape, these tumors are for the most part globular, and they are found by far more frequently on the face and scalp than in any other situation. Their number, although usually small, may be very great. Thus, in the case of a man, aged forty, I counted several hundred on the head and trunk alone. Most of them com- menced when he was quite young, soon after bathing in cold water. The tumors were of the meliceric kind, and the largest were about the volume of a hen's egg; the surface of many was uneven, and partially incrusted with hard, sebaceous matter of a dark color. Oc- casionally they occur in several members of the same family; and now and then they display an evident hereditary tendency, as in a case which fell under my observation in 1840. In this instance, the Sebaceous tumors of the scalp : a. A tumor laid open to show its cyst and contents. From a preparation in my collection. 310 SKIN. disease existed upon the scalp of a young woman of twenty-seven, and upon that of her father, a paternal aunt, and her paternal grandmother. The tumors were, respectively, from four to seven in number, and varied in volume from a marble to a walnut. Tumors of this kind are usually somewhat movable, although, in this particular, much depends upon their age and location. They are unattended with pain, have no ma- lignant disposition, and the skin covering them generally retains its natural character. Sometimes the contents of these tumors are thin, watery, and exceedingly offensive. In other cases, short hairs, very soft, and provided with well-formed roots, are found in them. (Fig. 107.) The sebaceous follicles, instead of secreting their accustomed humor, occasionally deposit a hard, calculous substance. Meckel1 relates the case of a young lad, the skin of whose buttocks was completely studded with small concretions of this kind; and similar bodies have been repeatedly found in the sebaceous follicles of the forehead and root of the nose. Their cyst of a sebaceous tumor, chemical composition has not been determined, with hairs in its interior. i . •. • i i i j.i j. xi • *. • i c but it is probable that they consist mainly of phosphate and carbonate of lime, agglutinated by a minute quantity of animal matter. 7. Hemorrhage.—The skin is sometimes the seat of hemorrhage. The only form which I shall describe is what is called purpura. Of this, three varieties may be recognized, the petechial, simple, and complicated, or, as it may be denominated, the hemorrhagic. These varieties are referable principally to the extent, form, and situation of the effused blood; and may all occur simultaneously or success- ively in the same individual. No period of life is exempt from this disease. In the petechial species, the blood is collected in minute isolated points, situated immediately beneath the cuticle; they are of a circular shape, from the fourth of a line to a line in diameter, seldom or never elevated above the surrounding surface, and usually of a pale color, though frequently of a deep red or purple. The lesion, generally concomitant of plague, typhoid fever, scurvy, and dysentery, is almost always most conspicuous on the chest, back, and inside of the extremi- ties. In simple purpura, the parts principally affected are the arms and legs, especially the latter. The effusions take place slowly and suc- cessively, so that, while some are fading and disappearing, others are forming and increasing. They are at first of a vivid red color; but, in a few days, they acquire a deeper and more livid hue; and, in pro- portion as the blood is removed by absorption, they become greenish, then yellowish, and ultimately vanish altogether. They are also of a circular shape, but much larger than in the petechial variety, being from one to eight lines in diameter, and seated between the cuticle and mucous network, or in the dermis and cellualr tissue, or in both 1 Voigtet's Handbuch der Path. Anatomie, Halle, 1804. Erster Band, p. 85. EXANTHEMATOUS DISEASE. 311 these situations simultaneously. The duration of the individual blotches is from six to ten days; of the disease, from one to twelve months. The essential difference between the preceding and the complicated variety of purpura, consist in the effusions, in the former, being con- fined to the external surface; whilst, in the latter, they not only occur in this situation, but also in other parts of the body, especially beneath the mucous and serous membranes of some of the principal organs. The blotches are likewise of a deeper color, larger, and less regular in their shape, in many cases bearing a striking resemblance totheecchy- moses which follow a bruise or contusion. Indeed, the slightest pressure is frequently sufficient to produce them, particularly in parts where the skin is very thin and the cellular tissue abundant. When the effusion is considerable, the cuticle is sometimes elevated into small bladders, which, on breaking, give vent to black, semifluid blood. This occurrence, however, is extremely rare, and, in general, there is not the slightest elevation. This variety of purpura usually begins on the legs and thighs, whence it gradually extends over the trunk and arms. The hands and face almost always escape. Are these effusions the result of a rupture of the vessels, or are they caused simply by exhalation? . Of the two, the latter suppo- sition is, perhaps, the more correct; at all events, we rarely find any communication whatever between them and the neighboring vascular branches. The subject, however, requires further investigation; for our knowledge of the morbid anatomy of this affection is, to say the least, extremely imperfect, and does not enable us to offer any satis- factory explanation, either of the nature of its predisposing causes, the character of the primary local lesion, or of its complications. Besides the varieties now described, there is another form of hemor- rhage, in which the blood oozes from certain regions of the cutaneous surface, in the same manner as it sometimes does from the mucous membranes. The discharge is most frequent in hysterical girls, about the age of puberty, and is usually vicarious of some similar natural or morbid state in a remote organ, which is almost always the uterus. The skin appears as if covered with a sort of dew, the blood being effused in minute globules, which, on being wiped away, are presently followed by others. The" exhalation, especially in females, is com- monly periodical, and shows itself simultaneously or successively at a number of points, as the face, chest, umbilicus, hand, and foot. II. CLASSIFIABLE LESIONS. 1. Exanthematous Diseases.—The exanthematous diseases are cha- racterized by the occurrence of more or less inflammatory redness in the superficial portion of the dermis, which momentarily disappears under the pressure of the finger, runs its course in from two to six days, and is always preceded and accompanied by constitutional symptoms. The efflorescence is sometimes circumscribed, sometimes diffuse, and occasionally, as in scarlatina, covers the whole body. The usual termination of these affections is by resolution and desqua- 312 SKIN. mation. Several of them are of a contagious nature, and occur only once in the same person. The diseases included in this group are roseola, urticaria, erythema, rubeola, scarlatina, and erysipelas. Roseola is characterized by rounded, circumscribed spots, closely set together, of a deep red color, and from four to six lines in diameter. These patches, which disappear in the course of twenty-four hours, are almost always dependent upon gastro-intestinal derangement, and are rarely followed by any appreciable desquamation. The disease is not contagious; it is commonly marked by febrile disturbance, and often covers only a part of the body, as the neck, trunk, or extremities. It may occur at any period of life, as well as in both sexes, but is most frequent in women and children. Roseola seems to be seated in the most superficial portion of the dermis, and to consist in a transient injection of the cutaneous capillaries. There is a variety of this dis- ease, in which the spots are arranged in the form of rings, the centres of which retain their normal color: two or three such rings, of variable breadth, are sometimes situated the one within the other. Urticaria, familiarly called "nettle-rash," is a non-contagious inflam- mation, the duration of which varies from a few days to several months. It appears in the form of prominent wheals, of an irregular shape, paler or redder than the surrounding skin, usually of short con- tinuance, and always attended by a peculiar stinging sensation. In severe cases, the wheals are often very large, hard, and deep-seated, involving the subjacent cellular tissue with a tense, sore, and tumid state of the skin. The favorite situations of the eruption are the shoulders, loins, forearms, thighs, and knees. The disease frequently changes its position, appearing at one time here, and at another there; as to the individual patches, their duration seldom exceeds twenty- four hours. The anatomical characters of urticaria are imperfectly understood. Erythema is an uninfectious exantheme, the distinguishing traits of which are superficial blotches, of a deep florid color, lasting from a few days to a fortnight, irregular in their shape, and varying in diam- eter from several lines to many inches; the redness momentarily dis- appears under the pressure of the finger, and is seldom attended with any appreciable swelling. The disease is most common in females, and young, weakly persons; and the neck and chest, together with the superior extremities, are its most frequent situations. Erythema oc- casionally occurs in regularly circumscribed spots, of a circular shape, and about the size of a split pea; they are slightly prominent, of a bright florid color at the commencement, and subsequently of a violet hue, especially at their centre. This constitutes the papular variety of Willan. Another form is the nodose, in which the patches, also con- siderably elevated, are of an oval shape, and from a few lines to an inch in diameter. In other cases, the redness is annulated, marginate, or diffused over a large extent of surface. In whatever form it may appear the blotches seldom suppurate, nor are they always followed by desquamation of the cuticle. Rubeola is an epidemic malady, occurring for the most part in young children, during the winter and vernal months. It rarely attacks SCARLATINA. 313 the same person more than once. The eruption appears about the fourth day from the commencement of the indisposition, and is first seen on the forehead, face, and neck, from which it gradually spreads over the rest of the body. It consists of small red pimples, which are slightly elevated above the surrounding level, and look very mu/m like so many flea-bites. In the progress of the disease, the little specks become more prominent; their color is heightened, and their diame- ter expands, until at length, coalescing with each other, large patches are formed, of an irregular semilunar shape, with small intervals of sound skin. A minute vesicle occasionally appears at the centre of each spot, filled with a whitish, watery fluid. The swelling of the skin is commonly very trifling, and the redness, which attains its acme in about twenty-four hours after its first appearance, has commonly a shade of purple. The eruption lasts from three to four days, de- clining pretty much in the order in which it began, and is constantly followed by a branny scurf-like exfoliation of the epidermis. Scarlatina comes on from three to six days after exposure. Attack- ing children in preference to adults, it often prevails epidemically, epecially in winter and spring, and in one form at least is a source of immense mortality. This form is the malignant, so termed from its being attended with great depression of the powers of life, and from being complicated with violent inflammation of the palate, tonsils, and pharynx. The efflorescence breaks out from twenty-four to forty-eight hours from the moment of the invasion of the disease, first on the face and neck, then on the trunk, and finally on the extremities. It con- sists of myriads of small red points, so closely grouped together that the whole surface exhibits a red scarlet hue, and feels rough to the touch, as if fine sand were strewed over it. The color is generally most intense in the evening, and has been compared, not.unaptly, to that of a boiled lobster; it reaches its height about the end of the third day, begins to fade on the fifth, and disappears entirely about the seventh. With this efflorescence there is usually violent heat of the skin, with a sense of fulness, and more or less itching; and, in many cases, the mouth and tongue, together with the throat, are of a deep fiery color, evidently from an extension of the disease. Small vesi- cles sometimes appear on the eruption, resembling those that are occasionally noticed in rubeola, and containing a thin sero-plastic fluid; they seldom continue longer than four days, and it is not im- probable that they are produced by some disorder of the sebaceous follicles. Their number is sometimes immense. In the case of a young girl twelve years of age, who came under my observation three years ago, the whole body was literally covered with them; they were about the size of a common pin-head, of a whitish color, and filled with a thin, tenacious fluid, which seemed to be gradually absorbed, as none of the little vesicles burst and discharged their contents. The desquamation, which is generally lamellar, begins about the seventh day, and is accompanied by disagreeable itching. The last disease to be described, under the present group, is erysipelas. In the United States, as well as elsewhere, this is an ex- tremely common affection; it may be idiopathic or traumatic, epidemic 314 SKIN. or sporadic; and is supposed, not without reason, to be sometimes contagious. It spares no period of life; for it occurs in new-born in- fants, in middle age, and in decrepitude. It is most common in per- sons of a deteriorated, worn-out constitution, and is usually preceded, as well as accompanied, by symptomatic fever. Although erysipelas may appear on any part of the body, the head, face, and legs are out of all proportion its most frequent situations. Of this disease, there are two important varieties, the simple and the phlegmonous. The first, which has its seat exclusively in the dermoid tissue, is characterized by diffused redness, with slight swelling, increased heat, and a tingling, burning sensation. The discoloration is of a deep cherry hue, and disappears momentarily under pressure. When the inflam- mation runs very high, the cuticle is elevated into vesicles, varying in size from a pin-head to a hazel-nut, isolated or conglomerated, and containing a thin, straw-colored, or bloody serosity. The vesications usually appear within the first forty-eight hours, break in a day or two after, and are replaced by thin, hard, yellowish crusts, which subse- quently blacken. In milder cases, the disease subsides much sooner: the redness, about the third or fourth day, assumes a dusky yellowish tinge, the swelling diminishes, the skin becomes wrinkled, and the epidermis is detached in small bran-like scales. Few or no vesicles are observed. This variety is sometimes erratic, that is, it suddenly disappears at one point, and attacks another, leaving no other traces than a slight desquamation. In the phlegmonous variety, besides the phenomena above described, there is often great swelling of the subcutaneous cellular texture, with infiltration of acrid and bloody serosity, suppuration, or sloughing. This form of the disease is most frequent about the eyelids and the legs, in old, intemperate subjects. Great constitutional disturbance usually attends: the affected part is exceedingly painful, and the der- moid and cellular tissues often slough in large patches, the latter com- ing away in dark-colored, dirty-looking shreds. 2. Pustular Diseases.—Pustules are produced by inflammation of the dermoid textures, terminating in an effusion of matter, which ele- vates the cuticle into small circumscribed tumors. The genera com- prehended in this order are acne, sycosis, ecthyma, porrigo, impetigo, vaccinia, variola and varicella. Some of these affections are acute, and others chronic; some are contagious, and others not; some are discrete, and others confluent. Differing as they do in these particu- lars, they all resemble each other in the fact of their terminating in a scabby incrustation, varying in thickness and density in different cases, and leaving, on dropping off) the surface to which it adhered, for some time, of a red color. Acne is a chronic inflammation of the sebaceous follicles, lasting from several weeks to as many years, characterized by the presence of small, isolated pustules, the most common seat of which is the upper and back part of the trunk, though they are often seen also on the fore- head, nose, chin, and temples. The limbs are seldom affected with them. The disease is equally frequent in both sexes, and is particu- larly apt to occur about the age of puberty. The follicles are enlarged, ECTHYMA. 315 their parietes are engorged with blood, and their orifices are marked by black points, giving the disorder its characteristic aspect. Each pustule is encompassed by a red areola; matter, mingled with the natural secretion, gradually forms in its interior; and, after a short time, a thin scab appears, which, on falling off, exposes a florid and slightly elevated prominence, that gradually sinks to the level of the surrounding surface. Small scars sometimes remain; and, in old chronic cases, the skin is often quite hard, exhibiting a rough, granu- lated appearance, with varicose enlargement of its vessels. Seated in the sebaceous follicles, and closely allied to the disease just described, is sycosis, the mentagra of Willan and Alibert. Its distinguishing feature is the successive evolution of numerous sharp- pointed pustules, scattered over the hairy scalp, upper lip, chin, lower jaw, and side of the face, occurring usually in adults, and preceded by considerable redness of the affected part, with a sense of heat and tension. Red vesicles soon become visible, which, by the third day, assume a pustular form, standing out like circumscribed elevations, the summits of which grow white, and gradually fill with pale yellowish matter. The prominences subsequently increase a little in size, and, when fully developed, are as large as a millet-seed. Between the sixth and seventh day, each pustule bursts, its sides shrink, and a slight discharge takes place, which dries into a brownish crust, that is feebly adherent to the skin, and insensibly lost in the adjacent epidermis.1 When the pustules are very numerous, they sometimes coalesce, and the inflammation is then apt to extend to the subjacent cellular tex- ture, which is rendered hard and painful, and exhibits all the appear- ances of a true phlegmonous swelling. The pustules themselves are quite large: they rest upon a red, tuberculated base, often contain bloody matter, and are covered with thick, dirty-looking incrustations. The skin is sometimes very much altered, sprouting out in the form of moist, vegetating excrescences. Arrived at this stage, the disease is extremely intractable, and presents a most loathsome aspect; the hair falls out, and the part is constantly bathed with a thin, sero-san- guinolent fluid, often excessively acrid in its character. Ecthyma is an inflammatory affection of the dermoid texture, non- contagious, and characterized, at its height, by large, rounded pustules, usually distinct from each other, and resting upon a hard, florid base. All parts of the body are liable to it; but the regions most frequently involved are the neck, chest, and shoulders. The eruption generally begins by small, reddish elevations, which rapidly augment in size, and become filled, in the course of a few days, with sero-purulent matter, the base, in the mean time, extending in diameter, and exhibit- ing a bright scarlet hue. In this state, the larger and more mature pustules have a conoidal shape, are hard and painful on pressure, and bear a close resemblance to small boils, their size being between that of a lentil and a pea. A pseudo-membranous substance is also fre- quently to be distinguished in their interior, particularly towards their centre. 1 Rayer's Treatise on Diseases of the Skin, p. 481. Second edition. London, 1835. 316 SKIN. In from three to five days, the contents of the pustules escape, and concrete into thick, whitish adherent scabs, the disengagement of which, occurring at indefinite intervals, leaves the part of a red, livid color, each spot being from four to eight lines in diameter, and marked at its centre by a minute, superficial cicatrice. Acute ecthyma is often ac- companied by severe lancinating pains, and has only one crop of pus- tules; whereas the chronic form of the disease, which is by far the most common, has always a continued succession of them. Some of the pustules occasionally terminate in ulceration, producing ill-con- ditioned, painful sores, attended with a sanious bloody discharge, and followed by thick, dark-colored crusts. Impetigo is a non-contagious chronic disease, which is exceedingly prevalent in this country, in young children during the period of den- tition, especially in such as are of a scrofulous habit. It is most fre- quently observed on the face and legs, and next in order on the forehead, neck, and trunk. In some instances—and these are not infrequent—the disease covers all these parts simultaneously, or gra- dually travels from one to the other. The pustules are small, irregu- larly circumscribed, with only a slight elevation of the cuticle, and terminate in thick, rough scabs. The disease is accompanied and produced by inflammation of the part affected, which continues for an indefinite period, and causes considerable enlargement of the capillary vessels, particularly of the veins. At first, the eruption is vesicular; but, like that of smallpox and other kindred disorders, it becomes pustular, the elevations being distended, in a few days, with sero-puru- lent matter, which is often poured out in great abundance, and rapidly hardens into thick, semi-transparent, friable scabs, resembling frag- ments of dried honey. Occasionally, the incrustations, instead of being of a clear yellowish color, are of a light greenish, brown, or mahogany hue. The scabs having fallen off, the denuded skin is observed to be of a deep red complexion, slightly fissured, abnormally thick, tender on pressure, and to exude a considerable quantity of sero-purulent matter. Impetigo appears under two principal varieties of form—the small pustules that characterize it being, in the one, irregularly disseminated, with healthy or more or less inflamed intervals—in the other, disposed in groups, generally of an oval shape, and resting on a tumid, rose- colored base. Each of these varieties is acute or chronic, according as there is only a single crop of pustules, or a successive reproduction. Closely as this disease resembles ecthyma in many of its features, it can always be easily distinguished from it by the smaller size of its pustules, their mode of development, and the lighter color of their base. The term porrigo is applied to a chronic inflammation of the skin, essentially contagious in its nature, and characterized principally by the appearance of its scabs, which are of a bright yellow color, very dry, thoroughly adherent, and of a circular shape, with a central, cup-like depression, and thick, prominent, and inverted edges. The most usual seat of the disease is the scalp, from which, however, it often extends to the forehead, temples, chin, eyelids, and other regions, VACCINIA. 317 until, in some instances, it covers almost the entire body. Occurring in both sexes, at all seasons of the year, and at all periods of life, it is most common in infancy and childhood, and is always of indefinite duration, lasting at one time only a few weeks, at another a number of months, and, in a third series of cases, perhaps several years. Alibert describes five varieties of porrigo ; AVillan not less than six. These divisions are certainly uncalled for, as they differ from each other merely in the intensity of the morbid action, the location of the disease, and the distribution of the pustules. The mildest form of the eruption affects the head and face of infants, and is usually known by the name of crusta lactea. Porrigo, in whatever form it may appear, or wherever situated, always commences in very small pustules, scarcely rising above the surrounding surface, and covered, from the very first, with a thin, yellowish crust, with a minute, central pit. Examined at this period, the pustules are found to contain a drop of sero-purulent matter, which, instead of escaping, as happens in most other kindred diseases, always remains, and dries in their interior. The scab, manifesting itself, as we have just seen, almost simultaneously with the eruption, goes on increasing until it reaches the diameter of a ten cent piece; its central depression in the mean time becomes remarkably distinct; and, in the course of a week or so, it acquires all the characters above assigned to it. When the pustules are confluent, the incrustations often cohere, and are detached in large yellowish masses, leaving the cuticle tender, red, elevated, and marked with deep lines. Excessive itching gene- rally attends this disease, and the scabs are often reproduced in great numbers and with astonishing rapidity. The odor of the scabs is peculiar. In general it resembles that of the urine of the cat. When the scabs are softened with emollient poultices, the smell changes, becoming faint, sickening, and a good deal like that caused by boiling bones with their ligaments. The substance of which they are composed has been analyzed by Thenard, who found that one hundred parts contain seventy of coagulated albu- men, seventeen of gelatine, five of phosphate of lime, and eight of water. Porrigo is supposed by some to be seated in the piliferous follicles, an opinion which seems so much the more plausible, when it is re- membered that the disease principally occurs in those regions which abound in these structures, and that a hair frequently occupies the centre of each pustule. However this may be, the hairs are always considerably affected ; they become dry, stunted in their growth, and many of them fall off. This is particularly apt to take place in chronic porrigo of the scalp, the furfuraceous variety of Bateman, which is almost always attended with permanent baldness. Occasionally, the piliferous follicles remaining, a new crop of hairs is produced, which are then thin, white, and downy. Vaccinia, vulgarly called cow-pox, is a contagious disease, which is transmitted by inoculation from one individual to another, and which is characterized by the development of large, multilocular, pearl-colored pustules, surrounded by an erythematous areola, and succeeded by a 318 SKIN. brownish scab, which falls off about the twenty-fifth day, leaving a pitted scar. Three well-marked stages are to be observed in the pro- gress of this affection. The first stage commences on the fourth day after the insertion of the virus, and terminates on the ninth. At this time the true vaccine inflammation first manifests itself, and the puncture, which until now resembled a mere scratch, assumes a pale rose color; it is somewhat conical in its shape, rises a little above the surrounding surface, and presents the appearance of a flea-bite. By the fifth day, the point has augmented considerably in volume; it is of an umbilical form, with a slight central depression, and its cuticular covering is elevated by a minute quantity of transparent fluid into a firm and resisting pustule. On the sixth day, all these characters are more distinct, and the affected part stands out in bold relief. The vaccine tumor is in- creased in all its dimensions, and its inflamed surface has a more transparent and polished aspect. The pustule, which until now was quite small, occupies a circle of about a line in diameter; its surface has a radiated, argentine appearance; its edges are smooth and rounded; and its centre is not only more depressed, but it is hard, dry, and of a darkish color. From this time on, the pustule gradually augments in size, the margin becomes more prominent, and the centre exhibits a concave cup-like form. During the second stage, that is, from the ninth to the eleventh day, the pustule attains its most perfect development, being about four lines in diameter, and projecting from one to two lines above the surrounding level. It is encircled by a vivid red areola, often several inches in extent, its margin becomes more full, and the central depression is either partially or wholly effaced. The erythe- matous surface around is the seat of a great number of minute vesicles, and there is marked swelling of the subjacent cellular tissue, extend- ing generally to the axillary ganglions, and rendering the limb stiff and painful. The virus, which is now ripe for use, is still limpid; and, if the pustule be punctured, it will ooze out, drop by drop, until the little cells containing it are emptied. These cells, as has been ascertained by dissection, are extremely small, as well as numerous, and perfectly distinct from each other, none of them communicating together. They are arranged in two concentric rows ; and the centre of each pustule is occupied by a minute quantity of yellow, muddy pus, contained in a sort of funnel-shaped receptacle just beneath the cup-like depression of the epidermis. On the eleventh day, the commencement of the third stage, the desiccating process sets in. The central depression assumes the ap- pearance of a light brownish crust, the contained virus acquires a muddy serous color and a viscid, ropy consistence, the areola gradually fades, the swelling decreases, and the epidermis falls off' in small fur- furaceous scales. By the fourteenth day, the pustule is greatly diminished in size, the scab is of a horny hardness and of a yellowish complexion, and the areola is reduced to a narrow purple circle not more than the eighth of an inch in diameter. From this period, the swelling and tension of the arm rapidly subside, while the vaccine crust VARIOLA. 319 augments in density and depth of color, and is detached about the twenty-fifth day, counting from the insertion of the virus. The scar thus disclosed, is slightly depressed, of a circular shape, from three to five lines in diameter, and of a pale, reddish hue, exhibiting a number of small honey-combed pits, indicative of the number of cells of the vaccine pustule. The cicatrice becomes ultimately whiter than the surrounding skin, and the pits remain indelible. The fallen scab is of a brownish mahogany color, hard, dry, brittle, of a circular shape, and more solid, as well as thicker and more opaque, in the centre than at the circumference. Its upper surface is smooth, convex, and somewhat polished; the other,'on the contrary, is rough, flattened, or slightly concave. Albumen is its chief ingredient. When recent, it may be cut into thin, grayish slices, which expand by macera- tion, turn white, and exhale a sickening animal odor. Drying hardens it very much, and trituration with water converts it into a ropy, cream- like mixture, which is capable of communicating the disease. The induration of the scab is much influenced by the atmosphere. If the air is excluded, the secreted matter is thrown off in small, soft pieces, without the formation, frequently, even of a scar. Variola is an acute cutaneous inflammation, consisting of numerous umbilical pustules, preceded and accompanied by fever. It is conta- gious, occurring generally only once in the same person, and running its course in about twenty-eight days. When the pustules are situated some distance from each other, the disease is said to be distinct, and confluent when they are agglomerated. It is also divided into natural and inoculated, according as it arises spontaneously, or from the in- troduction of the smallpox virus. The period which intervenes between the infection and the development of the disease varies from six to twenty days. The pustules not only cover the skin, but fre- quently also the mucous surfaces that are directly continuous with it, as the eyes, mouth, and pudendal lips. The eruption, which is sometimes preceded by a general erythema- tous blush, usually takes place from forty-eight to eighty hours after the commencement of the indisposition, appearing first on the face and neck, then on the chest, abdomen, arms and legs, and lastly on the hands and feet. This order of invasion, however, is not constant; for it not unfrequently happens that the disease first manifests itself on the trunk, and even on the extremities, before it attacks the head, although it is on the latter region that it is always most violent. The eruption begins in small, red, circular points, having very much the aspect of flea-bites, and which, although widely dispersed originally, rapidly multiply, and, in a few days, complete their number, the cutaneous surface being, in the mean time, hot, tumid, and shining. During the period which intervenes between the efflorescence and the suppuration, embracing nearly one week, the elevations gradu- ally increase, project above the level of the surrounding parts, and assume the appearance of distinct pustules, each of which exhibits a well-marked central depression. As early as the second day, these elevations are already bounded by a regularly formed ring of inflam- mation: their form is umbilical, and their summit contains a drop of 320 SKIN. limpid fluid. In this manner, the development proceeds until suppu- ration commences, which it usually does about the sixth day. During this period, constituting what is termed the eruptive stage, the pustules have a cellular structure, being composed of little compartments, sepa- rated by thin partitions which converge to a central point. The suppurative process having commenced, the pustules lose their umbilical shape and become hemispherical; their surface acquires a rough, whitish aspect; and their contents continue to grow more and more opaque, being at first of a milky hue, and afterwards of a pale straw color, with various degrees of turbidity. A small circular speck now generally appears in the centre of each elevation, which gradually extends towards the circumference, until at length the whole super- ficies assumes the same purulent look. Whilst these changes are taking place externally, the internal cellular structure gives way, the little compartments are broken up, and the matter occupies a single cyst, with dense, resisting parietes. With proper care, this cyst can be readily lifted out of its situation: it is of a rounded shape, from two to four lines in diameter, and is deeply lodged in the dermis, pro- jecting a considerable distance into its substance. The suppurative process usually begins on the forehead and face, and ends on the hands and feet, where the pustules also remain much longer before they break, owing, no doubt, to the great thickness of the cuticle. The intervals between the pustules, during this stage, are generally tumid, from the infiltration of sero-albuminous matter, and of a florid red, the inflammation being of a phlegmonous character; and the patient ex- periences a sensation of tension and soreness, occasionally amounting to real pain. About the tenth day, the pustules have arrived at their full height; they are filled with thick, yellowish pus, and present the appearance of so many little abscesses. The desiccating process always begins on the face, whence it gradually extends to the other regions of the body, occurring last on the feet and hands. It is usually accompanied with violent itching, and with a peculiar nauseous odor, not unlike that exhaled by the rattlesnake. The scabs, falling off from the tenth to the fifteenth day after the appearance of the eruption, are of a brown- ish color, lamellated, dry, and of a horny consistence. The scars which are left by their detachment, and which are commonly confined to the cranio-facial region, are depressed at their middle, and traversed by small narrow ridges, which often greatly disfigure the features, espe- cially in the confluent variety. In regard to their form the utmost irregularity prevails, some being circular, some oval, others angular. Their depth is usually considerable, presenting an appearance as if they occupied a goodly portion of the thickness of the dermis. These scars are at first red, but soon change to a dark purple color, which they retain for many weeks; by degrees, however, they grow whiter and whiter, but they always remain more pale and opaque than the rest of the skin. The skin of variolous subjects putrefies much more promptly than the cutaneous tissue in the sound state. By artificial injection all the capillaries can be so completely distended as to give the affected part PAPULAR DISEASES. 321 a red scarlet hue; but it is a singular fact that none of the matter ever finds its way into the pustules, or even into the dermoid substance immediately around them, owing to the circumstance that all the vessels in this situation are either obliterated or wholly destroyed, the tissue itself being of a deep, uniform color, and infiltrated with blackish blood. If mercury be used, a portion of it is generally effused both around and within the pustules; yet none of it appears to enter their vessels. Allied to the disease just described is varicella, which, like smallpox, is contagious, and usually occurs only once in the same individual, at- tacking children in preference to adults. Preceded by slight fever and other symptoms of derangement, the eruption generally commences on the body, though sometimes on the face and limbs, and gradually rises into small, red, circular points, which, in turn, are replaced by lenticu- lar, globular, or conical pustules, somewhat analogous to those of variola. The pustules are sometimes discrete, sometimes collected together; they are surrounded by a red, rose-colored areola, contain a transparent serous fluid, which in time assumes a thick milky appear- ance, are soft and flaccid to the touch, and generally terminate, from the fifth to the ninth day, with a thin, brownish, furfuraceous desqua- mation, which rarely leaves any cicatrice. The eruptive stage of varicella is rarely completed under two or three days, and hence the disease is often prolonged to a fortnight, the parts on which it first broke out being covered with scabs, when the pustules in other regions have scarcely arrived at maturity. 3. Papular Diseases.—The lesions arranged in this order are cha- racterized by hard, solid elevations, usually of the color of the skin, to which they impart a rough, uneven sensation, preceded and ac- companied by pruritus, and terminating by resolution, desquamation, or slight ulceration. Their progress is commonly slow; and there is no part of the cutaneous surface which is not liable to be attacked by them. The only diseases belonging to this division are lichen and prurigo. Lichen is a non-contagious disease, which may appear on any part of the body, though in most cases it manifests a decided preference for the neck, face, hands, and forearms. It is distinguished by hard, firm papulae, generally of a white color, sometimes red, almost always clustered together, and accompanied with considerable itching, which is augmented by the heat of the bed, and liable to well-marked exacer- bations. The elevations are seldom larger than millet-seeds; and, although commonly aggregated into irregular groups, yet occasionally they are united into circular patches, or into long, narrow strips, stretched spirally around the affected part. The accompanying redness, if there be any, disappears about the end of the fourth day, though sometimes not until much later, and is followed by a slight furfuraceous desquamation, which may continue for several weeks, or even months. In violent cases the papillae occasionally ulcerate, and discharge a thin, sero purulent fluid, which gradually concretes into small, soft, yellow scabs, somewhat rough, and easily removable. At other times, 21 322 SKIN. again, the elevations become confluent, and are surrounded each by a small, reddish border. In chronic lichen, the skin is harsh, dry, and sometimes considerably thickened. Deep fissures are also frequently observed, especially about the joints, and the cutaneous functions seem to be almost entirely suspended. Prurigo, in its essential characters, resembles lichen, but differs from it in the greater size of its papulae, the excessive itching, and the want of discoloration of the skin. It is always chronic, its duration vary- ing from one to many months; its most common seats are the neck, shoulders, and pudendal lips, where the desire to relieve the pruritus by scratching is frequently irresistible. The papulae are ordinarily very numerous, especially in young persons, and it is by no means unusual to observe several successive crops, new ones appearing as fast as the old ones heal. From the intolerable itching which attends them, they are apt to become torn by the nails, and replaced by small, blackish, circular scabs. 4. Bullar Diseases.—The bullar diseases, which are, properly speak- ing, only two in number—pemphigus and rupia—are marked by the formation of small bladders, of a circular figure, varying in size from that of a pea to that of a goose's egg, generally transparent, and filled with a serous, lymphy, or sero-purulent fluid, which is poured out between the dermis and cuticle. These small bladders attain their height in the course of seventy-two hours, when they commonly burst, and are succeeded by scabs, sometimes of considerable thickness. Their progress is generally chronic, and their, duration varies from one or two weeks to several months. Pemphigus is characterized by the formation of large bullae, gene- rally of a pale straw color, isolated, and occurring simultaneously on several parts of the body. In regard to its symptoms and duration, it may be divided into two distinct varieties, the acute and chronic. It is particularly apt to occur in adults and old persons, and is more common in males than in females. In the acute variety of this disease there are generally well-marked constitutional symptoms, which, in the course of two or three days, are followed by the eruption of small, red, circular spots, which, rapidly increasing in size, soon turn to a more dusky hue. They are then transformed into bulla?, varying from the magnitude of a pea to that of a large hazel-nut, of a rounded shape, and generally encircled by a vividly red border, from one to several lines in width. Their number is variable, from a single one to many; they increase in size during the first twenty-four hours, and the contained fluid, which is at first thin and limpid, becomes yellowish, turbid, and even reddish. They reach their acme by the end of the third day, when they shrivel and dry up; or they burst, and leave small, thin, brownish crusts. The spots exposed by these crusts are of a dull red color, of an irregular form, isolated, and liable, from time to time, to slight exfoliations. The duration of each bulla is about seven days, and not unfrequently there are several successive crops of them on different parts of the body, so that the disease may be protracted for two or three weeks. BULLAR DISEASES. 323 Chronic pemphigus differs from the acute principally in the greater tardiness of its progress, by the absence generally of the red areola, and in the peculiar mildness of the antecedent and accompanying constitutional manifestations. The bullae, also, are generally some- what larger; and, in some rare cases, they cover the whole surface of the body, though they are for the most part confined to particular regions. In three or four days from their first development, they usually break, pouring out a thin yellowish or reddish fluid, so acrid, in some instances, as to irritate the surrounding parts. The sores thus exposed present a red, inflamed aspect; and, as the epidermis dries over them and exfoliates, new bullae spring up in their neighbor- hood and follow the same course. In this way the disease may last for several months or even years. Old people are most liable to it, especially those whose constitution is exhausted by debauch and in- temperance. Rupia presents several varieties; but as they differ from each other merely in their extent and intensity, it will be sufficient, for all patho- logical purposes, to consider them under one common head. The affection, which is very analogous to ecthyma, usually occurs in a chronic form, its course being seldom run under several months. It is characterized by small, isolated, flattened bullae, about the size of a shilling, with or without redness of the skin, and filled with a serous fluid, which soon becomes opaque, puriform, or sanguinolent; and to which succeed thick, rough, dark colored crusts, somewhat thinner at the circumference than at the centre. Ulcerations, either superficial or deep, generally exist under these scabs, which fall off in the course of a few days, and are speedily succeeded by cicatrization. Such, however, is not always the progress of this disease. In some instances the sores remain open for a considerable period, forming scales which are removed as fast as they desquamate. Occasionally the disease disappears without the development of scabs. Rupia sometimes terminates in gangrene. This is particularly apt to take place on the thigh, breast, abdomen, and scrotum of young, cachectic children. The bullae in such cases are generally preceded by small livid spots, and they often form with great rapidity, their contents being somewhat acrid and of a blackish color. In a short time, the bladders give way, exposing extensive ulcerations bathed with a bloody, ill-conditioned sanies, and encircled by livid and pain- ful edges. Great constitutional disturbance usually attends this variety of rupia, and not unfrequently it terminates in death. Cica- trization is always slow, and the body is often disfigured with ugly scars. % 5. Vesicular Diseases.—This class of cutaneous diseases is character- ized by the evolution of small vesicles, acuminated or globular, distinct or confluent, and occurring generally in irregularly circumscribed spotsr the surface on which they appear being either of the natural color, or marked by inflammatory redness. The contents of the vesicles are at first thin and transparent, afterwards milky and opaque, or even slightly purulent. The eruptions arranged under this group may occur in any part of the body, are seldom serious, and may terminate either by 324 SKIN. resolution, desquamation, superficial excoriation, or the formation of soft yellowish scabs. Their duration varies from a few days to several weeks, or even months. Miliaria is an eruptive disease, generally, though not always, symp- tomatic of other affections, attended with profuse perspiration, and a feeling of heat and itching. Every portion of the body is liable to it, but the regions most frequently affected are the neck, breast, back, and inside of the thighs. Its duration is from one to three days. The vesicles, which are at first very small and transparent, are rarely confluent; but they often occur in irregular groups or patches, the sur- face over which they are scattered being either reddened, or of the natural color. When fully developed, as they generally are in the course of thirty-six or forty-eight hours, they are of a rounded form, pearly in their appearance, filled with a milky fluid, and about the size of millet-seeds. The eruption sometimes covers the greater part of the body, but usually it is widely scattered, and confined to par- ticular regions. From eczema this disease may be distinguished by the rapidity of its progress, the shortness of its duration, and by the larger size and greater distinctness of its vesicles. Eczema is an inflammation of the skin, non-contagious, and liable to occur on the scalp, ears, breast, scrotum, armpit, groin and pubes. Though usually limited to one or two spots, it sometimes occupies the whole surface of the body, and may be either acute or chronic. The disease is more frequent in warm than in cold weather, and in women than in men. Arising occasionally without any assignable cause, it is often induced by sudden vicissitudes of temperature, exposure to the hot rays of the sun, dry friction, and the internal or external use of mercury. Eczema is characterized, at its commencement, by an evolution of very minute vesicles, closely crowded together, transparent, silvery, and reposing upon a surface which is either of the natural color, or else more or less red and inflamed. After having continued for some time, the disease either becomes chronic, or it terminates in the absorp- tion of the fluid, or in superficial ulceration, followed by furfuraceous desquamation. Much itching and smarting often accompany this dis- ease, and hence it is frequently mistaken for scabies. From this affec- tion, however, it may be easily distinguished by its non-contagious- ness, and by the agglomeration and peculiar shining aspect of its vesicles. In violent cases of eczema, the vesicles become confluent, and are liable to break, giving vent to a thin, sero-purulent fluid, which gradu- ally concretes into soft, yellowish scales, often of considerable size and thickness. These are frequently denuded, leaving always, on being detached, a crimson surface, from which exudes a reddish serosity, which follows the same course until the inflammation subsides, the scabs becoming every time thinner and lighter, and the sore less red and sensitive. Cases of this kind frequently last for several weeks, some of the vesicles drying as others appear; and they are usually preceded, as well as accompanied, by strongly marked constitutional symptoms. VESICULAR DISEASES. 325 Fig. 108. When the disease runs into the chronic form, the skin being per- petually irritated by the evolution of new vesicles, and the constant discharge of ichorous matter, continues deeply inflamed, at the same time that it is very apt to become chafed and excoriated, especially about the joints. The eruption, in such cases, sometimes persists for months, the secretion, in the meanwhile, going on in full vigor; at other times, however, the discharge is either very slight, or the part is entirely dry, and covered with thin, soft yellowish scabs, which, on falling offj expose a cracked and slightly inflamed surface. Scabies is an inflammatory affection, contagious, accompanied by an insect, and characterized by pointed vesicles, transparent at the sum- mit, of a light rosy tint, and filled with a thin, viscid fluid. By scratch- ing, these vesicles are easily broken, when their contents escape, and ex- pose a corresponding number of small, red, inflamed specks, which fre- quently run into each other. The eruption is sometimes very trifling, but in many cases it is very ex- tensive, covering a large portion of the cutaneous surface. It never, however, appears on the face ; and is always most abundant at the flexures of the joints and between the fingers, owing, doubtless, to the great delicacy of the skin in these situations. In infants, the disease is usually developed in four or five days after exposure to the conta- gion ; in adults, in from one to two weeks. A slight itching is first felt in the parts, which is invariably increased by the warmth of the bed, by sitting near the fire, or by stimu- lating food and drink, and, in ple- thoric habits, is sometimes almost intolerable. No fever attends this affection. It has been already stated that this disease is accompanied by an insect. Whether this is a constant occurrence is not fully determined, but that it is occasionally observed is established beyond contradiction. The insect, the existence of which was long ago suspected, if not ac- tually demonstrated, by some of the older physicians, is called the acarus, or itch ciron, and is seldom to be found in the vesicle, but almost Fig. 109. 326 SKIN. always in a small epidermic canal, which leads from it, and which is either straight or tortuous, and several lines in length. The acarus (Figs. 108, 109) is of a white, opaque color, and about the size of the sharp extremity of the finest needle, presenting, when seen through the microscope, the form of a tortoise. It has eight small feet, and the head is a perfect retracting sucker; the belly presents several dark colored spots, and on the back are to be seen a number of eccen- tric lines, placed at short intervals, and having the appearance of joints. Herpes is characterized by distinct but irregular clusters of vesicles, which are set in close proximity upon a vividly red base, surrounded by intervals of sound skin. The spots thus formed vary in size from that of a guinea to that of the palm of the hand, and the vesicles from the smallest pin-head to that of a pea. The lymph of the vesi- cles, which is at first clear and colorless, becomes gradually milky and opaque, and ultimately concretes into thin brownish scabs, which fall off about the tenth day from the time of their eruption. Sometimes tedious ulcerations ensue, leaving strongly marked cicatrices; and now and then the disease disappears by desquamation, the fluid being absorbed by the end of the first week. In the zonoid variety, vul- garly called "shingles," the vesicles are aggregated into irregular oblique patches, in the form of a half belt. The patches generally begin at the centre of the body, whence they extend in an opposite direction, without ever passing the median line. Ringworm is another variety of herpes, the characters of which are so distinct as to render any particular account of it unnecessary. Herpes lasts from one to several weeks, passing through a regular course of increase, maturation, and decline. It is generally very mild in its character, may be seated on any part of the body, and often co- exists with other affections, either cutaneous or internal. 6. Tubercular Diseases.—The diseases arranged under this head are characterized by the development of small, solid, circumscribed tuber- cles, of a rounded or conical shape, of a reddish or purple color, gene- rally isolated, and confined to particular regions. After having con- tinued for some time, varying from a few months to several years, they either disappear, or terminate in ill-conditioned ulcers. The affections which properly belong to this division of the subject, and which are seldom seen except in tropical countries, are Greek elephantiasis, fram- bcesia, and lupus. Greek elephantiasis is a chronic affection, characterized by soft, promi- nent tubercles, which are irregular in their shape, and of a red, livid color. In their size they vary between a pea and a walnut: they are either painful or indolent; and, as they grow older, they gradually assume a dirty bronze complexion, at the same time that they acquire a greater degree of hardness and density. When ulceration sets in, they become the seat of ill-conditioned sores, discharging a thin, sanious fluid, which concretes into thick, adherent, blackish crusts. The most common seat of the disease is the face, the ear, nose, shoulder, buttock, and leg, which are often hideously distorted, both from the immense number of tumors, the furrowed state of the skin, and the SCALY DISEASES. 327 great swelling of the subjacent cellular substance. Does elephantiasis consist in a hypertrophied state of the cutaneous papillas? This is highly probable; but the question has not yet been determined by dissection. The disease is generally complicated with other affections, is almost always incurable, is occasionally hereditary, and is met with indiscriminately in adults of both sexes. Framboesia, vulgarly called yaws, is a chronic tubercular disease, indigenous in Africa, and extremely common in the West Indies. Although contagious, it can only be communicated by immediate con- tact, and is incomparably more frequent amongst blacks than whites. The period which elapses between the reception of the virus and the commencement of the eruption is not accurately determined, but pro- bably does not exceed several weeks. The disease affects the same per- son only once during life, and children are more obnoxious to it than adults. The eruption, which is generally preceded by slight constitutional symptoms, and which appears successively on different regions of the body, is characterized by minute flea-bite looking pimples, succeeded by irregular, prominent tubercles, which often present the shape, color, and size of a raspberry, a circumstance from which the disease has obtained its name. The vegetations thus formed are usually distinct at their summit, but almost always united at the base: they are firm, indolent, and covered with thin, dry, adherent scales. Finally, after remaining stationary for weeks, and months, if not years, they in- flame, become soft and spongy, and give rise to deep, foul ulcers, from which there is a constant discharge of a yellowish, acrid, and offensive fluid, which soon concretes into thick scabs. Their most common seat is the head; they also occur, though less frequently, in the axilla and groin, around the anus, on the scrotum, and on the pudendal lips. They likewise appear on the shoulders, buttocks, and limbs; but the scalp, forehead, and temples, scabbed and hideously disfigured, are the parts, of all others, which most frequently suffer. Lupus is a malignant disease, and belongs to the class of epithelial cancers. It is seated, for the most part, on the nose, cheek, and chin, and, if allowed to progress, successively destroys the cutaneous and cellular tissues, and finally the cartilages and bones. It usually com- mences in a small red point, which is hard and prominent, and appears to affect only the more superficial layers of the skin. The progress of the tubercle is slow and gradual, a long time often elapsing before it attains its full development. By and by, however, ulceration and scabbing commence; the sore is bathed with sanious matter, its edges are raised and indurated, and its bottom exhibits a foul, livid aspect. The tendency of the disease is to spread, both in depth and diameter; hence it frequently invades a large extent of surface, and produces the most frightful ravages. The ulcer sometimes heals spontaneously; the part of the skin over which the disease has passed remaining hard and red, like the cicatrice of a superficial burn. 7. Scaly Diseases.—The scaly diseases, located in the outer surface of the chorion, are characterized by the development of red spots, ele- vations, or blotches, over which the scarf-skin, dry, opaque, and thick- 328 SKIN. ened, incessantly exfoliates and reappears, the process of renovation and decay sometimes going on for years. Easily distinguishable from the crusts which attend vesicular affections, they generally proceed in a slow and insidious manner, unaccompanied with much local or con- stitutional disturbance; and, although they are rarely dangerous, they are always very disagreeable, as they have a tendency, especially if protracted, not only to disfigure the skin, but seriously impede the movements of the joints. Five genera of lesions may be described under this order, namely, lepra, pityriasis, ichthyosis, psoriasis, and pellagra. Lepra most commonly attacks the arms and legs, especially the su- perficial parts below the elbows and knees; it sometimes occurs on the hairy scalp, but seldom exclusively. Commencing in small, red, shin- ing points, scarcely elevated above the level of the skin, it soon forms pretty large patches, often an inch and a half in diameter, of an orbi- cular shape, disjoined or confluent, slightly depressed in the centre, and surrounded by a florid, prominent circle, from one to several lines in width. The epidermic scales are at first thin, smooth, polished, and transparent; but, in the course of a few days, they are replaced by others, which are lamelliform, hard, tough, opalescent, pearly, or of a pale straw color. These scales fall off, and are incessantly renewed, the surface beneath being somewhat rosy and inflamed, smooth in recent cases, and occasionally deeply chapped in old. This disease sometimes gets well spontaneously, the skin from which the scales are detached acquiring at first a peculiar grayish color, which sometimes persists for a considerable period afterwards. In the majority of cases, however, it slowly pursues its career, producing more or less thickening of the skin, and impairment of the locomo- tive powers. When leprosy is generally diffused, there is often con- siderable cutaneous inflammation, accompanied with extreme soreness, pain, and stiffness, sometimes amounting to such a degree as to render the motions of the joints impracticable, and confining the patient to his bed. The nails of the toes and fingers are frequently much thick- ened, opaque, of a dirty yellowish color, incurvated at the extremities, and very irregular on the surface; yet, notwithstanding this, there is rarely much constitutional disturbance. Pityriasis is a superficial inflammation of the chorion, chronic, non- contagious, and attended with an exfoliation of the epidermis, in the form of very thin, irregular, whitish scales, which are reproduced in great numbers and with astonishing rapidity. Considerable pruritus often attends this affection, leading to an irresistible desire to scratch. Sometimes the cuticle comes away in a mealy, furfuraceous, or pul- verulent desquamation; and, in the generality of cases, the chorion is singularly discolored, being sometimes of a copper tint, brownish, or almost black. The scales, whatever may be their size and form, are always dry, easily detached, and spread over a large surface, the affected part being often many inches in diameter, and interspersed with por- tions of sound skin. The most common seats of pityriasis are the scalp, eyebrows, breast, and epigastric region, together with the arms and shoulders. SCALY DISEASES. 829 Ichthyosis is a chronic cutaneous affection, appearing in large con- tinuous patches, which occasionally cover the greater part of the body. It is characterized by the formation of thick, rough scales, of a gray- ish-white color, and almost horny texture, without pain, heat or pruri- tus, and without the deciduous exfoliations which belong to lepra and psoriasis. The whole skin seems to be deeply involved in this affec- tion ; and hence, in the advanced stages, it is generally in an extremely dry, stiff, and Uncomfortable condition, at the same time that it is greatly hypertrophied and almost of gristly hardness, the different layers of which it is composed being no longer distinguishable from each other. In regard to their form, the epidermic scales present almost innumerable peculiarities. Sometimes they are of uniform thickness, and seem to be merely elevations of the common lozenges of the cuticle; sometimes they are flat, thin, and imbricated; some- times they have short rounded necks, with broad irregular tops; and occasionally, again, though very rarely, they sprout out in the form of excrescences, of a horny texture, and most grotesque appearance. The quantity of these morbid excretions is, in some instances, immense, the whole body being literally encased with them as with a shell. In old, inveterate cases, a considerable amount of calcareous matter is frequently poured out, both upon the surface of the scales, and in the intervals between them. The color of the scales varies not only in different subjects, but frequently in different parts of the same individual. As was before stated, most of them are of a grayish-white; but, in many instances, they are brownish, greenish, or blackish. They have also been known to exhibit a shining, pearly aspect, and to be surrounded by a blackish looking border. During the warm weather of summer, this disease sometimes nearly disappears, the scales dropping off in large quantities, especially at night. It is usually aggravated by arid states of the atmosphere, and is always most troublesome during the severe cold of winter. Un- pleasant sores sometimes attend ichthyosis, more or less painful, prurient, and discharging a thin, acrid humor: the general health is usually much impaired, and the whole body occasionally emits a peculiar, fishy exhalation. Sometimes the patient is harassed with pustular eruptions. Ichthyosis generally begins very early in life; and, in a number of instances, it has been known to be hereditary. The most common seats of the disease are the outer regions of the extremities, both upper and lower, the sides of the trunk, and the shoulders. The flexures of the joints and the inner surface of the thighs are seldom affected. Psoriasis, vulgarly called the scaly tetter, consists of solid, inflamma- tory elevations of the skin, forming various-sized patches, isolated or united, covered with thin, white, shining scabs, and commonly accom- panied by slight constitutional symptoms. The eruption sometimes affects a peculiarly tortuous, serpentine shape: in other instances, especially when it breaks out on the lips, it pursues a circular direc- tion, ring after ring forming regularly beyond the surface last attacked. The chorion is generally somewhat rosaceous, and, in bad cases, con- 330 SKIN. siderably thickened and chapped: a very disagreeable itching, attended occasionally with a good deal of pain, is pretty constantly present; and the scales, seldom very adherent, are frequently detached and re- produced. Sometimes the eruption is entirely confined to the limbs ; at other times it covers the whole body; and, in such cases, the patient appears to be literally inclosed in a squamous envelop. Occasionally, the nails split, become yellow, and at length fall off; and the least movement frequently produces rents in the skin, followed by a flow of blood. Occurring at all ages, it is liable to disappear, and recur at certain seasons; in some individuals it never entirely ceases. The fifth and last disease to be noticed under the present head is pellagra. This is very common in certain districts of Italy, where it sometimes prevails epidemically, especially during spring and summer, but is entirely unknown in this country. Adults alone suffer, and both sexes are equally liable to it. Its course, which is always chronic, lasts from one to several years, the complaint becoming annually more and more aggravated, until the unfortunate patient, harassed and dis- figured, finally sinks beneath its blighting influence. Dissection always discloses extensive lesion of the internal organs, particularly of the alimentary canal. More or less constitutional derangement usually precedes this affec- tion, which manifests itself by small, red, shining spots, accompanied with slight tumefaction of the skin, together with a sense of fulness and tension. By degrees, the color of these spots becomes deeper; their surface is covered with thin scales; and, as they augment in size, they unite, and form large, irregular-shaped patches. The skin, mean- while, is not only considerably thickened, but disfigured with deep rents and fissures. After remaining in this state for some time, the scales gradually drop off, disclosing a red, glossy surface, from which there is a constant bran-like exfoliation of the epidermis. The neck and limbs are the parts most usually affected. 8. Syphilitic Diseases.—The disorders comprehended under this ap- pellation are caused by the influence of the venereal virus, and mani- fest themselves under at least six varieties of form, the exanthema- tous, vesicular, pustular, tubercular, papular, and scaly. They are occasionally primary; that is, they appear simultaneously with the affection of the genital organs; but, in the great majority of cases, they are not developed until some time subsequently, generally, not under a few months; and they are then said to be consecutive. The eruptions appertaining to this group usually pursue a chronic course, are circular in their form, and present a characteristic copper color: though occurring in all parts of the body, they are principally ob- served on the forehead, nose, cheek, back, and shoulder, and are attended with thin, grayish scales, or with hard, thick, greenish scabs. In the exanthematous form, the spots are of a circular shape, and about the size of a quarter of a dollar: they are almost always situated on the trunk and extremities, are of a dark copper color, do not dis- appear under pressure, are never confluent, and generally terminate by a slight exfoliation of the epidermis. There is a variety of this erup- tion, which is characterized by small, irregular, grayish spots, of a SYPHILITIC DISEASES. 331 deeper red than the preceding, more transient, slightly confluent, and disappearing, though slowly, under the pressure of the finger. The vesicular form is extremely rare. It begins in minute, circum- scribed pimples, scattered over different parts of the body, to which succeed small vesicles, filled with a transparent fluid, and surrounded by a red, copper-colored areola; their progress is very slow, and their contents are either absorbed, or they concrete into thin scales, which, falling off at different intervals, leave the surface of a dingy, yellowish hue. The vesicles are sometimes extremely numerous, covering nearly the whole body. The third form of syphilitic disease is the pustular. This variety, as the name indicates, is characterized by the presence of small tumors, containing an ichorous, serous, or purulent fluid. Their size and shape are subject to considerable diversity. Occasionally, they are as large as a hazel-nut; but, under ordinary circumstances, they do not exceed the volume of a common pea, and, indeed, are seldom so large. In their shape, they are sometimes conical, sometimes oval, sometimes pediculated, sometimes rounded, and sometimes flattened, with a mi- nute central depression. Now and then, all these varieties are observ- able in the same individual. Their number is often immense, hundreds being scattered over a small extent of surface; and, as they form suc- cessively, they may be seen and studied in every stage of their develop- ment. Each pustule reposes upon a hard, copper-colored base: its internal structure is not known: it appears to be not unlike that of smallpox. After remaining for a short period, the contents of the pustules escape, concrete, and form hard, thick scabs, of a dark color, pretty firmly adherent, and sometimes circularly furrowed. In mild cases, the scabs soon fall off, and leave merely a chronic induration, a livid or grayish stain, or a slight cicatrice: in severe ones, on the contrary, deep, circular ulcers are exposed, with a foul, grayish bottom, and a hard, purple, and regularly-defined margin. In cases of the latter description, the scabs are frequently renewed, and are finally replaced by round, indelible scars. In the tubercular form—the most frequent, perhaps, of all—the erup- tion consists of small, red, copper-colored eminences, varyi-ng in size between that of a mustard-seed and an olive. Of a rounded, flattened, or conoidal shape, they are either isolated, assembled in groups, or arranged into perfect circles: they are smooth and polished, produce little or no pain, and become covered, in a short time, with a dry, scaly incrustation, which is generally reproduced as fast as it falls off. In the more aggravated forms of this variety of syphilis, the tu- bercles are inordinately large, prominent, of a deep violet hue, from three to six lines in length, and encircled by a well-marked, copper- colored areola. After continuing thus for some time, varying from a few months to several years, they become painful, inflame, suppurate, and are replaced by deep, foul, irregular ulcers, reposing upon a hard, purple base. A thick scab usually covers these erosions, which is repeatedly renewed, showing, each time that it is detached, that the sore is extending its ravages. When the tubercles are numerous, the 332 skin. ulcers, running together, often acquire a frightful size, and, on healing, leave disfiguring cicatrices. Papular syphilis is characterized by the occurrence of small, hard, solid elevations, containing no fluid, and terminating almost always in desquamation, seldom in ulceration, or in the formation of scabs. There are two varieties of the affection, one of which is acute and primary, the other chronic and secondary. In the first variety, which sometimes accompanies gonorrhoea, the eruption appears simultaneously on different regions of the body, and is completed in about forty-eight hours from the time of its first in- vasion. The papulae are extremely small, disjoined or grouped, of a red copper color, and of a slightly conical shape, being surrounded, here and there, by violet areolae, which are often confluent, and give the surface a characteristic yellow tinge. Ulceration rarely attacks these papulae: they disappear in a short time, and are followed by a furfuraceous desquamation of the cuticle. In the other variety, the eruption is developed in a slow and suc- cessive manner, being announced by small yellow spots, which are particularly numerous on the forehead, scalp, and extremities. The papulae, which are of a light copper color, are larger than the preced- ing, flat, of the size of small beans, grouped, and devoid of an areola. In time, the summit of each elevation becomes covered with a dry, grayish pellicle, which is regenerated as fast as it desquamates, until the disease finally entirely subsides. Meanwhile, the skin between the agglomerated papulae undergoes important changes; it assumes a dingy yellowish color, has a dry, shrivelled aspect, and is the seat of a constant exfoliation of the cuticle. The sixth form of syphilitic disease is the scaly, which manifests itself, as the name imports, by dry, grayish imbrications, situated on small, copper-colored elevations. This variety, which is always con- secutive, persists for a long time, and terminates by desquamation. The eruption, in the plurality of cases, appears in patches, which, although they may occur on all parts of the cutaneous surface, are most common on the forehead, scalp, and face. They are from four to eight lines in diameter, of an irregularly rounded shape, ordinarily isolated, smooth, polished, and somewhat elevated; each is covered with a thin, hard, whitish scale, which is very,slightly adherent, and which, on falling off, exposes a small, shining, copper colored eminence. 9. Stains.—There are certain discolorations of the skin, which, from the frequency of their occurrence, rather than from any pathological interest, require to be mentioned in this place. Of these, the principal are ephelis, lentigo, albinism, and nigritism. They are seated in the vascular network of the skin, and depend upon some alteration of the coloring matter; some of these stains are congenital, and it is a singular fact that they seldom affect the whole cutaneous surface. Their duration varies from several weeks to many years. Lentigo, usually called freckles, is characterized by yellowish, fawn- colored spots, varying in size from a pin-head to that of a five cent piece; they are most common on the face, neck, chest, and hands, in persons with light eyes and red hair; are often congenital, and last through STAINS. 333 life. When the spots are very numerous, they sometimes run into each other, and thus form large, irregular shaped patches. In ephelis, the stains are of a yellow saffron color, very irregular in shape, and much larger than in lentigo. Their most common situation is the neck, the anterior part of the trunk, and the inside of the thigh; they are never observed on the face, except during pregnancy, on which they are a frequent attendant. The spots, which are often pre- ceded and accompanied by considerable itching, are at first of a grayish color, small, isolated, and rounded; by degrees they assume a yellow tint, augment in size, and unite into large, irregular patches; their duration varies from a few days to several months, and their disappear- ance is frequently followed by slight exfoliation of the epidermis. The skin is sometimes converted into a dead, milky-white color, constituting what is termed albinism. This change, which is confined to no particular race, depends not upon the absence of the pigment, but rather, I apprehend, upon some modification of its component elements. Persons who present this peculiarity differ, in many re- spects from ordinary individuals. Their whole organization, both mental and physical, seems to be imperfect; the body is covered with a soft, silky down; the hair is often of a snow-white color; the eyes are feeble, and unable to bear the light; and the iris and choroid are of a light rosy tint, from the absence of black pigment. There is a variety of albinism, which is limited to particular regions of the body, usually the head and trunk, to which the term vitiligo has been applied. It commences in small, milk-white spots, which go on enlarging until they sometimes cover the whole surface. The spots are generally oval or rounded, and now and then they have an irregu- larly striated arrangement. When the disease occurs on the scalp, axilla, and pubes, the hair participates in it, and becomes deprived of its natural color. Negroes who exhibit this peculiarity are called piebald. Nigritism is the term employed to designate the reverse of the con- dition just described. The affection is generally local, appearing in small, irregular-shaped patches, from one to several inches in diameter; the parts of the body most subject to it are the genital organs of the male, and the nipple of the female. The face is also sometimes the seat of it, especially during pregnancy. It is well known that nitrate of silver, if administered for a long time, has the effect of imparting a gray slate color not only to the skin, but also to accidental cicatrices, the conjunctiva, and to the mu- cous membrane of the alimentary tube. The discoloration generally remains during life, and is always most conspicuous on the surfaces exposed to the light and air, as the face, neck, and hand. How this change is produced, the present state of our knowledge does not enable us to explain. The most plausible conjecture is that the color- ing matter of the skin has a special affinity for the substance in ques- tion, by which they combine with each other, at the same time that they undergo some alteration in their properties. What gives coun- tenance to this idea is, that the color remains after boiling, and that no impression can be made upon it by medicine. Mr. Brande asserts 334 NAILS. that he has detected oxide of silver in the stained organs. It should be added that the discoloration produced by this substance is occa- sionally of a dirty bronze appearance. SECTION II. NAILS. When a nail is torn away, it is gradually regenerated, the period required for this purpose varying from three to six months, according to its size, and the violence inflicted upon the secreting apparatus. Many years ago, I received a severe contusion on my left thumb, the consequence of which was an exfoliation of the corresponding nail. As the old nail became detached, a new one gradually formed, which, in six months from the time of the injury, had acquired its full size and development. Inordinate length of the nails is of very common occurrence, and would be still more so, were it not for the constant paring to which they are subjected. Left to themselves, they sometimes grow to the distance of three, four, or five inches, pursuing a tortuous, spiral course, so that they occasionally bear a much closer resemblance to claws than nails. Their thickness, under such circumstances, is gene- rally considerably augmented, from the superaddition of lamellae, which often overlap each other, like the scales of a fish. The exten- sion and thickening of the nails form a prominent feature in ichthyosis, leprosy, and elephantiasis. The nails, in these diseases, after having acquired a certain length, sometimes fall off, and are reproduced, though seldom perfectly. In Polish plait, the nails both of the fingers and toes often acquire a great size, and a yellowish, livid, or black complexion. The nails are sometimes absent, as a congenital defect. More fre- quently, they are unusually small, or developed imperfectly, their place being supplied by thick, horny cuticle. On herpetic persons we often find them very short, scaly, and of a thick, rounded, button- like form. In strumous subjects, they are sometimes deeply grooved, enlarged, and of an indurated, horny consistence. In protracted paralysis, the nails grow very slowly and imperfectly, from deficiency of nervous energy. A vicious situation is occasionally observed. Thomas Bartholin1 has recorded an instance where the nails occupied the anterior ex- tremity of the metacarpus, the fingers being absent. In other cases they occupy the lateral surfaces of the fingers. In monsters, the nails of the fingers are sometimes consolidated, and the same deformity has been observed in adults. In pulmonary phthisis, the nails are fre- quently incurvated. 1 Hist. Anat., t. i. 291. HAIRS. 335 The ungueal matrix is subject to a peculiar disease named onyxitis. It commences in a circumscribed swelling of the ungueal matrix, with pain and deep redness. In a short time, a thin, ichor- Fig. no. ous fluid issues from the cleft at the root of the nail, and at last the soft parts give way. The ulcer is at first very small, but gradually extends, until it finally involves the whole of the ungueal matrix, together with a portion of the dermis immediately Onyxitis, affecting the great toe. around it. The surface is brown and glossy, the margin thin and sharp, the discharge fetid and irritating. The pain is sometimes intense; at other times the disease is more indolent, and accompanied with little uneasiness. The nail is formed very imperfectly; it loses its natural shape and color, becomes irregular, dry and black, and at length falls off. When this happens, it is seldom completely regenerated. The surrounding skin is tense and livid, and the affected extremity assumes a bulbous appearance, often exceeding double the normal size; in cases of long standing, the disease sometimes invades the subjacent bone. Onyxitis occurs chiefly in young persons, and attacks the thumb more fre- quently than the fingers or toes. It may continue for years. SECTION III. HAIRS. 1. Most of the lesions of the hairs are directly referable to inflam- mation of their follicles. In general, the inflammation pursues a chronic course ; but what particular changes the structures in question undergo, is by no means ascertained. It is altogether probable that the piliferous follicles are considerably swollen and injected, and that their power of secretion is either suspended, or, at all events, very greatly modified; so that the stem, instead of presenting its normal characters, is variously altered, both in its consistence, its length, its thickness, and, above all, in its color. 2. The Polish plait, a disease endemic in Poland, Lithuania, and Tartary, is an inflammatory affection. It generally attacks an im- mense number of piliferous follicles, which in a short time acquire an extraordinary size, rising above the level of the skin, being painful on the slightest touch, and exuding a large quantity of viscid, brownish and offensive matter, by which the hairs are matted and glued into inextricable tangles, of great length. Even the stems are swollen and 336 HAIRS. increased in thickness; their cavity is also larger than in the sound state, and their areolar texture is rendered unusually distinct. This disease generally appears during the autumnal months, is observed chiefly in the lower classes, and is often extremely obstinate and per- sisting. Although the hairs of the head generally alone suffer, yet those of the beard, axilla, and pubes, are sometimes similarly affected. It has been asserted that the hairs occasionally bleed in this disorder, but this is still a litigated point. The late Professor Meckel, of Halle, carefully injected the scalps of two persons that died while laboring under the Polish plait, and in neither did he succeed in throwing any of the fluid into the matted mass or horny portion of the hair. These experiments, however, are far from being conclusive; for it is obvious that vessels might have existed in the parts referred to, and yet, owing to their extreme minuteness, the artificial fluid might have failed to reach them. 3. When the hairs are plucked out, they are always regenerated, provided the secreting pulp remains unimpaired. When this struc- ture is injured, the new growth is proportionably slow and imperfect. In old age, the piliferous sacs become atrophied; they lose their energy, diminish in size, and are at length completely annihilated. The same phenomenon occurs in certain diseases, as bilious fever, scarlatina, psoriasis, and secondary syphilis. The falling of the hairs is often temporary, and probably depends upon some transient disease of the piliferous follicles. A few years ago a friend of mine, after recover- ing from a severe attack of scarlatina, lost every hair on the body; in a few months new ones sprang up, and in time acquired all the cha racters of the former crop. Persons seldom grow bald all at once. The crown of the head is generally affected first, whence the depila- tion gradually extends in different directions. The piliferous follicles in this affection seem to die gradually; for, after the original hairs have dropped off, a new crop frequently appears, consisting of a thin, soft, whitish down, evidently formed by feeble attempts at reproduc- tion. 4. Hypertrophy of the hair is sometimes observed. It is most fre- quent on the head, but may also occur on other parts of the body, as the beard and pubes. The most remarkable case of hypertrophy of the hair of the head, of which I have any knowledge, occur- red in a friend of mine, a young lady about twenty years of age. From her earliest youth she was subject to cephalalgia, but did not appear otherwise unwell. Her complexion was unusually fair, her eyes light, and her hair of a flaxen hue. In consequence of her con- stant headaches, the hair was commonly kept short; but, to effect this, as it grew with extraordinary rapidity, it was necessary to cut it every few weeks. Within a year of her death, her general health gradually declined without any assignable cause, save the astonishing develop- ment of the hair, attended with severe cephalalgia. During the last three months, the hair, although it had been cut only a short time before, reached nearly down to the heel, and had a soft, oily feel: the pain in the head increased in violence, the countenance became blanched and almost transparent, and she died gradually exhausted, HYPERTROPHY. 337 having, within a few days of her dissolution, exhibited symptoms of acute phrenitis. On examination after death, the only remarkable circumstance observed was a slight accumulation of water in the ven- tricles and at the base of the brain. It is impossible to doubt that this abnormal growth of the hair depended on hypertrophy of their follicles, constantly inviting an excess of blood to the head at the expense of the rest of the system. This is proved by the extraordinary develop- ment of the hair, by the obstinacy of the cephalalgia, and by the symptoms which were present during the last few months of the young lady's illness. The particular state of the piliferous follicles was not ascertained. Scarcely less extraordinary is the development of the beard in the female. Of this species of hypertrophy not a few examples are re- corded by authors. A remarkable one came under my own observa- tion some years ago. The woman, who is the mother of a numerous offspring, is seventy-eight years of age, and has always enjoyed excel- lent health. The sides of the face, chin, and lips are all thickly covered with coarse hair, which she is obliged to shave off regularly once a week. Her whole aspect is remarkably masculine; and, but for the length of the hair of the head, she might be easily mistaken for a male. The hair of the pubes sometimes attains an extraordinary development, forming long, thick tufts; and similar appearances have been witnessed on the shoulders and buttocks. The hair often loses its normal form, hanging about the head in soft, straight locks. Cases have occurred in which it could not be kept in curl if there was the slightest indisposition; and, on the other hand, an instance is narrated in which it always curled in a fit of the gout. There are cases, again, wherein the hair, in consequence of some imperfection in its growth, becomes remarkably brittle. A curious case is recorded by Mr. Mayo1 of a young lady, whose hair, without any assignable cause, suddenly broke, at a quarter of an inch from the head, and fell off in large locks. This singular process was re- peated every three or four weeks. She was subject to severe headache, but in other respects her health appeared to be perfectly good. 5. A change of color of the hair is a natural consequence of old age, but it also occurs in different diseases, and from the influence of the depressing passions, such as grief and fear. What alterations the pilous system undergoes, under such circumstances, we have no means to determine. The discoloration, though for the most part gradual, has been known to take place in the course of a few hours. When caused by age, it generally begins at the loose extremities; the same fact is observed in animals which change their complexion for the winter. The restoration of color, on the contrary, always commences at the root. 6. An accidental development of hairs is not uncommon. This is often seen upon congenital moles, as well as upon parts of the skin that have been for a considerable period in a state of irritation. As occurring in the stomach, bowels, and urinary bladder, numerous cases 1 Outlines of Human Physiology, p. 468. 22 338 NERVOUS SYSTEM. have been recorded by Haller and other authors. They have also been found in the gall-bladder, in cutaneous tumors, and in the ovary. In the latter organ they generally coexist with dropsical accumulations, carcinoma, or extra-uterine foetation, and hence they are almost always accompanied by adipocirous matter, by teeth, and by pieces of bone. In most of the situations here specified, though not in all, they per- fectly resemble the normal hairs, both in their color and structure, being composed of distinct roots and stems. Concerning their mode of origin, however, we have no positive information. CHAPTER XI. NERVOUS SYSTEM. I. Lesions of the Brain.—Wounds.—Encephalitis.—Suppuration.—Abscesses.—Gangrene.— Softening.—Chronic Inflammation. —Induration.—Ulceration.—Sanguineous Effusions.— Hypertrophy and Atrophy.—Tubercles.—Melanosis.—Encephaloid.—Cartilaginous Forma- tions.—Calcareous Deposits.—Cysts and Hydatids.—II. Lesions of the Cerebral Envelops.— Inflammation of the Dura Mater.—Suppuration.—Fibrous Tumors.—Bony Deposits.—Hy- pertrophy of the Glands of Pacchioni.—Arachnitis.—Hydrocephalus.—Tubercles.—Diseases of the Pia Mater.—III. Lesions of the Spinal Cord.—Inflammation.—Heterologous For- mations.— Hydro-rachitis.—IV. Lesions of tlie Nerves.—Restorative Power.—Neuritis. —Suppuration.—Ulceration.—Hypertrophy and Atrophy.—Diseases of the Nervous Ganglia. SECTION I. BRAIN. The brain is subject to various forms of disease, amongst which acute and chronic inflammation, suppuration, softening, ulceration, sanguineous effusions, and new growths, are the most common and important. 1. Wounds.—Various experiments have been instituted by patho- logists, with a view of ascertaining whether wounds of the brain and spinal marrow are susceptible of cicatrization; but with so little success that the knowledge which has been thus obtained is comparatively unimportant. The cause of this is to be found chiefly in the fact that the animals, the subjects of the experiments, almost always die at an early period after the operation, from the effects of acute encephalitis, thus allowing the parts no chance of healing. If life be preserved for a few days, the edges of the wound are found to be greatly injected with blood, of a deep rose color, and considerably augmented in den- sity, the induration often extending to the distance of three or four lines into the surrounding tissue. AVith these changes is usually seen a small quantity of soft, reddish lymph, which is smeared over the INFLAMMATION. 339 incised parts, and serves as the basis of the future granulations, which always spring up, if the animal survive the operation a week or a fortnight. Not unfrequently the cerebral tissue, instead of grow- ing hard and firm, acquires an unusual degree of softness, from the infiltration of serosity, pus, or blood, or from the influence of all these fluids united. In other cases, these two characters are combined, the edges of the lesion being dense and indurated, whilst the parts imme- diately around them are soft, boggy, and permeated with liquids. Appearances of scars, sometimes of very large size, are not un- frequently discovered in the brain after death, for which pathologists have found it extremely difficult to account; that they are formed, however, by the same kind of mechanism as in the other textures of the body, is by no means improbable. Thus, when, for example, the cerebral substance is lacerated by an effusion of blood, the fluid, as will be subsequently shown, occasionally becomes organized and incased in a distinct cyst, which either remains during life, or, as is perhaps more generally the case when the extravasation is not very , copious, it is acted upon by the absorbents, by whose influence it is gradually destroyed, or reduced to a dense, fibrous texture. When this has been accomplished, there is generally to be found a true linear cicatrice, of a light citron color, and much harder than the cerebral substance, although softer than the scars which we find in most of the other tissues. These cicatrices have usually a laminated arrangement, with a thickness from the third of a line to the eighth of an inch or more; yet, not unfrequently, they are perfectly cellular, moist, vascular, and filled with serous fluid. 2. Inflammation.—Encephalitis, cerebritis, or inflammation of the brain, seldom exists as a primary, idiopathic, or uncomplicated affec- tion : most commonly it is the result of previous disease, as fevers, especially such as are of an eruptive nature, apoplectic effusions, tumors, and external injury. When produced by violence inflicted on the scalp and cranial bones, the inflammation is generally limited in extent, although intense in degree. It never involves the whole organ at once; for such a condition would be incompatible with the continuance of life. Ths disease may occur at all ages, and in all parts of the encephalic mass, although some are more obnoxious to it than others. The anatomical characters of the inflamed structure vary according to the duration and intensity of the disease. At first, there is merely a slight increase of vascularity, with a reddish rose-colored state of the cerebral substance. When sliced with a sharp knife, it presents a multitude of small red points, which give the section the appearance as if it were strewed with particles of vermilion. The capillaries are everywhere greatly injected; and so firmly is the blood crowded into them that it is with difficulty removed by ablution. Not unfre- quently small ecchymoses are met with, caused, no doubt, by a rupture of minute vessels, in consequence of the violence of the inflammatory action. Although the extravasation often occurs in distinct spots, yet it occasionally presents itself in irregular lines or streaks, which, when numerous, give the cerebral substance a singularly mottled aspect, with • 340 BRAIN. various tints of red, the color being usually more florid in the cortical than in the fibrous texture. At this early period of the inflammation, there seems to be no dis- tinct line of demarcation between the sound and diseased parts: in most cases they run insensibly into each other, the redness gradually declining in intensity as we proceed from the centre of the irritation towards the periphery; and, although the affected structure is less tenacious than in the healthy state of the brain, it is firmer than usual, from the turgescence, apparently, of its vessels. As the disease advances, the vascular injection becomes more and more strongly marked, and the reddish color which was displayed in the earlier stage, gradually deepens, until it acquires a brownish, claret purple, and occasionally even a greenish or dusky yellowish shade. With this augmented capillary turgescence, amounting almost to com- plete obstruction, the part becomes preternaturally soft, and assumes that peculiar alteration of character which has been described under the name of cerebral mollescence. The substance of the brain, when thus affected, has entirely lost its. natural properties: it has a humid, macerated appearance, from the infiltration of serosity, purulent matter, or blood, and is often con- verted into a soft, grayish pulp, bounded by a hard, vascular border, exhibiting all the signs of the first stage of inflammation. Several such disorganized spots are sometimes met with, either in close proxi- mity, or separated by considerable intervals. When the affected struc- ture is pervaded by numerous globules of pus, it is very apt to have a citron hue, and then constitutes what has been termed the yellow softening of the brain; from which the red softening differs only in being of a deeper color, the broken down pulp varying from a florid to a claret tint, with intermediate shades of violet, brown, chestnut, or cineritious. The different appearances now described are not unfrequently met with in the same diseased portion. Thus, we may have the reddened, indurated state at the circumference; next, that of serous infiltration ; and, finally, that of purulent softening in the centre. The pus always occurs here, as elsewhere, at first in disseminated globules, and after- wards, if the patient survive long enough, in distinct foci. The red and yellow softening are frequently combined, one portion of the in- flamed structure presenting the bloody, the other the purulent infil- tration. It has been already stated that the affected part, in the early stage of encephalitis, is, in the generality of cases, somewhat harder than it is in the normal condition. The degree of consistence is subject to remarkable variations, running through all the intermediate grades, from an indurated, firm, and elastic body to one of almost perfect fluidity. The softened mass, in such cases, is generally surrounded by the hardened, which is itself intimately, and, for the most part, insensibly blended with the healthy cerebral tissue. In the early stages of encephalitis the red color of the inflamed part cannot, as was before intimated, be removed by ablution, nor can the engorged vessels be filled with minute injecting matter, thus pre- SUPPURATION. 341 senting a striking analogy with what takes place, under similar circum- stances, in the serous and mucous membranes, as well as in the liver, spleen, and kidney. The vascular and serous envelops of the brain are not unfrequently affected in this disease. When the cerebritis is located superficially, the inflamed portions always adhere to these tunics with unnatural firmness, especially in the early stages of the complaint; and hence, in attempting to peel them off, fragments of cerebral substance, traversed by red and distended capillaries, generally follow. The vessels of the pia mater, under these circumstances, are commonly much engorged; the arachnoid is opaque and adherent; and the inter- gyral hollows are filled with sero-albuminous matter, with blood, or even with pus. From this rapid sketch of the anatomical characters of acute cerebritis, it will be perceived that the first effects of the disease consist simply in capillary engorgement, in punctated or striated redness, which is usually more conspicuous in the cortical than in the fibrous texture, and in increased hardness, varying in degree according to the intensity of the disorder; and, secondly, that, if the inflammation be allowed to go on unrestrained, it finally passes into mollescence, in which purulent, bloody, and cerebral matters are in general intimately blended together, forming a mass of a semi-liquid consistence, and of a light brownish color, with various shades of yellowish, grayish, claret, or even greenish. Although all parts of the brain are liable to acute cerebritis, yet there are some which are much more frequently affected than others. The most common seat seems to be the cineritious texture, the great vascularity of which strongly predisposes it to inflammation and its consequences. Thus, of forty-six cases of this disease, collected by Lallemand, the gray substance was the principal seat of the inflamma- tion in thirty-three, and the white only in eight. The surface of the convolutions, which consist entirely of cortical matter, was affected in sixteen cases; the striated bodies and optic couches, in which the same substance predominates, in thirteen; and the Varolian bridge, which is made up chiefly of fibrous matter, only in four. Some in- fluence must, also, no doubt, be allowed to the greater extent of surface of the gray substance, and to its intimate connection with the pia mater, which can seldom be much inflamed without the disease being propagated to the contiguous parts of the brain. Acute encephalitis usually reaches its full height within three or four days from its invasion. When partial, the patient often recovers; but should it occupy a large extent of surface, it generally proves fatal in a very short time, not unfrequently, indeed, in thirty-six or forty-eight hours. 3. Suppuration.—Inflammation of the brain not unfrequently passes into suppuration, the matter occurring either in the form of small yellowish globules, or in that of abscesses. The most common seat of the disease is in the anterior half of the cerebral hemispheres, on a level with the great commissure; no portion, however, of the cerebro- spinal axis is exempt from it, cases of it having been found in the 342 BRAIN. cerebellum, posterior lobes of the cerebrum, spinal cord, medulla oblongata, Yarolian bridge, and even the quadrigeminal tubercles and pineal gland. Collections of purulent fluid present themselves under several • varieties of form. In one, which may be denominated the undefined abscess, the matter is contained in a cavity, the walls of which are formed by the surrounding brain, and partly, perhaps, by its mem- branes, if it be seated superficially or near the ventricles. The inner surface of the abscess, though occasionally smooth and even, is generally rough, granulated, and shaggy, the purulent fluid adhering to it with various degrees of tenacity. The cerebral tissue immediately around the cavity is usually remarkably sound, there being seldom any sign of inflammation, induration, or softening. The size of these collections is variable. Not unfrequently they are as large as a walnut; but, for the most part, they do not exceed the volume of a pea, a grape, or an almond. Occasionally, almost the whole of one hemisphere is con- verted into a soft, purulent mass. The second variety of abscess is the encysted. The pus in this species, as the name indicates, is contained in a distinct capsule, formed by the deposition of plastic lymph. The capsule is, at first, soft, delicate, and easily torn: in time it becomes dense, remarkably firm, and completely organized, vessels ramifying through it in great numbers from the circumjacent cerebral tissue. The outer surface of the sac at this stage is rough and flocculent; the internal is smooth, of a rose color and somewhat villous, like the mucous coat of the stomach. Its thickness rarely exceeds that of the pericardium; but instances occasionally occur in which it is several lines thick. In cases of very long standing, the cyst is often very firm and indurated, from its conversion into fibrous, cartilaginous, or osseous texture. Under such circumstances, it is not unusual to find it composed of several folds, intimately connected with each other, but differing remarkably in their color, density, and thickness, the softest being generally internal, as if they had been secreted by the others. Cases, again, occur in which the cyst is divided into numerous cells, formed by hard, grayish, intersecting bands. The object of these cysts evidently is to serve as barriers to the extension of the pus which they inclose. Eudiments of them are occasionally found as early as the end of the first week; and it is not uncommon to see them perfectly organized at the expiration of a month. Patients thus affected not unfrequently live for a long time before the brain is so far destroyed as to render the continuance of life impossible. Horner mentions an instance in which the interval between the infliction of the injury—a pistol wound—and the fatal termination was nearly twelve months; Sir Everard Home, one of nineteen months; and Dr. Copland, one of upwards of three years. Similar cases are to be found in the writings of Sir Astley Cooper, Hennen, and other surgeons. When the cyst finally becomes the cause of death, it is by exciting fresh inflammation in the surrounding cerebral texture; or it may, acting in the capacity of a foreign body, SUPPURATION. 343 excite inflammation in the arachnoid membrane, and destroy life by the consequent effusions. Abscesses of the brain, however, do not always terminate fatally; for numerous cases occur in which there is every reason to believe that the pus is absorbed, and the cavity of the cyst gradually ob- literated by the approximation of its walls. The opinion, at all events, derives confirmation from the appearances of the large cicatrices which are so often found in the brains of old persons, and from the inter- secting bands which are occasionally seen uniting the sides of encysted abscesses. In respect to its appearance, the pus found in the brain differs in no essential particular from that in other parts of the body. In the generality of cases it is of a pale straw color, thick and inodorous; not unfrequently, however, it is greenish, reddish, or dirty white, thin, and remarkably fetid: this is particularly the case in young subjects who die from the extension of inflammation of the ear to the brain. In scrofulous persons, the pus is generally very thick and tenacious, from the admixture, probably, of plastic lymph. Suppuration of the brain sometimes takes place with great rapidity, as in two or three days. Laennec asserts that he has known pus to form here in less than twenty-four hours. The purulent fluid, when encysted, often manifests a tendency to pass from its original situation to some other. Thus, when it is seated in one of the hemispheres, it may work its way gradually to the surface, or into one of the ventricles, destroying occasionally, in the former case, the lining membranes, with the con- tiguous bone. In 1827, I examined the body of a stout athletic man, forty years of age, who died nearly three weeks after the removal of an osteo-sarcomatous tumor from the nose by the late Professor George McClellan, of this city. For the first two weeks after the opera- tion, the patient did remarkably well, and talked of returning to his friends, who lived several hundred miles off. A few days, however, before he had determined to leave, he was suddenly seized with violent rigors, followed in a short time by deep coma, and he expired after an interval of thirty-six hours from the attack. On examination, Dr. Gardner and myself found a large, undefined abscess, filled with thick, offensive matter, on the lower surface of the right anterior lobe of the cerebrum, with partial destruction of the cribriform plate of the ethmoid bone and the intervening membrane in its immediate vicinity. The brain is occasionally the seat of metastatic abscesses, but much less frequently than the lung and liver. They do not, as in these two organs, exhibit, at first, the rounded, circumscribed form, but ap- pear in small isolated points, which are extensively scattered through the cerebral tissue, and rarely, even in the worst cases, exceed the volume of a hempseed, or a small pea. Their number is sometimes immense. They are situated chiefly in the gray substance of the hemispheres and striated bodies: the cerebellum is also occasionally affected, but much more rarely than the cerebrum. The tissues in the immediate vicinity of the purulent collections are generally unaltered. 344 BRAIN. The disease, as in other parts, is very insidious in its mode of develop- ment, and is usually dependent upon injury of some distant organ. 4. Gangrene.—Gangrene of the cerebral tissues is a very rare affection, and probably never occurs except as a result of external violence. As an idiopathic disease, I am not aware that a single instance of it is to be found in the writings of pathologists. In this affection, the cerebral substance is at first of a reddish-brown color, but in a very short time becomes spotted with an immense number of minute points, resting upon a lilac, violet, or purple ground. At a more advanced stage, when the mortification may be considered as fully established, the affected part is converted into a soft, pulpy cartilage, of a blackish, brownish, or greenish color, and extremely fetid, a character which distinguishes this lesion from the simple softening presently to be noticed. The cerebral texture immediately around the sphacelated mass generally forms a hard, reddish belt, highly in- jected, and occasionally even slightly ecchymosed from sanguineous effusions. 5. Softening.—Softening of the brain is exceedingly frequent, both as an acute and as a chronic affection. It is by far most common in old subjects, but no age is exempt from it, not even early infancy. The parts of the brain which, according to my own experience, are most liable to it, are such as are most obnoxious to sanguineous effusions, as the fornix, interventricular septum, great commissure, optic couches, and striated bodies; the frequency with which they are affected being in the order here enumerated. In the majority of cases I have found the figurate bodies alone implicated, the convolutions and other struc- tures retaining their normal characters. Both cerebral substances are almost always simultaneously softened, though the white is often affected in a much greater degree than the cineritious. The extent of the lesion varies in different cases. Occasionally large masses are involved, as one-third, one-half, or nearly the whole of one hemisphere; more generally, however, the lesion occurs in circumscribed spots, varying from several lines to one or two inches, and leaving the rest of the organ of its natural color and consistence. Sometimes the softening occupies a space not larger than a cherry, a pea, or a millet-seed, while in others it is spread over almost the entire surface of both hemispheres and that of the ventricles. A remarkable example of softening of the brain came under my notice in 1836, in a man forty-five years old. In this case, examined twenty-seven hours after death, both the white and gray substance had lost much of their natural firmness and cohesion. The whole of the fornix, excepting its anterior pillars, the interventricular septum, part of the great com- missure, and the pineal gland, were completely dissolved. The striated bodies, optic couches, and quadrigeminal tubercles, were likewise much softened; and so tender was the base of the brain that the medulla oblongata, cerebral crura, and roots of the nerves, were all left behind in the attempt to remove the organ from the skull. In the cerebellum, the parts which were more particularly diseased, were the cerebello-testicular processes, the Vieussenian valve, and the gray substance at the under surface of each lobe. The vessels of the pia SOFTENING. 345 mater were excessively gorged with blood; and the fibrous texture of the hemispheres, especially of the right, exhibited a considerable num- ber of small, rose-colored patches, dappled with black points, corre- sponding with the orifices of divided capillaries. No lesion, so far as could be discerned, existed in any other organ. The appearance and consistence of the part affected vary according to the duration of the disease and the intensity of the exciting cause. In the early stages the changes are always very slight, and can only be recognized by the touch. At a more advanced period, the con- tinuity of the organic particles is sensibly disturbed, and the nervous substance is so soft that it may be readily broken down with the finger into a thin, pap-like mass. It is no longer able to sustain the slightest weight, and frequently has no more consistence than so much cream or thickened milk; it may be easily scraped with the knife, but to cut it smoothly is impossible. Having attained this degree of softening, the cerebral tissue soon falls to pieces, forming thus a breach of continuity occasionally of very considerable extent. If examined with the microscope, the small vessels appear coated with granular matter, and in the softer portions of the mass numerous granules and exudation corpuscles are seen mixed with portions of nerve-tubes. An odor like sulphuretted-hydrogen sometimes exhales from the disorganized mass; but this is rare. Although the softened parts are occasionally separated from the sound by a distinct line of demarcation, yet more commonly they run insensibly into each other. The color varies according to the time that has elapsed since the invasion. In the early stage, when there is usually a considerable degree of inflammatory turgescence, it is often of a uniform rose tint, studded with red dots, or marked with purple arborescent lines; more rarely we find small hemorrhagic effusions, and patches of a dark leaden hue, produced doubtless by intense capillary injection. At a later period of the disorganization, the part is usually of an opaque white, brownish, yellowish, or green- ish color ; or these tints are blended, different shades of them occurring at different points, or even at the same place. The dull milky hue, which is so frequently observed in this affection, is supposed by Lalle- mand to be caused by an infiltration of pus, an opinion which is evidently unfounded, as in the vast majority of cases no such fluid whatever is to be seen. In this condition, which is often found after hydrocephalus, the cerebral mass seems to be perfectly anaemic, not a drop of blood oozing from the affected part when cut. In some instances, the color remains natural. When this happens, which, however, is rather rare, the softening is usually confined to the fibrous structure, and may readily escape notice. In this affection, the pia mater is sometimes seriously implicated. When the softening is seated on the convoluted surface of the cere- brum or cerebellum, or on the surface of the striated bodies and optic couches, the membrane is generally preternaturally red and rough, and, on attempting to raise it, the disorganized gray substance often separates along with it. In other cases, I have found portions of the pia mater completely destroyed, or converted into a dirty brownish 346 BRAIN. pulp, devoid of every feature of the original texture. These changes are particularly liable to happen when the softening affects the surface of the figurate bodies in the floor of the lateral ventricles. In these cases the arachnoid frequently experiences the same fate. Chronic softening of the brain is probably quite as frequent as the acute form of the disease, of which it may be either a consequence, or it may exist as an original and independent affection. It may occur at any period of life, and all parts of the organ appear to be liable to it, though not in an equal degree. It may be limited to the white or cineritious substance, to a single convolution, to the striated body, or to the optic couch. Occasionally it is diffused throughout the dif- ferent cerebral structures, not uniformly, but in patches of variable extent. The most common seat of the lesion is the hemisphere, in- cluding the striated body and optic couch. The color of the softened part varies according to the nature of the cerebral tissue. In the fibrous substance it is always milk-white, dull-white, opalescent, or of a pale yellow; never red, brownish, or brown-red, as in the acute form of the lesion. There is a total ab- sence of congestion, and in many cases there is hardly even a vestige of capillary vessels. Occasionally, though very rarely, a few long, slender arterial and venous twigs are observed, but the interlacement which they exhibit is very different from the normal capillary plexus. In the cortical substance the color usually partakes more or less of the natural complexion of that tissue, that is, it is either a light gray, or a pale ash. This is particularly the case in the early stages of the disease. At a more advanced period, the affected part gradually loses its grayish color, and assumes a yellowish, or pale dusky aspect. This discoloration may be greater at one point than at another, but in the majority of cases it is pretty uniformly diffused over the seat of the disease. In the chronic, as in the acute form of the disease, the degree of softening may vary from a slight diminution of the natural cohesion of the cerebral substance to that of a thin solution of starch, or arrow- root, cream, or even milk. In the advanced stage of the disease, when the process is fully established, the affected structure is infiltrated with an unusual quantity of serosity, and reduced to a semi-fluid pulp, which is easily removed by the finger, the handle of a scalpel, or by a small stream of water. These changes, which are generally more conspicuous in the white than in the gray tissue, are frequently fol- lowed by the removal of the softened and disorganized matter, leaving in its place a small quantity of cellular substance, of a whitish aspect, traversed by bloodvessels, and exhibiting numerous meshes, filled with a turbid, whey-like fluid. The meshes are of an irregular form, and vary in size from a pin-head to that of a small pea; their walls are extremely delicate, and the fluid by which they are occupied is often mixed with flocculi, which appear to be nothing more than frag- ments of cerebral pulp. When the patient survives an attack of this kind, the cells thus formed are filled with plastic matter, which be- comes speedily organized, and gradually increases in firmness until it finally acquires all the properties of the cellulo-fibrous, fibrous, or SOFTENING. 347 fibro-cartilaginous tissue. In no case does there appear to be a re- production of cerebral matter. In the gray substance, in the advanced stage of the disease, there is a singular tendency to the production of yellow patches, of a flat- tened form, finely tuberculated, and extending, when the lesion oc- cupies the superficial portion of the brain, over two or more convo- lutions. They are remarkably coherent, their surface is traversed by minute vessels, and their consistence may be so great that they are with difficulty torn. In some instances they are surrounded by pulpy matter, and in others, though this is very rare, the cortical substance seems to be destroyed by ulcerative absorption.1 The duration of chronic softening of the brain is too uncertain to enable us to affix any precise limits to it. While some cases termi- nate in three or four weeks, others continue for several months, and even years; the disease in the mean time making very little progress, or even remaining perfectly quiescent. Softening of the cerebral tissue is usually of inflammatory origin. This is proved, first, by the fact that this lesion occurs at all periods of life, as well as in all parts of the encephalic mass, at one time as an acute, and at another as a chronic affection; secondly, that it is often produced by external injury, and by the pressure of certain tumors, or apoplectic effusions; thirdly, that it is frequently combined with suppuration in other parts of the brain; and, finally, that it occasion- ally supervenes during the progress of malignant and other fevers. That obstruction of the arteries, and a consequent interruption to the passage of the blood, followed by diminished vital power and cohesion of the part affected, may operate as an exciting cause of the malady in old subjects, is what may be easily supposed; but I am by no means certain that in cases even of this description there is of necessity an absence of all inflammatory irritation. Gangrene under such circumstances is usually, if not invariably, a gradual process, preceded and accompanied by perverted, if not incited, action. Softening of the brain is often found in connection with ascites, pulmonary phthisis, diabetes, chronic pleuritis, marasmus, and pro- tracted fevers. Grief, anxiety, and intense study, sometimes produce it. This was the appearance which the brain of Sir Walter Scott exhibited. The mollescence involved nearly the whole of the medul- lary texture of the left hemisphere, which was converted into a soft, flaccid mass, interspersed with numerous globules of water. This mis- chief was the result, in all probability, of a slow, chronic irritation, produced by the excessive intellectual labor to which this great man subjected himself during the last five or six years of his life, in con- sequence of his pecuniary embarrassments. Protracted confinement, with inactivity and low diet, has also a tendency to impair the natural consistence of this organ. A similar state has been witnessed in the cerebral tissues of idiots, lunatics, and epileptics. In an elaborate account of the anatomical changes found in the brains of maniacs and epileptic persons, published, in 1771, 1 Durand-Farel, Traite du Ramollissement du Cerveau. 348 BRAIN. by Dr. Greding, fifty-one cases are detailed, in more than one-half of which the organ in question was either partially or generally softened. Observations confirmatory of these have since been recorded by other writers. How softening, under the circumstances here specified, is in- duced, whether from diminished nutrition of the cerebral textures, or from irritative action, giving rise to an infiltration of serous fluid into its intermolecular spaces, is a point which challenges further re- searches. Old age, also, se ms to predispose to this affection; and the same may be said of arteritis. Obstructions and various morbid changes in the cerebral vessels, or in the arteries leading to the brain, are capable of causing the lesion. Thus, ligature of the carotid is sometimes followed by it, and so also is ossification of the cerebral arteries. Similar effects some- times follow obstruction by plugs of fibrin, washed from other parts of the system into the vessels of the brain. Sometimes the bloodves- sels leading to the part, as well as the capillaries in the part, are in a state of fatty degeneration; a circumstance on which considerable stress has been laid by some pathologists, who deny that the white form of softening with which it is associated, is ever of inflammatory origin. Minute examination of the softened tissue shows them to be,at times, filled with exudation corpuscles, especially in the acute or red soft- ening, whilst in the white softening these are absent; in fact, the cells and tubes are here sometimes apparently unchanged. Dr. Todd has, however, frequently detected in the white creamy matter a great num- ber of large cells containing oily substance. These curious organic globules would suggest, he thinks, that some active process had been going on during life. Softening of the brain is susceptible of reparation, the appearances varying in the gray and white substance. In the gray substance, the traces of the cure, when fully established, are, a peculiar cribriform aspect of the convoluted surface of the brain, either alone, or com- bined with atrophy and flattening, together with adhesion of the pia mater to the affected part. In the white substance, cicatrization is in- dicated by numerous little cells, containing a limpid fluid, and lined occasionally by a fine, delicate, transparent membrane, of a light fawn color. These cells have sometimes a worm-eaten appearance, and not unfrequently they seem as if they had been scooped out with a sharp instrument. In their figure, they strongly resemble the pores observ- able in new bread, their size varying from a pin-head to that of a bean. The cerebral tissue in the immediate neighborhood of these cicatrices is either of the natural consistence, slightly softened, or, as is more frequently the case, considerably indurated, according to the period that has elapsed since the commencement of the healing process. Occa- sionally the white matter has a peculiar granular aspect. 6. Chronic Inflammation.—Chronic inflammation of the cerebral tis- sue is much more common than acute, of which, indeed, it is not unfrequently a result. Its anatomical characters, though occasion- ally similar, are yet, in the great majority of cases, widely different; and it is therefore necessary that they should be considered under a distinct head. ULCERATION. 349 The most important feature of this disease is the augmentation of density of the affected tissue, giving rise to induration of the cerebral tissue. Not a little diversity is observable in regard to the degree of hardening. In the generality of cases, the consistence does not exceed that of concrete albumen; not unfrequently, however, the part is as firm as cheese; and instances occur, although very rarely, in which it is as dense and elastic as fibro-cartilage. The latter species of induration is generally seen in small, isolated masses around old apoplectic cysts, tubercles, and fungous growths. The other two, which often occupy a considerable extent of surface, sometimes coexist, running insensibly into each other. General induration has hitherto been seen chiefly in individuals that have died of typhus fever; and Andral tells us that he also witnessed it several times in persons who had been in the habit of working among lead, and who expired in a state of universal con- vulsion. The proximate cause of cerebral induration is a deposition of lymph into the connecting cellular tissue, by which the intermolecular inter- vals are filled up, and the fibres of the brain firmly cemented together. That this is the case, is not only analogically inferrible, but may be readily proved by examination with the microscope. A portion of brain thus affected possesses little or no moisture, recoils with elas- ticity when stretched, and tears with a rough and slightly granulated surface. The natural vascularity is usually very much diminished, probably from an obliteration of some of the capillary vessels; and hence the ordinary color is yellowish white, milky, or grayish; seldom reddish, brown, or claret, as we find it to be in acute softening of the cerebral tissue. Chronic cerebritis, after having existed for some time, may suddenly assume an acute character, and thence pass into suppuration. A shade of green usually announces this event; and, as the process advances, the part gradually acquires a yellow tinge, and a soft, pulpy consist- ence. The pus is rarely confined in a distinct cavity; on the contrary, it is usually diffused through the softened mass, oozing out of it, when a section is made, in the form of small globules. 7. Ulceration.—Ulceration of the brain is very uncommon, and has hitherto been found chiefly on the striated bodies, the optic couches, and the convoluted surface of the cerebrum, in the latter of which it is by far most frequent. The ulcers, which seldom penetrate beyond the gray substance, and which affect various forms, have generally rough, indented edges, with an irregular surface, covered, for the most part, with reddened lymph, in some cases with pus, and occasionally even with blood. Instances occur in which they are hard and dry; and sometimes, though rarely, they communicate together by fistulous tracks, in the same manner as ulcers occasionally do in other parts of the body. In their dimensions they vary from a few lines to several inches, the^ largest being almost always seated on the external surface of the brain. The cerebral tissue immediately contiguous to these ulcers usually exhibits signs of inflammation, being of an unnaturally red color, and 350 BRAIN. of varying degrees of consistence. The pia mater and arachnoid are also more or less affected; a circumstance from which some patholo- gists have been led to infer that these ulcers rather appertain to them than to the cerebral substance. This, perhaps, with a few exceptions, is true. Occasionally, the ulcer communicates with deep-seated ab- scesses. 8. Apoplexy.—Apoplexy exhibits remarkable variety as to its seat and extent. In many cases the blood is poured into the substance of the brain; in some, upon the external surface; and in some, again, into the ventricles. Of these three forms, the last is by far the least frequent; next to this is the meningeal, or that in which the fluid is extravasated upon the surface of the brain ; and the most common of all is where it is diffused through the cerebral tissue. It has also been found that certain parts of the encephalic mass are more liable to hemorrhage than others. Thus of 392 cases of this disease, col- lected by Andral from the writings of different pathologists, 202 affect- ed the interior of the cerebral hemispheres on a level with the floor of the lateral ventricles; in 61, it was seated in the striated bodies, and in 35, in the optic couches. The cerebellum and cerebrum are rarely affected. In regard to the extent of these extravasations the greatest possi- ble variety obtains. The quantity is often very trifling, not exceed- ing a few drops, or the volume of an ordinary pea; sometimes, how- ever, the effusion is quite copious. In one instance, that of a female fifty-six years of age, I found it amounting to nearly eight ounces. The number of extravasations is also liable to much variation. Very frequently there is only a solitary one, whilst at other times there are as many as ten or a dozen. When numerous, the hemorrhagic depots usually exhibit different appearances, as if they had occurred at differ- ent periods. The extravasated blood varies in its character according to the length of time that has elapsed between the attack and the death of the patient. When the apoplexy proves suddenly fatal, the fluid is dark colored, almost fluid, or in soft, semi-liquid masses. If the indi- vidual survive some time, the clot acquires a greater degree of con- sistence, and is of a pale red, grayish, or yellowish tint. At a still more advanced stage it becomes hard, dense, and fibrinous, and is either organized, partially or entirely absorbed, or converted into a loose, drab colored cellular substance, presenting, when cut, a peculiar appearance, not unlike that of a honeycomb. These changes usually begin within the first fortnight after the attack, and are completed at the expiration of several months, the length of time being always greater in proportion to the size of the clot. The peculiar crystals of the blood are described by Virchow as seen in apoplectic clots, but are not generally observed before the third week. The substance of the brain around the extravasated blood often pre- sents important lesions, consisting chiefly in a change of color and consistence. Very frequently, it is softened, lacerated, and infiltrated with serosity, with blood, or even, with puriform matter, or perhaps all these fluids are found in intimate combination. The color, in such APOPLEXY. 351 cases, is either natural, reddish, yellowish, or greenish, according to the degree of capillary injection, or the amount of inflammatory irri- tation. In some instances, we find the apoplectic cavity intersected with shreds of cerebral substance, so incorporated with the extrava- sated fluid as to be hardly distinguishable from it. In chronic cases, the surrounding parts are more commonly indurated and brittle; but this occurrence is by no means constant. The effused blood is often surrounded by a distinct cyst, formed by plastic matter, from the fourth of a line to the eighth of an inch in thickness. At first, the sac is quite soft; but it gradually increases in consistence, and is finally completely organized, its parietes being abundantly supplied with vessels, which not unfrequently extend even into the inclosed clot itself. Its external surface is generally floccu- lent, and the cerebral tissue immediately around it is variously altered, being either softened, infiltrated with pus, or indurated. In time, the sac becomes both an absorbing and a secreting texture, as is evinced by the fact that its interior is often filled with substances quite differ- ent from those that were deposited in the first instance; and also by the circumstance that it is sometimes completely cicatrized, its walls being brought" so closely together as to leave merely a hard fibrous band. The number of apoplectic cysts usually corresponds with the num- ber of sanguineous effusions, and hence several are occasionally seen in different parts of the same brain. In examining, not long ago, an old man who died of softening of the brain, produced by the irrita- tion of a large clot of blood, I found as many as a dozen of such sacs scattered through various portions of the cerebral hemispheres, the largest of which hardly equalled a hazel-nut: they were of a yel- lowish color, of the consistence of cellular tissue, and marked off each into several little cavities, filled with thin, turbid serosity. The preceding facts are interesting, as showing how much may be effected by the restorative powers of the system. No sooner has the effusion taken place, than nature sets up a process of reparation, in which she is often so successful that in the course of a short time the clot is either absorbed, encysted, or so altered in its physical and vital properties as to be no longer viewed by the organ in the light of a foreign body. There are several circumstances which favor the ab- sorption of the coagulum, but none so powerfully as a healthy condi- tion of the cerebral circulation ; a fact of great practical moment, as it inculcates the importance of paying attention to the head, long after the apoplectic seizure has taken place. Apoplexy has been observed at all periods of life, in infancy, child- hood, adolescence, old age, and decrepitude. Experience, however, has demonstrated that the most obnoxious time is after the fiftieth year. The disease is more common in men than in women, probably because the former are more addicted to all kinds of excesses, both bodily and mental, than the latter. Occasionally it appears to be hereditary. One of the most frequent lesions in cases of apoplexy is disease of the bloodvessels. It is only of late years that the state of the 352 BRAIN. bloodvessels surrounding apoplectic effusions has been studied, and much yet remains to be done in this respect. Sufficient facts have, however, been gathered to prove that in many cases of apoplexy the capillaries, as well as the larger vessels, are affected. The changes that seem to occur most frequently in them, are atrophy and fatty deposits, rendering their walls unable to withstand the pressure of the circulating blood. In many cases the diseased and lacerable condition of the cerebral vessels is accompanied by softening of the nervous pulp, which thus powerfully predisposes to hemorrhagic effusion. Accidental accumulations of blood occasionally exist upon the sur- face of the brain from the rupture of an aneurismal sac, a blow upon the skull, or the pressure upon the child's head during parturition; but these are not, strictly speaking, apoplectic in their character. 9. Hypertrophy and Atrophy.—The brain is sometimes hypertro- phied. In this state the convolutions of the organ are singularly compressed and flattened, and the intervals between them are almost obliterated, the investing membranes being at the same time partially stretched, and appearing as if they were too tight for the inclosed mass. The ventricles are very nearly effaced, and the various sur- faces of the organ are deprived of their ordinary moisture. The cerebral substance is unusually firm, almost destitute of blood, and remarkably dry when cut. The hypertrophy commonly involves both hemispheres; occasionally, however, it is confined to particular parts; and in some instances, again, the increased growth is so great as to produce an evident enlargement of the skull. It is rare in the cere- bellum. Children and very young persons, particularly such as are subject to frequent attacks of epilepsy, are most liable to it; but even in them it is extremely rare. Atrophy, the opposite of the above state, is sometimes witnessed. In idiots, in cases of hydrocephalus, and in aged persons, the brain occasionally undergoes a remarkable diminution in all its parts, both gray and white; and the same circumstance is not unfrequently observed in young people who have suffered from long-continued wasting disorders. The marks by which atrophy may be recognized are, a flaccid and shrunken state of the convolutions, interstitial cellular infiltration, peculiar stringiness of the cerebral pulp, and dilatation of the bloodvessels, whether empty or filled. Conjoined usually with these appearances are thickening of the cranial bones, and distension of the ventricles. Like hypertrophy, the affection in question may be general or partial. The latter variety is most commonly seen in the striated bodies and optic couches. In place of the natural rotundity, the sur- face of these structures is remarkably flattened, contracted in its dimensions, or even scooped out, as it were: and, on cutting into them, their substance appears loose and cellulated. Very frequently in- stances of partial atrophy are witnessed on the convolutions, which are either smaller and less numerous than usual, or almost wholly absent. In such cases there is often very little gray matter. Atrophy of the cerebellum is by no means uncommon, and sometimes amounts to almost entire absence of this portion of the encephalic mass. MELANOSIS. 353 10. Tubercles.—Tubercles of the brain are found chiefly in child- hood, seldom in very young infants, and still more rarely in adults. The disease is always associated with a scrofulous habit of the con- stitution, and hence occurs most frequently in conjunction with tuber- cles of the other organs, especially of the lung, spleen, and mesenteric ganglions. The localities of the brain in which tubercles are most commonly found are, the cerebral hemispheres, cerebellum, great commissure, medulla oblongata, cerebral and cerebellic crura, the optic couches, and striated bodies, the frequency of their occurrence being in the order here enumerated. They may occupy, indifferently, the cortical or fibrous substance; and occur either in groups, or, as is more com- monly the case, in disseminated masses. Although the number of these bodies seldom exceeds half a dozen, yet cases occasionally occur in which there are as many as twenty, fifty, seventy-five, or a hundred. In size, they vary from that of a millet seed to that of a walnut, their magnitude being generally in an inverse ratio to their number. Not unfrequently they are so large as to occupy the greater part of one of the lobes of the cerebellum, or of one of the hemispheres of the cerebrum. In form, they closely resemble tubercles in other organs and textures. In some instances, especially when they are clustered together, they are uneven, nodu- lated, and separated into lobes, connected by dense cellular tissue. Their color is a pale yellow, white or bluish, and their consistence is like that of soft cheese, though occasionally much firmer. Apparently destitute of vessels, these bodies exhibit no trace what- ever of being organized; yet that they are so, cannot be well doubted. In the generality of cases, if not in all, they are surrounded by a dis- tinct cyst, often remarkably thin, but which now and then is of great thickness, and of a fibrous, cartilaginous, and even bony texture. After these tubercles have existed for some time, they assume an opaque, dusky appearance, and are finally converted into a soft, cheesy matter, precisely analogous to that of tubercles in other situations. Nume- rous abscesses are thus occasionally formed, which may be readily discriminated from such as are of a simple inflammatory origin, by the nature of their contents. The cerebral tissue around these tubercles is variously affected. During the early periods of their formation it may be quite natural; but, as they proceed in their development, inflammation is often ex- cited, which generally leads to induration, softening, or purulent infil- tration. 11. Melanosis— Melanosis of the brain is among the rarest produc- tions to which this organ is liable. Though it occasionally occurs in small dots and narrow streaks, the most common form in which it appears is that of spherical masses, of a jet black brownish, or livid color varying in size from a mustard-seed to that of a hen s egg. They are distinctly circumscribed, but apparently without any cyst, and closely surrounded by healthy brain, from which they can be easily lifted with the forceps. Vessels may frequently be traced into their interior; and, when they are seated on the convoluted or figurate sur- 23 354 BRAIN. face of the organ, it is not unusual to find them intimately adhering to the pia mater. Their softness is often remarkable, the black color- ing matter which they contain being nearly as fluid as ink. If these tumors be divided with a sharp knife, and washed with water, the coloring matter disappears, and nothing but a soft, shaggy substance, of a cellulo-fibrous nature, remains. This, no doubt, is the nidus in which the melanotic matter is originally deposited. 12. Encephaloid.—Encephaloid is occasionally met with in the brain, chiefly in young subjects, before the age of twenty, in the form of soft, spongy, compressible tumors, enveloped by a distinct cyst. The sur- face of these tumors is frequently tabulated, and their interior closely resembles the gray substance of the brain, with a tinge of red. When cut with a knife, the section is smooth, and the instrument is covered with a soft, unctuous, cream-like matter. The capsule itself, varying in thickness from one to several lines, is often of a deep reddish color, liberally furnished with vessels, externally flocculent, and closely ad- herent to the surrounding parts. Solid masses of extravasated blood are occasionally intermixed with these tumors; in many cases the cerebral tissue immediately around them is in a state of softening. 13. Cartilaginous and Calcareous Deposits.—Masses of cartilage have been found in the brain ; but they are uncommon. They may attain a very considerable volume, and they are generally of an irregularly rounded shape, with a rough, tabulated surface; of a dense, gristly consistence; and of an opaque, bluish color; internally they present a radiating, fibrous arrangement, not unlike an unripe pear. When old, they not unfrequently contain small cavities, filled with curdy, gelatin- ous, or sanguinolent matter. They are seldom, if ever, enveloped by a distinct cyst. Calcareous deposits are also very unfrequent. They occur chiefly in old consumptive subjects, in the form of scattered granules, about the size and shape of saw-dust; sometimes, however, they are seen in irregular nodules, varying in volume from a small pea to that of a large plum. Composed chiefly of phosphate of lime, in combination with a minute proportion of animal substance, these concretions are commonly of the consistence of dry mortar, and readily yield to the pressure of the finger. Cases occur in which they consist of alternate layers of chalky matter and solid albumen; whilst some, although gritty to the touch, contain no chalky matter at all, but present the reaction of starchy granules, being ordinarily somewhat reddish, with a rough, tabulated, or spicular surface; and they are generally surrounded by a delicate vascular membrane, which connects them to the contiguous cerebral substance. Earthy concretions are very common in the pineal gland. In this situation, they are almost always agglomerated into an irregular-shaped mass, varying in magnitude from a pin-head to an apple-seed, the largest being usually in the centre. They are of a yellow citron color, hard, rough, and gritty, and, what is remarkable, are never found until about the age of seven or eight years. After this period, there are few individuals in whose brains they do not occur. Their presence does not seem to occasion any particular inconvenience. HYPERTROPHY AND ATROPHY. 355 14. Cysts and Hydatids.—Small cysts, containing a transparent yel- lowish fluid, of the character and consistence of serum, are sometimes met with in different parts of the brain, especially at its base, on the floor of the lateral ventricles, and on the convoluted surface of the hemispheres. Of this variety of morbid growth I saw, not long ago, an interesting case, in a hydrocephalic child ten months of age. The tumor, situated at the posterior and inner part of the right ventricle, which was itself enormously enlarged, was about the size and shape of a hen's egg, with perfectly smooth, polished, and transparent coats, not thicker than the healthy omentum. The fluid which it contained was thin and colorless, like the clearest spring-water. But such is not always the appearance of these cysts. Often they are quite opaque, speckled with grayish dots, and of a dense, fibrous texture. Their contents, in such cases, are of a milky-white, gelatinous, and readily coagulable by heat, which is not the case when their structure is very delicate. Several such tumors are occasionally found in the same brain, either in different parts or in close proximity with each other. The acephalocyst, or headless hydatid, is rarely seen in the brain. This animal is inclosed in a distinct membranous sac, and seldom acquires any great size. 15. Tumors.—The adipose tumor is rarely found in the brain. It varies in size from a small hickory-nut to a hen's egg, is rough and tabulated on the surface, of the color of fat or adipocire, of the con sistence of spermaceti, tallow, or soft wax, and enveloped by a fine, delicate, vascular cyst. It is composed of very minute and closely aggregated lobules. Occasionally it is made up of concentric layers, united by dense cellular tissue: Otto saw a tumor of this kind which contained hair. Chemical analysis has shown that this growth con- sists principally of fatty matter, with a minute amount of cholesterine. This latter ingredient is so much the more remarkable, inasmuch as the human brain always contains a small quantity of it in the normal state. The fibroid tumor has been but seldom noticed by pathologists. Most generally of the size of a small nut, and of an oblong shape, it is of a pale flesh color, hard, firm, but somewhat spongy in its texture, and enveloped by a distinct cyst, having apparently very little con- nection with the cerebral substance. It may occur in any part of the brain, and in some instances exists in considerable numbers. The origin of fibroid tumors is still involved in obscurity. Taking into consideration, however, their peculiar texture, and flesh-colored aspect, it appears not improbable that, in the generality of cases at least, they are the result of apoplectic effusions, the blood being merely deprived of some of its red particles, and the remainder modified in such a way as to assume the characters which appertain to this kind of deposit. The supposition certainly derives support from the fact that the subjects of these tumors are, for the most part, persons who have labored, at one time or other, under symptoms of palsy, apoplexy. epilepsy, or mental derangement. 356 ENVELOPS OF THE BRAIN. SECTION II. ENVELOPS OF THE BRAIN. I. Dura Mater.—The dura mater is susceptible of inflammation. The disease, which generally occurs in irregular circumscribed patches of greater or less size, rarely exists, except as a consequence of external injury. When thus affected the membrane presents numerous fine ves- sels, filled with florid blood, and scattered about in beautiful arborescent lines. The discoloration is often of a peculiar bluish tint, not unlike what we see in sclerotitis; and, although the injection is sometimes remarkably great, yet the inflamed portion is never so much crowded with vessels as some other membranes, which are naturally more vas- cular. In most cases, the inner surface of the dura mater is covered with small masses of lymph, and it may even be lined by a tolerably thick, adventitious membrane. In this manner, extensive adhesions may be formed between it and the other tunics, or even between it and the convoluted surface of the brain. Suppuration of the dura mater is seldom met with, except as a con- sequence of external violence. The matter is commonly deposited upon the inner surface; but instances are witnessed in which it is situ- ated externally. In the latter case, when the fluid is considerable, long retained, or of an acrid quality, it may destroy the membrane and escape into the arachnoid sac. Occasionally, too, it produces caries, and perforation of the cranial bones; but such occurrences are unfrequent. The changes which result from chronic inflammation of the dura mater are various. The most important, however, are thickening, fibrous growths, and ossification. The thickening, which is almost always conjoined with induration, may be so great as to occasion symptoms of cerebral pressure. It is sometimes found in fatal cases of epilepsy and paralysis. In one instance which fell under my notice, the thickening was connected with caries of the frontal bone, the membrane presenting a very rough, fungous appearance. The reverse of this state is sometimes observed, the dura mater being remarkably thin and attenuated. Fibrous tumors, of the size of a small nut, sometimes grow from the dura mater, generally from its inner surface, to which they adhere either by a narrow footstalk, or by a broad base. They are of a grayish color, of a dense, fibrous texture, hard, inelastic, and seldom acquire any great bulk. One of the most common morbid appearances of the dura mater, is a deposit of osseus matter. It usually occurs in the form of thin plates, and probably always takes its rise in the subserous cellular tissue, and not in the substance of the membrane itself. It is most generally noticed in the great falciform process, where it occurs in CARCINOMA. 357 Fig. 111. small, irregular masses, not larger than a finger nail. In several in- stances, however, I have seen it of the size of a Spanish dollar; and cases occur in which it occupies nearly the whole of the dura mater of one hemisphere. These bony substances are generally very hard, of a whitish aspect, more or less rough on the sur- face, and, when sawed, they occasionally exhibit a real porous structure, like the natural osseous tissue. Fig. Ill repre- sents several plates of this kind on each side of the longitudinal sinus. The drawing is from a preparation in my private collection. Bony growths attached to, and press- ing on, the dura mater, are frequently observed in women who die during, or shortly after, pregnancy. They do not spring from the dura mater but appear merely to be connected with it. Roki- tansky, who first observed them, terms them puerperal osteophytes, and regards them as of regular occurrence during pregnancy. Various other kinds of morbid growths and deposits are found in the dura ma- ter; but their occurrence is so extremely rare, and their nature so little under- stood, as to render it useless to give any account of them in this place. I am not aware that carcinoma has ever been observed in the dura mater as a primary affection. As a secondary effect, however, cases are sometimes met with, although they are rare. The adjoining sketch (Fig. 112) was copied from a specimen sent me, some years ago, by Professor Buchanan, of Nashville, of epithelial cancer of the face, which, as it extended its ravages, caused the most frightful gap in the head, consuming the eyes, nose, and frontal bone, and finally reaching the brain. The patient was an elderly man, who had been several times subjected to opera- tion, without any material benefit. A tumor of a globular shape, tole- rably firm, and tuberculated on the surface, is seen on each side of the falx, intimately connected with the dura mater, from which it evi- dently took its rise, as it was en- tirely unconnected with the main disease. The Pacchionian glands are occa- Osseons deposits upon the dura mater From a preparation in my cabinet. Fig. 112. Carcinoma of the dura mater. From a preparation in my cabinet. 358 ENVELOPS OF THE BRAIN. sionally much enlarged, indurated, and changed in their appearance. The sinuses of the dura mater are also sometimes diseased. The most frequent affection is inflammation of their lining membrane. In this condition the serous tunic is unnaturally vascular, opaque, and in- crusted with lymph. The sinuses are sometimes partially filled with pus ; and it is not uncommon to find them obstructed with firm, dense, fibrinous concretions. II. Arachnoid.—The arachnoid is liable to acute and chronic in- flammation, and to various morbid deposits. The most important anatomical characters of acute arachnitis are increase of color, opacity, thickening, and preternatural firmness, with effusion of serum, lymph, pus, and sometimes blood. In the early stage of the disease, the membrane does not present any perceptible alteration, but remains thin and transparent as in the normal state ; and, what is remarkable, the pia mater is almost always affected first, being usually thickened and deeply injected, long before any change can be recognized in the arachnoid itself. All parts of the arachnoid do not seem to be equally susceptible of inflammation. The portions most frequently implicated are those in the ventricles of the brain, on the convexity of the hemispheres, at the base of the cerebellum, the junction of the optic nerves, the Varo- lian bridge, and lastly, at the internal flat surface of the hemispheres. Such, at least, is the result of my own observations, corroborated by that of some of the most distinguished pathologists of the age. * The redness of the arachnoid is usually limited in its extent, being restricted to a few points on the convexity of one or both hemispheres, at the base of the brain, or between the lobes of the cerebellum. Oc- casionally, when the inflammation is very intense, the redness occurs in pretty large patches, and appears to be caused by a real extravasa- tion of blood ; but, even under these circumstances, it is quite impossi- ble to trace any vessels into the affected membrane; they belong, in fact, rather to the pia mater and the connecting cellular tissue than to the arachnoid itself. What strengthens this opinion is, that the color may frequently be removed by scraping the part with the scalpel, or exposing it for a few minutes to a gentle current of water; which would be impracticable if it existed in the substance of the membrane. With this augmented vascularity, if so it may be styled, is usuallv conjoined, at an early period of the disease, a loss of the natural trans- parency. At first there is merely a slight degree of opacity, scarcely appreciable without the closest examination; but, by degrees, the mem- brane assumes a whitish, milky aspect, interspersed, not unfrequently, with shining pearly specks, and small patches of red. Cases occur in which the arachnoid exhibits a dark mottled appearance; but this is rare. The vessels, as an examination by the microscope proves, con- tain many granules and inflammatory corpuscles; and similar bodies may also be observed lying loose in the surrounding structures. After the disease has existed for some time, especially if it have been very violent, the membrane is found to have a real increase both of thickness and of density, so that it may be easily detached from thu surface of the brain, and even from the dura mater. These changes ARACHNOID. 359 although they sometimes occupy a considerable extent of surface, usually occur in small patches, which are confined to some parts of the upper surface of the hemispheres, the cerebellum, or base of the cere- brum. In cases of this kind, the pia mater is not only deeply injected, but the cellular tissue between it and the arachnoid is infiltrated with various kinds of fluids, as serum, lymph, blood, and occasionally even pus. These substances may all be witnessed at the same time; but, in the generality of instances, the first two alone are met with. Occa- sionally, the subarachnoid tissue is emphysematous. The effusion of serum is sometimes very copious; and, in parts where the subarachnoid cellular tissue is very loose and abundant, as, for example, in the intergyral spaces, at the fissure of Sylvius, the Varolian bridge, and the junction of the optic nerves, the distension may be so great as to raise the membrane in the form of considerable vesicles, of a gelatinous appearance. In quantity, it may vary from a few drachms to several ounces, being always more copious in the ventricles than on the surface or base of the brain. In its appearance, it is usually limpid, but now and then opaque and milky, from the ad- mixture of lymph. When the inflammation is very severe, we some- times meet with deposits of pure blood, either in the subarachnoid cellu lar tissue, in the substance of the pia mater, or in the intergyral spaces. The presence of puriform fluid is always indicative of high vascular excitement, and frequently attends wounds, contusions, and other lesions of the head. Dryness of the arachnoid is occasionally observed, generally in small patches, of a hard, shrivelled aspect. Their pre- sence always denotes excessive cerebral irritation. The deposition of lymph is much less frequent upon the arachnoid than upon the pleura or peritoneum; yet that it is very often met with here, is certain. Nor is it always confined to the free surface of the membrane. In the majority of cases, indeed, it occurs in the subja- cent cellular tissue, in the form of a yellowish or greenish infiltration. In some instances, again, it follows the course of the pia mater, pro- ducing adhesion between the convolutions, and filling up their intervals: occasionally, though rarely, it is witnessed in the ventricles, over the choroid plexus; and a very common seat of it is the superior surface of the tentorium. In its color, this deposit is generally more or less opaline, with various shades of green and yellow. When occurring upon the free surface of the arachnoid, the lymph is often moulded into a distinct membrane, the thickness, color, and consistence of which are materially influenced by the length of time it may have existed, as well as by the violence and extent of the attend ant inflammation. In a stout athletic man, thirty-five years of age, who died of acute meningitis, brought on by a most extensive frac- ture of the skull, the exudation, which covered the greater part of the right hemisphere, was about the thickness of a common wafer, of a pale straw color, inclining to greenish, and of the consistence of the buffy coat of the blood, before it has undergone perfect coagulation. The rapidity with which this deposition may take place was well ex- emplified in this case, in which the patient expired in less than three days from the occurrence of the accident. In instances of long stand- 360 ENVELOPS OF THE BRAIN. ing, the color is usually lighter, the consistence more firm, and the thickness greater: occasionally the adventitious membrane is vascu- larized. In children, acute meningitis is generally dependent upon the pre- sence of tubercles in the subarachnoid cellular tissue. They are com- monly most numerous along the course of the large vessels on the hemispheres and at the base of the brain, particularly in the fissure of Sylvius. In their size they vary from that of a grain of sand to that of a millet-seed, which they seldom reach, and never exceed. They are rounded or flattened, of a whitish, opaline, or grayish tint, semi- transparent, and generally isolated, or disseminated, but sometimes grouped. Their consistence ranges from semi-concrete lymph to fibro- cartilage. The older granulations are commonly opaque, hard, of a pale yellowish color, and firmly adherent to the parts in which they are developed. The arachnoid in this disease is ordinarily free from adhesions, smooth, and more or less transparent. Its surface may be dry or moist, and in many cases it is covered with a viscid, glutinous, or sticky secretion. The pia mater, the principal focus of the disease, is preternaturally red, engorged with blood, and infiltrated with sero- sity. When the latter exists in considerable quantity, it is often of a greenish tint, and of a thick, jelly-like consistence. The vessels, both large and small, on the surface of the brain, are generally excessively distended, especially when the tubercles are numerous, and the disease has been unusually tardy. Along with these changes there may be deposits of lymph on the free surface of the arachnoid, more or less "flattening of the convolu- tions of the brain, softening of the figurate bodies, and effusion of serosity in the ventricles. The degree of softening varies in different cases, and is always most conspicuous in the fornix and inter-ventri- cular septum, which are occasionally converted into a white, pulpy, diffluent substance, of the consistence of thick cream, thin starch, or custard. In some rare cases the softening extends to the striated bodies and optic couches. The serum in the ventricles varies from a few drachms to several ounces; it is commonly clear and limpid, but now and then it is turbid, or white and milky, especially when there has been inflammation of the choroid plexus. The occurrence of purulent matter in this form of the disease is rare. Tubercles of the subarachnoid cellular tissue usually coexist with similar deposits in the lungs and lymphatic ganglions. This is parti- cularly true of infants; in adults the coincidence is less frequent. The disease may occur at any period of life, but is most common from six to ten years, then from three to five, next from eleven to thirteen, and finally from one to two. Like tubercular formations in other parts of the body, it is occasionally hereditary. Death may occur from a few days to several weeks. The disease sometimes pursues a strictly chronic course. Such are the principal anatomical features of the two forms of acute arachnitis. In the chronic variety the alterations are still more diver- sified, consisting of more or less thickening and opacity of the arach- ARACHNOID. 361 noid and pia mater, increase of firmness and tenacity, organized adven- titious membranes, tubercles, cartilaginous and osseous concretions, and, in some cases, of copious effusions of serum, giving rise to what is named hydrocephalus. In acute arachnitis, as has been stated, the quantity of serum seldom exceeds two or three ounces; in chronic, on the contrary, it is always very considerable. I have myself seen more than two quarts of fluid; and cases are narrated in which it amounted to upwards of two gallons. Chronic hydrocephalus not unfrequently exists as an intra-uterine affection; more commonly, however, it makes its appearance soon after birth, and proceeds until the head attains an enormous development, out of all proportion to the rest of the body. The fluid of hydrocephalus is generally perfectly clear and limpid, possessing, indeed, very much the same qualities as the serum of the blood, from which it is derived. In most cases, it is without smell and taste, although the latter is sometimes slightly saline. By ex- posure to heat, it is occasionally as perfectly coagulable as the water of ascites, hydrothorax, or hydrocele; but in general the quantity of albumen is much less than in those diseases; and hence heat, alcohol, and acids seldom exert upon it the same marked effect. The specific gravity of this fluid is a little greater than that of water, in the proportion of about a twentieth part. The best analysis is that by Dr. Marcet, who found the solid contents of one thousand grains of the fluid of the ventricles to consist of— Water............990.80 Muco-extractive matter, with a vestige of albumen . . . 1.12 Muriate of soda .......... 6.64 Subcarbonate of soda, with a vestige of an alkaline sulphate . . 1.24 Phosphate of lime, with traces of phosphate of magnesia and iron 20 1000.00 Chronic hydrocephalus is usually connected with softening of the cerebral tissue, which is not unfrequently quite pulpy and reticular. The parts most commonly affected are the great commissure, fornix, and inter-ventricular septum. In young children, who are mostly the subjects of this accumulation, the bones of the skull are often widely separated, the brain is unfolded, and the whole head is remarkably distorted. In a case which I recently examined, a considerable num- ber of minute apoplectic effusions were discovered, particularly in the right cerebral limb, just in front of the Varolian bridge, where there were as many as a dozen. The ventricles of the brain are variously affected. When the quan- tity of fluid is considerable, they are expanded into large sacs, fre- quently lined by a thin layer of lymph, into which vessels may be seen dipping from the subjacent parts. In such cases, the figurate bodies of the brain are sometimes wholly destroyed, the convolutions effaced, and the gray substance compressed into a thin shell, occasion- ally not more than half a line in thickness. The arachnoid, like other serous sacs, is liable to hemorrhage. The occurrence is chiefly met with in children under two years of age, in 362 ENVELOPS OF THE BRAIN. whom, in fact, it constitutes by far the most frequent form of cere bral hemorrhage. The most common site of the effusion is the con- vex surface of the brain: it may also occur on the plane surface of the cerebrum, but never on that alone. It is usually present on both hemispheres, but does not appear to be more frequent on one side than on the other. The blood is seldom found in an unaltered state; on the contrary, it speedily separates into serum and crassamentum, the latter of which, in a short time, assumes the form of a clot or layer, of a black, dark red, brownish, or pale yellowish color, thicker at the centre than at the circumference, irregular in its shape, lacerable, and from a few lines to several inches in diameter. One surface is commonly free, while the other almost always adheres to the parietal layer of the arachnoid, from which, however, it is easily detached, leaving the part with which it was in contact smooth, polished, and unaltered. The number of clots is variable; sometimes there is only one, while at other times there are several. In either case, they usually coexist with a thin, yellow, or transparent membrane, with the edges of which they are insensibly blended. Whether this mem- brane, which is sometimes opaque, firm, and pearly, like the dura mater, is produced by a deposit of plastic lymph, or whether it is caused simply by the transformation of the effused blood, is not de- termined. Their continuity would seem to point out a common origin. In the adult the membrane has been observed, in a few rare instances, to have a distinctly stratified structure, indicating that there were several successive deposits of blood. When this adventitious membrane adheres, as it sometimes does, to both surfaces of the arachnoid, it may be converted into a kind of cyst, which usually contains from a few drachms to several ounces of clear. limpid fluid. When the quantity is more considerable, the fluid will necessarily, on the one hand, compress the brain, and, on the other, distend the yielding walls of the cranium, producing thus a translu- cent, fluctuating tumor, either diffused or circumscribed, very similar to that of ordinary chronic hydrocephalus. In this way the disease may ultimately prove fatal, or the accumulated water may be absorbed and the cavity of the sac be obliterated. III. Pia Mater.—The pia mater, considered separately, is not, on the whole, very often diseased. In arachnitis, it is not unusual, as was before stated, to see its substance inflamed, and its vascularity greatly augmented, with small masses of lymph adhering to its surfaces, espe- cially the outer. Under these circumstances the vessels of the pia mater, unnaturally conspicuous, and filled with florid blood, form, by their anastomoses, a beautiful network. Most generally, this aug- mented vascularity occurs in considerable patches, which are often of a bright red color, and easily detached from the convolutions of the brain. Small sanguineous effusions are occasionally observed; and, in some instances, the part presents an ecchymosed aspect. When the pia mater is inflamed in a high degree, pus is commonly formed, which may diffuse itself over the whole upper surface of the brain, or finally destroy the membrane, and thus come in contact with the cerebral PIA MATER. 363 tissue. Ulceration and mortification, however, are rare consequences of inflammation of the pia mater. Ossification of the pia mater is very uncommon, and the same is true of fungous, bloody, and encysted tumors. An instance is mentioned where an encysted tumor of the pia mater contained fat. Diseased appearances are sometimes noticed in the lateral ventricles, especially in the choroid plexus. As a consequence of inflammation, the lining membranes are sometimes very much thickened and indu- rated, their vessels gorged with blood, and their free surface covered with patches of lymph, of variable thickness and density. In the choroid plexus, the most common appearances are serous cysts, formed by a very delicate, vascular, and transparent membrane, and filled with a clear, limpid fluid. I have never seen them very large, though occasionally they attain a considerable bulk. Their number is often very great. In an old man of seventy-five I found a dozen clustered upon the right choroid plexus, the largest of which hardly equalled a common cherry. Instances are recorded in which as many as a hundred were seen in the same individual. The ventricles of the brain seldom contain hydatids; and there is reason to believe that the serous cysts, just described, are frequently mistaken for them. The two varieties which have hitherto been ob- served are the headless and bladder-tailed ; of the latter of which five species have been seen by different pathologists. The vessels of the choroid plexus are sometimes greatly enlarged, tortuous, and almost varicose. Upon the choroid plexus, as well as on the lining of the ventricles, abundant granules are frequently met with. Many are ordinary calcareous corpuscles; but others, if treated with iodine and subsequently with sulphuric acid, display the violet color characteristic of vegetable cellulose. This interesting observa- tion, first made by Virchow, has been abundantly confirmed by other observers. These cellular corpuscles are, however, by no means re- stricted to the ventricles. They have been found on the surface of the brain, optic nerve, or the retina, and also, as will be hereafter described, in several of the viscera. What their exact pathological import is we have as yet no means of judging. Possibly they may be physiological structures. In making examinations of the brain we occasionally meet with bubbles of air in the vessels of the pia mater, under circumstances which preclude the possibility of their being the result of putrefactive decomposition. I have repeatedly noticed this phenomenon in my own dissections, and cases of the kind are related by numerous writers. Whether the fluid is the product of a process of secretion, as has been maintained by some pathologists, or whether it is caused by the intro- duction of the air in consequence of injury done to the vessels of the pia mater, or of its passage along the carotid artery or jugular vein, are questions which are still unsettled. The gas generally presents itself in the form of white pellucid globules, looking like small pearls, mov- able, and contrasting strikingly with the natural contents of the vessels. 364 SPINAL CORD AND ITS ENVELOPS. SECTION III. SPINAL CORD AND ITS ENVELOPS. Having already dwelt at considerable length upon the anatomical characters of the various lesions of the encephalon, it only remains to make a few remarks concerning those of the spinal cord; and these will be so much the more concise, inasmuch as the foregoing observa- tions embrace nearly all that might otherwise be necessary to be said under the present head. Inflammation of the spinal cord may be traumatic or idiopathic; and, if not timeously arrested, may pass into suppuration, the matter being of a pale straw-color, of a thin cream-like consistence, and either in- filtrated through the proper substance of the cord, or collected into a distinct abscess. Both occurrences are rare, especially the latter, for the reason that life is usually destroyed before the morbid action reaches the suppurative stage. Abscesses in this situation occasion- ally attain a considerable bulk, and are invested by a distinct cyst, of a firm consistence, and upwards of half a line in thickness. The nerv- ous structures around are always much softened, or even converted into a thin, diffluent substance, and the lining membranes exhibit marks of high inflammation. Softening of the spinal cord is not uncommon; it may be partial or general, and in some instances it is limited entirely to the internal gray substance. Cases occur in which the disorganized texture ex- hales an odor similar to that of sulphuretted hydrogen. Induration of the spinal cord, although it chiefly affects the white substance, is sometimes entirely confined to the gray. The affection may embrace the whole cord, from one extremity to the other. In such cases, the induration may be so great as to enable the organ, after being divested of its tunics, to resist considerable efforts at lacerating it. Hypertrophy of the spinal cord is uncommon, much more so, indeed, than of the brain. The affection is characterized by the enlargement and extreme firmness of the cord, with diminution of the natural vas- cularity, and has hitherto been noticed principally in children. Occur- ing generally in isolated portions, the hypertrophy is sometimes observed throughout the whole extent of the cord, which may attain such a volume as to fill almost completely the vertebral canal. Atrophy of the spinal cord is occasionally observed. When gene- ral, as it sometimes is, the cord is reduced, throughout its whole extent, in bulk. In most instances, however, the atrophy is partial, or limited to particular portions. The spinal cord is sometimes absent as a con- genital defect; and instances are occasionally observed in which it is hollow, at the expense, evidently, of the central gray substance. Tubercles, acephalocysts, sanguineous and serous effusions, and vari- ous kinds of tumors, are met with in the spinal cord, or in its mem- branes; but these it is unnecessary to describe, inasmuch as they are SPINAL CORD AND ITS ENVELOPS. 365 precisely of the same nature as in the brain. Ulceration of the spinal cord has not been described as a distinct lesion. Hydro-rachitis is a congenital defect, consisting in a cleft condition of the vertebral column, with a protrusion of the lining membranes of the spinal cord. The lesion, which is evidently caused by an arrest of ossification, and a consequent deficiency of the vertebral rings, is generally situated in the lumbar region, but occasionally it affects the dorsal or cervical portions, or even those of the sacrum. It is fre- quently associated with hydrocephalus, and is analogous to those mal- formations which originate from a want of union of the two halves of the foetus during utero-gestation, such as hare-lip, cleft-palate, and opening of the linea alba. The malformations of the spinal column accompanying this affection may be arranged under the following heads: 1, division of the entire vertebra, even of its body; 2, partial or complete absence of the lateral arches; 3, perfect development of the lateral arches with want of union at the median line. Of these varieties the first is very rare; it may occur in any portion of the spinal column, even in the atlas and sacrum, and, when the cleft is considerable, the hydro-rachitic tumor may project into the abdominal cavity, immediately behind the peri- toneum. In the second form of the affection, all the arches may be wanting on both sides, or they may exist on one side, and be absent on the other. They are frequently very short, stunted, curved or distorted, and even fused together, either in part, or in whole, by bony or cartilaginous matter. In the third variety, the lateral arches are well formed, but open behind. The cleft varies in breadth from a few lines to half an inch or upwards. Occasionally, though rarely, the arches are bent outwards, so as to form a plane continuous on each side with the body of the bone. These three varieties, which may involve one or more pieces at the same time, are generally associated with defective development of the spinous processes. The protrusion of the spinal en- velops generally takes place during the latter months of foetal life; oc- casionally, however, it is not ob- served until some weeks or months after birth. When the tumor first shows itself, it is perhaps not larger than a pea; but, as the disorder pro- gresses, it gradually increases in size, varying in proportion to the defi- ciency of the vertebras. Although the swelling does not, in the plurality of cases, exceed the size of an orange, yet occasionally it reaches that of the fist, or even of the patient's head. The skin is commonly very smooth, delicate and thin; sometimes, how- preparation in my collection. 366 SPINAL CORD AND ITS ENVELOPS. ever, it retains its normal thickness, or it becomes red, rugose, and horny; in a few rare cases, it is entirely wanting. The tumor is either soft, flabby, and fluctuating, or it is full, hard, and shining; when pressed upon, it gradually diminishes in volume, or completely re- cedes; but no sooner is the force removed than the fluid re-accumu- lates, and the part regains its previous bulk. In its form, the swelling is globular, ovoidal, or pear-like, with a short, narrow neck, by which it reposes upon the cleft bone. Fig. 113, from a preparation in my possession, exhibits a tumor of this kind in the lumbar region; it was about the size of a common orange, and was taken from a child five months old. Its cavity, which is here laid open, had been exposed by ulceration. The fluid of a tumor of bifid spine is generally of a thin, limpid character, slightly saline in its taste, and almost uncoagulable. The best analysis that has been furnished of it is by Berzelius, according to which it consists of the following ingredients:— Water..........97.8 Muriate of soda ......... 1.0 Albumen .......... 0.5 Mucus..........0.5 Gelatine .......... 0.2 Fin-. 114. 100.0 In some instances, the fluid is of the color and consistence of synovia, or it contains flakes of lymph and particles of pus. These appear- ances are seldom present until after the tumor has burst, and discharged its original contents. In regard to its precise seat, it may be mentioned that it is most fre- quently found in the arachnoid sac, but occasionally it has been known to exist between it and the pia mater, between it and the dura mater, and sometimes, though rarely, in all these situations at the same time. The tumor usually consists of a single cyst; but there may be several, as in the multilocular variety of ovarian dropsy. In such a case it would be diffi- cult, if not impossible, to draw off all the fluid by operation. The contents of the vertebral canal in the immediate neighborhood of the lesion are variously affected. The portion of the spinal cord surrounded by the tumor is often very much softened, or converted into a thin, diffluent substance; sometimes it has been found abnormally hard; some- times it is not so large as natural; and sometimes it deviates remarkably from its accustomed route, being forced through the opening in the vertebras, and partially Bifid spine, showing the distribu- tion of the nerves. From a prepara- tion in my cabinet. NERVES AND THEIR GANGLIA. 367 contained in the swelling. The nerves are always more or less dis- placed, and, in some instances, they are dragged out of the spinal canal, and distributed over the internal surface of the cyst in a beau- tiful plexiform manner, not unlike that of the fleshy columns of the heart. This appearance is well seen in Fig. 114, from a specimen in my collection. The arachnoid membrane and dura mater are usually not much altered in the early stage of the affection; but as the fluid accumulates, they become excessively attenuated, and, together with the superimposed skin, finally give way at one or more places. When this happens, the parietes of the tumor shrink, and become greatly thickened, by the deposition of plastic lymph upon their interior. A thin, turbid fluid, mixed with pus, continues to exude from the part, and the patient is rapidly carried off by constitutional irritation. The preternatural aperture is ordinarily limited to the posterior surface of the bone, but it may extend through its whole substance, so that the finger may be readily passed into the abdomen, or coils of intestine find their way into the tumor. SECTION IV. NERVES AND THEIR GANGLIA. 1. The nerves are liable to acute and chronic inflammation, sup- puration, ulceration, gangrene, hypertrophy, atrophy, and different kinds of tumors. When a nerve is cut across, restoration generally takes place in a short time by the adhesive process, the small cicatrice thus formed offering no obstacle to its functions. When a portion is removed, the divided extremities, in the course of twenty-four hours, become en- larged and vascular, and the surrounding cellular tissue, taking on inflammation, pours out coagulating lymph, which finally incloses and cements them together. After some time, varying according to the thickness of the nerve, and the distance between the divided ends, the matter thus effused is organized, assuming a whitish, gristly appear- ance, and the function of the organ is either partially or wholly re- established. Sensibility commonly returns more quickly than volun- tary motion. It has been found that the sentient nerves, when thus mutilated, generally begin to regain their functions early in the third week, while the motor nerves do not recover any of their powers till after the fourth. It is proper to observe that, if the interval between the divided extremities is very great, as from one to two inches, the union is either quite imperfect, being effected solely by condensed eel lular tissue, or, as is more commonly the case, nature entirely fails in her efforts, and the function of the part is thus permanently destroyed. In acute neuritis, the nerves are of a bright reddish color, and their capillary vessels, which run longitudinally, are united by thousands of transverse twigs, which, in the normal state, always elude the closest 368 NERVES AND THEIR GANGLIA. scrutiny. When the inflammation is very intense, the affected part generally assumes a dark violet tint, either uniformly diffused, or occurring in small patches, like so many ecchymoses. These changes are always most distinct in the neurilemmic coat; but they extend by degrees to the interstitial cellular substance, which at the same time becomes distended with serous, bloody, or purulent fluid, the natural tendency of which is to separate the filaments of the nerve, and give it a tumid aspect. As the disorder progresses, the affected part loses its peculiar texture, diminishes in strength and consistence, and resem- bles a cord of inflamed cellular substance rather than a nerve. Inflammation of a nerve, when artificially induced, always has a tendency to excite inflammation in the organ to which it is distributed. Thus, inflammation of the fifth pair will produce ophthalmia; of the eighth pair, gastritis; but, what is remarkable, not pneumonitis. The reverse of this probably sometimes occurs, the inflammation being pro- pagated from the organs to the nerves. The anatomical characters of chronic neuritis are increased vascu- larity and consistence of the affected part, with slight swelling and friability. The neurilemmic coat is considerably indurated, the inter- stitial cellular substance is infiltrated with serous fluid, and the capil- lary vessels are often so much loaded as to exhibit a varicose arrange- ment. This affection, which is probably much more common than has been imagined by pathologists, is almost always attended with severe pain, and, like the acute form, may be confined either to a small portion of a nerve, or diffused over an extent of several inches. Suppuration of the nerves is very rare. The matter, which is com- monly of the character of healthy pus, is usually infiltrated into the interfibrillar cellular tissue, in which it appears to be originally formed, the nervous substance itself being little altered. Occasionally the pus lies immediately beneath the neurilemmic coat, which it raises in the form of a little abscess. Hemorrhagic effusion was found by Martinet in the sciatic nerve of a man who had been affected with excruciating pain in the posterior part of the thigh, aggravated to almost absolute intolerance by the least motion; and Cotunni noticed, long ago, that serous infiltration is often connected with neuralgia. Ulceration of the nerves is still more rare than suppuration. It never occurs spontaneously after inflammation, but is always dependent upon injury or disease of the adjacent structures. In a case of ulceration of the peroneal nerve, reported by Mr. Swan, of London, there was a fun- gous ulcer of the leg, with violent pain of the whole limb, which ren- dered it necessary to amputate. Gangrene of the nerves, like ulceration, is generally complicated with lesion of the surrounding parts, being seldom, if ever, present as a pri- mary affection. In whatever manner it may be induced, the nerves are of a dark brownish color, highly offensive, and converted into soft pultaceous cords, entirely destitute of their natural characters. The parts immediately above and below the seat of the disorganization are of a reddish tint, swollen, and infiltrated with serous fluid. Carcinoma seldom affects the nerves, at least very few well-authen- ticated cases of this disease are to be found on record. It has been NERVES AND THEIR GANGLIA. 369 witnessed in the external saphenous nerve, the posterior tibial, the trifacial, and the median, and I have myself met with it in the optic nerve. Berard has related an example, the only one of which I have any knowledge, of melanosis of these cords. The heterologous matter was embedded in the right phrenic nerve, and presented itself in the form of a blackish tubercle, of the volume of a small pea, and of a firm dense consistence. Of tubercular disease of the nerves hardly anything is known. Nek- ton has related a case in which this deposit took place in the origin of the third, fifth, seventh and eighth pairs of nerves, which were°all very much enlarged, and the seat of small spheroidal tumors, from two to three lines in diameter, and composed of yellow, opaque matter, evi- dently of the nature of that in question. The subject was a female twenty-one years of age. The nerves are occasionally found in a state of hypertrophy. In chronic affections of the leg, nothing is more common than to see the subcutaneous nerves thickened and injected. In dissecting, not long ago, the left leg of a man, thirty years old, removed for caries of the tarsal bones, I found the posterior tibial nerve, nearly in its whole length, very much indurated, and at least three times as thick as usual, all its fibres being extremely distinct and well defined. The nerves of the womb are hypertrophied during pregnancy, and the same phenomenon is frequently observed in subcutaneous and other tumors. Atrophy of the nerves, a state the reverse of that just described, generally arises from mechanical injury, or the pressure of a tumor; yet that it occasionally exists as a primary affection seems undeniable. Whenever an organ of sense is destroyed, the nerve leading to it wastes, usually by degrees, but sometimes with great rapidity. In such cases, the nerve assumes a peculiar buff-colored appearance, and often shrinks to less than one-third its normal bulk, its pulpy substance being some- times totally absorbed, so as to leave nothing but the dense and indurated neurilemma. Neuromatous tumors, the anatomical characters of which are variable, are sometimes developed in the nerves, the component threads of which they sepa- rate from each other like the ribs of a fan. They occur most commonly in the nerves of the upper extremity, especially the radial and ulnar, and are generally attended with severe pain and numbness; at times they are found on nearly all the spinal nerves of the body. The origin of these tumors is still involved in obscurity; in some instances, they are evidently connected with the nervous substance; 24 Fig. 115. Section of a neuroma; three nervous trunks terminating in it. The fibrous ar- rangement shown, as observed by the naked eye. 370 NERVES AND THEIR GANGLIA. Fig. 116. whereas, in others, they arise, with equal certainty, from the neu- rilemmic covering. In a case mentioned to me by Professor Par- ker, the tumor, about the size of a hen's egg, was developed in the centre of the ulnar nerve, the fibres of which it forced apart, and was of a compact solid texture.1 This is, perhaps, the most ordinary structure of these swellings; but, occasionally, they are composed of a dense cyst, filled with a transparent jelly-like fluid. Their magnitude seldom exceeds that of a walnut; in most cases, indeed, they are not larger than a pea, filbert, or peach-stone. After amputation, the ends of the divided nerves are sometimes expanded into white, semi-carti- laginous bulbs, which frequently become the seat of morbid sensibility and neuralgia. 2. Concerning the lesions of the ganglia, very little is known. That they are liable, like the nerves with which they are connected, and of which they are a part, to inflammation and some of its more ordinary consequences, would seem probable, from the similarity of their struc- ture; but what the resultant changes are, the present state of the science does not enable us to point out. A number of examples of considerable increase of bulk of the ganglia of the sympathetic, from the influence of chronic irritation, are recorded. The enlargement, which has been known to ex- ceed six or eight times the normal size, is met with chiefly in the cervical ganglia; but, occasion- ally, it has been seen in those of the thorax and pelvis. A remarkable case of hypertrophy of these bodies, probably produced by chronic in- flammation, has been published by Cruveilhier; he observed it in a subject in the dissecting- room of the "Ecole Pratique," of Paris, con- cerning the previous history of which nothing whatever could be learned. All the cervical ganglia of the left side were enormously en- larged, especially the middle, which was two inches and a half in length by one inch in thick- ness. (Fig. 116.) They were of a grayish-white color, and of a very dense, compact consistence, creaking very sensibly under the knife. On further examination, they were found to be of a fibrous structure, arranged in such a manner as to form a great number of cells, filled with a sort of gelatinous substance. The compo- nent nervous filaments were in a state of com- Hypertrophy of a nervous . i i i vv»." ganglion. plete atrophy, the only part that was left being 1 A beautiful tumor of this description, developed in the substance of the peroneal nerve, is contained in my private collection, having been kindly sent to me by Drs. Hoffman and Dalton, of Logan, Ohio. LACHRYMAL APPARATUS. 371 their neurilemmic covering. The nervous cords between the diseased ganglia, as well as those which passed off from them, were very much enlarged, of a pale-grayish color, and abnormally firm in their consist- ence. CHAPTER XII. EYE. I. Lesions of the Lachrymal Apparatus.—Lachrymal Gland.—Ducts and Sac.—II. Lesions of the Ball of the Eye.—The Conjunctiva. — Pterygium. — Lachrymal Caruncle.—Acute Corneitis.—Ulceration and Ossification of the Cornea.—Fleshy Excrescences.—Alterations of Form. — Diseases of the Sclerotica. — Choroid Tunic. — The Retina.—Amaurosis.—Optic Nerve.—Membrane of Demours.—Hsemophthalmus.—Lesions of the Iris.—Alterations of the Pupil.—Capsule of the Crystalline Lens.—Liquor of Morgagni.—Varieties of Cataract. —Vitreous Humor.—Heterologous Formation^. Several structures, entirely different from those in other organs, enter into the formation of the eye. Altogether it is a most compli- cated apparatus; and hence, as might be expected, the diseases to which it is subject are at once numerous and interesting. This ren- ders it incumbent upon us to consider them somewhat in detail.. SECTION I. LACHRYMAL APPARATUS. The lachrymal gland is liable to inflammation, but the disease is so rare that its anatomical characters still remain uncertain. So far, how- ever as our observation extends there is reason to conclude that they are similar to those of other glandular organs. In the early stage of the disorder, there is merely an augmented flow of tears, with slight uneasiness in the situation of the gland: as it progresses, however, the natural secretion diminishes, and the movements of the eye become constrained and painful. The vessels of the little body are engorged with blood, its substance assumes a deep reddish complexion, and the interlobular cellular tissue is infiltrated with serous fluid, the swelling from this source being sometimes quite considerable. _ When the in- flammation is violent, it may terminate in suppuration, but this is extremely rare. When matter forms, it usually points, above the upper lid; occasionally, it escapes into the cellular tissue of the orbit, and gradually works its way out through a fistulous opening. There is a chronic form of the disease, in which the gland often be- 372 LACHRYMAL DUCTS. comes hypertrophied, and acquires a firm, compact texture, not unlike an indurated pancreas. The enlarged organ either remains stationary, or it passes into tedious and imperfect suppuration: the disease is most frequent in scrofulous children, and is seldom attended with much pain. Chronic inflammation sometimes produces atrophy of this gland. I once dissected an encephaloid eye, in which this body was reduced to the size of a small bean, its substance being indurated, and of a yellowish-drab color. The subject of the disease was a child ten years of age. The lachrymal gland is liable to scirrhus, forming a hard, elastic, tabulated mass, of the consistence of fibro-cartilage. Under these circumstances the organ may be larger than an almond, or even of the size of a hen's egg. Its substance is of a white grayish color, dense, crisp, and intersected by membranous bands, resembling the interior of an unripe pear. Small cysts, filled with thin, glairy fluid, or with firm fatty, melliceric, or sebaceous matter, are sometimes interspersed through the diseased mass. Scirrhus seldom occurs before the middle term of life. Serous cysts, containing a thin limpid fluid, have been found in the lachrymal gland. Although generally very small, they have been observed, in a few cases, to be as large as a hen's egg. It has been supposed that these cysts are identical with hydatids; but the more probable opinion is, that they are nothing but dilated excretory ducts: a conjecture which receives corroboration from the fact that these tumors are generally distended with a fluid possessing all the pro- perties of the lachrymal secretion, being of a thin, watery consistence, and of a sharp, saltish taste. It occasionally happens that one of the excretory ducts of the lachrymal gland becomes dilated near its terminal extremity, forming a circum- scribed, elastic swelling, immediately behind the upper lid, towards the temporal side of the orbit. It is semi-transparent, unusually deli- cate, and of an ovoidal shape, and often attains the size of a pigeon's egg, though generally it does not exceed that of a hazel-nut. The lachrymal ducts are liable to inflammation, which sometimes ends in suppuration, at other times in the obliteration of their caliber. Similar lesions occur in the nasal canal. The obliteration here, however, is usually partial, existing in the form of a stricture. Though the nasal canal is scarcely half an inch in length, there are three points in its course at which stricture may be located, namely, at its junction with the lachrymal sac, at its middle, and at its entrance into the nostril. The disease is produced in the same way precisely as stricture of the urethra; that is, by inflammation of the lining membrane, accompanied by effu- sion of lymph into its substance, and into the subjacent cellular tissue. Permanent obstruction, either partial or general, may also be produced by inspissated mucus, and by fibrin poured upon the free surface of the membrane. M.Bouchardat1 has recently published the case of a woman sixty-six 1 Annales Oculistique, Juillet, 1842. BALL OF THE EYE. 373 years of age, whose lachrymal canal contained a calculus, weighing four-tenths of a grain, and composed of the following ingredients:— Carbonate of lime.........48 Phosphate of lime and magnesia......9 Concrete albumen.........25 Mucous matter..........18 Fat and chloride of sodium, a trace. 100 The diseases of the lachrymal sac do not require special notice, as they do not differ from those of other mucous textures. Suppuration often occurs here, and the matter, being unable to find its way down into the nose or up into the eye, is apt to escape through the skin, leaving a fistulous aperture, which it is always difficult to heal. SECTION II. BALL OF THE EYE. 1. Acute conjunctivitis is announced by more or less redness, which usually begins at the palpebral portion of the membrane, and gradu- ally extends to that over the sclerotica. The injection is at first ar- borescent; by and by it becomes capilliform, and, in certain cases, it is so close as to give the organ the appearance of being bloodshot. With this augmented redness, the membrane loses its natural polish, the temperature of the part is augmented, its sensibility is altered, and there is a suppression of the mucous as well as of the lachrymal secre- tion. The discoloration now becomes more and more vivid and in- tense; the conjunctiva assumes a villous aspect; serosity is poured out into the cells of the ocular fascia; the tears flow in great abund- ance; and the mucous discharge is not only restored, but uncommonly copious. Blood is sometimes extravasated beneath the conjunctiva; and occasionally there is a secretion of lymph, by which the margins of the lids are completely agglutinated. In violent cases, such as we have here described, the disease is frequently propagated to the other textures of the eye, and the discoloration extends backwards to the posterior section of the sclerotica. Acute conjunctivitis often passes into suppuration. The matter, which is at first merely puriform, becomes gradually purulent, thick, and of a yellowish straw color. The quantity secreted is sometimes surprisingly great—much more so than in any other mucous mem- brane of equal extent—from four to eight drachms being discharged in the twenty-four hours. Like the matter of gonorrhoea, it is fre quently of a highly acrid and irritating nature, and has the property, when applied to the sound eye, of engendering the same affection. Manv surgeons have disbelieved this; but the experiments of Guille, Hupsch, Kirkhoff, and others—which consisted in inoculating differ- ent persons with matter taken from patients afflicted with ophthalmia 374 BALL OF THE EYE. —have affirmatively settled the point. The disease, when thus pro- duced, usually appears in from one to three days. There is a variety of this disease in which the effusion of serosity is so great as to give the eye a truly oedematous aspect. The sclerotic portion of the conjunctiva is elevated into a soft, transparent tumor, forming a ring around the cornea, which appears deeply sunk, and sometimes almost entirely concealed: the effusion often encroaches considerably upon the lids, which are thus rendered tumid and everted. Very little vascularity attends this variety of ophthalmia. In severe cases, the conjunctiva has been known, from this cause, to form a tumor as large as a walnut. In another series of cases the mucous membrane is raised into small vesicles. Seated in the subjacent cellular tissue, they are produced by an effusion of serous fluid, and seldom exceed the size of a common pin-head; they are of a spherical shape, diaphanous, and most fre- quent in that species of ophthalmia which affects the conjunctival covering of the cornea. Their number is sometimes considerable; on bursting, they leave an ulcer which it is often difficult to heal. The corneal portion of the conjunctiva is also liable to the forma- tion of vesicles. Occurring in persons of all ages, they are most fre- quently met with in children, and sometimes spread through whole families, being generally concomitant of smallpox, measles, and aph- thous affections of the mouth. The vesicles are usually situated near the margin of the cornea, are encircled by minute vessels, and appear like small dusky spots, of a pale reddish color, slightly elevated above the level of the surrounding surface. If the inflammation be allowed to go on, purulent matter is formed, their apex ulcerates, their con- tents are discharged, and a cavity is left, the edges of which are dense and opaque. Chronic, like acute inflammation, usually begins in the palpebral conjunctiva, and is often entirely confined to that part. The mem- brane, which is of a uniform reddish color, Fig-117> verging on purple, is thickened by an effusion of lymph, and converted into a dense, fleshy- looking substance. Its surface is always more or less rough ; and, in many instances, it is studded with small, spherical bodies, im- properly called granulations. (Fig. 117.) These bodies are generally dispersed over the whole surface of the lids, especially the upper, and seldom extend over the sclerotic and corneal portions of the membrane. Being of a soft, fleshy consistence, they are of a florid color, extremely vascular, highly sensitive, and liable to bleed on the slightest touch. The size which they attain, in puru- lent ophthalmia, is sometimes surprising. It is probable that these vegetations are nothing but enlarged villosities, with which the surface of the membrane, like every other of a similar kind, is naturally covered. If the inflammation recurs from time to time, or is unusually pro- tracted, the vessels of the conjunctiva become permanently enlarged. BALL OF THE EYE. 375 Fig. 118. The veins, especially, may be observed to be tortuous, of a dark color, and irregularly nodulated, like varicose veins in other parts of the body. ^ The arterial capillaries participate in the enlargement; and there is generally considerable thickening, with opacity and relaxation of the conjunctiva: the lachrymal caruncle is hypertrophied, as are also the Meibomian follicles, and the secretion from these structures is unnaturally thick and copious. A membrane occasionally forms on the conjunctiva, producing what is called a pterygium (Fig. 118); it is most common in old people, though no age is exempt from it. It is generally of a flat, triangular shape, with the apex di- rected towards the pupil; has a fleshy look and consistence; and almost always grows at the internal angle, tending, in its progress, to encroach upon the cornea. Its vascularity is often quite great, the vessels running in a straight line, and presenting a varicose state, es- pecially when of long standing. In most instances, the morbid growth is soft and movable; now and then, however, it is found firmly adherent, thick, hard, and coria- ceous. Two pterygia sometimes form on each eye. 2. The lachrymal caruncle is sometimes hypertrophied, forming what is called encan- thus (Fig. 119). This structure is naturally quite small; but, when diseased, it often ac- quires the volume of a pea, or even of a cherry. It is generally of a pale reddish color, and of a soft fleshy consistence, with a rough tuber- culated surface. Sometimes it is very dark, and almost black. 3. The healthy cornea readily unites when Encanthis. divided, the process by which this is effected being the same as in other parts of the body. If a portion be re- moved, it is never completely regenerated; but the chasm is filled up with an opaque substance, of a hard, fibro-cartilaginous consistence. Although acute corneitis occasionally arises without any assignable cause, yet, in most instances, it is directly chargeable to external violence. In the early stage of the disease there is scarcely any perceptible alteration in the part concerned, the only change being a slight degree of haziness. By and by, however, the membrane loses its transparency, assumes a bluish milky aspect, softens, and becomes distinctly vascular, hundreds of vessels, extremely fine and delicate, running in every direction from the circumference towards the centre. In aggravated cases, blood is sometimes effused into the substance of 376 BALL OF THE EYE. Fig. 120. the cornea, or the capillary injection is so great as to give the mem- brane the appearance of a piece of scarlet cloth. Yery often a red zone is seen around the fore part of the sclerotic coat, formed by a wreath of ves- sels which freely anastomose with those of the cornea. The anterior surface of the membrane is occasionally quite rough, and the conjunctiva is generally exten- sively implicated: in strumous habits, the inflammation frequently spreads to • the iris, the choroid, and the retina, lead- / ing to great and permanent mischief. Acute corneitis sometimes passes into suppuration. The matter collects either corneitis. immediately beneath the conjunctival covering, or else between the lamellse of the proper substance of the membrane, and generally appears in the form of a small abscess. This gradually increases in size, until it produces a considerable prominence, when it either bursts, or its con- tents are removed by absorption. The pus, which is usually very white and mixed with lymph, occasionally escapes into the anterior chamber. The parts immediately around the abscess are always more or less softened, vascular, and opaque. In violent grades of inflammation, especially when occurring in persons of a strumous habit, the cornea sometimes loses its vitality, and is detached in grayish, dirty-looking eschars, leaving one or more openings through which the iris protrudes. Some anatomists have doubted whether the cornea is susceptible of this change; but careful observation has fully settled the question. The change is most apt to take place in the pustules which form on the eye in cases of confluent smallpox. In chronic corneitis, the membrane is opaque, of a grayish tint, con- densed, indurated, and thickened, yet more easily torn than in the healthy state. Yessels may be traced over its anterior surface, which are much larger than in the acute form of the complaint, and their contents are also of a darker hue. Little pain is present; objects are perceived indistinctly, everything having a hazy appearance; and, if the cornea is incised, it is generally slow in uniting. In cases of very long standing, the thickening and opacity of the cornea are sometimes very great: the surrounding textures are deeply implicated, and the ball of the eye appears as if covered with a strong fascia, the fibres of which converge towards the centre of the cornea, and exhibit a yellowish pearly lustre, not unlike the inner surface of an oyster-shell. Ulceration of the cornea (Fig. 121) is a very com- mon consequence of the bursting of an abscess; but it may also take place without any antecedent suppuration. A species of softening sometimes precedes this process, leading to the formation of numerous erosions, so exceedingly minute Fig. 121. FATTY DEGENERATION—OSSIFICATION. 377 as almost to escape the naked eye: they are superficial, rough, irregu- lar, and without any circumjacent vascularity. In the majority of cases, however, the ulcer presents a more decided character; it is deep, well-defined, and of a pale ash color, with high, jagged edges; its surface is bathed with a thin, acrid fluid; the part is extremely sensi- tive; and the sore manifests a strong tendency to spread in depth and diameter. In this manner the disease often progresses until the cornea gives way, followed by an escape of the aqueous humor, if not a total destruction of the organ. In old people we sometimes meet with superficial crescentic ulcers situated near the circumference of the cornea. Ulcers of the cornea, of whatever form or extent, are susceptible of cicatrization. Frequently, after they have existed for a while, their progress seems to be suddenly arrested; the eye becomes less irri- table ; granulations appear; and thus the excavation is gradually filled up, the new texture at length assuming the properties of the old. Most generally, however, the reproduction is imperfect, the cicatrice which is left being opaque, and depressed in the centre. The lymph effused in inflammation sometimes remains unabsorbed, and gives rise to opacity. This occurs in every intermediate degree, from a slight haziness to entire loss of transparency, and may be either superficial or deep-seated, circumscribed or diffuse, punctiform or linear, circular or crescentic. In many cases, the opacity continues through life, the lymph upon which it depends becoming organized and thoroughly incorporated with the pre-existing tissues. Fatty degeneration of the cornea is witnessed chiefly at the outer cir- cumference of this membrane, at or near its junction with the sclero- tica, and constitutes what is called the senile arch. The affected part is of a dim pearly aspect, loaded with oily matter, and a good deal softer than the adjacent healthy structure, in which it appears to be abruptly lost. In many cases it forms a complete circle around the circumference of the cornea. Mr. Canton, of London, who has paid particular attention to this affection, is of opinion that it is generally associated with fatty degeneration of the heart and other viscera, and is inclined to lay great stress upon its occurrence as a diagnostic sign of this disease. The change is by no means peculiar to the old, as the term senile arch would lead us to infer; on the contrary, it is often witnessed in middle age, and occasionally even long before. I have myself seen several cases of it before the twentieth year. The white spots on the cornea, constituting various forms of opacity of that mem- brane, occasionally undergo the fatty degeneration. The cornea is liable to ossification. Wardrop saw a case in which the whole eye had changed its form, and the cornea contained a hard, smooth, oval plate of bone, weighing two grains. A piece of bone was also found between the choroid coat and the retina of the same eye.1 In another case, referred to by Yoigtel,2 a German author, a piece of cornea, taken from a man sixty years of age, was converted ' Morbid Anatomy of the Eye, vol. i. p. 74. Second edition. London, 1834. 2 Handbuch der Pathologischen Anatomie, b. ii. p. 92. Halle, 1804. 378 BALL OF THE EYE. Fig. 122. Conical cornea. into osseous matter. It was three lines long, two broad, and weighed two grains. A still more remarkable example is reported by Dr. Monet, in the Nouvelle Bibliothlaue Medicate, for May, 1817. It oc- curred in an old man, and the cornea is said to have been ossified throughout. The transformation is by no means so frequent as the cartilaginous, of which a considerable number of instances are related by authors. Fleshy excrescences occur on the cornea. They are occasionally of a fungous character, and in a few instances they have been found to contain hair. These morbid growths appear to have their origin, for the most part, on the conjunctival covering of the cornea. Alterations in the form of the cornea occur under two principal varieties, the conical and spherical. The conical (Fig. 122) is some- times congenital, or begins soon after birth; more commonly, however, it does not come on until about the age of puberty. The alteration generally advances slowly, and oc- casionally affects both eyes, though seldom in an equal degree. The cornea, which is at first only somewhat prominent, gradually assumes the conical shape, and has a pecu- liar sparkling, crystalline appearance, pre- venting the pupil and iris from being dis- tinctly seen. After awhile, small whitish specks are observed, which sometimes coalesce until the whole struc- ture is rendered perfectly opaque. In some instances ulceration sets in, and is eventually succeeded by a protrusion of the iris. Both in this and in the next variety, the surface of the staphylomatous pro- trusion displays arborescent vessels, conveying red blood, and, when the tumor is large, acquires a cuticular incrustation. In the other variety (Fig. 123), which is the more common, and which usually follows ulceration, or the bursting of an abscess, the cornea forms a whitish, pearl-colored projec- tion, of a spherical figure, and often of con- siderable magnitude. The membrane is un- equally thickened; its laminar arrangement is destroyed; its texture is generally more or less softened; and numerous vessels can be seen towards its circumference, and some- times even towards its centre. In this va- riety the anterior chamber of the eye is annihilated; the iris is torn into radiated fragments; and vision is lost or impaired, according to the extent of the projection and the opacity of the mem- brane. A cyst, containing a thin watery fluid, is sometimes found in the cornea, growing between its lamellae, and liable to reappear after the evacuation of its contents. It is apparently of a serous structure, but its precise nature is not ascertained. Fig. 123. Staphyloma. SCLEROTIC—CHOROID. 379 4. I he sclerotic coat, like other fibrous textures, takes on inflamma- tory action with great reluctance; but the disease, after having once set in, is always obstinate, painful, and difficult of cure. It is gene- rally confined to the anterior half of the membrane, is very apt to involve other parts of the eye, especially the conjunctiva, cornea, and ins, and is most frequently observed in persons of a gouty and rheu- matic predisposition, its favorite period of attack being the spring. It is characterized by deep-seated redness of the eyeball, verging upon lilac, unaccompanied with thickening or opacity. The distended vessels form a beautiful zone about a line behind the cornea, whence they proceed backwards in a radiating direction, until they gradually lose themselves in the posterior part of the organ: they do not branch out like those of the conjunctiva, nor are they so movable under the folds of this membrane. Coagulating lymph is rare- ly poured out by the sclerotic coat when inflamed, Fig. 124. and the membrane seldom, if ever, suppurates. In chronic cases, the redness is considerably dimi- nished, the affected part is rendered preternatu- rally flaccid, and the whole eyeball assumes a sickly yellow hue. The sclerotic coat is sometimes remarkably thin and flaccid, so as to be incapable of maintaining the globular shape of the eye. This state is usu- ally connected with disease of the other mem- branes, and with disorganization of the vitreous humor. When the attenuation is very great, a portion of the tumor may bulge out as a staphy- Slaphyl0ma of the scle. lomatOUS tumor, Soft tO the tOUch, and Of a dark ■ rotic coat, seen in profile. bluish color (Fig. 124;). On the other hand, the sclerotic coat is sometimes unnaturally hard and thick, and it has been found even partially ossified. 5. In inflammation of the choroid, there is little external redness, and the enlarged vessels which appear on the white of the eye are deep- seated, corresponding to the posterior ciliary arteries. When the dis- ease is violent, suppuration may take place; not unfrequently there is an absorption of the black pigment, or this substance is deposited in an altered and imperfect manner, or variously changed in color. The membrane is sometimes broken down in its texture, and its inner sur- face has been found coated with flakes of lymph. Varicose enlarge- ment of the vessels occasionally attends this complaint; but this is rare, except in cases of long standing. The disease is most commonly met'with in-strong, plethoric persons. Small cysts, flakes of lymph, and deposits of a thin, glairy fluid, like the white of egg, have been noticed between the choroid and rctinu. Ossification of the choroid is quite rare, and has been witnessed chiefly in old persons. Though for the most part partial, the trans- formation sometimes affects the whole membrane, converting it into a thin osseous cup, perforated behind for the passage of the optic nerve. 380 BALL OF THE EYE. (Fig. 125.) The disease has been supposed to have its seat in the membrane of Jacob; an opinion which I am inclined to adopt from the fact that this tunic is of a serous texture, which is known to be par- ticularly prone to this kind of transformation. 6. Observations are still wanting to enable us to give a complete history of the morbid ana- tomy of the retina. That this membrane is liable to inflammation cannot be doubted; but, as to the changes which it undergoes when thus affected, nothing satisfactory is known. Ward- rop once saw it of a buffy color, produced, as he supposes, by an effusion of albumen; in another case he found it quite opaque, tough, and thick- ened. Magendie noticed an instance where the ossification of the choroid. retina was converted into a white, firm, fibrous structure, analogous to an aponeurosis. Cases occur ;n which this membrane is partially atrophied, or even completely wasted, as in persons who have long been affected with amaurosis. In amaurosis the vessels of the retina become enlarged and varicose. This change very probably takes place in those cases of the disease which are dependent upon cephalic congestion, and which are charac- terized by figures of various forms floating before the eyes. The disease may sometimes be relieved by depletion; but, in the gene- rality of cases, it remains permanent and irremediable. Amaurosis often depends upon a deranged condition of the chylopoietic viscera, by correcting which the patient speedily recovers his sight; in other cases, it is owing to disease of the optic nerve, or even of the brain; in others, it seems to arise from a palsied and disorganized state of the retina itself. In persons who have been long blind, the retina is altered in color, and changed in consistence, being either firm and fragile, or soft and pulpy. 7. The optic nerves are liable to disease. They have been found much reduced in size. Sometimes they are flattened, like pieces of tape, and of a yellowish, cineritious, or brownish hue. Occasionally they are the seat of calcareous concretions, of fibrous tumors, and of hydatids, although these affections are extremely rare. 8. The membrane of Demours, which furnishes the aqueous humor, is liable to inflammation, constituting what has been termed aquo-cap- sulitis. In this condition it is rendered more or less opaque, and pours out globules of lymph, some of which, becoming detached, float about in the anterior chamber, or form adhesions with the iris and the adja- cent parts. The aqueous humor is at the same time rendered turbid, and so abundant as to give the eyeball an unusual degree of promi- nence. Besides these phenomena, the posterior surface of the cornea often presents small milk-like specks, environed by a sort of disk, giving the membrane a singularly mottled appearance, and regarded as characteristic of the disease. No capillary injection is noticed in this inflammation, though the vessels of the surrounding parts are often very much distended, especially those of the sclerotic coat, which ACUTE IRITIS. 381 Fig. 126. Cellular hydatid. sometimes form a beautiful zone just behind the cornea. Pus is occa- sionally poured out, but this is rare. The lymph that is effused in this disease varies considerably in quantity. When there is only a little, it is generally absorbed; in opposite cases, it is apt to remain and to become organized, red vessels passing through it in different directions. The form of the pupil is often remarkably altered by this substance, and even entirely closed by it. _ The membrane of Demours is occasionally ossified; and the an- terior chamber has been known to be the seat of small pieces of bone or little earthy concretions. 9. The aqueous humor— the product of the membrane whose dis- eases have just been sketched—is sometimes altered in quantity or in quality. The fluid in the healthy eye does not exceed five drops; in old peo- ple, it is considerably less; and, in cer- tain diseases, it is so much augmented as to constitute real dropsy. The aqueous humor is sometimes quite acrid. The cellular hydatid (Fig. 126) has been re- peatedly found in this fluid. In the horse, especially in India, it is sometimes inha- bited by a worm, which, in size and color, % resembles the common ascaris. The ani- mal, which has received the name of fila- ria papillosa, is about an inch long, of a grayish color, equal in size to a sewing-thread. It has also been found in the ox, buffalo, hare, and hadock. It is seldom met with in birds. An effusion of blood into the chambers of the eye from mechanical injury, is sufficiently common; but its spontaneous occurrence in per- sons in other respects well, although sometimes observed, is extremely rare. The lesion is technically denomi- nated hozmophthalmus. In some rare in- stances, the effusion seems to be vicarious of the menstrual function, recurring regu- larly at the monthly period, and supplying the place of the suspended secretion. In whatever manner the effusion is induced, it generally disappears completely in from two to eight days, leaving the chambers of the eye perfectly clear, and vision un- impaired. 10. One of the most striking pheno- mena of acute iritis (Fig. 127) is the vas- cular zone around the anterior margin of the sclerotic coat, formed by the minute ramifications of the ciliary arteries. This zone, which is not always complete, varies distinctness, according to the inten- and duration of the disease. The Fig. 127. in sity Iritis ; showing Uncharacteristic vas- cularity of the globe, the iris clogged with lymph, the pupil contracted and irregular. 382 BALL OF THE EYE. vessels composing it seem to terminate abruptly at the circumference of the cornea, very few of them extending forward over its anterior surface or into its substance. The iris itself is discolored, dull, and thickened; the aqueous humor is more or less turbid; and the pupil is contracted, motionless, and irregular. Very frequently, perhaps most generally, the anterior surface of the iris is corrugated, slightly bulging, and covered with globules of lymph, of a whitish, yellowish, or reddish hue. Vessels and spots of blood are sometimes seen upon it; and, occasionally, especially in the more aggravated forms of the disease, the whole membrane has a brick-colored, ecchymosed appear- ance. Minute abscesses also sometimes form, and, breaking, discharge their contents into the anterior chamber. The quantity of effused lymph is often considerable, and the fluid either floats about in the aqueous humor, adheres to the surfaces of the iris, or fills up the pupil, tying it firmly to the capsule of the crystalline lens. Permanent ad- hesion of the iris to the lens, and lesion of the internal structures of the eye, are among the dangers which occur if the inflammation be permitted to progress. There is a very slow, insidious form of iritis, which may be said to be chronic almost from the beginning. There is commonly very little redness, and the patient complains chiefly of dimness of vision, which is so gradually impaired, that the sight is lost before he is aware of his misfortune. The most remarkable anatomical feature is the change of color of the iris, which is almost always of a singularly greenish cast; the membrane is also thickened, rough, and puckered, and the pupil is irregularly contracted, and fringed with lymph. The aqueous humor retains, for the most part, its natural aspect; there is little pain or intolerance of light; and the other structures of the eye are little or not at all affected. This form of iritis is generally present when the membrane protrudes from ulceration of the cornea. Prolapse of the iris (Fig. 128), produces a slow change in the tex- ture of this membrane, rendering it unnaturally hard, and altering its form; complete adhesion is often established between it and the cornea; in many cases it is incrusted with partially organized lymph; and occasionally it assumes a granular appear- Fi§- 128- ance, resembling a piece of flesh. Small tu- mors, of the nature of polypes, are sometimes found on the iris; they seldom acquire a large size, and are generally exceedingly vascular, bleeding on the slightest external injury, or even without any assignable cause. ThepupiUs liable to various alterations, either congenital or acquired. Thus it has been found to be oval, rectangular, indented, slit-like, and Prolapse of the iris. even double; what is more remarkable, however than all, is, that these malformations are some- times hereditary. Children are occasionally born without a pupil. This usually arises from the persistence of the pupillary membrane, which has been known to continue until the tenth, fifteenth, and even CAPSULAR CATARACT. 383 thirtieth year. The changes produced in the pupil by disease have been already noticed. 11. The first change occasioned in the capsule of the lens by inflam- mation, is a loss of transparency, arising from too great a fulness of its serous vessels. These vessels are arranged in the form of a wreath, composed of several distinct arches, situated about a fourth of a line from the pupillary margin of the iris. Running backwards from this wreath, in different directions, are numerous hair-like branches, which gradually lose themselves at the circumference of the lens, in the iris, and in the ciliary processes. From its excessive delicacy, this vascular arrangement can seldom be discerned without the aid of a magnifying- glass ; and, occasionally, there is reason to believe that it is altogether wanting. Accompanying this injected state of the membrane is an effusion of lymph, which has always a tendency, when the disease in- volves the anterior hemisphere of the capsule, to produce adhesions between it and the iris. At other times, the fluid is poured out in the form of small flakes, which float about in the chambers of the eye, where they are either gradually absorbed, or become attached to the surrounding parts. Occasionally the lymph connects itself at each side with the edge of the pupil, and shoots forward like a thin, narrow bar, which, in cases of long standing, has been known to have a cartilagi- nous, and even an osseous consistence. In regard to the membrane itself, its texture is always remarkably altered, becoming thick, tough, and of a white, opaque, milky appearance. Similar changes occur when the disease attacks the posterior segment, with the addition of much greater vascularity. The inflammation of this membrane generally observes a chronic course. It proceeds very slowly, and is attended with little or no pain. It is most common about the age of forty, and usually attacks subjects of a cachectic disposition, with light eyes. The iris, of a darker color than natural, is sluggish in its motions, and the pupil is contracted, irregular, and encircled by a black, narrow rim. When the disease has continued for a long time, the vessels of the capsule are apt to become permanently varicose. Pus sometimes forms; and cases occur in which the inclosed lens is completely dissolved. Opacity of this structure forms a species of cataract, denominated capsular, a disease which is often congenital. As already hinted, it may affect either a part or the whole of the membrane; but, in the majority of instances, it is restricted to the anterior segment. The color of the cataract is very various. Sometimes it is of a dull milky appearance; sometimes white and glistening; sometimes mottled, gray- ish, yellowish, or brownish. Its texture also is very various, being at one time soft and pulpy, at another brittle and easily ruptured, at an- other tough and elastic, or of the thickness and consistence almost of the cornea. In advanced life, the capsule is sometimes ossified, either in part, or through its whole extent. In the natural state, there is always found between the capsule and the lens a minute quantity of thin, pellucid fluid, called the liquor of Mor- gagni. This fluid occasionally becomes opaque, and thereby constitutes 384 BALL OF THE EYE. a species of cataract. It is also the seat, in some rare instances, of a species of threadworm, the ocular filaria of Nordmann.1 In one of the cases narrated by this writer, the animal was three-quarters of a line long, extremely narrow, and of uniform thickness, like the most slender thread. It was spirally convoluted, and had a simple intesti- nal tube, with a mouth, a uterus, and a prominent anal aperture. In another patient, an old female, Dr. Nordmann found the eye occupied with microscopical entozoa, possessing distinct suckers, and apper- taining to the monostomatic genus of Rudolphi. The individuals, which were eight in number, were situated in the upper strata of the crystalline lens, were one-tenth of a line in length, and moved sluggishly on being placed in tepid water. The substance of the lens was still soft, and retained a considerable degree of trans- parency. 12. It is doubtful whether the crystalline lens is susceptible of acute inflammation; but that it is often affected chronically is abundantly established by the changes which it undergoes in its color, shape, and consistence. These changes generally occur slowly, and, taken together, constitute what is termed lenticular cataract. Existing either singly, or, as is more frequently the case, in combination with an altered con- dition of the investing membrane, lenticular cataract has been ob- served at all ages, but is most common, by far, in young children and in old persons. Infants are often born with it, and in some cases it is hereditary. AVardrop knew a father, son, and grandfather affected with it; and examples of a similar nature are recorded by different authors. Janson saw a whole famjly, consisting of six members, blind from this disease. A similar case was mentioned to me by the late Professor Drake. Males are much oftener affected than females, owing chiefly to their greater liability to all kinds of exposure. The disease generally proceeds slowly, so that vision is not de- stroyed for several years. Occasionally, however, the reverse obtains, the patient becoming blind in a very short time, as a few hours or days. The disease may go on simultaneously in both eyes, but gene- rally it begins in one, and in time attacks the other. The starting- point of the opacity is usually the centre of the lens, from which it gradually extends towards its circumference. The consistence of a lens in a state of opacity may be natural, augmented, or diminished. An increase of consistence is most com- mon in old persons and in cases of long standing. After the sixtieth year, and occasionally even before that period, the cataract is frequently so hard that it cannot be divided by the needle; and cases are not wanting in which it is completely ossified. A natural consistence is of rare occurrence, and is seldom seen except in young subjects, or in persons in whom the disease forms with extraordinary rapidity. A diminution of consistence is most common in childhood, and is some- times very considerable, the lens being reduced to a thin milky fluid, or to a substance resembling half-boiled glue, arrowroot, or soft curds. 1 Mikrographische Beitrage zur Naturgeschichte der Wirbellosen Tliiere : Erstes Heft, pp. 11-13. HETEROLOGOUS PRODUCTS. 385 The color of a cataract is extremely variable. In children the opacity is generally white, like milk; in older subjects, it is often of the hue of isinglass, a solution of starch, or a half-boiled egg', in aged persons, still darker, of a yellowish amber color, grayish, or brownish. A mottled appearance is not uncommon; and, in some cases, though this is rare, the lens presents a radiated arrangement, the opaque lines converging towards the centre of the affected organ. It is important to remark that a diseased lens is seldom of the same color in the eye that it is out of it. A change of form is of rare occurrence, and cannot be regarded as a necessary consequence of opacity. The volume of the affected lens may be natural, increased, or diminished. An augmentation of size is seldom observed, and then chiefly in cases of soft cataract. Atrophy of the lens is very common in old people, and often takes place with- out any accompanying opacity. 13. The vitreous humor, when evacuated, is never reproduced. The changes which it undergoes from disease have not been much studied, and we know, therefore, very little about them. It is some- times unusually thick or thin, increased or diminished in quantity, and more or less altered in color. The capsule itself, being of the same structure as the membrane of the aqueous humor, is liable to the same morbid states. These, however, have not been observed with sufficient accuracy to admit of description. The membrane has been found ossified. 14. Heterologous Products.—We have thus taken the eye apart, as it were, and analyzed the diseases of its different structures. Considered as a whole, it is sometimes affected with atrophy and various malig- nant growths. Of these, the most frequent are encephaloid and mela- nosis. Encephaloid, although most frequent in children, is by no means peculiar to them. I have noticed it repeatedly in adults; and, in one case, in a lady, forty-two years of age. In this case, as in many others, the disease was evidently excited by external violence. For awhile, it grew very slowly; but, on reaching the sclerotica, it advanced with great rapidity, so as to acquire, in a few months, a large size. In October, 1837, when the patient was admitted into the Cincinnati Hospital, under the care of the late Professor Drake, the eye was of a cylindrical shape, ulcerated, of a dark livid color, and the seat of repeated hemorrhages. It projected at least an inch and a half beyond the lids, but could still be moved by its own muscles, and did not appear to be attached to the socket. Her general health was infirm. ]n this condition the organ was removed, when I observed the following appearances: the entire mass, after being divested of the muscles and cellulo-adipose tissues of the orbit, all of which were quite healthy, was nearly three inches in length by five and a quarter in circumfer- ence its weight being a little upwards of two ounces. The eye itself was of the ordinary form and volume, but was considerably thrown out of its position by the morbid growth, which was of an irregularly oval shape, and sprung from the inner side of the sclerotica, near its iunction with the cornea. This connection, however, was rather ap- 25 386 BALL OF THE EYE. parent than real; for, on tracing the heterologous mass, it became evident that it originated in the retina, which had itself almost disap- peared. The anterior surface was closely invested by the conjunctiva, which had a rough, fleecy aspect, from the morbid enlargement of its villosities: about its centre was an incrusted ulcer, three-fourths of an inch in diameter, around which the parts were somewhat knobby, and of a bluish livid color. On cutting through this portion of the tumor, it was found to consist essentially of vessels, some of which had been opened by the erosive process, and formed the source of the frequent hemorrhages with which the patient had been latterly affected. Posteriorly the mass was of a much lighter complexion, as well as more soft, and exhibited that peculiar tuberoid arrangement so characteristic of encephaloid. The cornea, although still transparent, was considerably diminished in size, and adhered firmly to the iris. The sclerotica was of the natural thickness, extensively attached to the choroid, and of a yel- lowish buff color. The choroid itself was of a speckled, brownish appearance; at some points, it was completely disorganized; and, at one part, nearly opposite the morbid growth, there was a thin, black layer of blood beneath it. The retina, as before stated, was almost entirely destroyed; and, in place of the vitreous humor, there was a dense, solid, whitish mass, evidently the result of an effusion of fibrin. The anterior chamber of the eye was obliterated, and the iris trans- formed into a substance resembling fibro-cartilage. The optic nerve, near its entrance into the sclerotica, was slightly enlarged, bulbous, and pervaded by encephaloid matter. The appearances of the eye are pretty well shown in the annexed sketch (Fig. 129), taken from the actual specimen. In this case the retina was probably the primary seat of the disease, as in fact, it nearly always is. The rapidity Fig. 129. with which encephaloid of the eye runs its course varies from a few months to a year and a half; when extirpated it almost in- variably returns. Melanosis of the eye generally originates deep in the organ; and always involves the retina, if indeed it do not commence in it. The optic nerve is frequently implicated, which is another proof that the hetero- logous growth may arise in this manner. Encephaloid of the eye. From a In a case recorded by Mr. Allan Burns, preparation in my cabinet. the cord within the cranium was as thick as the little finger and as black as ink. The disease usually coexists with the same affection in other parts of the body, and has hitherto been noticed principally in persons above the middle age. Like encephaloid, it gradually involves all the tex- tures of the eyeball, finally protrudes, and terminates in destructive ulceration. POLYPUS. 387 CHAPTER XIII. EAR. Malformations of the External Ear.—Polypous Growths—Lesions of the Tympanum.—Bones of the Ear.—Eustachian Tube.—The Labyrinth and Vestibule.—Diseases of the Auditory Nerve. 1. The external ear, embracing the auricle and auditory tube, affords a subject for pathological consideration, chiefly on account of congenital malformation and polypous growths. The former of these is usually comprehended under the title of imperforation of the ear. It is caused by the development of a membrane, varying in extent and thickness, simple, or complex, and accompanied with deficiency of the auricle and auditory canal. The commonest form in which it is presented is that of a single skin-like membrane, with a central indentation, corre- sponding with the entrance of the natural orifice; the depth at which the septum is situated is from half a line to the third of an inch; occasionally, indeed, it lies almost in contact with the tympanum. In the more complicated cases, there is not only such a structure as that here mentioned, but great malformation of the outer ear generally. Sometimes the external ear is entirely wanting. The malformation is usually confined to one side, and is almost constantly connected with defective organization of the auditory passage. The hearing is not always lost when this state of parts exists. Another deviation from the normal standard is the congenital absence of the lobule of the ear, or its adhesion to the side of the head. An anomaly of an opposite character is the enormous development of these parts. The auditory canal, as before stated, is sometimes imperforate; at other times it is very much diminished, and occasionally it is closed up by a dense, gristly substance, possessing all the properties of fibro: cartilage. Contraction of the canal may depend upon malformation of the temporal bone, or upon thickening of the soft parts, particularly the cuticle. Deviations in the direction of this passage are now and then observed; but this is rare, and seldom exists singly. Sometimes its orifice is a mere slit instead of a round opening, and instances occur in which it is seriously encroached upon by the tragus, antitragus, and antihelix. . . The lining membrane of the auditory tube is sometimes the seat of polypes. Soft and spongy in their consistence, they are of a pale reddish color, possess little sensibility, are very prone to bleed when injured, and seem to consist principally of a congeries of bloodvessels,. connected by loose, cellular tissue, and inclosed by a thin, delicate 388 EAR. epithelium. They are generally of a conical shape, their attachment being by a narrow pedicle, whilst the body fills up the auditory passage, and sometimes projects a considerable distance beyond its orifice. Occasionally there are several such excrescences; and they have been known to be of the form, color, and consistence of a mulberry. Their progress is slow, and they may exist for a long time without destroying the functions of the ear. When connected, as they sometimes are, with the tympanum, they are apt to produce permanent deafness. The exposed parts are commonly indurated, and of a whitish color, from the influence of the atmosphere. These growths of the ear are always attended with an increase of the natural secretion, which is generally very fetid and acrid. The adjoining sketch (Fig. 130) represents Fig. 130. a beautiful specimen of the gelatinoid polype, which I removed some time ago from the right ear of a young man of twenty-six. It completely filled the auditory tube. Gelatinoid polype of the j)0 wounds of the tympanum ever cicatrize? ear. From a preparation in-^..,-. . , , . -i , i • my cabinet. Daily observation has long since answered this question affirmatively. Nor are there experiments wantino- to illustrate the subject. Valsalva repeatedly perforated, and even lacerated, this structure in dogs, which, after some time, he killed. In every one, the wounds were perfectly closed and cicatrized. Similar experiments, performed by others, were followed by similar results. Indeed, so fully are surgeons aware of this occurrence that particular instruments have been devised for the purpose of preventing it. The period required for this reunion in the human subject varies from six to eighteen days, according to the size and shape of the opening, and the state of the membrane at the time of the operation. Acute tympanitis is by no means unusual; and the rapidity of its course, as well as its mode of termination, is extremely variable. Generally only one ear suffers at a time, though it often happens that both are affected simultaneously. The anatomical characters are increased opacity and thickening, with perverted secretion. In mild cases, the redness is usually very slight, only a few straggling vessels being seen; but when the inflammation is intense, the affected part is of a scarlet hue, and the capillaries are so numerous as to exhibit the appearance of a beautiful network. The normal transparency also is destroyed, and the parts look swollen and protuberant. Although lymph is seldom found upon the free surfaces of the membrane, yet in very severe cases it is not uncommon for this substance to be effused into its interlamellar structure. The ceruminous secretion is frequently suppressed, but the auricle and auditory tube remain un- altered. This disease, which may affect either a part or the whole of the mem- brane, sometimes terminates in suppuration.. The matter is rarely of a healthy character; on the contrary, it is usually muco-purulent, thin, fetid, and so acrid as to erode the structures with which it comes in contact. Blood is occasionally blended with it, the result, probably, in most instances, of exhalation. If the suppurative process be al- INFLAMMATION. 389 lowed to pursue its course, ulceration is superadded, which often con- tinues until the membrane is seriously injured. The part of the membrane most liable to be thus affected is that immediately around the insertion of the handle of the malleus. The number of ulcers is always small: they are, for the most part, of an oval shape, and they vary in size between that of a pin-head and a split pea; in many instances they embrace the whole thickness of the affected part, leading to perforation and discharge of the bones of the ear. Ulcers in this situation sometimes cicatrize. In chronic inflammation, although the vascularity is usually much less than in the acute form, the membrane exhibits every shade of color, from a light pink to a deep red. Striking alterations in the texture of the affected part are also observed. It is opaque, uneven, and thickened, so that the concavity of the membrane is effaced, and the insertion of the malleus can no longer be recognized^ even in strong light. Minute granulations are often seen upon the inflamed surface, of variable consistence, and of a pale ash, greenish or reddish color: they are seldom larger than a clover-seed, and are generally excessively sensitive, as well as vascular, giving rise to considerable pain, and bleeding on the slightest touch. Small openings are frequently ob- served; added to which there is always a muco-purulent secretion, which is often discharged in great quantities, both externally and along the Eustachian tube. The matter is usually excessively offen- sive, particularly in scrofulous subjects, and of a greenish yellow color. In other cases, it is thin and glairy, like the white of eggs, and exhales a disagreeable ammoniacal odor. When the inflammation continues very long, the tympanum, if not wholly destroyed, not only becomes opaque and thickened, but acquires a dense, fibrous consistence. In severe cases of this disease, it is not uncommon for the cellular tissue and periosteum of the middle ear to become involved. A de- struction of the tympanum, together with a discharge of the small bones, is the usual consequence of this state. In addition to this, there is generally extensive suppuration; the middle ear, the labyrinth, and the mastoid cells are filled with acrid pus; the petrous portion of the temporal bone is carious; the adjacent part of the dura mater is thick- ened, discolored, and partially detached; and the brain is softened and otherwise disordered. Pus, chalky concretions, and tubercular matter are sometimes found in the tympanic cavity; and Morgagni observed a case in which it was intersected by delicate membranous bands, the result, probably, of former inflammation. Itard saw it filled with thick, yellow lymph; and, in one instance, he noticed a thin, watery fluid inclosed in distinct cells. Rosenthal witnessed similar appearances in the tympanum of a deaf mute. The proper bones of the ear may be wanting as a congenital defect, or as the result of ulcerative action of the tympanum. It is seldom that they are all absent. 2. The lesions of the Eustachian tube may be thus stated: 1, con- genital imperforation; 2, acute and chronic inflammation, with indu- 390 EAR. ration and thickening of the lining membrane; 3, partial stricture; 4, the presence of chalky matter; 5, mucous obstructions. Similar lesions occur in the mastoid cells. 3. Of the diseases of the labyrinth very little is known; it is certain, however, that they are infrequent, and that their anatomical characters have hitherto been very little studied. Nature may leave the structure of the labyrinth imperfect, or it may, so to speak, wholly neglect its organization. In a case mentioned by Saissy, although the ear was well formed, the essential part of the auditory apparatus was entirely absent, there being no trace whatever of the vestibule, cochlea, or semicircular canals. The small bones, however, were present, and the cavity of the tympanum was filled with a mucilaginous fluid. The Eustachian tube exhibited nothing unusual. The labyrinth is sometimes imperfectly ossified, exposing thereby a portion of its membranous structure; and cases are observed, though they are very rare, in which it is composed of a single cavity, having no communication with the tympanum. Malformations of this kind are analogous to what naturally occurs in the organ of hearing in crustaceous animals. The vestibule, as well as the rest of the labyrinth, is occasionally filled with a substance resembling cheese. Haighton and Cline each 'met with an interesting case of this kind, attended with congenital deaf- ness. Itard found the vestibule occupied with calcareous matter. Duverney often saw the labyrinth filled with thick, purulent fluid. This appearance is most common in young children, and in nearly every case is connected with disease of the cavity of the tympanum. Another malformation of this portion of the auditory apparatus is that of the round and oval apertures. These openings are not only unusually small in some instances, but even entirely wanting. The membranes closing them may also be diseased. Long-continued irri- tation has a tendency to render them thick, hard, and dry; and cases occur in which they are completely ossified. It has been seen that the Cotunnian liquor is liable to degenerate into substances not naturally contained in the internal ear. Of the diseases of the auditory nerve we are totally ignorant. That it is liable to be variously affected there can be no doubt; and that deafness, partial or complete, may be thus induced appears equally certain. The nerve is sometimes unnaturally small, soft, or hard. THYMUS GLAND. 391 CHAPTER XIV. THYMUS GLAND. Weight and Size.—Development and Decay.—Hypertrophy.—Thymic Asthma.—Inflamma- tion.—Ulceration.—Scirrhus.—Tubercular Deposits.—Ossification.—Steatomatous degenera- tion. The weight of the thymus at birth varies from a drachm and a half to three drachms and a half, or even four drachms, according to the size of the foetus, and the quantity of sero-albuminous fluid contained in the cavity of the organ. The gland sometimes consists of two dis- tinct lobes, connected together by a narrow isthmus; at other times it is extremely small, weighing, perhaps, scarcely a drachm, and in a few instances it has been found entirely wanting, as a congenital defect, in acephalous or anencephalous monsters. The size of this organ is not less variable than its weight. The following are the dimensions of eleven thymus glands, as furnished by Dr. Roberts, of New York. Number. Length. Breadth 1 1 inch . 1 inch 2 xl 0 1 » 3 9 2 Z2 0" 2 4 2ft 1ft 5 2 2* 6 2* 2* 7 1\ 1ft 8 n H 9 3J 2i 10 3ft • • u 11 2f • • If The thymus gland is subject to very few diseases; the principal, requiring consideration, are atrophy and hypertrophy, together with the tubercular and carcinomatous degeneration. The organ is very little disposed to common inflammation; and hence abscesses are of very infrequent occurrence. The development and decay of this organ have received much attention from anatomists. It becomes visible during the third month of gestation, and continues to grow until the end of the second year. Between this period and the commencement of the second dentition, the gland remains nearly stationary in its size, un- dergoing, however, certain changes in its structure and consistence, by which, whatever be their nature, it is probably rendered unfit for the further performance of its functions. It is only after the evolu- Thickness. 5 lines. 7 TO" 392 THYMUS GLAND. tion of the permanent teeth that the organ begins to experience any decided decrease: it now rapidly diminishes in volume; its vessels shrink; its cells are obliterated; and, as the juice by which it is moistened dries up, its substance becomes hard and shrivelled. At a still later period, the gland loses its granular structure, and no longer exhibits any traces of its lobular arrangement, a soft, dingy, cellular tissue being all that is left, and this, in time, is wholly absorbed. The precise age at which the last traces disappear does not seem to be ac- curately ascertained ; many highly respectable writers fixing it at the twelfth year, while others maintain that it is not completely absorbed until thirty. Caldani and Sir Astley Cooper, indeed, assert that it never entirely disappears, but that vestiges may always be found, whatever may be the age of the individual. My own dissections lead me to the conclusion that this organ varies very greatly, in respect to its disappearance, in different persons, being atrophied very early in some, and in others not until very late. In the generality of cases, it is completely effaced between the twelfth and fifteenth years. Al- though the changes here described are altogether of a physiological character, there is reason to believe that they are occasionally ex- pedited by accidental circumstances, as the pressure of an enlarged heart, a diseased lung, or an aneurismal state of the arteries at the base of the neck. Hypertrophy is rather a common affection of this gland. The organ is enlarged in every direction, but most of all in thickness. The weight usually varies from six to eight drachms. In some in- stances, it has amounted to nearly two ounces. When very bulky, the organ compresses the lungs and trachea, inducing that peculiar train of symptoms known as thymic asthma. Occasionally, the en- largement is so great as to conceal the heart, and obscure its pulsations. Morbid adhesions are sometimes formed between the gland and the surrounding structures; and the large veins at the base of the neck are often so much obstructed as to prevent the ready return of the blood from the brain to the heart. The substance of the gland may be in a normal state, or variously altered in color and consistence. Occasionally, it is pale, soft, and pulpy. More commonly it is preternaturally red, and of a dense, fleshy consistence, with numerous vessels running over its surface, and penetrating its interior. On cutting into it, a dirty milk-like fluid sometimes exudes from it. Inordinate development of this gland is supposed by Kopp and others to be the cause of thymic asthma. The disease generally comes on between the fourth and tenth months, lasting from three to eight weeks. It is believed to be most common in scrofulous subjects; males are more liable to it than females; and it appears to be often associated with an open state of the oval foramen. The thymus gland is doubtless subject to common inflammation, both acute and chronic; but the disease has been so seldom observed that no one has yet attempted to point out its anatomical characters. Many cases are on record in which purulent fluid was found in its interior; but there is reason to believe that, in a great majority of 1 THYROID GLAND. 393 them, if not in all, it was the result of the softening of tubercular matter, and not of ordinary suppuration. What countenances this opinion is the fact that the pus usually coexists with tubercular disease of other parts of the body, particularly the lungs, spleen, and lym- phatic ganglions, and that it is almost always of a curdy or caseous nature, similar to that of a lumbar abscess, a scrofulous joint, or a pul- monary excavation. Ulceration of this gland has been observed in a few rare cases. This organ is said to be occasionally the seat of scirrhus, but this is questionable. Of encephaloid, melanosis, and colloid, as occurring here, we have no knowledge. Tubercles of the thymus have been noticed by a considerable num- ber of pathologists. A very interesting case of the kind fell under my observation many years ago, in a phthisical child, fifteen months old. The tubercles- were of large size, and in a state of partial soft- ening. The glandular structure immediately around them was un- usually hard, and of a deep red color, from the great distension of its vessels. Tubercles, some of them in a state of suppuration, also ex- isted in immense numbers in the lungs and spleen. All the other viscera were sound. The thymus has been found partially ossified, and cases have oc- curred where it was enlarged and occupied by calcareous concretions. Writers also speak of the steatomatous degeneration of this organ, but of this there are no well-authenticated examples on record. CHAPTER XV. THYROID GLAND. » Acute Inflammation.—Suppuration.—Goitrous Enlargement.—Sanguineous Effusions.— Atrophy.—T ubercularDeposits. —Scirrhus. There are few organs more exempt from disease than the thyroid gland. The principal affection to which it is liable is bronchocele, goitre, or chronic enlargement; it is likewise susceptible of acute inflammation, suppuration, carcinoma, and several kinds of degenera- tion. Gangrene rarely, if ever, occurs. 1. Acute inflammation of the thyroid gland may be ranked among the rarest affections. Existing occasionally as an idiopathic disease, it is generally caused by external violence, local irritants, or lesion of some contiguous structure, as the larynx, trachea, or oesophagus. The anatomical characters are very similar to those which take place in inflammation of the other organs. The gland is soft and succulent, considerably augmented in bulk, and of a dark purple hue; all its vessels being abundantly loaded with blood. Sometimes its substance 394 THYROID GLAND. is remarkably tender, yielding under the slightest pressure of the finger; in a few rare instances it is infiltrated with blood, sanies, or pus. Matter is seldom found as a consequence of acute inflamma- tion ; still more rarely is it deposited in the form of an abscess. Of this, however, I have seen a most interesting example, in a man forty- four years of age, who died of pneumonitis after an illness of three weeks. On inspection, I found the whole gland, with the exception of a small portion of its inferior extremity, converted into a thin, delicate sac, containing nearly three ounces of thick, cream-colored pus. The thyroid cartilage was completely denuded, and the matter had burrowed upwards, underneath the hyoid bone on the left side, as far as the root of the tongue. The most extraordinary circumstance in this case was, that the patient had never experienced the slightest uneasiness in this part during his indisposition, and it was only by accident that the lesion was discovered on the examination. More frequently the sup- puration follows on chronic inflammation. The matter is tardily secreted, and the integuments become gradually distended, until they form a large pouch, which hangs sometimes over the sternum. From the effect of the muscles and cervical aponeurosis, it is generally slow in making its way to the surface. In some instances, it bursts into the trachea, and destroys the patient by suffocation. 2. Chronic enlargement of the FiS- 131- thyroid gland, constituting what is called bronchocele, hypertrophy, or goitre (Fig. 131), occurs at all periods of life, from infancy to old age, and is principally ob- served in the female sex. It is most apt to appear within the first twelve years after birth; and instances are not wanting, though they are rare, where it is congenital. The disease has been noticed in the horse, cow, sheep, dog, and other inferior animals. There are certain localities in Goitre. From a preparation in Professor Mutter's dlfrerent quarters of the globe collection. in which this disease is much more common than in others, for what reason is not known. In the United States, it is mostly observed in the mountainous districts of Pennsylvania, Virginia, New York, New Hampshire, and Vermont; in England, it is very common in Derbyshire, Norfolk, and Surrey; and, in the valleys of the Alps, Apennines, and Pyrenees, it not unfrequently prevails endemically, almost all the native inhabitants being more or less affected with it. The enlargement is often attended with a stunted development of the body; and, in certain parts of Switzerland, Savoy, Lombardy, and the Tyrol, it is apt to-occur in combination with cretinism; a state HYPERTROPHY. 395 characterized by great deformity of the head, and entire absence of intellect. Hypertrophy usually begins in the form of a small tumor, on one or both sides of the trachea, which, gradually enlarging, at length occupies the whole anterior part of the neck, from the chin to the top of the breast-bone. In some instances, the swelling is of frightful magnitude, extending upwards as far as the ears, and downwards a considerable distance over the chest. In the early stage of the disease, the substance of the tumor is not materially altered; it is unnaturally vascular, slightly indurated, and still elastic; as the enlargement pro- gresses, however, it becomes more and more firm, until ultimately it acquires the density of a hepatized lung, or even of fibro-cartilage. The hypertrophy, although it usually begins simultaneously in both lobes, seldom proceeds equally, and occasionally it is seated chiefly in the isthmus of the organ, the remainder being little affected. The internal substance of the tumor is liable to considerable variety, depending upon its age and progress. When of moderate standing, it is generally of a soft, gelatinous consistence, emitting, on pressure, a ropy, glutinous fluid. In more ancient cases it is of a pale cinna- mon tint, hard to the feel, and interspersed with numerous cysts, generally not larger than a pea, containing a serous, glairy, or melicerous substance, and occasionally pus, fibrin, or even pure blood. These cysts are merely enlarged cells, which are dis- persed through the organ in the natural state. Fig. 132 exhibits these cavities hypertrophied from disease, and occupied by a white, semi-concrete substance, similar to coagulated lymph. Calcareous concretions are sometimes found, either atane, or in union with cartilaginous and osseous productions. In a small goitrous tumor, which I removed from a man fifty years of age, and which is now in my private collection, there are several small steatomatous masses, with a circular nodule of bone, about six lines in diameter. It is of a yellowish color, very compact in texture, and surrounded by a thin, imperfect capsule. Occasion- ally the whole organ is transformed into an osseous cyst, filled with various kinds of matter, especially the jelly-like, the suety, and the meliceric. I have a spe- cimen of this kind in my cabinet; one of the lobes has almost entirely disap- peared, whilst the other is converted into a firm, solid capsule, as hard as bone, though scarcely a line in thickness. -On sawing through this osseous tumor, which does not exceed the volume of a hen's egg, Cellular structure of a goitrous thy- roid gland From a preparation in my collection. Fig. 133. Ossified thyroid gland. From a specimen in my cabinet. 396 THYROID GLAND. I found it filled with a white, curdy, friable substance, not unlike semi-concrete cheese. The annexed sketch (Fig. 132), represents a section of it. The thyroid arteries are commonly much enlarged; and, in some cases, the goitrous swelling seems to consist almost wholly of a con- geries of varicose veins. Under such circumstances it is by no means unusual to meet with considerable sanguineous effusions, in various stages, so to speak, of maturation, some being quite fluid, others semi- concrete, and some, again, of a dense, firm consistence, like old apo- plectic depots of the brain. The blood is commonly poured into the enlarged vesicles, but occasionally it finds its way into the connecting cellular substance, which is, at the same time, more or less lacerated. In some instances, it may be traced directly to a ruptured vessel. In the early stage of the disease, the skin over the affected gland is perfectly natural, both as regards its color and mobility; by and by, however, as the hypertrophy increases, it becomes dark, dense, vas- cular, and irregularly adherent. The enlargement is usually very slow and gradual, years often elapsing before it attains much bulk. Occasionally the gland, after having become partially hypertrophied, remains stationary for a while, and then goes on increasing; or sup- puration sets in, and the substance of the organ is absorbed; nature thus effecting a sort of spontaneous extirpation. Of the remote causes of goitre, nothing satisfactory is known. By many it has been attributed to the use of impure water, to innutritious diet, to the repulsion of cutaneous diseases, and a variety of similar circumstances equally hypothetical, and, for aught we know, un- founded. The proximate cause appears to be inflammatory irritation of the thyroid tissues, pursuing a slow, chronic march. That this is the fact is at once indicated by the morbid alterations which the organ experiences during the progress of the enlargement, and which can only be explained on the ground here assumed. 3. The thyroid gland is sometimes partially atrophied. I have re- peatedly found it reduced to a soft, spongy, dirty-looking mass, less than one-third the ordinary bulk. The wasting, which is more common, in men than in women, is observed chiefly in advanced life. The vessels supplying the atrophied gland are usually very much diminished in volume, many of the smaller branches appearing to be wholly obliterated. The nerves are also abnormally delicate. 4. Tubercles are among the rarest productions of the thyroid gland; and the same remark is true respecting carcinoma, whether of the encephaloid or scirrhous variety. Of colloid, as occurring in this body, no example is on record. Melanosis, on the contrary, is occasionally observed, and is probably more common than any other of the hetero- logous formations. In a case which fell under my observation in 1855, in a man aged fifty-nine, the black matter formed a large nodule on each lateral lobe, of a dense, firm consistence, distinctly visible beneath the skin. Similar deposits existed in various other organs. AIR-PASSAGES. 397 CHAPTER XVI. RESPIRATORY APPARATUS. I. Lesions of the Air-Passages.—Inflammation of the Larynx.—Membranous Croup.—(Ede- ma of the glottis.—Ossification of the Laryngeal Cartilages.—Polypous Growths.—Warty Excrescences.—Tubercles and Hydatid?.—Tracheitis.—Stricture.—Dilatation.—Inflamma- tion of the Bronchias. Dilatation.—Contraction.—Flattening.—II. Lesions of the Lungs. —Acute Inflammation. — Hepatization.—Abscess. — Gangrene. — Chronic Pueumonitis. — Carnification.—CEdema.—Emphysema.—Apoplexy. — Encephaloid Disease. — Melanosis.— Serous Cysts.—Hydatids.—Calcarerous Concretions.—Hypertrophy.—Atrophy.—Tubercular Phthisis.—III. Lesions of tlie Pleura.—Acute Inflammation.—Formation of Matter.—Gan- grene.—Chronic Pleuritis.—Ossification.—Accumulation of Gas.—Ulceration.—Tubercular Deposits. SECTION I. AIR-PASSAGES. 1. Larynx.—The larynx is liable to inflammation, oedema, abscess, ulceration, ossification of its cartilages, and polypous growths. Preternatural vascularity, and redness of the lining membrane, either diffused or in patches, with tumefaction of the mucous follicles and the secretion of a clear limpid fluid, constitute the anatomical characters of acute laryngitis in its earlier stages. By degrees, the redness increases in intensity, and extends, on the one hand, down into the trachea, and, on the other, up into the fauces, affecting, in some instances, the tonsils, soft palate, and even the root of the tongue. The epiglottis is variously affected. In some cases it is thickened, infiltrated, and so erect as not to cover the mouth of the larynx; in others, it is highly vascular, dotted with lymph, and studded with enlarged follicles. Within the larynx itself, the tume- faction is seldom very conspicuous, except sometimes in the ventri- cles; and it almost always terminates at the junction of the trachea, although, as was before mentioned, the redness often extends beyond it. In the progress of the disease, the natural secretion becomes much altered; it is no longer thin, sparse, and watery, but thick, tough, abundant, and of a yellowish tinge. Acute laryngitis usually runs its course in from three to five days. It almost always occurs in the prime of life, between the years of puberty and forty-five, in which respect it differs remarkably from croup, which, as will be presently seen, is most common in young children. It has been already intimated that one of the effects of acute laryn- 398 AIR-PASSAGES. C, (Edema of the glottis, a. Tongue b. Mouth of the larynx; c. Trachea. From a specimen in my cabinet. Fig. 134. gitis is an effusion of serum into the sub- mucous cellular tissue. The infiltration, which is occasionally very great, is always most abundant around the edges of the glottis, which are frequently elevated into white, glossy, pendulous bags, resembling the gelatinous effusion which we sometimes see under the epidermis, after the applica- tion of a blister. This pathological state constitutes what is named oedema of the glottis (Fig. 134), an affection which is much more common in adults, after the age of thirty-five, than in early life. Its progress is usually very rapid, and its termination almost uniformly fatal, death being preceded by great anguish, and symptoms of suffo- cation. The difficulty of breathing, in this affection, results not so much from the ab- solute constriction of the chink of the la- rynx, as from the manner in which the tumid and infiltrated lips of the glottis are drawn in by the air, as it rushes from the mouth into the lungs. Suppuration of the larynx is sufficiently common, but it is rare that we meet with abscesses. Their ordinary site is the ventricle of Mor- gagni, between the mucous membrane and muscles, or between this organ and the pharynx. In other cases, together with the inflamed condition of the mucous lining, there is an exudation of lymph, either in dots, in patches, or in the form of a continuous lamella, as in Fig. 135, from a preparation in my cabinet. In simple laryngitis, this deposit is ex- tremely rare; but, in that variety of the disease which is known by the name of croup, nothing is more common. In this affection, which differs further from ordinary inflammation by its being almost exclusively confined to infancy and child- hood, the effusion is often very rapid, and moulds itself accurately to the shape of the organ, to the walls of which it sometimes adheres with consi- derable pertinacity. Athough it is occasionally limited to the larynx, yet the membrane usually passes into the trachea and bronchia?, becoming gradually softer and more delicate, until finally, in the binary and ternary divisions of these tubes, it appears like a thin, mucous film. It sometimes extends upwards over the fauces into the mouth, and even into the nasal cavities. In 120 cases examined by Houssenot, the false membrane was limited to the larynx and trachea False membrane of croup From a specimen in my ca binet. LARYNX. 399 in 78, while in 42, or one-third, it extended to the larger bronchia?. Fig. 136 represents a portion of plastic lymph expelled from the lungs; it has a ramiform appearance, and must have reached into the smaller bronchial tubes, which, however, is infrequent. Varying in thickness, in different cases, the membrane seldom ex- ceeds the fourth of a line, though in some instances it is much greater. It is of a light grayish color, is composed chiefly of albumen and fibrin, and is generally much stronger, more tenacious, and more firmly adherent in the larynx than in the trachea and bronchial tubes; in the latter, indeed, it is often loose or even floating. The mucous coat beneath this lining is usually highly injected, inflamed, and un- naturally rough, from the projection of its mucous follicles. In slight cases, the color is of a light red, and occurs in patches, streaks, or points; in the more severe it is scarlet, brownish, or purple, and uniformly diffused. To the presence of this plastic production, together with the tume- faction of the lininsr membrane of the tra- chea and bronchia?, which so often accom- panies the disease, is to be imputed, in great measure, the impediment to the res- piration in croup. Sometimes portions of it are detached, and, by sticking in the air passages, cause suffocation. In other in- stances, it is coughed up, either piecemeal, or in the form of a dense, inspissated cylin- der, and the patient recovers. The organ- ization of this membrane is admitted rather from analogy than from any positive ob- servation. The occurrence, if possible, must be extremely rare. Membranous croup, as already stated, is essentially a disease of early life. It is most frequent from the second to the tenth year, and seldom, if ever, takes place in a pure uncomplicated form, after the period of puberty. It sometimes occurs within the first few days after birth. It is worthy of remark that this disease is more common in male than in female children, owing mainly, perhaps, to the circumstance, that the former are more ex- posed than the latter to its various exciting causes, such as cold and damp. Of 252 cases, treated by Goelis from 1797 to 1808, 144 were boys, and 180 girls. Jurine met with 119 cases of this disease, of which 72 belonged to the male and 47 to the female sex. Of the cases treated by Eumsey, by far the larger number were boys. False membrane of the bronchial tubes. 400 AIR-PASSAGES. Croup occasionally assumes an epidemic feature, and it has been supposed that it might even be infectious, though of this there is not sufficient proof. It is most frequent in winter, late in autumn, and early in spring, particularly during the prevalence of northeasterly winds, and is often complicated with disease of the lungs, bronchia?, tonsils, and fauces. Laryngitis sometimes becomes chronic, or it may have a disposition to assume this type from the very beginning. Such an alarming de- gree of prevalence has this form of the disease assumed among our clergy that it may almost be viewed in the light of an epidemic. The inflammation is confined exclusively to the mucous lining of the larynx, and its peculiar characteristic is to terminate in ulceration. As the malady advances the uvula becomes elongated, the tonsils and soft palate are ulcerated, and the vocal cords are so much thickened as to encroach upon the glottis. The lining membrane of the larynx is usually tumefied, its glands are enlarged, and its vessels are engorged with dark blood. Inflammation of the larynx sometimes terminates in ulceration. This is very common in persons who are cut off by tubercular phthisis. In 102 patients, M. Louis found the epiglottis ulcerated in 18, and the rest of the organ in 23. The erosions in the former of these structures were nearly always seated on the inferior surface; and, although they were generally superficial, yet they sometimes extended into the sub- stance of the cartilage, destroying it partially in four cases, and com- pletely in a fifth. In the larynx, properly so called, the ulcers were usually deep, from one to two lines in diameter, and of an irregularly circular shape, with pale grayish looking edges, occasionally indurated and brittle. Their most frequent seat was, first, at the junction of the vocal cords; then these cords themselves; next, the base of the aryte- noid cartilages; and, finally, the interior of the ventricles of Morgagni. Sometimes the vocal cords were partially destroyed, and the arytenoid cartilages stripped of their natural coverings. A fact worthy of notice, in connection with this subject, is, that ulcerations of the epiglottis were remarked twice as often in men as in women. The textures in the immediate vicinity of these erosions are seldom much altered, either in color or consistence. When the symptoms which precede dissolution are denotive of high inflammatory action, the mucous membrane is apt to be reddened and slightly softened; but, in most cases, it is of a grayish hue, moderately dense, or even indurated. Ulceration of .the cartilages of the larynx occasionally leads to perforation, the symptoms which precede dissolution resembling those of phthisis. The diseased structures are slightly tumefied, and softened around the ulcers, the edges and base of which are rough, and of a light brownish color. The perichondrium always participates in the mischief, being injected, dark, thickened, ragged, and bathed in un- healthy looking pus. These ulcerations are most frequent in venereal, mercurial, and phthisical affections, in which large portions of these cartilages, or even entire pieces, are sometimes discharged. POLYPES. 401 The laryngeal cartilages are liable to the osseous transformation (Fig. 137). The pieces in which this change, which is natural in the aged, is most apt to take place, are the thyroid and cricoid, of each of which I have seen a number of specimens. When thus affected, these bodies are usually very brittle, and contain a con- siderable quantity of thin, reddish, oily fluid. I have seen them, however, quite hard and firm, like the most perfect bone. AVhen found in advanced life, ossification of these cartilages is not to be re- garded as a morbid condition, but as a natural pro- cess, which often commences as early as the thirty- fifth or fortieth year, and progresses until the con- version is completed. Ossification of the tremely rare, and of arytenoid cartilages is ex- ossification of the epiglottis is hardly a well authenticated case on re- Ossificalion of the car- tilages of the larynx. From a specimen in my collection. there cord. The epiglottis may be affected without the rest of the larynx partici- pating in the lesion. The simplest form of disease is thickening of its mucous membrane, with ulceration of its inferior surface. The abra- sions are generally small, superficial, and irregularly circular, their base, for the most part, being formed by the submucous cellular tex- ture, though occasionally they extend into the substance of the fibro- cartilage. Sometimes, indeed, this body is entirely destroyed. Occa- sionally, the epiglottis is remarkably shrivelled and contracted, or singularly thinned and elongated, its form being altered so as to re- present the shape of a battledore, the narrow extremity being at the mouth of the larynx. The muscles of the larynx may also be diseased. In some cases, they are infiltrated with tubercular matter; but more commonly they are atrophied, and thus cause various alterations of the voice, Demo- no longer capable of producing proper tension of the fibro-elastic struc- tures of the organ. The vocal cords are occasionally affected. They have been found converted into a soft, inorganic pulp; and occa- sionally they are entirely destroyed, leaving the thyro-arytenoid muscles completely bare. In chronic inflammation, it is very com- mon to find the ventricles of the larynx contracted; so that, in the advanced stages of the disease, they are merely represented, as it were, by a superficial transverse groove. This narrowing seems to arise from hypertrophy of the mucous and submucous textures, by which the edges of the cavities are gradually approximated. Polypes, of the same nature as in other parts of the body, are occa- sionally found in the larynx. Being of various sizes, and of a globular or conical figure, they are usually attached by a thin narrow pedicle, their free extremity being sometimes bifurcated. They are of a fleshy consistence, more or less elastic, and of a pale rose, gray- ish or whitish color. When laid open they are found to consist of cellular tissue, or of cellular tissue and fatty substance, invested by a prolongation of the mucous membrane. In their volume they vary 2o 402 AIR-PASSAGES. Fig. 138. from that of a large bean to that of a hickory-nut or even a guinea egg, and they are generally attached either to the ventricles of the larynx, to one or both of the vocal cords, to the lips of the glottis, or to the root of the epiglottis. When they are very large, or when their pedicle is of considerable length, they may project into the pharynx, over the lateral boundaries of the larynx. In some instances a sort of pouch is formed within the larynx for their accommo- dation. Fig. 138 repre- sents a small pediculated polype attached to the left vocal cord. These polypous growths are most common after the fiftieth year, in persons affected with pulmonary phthisis. They have been observed with nearly equal frequency in both sexes. The interior of the larynx is sometimes the seat of warty excrescences, not unlike those found upon the male and female organs of generation. They are usually connected with thickening of the lining membrane, and are probably the result of a syphilitic taint of the system. They are attached either by a narrow pedicle or a broad base, and vary in length from half a line to a quarter of an inch; in their shape they are rounded, ovoidal, or conical; they are of a soft, fleshy consistence, and of a grayish or pale reddish color. Their surface is sometimes fissured or tuberiform, like that of a cauliflower. When these bodies are very numerous, the surface of the larynx looks as if it were stud- ded with them. Tubercles and hydatids are also sometimes found in the larynx; the latter are very rare, and the former generally coexist with pul- monary phthisis. Carcinoma of the larynx is also very uncommon. In fact, I am not aware that scirrhus, colloid, or melanosis has ever been met with in this situation. Encephaloid is likewise extremely rare. 2. Trachea.—The diseases of the trachea may be classed under the Polypf of the larynx, a. Tongue; 6. Polype; c. Larynx; d. Trachea.—From Rylaxd. TRACHEA-^DILATATION. 403 heads of inflammation, ulceration, stricture, dilatation, laceration, and ossification. Tracheitis exhibits the same anatomical characters as inflammation of the larynx. The lining membrane is crowded with multitudes of minute florid vessels, its follicles are enlarged and unusually distinct, and its surface is besmeared with thick ropy mucus. Purulent fluid is occasionally found; and in some instances, as in croup, the whole tube is lined with a layer of adventitious membrane. Softening is seldom ot never present, either in this affection, in laryngitis, or in inflammation of the bronchia?. In chronic cases, the redness is less; but the vessels have occasionally a varicose arrangement; and the mucous tunic may be ulcerated, thickened, or indurated. Ulceration of the trachea is not unfrequent in tubercular phthisis, Louis having noticed it in 31 patients out of 102, who died of this disease under his care. More common in the inferior than in the superior half of the tube, and behind than in front, or at the sides, the ulcers are generally of a circular shape, sometimes oval or oblong, and from the twelfth to the sixth of an inch in diameter, with flat, reddened edges, as if they had been scooped out of the subjacent cellular tissue. In some instances, the erosions are so small, close, and numerous, as to give the whole of the inner surface of the trachea a sieve-like aspect. When large and deep, the ulcers may denude the cartilaginous rings, invade their substance, and finally, destroying them, lead to perforation. In a few instances, there is a complete re- moval of the mucous lining over nearly the whole of the muscular structure, which, in such cases, is always much thickened and indurated. Ulcers of the trachea sometimes heal. The trachea is liable to become contracted by the thickening of its lining membrane, thus forming a stricture, varying in length from a few lines to several inches. In other cases the diminution of the caliber of the tube may be produced by the pressure of an aneurismal tumor, an abscess, an enlarged thyroid gland, or a mass of diseased lymphatic ganglions. The degree of contraction may vary from the slightest change in the natural size of the trachea to almost complete obliteration. Dilatation of the trachea may occur under two varieties of form; in one it affects the entire circumference of the tube, in the other it is limited to its posterior surface. In the first, which is the more fre- quent of the two, the walls of the trachea are atrophied, and its caliber is more or less increased in diameter, sometimes a fourth or even a third beyond the normal state. The dilatation seldom involves the whole length of the canal; it is most common in old subjects, and is usually associated with marasmus and pulmonary emphysema. The second form of dilatation is the saccular. It is confined to the posterior wall of the tube, and consists in an extrusion of the mucous membrane across the muscular fibres, which are unusually florid and hypertrophied, while the yellow elastic tissue behind them is wasted and hardly perceptible. The mucous lining itself is thickened, and sprinkled with enlarged follicles. The number of sacs varies; some- 404 AIR-PASSAGES. times, there is only one, sometimes there are two or three, and some- times, again, they extend along the whole course of the trachea, and even beyond it to the bronchial tubes. They are of a rounded or ovoidal shape, and rarely exceed the volume of a cherry or filbert. This form of dilatation is generally produced under the influence of chronic inflammation of the lining membrane of the trachea. Laceration of the trachea is unusual. The immediate cause of the accident is generally a violent and sudden effort at inspiration after the integrity of the tube has been impaired by atrophy or ulceration. The following case, for which I am indebted to Dr. Thomas Marshall, of Virginia, affords an excellent illustration of at least one form of this lesion. The patient, Thomas Partriot, a large muscular man, aged twenty- eight, an inmate of the Philadelphia Hospital, Blockley, labored under symptoms of asthma, attended with immense difficulty of inspiration and great loudness of the respiratory sounds, completely obscuring the sounds of the heart. On the day of his death, which took place nearly a month after his admission, the cellular tissue of the neck and chest became enormously emphysematous as low down as the eighth rib. The lungs were found to be very much collapsed, and there was a large aneurismal tumor at the arch of the aorta, compressing the trachea, and diminishing its caliber. Immediately above the tumor, between two of the rings of the tube, a little towards the left side, was an elliptical opening, about two lines in length by one line in breadth. The walls of the aneurism were thick and firm. The open- ing in the trachea had evidently been produced by the desperate inspiratory efforts of the patient, a short time before he expired, the coats of the tube having been atrophied by the pressure of the aneurism. The rings of the trachea, being of a fibro-cartilaginous texture, seldom ossify. When this transformation takes place it usually occurs in small points, which, coalescing, may at length embrace the entire ring, as I witnessed, not long ago, in a man seventy-five years of a^e. The different tissues of the tube were remarkably dense, inelastic, and brittle, requiring only slight traction to tear them. All the rino-s were completely ossified. 3. Bronchia^.—Acute bronchitis, although it may exist as an inde- pendent disease, yet in most cases it is united with inflammation of the trachea, larynx, or pulmonary tissue. The mucous coat is found, on dissection, to be deeply injected, and of a bright crimson lilac or purple color, diffused, or in patches of various size. It is rarely much thickened or softened; but sometimes it is augmented in firmness and density, so as to tear no longer with the same facility as in health. Purulent matter is occasionally observed; and, in violent cases it is not unsual to find the smaller tubes filled with bloody serosity blended with froth and globules of pus. In the early stage of the disease, there is always a suspension of the natural secretion. In a short time however, this is re-established, and it is then found to be thin, transpa- rent, and somewhat acrid. As the inflammation advances, it becomes BRONCHIA — ULCERATION. 405 thicker and more abundant, assumes a yellowish color, with a slight greenish cast, and adheres with so much firmness and tenacity to the bronchial tubes, as to be expelled with great difficulty. Obstruction is thus created in the air-vesicles of the lungs, and hence, on opening the thorax, these organs seldom collapse. In chronic bronchitis, a disease of very frequent occurrence, the color of the mucous tunic is usually several shades darker, verging more on livid, violet, or mahogany. Not unfrequently, however, the mem- brane is of a light grayish tint, or even much whiter than in the nor- Fig. 139. Uniform dilatation of the bronchise. been accurately determined. In chronic bronchitis, the expectoration is generally puriform, and sometimes of a greenish, dirty grayish, or brownish color, from the admixture of black pulmonary matter. In neither of these complaints are the sputa much offensive; in most cases, indeed, they are perfectly inodorous. Ulceration of the bronchial mucous membrane is less frequent than that of the trachea, and still less than that of the larynx. The ulcers are generally small, clean, superficial, and of a dirty grayish color, with somewhat tumid and reddened edges. They seldom extend be- yond the mucous and submucous textures, and are rarely met with in the small bronchial tubes. mal state. The thickening and augmentation of density are carried much farther than in acute bronchitis; and the natu- ral secretions are usually very copious, opaque, of a deep yel- lowish color, and almost always puriform. With these signs of disease, we frequently find small ulcers, hypertrophy of the mu- cous and other textures, and dilatation of the bronchial tubes. Softening is sometimes present, but never to any very great extent. There is a form of chronic bronchitis in which casts of lymph are continually being thrown off from the mucous membrane of the bronchial tubes. These casts vary much / in size; at times they are accu- // rately moulded to the tubes and L of considerable size, but most '\[ generally they are merely frag- W ments of a yellowish exudation- /''/;: matter. The appearance of the {<)■) mucous membrane in this plas- tic bronchitis has not, as yet, 406 AIR-PASSAGES. Dilatation of the bronchia? is frequently met with in old asthmatics, and in children after severe attacks of hooping-cough. It presents itself under two varieties of form. In the first (Fig. 139), the dilatation is uniform through- out, and may attain the diameter of a goose-quill, if not of a finger. Some- times several branches of the same trunk are thus affected, each terminating in a sort of cul-de-sac. In other cases, the dilated tube regains its normal caliber, and ends in the usual way. In the se- cond variety (Fig. 140), the bronchia presents a nodulated appearance, like a, varicose artery or an absorbent vessel, forming a series of globular swellings, on each side of which the canal is of the natural size. Occasionally, there is only one such dilatation, which may attain the magnitude of a cherry-stone, a marble, or a walnut. The appearances of the mucous mem- brane in this affection are various. In the generality of cases it is thickened, injected, and indurated, with its surface covered with dense, inspissated mucus. In others, especially in the second variety of the disease, the membrane is transpa- rent, and so extremely attenuated as to look like a shining vesicle. Occasionally, again, all the component tissues are in a state of hypertrophy, or they are indurated, rigid, and almost of a fibro-cartilaginous consistence. Cases also not unfrequently occur in which the mucous tunic is softened, and convertible into a orayish pulpy substance. When the dilatations are considerable, and embrace a large number of tubes, the intervening pulmonary tissue is hardened, probably from the effects of chronic irritation, imperfectly crepitant, and of a much lighter color than natural. This lesion is most common in the upper lobes of the lungs, and rarely affects the entire organ. It is usually dependent upon chronic inflammation, and is sometimes produced with much celerity. In hoop- ing-cough, it has been known to attain a very considerable height in the course of a few months. A frequent, forcible inhalation of air, when the bronchia? are enfeebled by disease, and obstructed with thick, ropy mucus, seems to be the immediate cause of this dilatation. It occurs at all periods of life, and is occasionally observed in infants. Dilatation of the bronchial tubes may be the result of the infiltra- tion of the cellular tissue of the lung with plastic matter, connecting the air-cells and lobules. In this disease, termed by Corrigan cir- rhosis of the lung, the dilatation is probably owing to the slow con- Sacculated dilatation of the bronchiae. OBLITERATION. 407 traction of the tissues between the tubes, thus drawing the parietes of one canal towards the parietes of another; and to the expansive action of the thorax in inspiration, causing the tubes to dilate, whilst the air- vesicles are incapable of any such action. Obliteration of the bronchial tubes affects mainly the smaller branches, especially when it is produced by inflammatory irrita- Fig. 141. tion, accompanied with effusion of lymph. In such cases, the contraction is liable to be mis- taken for an obliterated vessel. When, on the other hand, it is caused by the pressure of an ex- ternal tumor, it occasionally in- volves the larger-sized branches, or even one of the primitive trunks. Hypertrophied lym- phatic ganglions sometimes give rise to an obstruction of this kind, followed by a gradual wasting of the corresponding lung. The lesion under consi- deration is most common in the superior lobe of the pulmonary organs; a circumstance which is easily explained by the great frequency here of tubercular dis- ease, with which it often coex- ists. The number of tubes that may be thus affected is variable; occasionally, only a single one is obliterated; at other times, the lesion is observable in three or four; and in a few rare cases, all the branches of an entire lobe are implicated. Obliteration of the air-passages presents itself under two varieties of form. In the first, which is by far the more common, the tube is uniformly contracted throughout its entire length, being converted into a firm fibro-cartilaginous cord, from the sides of which numerous processes are detached, which ramify in an arborescent manner, and the diameter of which scarcely equals that of a bristle (Fig. 141). This variety, which may be said to resemble the continuous stricture of the urethra, usually affects the smaller divisions of the bronchia?, and is almost always complicated with dilatation, the caliber of the tube above the constriction being seldom perfectly natural. In the second variety (Fig. 142), the obliteration occupies only a very small portion of the tube, and is observed principally in bronchia? of the second and third order. The affected part rarely exceeds half an inch in length; generally, indeed, it is not near so long, and not unfrequently it presents the appearance as if the tube had been com- Obliteration of the bronchia. 408 AIR-PASSAGES. pressed by a narrow tape or ligature. In this variety, the diameter of the bronchia? above and below the obliterated point may be natural, diminished, or, as is more commonly the case, increased. Several tubes may present this species of Fig. 142. contraction in the same lung. The causes of this lesion are various, but they may all be re- ferred to the following heads: 1, the formation of fibrinous concre- tions ; 2, thickening of the mucous membrane; 3, external pressure; 4, the existence of accidental pro- ducts within the tube. Of these, the first and second are by far the most common, and they are both the immediate result of inflamma- tory irritation. The principle on which the one acts is similar to that which obtains in the production of contraction and obliteration of the arteries: the type of the other is to be found in the formation of stricture of the urethra, the nasal duct, and oesophagus. To explain. It is well known that the bronchial tubes are liable to inflammation, followed, not unfrequently, by an effusion of plastic lymph. The substance thus poured out being permitted to remain, it gradually contracts adhesions with the mu- cous membrane; and, in this way, an effectual barrier is formed, by which the ingress of the air is per- manently interrupted. Thus, the tube is deprived of its function; and, in time, converted into a firm, fibrous cord, like an artery that has been tied with a ligature. Thickening of the mucous membranes is observed in all parts of the body in which these structures are found; and it is therefore not at all surprising that it should occasionally produce narrowing and obliteration of the bronchia?. In the urethra it is a frequent cause of stricture ; in the nasal duct of lachrymal fistule. The third cause which has been enumerated, as liable to produce obliteration of the air-passages, is external pressure. This may be occasioned, as already stated, by a tuberculated lymphatic ganglion, an aneurismal or other tumor, or, as more generally happens, by pleu- ritic effusions, exerting a permanent influence. Lastly, obliteration of the bronchia? is occasionally caused by the presence of inspissated mucus, by deposits of tubercular matter, and by the inhalation of particles of foreign substances. A peculiar flat- Obliteration of the bronchiae. LUNGS. 409 tening of the left bronchial tube is occasionally produced by dilatation of the cavities of the heart, especially the left auricle. The mucous membrane, near the point of obliteration, may be normal, thickened, or attenuated: in some instances it is unnaturally red, softened, or incrusted with lymph. In the majority of cases, as was previously stated, the lesion is associated with dilatation, either of the same, or of the neighboring tubes. This is particularly apt to happen when it implicates the larger trunks. The parenchymatous substance itself is variously altered. Frequently it is remarkably em- physematous, or even rarefied; and, on the other hand, it is sometimes quite dense, solidified, and impermeable to the air. The adjoining vessels are seldom much affected, except when the obliteration occu- pies a large extent of surface; in which case, the smaller branches are often very much diminished in size, plugged up with fibrinous con- cretions, or transformed into dense, thread-like cords, which are easily distinguished by their dark grayish color. The consequences of obliteration of the bronchia? are exceedingly variable, and can be pointed out only in a very general manner. When of limited extent, the lesion does not produce any marked difficulty, as the neighboring tubes, under such circumstances, are always rendered sufficiently large to compensate for the loss sustained by the affected part. Should it, on the contrary, be more considera- ble, the effects will of course be more serious. The corresponding portion of the lung, for example, being deprived of air, will gradually fall into a state of atrophy, its surface will become puckered, and its substance rendered abnormally dry and dense, almost like a piece of liver. The bronchia? are liable to ossification, by which many of the more minute, and even some of the larger branches are occasionally con- verted into hard, solid pencils, perfectly impermeable "to the air. Andral' gives a singular example of ossification of these tubes. In dissecting the body of an old man, he found the lung full of hard masses, which were composed of an infinite number of bony spicules, arranged in a beautiful arborescent form, with a cavity in each so small as scarcely to admit a hair. Laennec and some others speak of having met with polypous growths in the bronchia?; but the occur- * rence of these bodies in this situation is by no means established. SECTION II. LUNGS. The pathological changes which are displayed in the lungs, may be arranged under the following heads: 1, acute inflammation; 2, abscess ; 3, gangrene ; 4, chronic inflammation; 5, oedema; 6, emphy- ' (Pathological Anatomy, vol. ii. p. 308. 410 LUNGS. sema; 7, apoplexy; 8, hypertrophy; 9, atrophy; 10, serous cysts ; 11, hydatids; 12, calcareous concretions; 13, encephaloid; 14, mela- nosis ; 15, tubercular phthisis. 1. Acute Pneumonitis in the Adult.—Inflammation of the pulmonary tissue, usually denominated pneumonitis, is a very common and fatal disease, especially in cold climates, where it not unfrequently prevails epidemically. Commencing with all the symptoms of an ordinary catarrh, it is soon followed by more or less pain in the chest, difficult respiration, and convulsive cough, with expectoration of a thick, ropy mucus, always streaked, in bad cases, with blood. If the patient suc- cumb, the anatomical characters will be found to vary according to the extent of the inflammation, its severity, and its duration. In this respect the disease may be considered as being divisible into three stages, each of which has some features peculiar to itself. In the first, the pulmonic tissue is marked by excessive engorgement of blood; in the second, it is dense, and hepatized; and in the third, it is infiltrated with purulent matter. In the first stage of the disease, the inflammation appears to be wholly confined to the parenchymatous texture, the only change ob- servable in the bronchial tubes being preternatural vascularity of their lining membrane. The lung is externally of a dark livid color, pits on pressure, and has an unusually heavy, solid feel. With these changes, the natural crepitus and elasticity are impaired ; and hence, on opening the chest, the organ seldom completely collapses. The internal structure exhibits various shades of color, from crimson red to livid black, occurring either continuously, in large patches, or in small circumscribed spots, according to the extent of the disease. When cut, blood freely issues from the incision, mixed with white frothy matter; the intervesicular cellular tissue is infiltrated with a large quantity of serosity; and all the vessels are in a state of the utmost engorgement. The lung, in this condition, still floats in water, owing to the fact that it still contains air, and, by careful washing, may be made to resume its spongy, vesicular structure, together with most of its normal characters. In very violent cases, such, for example, as run a very rapid course, we sometimes meet with small hemorrhagic effusions, traceable to ruptured vessels; and also with slight softening of the pulmonic tissue. The duration of this stage is usually from one to five days. In the second stage, the lung is hard and solid, being converted into a heavy, inelastic substance, similar to that of the liver. The crepitus, so distinct in the sound state, is no longer perceptible; the organ does not collapse, or only slightly, on opening the chest; and if the affect- ed part be torn across, it will exhibit a large number of granulations, which are nothing but the natural air-cells filled with bloody inspis- sated lymph. These little bodies are of a spherical shape, closely grouped together, and so solid that, with great care, they may be lift- ed out of their bed. The parenchymatous texture is specifically heavier than water, and of a deep fleshy red, interspersed with various shades of grayish, pink, brown, or even black: it is much more fri- able than in the preceding stage, breaks readily down under the ACUTE PNEUMONITIS IN THE ADULT. 411 finger, and is so dry that but little blood follows the knife employed in dividing it. By scraping the incised surface, however, or pressing the part between the fingers, a small quantity of sanguinolent fluid may be obtained, mixed either with thin froth, or, as more fre- quently happens, with purulent matter. There may also be observed along the incision a considerable number of whitish-looking points and stria?, which correspond with unaltered portions of bloodvessels and bronchial tubes. This stage seldom continues beyond three or four days, when it passes into that of purulent infiltration. It has just been seen that the color of a hepatized lung is liable to considerable variation. This is owing altogether to the nature of the effused fluids on which the solidification depends. When the product consists simply of plastic lymph, the hepatized part is generally of a grayish white; but when this substance is blended with ha?matin, as it commonly is when the inflammatory irritation runs high, the color is always more or less red. In the third stage, the lung, although it exhibits the same or even a greater degree of hardness, and the same granular structure, as in the second, assumes a pale yellowish cast, variegated with hepatized patches of red, gray, or bluish. A pus-like fluid always exists in this state, appearing at first in small isolated points, but which in a short time coalesce, and thus impart to the pulmonic tissue a uniform citron color. If an incision be made into the lung, it will be followed by the escape of an opaque ropy fluid, evidently of a purulent nature, but almost devoid of smell, or at least much less offensive than the matter of an external wound. As might be expected, from what has been just stated, the parenchymatous structure is extremely moist, soft, and lacerable, the slightest pressure of the finger converting it into a Fig. 143. a. The fibrous tissue forming the walls of the air-cells distinct and inclosing a few granules ; 6. Very granular epithelial cells of bronchia and air-vesicles ; c. Small nucleated cells and exudation-corpuscles, lying partly within, partly outside of the air-vesicles ; d. Blood- corpuscles.—After Dr. Da Costa. yellowish, pulpy mass. The smaller bronchial tubes, in the third stage of pneumonitis, are completely obstructed; the larger ones, on the contrary, contain more or less purulent matter, and their mucous lining is thickened, injected, and of a brownish red color. The anatomical characters of the three stages here described frequently occur in the same lung, dividing it into so many zones, which gradually and in- sensibly run into each other. The minute changes disco- verable by the aid of the micro- scope and by chemical analysis vary considerably according to the stage of the disease. At the commencement of the first stage the air-vesicles and their 412 LUNGS. Fig. 144. fluid contents are more granular than in normal or simply congested lungs. As the inflammation leads to deposit of a more solid character, we find a large number of exudation-corpuscles, as well as blood-cor- puscles, and the epithelial cells are more granular. Fig. 143, by Dr. Da Costa,1 represents this condition. In the second stage the air-cells are blocked up by lymph, and round or slightly oval inflammatory cells may be detected lying closely to- gether on the basement membrane of the air-vesicles. These cells are extremely varying in contents and shape. Some inclose one or two distinct nuclei, others are entirely filled up by granules. Other bodies found in the exudation are fibrinous casts, first noticed by Remak, by whom they are described as ramifying through the smallest bronchial tubes, and even through the air- vesicles. Fig. 144, represents lung tissue in a state of red hepatization. The third stage is generally believed to be owing to the occurrenceof suppuration. Yet pus-corpuscles are by no means the most prevalent element. Dr. Da Costa, in the work referred to below, describes distinctly marked corpuscles much larger than those of pus, and filled with granules and small oil-drops. Ether clears them to a large extent of their granules, and renders them transparent vesi- cles ; a circumstance which proves the fatty nature of the contents, and would lead, taken in con- nection with the frequent absence of pus-cells, the soft broken-down appearance of the lung parenchyma and the increased quantity of fat which can be detected in solidified lung, to the view that gray hepa- tization is, in many instances, not a true suppuration, but rather a breaking down of the exudation, not dissimilar to a fatty degeneration. Be this as it may, it is undoubted that the ordinary elements of sup- puration are not present in a large number of cases of gray hepatiza- tion, and especially are Ihey absent in that heavy, dense, yellowish- gray variety, the result of a peculiar kind of inflammatory lymph, which, on account of its color, has always been confounded with the third stage of pneumonia. The chemistry of the pneumonic lung is not satisfactorily understood. The peculiar lung-acid seems to increase; and there is also more fat. Much diversity prevails in regard to the extent of the disease. Sometimes we see it occupy almost the whole lung; most generally, however, it affects only a single lobe, or small detached masses. We a. Air-vesicles filled with inflammatory cells, some of which are nucleated ; 6. Concrete albuminoid mass- es ; c. Granule-cells.—After Dr. Da Costa. 1 American Journal of Medical Sciences, October, 1855. ACUTE PNEUMONITIS IN CHILDREN. 413 never find the whole of both these organs hepatized at the same time, for the obvious reason that an obstruction of this kind would be in- compatible with the respiratory functions. The right lung suffers more frequently than the left. Thus, in 868 cases, analyzed by Dr. Lombard, of Geneva, 195 occurred in both lungs, 260 in the left, and 413 in the right. Various explanations have been proposed of this fact; but none are sufficiently plausible to deserve special mention. The disease ordinarily begins in the inferior parts of the lung, from which it radiates in different directions, until it involves a greater or less extent of tissue. This statement accords with that of Laennec, and many of the best authorities of the present day; but it is opposed to the results of the observations of Broussais, Chomel, and several other highly respectable pathologists. In fifty-nine cases, Chomel found the upper lobes affected in thirteen; the inferior, in eleven ; the whole of one lung, in thirty-one; the posterior parts, in two; and the middle, in one.1 The universality of this occurrence, on the whole, is perhaps not so great as was imagined by Laennec: still, I feel satis- fied, both from my own observations and those of others, that his statement is applicable to the great majority of cases of this complaint, whether occurring in old age, in infancy, or in youth. Acute Pneumonitis in Children.—Pneumonitis is a very common dis- ease in children under six years of age; it attacks boys more frequently than girls, and usually occupies the lobules instead of the lobes, as it almost always does in older subjects. Hence the term lobular, by which it is generally designated by pathologists. This form of the disease may occur as an idiopathic affection, but in general it is in- grafted upon hooping-cough, bronchitis, croup, typhoid fever, measles, scarlatina, and gangrene of the mouth. It may begin at a single point, or simultaneously at several, and in its progress involve an entire lobe, or the greater part of one entire lung. It is ordinarily double. The most frequent complications of infantile pneumonia are, dilatation of the bronchial tubes, emphysema, especially the vesicular variety, pleuritis, and inflammation of the bronchial lymphatic gan- glions. The disease, anatomically considered, may be divided into three stages. In the first, the affected part has a marble, red, or rosy-gray complexion; and is somewhat softer, or a little less firm, than in the healthy state; it floats in water, crepitates under the finger, and emits, when pressed, a thin, frothy fluid. In the second stage, the pulmonary tissue is of a deeper color, reddish-gray, violet, or purple, generally well-circumscribed, solid, knotty, almost increpitant, and indisposed to collapse on opening the chest. The affected part, which often com- prises from three to five lobules, is of the size of an almond, or a small walnut, and usually of a rounded shape, though sometimes it is elongated, ovoidal, or polyhedral; the mass is easily penetrated by the finger, sinks in water, exhibits a rough granulated appearance on being torn, and is saturated with a sanious, acirated fluid. In the third 1 Laennec on the Chest, p. 204, note, by Dr. Forbes. 414 LUNGS. stage, the diseased structure is of a grayish, or yellowish color, friable, and infiltrated with globules of pus; it bears, in fact, a very close resemblance to gray hepatization; when cut, the part has a shining homogeneous aspect; the vessels are still visible, as white lines; and the bronchial tubes, although much compressed, may be traced with a little care. The lining membrane of the tubes may preserve its white, transparent appearance; but in general it is abnormally red, and bedewed with mucous fluid. When inflammation is very intense, or spread over an unusually large surface, the secretion is sometimes puriform, or purulent. It is not often that the pneumonia of children terminates in the formation of abscesses. When this takes place the pus is of a thick, cream-like consistence, and of a yellowish or greenish-yellow_ color, non-aerated, and perfectly free from odor; sometimes it is thin and reddish; and in a small proportion of cases it is mingled with clots of blood, or flakes of fibrin. The abscesses vary in size from that of a millet-seed to that of a pea; there may be only one, or they may be so numerous that they cannot be counted; they are generally round, or slightly oval; and they are found in the centre of the lung, as well as at the surface, to the latter of which they ordinarily tend. In recent cases the matter is immediately surrounded by a layer of hepa- tized pulmonary tissue; in those of longer standing, on the contrary, it is occasionally inclosed by a false membrane, thin, smooth, and polished, or by a small quantity of concrete pus, or broken down lymph. When several abscesses coexist they sometimes coalesce, and thus form a considerable-sized cavity, either single, or multilocular. The matter is either absorbed, or it bursts into a bronchial tube, and is finally expectorated. When it is situated near the surface of the lung, it may erode the pulmonary pleura, and so escape into the thoracic cavity. This, however, is exceedingly rare. Considerable light has been thrown upon the whole subject of lobular pneumonia by modern research. MM. Bailly and Legendre, struck with the close resemblance of the affected tissue to foetal lung, tried the experiment of inflating the apparently condensed organ. The result showed that the lobules could be almost completely restored, being rather in a state of collapse than filled with inflammatory lymph. Much ingenuity has been expended to account for this pulmonary collapse. The causes that give rise to it are undoubtedly most fre- quently of a mechanical nature, especially the presence of viscid mu- cus in the smaller bronchial tubes which the patient is unable to expectorate; the pulmonary vesicles thus losing the air they contain. The engorgement is a secondary occurrence. This collapse may be observed in young children and old persons. It may result in death, or terminate in recovery. The pulmonary tissue is, at times, soft, and frequently it is filled with fluid, but the great distinguishing mark between it and true hepatization, is the possibilty of inflating the collapsed lung. Pneumonitis frequently terminates, at all periods of life, in resolution, especially when it does not transcend the second stage. When this event ABSCESS. 415 is about to take place, the preternatural vascularity gradually disappears, the effused fluids are absorbed, and the air-cells regain their primordial volume and figure. Sometimes the pulmonic texture continues for awhile to be oedematous, being characterized by slight dulness on per- cussion, and indistinctness of the respiratory murmur. The progress of a portion of hepatized lung is more tardy, a considerable period generally elapsing before the granulations give way to the develop- ment of the air-filled vesicles. The first perceptible change is a dimi- nution of color, accompanied by an absorption of the lymph which gave rise to the solidification. As the process advances, the pulmonic tissue becomes gradually more yielding and elastic, it loses its dry- ness and fragility, and is infiltrated with a thin serous fluid, charac- ters which closely assimilate it to the normal texture. In the third stage, resolution is a rare occurrence; but, should this take place, the yellow color may be supposed to be lighter, and the pus more liquid, from the admixture of serum. Air-vesicles afterwards appear, and continue to increase, while the purulent fluid is reduced to small points, which progressively diminish in number as the vesicular structure returns. 2. Abscess.—The formation of abscesses, as an effect of pneumonitis, is extremely rare. Laennec states that, in several hundred examina- tions of persons who died of this disease, he never met with more than five or six cases in which the pus was concentrated into a focus.. The testimony of the later pathological anatomists of Europe and this country is precisely of the same import. Broussais declares that he met with this termination only once; Andral and Louis also con- sider it as very infrequent; and Dr. Horner, who dissected more than fifteen hundred bodies, observed it only in two instances.1 In my own examinations, I have not been more fortunate, having hitherto seen pulmonic abscesses only in two persons, the one an adult, aged forty, the other a child of fifteen months. In this case, the abscesses, which occupied the inferior lobe of the right lung, were about twenty in number, the largest of which' scarcely equalled a cherry-stone. No tubercles were found: the child had been sick about four weeks. The reason why the termination of pneumonitis by abscess was formerly considered as so very frequent, no doubt arose from mistak- ing tubercular excavations, which are of such common occurrence in consumptive subjects, for collections of this kind. Of this, any one may convince himself by a careful perusal of the works of Bonetus, Morgagni, and other pathologists of the seventeenth and eighteenth centuries. Even Dr. Baillie,2 so justly distinguished for the accuracy with which he generally conducted his researches, did not escape this error. The walls of these abscesses are formed by the pulmonic tissue, which is usually infiltrated with pus, and in a state of putrilaginous softening. In one of the cases to which I before referred, the matter 1 Pathological Anatomy, p. 241. 2 Morbid Anatomy, p. 42. 416 LUNGS. was bounded by a dark, flesh-colored substance, very considerably in- durated. Occasionally, the abscesses are encysted, or inclosed by a false membrane: cases of this kind, however, are very rare, and I have never met with them. Their size varies infinitely: in a few instances, they have been found as large as an adult fist; but, in general, they do not exceed a nutmeg, hickory-nut, or small apple. Frequently they communicate with the bronchial tubes, through which the matter is at length discharged, when the cavity heals, and the individual recovers; the mode of cicatrization being, in every respect, analogous to that which takes place in the spontaneous cure of a tubercular exca- vation. In old cases, the pus is usually of a thick, creamy nature; while in recent ones it is apt to be semi-concrete, from the admixture of an undue proportion of lymph. The purulent depositions are commonly seated near the surface of the lung; seldom deep in their structure. Abscesses of the lungs can occur only in association with, or as a consequence of, inflammation, whose limits are properly circumscribed; in other words, the disease must be confined to particular parts, lobes, or lobules. The rationale of this is obvious. In universal pneumo- nitis, death must necessarily ensue before the matter can break up the cellular tissue and collect itself into a focus; which need not be the case when the inflammation is limited, nature, properly assisted by art, being often capable here of warding off this occurrence until after the establishment of the suppurative process. Metastatic abscesses of the lungs are sometimes met with, generally as a result of phlebitis, produced by wounds of the head, comminuted fractures of the extremities, and great surgical operations; they may also arise from burns and scalds, erysipelas, smallpox, and other violent diseases. Their number is exceedingly variable; sometimes there is only one; at other times there are as many as six or a dozen; and occasionally, though rarely, there are several hundred. In their volume they may be as small as a mustard-seed, or as large as a pigeon's egg. They are of a rounded shape, distinctly circumscribed, superficial, and nearly always most numerous in the inferior portion of the lungs. Their contents are of a tough, fibrinous consistence, and of a reddish, brownish, or blackish color. The pulmonary tissue around them is unnaturally vascular, oedematous, hepatized, and friable: the smaller veins are inflamed, and filled with black or red- dish concretions. The insidious manner in which these abscesses are developed has been a common remark among pathologists. They are liable to be confounded with pulmonary tubercles, but may be readily distinguished from them by their larger size, by their darker color, and by the fact of their being usually the result of a distant lesion. 3. Gangrene.—The lungs are liable to gangrene, sometimes as an effect of acute pneumonitis, but more generally without any assignable cause. The disease may occur in circumscribed spots, or it may in- vade an entire lobe, or even the whole of one of these organs. It may be readily detected by its intensely fetid odor, and by its greenish GANGRENE. 417 brown, dirty olive, dark brown, or black color. The pulmonic tissue is softened, and converted into an offensive putrilaginous mass, not unlike decomposed blood. When cut, the part affected often gives vent to a turbid, sanious fluid, of a greenish tint, and an almost in- supportable smell: in rare cases, the sphacelated mass is dry and friable, like a rotten pear. When the gangrene is circumscribed, an imperfect factitious membrane may sometimes be discovered; but, in most instances, where there is a distinct line of demarcation, the living part is preternaturally injected and infiltrated with sanguinolent liquid, with cellular shreds and vascular filaments hanging from its borders. By degrees, the putrid pulp finds its way into >the adjoining bronchial tubes, and is finally ejected by expectoration. The cavity which is thus left, is either filled up with lymph, or, as more commonly hap- pens, its walls are lined by a false membrane, which continues to secrete, for a time, a thin, imperfect pus. Gangrene of the lungs is of much more frequent occurrence than was formerly supposed. It is most prevalent in cold weather, and occa- sionally betrays an epidemic tendency. It makes its attacks at all periods of life; but the aged, and especially such as are of intemperate habits, are most prone to it. A singular fact respecting gangrene of the lungs has been witnessed by Dr. Guislain,1 a French physician. Out of thirteen insane patients who died of inanition in the hospital at Gand, nine were affected with this disease. In one case, both lungs were involved; and in nearly all of them the sphacelation was con- fined to the posterior and upper part of these organs. How is this occurrence to be explained ? The present state of our knowledge does not enable us to give a satisfactory answer. In my private collection are two beautiful specimens of gangrenous lung,-of which I annex a brief description. Of these, one belongs to the circumscribed variety, and was taken from a mechanic, forty years old, who died from its effects. On inspection, I found the left lung, at the part corresponding with the interlobular fissure, reduced, for about one inch in diameter, to a dark, pulpy, gangrenous mass, so excessively offensive that it was almost impossible to remain in the apartment where I was conducting the examination. The eschar, which reached as far as the surface of the lung, communicated with a large bronchial tube, and had been discharged in part by expectora- tion. The pleura immediately over it was in a state of sphacelation, and the matter was evidently prevented from escaping into the chest by the adhesions which the lung had formed with the wall of that cavity. The pulmonic tissue round the gangrene was rather soft and injected, and the whole surface of the organ was covered with a false membrane, thick, dense, and highly vascular. In the other specimen, which belongs to the diffuse variety, the gan- grene involved nearly the whole of the right lung, which was of a dark, dirty olive color, extremely soft and friable, and exhaled a most intolerable odor. The pulmonary pleura was perforated in^ several 1 Gazette Medicale de Paris, January, 1836. 27 418 LUNGS. places, and a considerable quantity of black, offensive matter was found in the corresponding cavity of the chest. The disease, in this case, supervened upon an attack of typhoid fever, and was marked by a brownish, fetid expectoration, which set in a few days before death. The patient was a young printer, twenty-three years of age. The progress of this disease, if at all extensive, is generally rapid; and the expectoration, which is of a dirty black, green or brown color, is so horribly offensive that it may be considered as pathognomonic of the disease. 4. Chronic Pneumonitis.—Chronic pneumonitis, as a distinct disease, is extremely infrequent, so much so, indeed, that its very existence has been denied by many writers. That it does occur, however, is indisputable. As a consequence of acute inflammation it is sufficiently common; and the exudation occurs, both in the air-vesicles and in the connecting cellular tissue; and not, as some assert, exclu- sively in the one or the other of these structures. A chronically inflamed lung is hard, dense, and dry, yield- ing little or no moisture on pressure; it tears with a granu- lated surface, pits under the finger, and cuts a good deal like a sponge. Here and there a reticulated structure, caused by some remains of the air-cells, is visible; and, scattered through various parts of it, numerous tuber- cles may sometimes be ob- served, of a pale grayish hue, semi-concrete, and easily re- movable. The color of the indurated organ being alto- gether of an accidental cha- racter, varies in different cases. Thus, it may be red, grayish, pale yellow, iron gray, brown- ish, or even black, or these tints may be blended, and so the part have a mottled aspect. In my collection is a specimen of the color of flesh ; and another which is of a light grayish hue beautifully dappled with black. These, to- gether with a specimen taken from a young horse that died of pneu- monitis, complicated with chronic pleuritis, are the only instances, so far as I now recollect, that I have seen of this affection. In neither of them were there any tubercles. The pulmonary tissue in all was remarkably dry, hard, tough, smooth, and shining when incised, rough and granular when torn. The bronchial tubes seemed to have been Fig. 145. Chronic inflammation of the lungs ; the air-cells and smaller bronchial tubes being entirely obliterated. From a preparation in my cabinet. 03DEMA. 419 entirely closed : many of the larger vessels were filled with red, clotted, friable blood, and the smaller ones were either obliterated, or so in- corporated with the indurated mass as to have completely lost their original features. These appearances are well seen in Fig. 145. The disease may be limited to a few lobules; but in general it affects one or more lobes, and sometimes one entire lung. It is occasionally observed around pulmonary abscesses, and very commonly around tubercular excavations. The indurated part is usually much dimi- nished in volume, and does not, according to my observation, sink so readily in water as in the acute form of the lesion. The two speci- mens above alluded to, notwithstanding the induration was very oreat, were both specifically lighter than this fluid. Chronic pneumonia may pass into purulent infiltration, abscess, and gangrene. When fully formed, it is doubtful whether it is suscep- tible of resolution, since the various textures are so firmly cemented together by lymph as to render it impossible for the absorbents to effect their restoration. When idiopathic, the progress of the affec- tion is gradual, exciting little attention until a large portion of the pulmonarj' tissue has become impermeable to air. There is a peculiar state of the pulmonary tissue to which patholo- gists have applied the name of carnification. How it is produced is not determined, but the probability is that it is merely one of the effects of pneumonia. It attacks both lungs indiscriminately, and usually occupies their lower extremity. The affected part closely re- sembles a muscle, the fibres of which are compressed and indistinct; it is hard, dense, and resisting, instead of being soft, flaccid, and friable, as in ordinary cases; it is non-crepitant, and is penetrated with diffi- culty by the finger; the cut surface exhibits a smooth appearance; and, when pressed, it yields a small quantity of sanious, bloody fluid. Its color is violet, rose, or pale red, and mottled with white radiating lines, which are disposed in the form of lozenges, and indicate the situation of the lobules. The lung itself has a remarkably depressed appearance, similar to what is observed in an imperfectly inflated foetal lung, so well described by Jorg, under the name of pulmonary atelecta- sis. It is, indeed, highly probable that carnified lungs are in reality lungs deprived of air, in a state of collapse. 5. (Edema.—The lungs are occasionally the seat of oedema, a dis- ease which, as its name imports, consists in an effusion of serum into their cellular texture. The anatomical characters vary according as the lesion affects either the whole or only a part of the respiratory organs. When the entire lung is involved, it does not collapse on opening the chest; it is denser and heavier than in the normal state; pits on pressure; and, when cut, exudes a large quantity of clear, j^ellow- ish serosity. This fluid is intimately blended with the interstitial eel lular tissue of the organ, into which it is originally deposited, and can be easily discriminated from that which is diffused during the first stage of pneumonitis, by its being less frothy, and of a lighter com- plexion. The lung, when thus affected, still crepitates on pressure. This disease is rarely idiopathic; on the contrary, it is usually associated with other dropsical disorders, occurring, for the most part, 420 LUNGS. in worn-out cachectic individuals towards the close of painful and pro- tracted fevers. Sometimes it accompanies organic affections of the heart. Chronic bronchitis likewise predisposes to it; and it is the cause of the embarrassment of breathing which so often exists as a sequel of measles, smallpox, and scarlet fever. The oedema seldom lasts beyond a few days; occasionally, however, it continues for several weeks or even months, when the fluid is either absorbed, or the case proceeds to a fatal termination. 6. Emphysema.—Of emphysema there are two varieties—the vesicu- lar and interlobular—the one consisting in a dilatation of the pul- monic cells, the other in the extravasation of air into the interstitial cellular tissue. These two forms seldom coexist; and the latter, com- pared with the former, is usually regarded, though erroneously, as a most rare disease. In the vesicular emphysema (Fig. 146), the air-cells are preternaturally dilated, atrophied, and distorted in shape. Their size varies in different cases. In general, they equal the head of a common pin; in others, they are as large as a currant; in others, again, as big as a cherry-stone, or even a French bean. When the cells are of the latter dimensions, which, how- ever, is very rare, it is not improbable that several of them are thrown into one, by the rupture of the intervening tex- ture : in some instances, notwithstanding, the enlargement evidently results from a single vesicle, the walls of which, instead of yielding to the distending cause, are expanded into thin transparent bags. Occasionally, all the cells disappear from one entire lobule, leaving merely some vascular and cellular shreds. In this manner a capacious cavern is sometimes produced, which projects beyond the surface of the lung, in the form of one or more globules. The lung, in this variety of the disease, seems to be augmented in volume, and to have lost its natural resiliency. It is considerably paler than the sound organ, less crepitous, more dry and elastic, and does not collapse on opening the chest. Its specific gravity, also, is increased; the surface is often studded with small vesicles; and many of the minute bronchial tubes are in a state of dilatation. Vesicular emphysema is rarely observed before the age of fifty. It may exist in both lungs at the same time, or it may be limited to one of these organs, to one lobe, or to a small portion of a lobe. In eigh- teen cases out of forty-two, observed by Louis, it was found to be general throughout both lungs. It is a very common attendant on tubercles, aneurismal tumors of the heart and aorta, enlargements of the bronchial glands, and asthmatic disorders. Amongst the occasional causes may be Vesicular emphysema. EMPHYSEMA. 421 enumerated whatever has a tendency to over-distend the air-cells of the lungs, as playing upon wind instruments, singing, and loud screaming. The second variety, or the interlobular emphysema Fig. 147. (Fig. 147), consists, as was before stated, in the dif- fusion of air through the interareolar texture, in consequence of the rupture of some of the pulmonary vesicles. So far as an opportunity has been af- forded me of judging, no period of life is, I am in- clined to believe, wholly exempt from it. Males, between twenty and thirty, have appeared to me to be particularly Subject tO it; Interlobular emphysema. much more so than at an earlier or a later age, or than the other sex. I have never observed this affection in newborn infants; but in one instance, I noticed it in a child of seven months, who died under symptoms of pneumonitis, complicated with hydrocephalus. Of nineteen cases of this disease, of which I have kept a record, six occurred in association with bilious and typhoid fever, four with dysentery, three with hooping-cough, one with acute inflammation of the lungs, four with tubercular phthi- sis, and one with infantile cholera. In twelve of these cases, the emphysema affected both organs, though not to the same extent. In five it was exclusively confined to the right lung; in two to the left. In nearly all, it was most distinctly marked along the interlobular intervals and the free margins. In a few only was it noticed at the base of the organ, and in not a single one at the apex, or at the posterior part of the internal surface. Why these differences should obtain, or why certain portions of the lungs should be more frequently affected in this way than others, are circumstances in the history of this lesion which, in the present state of the science, we are totally incompetent to explain. When a lung is thus affected, the diseased part is easily recognized by its peculiar whitish appearance, which contrasts singularly with the red colored textures around it. It distinctly crepitates under the pressure of the finger, the contained air being readily pushed from one place to another, and the serous covering of the viscus appears, as in truth it is, to be lifted off from the parenchymatous substance. In this way, I have repeatedly known thin, flattened bags to be formed from two to three inches in length, by six or eight lines in breadth, and as perfectly pellucid as the most delicate soap bubble. In other instances, the pleura is raised into little globules, so closely clustered together as to bear a strong resemblance to a string of pearls. But, whatever may be the form or extent of the elevation, the parenchy- 422 LUNGS. matous texture beneath is always more or less lacerated, of a pale color, and generally reduced, especially in cases of long standing, to a sort of network, consisting solely of vascular and bronchial ramifi- cations. These are generally arranged in transparent bluish bands, as in Fig. 147. In this, as in the preceding variety, the lungs do not collapse on opening the chest, and they also cover, to an unnatural extent, the surface of the pericardium, which, especially when the emphysema is very great along the anterior margins of both viscera, is sometimes almost entirely concealed. Occasionally, the air escapes into the cellu- lar substance of the mediastinal cavity, where it is either arrested, or it extends up the neck, and forms an irregularly flattened tumor, which sensibly crepitates on pressure. In this way, the fluid may reach over the whole body. The most frequent cause of interlobular emphysema is the forcible and prolonged retention of the air during severe mus- cular efforts, as in lifting heavy weights, in parturition, in hooping- cough, croup, and other affections of the respiratory passages. 7. Pulmonary Apoplexy.—Like the disease just considered, pulmo- nary apoplexy may be distinguished into two varieties—the vesicu- lar and interlobular—the blood in the one being retained in the air- cells, in the other, extravasated into the connecting cellular tissue. As might be expected, the anatomical characters vary, as the fluid occupies the vesicular or the interstitial cellular texture. In the former case, the blood is collected into round, circumscribed masses, from the size of a pea to that of a large apple. When incised, the section has a deep red, granular aspect, of the consistence of a hepa- tized lung, with numerous intersecting vessels and tubes of a much lighter color. By scraping with the handle of the scalpel, the clotted blood is removed from the air-cells, and the part exhibits a beautiful honeycomb arrangement, the pits being separated by irregular par- titions. In the second variety, the fluid ruptures the air-vesicles and is ex- travasated into the intervening cellular tissue, breaking it down into a ragged, shreddy substance, in appearance not unlike a coarse sponge, saturated with dark blood. Large cells and excavations may thus be formed, penetrating to a considerable depth, and converting the lung, in some cases, into a soft, irregular, fluctuating mass. Occasionally, the apoplectic effusion is so great as to lacerate the pleura, and escape into the thoracic cavity. When the effusion is very profuse, as when it proceeds from a rup- tured vessel of considerable magnitude, death may occur in a few hours, if, indeed, not almost instantaneously. In other cases, the blood is discharged by the mouth, or a portion of it remains, and gradually assumes new properties. If the individual is cut off durino- the attack the blood is found, upon inspection, to be of a dark venous hue, and only partially, if at all coagulated. In cases of an opposite character, however, it is uniformly clotted, more or less firm, and of a light brownish, pale, gray, dun, or drab color. These alterations are always more conspicuous in proportion to the length of time that has elapsed PULMONARY APOPLEXY. 423 since the apoplectic attack, and are dependent upon the absorption of the serum and coloring matter of the extravasated fluid. The tissues around the clot may be quite sound and crepitous, but commonly they are pale and indurated. Sometimes the clot acts as a foreign body, producing inflammation, softening, suppuration, and even gangrene. Should the effusion be small, limited in extent, or not have caused much injury, it may be entirely absorbed, and the vesicular structure resume its normal characters. In other cases, again, though this is rare, nature makes an effort at reparation by organizing the clot, or inclosing it in a cyst, as in apoplexy of the brain. The blood, in pulmonary apoplexy, may flow from two distinct sources, either from the mucous membrane of the bronchios, as a simple exhala- tion, or directly from a lacerated vessel. When depending upon the lat- ter source, the hemorrhage is often extremely profuse, and may prove rapidly fatal. Several years ago, I examined the body of a man, thirty- two years old, who died about twelve hours after an attack of pulmonary apoplexy, in which he lost nearly a gallon and a half of blood. The stomach contained almost a quart of this fluid; the bronchiee, trachea, and larynx were nearly filled with it; and a large tubercular excava- tion in the upper lobe of the right lung, capable of holding five ounces, and from which the hemorrhage proceeded, was also occupied with it. A loss of blood, of three or four pounds, is by no' means unusual in seizures of this kind. Much dispute existed, at one time, concerning the probability of the blood in this disease emanating from simple exhalation of the mucous membrane of the bronchial tubes. The subject is amply discussed by Bichat, who espoused the affirmative side of the question; and his opinion has been abundantly confirmed by the more elaborate re- searches of modern pathological anatomists. It is now, indeed, well ascertained that the occurrence is not only possible, but much more frequent than is generally imagined. The, hemorrhage, though some- times profuse, is seldom so great as when it proceeds from a ruptured vessel. Hypertrophy of the right ventricle of the heart, with contraction of the mitral valves, seems to be the most frequent cause of this lesion. Indeed, apoplexy of the lungs may be said to have the same connec- tion with hypertrophy of the right side of the heart, that apoplexy of the brain has with that of the left, the tendency, in both cases, being to throw the blood with more impetuosity and force upon the respect- ive organs. Should there be a contraction of the mitral valve, the blood will stagnate in the left auricle, and the pulmonary vessels be constantly engorged from the obstacle in the venous circulation. When this state is conjoined with thickening of the walls of the right ventricle, nothing, it may be presumed, would be more easy than the supervention of hemorrhage, whether as a simple exhalation, or as the result of a laceration of one or more vascular branches. The deposit of blood in the pulmonary tissues is also a frequent attendant upon phthisis; and, in some instances, it is found to be accidental, the fluid being poured down the windpipe from an ulcerated artery of the tongue, palate, or fauces, or from the bursting of an aneurismal sac. 424 LUNGS. 8. Encephaloid.—Encephaloid seldom occurs in the lungs. It may exist under several varieties of form. Thus, it may be diffused through the intervesicular tissues, in small, uncircumscribed patches ; or it may be deposited in irregular spherical masses, varying in size from a small pea to that of a full-grown foetal head; or, lastly, it may present itself in the character of an encysted tumor, which, in fact, is most usually the case. In this variety, the heterologous growth rarely exceeds a common-sized apple, and the capsule surrounding it, although hard and tough, is scarcely the fourth of a line thick, and of a white grayish color; the adhesion between the two structures is usually very slight, and the vessels which are so abundantly distributed upon the latter, can seldom be traced to any great depth into the former. In some cases, the medullary matter occupies only a single cyst; in others, there are as many as six or eight, united together into one tabulated mass. Clots of blood, of a deep red, brown, or blackish color, are frequently inter- mixed with this substance, altering its appearance and consistence. Dr. Da Costa recently showed me a beautiful specimen of encepha- loid of this organ. It occurred in a man, aged thirty-five, who had been operated on for a cancerous tumor of the knee. The pulmonary disease was evidently secondary. It involved both lungs, and con- sisted of a great number of large and well-marked nodules, some of which were very vascular, being pervaded by many fine vessels. The intermediate pulmonary tissue was sound, but the pleura over the nodules was thickened. 9. Melanosis.—The lungs are liable to melanosis, though this may be classed amongst the rarest affections met with in these organs. It is commonly seen in amorphous masses, in small nodules, in thin, irregular laminae, or in minute dots. The tuberiform variety, which is perhaps the most common, occurs in globular, oval, or pyriform tumors, from the size of a currant to that of an egg, or even an apple. Sometimes they are encysted, the capsule by which they are inclosed being com- posed of dense, cellular tissue, about a fourth of a line thick. Their surface is either smooth, tabulated, or tuberculated, their consistence varying between tallow and a lymphatic gland, though occasionally they are quite fluid. The circumjacent textures are generally sound, and the connection between them and the heterologous bodies is often so slight as to require but little dissection to separate them from each other. There is a variety of black substance, which, instead of being a product of secretion, like that just described, is introduced with the air in breathing, and carried by the absorbent vessels into the inter- vesicular tissues. It is most common in colliers, moulders, and other persons who are habitually exposed to the inhalation of carbonaceous matter. Old age is the period pf life most liable to it, though it has been noticed in comparatively young subjects. The foreign substance may be solid, semi-liquid, or fluid, and may occur as an infiltration, or in the form of granules, or, finally, in lines or streaks, having a retiform or pentagonal arrangement. Both lungs are generally affect- ed at the same time and in an equal degree; they are of a uniform black, or bluish-black color, indurated, friable, and infiltrated with SEROUS CYSTS — EARTHY CONCRETIONS. 425 black serosity. Sometimes, especially when the deposit coexists with tubercular disease, they contain excavations, the parietes of which are bedewed with the foreign matter, and which is then often expectorated, for weeks and months together, in considerable quantity. The bronchial lymphatic ganglions almost always participate in the black discoloration. This matter is without taste or smell, insoluble in muriatic and nitric acid, miscible with water, and of a black color, like charcoal, soot, bistre, or China-ink. It is not bleached by chlorine, nor is it affected by putrefaction. When dried, it burns like charcoal, with scarcely any animal empyreuma, and leaves a considerable quantity of pale-gray ash. It is of an inorganic carbonaceous character, and bears the closest resemblance to lamp-black. In persons, furthermore, whose lungs have been congested for any length of time, it is not un- usual to find black pigment in the lung, probably the result of trans- formed blood. Destructive analysis yields carburetted hydrogen, and the other usual products. 10. Serous Cysts.—Serous cysts, containing a thin, limpid fluid, are occasionally found in the lungs. They are more common in the infe- rior animals, as the ox, sheep, and goat, than in the human subject, and seldom attain a large size. In general, also, they are single, though sometimes several have been seen in the same lung. 11. Hydatids.—Hydatids of the lungs are also rare. Of a globu- lar, ovoidal, or pyriform shape, they are of variable magnitude, of a" firm, semi-concrete consistence, and usually, if not always, of the ace- phalocystic kind. Their coats are of a light grayish color, some- times speckled with opaque, yellowish dots; and their contents, which are generally of a thin, limpid nature, are often milky, brownish, or sero-sanguinolent. The internal surface of the hydatid is frequently rough, and lined with lymph. The number of these bodies is seldom considerable, or their size large. Occasionally, however, there is a very large one, including several of smaller dimensions. 12. Earthy Concretions.—Calcareous, earthy, or cretaceous concretions of the lungs are sufficiently common. They usually occur in small rounded nodules, of a grayish-white color, friable, semiconcrete, or very hard, and consisting almost entirely of phosphate and carbonate of lime, with a minute proportion of animal matter. Cases are seen in which these concretions are of a dark color, oval, cylindrical, or pyriform, hard and gritty, or rough on the surface, like a mulberry calculus of the urinary bladder. Their dimensions are very variable. From the size of a mustard- seed they may attain, and even exceed, that of a peach-stone; though, in the generality of cases, they do not surpass the volume of a cur- rant, a pea, or a small cherry. Their number is in an inverse ratio to their size. The case of a phthisical person is recorded, who, during the eighteen months immediately preceding his dissolution, ejected upwards of two hundred small stones; and in another, between five and six hundred were expectorated. These concretions are sometimes perfectly white like chalk, and of the consistence of putty, or fresh mortar. They are generally invested 426 LUNGS. by a cyst, which is of a pale bluish, grayish, or drab color, fibrous, or fibro-cartilaginous in its structure, and from the sixth of a line to a line and a half in thickness. There can be no doubt that these con- cretions, whatever be their color and consistence, are merely degene- rated pulmonary tubercles. In proof of this it may be stated that the cretaceous deposit, as it is called, is often seen at one point, the calcareous at another, and the tubercular at a third. The conversion constantly begins at the centre of the morbid mass, in the form of pultaceous, chalky, or putty-like matter, which in time completely sub- verts the original structure, and is itself ultimately replaced by cal- careous substance, the last alteration of which these formations are susceptible. Advanced age favors this degeneration; which, however, is sometimes observed in young subjects, and even in children. Of 100 old persons examined by Roge'e, not less than fifty-one had cal- careous concretions. 13. Hypertrophy.—The lungs are liable to hypertrophy. It is a law of the animal economy that in proportion as a part is exercised so will be its size and strength. This is strikingly exemplified in the muscular system, and also in some of the other organs, as the lungs, testicles, kidneys, and mamma?. Under such circumstances, the organ increases in bulk, its texture becomes more firm and elastic, and the air-cells are enlarged, at the same time that their walls are thickened and strengthened. The augmentation of volume is sometimes extra- ordinary. I have more than once seen the hypertrophous lung per- manently dilate the chest, force down the diaphragm, displace the heart and mediastinum, and project up nearly two inches into the neck between the clavicle and spinal column. In this way, although one lung may be entirely gone, the individual may live for years in tolerable comfort. 14. Atrophy.—Atrophy of the lungs, the reverse of the condition just described, is generally produced by accidental circumstances. In great emaciation of the body, such, for example, as is witnessed in protracted fevers, or painful local disorders, the lungs do not seem to participate in the decay, at all events, not to any appreciable extent. That these organs experience some changes in cases of wilful absti- nence, when all the other viscera are in a normal state, has been al- ready seen in the chapter on gangrene; but what these changes are, whether they consist in some structural lesion, or in some derange- ment simply of the nutritive function, has not been determined. In old age, the pulmonary tissue becomes sensibly altered; it no longer possesses the same softness, the same pliancy, or the same color, that it did in youth or adolescence; on the contrary, it is dry, imperfectly elastic, of a pale grayish tint, and comparatively ill supplied with blood. Its absolute bulk and weight are diminished, and the parietes of the air-cells are attenuated and enfeebled. But these are not the only causes of pulmonary atrophy. In most cases, as was before intimated, it is dependent more immediately upon causes exerting a local influence, and hence it is usually found in association with effusions of water, lymph, pus, or air into the thora- cic cavity, or with tumors pressing upon the large bronchial tubes. In PULMONARY PHTHISIS. 427 such cases, we often find the lung reduced to a mere cake, scarcely more than an inch in thickness, by several inches in diameter, with a dark, dense, inelastic structure, almost devoid of air-cells. This acci- dental atrophy, which may occur at any period of life, is usually con- nected, provided the patient survives sufficiently long, with hyper- trophy of the opposite lung. 15. Pulmonary Phthisis.—By far the most interesting disease of the lungs is phthisis, whether we consider the frequency of its occurrence, the rapidity of its progress, its almost uniform fatality, or the obscu- rity which still envelops its etiology. This affection essentially con- sists in a slow disorganization of the pulmonary tissue, occasioned by the development of tubercles. The opinion now generally prevails that the primary seat of tuber- cular matter is in the air-cells and minute bronchial tubes. That this is true, as a general rule, observation has fully convinced me. Nevertheless, I am far from believing that it is applicable to all cases; for an instance occasionally occurs, where the matter is evi- dently, in a great measure, if not wholly, confined to the cellular tex- ture. These cases are certainly rare, yet that they really exist, is indisputable. Independently of their easy demonstrability, in this situation, analogy is strongly in favor of the position here contended for. In the kidneys, for example, how often does it happen, that the heterologous bodies are seated exclusively in the so-called cortical tissue, notwithstanding the amount of mucous structure within ? They are also frequently seen in the bones, in the substance of adventitious membranes, in the interior of the spleen, and on the surface of the serous membranes, parts which are perfectly devoid of the tissue under consideration. The presence of this tissue is therefore not at all necessary to the production of tubercles, nor is there any reason for concluding that these deposits should be invariably formed by it, even where it abounds in an organ, as it does in the lung. The varieties of form in which this matter is deposited were pointed out in a previous section. Referring the reader to the general history of tubercle, I shall limit myself here to the statement of a few leading facts, which will enable him, it is hoped, more fully to comprehend the character of this lesion. Of the four varieties of tubercular deposits of the lungs, the miliary is by far the most common. It occurs in at least forty-nine out of every fifty cases of phthisis. The individual granules vary in volume between a mustard-seed and a filbert: they are generally of a pale yellowish color, and of a semi-concrete, friable consistence. A gray- ish hue is not uncommon, especially at first, although it is now a settled point that the deposit may be yellow from the onset and re- main so; and, on the other hand, that the gray tubercle may be con- verted into the yellow, both being merely forms of the'same disease: occasionally they have a greenish, vitreous aspect, with a degree of firmness amounting to fibro-cartilage. This is especially the case in that variety of these little bodies to which Bayle has applied the appellation of gray granulations, and which this celebrated author con- sidered, though erroneously, to be distinct from genuine tubercles. 428 LUNGS. In the early stage of their development, the granules, whatever may be their appearance, are always soft and isolated; by and by, however, they augment in consistence, and run into each other, forming thus large nodules, of variable color, size, and shape. Sometimes they con- tain particles of foreign matter, such as grains of sand, especially in miners, masons, and grinders; and cases occur in which their central portions remain empty, producing an arrangement, when divided, of internal depressions. At other times there is a distinct nucleus of inspissated mucus, around which the tubercular matter is deposited. The number of miliary tubercles is extremely variable. In some instances, though this is rare, there are a few, perhaps, indeed, only a solitary one; but, in the vast majority of cases, there are hundreds and thousands, of all sizes, from that of a pin-head to that of a hazel-nut. All parts of the lungs are liable to them; but, as will be shown by and by, the superior lobes are their most frequent seat. Occasionally, they are confined to the interior of the organs, the external surface being entirely free from them. This, however, is rare. These little masses sometimes appear to be encysted; but this arrange- ment is in most instances altogether deceptive, as it probably depends entirely upon the manner in which the tubercular matter is impacted in the bronchial tubes. Such, at any rate, I have found to be the case in my own dissections; for, except on four or five occasions, I have not been able to detect anything like a cyst of new formation. The stratiform variety is also very rare in the lungs; so likewise is the infiltrated. The former I have observed only in a single instance, and then not in the human subject: the latter I have noticed several times, but never to any considerable extent, except in connection with tubercular caverns. The matter, in this form of the disease, may be diffused through several contiguous lobules, an entire lobe, or even the whole lung; generally occupying the air-cells and the minute bronchial tubes, the parietes of which are at the same time some- what thickened, and preternaturally brittle. Although usually of a yellowish color, it often varies from a light gray to a dark slate, aris- ing from the intermixture of black pulmonary matter, which occa- sionally imparts to it a variegated marble tint. Its texture is homo- geneous, opaque, and of a firm, semi-cartilaginous consistence: when torn, it exhibits a rough, granular surface, and seems to be entirely composed of small, irregular bodies, which, from the peculiarity of their arrangement, have been compared, not inaptly, to the eggs of certain insects, placed in close contact with each other. The tuber- cular infiltration is originally deposited in detached lozenge-shaped patches, which, in time, coalesce, and so involve a considerable portion of pulmonary tissue: it is most common around old caverns, and is occasionally seen in conjunction with some of the preceding varieties, especially the miliary. The pulmonary tissues around these deposits are variously altered. In the early stages of the disease, before the secretion has made much progress, it is not unusual to find the surrounding parts quite sound. This state, however, rarely continues very long; for, after the tubercles have existed for some time, they invariably act as extraneous bodies, PULMONARY TISSUES. 429 the more so if they are very large or numerous, producing different morbid changes, such as congestion, inflammation, softening, indura- tion, serous infiltration, and the formation of accidental tissues. Of these pathological conditions, the most common, perhaps, is con- gestion, owing probably to the compressed and obstructed state of the pulmonary veins. The blood, being thus prevented from findinga ready outlet, must necessarily accumulate in the capillary vessels around the morbid deposits, which, in consequence, often exhibit quite a red appearance, the vessels being arranged in beautiful arborescent lines, some of which are occasionally traceable into their substance. As the result of this engorged condition, the pulmonary tissues are frequently infiltrated with serous fluid, the quantity being sometimes so considerable as to lead to great embarrassment of breathing, from the want of free admission of air into the lungs. Haemoptysis is also not uncommon. Pure uncomplicated congestion occurs much oftener, according to my observation, in chi-ldren and young persons than in the old, or in such as are much exhausted by the disease. If it be allowed to go on unrestrained, it produces, sooner or later, an effusion of lymph, with consequent hardening and shrinking of the pulmonary textures. Softening, gangrene, and ulceration, are also occasionally noticed, but much less frequently, I apprehend, than has been ima- gined. The air-cells and minute bronchial tubes, commonly the primary seats of the morbid deposit, are usually more seriously affected than the rest of the anatomical elements of the lungs. Not only are they obliged to bear the brunt of the disease, but, as might be anticipated, they must generally labor under considerable irritation, even for some time before the matter is poured out. Nor is it reasonable to pre- sume that the irritation thus set up will wholly subside during the progress of the secretion. As the matter accumulates in these reser- voirs, it presses upon them on all sides, by which, whilst their caliber is enlarged, their parietes are generally attenuated, and finally destroyed by ulcerative absorption. Hence, when caverns form, the bronchial tubes generally open into them abruptly, as if they had been cut across with a sharp instrument. Along with these changes, there is very commonly a red and injected state of the lining membrane, which sometimes extends up into the trachea, and even into the larynx. After having existed for some time, varying, on an average, from one to nine months, the tubercular matter, whatever may be the form in which it is deposited, manifests a disposition to become soft. The process by which this is effected was pointed out in a previous chapter, to which the reader is referred for an account of it. I shall, therefore, content myself here with a description of the changes which are in- duced by it in the pulmonary tissues. Of these changes, the most important is the formation of excavations, caverns, or fistulous apertures. These were formerly considered, under the name of vomicae, to be essential to the condition of phthisis. It is now well known, however, that the disease may prove fatal without them, especially that variety of it which is vulgarly denominated " galloping consumption," and which is marked by great febrile dis- 430 LUNGS. turbance. In their size, these cavities are very variable; but, as a gene- ral rule, it may be said to be in direct ratio to their number. When there is only one, it may be as large as a fist, and capable of holding half a pint of fluid; on the other hand, when they are numerous, they Fig. 148. Pulmonary caverns. From a preparation in my collection. rarely exceed a walnut, and frequently they are not larger than a hazel- nut, an almond, or a pigeon's egg. In their shape, they are for the most part irregularly rounded, sometimes ovoidal, and occasionally angular. In respect to their number, not less than in regard to their size and shape, much diversity obtains. It is seldom that there are more than two or three, yet, in some instances, the number is extraordinary. Not long ago, I examined the body of an old man, sixty-two years of age, whose right lung was literally one continuous chain of excava- tions, the largest of which was scarcely as large as a billiard-ball. Up- wards of forty were counted. Many communicated together by short, fistulous tracks, and nearly one-half of them were completely empty. The largest excavations are almost always found in the superior lobes, inasmuch as the softening process usually proceeds there to a much greater extent than elsewhere. It also, for the most part, com mences at this situation. Hence nothing is more common, in making examinations, than to meet with caverns in the summits of the lungs, with half-softened tubercles further down, and with crude tubercles and sound pulmonary substance at the base of these organs. In the majority of cases, the cavities occur in both lungs. In children they are generally much smaller, as well as much less numerous, than in adults, and they rarely exist simultaneously in both organs. They are, moreover, commonly seated in the middle or lower lobes, instead of in the upper, as in adults. When recent, the walls of the excavations are soft, and lined by a thin layer of lymph, which is easily separated from the surrounding parts: in more protracted instances, the false membrane is dense, grayish, sometimes fibrocartilaginous, and from one-fourth to one- third of a line thick. Occasionally several lamellae are thus deposited, PULMONARY CAVERNS. 431 the one last formed being always more delicate, more easily torn, and of a more yellowish color. In some instances, the excavation is entirely destitute of a lining membrane, the parietes being formed by indurated pulmonary tissue, having a raw, fleshy appearance, not unlike the sur- face of a granulating ulcer. The contents of these cavities vary, according to their age. Such as are recent generally contain thick, cream-colored, inodorous matter, like common pus; whilst, in those of long standing, the fluid is of a thin, bloody, sanious character, and often quite offensive. Cretaceous matter is also sometimes found in them, and occasionally a substance resembling fibro-cartilage. It is only in recent cases, and then very seldom, that the excavations contain fragments of pulmonary tissue. The period required for emptying themselves varies from a few weeks to several months, according to the size of the tubercular mass, the extent of the local disease, and the state of the system. It is very seldom that we find the older caverns perfectly smooth internally; their surface is almost always ragged and uneven, and the irregularity is apt to be still further increased by their being intersected in different directions by small cord-like bodies, consisting either of con- densed cellular sub- stance, or of impervious vessels. (See Fig. 149.) In their shape, these little bundles bear a very close resemblance to the fleshy columns of the heart; their length is variable; in thickness, they are from one to two lines; they are thinner at the middle than at the extremities; and they are usually in- crusted with tubercular matter. It is singular that these excavations seldom, if ever, contain any remains of the bron- chial tubes. The pres- sure that is exerted upon these structures by the tubercular matter, both internally and externally, seems to be sufficient to produce their speedy destruction; and hence it is extremely rare to find the slightest relic of them, even where the cavern is only partially evacuated, or the heterologous deposit only slightly softened. Nor does the cavity always com- municate with the air-passages. In some instances—and these are not unfrequent—it is completely closed, so that its contents, being unable to find their way out, either remain, or are finally absorbed. Pulmonary caverns intersected by cord-like specimen in my cabinet. 432 LUNGS. More commonly, however, one or more bronchial tubes open directly into it, and thus serve to carry off whatever may be lodged within. Occasionally the matter escapes into the pleuritic sac, where, in a short time, it excites fatal inflammation. The late Dr. Morton, of this city, describes an interesting case, where the cavern, which was encysted, and situated in the apex of the right lung, communicated, by a fistulous opening, with a large abscess in the back. It has been already stated that tubercular caverns are often inter- sected by small vascular cords, the vestiges, evidently, of the arterial and venous branches that supplied the affected structure. The changes which these vessels undergo, in such cases, are exceedingly interesting. Long before the softening begins, their caliber is obliterated, as if nature, intent on preventing hemorrhage, took care to anticipate the ulcerative process. In the early stage of the disease, the vessels are merely forced aside, and compressed by the tubercular matter; but as the deposition advances, they gradually become impervious, and are at length converted into hard, fibrous cords, like the umbilical vessels of the infant after parturition. Thus affected, they are greatly dimin- ished in volume, and no longer admit the finest injecting matter; even air cannot be made to pass along them; in a word, they are completely, effectually, permanently obliterated. But for this provision, which is as wonderful as it is beneficent, few individuals would survive the softening process. As it is, with all the care that nature can exert, fatal hemorrhage is unfortunately of too frequent occurrence, arising from the rupture of the affected vessel, in consequence of the inability of its walls to withstand the shock of the circulating fluid. The blood occasionally finds its way from the cavern by a fistulous opening into the oesophagus, or some of the neighboring parts. Owing to the crippled and embarrassed condition of the branches of the pulmonary artery, above alluded to, nature is not slow in establishing a supplementary circulation, to compensate for the defects of the old. The new vessels appear as red lines, which taper off at each end, and are scarcely a millimetre in diameter; their parietes are extremely delicate, and they are at first perfectly isolated, but in time they assume a retiform arrangement, and communicate not only with each other, but likewise with the bronchial arteries, or with those of the walls of the thorax. The latter connection is effected by means of new vessels developed in the false membranes of the pleura. The amount of vascularization established in this manner increases in proportion to the amount of the tubercular deposit; it pervades the whole of the affected lung, and serves as a substitute for the obliterated branches of the pulmonary artery. How far these new vessels, which may frequently be rendered remarkably distinct by artificial injection, contribute to the vitality of the heteroclite deposit, is unknown. It has been maintained that they are specially created for its nutrition and the promotion of its growth; an opinion which is, to say the least, highly plausible. _ This, however, if it be one of the uses of this supplementary circulation, is not the only one. Another and perhaps still more important office, is the influence which it exerts upon the oxygenation of the blood, which is distributed to it by the aorta CICATRIZATION. 433 through the bronchial arteries, and which is returned to the heart by the bronchial, pulmonary, and azygos veins. One of the most interesting facts, in relation to these caverns, is, that they are susceptible of cicatrization. That this occurrence is rare, common sense alone, unaided by observation, is sufficient to convince us; but that it occasionally takes place has been abundantly proved by pathological researches. There are three modes in which this pro- cess may be effected, each of which is deserving of brief notice. In one, which is by far the most common, the cavern remains open, and its surface becomes lined with a thin layer of lymph: this adheres Fig. 150. The section of a lung seen from within, the apex having been left entire to show the deep puckerings which covered its surface. The line of the healed cavity is densely loaded with black carbonaceous deposit, in which are seen five cretaceous concretions, three of them encysted. This preparation is, per- haps, a unique specimen, proving the healing, by cicatrization, of an enormous tubercular excavation in the lung. Natural size.—After Bennett. more or less strongly to the surrounding textures, is gradually or- ganized, and finally converted into a membrane, which possesses all the properties of the mucous tissue, excepting that it is devoid of mucous glands, and therefore incapable of secreting genuine mucous 28 434 LUNGS. matter. Secondly, the cicatrization may be effected by the contrac- tion of the excavation, and the slow but steady agglutination of its sides, through the intervention of dense cellular substance of new formation. Thirdly, it may take place by an effusion of lymph, or by repeated deposits on the inner surface of the cavity, forming a white bluish mass, more or less dense in its structure, in which the bronchial tubes may be seen abruptly terminating. In the last two varieties of cicatrization, the contraction of the accidental tissue gives rise to a puckering of the lung, which is most distinctly marked when the serous envelop of the organ is forced to follow the retrocession of the parenchymatous substance. These scars—for thus they may be called—are most common in the apex of the lung; and they may be of various figures, as oval, circular, linear, arborescent or stellated Appearances similar to these may be produced by the deposition of fibrin upon the pulmonary pleura. In acute inflammation of the serous membrane of the chest, Fig. 151. there is generally an effusion not only of this substance but also of serosity, either simultaneously or successively. Should the serosity be poured out first, it will have the effect of compressing the lung and of preventing adhesion be- tween the pulmonary and costal pleura. As the effused matter is absorbed, the organ gradually expands, and ultimately regains its original form, volume, and situation. If, however, while the lung is in this position, a layer of fibrin be deposited upon its sur- face, it will be liable to be perma- nently compressed, and at length, owing to the contraction of the new substance, exhibit the de- pressed, corrugated, puckered, or mammillated appearance, so often mistaken for the cicatrice of a tubercular excavation, and as an internal section of the summit of the left lung evidence of the cure of pulmonary showing the stellate puckering at the apex, and an. rthrhl 165> Jt ig represeilted 0f the natural size and shape. The principal disease of the sublingual gland is ranula, generally supposed to depend upon the dilatation of one of its ducts, but in reality, an encysted tumor. It is usually occupied by a thick, glairy fluid, like the white of eggs, but which is sometimes watery, or of a pultaceous consistence: occasionally, it resembles the synovial liquor of the joints, and contains particles of gritty matter, probably a mix- ture of phosphate and carbonate of lime. The size of the tumor varies from that of a pea to that of the fist; its form is irregularly oval, and its parietes are thin, and for the most part translucent. The submax- illary gland is sometimes similarly affected. Finally, the salivary, like the other secretions, is liable to various morbid alterations. Thus, it may be diminished or increased in quantity, puriform, bloody, acid, alkaline, saline, calcareous, or fetid. In certain diseases, as in fevers and inflammations, the salivary secre- tion is sometimes nearly entirely suspended, the mouth being dry, and the thirst more or less urgent. In nervous affections, on the other hand, it is often very much augmented, as well as remarkably changed in its properties. In hydrophobia it is poisonous, and capable of com- municating the disease. IV. Teeth.—A tooth taken from the jaw of a living person, and immediately replaced in its former socket, will contract adhesions to the raw surface, and be permanently retained. The singular experi- ment of Mr. Hunter is well known. This ingenious physiologist transferred a tooth from its cavity into an incision in the comb of a cock, to which it became so firmly united that, on killing the animal some time subsequently, and injecting its head, the fluid ran freely into the internal 'membrane of the transplanted organ. It was upon a knowledge of this fact that was founded the disgusting practice, so common in the last century, of extracting teeth from one person and inserting them in the mouth of another. Experience has shown that the root of a tooth, when fractured, may reunite, the process being similar to that of a broken bone. The blood which is poured out at the moment of the accident being absorbed, CARIES —GANGRENE. 485 lymph is effused ; this is soon succeeded by cartilage, and this, in time, by osseous substance. The most common disease of the teeth is caries, a lesion which is strictly analogous to ulceration of the osseous tissue. Commencing always in the bony substance of the crown, immediately under the enamel, it presents, at first, the appearance of a minute, opaque, brownish speck, which gradually extends towards the centre of the organ, assuming at length a blackish color, and becoming so soft and brittle as to be crushed on the slightest touch. Thus a large cavity is exposed, which perhaps had not previously been suspected to exist. As it advances, the disease frequently destroys the entire crown, or converts it into a dark, pulverulent substance, without any trace of its primitive texture. The roots are usually the last to decay, and it often happens that they retain their vitality long after the other parts have perished. In this condition, however, they act as extraneous bodies, exciting ulceration of the gum and alveolar processes, whereby they lose their connection, and are finally dislodged. Figs. 166, 167, and 168 exhibit some of the more ordinary forms of this disease. Fig. 166. Fig. 167. Fig. 168. The teeth most liable to this disease are the last grinders, probably from some defect inherent in their constitution in consequence of their late development. The upper central incisors are also frequently affected, as are likewise the first molar teeth, particularly those of the under jaw. The lower incisors, on the contrary, are rarely attacked. Every part of the crown appears to be equally liable to caries ; and it often happens that the disease begins simultaneously at several points. Persons of a tubercular constitution are very subject to this species of decay, which often sets in at a very early period of life, and pro- ceeds until nearly every tooth is destroyed by it. The upper incisors of children are frequently attacked in this way within a short time after their appearance, and occasionally, indeed, when they are still partially covered by the gum. There is sometimes an hereditary pro- clivity to this disorder; as is evinced by the fact that it often occurs in a considerable number of members of the same family, and in the children of parents who had been similarly affected. Gangrene of the teeth is usually caused by external violence, the effects of mercury, or a syphilitic taint of the system. In scurvy, too, they often lose their vascular connection, and ultimately perish. When 486 TEETH. Fig. 169. affected in this way, they assume a dull, yellowish, brownish, or black- ish appearance, and finally drop out of their sockets. In most cases, death is universal; not limited to particular parts of a tooth. The lining membrane of the teeth is occasionally affected with inflam- mation, the other anatomical elements of these organs being appa- rently in a sound state. The disease, if allowed to go on, almost always leads to the formation of an alveolar abscess. In other cases, there is a pretty abundant deposit of fibrin, both within the canal of the af- fected organ and around its roots, the latter of which exhibit a singu- lar shreddy aspect, the plastic, organized lymph hanging from the thick- ened periosteum in all directions (Fig. 169). Occasionally, again, though this is not very common, purulent matter is poured out. form- ing an abscess analogous to what is sometimes observed in the interior of a bone. When the quantity of fluid is considerable, it is very apt, from its confined situation, and consequent pres- sure, to produce mortification of the lining mem- brane, with absorption of the parietes of the cavity. By this means the pus gradually escapes at the ex- tremity of the fang, the foramen of which is much enlarged. Ulcerative inflammation is next set up in the alveolar process and gum, which continues its ravages until the inclosed matter, now extreme- ly offensive, obtains an outlet, the affected tooth meanwhile losing its vitality, and presenting a dull yellowish, dark, or brownish color. The exposure of the internal membrane from gangrene, fracture, or other causes, not unfrequently leads to the formation of fungous tumors, varying in volume between that of a pin-head and an ordinary pea. (Fig. 170.) Of a pale reddish color, they are of a soft, fleshy consistence, and are essentially composed of a plexus of vessels, connected together by delicate cellular substance, and traversed by minute nervous filaments. From their excessive vascularity, these growths are liable to bleed upon the slightest touch; and, although they are occasionally as insensible as healthy gum, yet in the majority of cases they are the seat of the most exquisite pain. The period re- quired for their development varies from a few months to several years; but, from the great suffering which they induce, they are seldom permitted to remain for any length of time. They appear to arise, for the most part, from the lining membrane of the fang, from which they proceed more or less rapidly until they fill the whole cavity of the organ. Occasionally, there is reason to believe that these growths spring directly from the dental nerve, which be- comes exceedingly vascular, elongated, and thickened. The teeth most frequently affected with this disease are the central incisors and the large grinders. Such a tumor is occasionally the seat of periodical hemorrhage, apparently vicarious of the menses. Inflammation of the dental periosteum is sufficiently common. It is characterized, anatomically considered, by an increase of vascularity, and by a softened, pulpy condition of the membrane, and often termi- INFLAMMATION—EXOSTOSIS. 487 nates in suppuration and abscess. As the disease progresses the peri- osteum is detached at the most highly in- flamed part, which is usually around the pig- l~l- Fig. 172. extremities of the fang, and the sac thus formed becomes the receptacle of the pus. The denuded portion of the tooth loses its vitality, thereby adding to the irritation of the socket, which, in consequence, takes on ulcerative action, followed by a fistulous opening, and the escape of the accumulated fluid. If the tooth be extracted after this occurrence, the sac will often^come away in the form of a red fungous mass, not unlike a small polype. Figures 171 and 172 are excellent illustrations of different forms of the sac in alveolar abscess. When we consider that, with the exception of the enamel, the teeth , are essentially composed of the same anatomical elements as the bones, it is not surprising that they should be the seat of exostosis. The sub- stance which is thus added differs from the pre-existing structure prin- cipally in being of a denser consistence, and of a yellowish transparent aspect, not unlike chalcedony. The deposit ordinarily takes place at the root of the organ, but in some instances it affects the body, and it may even extend as high up as the crowm. Analogy would lead us to infer that the new matter is furnished exclusively by the vessels of the periosteum ; and this, doubtless, is true in the generality of instances. The progress of this disease is usually very tardy, a long time elapsing before the bony tumor acquires much bulk. There is a singular affection of the teeth, described by dentists under the name of " the denuding process," the precise nature of which is still unexplained. It consists in the gradual removal of the enamel, generally without the slightest discoloration or diseased appearance. It is most frequently observed in the incisors, especially the inferior, but occasionally attacks the whole dental arch. As the denuding process advances, the crown of the tooth is slowly worn away, the enamel first disappearing at the top, and subsequently at the sides, until the greater part is removed. The organ, in the meanwhile, changes its color, gradually becoming more yellow, and finally, when the enamel is completely destroyed, assuming a brownish aspect. The most curious circumstance in the history of this lesion is the beautiful provision by which the cavity of the tooth is protected from exposure. This consists in a deposit of new bony matter, perfectly hard and solid, but so transparent that nothing but the closest examination could detect it. Thus a sort of permanent plug is formed, which effectually defends the delicate structure within, and which exactly resembles the transparent layers of an aagose pebble, surrounded by a more opaque mass. In what this lesion essentially consists it is not easy to determine, though it is not improbable, I think, that it depends upon some original or acquired defect of the enamel, whereby it is made to yield more readily to the mechanical attrition to which the teeth are constantly 488 TEETH. subjected. It is witnessed at nearly every period of life, but is by far most common in old people. The teeth, from want of cleanliness, as well as other causes, are very apt to become the seat of calcareous concretions. When first deposited, tftis substance possesses the character of a soft, friable, porous paste, which by degrees acquires the consistence of hardened mortar, and often scales off in large masses, having the shape of the organ around which it was formed. Its usual color is a dull whitish yellow, though in some cases it is dark brown, blackish, or even greenish. The specific gravity of this matter is 1.571. From the analysis of Pepys it would appear to be composed principally of phosphate of lime, in association with a small quantity of cartilage and fatty substance. This matter has also been examined by Berzelius, who states its com- position to be as follows:— Salivary matter......... 1.0 Salivary mucus ......... 12.5 Earthy phosphates.........79.0 Animal matter dissolved by muriatic acid . . . . 7.5 100.0 The accumulation of this substance often takes place with great rapidity, so that in a short time the dental arches are almost completely incrusted with it. Calculous and gouty persons are particularly liable to it; and it is also frequently witnessed in lying-in females. It is ordinarily deposited, at first, around the necks of the teeth, just beneath the free margin of the gum. As it increases in quantity, it produces the most disastrous effects, exciting irritation in the soft parts, which leads to absorption of the gum and alveolar processes, until the teeth, deprived of their support, are loosened, and at length drop out. It has been supposed that this matter is derived directly from the mucous secretions of the mouth, vitiated by chronic irritation; but the more plausible opinion is, that it is furnished solely by the salivary glands, being held in solution by the fluid which it is the office of these organs to elaborate. This view of the subject is not only supported by the analogy which obtains in the formation of urinary calculi, but by the fact that this substance is always deposited in greatest abund- ance upon the superior grinders and the inferior incisors, teeth which lie in the immediate vicinity of the orifices of the salivary ducts, and also by the circumstance that it is composed of the same elements as the fluid just referred to. The teeth experience important changes in consequence of age. As life advances they gradually lose their whiteness, and assume a pecu- liarly yellowish tint, which is often remarkably conspicuous in old people. They become likewise more brittle, and the enamel exhibits an irregularly abraded appearance. These changes are produced by certain alterations which take place in the anatomical constitution of the teeth, from the obliteration of their vessels, and their consequent diminished supply of blood. , The temporary teeth are surrounded each by a membranous cyst, which often inflames during dentition, and thus gives rise not onlv to GUMS. 489 Fig. 173. Such a much local uneasiness, but occasionally to great disturbance in other organs, especially the stomach and bowels. The gum at the same time becomes red and tumid, and there is generally an inordinate secretion of salivary fluid. When the tooth is fully formed, the sac is no longer of any use, and is therefore gradually absorbed. Lastly, the teeth are liable to certain congenital vices in regard to their development, situation, and direction. In persons affected with hare- lip and cleft palate, the upper incisors are almost always badly formed, and thrust out of their natural position. Instances also occur in which some of these organs are firmly united together by osseous matter; and Albinus has related a case where the crown of the eye-tooth was turned towards the maxillary sinus, the situation of the fang being reversed. A case precisely similar occurred in my practice some years ago, in a young lady of twenty-three. The irritation which it caused in the jaw gave rise to a tumor requiring surgical interference. Fig. 173 represents the wisdom tooth of the upper jaw of the right side, inseparably fused with the fangs of the last grinder, the parts looking as if they had been ingrafted upon each other. The tooth was situ- ated horizontally under the gum, by which it was nearly concealed. It was extracted from a woman, aged thirty, by Dr. Somerby, of Louisville, to whom I am indebted for the specimen. Cases occur in which the fangs of the teeth are very crooked, thus opposing a great obstacle to their extraction. malconformation is represented in Fig. 174, where one of the roots is nearly horizontal. In a second series of cases the roots are all remarkably divergent; while in a third they are, perhaps, all soldered together by osseous matter. I have several specimens in my col- lection in which the teeth are inseparably connected, in a similar manner, with the walls of their sockets. V. Gums.—Another structure which requires brief notice is the gum. Of ordinary inflammation, to which the gum, in common with the rest of the mucous system, is liable, it is not my intention here to speak; but there are several lesions which are either peculiar to this situation, or which are produced by irritation of diseased teeth, of which it will be necessary to treat with some degree of minuteness. The most frequent lesion of the gum is ulceration, produced by the accumulation of tartar around the necks of the teeth. The pressure that is thus exerted excites inflammatory action, leading to great thick- ening, sponginess, and discoloration of the gum, with erosion of its substance. In this way the teeth are entirely denuded at their necks, in consequence of which they often drop from their sockets, or become so loose as to be useless. The gum, in common with the rest of the mucous membrane, is liable to sloughing, from excessive mercurial action, and probably also from causes which exert their influence chiefly through the constitu- tion. Of this nature appears to be that variety of mortification which Fig. 174. 490 GUMS. has been so ably described by the older writers under the name of "black canker," and by Dr. Coates1 under that of the "gangrenous ulcer" of the mouth. Although it may begin at any part of the mu- cous membrane, yet, in by far the greater number of cases, it makes its appearance at the edges of the gum, over the neck of the central incisors of the lower jaw, in the form of a whitish, cineritious, or red- dish ulcer, which varies in diameter, from half a line to the eighth of an inch. In this state, the disease may continue for several weeks, or even months; but more commonly it extends its ravages, affecting either a large portion of the dental arches, or passing down in the direction of the sockets of the teeth, which, together with their peri- osteum and the alveolar processes, are gradually deprived of their vitality. The soft parts, in the meanwhile, assume a dirty blackish appearance; and, on being detached, they leave a ragged, sloughing ulcer, which is the seat of a foul, sanious discharge, of so excessively acrid a nature as to excoriate whatever texture it may happen to come in contact with. In this manner, the disease appears to be frequently propagated to the mucous membrane of the cheeks and lips, where it generally spreads with great rapidity, until the parts are completely perforated, or a black gangrenous spot manifests itself upon the external surface. The true pathology of this disease is still enveloped in obscurity. It is almost wholly confined in its attacks to young, weakly subjects, and occasionally displays an endemic tendency. Out of 240 children observed by Dr. Coates in the Philadelphia Asylum, upwards of 70 were more or less affected with the primary ulcer at one time. In the early stage of the complaint there is little or no pain, the system is free from excitement, and the appetite and strength are scarcely at all impaired. When the sloughing process, however, has fairly commenced, the child suffers much local distress, and is harassed with constant fever. Dissection has thrown no light on this singular variety of gangrene. The gums are subject to congenital hypertrophy, sometimes giving rise to remarkable deformity of the mouth and lips. The only case of the kind that I have ever seen came under my observation in 1855, in a lad ten years old, remarkable for his stunted development, ill- shaped head, and large abdomen. The morbid mass affected the gums of both jaws, and was of a dense fibroid structure. It first began to attract attention at the age of nine months, but there can be no doubt, from its history, that it(had existed from birth. The gum of the upper jaw formed a tumor of a pale color, inelastic, perfectly insensible, and of firm consistence, presenting very much the appearance of the snout of a hog. It stood off very obliquely, and received but a very partial covering from the corresponding lip. It was rough on the surface, and was about an inch and a quarter in its antero-posterior diameter, its length having been about one inch and a half. At its free margin, which was quite irregular, was seen the tip of the left central incisor. Extending back from this tumor 1 Description of the Gangrenous Ulcer of the Mouths of Children. By B. H. Coates, M. D., one of the physicians of the Philadelphia Children's Asylum. North American Medical and Surgical Journal, vol. ii., 1826. ABSCESS — EPULIS. 491 on each side the whole length of the jaw, was the enlarged gum, form- ing a thick, broad ridge, completely imbedding the teeth. At several points, particularly behind, the morbid growth was more than nine lines in width; in front and at the middle it was less. It was of a more florid color than the main tumor, but of about the same degree of consistence. Opposite the site of the bicuspid teeth, on each side, it exhibited a remarkably granulated appearance, the excrescences hav- ing a pediculated form, and being folded upon each other. Projecting towards the roof of the mouth, it greatly encroached upon this cavity, lessening its capacity, and thus interfering with its functions, as well as with speech and respiration. The lower gum was in the same condition as the upper, equally hard and insensible, but less developed. It was of a bluish florid complexion, and larger in front and behind than at the intermediate points; its free surface was uneven, and so prominent as to hide all the teeth, except the central incisors, the point of the right cuspid, and the cusps of each deciduous and first permanent molars. Enormous enlargement of the gums is sometimes witnessed in scurvy. They assume, often at an early stage of the disease, a red, livid, or purple appearance, become soft and spongy, generally bleed- ing on the slightest touch, and form two large ridges in which the teeth, loose and discolored, are, at times, almost completely buried. The enlargement is of an inflammatory nature, and probably depends upon a depraved state of the system, produced by impoverished diet. Another disease deserviag of mention here is alveolar abscess, or, as it is familiarly termed, gum-boil. Although this may be produced by a great variety of causes, yet the most common by far is the irri- tation of toothache, or the existence of a dead fang. This, acting as an extraneous body, excites inflammation in the periosteum of the alveolar cavity, followed by an effusion of plastic lymph, which becomes condensed into a sac, in the centre of which pus is formed. This sac, which is commonly of an ovoidal figure, closely embraces the root just above its extremity, which is, as it were, bathed in the purulent matter. The quantity of pus cannot of course be great, but the pressure which it exerts upon the investing parts always in- duces ulcerative absorption, by which it gradually makes an outlet through the gum, generally opposite the base of the dead fang. One of the most formidable diseases of the gum, though fortunately not a very common one, is epulis, as it is termed, which generally presents itself in the form of a small wart-like excres- cence, of a reddish color, and of a hard, gristly consistence. Its growth is sel- dom rapid, nor is it attended, at first, with any decided pain or inconvenience. After having remained for some time, it loses its solid feel, becomes soft and , . - , vi, v Epulis in its earlier stages. From a spe- spongy, bleeds upon the slightest touch, cimen ln my cabinet and throws out an abundance of irregu- lar cauliflower-like processes. Ulceration now commences, the morbid 492 TONSILS. mass rapidly augments in volume, and there is a constant discharge of fetid, purulent matter. At this stage of the disease, the gum has a remarkably red and spongy aspect, the teeth drop' from their sockets, and the lymphatic ganglions in the neighborhood are more or less contaminated ; the pain is also very great, and the system labors under hectic. If the tumor be excised, it almost invariably returns, and requires a fresh operation, especially if a part be left behind. Epulis never occurs in those situations of the gum from which the teeth are perfectly removed; nor is it usual to see it without some disease of these organs, or of the sockets in which they are contained. Its most frequent, though not constant, seat is on the transverse process of the gum, between the teeth. There is a milder form of epulis, consisting of a mere local hyper- trophy, varying in volume between that of a pea and an egg. It is invested by a prolongation of the mucous membrane of the gum, and is intersected by fibrous filaments, which add much to its density and cohesive power. Vessels enter it at every point, and, in some cases, the tumor appears to be almost entirely made up of them. VI. Tonsils.— The most common diseases of the tonsils are inflam- mation, suppuration, hypertrophy, and ulceration. Gangrene and the heterologous formations are very infrequent. Tonsillitis is a very common complaint in cold and variable cli- mates, particularly in spring and autumn. It is occasionally epi- demic, but never contagious, and often coexists with laryngitis, bron- chitis, pneumonia, scarlatina, small-pox, and measles. It is, perhaps, equally frequent in both sexes, and generally affects both glands simultaneously, though seldom in an equal degree. The disease may occur at any period of life, but is most common in children and young adults. It is announced by a sensation of dryness, heat, and pain in the fauces, with difficult deglutition, and a high grade of febrile excitement. On inspecting the throat, the organ is found to be considerably swollen, and of a uniform crimson color. The natu- ral secretion is, at first, partially suspended, but in a short time it augments in quantity, becomes remarkably tenacious, and presents a pale, cream-like aspect. AVhen the inflammation is at its height, the surface of the organ is of a dark purple color, traversed by an immense number of vessels, and incrusted with patches of lymph, of a dirty grayish tint, tough, firmly adherent, and resembling super- ficial sloughs. The swelling is often so great that the glands touch each other at the median line. The proper substance of the tonsil is unnaturally soft, infiltrated with serosity, vascular, and of a deep fleshy red, with various shades of brown, violet, and purple. Occa- sionally small ecchymoses are observed beneath the mucous mem- brane, and, in violent cases, pure blood is effused in the parenchy- matous texture. When there is much swelling, the mouths of the mucous follicles are either entirely obliterated by compression, or closed with thick, viscid mucus, or plugs of fibrin. This disease is seldom wholly confined to the tonsils. In the gene- rality of cases, it extends to the root of the tongue, the uvula, the curtain of the palate, and even to the Eustachian tube, giving rise to GANGRENE— ULCERS. 493 pain in the ear and to partial deafness. Occasionally it affects the larynx. Tonsillitis often terminates in abscess. The period which inter- venes between the commencement of the inflammation and this oc- currence varies from six to eight days. The pus, which is generally excessively fetid, is of a thick, cream-like consistence, of a pale yel- lowish color, and intermixed with flakes of lymph. It is commonly deep seated, and almost always breaks into the mouth. In rare in- stances it has been known to work its way out under the angle of the jaw. In a case observed by Londe, the matter passed down the neck along the great vessels, and finally penetrated the chest, where it speedily induced fatal inflammation. Both tonsils occasionally sup- purate simultaneously. One of the most frequent affections of the tonsils is hypertrophy, induced by frequent attacks of chronic inflammation. The organ in this disease is enlarged in all directions, and is of a firm, almost fibrous, consistence; its surface is Fig. 176. of a pale reddish, or cineritious hue, and its mucous follicles are often five or six times the natural size. (Fig. 176.) Sometimes the orifices of these follicles are closed with inspissated mucus, earthy concretions, fibrinous plugs, or tubercular matter. Instead of being tough and indurated, the organ may be remarkably friable, distinctly tabulated, and Of a red, brownish. Or Hypertrophy of the Ton- J ' ' • . sil. From a specimen in violet complexion. This state is most common in my cabinet. scrofulous children under ten years of age. Hypertrophy of both tonsils is apt to be attended with defective speech, hearing, and breathing, together with a singularly altered con- dition of the chest, which is rounded and arched behind, contracted in front, and flattened at the sides. The neck is bent forwards, and the patient labors under an habitual stoop. During sleep the breathing is excessively embarrassed, the head is thrown back so as to bring the mouth on a line with the larynx, and the surface is bathed with per- spiration ; effects evidently produced by the inordinate action of the respiratory muscles to overcome the mechanical obstacle which the enlarged glands offer to the introduction of the air into the lungs. The disease, which often continues for years, occurs mainly in persons of a scrofulous predisposition, and is seldom, if ever, witnessed in advanced life. Gangrene, as a termination of this disease, is extremely rare. The event is announced by the fetidness of the breath, the livid state of the parts, and the dark, sanious discharge from the throat. On ex- amining the tonsils after death, they are found to be pulpy, disor- ganized, and of a deep gray, ash, or mahogany color. Gangrene and sloughing of these parts are most common in some of the exanthema- tous fevers, especially in scarlatina. Ulcers of the tonsils are most frequent in syphilitic subjects, or in persons who are laboring under syphilitic and mercurial disease. In either case, they have generally an excavated appearance with ele- 494 PALATE AND UVULA. vated edges, and a foul, dirty-looking bottom. The surface around is inflamed and of a copper color. Occasionally, the sores present them- selves in the form of chaps, fissures, or narrow lines. When the morbid action is severe, and the constitution very irritable, the ulcers are apt to assume a phagedenic character, spreading in different direc- tions, and causing great destruction, not only in the tonsils, but in the adjacent parts. The -tonsils, in common with other parts of the body, are liable to some, if not all, of the heterologous formations. Of these the most common is the tubercular. The matter is of a pale yellowish color, semi concrete, and arranged in small, isolated particles, from the vol- ume of a pin's head to that of a hemp-seed or a pea. It may undergo more or less complete softening, and is often transformed into chalky concretions. The disease is generally associated with hypertrophy of the gland and tubercular deposits in other structures, particularly the lungs and lymphatic ganglions. It is most common in young scrofu- lous subjects. Encephaloid of the tonsils has been occasionally observed. The disease, however, is exceedingly rare, and usually coexists with similar deposits in other organs. It may occur as an infiltration, but most com- monly presents itself in disseminated masses, or as a solitary tumor, of variable shape and size. The two forms of carcinoma, termed scirrhus and melanosis, probably never attack this organ. An instance has been observed in which a hypertrophied tonsil contained a large cyst, filled with serous fluid. The tonsil is sometimes the seat of chalky, calcareous, or earthy concre- tions. They may be situated in the parenchymatous texture of the gland, or, as is more commonly the case, in its follicles or excretory ducts. Their composition is phosphate and carbonate of lime, agglu- tinated by a small quantity of animal matter. They have usually a white, grayish, or light brownish color, a spherical figure, and a finely tuberculated surface. Their volume seldom exceeds that of a mustard seed. In number they vary from one to half a dozen or upwards. They have occasionally a lamellated arrangement, with a distinct cen- tral nucleus. Concretions of a purely animal character occasionally block up and distend the lacuna? of the tonsils. They are of a whitish, grayish, or yellowish tint, unctuous or greasy to the touch, extremely fetid, and from the volume of a hemp-seed to that of a pea. Their composition appears to be fibrin in union with mucus. VII. Palate and Uvula—The lesions of the soft palate do not differ, on the whole, from those of the tonsils, and any labored description of them would therefore be superfluous. Polypes sometimes grow from this part. I have repeatedly seen little tumors of this description hanging down from the- soft palate into the fauces, their attachment being usually effected by a very slen- der pedicle to the side of the uvula, or to the mucous membrane over the palato-pharyngeal muscle. They are always of a florid color, and of a soft spongy consistence. Split-palate is a congenital defect, analogous to hare-lip, with which PHARYNX. 495 it often coexists. It occasionally affects only the soft parts, in which case there is no lack of substance, but the opposite halves recede from each other at an angle of about thirty degrees. When the maxillary and palate bones are involved, the fissure always corresponds with the mesial plane, and is sometimes so great as to throw the buccal and nasal cavities into one large sinus. In cases of this kind, there is, of course, an entire absence of the vomer, if not also of the perpendicu- lar lamella of the ethmoid bone. Even the cribriform plate of this bone may be deficient, the olfactory nerve wanting, and the cerebrum considerably malformed. The uvula, like the soft palate, originally consists of two lateral pieces, which, in some instances, remain ununited at the raphe', thus forming a congenital defect parallel to hare-lip and split-palate. This malformation, however, rarely exists singly. The most common lesion of the uvula is hypertrophy, in which the organ becomes abnormally long and bulky. Its consistence is also sensibly increased; its vessels are enlarged; and its color is a light grayish, instead of a florid red. The consequences of such changes are well known. The part becomes troublesome in deglutition and talking, and causes a disagreeable tickling at the root of the tongue, attended with an annoying cough and frequent retching. Gangrene rarely affects the uvula. In anginose inflammation, it is often remarkably oedematous or incrusted with lymph, which is de- tached either piecemeal, or in the form of a nipple-shield, a thimble, or the finger of a glove. In syphilitic sore throat, the uvula is some- times entirely destroyed; at other times it is perforated at its base. VIII. Pharynx.—The lesions of the pharynx resemble, for the most part, those of the tongue and tonsils; but there are several which are peculiar, and which therefore demand separate consideration. Acute pharyngitis is ordinarily characterized by redness and tume- faction of the affected part, with a secretion of thick, grayish mucus. In the more severe forms, however, there is, additionally, an effusion of lymph, which appears either in small patches, or, as is more fre- quently the case, as a continuous layer over the whole surface of the reservoir. Hence, on the one hand, the exudation generally extends upwards over the tonsils and the soft palate; and, on the other, down- wards into the oesophagus, the larynx, the trachea, and even the bron- chial tubes. Much diversity obtains in regard to the color and con- sistence of these adventitious membranes. When first formed, they are usually of a light yellowish tint, and so soft that they can be easily wiped off with the finger; in a short time, however, they become grayish, and acquire considerable tenacity, forming pretty hard incrus- tations. In very intense cases, blood is apt to be exhaled, which, mix- ing with the exudation, imparts to it a dark brownish hue. The mucous membrane itself is of a deep livid complexion; the subjacent cellular tissue is infiltrated with serosity; and all the vessels are en- gorged to such a degree that it is impossible either to inject or unload them by pressure and ablution. This disease, known under the name of diphtheritic inflammation, is by no means an uncommon attendant on smallpox and scarlet fever, 496 (ESOPHAGUS. but also occurs very frequently as an idiopathic affection in children, especially in such as are naturally weak, or who have become so by indisposition or impoverished diet. The symptoms are generally severe ; and, when the exudation extends down the air-passages, death is often induced by suffocation, in the same manner as in pseudo- membranous croup. Abscess of the pharynx is of rare occurrence. The matter is seated in the cellular tissue behind the mucous membrane, and may show itself as the result of acute inflammation, or of tubercular irritation. Of the latter form of the disease I have observed several instances in subjects of a strumous constitution. In one, a young man between twenty-five and thirty, the abscess was situated on the left side of the middle line, and contained nearly an ounce of thin, greenish pus, intermixed with caseous substance. The tumor, which fluctuated under the finger, produced so little inconvenience that the patient, who was far advanced in phthisis, had not even suspected its exist- ence. The mucous membrane of the pharynx, both over and around the abscess, exhibited no unusual appearances. When the abscess is acute, the matter, although usually small in quantity, may, by pressing on the glottis, produce great distress in the throat, with dysphagia, aphonia, and dyspnoea, followed in some instances by death. The pharynx is occasionally the seat of tubercle, scirrhus, and ence- phaloid. When the latter of these growths attain a considerable mag- nitude, as they sometimes do, they are apt to prove troublesome by their mechanical obstruction. Polypous growths are sometimes met with in this situation, of a florid color, soft consistence, globular or pear-like in shape, and attached by a long, slender footstalk. Such growths, although they rarely attain much volume, may cause serious inconvenience by their mechanical obstruction to respiration and deglutition. The pharynx is liable to become sacculated, a blind pouch being formed at its junction with the oesophagus. This is most apt to happen at the posterior part of the tube, and the disorder is chiefly inconvenient, as having a tendency to entrap particles of food in their descent from the mouth to the stomach. A bag capable of holding several ounces may thus be formed. IX. (Esophagus.—The diseases of the oesophagus, though much less numerous than those of the mouth and fauces, are not less dangerous in their tendency, or less interesting to the student of morbid anatomy. Amongst the most important of these lesions are diphtheritic inflam- mation, ulceration, softening, stricture, scirrhus, and laceration. Simple oesophagitis is marked by the usual symptoms of redness pain, and tumefaction, with dryness of the part, and difficulty of deglu- tition. In violent cases, as, for example, when the inflammation is caused by corrosive poisons, there is an abrasion of the cuticle, and an effusion of lymph. The diphtheritic form of the disease has been witnessed in hydrophobia; and there is reason to believe that it is sometimes caused by a suppression of the cutaneous perspiration. In the winter of 1838, I saw the stomach and oesophagus of a boy, thir- teen years old, who suddenly expired in convulsions after an illness OESOPHAGUS — ULCERS — SOFTENING. 497 177. of three days. The patient complained of severe pain in the fauces, and had great difficulty of swallowing, every attempt of this kind being followed by spasm of the throat, especially when the substance was of a fluid nature. On inspecting the oesophagus, I found it lined throughout by a thin layer of lymph, closely adherent to the mucous coat, which was itself highly injected, and of a bright red color. The stomach was perfectly sound, the inflammatory appear- ances terminating abruptly at the cardiac orifice. Dr. Mount, who attended the lad, and was present at the examination, informed me that he had traced the adventitious membrane also around the mouth of the larynx and over the whole of the fauces during life. The case was supposed to have been one of hydrophobia. These membranes rarely become organized. When the inflamma- tion subsides, they gradually lose their moisture, together with their ad- hesive properties, and are either vomited up in small tubular fragments, swallowed and digested, or swallowed and passed by stool. A case has been reported where an exudation of this kind was found in the oesophagus of a new-born infant. It lined the tube for about a third of its extent, and seemed to be closely iden- tified with its proper substance. Fig. 177 represents a tubular piece of lymph cast off by the oesophagus during a fit of vomiting. The patient, a man about thirty years of age, was affected with mania-a-potu, of which he finally died. The drawing is from a prepa- ration in my cabinet. Ulcers of the oesophagus most frequently occur at the upper part of the tube, near its junction with the pharynx. They may be of various forms and dimensions; and, in the generality of cases, their edges are smooth and rather thin. When, however, they are associated with scirrhus, the" surrounding structure is very much elevated, and often consists of a dense fleshy substance, inter- spersed with gristly matter. These ulcers sometimes lead to perforation. Abscesses may form between the coats of the oesophagus, and, by compressing the trachea, affect the breathing. When very large, they encroach upon the caliber of the gullet, and impede deglutition. Dysphagia may also result from enlargement of the thyroid gland, projection of the dorsal vertebras, and aneurism of the aorta. In a man, forty-nine years of age, whom I examined in 1827, the oesophagus and aorta communicated by a large aperture, through which more than half a gallon of blood had suddenly passed into the stomach, and thus caused death. Softening of the oesophagus, of the same nature as that of the stomach, is sometimes observed. One of the most common effects of 32 False membrane of the oesophagus. From a specimen in my cabinet. 498 (ESOPHAGUS. Fig. 178. the lesion is perforation of the walls of the tube, and an escape of fluid into the thorax. The opening usually occurs near the cardiac extremity of the oesophagus, in connection with an inflamed, softened, or perforated state of the stomach, though occasionally there is no appreciable altera- tion whatever in any of the surrounding textures. No age, not even early infancy, is exempt from this lesion. Stricture of the oesophagus almost always results from inflammatory thickening of the submucous texture, with more or less alteration of the proper lining. A sort of ring, of variable depth and firmness, is thus formed (Fig. 178), which encroaches upon the channel, and produces great difficulty in swallowing, aggravated frequently by spasmodic exacerbations. In a case which I examined some years ago, the tube was so much contracted that it would scarcely admit a common-sized quill. The stric- ture, about six lines deep, and of gristly firmness, was seated within three inches of the cardiac extremity of the stomach, and caused death by inanition. The ordinary place of stricture, however, is not so low down, but near the junction of the tube with the pharynx. If neglected, the con- traction progressively increases, and the oesophagus, ulcerating, may finally open into the posterior mediastinal cavity, the trachea, or the lungs. The part above the stricture is sometimes sacculated, and so large as to be capable of holding from a pint to half a gallon of fluid. Dilatation of the oesophagus, consequent upon stricture, is well shown in the adjoining sketch (Fig. 179), taken from a gentleman, about forty years of age, who died in 1849, of scirrhus of the cardiac extremity of the stomach. Some time prior to this event, he consulted the late Dr. Drake and myself on account of difficult deglu- tition, of long standing, attended with a constant sense of constriction in the chest, frequent paroxysms of choking, occa- sional cough, and progressive emaciation. In swallowing food and drink, he was conscious of a feeling of obstruction in the oesophagus, but the passage of a pro- bang failed to throw any light upon its site and extent. Upon dissection, the Dilatation of the oesophagus, from tube was found to be enormouslv dilated organic disease of the cardiac extremity • :< __, ,• 1 ,i . ,, . •'„ . , of the stomach. From a drawing in my 1Q, ltS eDtlre lengtn» especially infenorly, possession. where it was three inches in diameter. Stricture of the oesophagus. Fig. 179. CARCINOMA — LACERATION. 499 Fig. 180. It contained upwards of a pint of fluid, swallowed two hours before death, and was as elastic as a piece of India-rubber. A tight stric- ture, half an inch long by three-eighths of an inch in diameter, of a whitish, gristly nature, and hardly large enough to admit the handle of a scalpel, existed at the cardiac extremity of the stomach, which was itself much reduced in size, although sound in other respects. The immediate cause of death was a large abscess, extending along the right side of the spine, from the second rib to the diaphragm, con- taining not less than a quart of matter, the lung being firmly attached to its outer surface. The left lung was healthy, but some of the principal bronchial tubes were filled with pus. The aorta was much enlarged, while the heart was smaller than natural, although otherwise sound. No disease was observed in any of the other organs. Occasionally the stricture is of a spasmodic nature, being produced by the contraction of the circular fibres of the oesophagus. In this case the difficulty is generally temporary, and may be easily overcome by a bougie. Carcinoma (Fig, 130) of the oesophagus is uncommon, and is generally of the scirrhous character, its ordinary site being the inferior half of the tube, and its favorite period of life old age. Taking its rise usually, if not always, in the submucous cellular tissue, it extends in different directions, forming gradually a large mass, which seriously encroaches upon the caliber of the tube, and ultimately destroys life either by irritation, hemorrhage, or inani- tion. I have never met with melanosis, colloid. and encephaloid in the oesophagus, but a few cases of the latter have been reported by authors. Tubercle rarely, if ever, occurs here. Laceration of the oesophagus generally takes place during the act of vomiting, without any antecedent structural lesion. The rent is commonly transverse or somewhat oblique, and varies in extent from a few lines to half an inch or more. The inferior portion of the tube gives way more fre- quently than, the upper or middle; sometimes the rupture is situated immediately above the cardiac extremity of the stomach. The acch dent is characterized by violent pain, with symptoms of sinking, and usually proves fatal, in from thirty-six to forty-eight hours. The oesophagus, finally, is liable to various malformations, which, although not of frequent occurrence, constitute an interesting subject of study. A bare enumeration of them, however, is all that we can attempt here. The following arrangement will be found to embrace the most important deviations which have hitherto been observed: 1, the oesophagus terminates in a cul-de-sac, either within a few inches below the pharynx, or at a short distance above the cardiac extremity Ulcerated scirrhus of the oeso- phagus. From a preparation in my collection. 500 STOMACH AND BOWELS. of the stomach; 2, it is obliterated, contracted, or converted into a solid cord; 3, it is unnaturally dilated, or even double; 4, it is totally deficient, the pharynx ending in a blind pouch, and the stomach having no car- > diac orifice; 5, it communicates with the trachea. Of the latter variety, an interesting and instructive case was observed by Dr. Martin, of Marseilles, in an infant that died thirty-six hours after birth. On dissection, there was found to be an entire absence of the pharyngeal extremity of the oesophagus; but an aperture existed in the trachea, just above its bifurcation, through which a probe could be passed into a thin, membranous, elastic tube, of the diameter of a small quill, that led to the stomach, and thus established a communication between the cavity of that organ and the air-passages. CHAPTER XX. STOMACH AND BOWELS. I. Consistence and Color of the Gastro-Enteric Mucous Membrane ; how modified by Age, Diges- tion, and other circumstances.—II. Inflammation.—Anatomical Characters of the Acute Form of the Disease.—Increased Vascularity.—Dryness.—Thickening.—Softening.—Deposi- tion of Lymph.—Formation of Vesicles.—Effusion of Blood and Serum.—May pass into Gan- grene or become Chronic.—III. Softening; of two kinds, from Inflammation, and the Ac- tion of the Gastric Juice.—IV. Diseases of the Stomach.—Ulceration.—Hypertrophy and Atrophy.—Formation of Pouches.—Cartilaginous Degeneration.—Carcinoma.—Laceration. —V. Lesions of the Duodenum.—VI. Affections of the Small Bowels, properly so called. Ulceration of the isolated Crypts and of the Glands of Peyer.—Typhoid Fever.—Infan- tile Cholera.—Tubercular Deposits.—Melanosis. —Intussusception. —Hernia.—Abnormal Pouches.—Repair of Wounds.—Atrophy and Hypertrophy.—Earthy Concretions.—VII. Lesions of tlie Large Bowel.—Ulcers.—Wart-like Vegetations.—Singular Contraction of the Colon.—VIII. Vermiform Appendage.—IX. Recto-Anal Region.—Carcinoma.—Fissure of the Anus.—Enlargement of Pouches.—Organic Stricture of the Rectum. — Polypes.— Hemorrhoids.—Fistule.—Prolapse of the Bowel.—Congenital Vices.—X. Intestinal Worms. —Lumbricoides.—Oxyuris.—Tricocephalus.—Taenia Solium.—Ttenia Lata. SECTION I. CONSISTENCE AND COLOR OF THE GASTRO-ENTERIC MUCOUS MEMBRANE. The natural consistence of the mucous membrane of the alimentary tube is liable to considerable variation; but it may be stated as a general rule, that it is in direct proportion to its thickness. Thus it is much more firm in the pyloric half of the stomach than in the car- diac ; and it is in that situation, also, that it has the greatest deoree of thickness. In the duodenum the rule does not hold gooof- for CONSISTENCE AND COLOR. 501 although the mucous membrane is thicker and more opaque here than in any other portion of the digestive canal, yet, owing to the presence of the glands of Brunner, which are remarkably large and numerous, as well, perhaps, as to some peculiar mode of organization, the struc- ture in question is exceedingly brittle, and can seldom be raised except in very small fragments. Lower down, the consistence of the mem- brane progressively increases, so that in the inferior third of the jejunum and in the ileum it may be torn from its connection, in pieces varying from three lines to half an inch in length. In the large bowel, the cohesive property again diminishes, the membrane being detachable only in small, shreddy patches. It need hardly be remarked that the normal consistence of the mucous coat of the alimentary tube is much less in the infant than in the adult. At what period of life it attains its maximum development, in this respect, is a point concerning which we have no positive intelligence. The color of the gastro-enteric mucous membrane varies at different periods of life. In the foetus, and the child soon after birth, it is of a light rose, interspersed with small milky spots; in the adult, it is more of a whitish appearance, but still preserves some degree of its reddish tint; towards middle life it assumes a dull grayish aspect, which continues, gradually increasing, until finally, in decrepitude, it becomes quite cineritious. During digestion, the mucous membrane of the stomach is of a light red color, approaching almost to vermilion, especially in young sub- jects from the second to the tenth year. The duodenum, and occa- sionally even the jejunum, participate in this increased vascularity, which always diminishes in proportion as the process of chymifica- tion advances to completion. Except from this circumstance, this portion of the small intestine never presents that red dye which has been so often ascribed to it. Although this redness uniformly exists, to a greater or less extent, during digestion, yet there is no doubt it is essentially modified by the quality, as well, perhaps, as by the quantity of the food.1 It has been ascertained that if two dogs, of the same size and age, be fed, the one upon milk, and the other upon fatty broth, highly seasoned with salt and pepper, and both be killed an hour after, the mucous membrane of the stomach of the latter will be of a much deeper red than that of the former, at the same time that the augmented vascularity will extend much further down the small bowel. From this circumstance, which exerts so great an influ- ence upon the rest of the alimentary tube, the ileum and colon expe- rience little or no variation in their appearance. The redness which supervenes during digestion is remarkably lessened, but never completely effaced, by exsanguification. Of this any one may convince himself by opening an animal during the process of chymification, and cutting the aorta and vena cava, the 1 The late Dr. Beaumont, of the United States Army, who had the rare opportunity of inspecting the gastric mucous membrane through a fistulous channel in the abdo- men, states that the color of the inner surface of St. Martin's stomach, when empty, was usually of a pale pink; but that, on the application of food, the action of the vessels became augmented, and the color of the villous tunic considerably heightened. 502 STOMACH AND BOWELS. latter especially, which, as is well known, has always the effect, when divided, of giving the surface of the alimentary tube a pale, blanched appearance. The color of the gastro-enteric mucous membrane is considerably influenced by the kind of death. In general, the rosy tint very much diminishes, so that we commonly find in young children that have died of protracted diseases, an unnatural pallor, amounting sometimes almost to a milky whiteness. In persons who are drowned, hung, or otherwise asphyxiated, the inner surface of the stomach and bow- els is often of a crimson color, occurring either continuously or in large patches. Dr. Yelloly, of England, who devoted much attention to this subject, states that he has observed this condition of the mucous coat of the stomach successively in five executed criminals ; and Professor Monro, of Edinburgh, informs us that he has repeatedly, under similar circumstances, seen the gastric lining of a tile red. In a mulatto woman, who was executed in the winter of 1835, and whose body I had an opportunity of inspecting soon after the event, the whole mucous surface of the alimentary tube was so deeply injected, as to present a deep lake color, especially distinct in the stomach, and in the inter-valvular spaces of the jejunum. Similar phenomena I have had occasion to witness in a female who was destroyed by manual strangulation, in a man who hung himself, and in dogs and rabbits asphyxiated for experimental purposes. If an animal be kept without food for three or four days, and then killed, the stomach and bowels will be found to be of a red rosy color; the mesenteric vessels considerably distended with blood; the isolated follicles enlarged; and the villous membrane unnaturally rough, softened, and easily detached. Not unfrequently, indeed, the color of these organs, under such circumstances, will be of a cherry red, bright lake, or vermilion. If the abstinence, however, be prolonged for a considerable period, then the mucous membrane, participating in the general anaemia of the s}7stem, will be apt to be pallid, though cases occasionally occur, even in the human subject, in which the reverse of this obtains. Various substances, when taken into the stomach, have the property of imparting to the mucous membrane a deep red color, which may be mistaken for the effect of poison. Of this nature are the infusions of logwood and red poppy, together with black currants, the tincture of cardamom, and the compound spirits of lavender. A knowledge of these facts is of much importance in a medico-legal point of view; as a person, after having swallowed some one or other of these sub- stances, might suddenly expire, and from the mucous membrane of the stomach and bowels being found of a red tinge, the suspicion might arise that he had been poisoned. I have stated, elsewhere, that nitrate of silver, when taken inter- nally for a long time, had the effect of staining the external integu- ment with a gray slate color. Similar results follow in regard to the mucous membrane of the alimentary canal. In a case examined by Dr. Kayer, of Paris, where the substance in question had been taken for thirteen months, for the cure of epilepsy, consequent on disease GASTRO-ENTERIC MUCOUS MEMBRANE. 503 of the brain, the internal surface of the whole alimentary tube, toge- ther with the interior of the mouth and sides of the tongue, was of a gray slate color. In the stomach the tint was extremely deep, and uniformly diffused ; in the bowels, it was somewhat more faint, but still quite appreciable, and was interrupted here and there by minute vascular specks. The skin exhibited a precisely similar hue. In traumatic fever, caused by wounds of the head or extremities, the mucous membrane often assumes a bright reddish color, which, although it does not seem to be always associated with derangement of the digestive passages, cannot be easily removed by exsanguifica- tion. This fact, first experimentally ascertained by Gendrin, has been fully corroborated by the later researches of Mr. Swan,1 of London. The numerous observations of this distinguished anatomist have proved, in the clearest manner, that the insertion of any of the mineral poisons, or even mercurial frictions, on the back of a dog, after shaving off the hair, communicates a red color to the villous coat of the whole alimentary tube. SECTION II. INFLAMMATION OP THE GASTRO-ENTERIC MUCOUS MEMBRANE. With these preliminary observations concerning the healthy con- sistence and color of the gastro-enteric mucous membrane, designed to enable the young pathologist to avoid some of the many difficulties which beset this interesting field of inquiry, I proeeed to take up the subject of its morbid anatomy. In entering upon this important topic, I do not deem it necessary to consider the lesions of each portion of the alimentary tube separately ; to do so, would only lead me into useless repetitions, and compel me at every step to recount what has been already stated. Possessing the same structure, the stomach and bowels, small as well as large, are liable to the same diseases, whether acute or chronic, whether simply inflammatory or organic; and there- fore, for all practical purposes, there can be no reason whatever why they should not be all described under one general head. Neverthe- less, the method that I shall pursue will be somewhat different from that which the plan here stated might be presumed to indicate. Thus, after having discussed the subject of acute inflammation, together with its several terminations, with reference to the gastro-enteric mucous membrane generally, I shall speak of the more uncommon lesions as they affect each section of the alimentary passages in par- ticular, pointing out whatever may be peculiar to them. Acute Inflammation.—The anatomical signs of acute inflammation of the mucous membrane of the alimentary tube are, increased vascu- larity, loss of transparency, dryness, thickening, softening, deposition of 1 Monro, Morbid Anatomy of the Gullet, Stomach, &c, p. 313. 504 GASTRO-ENTERIC MUCOUS MEMBRANE. lymph, and the formation of small vesicles, with alteration of the natu- ral secretion and effusion of serum into the submucous cellular tissue. The first perceptible effect produced in the inflamed membrane is a change of color, caused by an augmented flow of blood to the affected part. The shades of tint are extremely numerous, but they may all be referred to modifications of red, brown, slate, and black. Of these, the first is by far the most common in acute inflammation, whilst the others are more usually the product of the chronic process, in which the coloring principle of the blood, perfectly incorporated, as it were, with the mucous texture, is variously altered in its properties, either from simple stagnation in the minute capillaries, or from contact with the acid and gaseous contents of the alimentary tube. The inflammatory redness, although sometimes widely diffused, usually occurs in small irregular patches, separated by intervals of sound membrane. Varying in diameter from a few lines to several inches, they often project sensibly beyond the level of the circumjacent parts; and, in violent cases, are always of a bright red color, looking a good deal like so many pieces of scarlet velvet. Connected with this augmented vascularity, are commonly certain changes in the mucous and subjacent textures. In the early stage of the disease, there is perhaps merely a slight degree of opacity, with a rugose con- dition of the free surface of the membrane. Afterwards, however, as the inflammation progresses, the reddened patches lose their tenacity, and become covered with a thick, ropy mucus, elevated into small vesicles, chapped, or fissured, or studded with flakes of lymph. When all or several of these phenomena are present, no doubt can be enter- tained concerning the true nature of the disease, inasmuch as they are absolutely unequivocal. But it is not always that the inflammatory redness is thus distinctly marked; and hence much difficulty is sometimes experienced in dis- criminating between it and that which is natural. Attention has been already directed to the well-ascertained fact that stimulating viands or drinks, received into the alimentary canal, produce an afflux of blood to the vessels of this cavity, by which the color of the mucous mem- brane is often so greatly heightened as to exhibit an appearance not unlike that observed in inflammation. This circumstance should be constantly borne in mind in making post-mortem examinations, other- wise the most serious mistakes must arise. How, then, are these two conditions to be distinguished from each other ? for upon the correct decision of this point hinges the pathology of a large number of the diseases of the stomach and bowels. The answer is obvious—by comparison. Thus, the inflammatory redness has rarely that uniform tint which is to be observed in the sound membrane; on the contrary, it is usually somewhat mottled, and, instead of terminating, as does the other, by insensible gradations, it almost always stops abruptly. The inflammatory discoloration occurs most frequently in small irregular spots, situated at different points of the circumference of the tube; whereas that resulting from simple congestion is commonly diffused over a large extent of surface, or is confined to the most depending "s. INFLAMMATION. 505 parts. Another important feature is derived from the condition of the abdominal vessels. In inflammation, the distended capillaries seem as it were lost,being no longer traceable to any particular trunk; the reverse of which obtains when the redness is cadaveric, or caused by mechanical obstruction. The blood, too, in the former case, cannot be pushed about so easily from one place to another, from the great firmness with which it is impacted in the minute vessels, added, per- haps, to the preternatural viscidity of its fibrin, and to the abstraction of its aqueous principles. For the same reason, also, maceration pro- duces its effects much more slowly than in the sound state, and minute injections seldom succeed so well, many of the vessels giving way in consequence of the difficulty of displacing their contents. These characters are not, of course, so well marked in incipient as in con- firmed inflammation; nevertheless, they almost always exist to a greater or less extent. Besides these diagnostic signs, the inflamed membrane is always opaque, from the engorgement of the capillary vessels, which, exhibit- ing the appearance of a fine network, are more distinct generally at the adherent than at the free surface of the mucous tunic. In the healthy state, on the contrary, or even when there is a slight degree of con- gestion, as occurs, for example, during chymification, the membrane is diaphanous, or at least very nearly so, and if a portion of it be detached, and held before the light, it will be found to be of a uniform rose tint. The inflamed part offers considerable diversity in regard to the mode of its vascularity. Most commonly it is arborescent, the vessels being spread out like the branches of a tree. This species of injection, however, is never indicative of high inflammatory action, except when conjoined with softening of the mucous tissue, or deposition of lymph upon its surface. Hence it either soon disappears, without producing any appreciable symptoms, or it loses its dendritic arrangement, and becomes capilliform. A fine example of the present variety of vascu- larity is often to be noticed in the conjunctiva, when, from any tran- sient cause, its minute vessels are made to convey red blood. The capilliform injection always denotes, as just intimated, a much higher grade of irritation than the dendritic, to which it succeeds. In this variety, the capillary vessels are excessively crowded with blood and intersect each other in such a manner as to form a most intricate net- work, often particularly conspicuous round inflamed ulcers, the isolated follicles, and the glands of Peyer. It is frequently attended with soft- ening of the subjacent cellular tissue, and can be completely removed by maceration in water for twenty-four hours. Either alone, or conjoined with one or the other of the preceding varieties of vascularity, there is occasionally a singularly speckled appearance of the mucous membrane. When the dots are numerous, the affected surface looks very much like the section of an inflamed brain. It may also be imitated, with great nicety, by scattering fine grains of powdered vermilion upon a moist sheet of white paper. The appearance is much more frequent in the stomach than in the intestines, though at times it is found in nearly every membrane of the body. I have seen it, in the same individual, in the pleura and 506 GASTRO-ENTERIC MUCOUS MEMBRANE. pericardium, the stomach and bowels, the spleen, mesentery, and omentum. The specks, sometimes very closely set together, vary in diameter from the smallest pin-head to that of a mustard-seed, and in color from a light rose to a deep cherry red. This species of vascu- larity, which does not denote an intense degree of irritation, pro- ceeds from slight extravasation of blood, caused by the rupture of capillary vessels, in consequence of the impulse with which the fluid is forced into them at the onset of the inflammation. When it is conjoined, as very often happens, with the diffused redness, the dots generally occupy a considerable extent of surface, and occasionally run into each other so as to give the part a striated, streaked, or linear disposition. In the highest degree of inflammatory action, as in that, for instance, resulting from the administration of some of the acrid poisons, ex- travasations of blood, of considerable magnitude, are not unfrequently met with. In such cases, the fluid seems to be originally poured out into the submucous cellular tissue, whence it extends into the proper villous membrane, forming patches of a dark livid hue. Dissection does not always reveal the true cause of these extravasations. Very frequently they can be traced directly to one or more ruptured vessels; in many cases, however, the capillaries of the part seem to be in a state of the most perfect integrity. How far, under these cir- cumstances, we are authorized to ascribe the phenomenon in question to simple vascular exosmosis, it is not easy to determine. Judging from what we observe upon the free surface of the mucous and other membranes, where blood is often thrown out in considerable quantities, without any laceration of the vessels, it is not unreasonable to conclude that the ecchymoses here adverted to have occasionally a similar origin. This bloodshot appearance, indicative of the most intense irritation, is often attended with thickening and softening of the villous tunic, together with a deposit of lymph upon its free surface, an effusion of serosity into the subjacent cellular tissue, and the secretion of an inspissated and tenacious mucus, or even of purulent matter. The brown, slate, and black color, with their various intermediate shades, are usually ascribable to a process of chronic irritation, or to inflammation of long standing. They are seen, however, occasion- ally in cases of a high degree of acuity ; in such, for instance, as result from corrosive poisons, violent diseases of the bowels, and the more severe forms of bilious fever of warm climates. The black color is often witnessed in protracted diarrhoea and dysentery, and is always characteristic of profound morbid action. An interesting question arises here, can an inflammatory redness exist, and yet wholly disappear after death ? Many pathologists think that it may; and, as the doctrine is of much importance, from the dangerous use which may be made of it in pathology, it demands a brief examination in this place. Those who have advocated the possibility of this occurrence, have adduced the fact that in many cases the traces of erysipelas will greatly diminish, if not entirely disappear, after death; and the same circumstances, it is well known, INFLAMMATION — VASCULARITY. 507 are often observed with respect to the redness of tonsillitis, and other inflammatory affections of the throat. This condition has been ex- plained, by some, by assuming that the injection of the capillaries ceases as soon as the irritation causing it becomes extinct; whilst others have endeavored to account for it by supposing that, during the agonies of dissolution, the vitality of the affected part is so much diminished that it has no longer the power of attracting the blood in preternatural quantity. In regard to cutaneous diseases, this is unquestionably true; but, even here, cadaveric pallor of parts pre- viously inflamed is far from being a general phenomenon, the redness oftentimes remaining long after death, especially in high grades of erysipelas, scarlet fever, measles, and old irritable ulcers. But is this comparison strictly applicable to the mucous coat of the stomach and bowels? Closely as the skin and lining membrane of these hollow organs are related to each other by similarity of structure and function, and intimately as they are associated by sympathy, it is well known that their capillary injection is widely different under inflam- matory irritation. Even in the highest grade of erysipelas, the blood can be easily enough forced out of its vessels, so as to give the part a pallid aspect, but nowhere can this be done, so far as we have op- portunities of observing the fact, in confirmed inflammation of the mucous membrane. Compression of a highly irritated tonsil, or of a prolapsed rectum, never displaces the sanguineous fluid to so great an extent as in the skin, because it is impacted much more firmly into the minute vessels, the coats of which will often yield rather than allow their contents to be pushed along. Moreover, the blood has not that natural tendency to recede from the mucous membrane during the last struggles of life that it has to recede from the skin: on the contrary, so far from this being the fact, we uniformly find the fluid to accumulate in the interior of the body; and, in many instances, if not indeed in most, there is reason to believe that this process goes on for some time after the heart has ceased to act, and the vital principle fled. The redness, therefore, of the inflamed membrane, so far from diminishing on the approach of death, would have a tendency rather to become heightened ; and this no doubt occasionally happens, though, taking all the facts which have been adverted to into consideration, we must assume, as a general pro- position, that the color remains precisely as it was during life. Yet, although this subsidence does not take place in the generality of cases, it may, nevertheless, occur under certain circumstances. Thus, a high degree of irritation accompanied with deep redness, may exist in the lining membrane of the stomach; but, a severe dysentery supervening, a powerful revulsion will be the result, in consequence of which the original disease, with its attendant vascularity, will in a great measure subside; so that, on inspection, hardly any trace of gastritis shall be discernible. The same thing occasionally occurs in persons that are cut off, in a few hours, by violent attacks of cholera morbus. In some instances of this kind, where, from the intensity of the symptoms, no doubt could be entertained of the existence of the most intense inflammation, I have not been able to detect after death 508 GASTRO-ENTERIC MUCOUS MEMBRANE. the slightest vascularity of the mucous membrane. Life, in such cases, seems to be destroyed by some lurking poison, exerting its baneful impression peculiarly upon the nervous system, without leaving any visible alteration in the organs whence it radiates its influenoe._ Enough, surely, has now been said to enable us to distinguish the different kinds of inflammatory redness, not only from each other, but also from that which appertains to the mucous membrane in the nor- mal state. As the discussion of this subject has been carried to a considerable length, I shall content myself, in concluding this article, with a brief analysis of the other anatomical characters which are to be found, either alone or conjointly with this discoloration, in the acute variety of gastro-enteritis. These, it will be remembered, are opa- city, thickening, softening, vesicular eruptions, and vitiated secretions. One of the earliest effects, in addition to an alteration of color, of acute inflammation of the mucous membrane, is a diminution of its natural transparency. Even when there is but a slight degree of red- ness, the irritated spots lose, in a great degree, their diaphanous aspect; but, should the discoloration be deep and uniform, the opacity will be complete, owing to the extreme injection of the capillary vessels. At the onset of the disease, the secretion of the membrane is some- what augmented in quantity, but thinner and less viscid than in the normal state; the mucous follicles are also perceptibly engorged, and more prominent than usual, being encircled by a beautiful vascular wreath. When the inflammation is at its height, the secretion is almost suppressed, and the membrane, consequently, is dry, as happens in in- flammation of the Schneiderian lining of the nose; but, as this period is always of short duration, the secretion is soon re-established, and often discharged in considerable abundance, being of a thick, ropy consistence, and of a grayish opaline color; occasionally, also, it is of a greenish tint, or dark and sanious. The orifices of the mucous follicles are enlarged and patulous; and if, under these circumstances, the membrane be carefully washed, it will be found to exhibit a granu- lated aspect, not unlike a pale fungous ulcer. Towards the decline of the disease, the secretion sometimes assumes a puriform character, and is often quite copious. Dryness of the mucous membrane, as a result of inflammation, is much less usual than in some of the other textures of the body. The phenomenon is by no means uncommon, for instance, in the arachnoid tunic, where it is always indicative of intense irritation. The same circumstance is occasionally witnessed in the alimentary tube, and sometimes to a very considerable extent. The surface of the inflamed membrane loses much of its natural softness; it becomes rough, from the turgid condition of its villosities and follicles, and, in very intense cases, it is not unusual to find it chapped, cracked, or fissured. Increase of thickness is a pretty constant attendant on acute inflam- mation, the tumefaction appearing either contemporaneously with, or soon after, the redness. Effusion of sero-albuminous matter into the submucous cellular tissue, added to the injection of the capillary ves- sels, is the main cause of this anatomical character, which is never INFLAMMATION—LYMPH. 509 so well marked in the stomach and bowels as in the larynx, conjunc- tiva, or fauces. Occasionally, the thickening proceeds almost wholly from the mucous follicles, which may be so much enlarged as to give the surface of the affected membrane, as already stated, a rough, gra- nular appearance. At an early period of the attack, the density of the membrane is commonly somewhat augmented; but, in its progress to its height, as well as during its decline, it is always preternaturally softened. In this condition, which is deserving of much attention, both the mucous and submucous textures are frequently infiltrated with serum, muco-puru- lent matter, and even with blood; at the same time that they become so pulpy and disorganized as to admit of being scraped away with the finger-nail or the handle of the scalpel. Inflammatory softening, as will be shown hereafter, is much more common in some parts of the alimentary tube than in others, and, what is remarkable, is seldom attended with any decided redness, the part, which is opaque, and elevated, having every appearance as if the blood had ceased to pene- trate it for some time prior to the extinction of life. Thus, then, whenever the irritation is of a high grade, the submucous cellular tissue uniformly participates in the disease. A vesicular eruption is sometimes met with in this disease. It is in- dicative of a high degree of inflammatory action, and has hitherto been noticed chiefly in dysenteric affections and Asiatic cholera. The erup- tion consists in the development of minute spherical vesicles, very little elevated, and discharging, when punctured, a small quantity of clear limpid fluid. Their walls are perfectly transparent, and but few exceed the diameter of a grain of mustard. They often occur in thick clusters, hundreds being found upon a surface not larger than a square inch. No part of the alimentary tube is ex- empt from this eruption. It is observed, however, most frequently upon the valves of the jejunum, along the roots of which it is some- times perfectly confluent, like the eruption of small-pox. In the ileum and colon, the vesicles are more scattered, and consequently much less numerous. They are generally associated with a chapped or exco- riated condition of the mucous membrane, preternatural vascularity, deposition of lymph, and effusion of sero-albuminous, bloody, or puru- lent matter. How they are produced is still undetermined. A plastic exudation is a frequent effect of inflammatory action. In the stomach and bowels, the deposition of this substance is much less frequent than in the supra-diaphragmatic portion of the alimentary canal. In children, the mouth, pharynx, and oesophagus are some- times completely lined with it; but even in them it is far from being common, and seldom extends along the rest of the digestive tube. After puberty, this exudation is equally uncommon, both in the sto- mach and the intestines; but much more so in the former than in the latter. It is often met with in the large bowel of persons who die of dysentery and bilious fever. I have noticed it in this disease in a very great number of cases, in every part of the tube, but more par- ticularly in the rectum, and ascending portion of the colon. The 510 GASTRO-ENTERIC MUCOUS MEMBRANE. ileum also frequently suffers in this complaint, but I have never ob- served the exudation extend into the jejunum and duodenum. The inflammation giving rise to this lymphy exudation occasionally assumes an epidemic type. Thus, in the spring of 1817, an abdominal phlegmasia prevailed extensively in Paris, in which nothing was more common than a discharge of pseudo-membranous matter both by the mouth and anus. In most of the patients that were admitted into the wards of the Hotel-Dieu, the inflammation, especially during the de- cline of the epidemic, affected originally the stomach and small bowels, from which it gradually descended into the colon and rectum. In a large proportion of those who died of the disease, the pyloric half of the stomach was covered by an adventitious membrane, and the whole gastro-enteric lining was of an erythematous red color. The mucous corion was sensibly thickened as well as softened ; and, in many places, there were small brownish-looking zones, likewise studded with fibrinous matter. The membranous exudation usually takes place, in the first instance, in small whitish specks, separated by considerable intervals; these, gradually coalescing, form large patches; and these, again, continuous lamellae, which often cover a very great extent of surface. A few years ago, I met with a specimen, in a young man who died of acute enteritis, after an illness of two weeks, in which nearly the whole of the lower half of the ileum was lined by a false membrane, in many places fully half a line in thickness: it adhered with considerable firmness to the surface beneath, which was extensively fissured, and of a dark, gangrenous color. The patient had suffered under all the symptoms of the most intense inflammation. Is this substance, when thrown out upon the surface of the stomach or bowel, susceptible of becoming organized ? Upon this subject the opinions of anatomists can scarcely be said, in any way, to accord. That the occurrence is possible, may be readily supposed from what occasionally happens in the larynx, the womb, and urinary bladder: that it is extremely infrequent must be equally plain, especially when we take into consideration the heterogeneous contents of the aliment- ary tube, and the tendency which they must have to thwart a process of such delicacy and refinement. Whether organized, however, or not, the adventitious membrane is always, sooner or later, detached, either in small semi-concrete masses, or, as sometimes happens, in long tubular pieces. When acute inflammation runs so high as to give rise to bloody infiltrations beneath and within the substance of the mucous coat or even to small ecchymoses, it occasionally terminates in purulent effu- sions. Under such circumstances, it is by no means rare to meet with considerable abscesses, either in the walls of the digestive passages, or in the contiguous portions of the mesentery, produced by an extension of the irritation, and opening most generally into the bowel. The mucous membrane, thus bathed and infiltrated with pus, is commonly of a reddish-gray color, very soft and yielding, being sometimes wholly disorganized, and converted into a dirty-looking, pultaceous substance. INFLAMMATION — BLOOD. 511 Considerable quantities of pus are frequently discharged by the in- flamed tunic, without any solution of continuity. Blood, either pure or mixed with mucus and other matter, is often thrown out in violent attacks of this disease. This exhalation, for such in truth it generally is, is almost constantly present in dysentery and yellow fever, both of them high grades of inflammation, affecting, in the one case, the mucous coat of the colon, in the other, the mucous coat of the stomach. No doubt can be any longer entertained that the matter of black vomit is merely a transudation of blood, altered in its physical, and probably also in its chemical properties, by contact with the gastric acid. That it is a secretion from the vessels of the stomach, is an opinion now generally admitted. The quantity of this singular looking matter, once supposed to be nothing but vitiated bile, is sometimes exceedingly great; and yet, upon examination, no structural lesion whatever, excepting lymphy exudation, and perhaps softening of the mucous membrane, is to be found in the organ which is its seat. The changes which the blood experiences, when brought in contact with the acid and gaseous contents of the stomach and bowels, are curious and important. When thus effused, the fluid is speedily deprived of its natural color, and converted into a soft, black sub- stance, resembling thin pitch. Very much the same appearance is sometimes observed when the blood becomes stagnant in the villous and follicular structures of these organs, from the influence, probably, of the same cause. This discoloration will always be much greater, there is reason to suppose, in proportion to the quantity and vitiated condition of the gastric juice. Hence the reason, perhaps, why it generally has that peculiar coffee-ground appearance in yellow fever. Thus, then, an exhalation of blood, either pure or variously altered by the gastric contents of the alimentary tube, may be another effect of acute inflammation of the mucous membrane. The attendant red- ness is generally patch-like or diffuse, and is not unfrequently accom- panied by considerable-sized ecchymoses. Conjoined with these appearances may be softening, excoriations, and thickening of the villous tunic, with vesicular eruptions, and deposits of lymph. It may be added, in this connection, that, when ulceration and hemorrhage coexist, they should not necessarily be viewed in the light of cause and effect, since the latter, although thus associated, may be the result simply of exhalation. Produced by the same process is the thin rice-watery secretion, which forms so prominent a feature of Asiatic cholera and violent diarrhoea. The essential character of this secretion is sero-albuminous, and the quantity poured out is often very great, several quarts being occasion- ally discharged in the course of a few hours. The fluid is, for the most part, inodorous, whitish, and of an aqueous consistence, \yith nu- merous flakes of lymph floating through it, which frequently impart to it a turbid, milky aspect; in diarrhoea, it is seldom so pure as in cholera, and it is also more apt to be offensive, from the union of feculent matter and vitiated mucus. It is partly coagulable by heat, alcohol, and acids. 512 GASTRO-ENTERIC MUCOUS MEMBRANE. The most prominent lesions connected with this sero-albuminous secretion are, softening of the villous membrane and hypertrophy of the follicles, with occasional depositions of lymph. What is remark-, able, there is sometimes a complete absence of redness of the lining membrane, both of the stomach and bowels; a circumstance which may be satisfactorily accounted for, by supposing that the immense rice-watery discharges relieve the vascular engorgement prior to dissolution, so that, upon inspection, no discoloration whatever is per- ceptible. Inflammation of the lining membrane of the alimentary tube fre- quently produces, even when it is entirely confined to the mucous corion, a well-marked injection in the other tunics. When the dis- ease is very extensive and intense, the vascular injection may not only pervade the whole thickness of the stomach, small or large bowel, but even extend to the mesentery. Under such circumstances, the distended state of the neighboring vessels, and the purple discoloration and arborescent appearance of the peritoneal covering, either alone or in conjunction with flakes of adherent lymph, generally afford abund- ant evidence of the probable extent of the internal lesions. The mesenteric glands are sometimes swollen and inflamed, though seldom so much as in ulceration. In active inflammation, the digestive tube is ordinarily dilated; this, however, continues only so long as the irritation is limited to the mucous lining; for as soon as it extends to the muscular tunic, the canal becomes invariably contracted. One of the most singular circumstances connected with acute in- flammation of the digestive passages, is a development of gas. This phenomenon has been variously explained by different pathologists; some supposing that it arises merely from a species of fermentation of the fluids which may be contained at the time in the stomach and bowels; others, that it is the result of a peculiar secretion, the nature of which is not understood. Without denying the truth of these ex- planations, both of which are, perhaps, to a certain extent, well founded, it may yet be doubted whether they are sufficient to account for the fact that this evolution of gas is present in some cases and absent in others. With a view of deciding this question, Gendrin irritated a portion of bowel in several dogs by caustic, alcohol, or boiling water, and then intercepted the inflamed part between two ligatures, having previously exhausted the air with a syringe. In two out of five of the animals thus treated, the gut was distended, in twelve hours after the operation, with an inodorous gas, the inflam- mation in both being rendered evident by the lively redness of the villous tunic; in the other dogs, although the discoloration was equally conspicuous, and produced by the very same substances, no air whatever was to be found. Is it probable that this fluid is dis- engaged from the bloodvessels of the affected part ? This is not un- likely, when it is recollected that carbonic acid gas is evolved in great quantity, from the same source, in the lungs during respiration. It is not unfrequently found that the inflammation, instead of in- vading the villous texture, properly so termed, begins in, and is con- ACUTE INFLAMMATION. 513 fined exclusively to, the isolated follicles, scattered in such profusion over the alimentary tube. In the inceptive stage of the disease, the affected glands look like little boils, moderately projecting beyond the level of the surrounding surface. Varying in size from a small pin- head to a mustard-seed, they are generally of a spherical shape, soft, and of a reddish glossy aspect, each being marked by a minute, cen- tral aperture, indicating its natural orifice. At this period of the dis- ease, the glands are already quite injected, and, if they be closely examined, it will be found that they are encircled by a beautiful wreath of vessels, so fine as to be almost undistinguishable by the naked eye. At a more remote stage, their color is of a light brown, their bulk is considerably augmented, and their surface, instead of being lubricated, as before, by an abundant mucus, is nearly dry, their secretory functions being in great degree suspended. This state, however, soon disappears, and is followed by a copious flow of fluid. When, as often happens, the villous membrane between the follicles participates in the disease, it gradually loses its natural cha- racters, and exhibits some of those appearances which have been pointed out as denoting acute inflammation. The glands themselves are often very much softened, or so greatly disorganized as to give the surface of the digestive tube a singularly cribriform aspect. Not unlike the preceding are the changes which the glands of Peyer undergo in acute inflammation. In the normal state, these bodies are seldom very distinct; when affected, however, by disease, they are rendered quite prominent, being considerably raised above the sur- rounding surface in the form of elliptical, ovoidal, or circular patches, from a few lines to several inches in diameter. In this state, they are of a florid color, from the injection of their capillaries, and their sur- face has an uneven, granular, or honey-comb-like appearance, from the projection of their follicles. The submucous texture is also consider- ably thickened, and the intervening membrane is more or less altered, according as it participates or not in the inflammation. Ulceration often follows this process. Acute inflammation, whether affecting the villous or follicular tex- tures, or both at the same time, may either terminate by resolution, pass into the chronic form, or proceed to disorganization. When it goes on favorably, the infiltrated fluids are gradually absorbed, the vascularity diminishes, the natural secretions are restored, the absorb- ing faculties become more and more vigorous, and, at length, the func- tions taf the part are entirely re-established, the only alterations which remain being a thickened, and, occasionally, a slightly indurated state of the mucous and submucous textures. If the follicles have been mainly involved, the affected surface exhibits, after the lapse of some time, numerous dark dots, which have been compared, not unaptly, to those of a newly shaved beard. With regard to acute inflammation, it may be observed, in conclu- sion, that its relative frequency is much greater in some parts of the alimentary tube than in others. The inferior half of the ileum, the stomach, and the commencement of the colon, are, without doubt, most commonly engaged, either alone or conjointly. This latter cir- 33 514 GASTRO-ENTERIC MUCOUS MEMBRANE. cumstance has given rise to the term gastro-enteritis, so much in vogue amongst the French pathologists, but which is not always applicable, inasmuch as the coincidence is by no means universal, or even general. Gangrene.—Although acute inflammation occasionally terminates in gangrene, yet this effect is by no means so common as was at one time supposed by pathologists. By a reference to the works of the older anatomists, it appears that they were constantly in the habit of con- founding high discoloration, whether proceeding from simple conges- tion, effusion of blood, or melanotic deposits, with mortification of the mucous texture. Since, however, a more accurate method of investi- gation has been introduced into science, it has been abundantly es- tablished that this lesion is of very rare occurrence. This remark applies, of course, solely to the idiopathic variety of inflammation, and not to that which is occasioned by strangulation, intussusception, external violence, or corroding poisons. It is now well ascertained that some parts of the mucous membrane of the alimentary tube are much more liable to gangrene than others. The inferior half of the ileum is the section most commonly affected, and next in point of frequency stands the colon, particularly the ascending portion. It is an extraordinary fact that the stomach, jejunum, and duodenum are seldom implicated. Why these reservoirs should enjoy this remarkable immunity, both from this and some other affections, is inexplicable. Large portions of the mucous membrane are sometimes deprived of their vitality. In general, however, the gangrene is much less exten- sive, occurring in small patches, of an irregular shape, and from one to several inches in diameter. The textures primarily affected are, the mucous and follicular, from which the disease may gradually spread to the other tunics, converting them into soft, dark-colored sloughs, incapable of resisting the slightest distension from fecal matter. Hence it not unfrequently happens, if the patient survives sufficiently long, that the intestinal tube gives way in one or more places, and discharges its contents into the abdominal cavity, as in perforation from ulcera- tive action. The color of the sphacelated part is variable. Occasionally it is of a dark drab, dirty ash, or greenish tint; more commonly it is of a mahogany-brown, black, or livid, from the imbibition of the ichorous matter, which is often poured out in such abundance during the height of the inflammatory stage of the disorder. The mucous membrane which surrounds the slough is generally very much injected, and of a red mulberry color, indicative of excessive irritation. With this change of color, the mucous membrane is generally so much softened that it can be removed by simply passing over it the handle of the scalpel. Usually the gangrenous part is remarkably offensive: it is frequently covered with flakes of lymph, and occasionally, though rarely, there are little phlyctenae, not unlike those which are witnessed in mortification of the skin and cellular tissue. An em- physematous condition of the submucous cellular tissue is also some- times found; but this, in the majority of cases, is to be regarded rather as a result of putrefaction than of inflammation. CHRONIC INFLAMMATION. 515 When gangrene seizes upon the glands of Peyer, which, however, is not often the case, the sloughs are of a dark brownish color, soft and fetid, very much as in the preceding case; and, on being detached, deep excavations are formed, with loose, ragged edges. Although in the generality of cases these excavations do not extend beyond the submucous coat, yet occasionally they invade the whole thickness of the ileum, and thus give rise to perforation and fatal effu- sion. Sometimes, even when the gangrene stops short at the mucous and subjacent cellular textures, considerable bloodvessels, branches of tha mesenteric arteries and veins, are laid open, and the patient per- haps perishes from hemorrhage. Appearances very similar to these are observed when the gangrene invades the isolated follicles, except that the surrounding parts are usually less red and injected. Chronic Inflammation.—Chronic inflammation of the mucous mem- brane of the alimentary tube is much more frequent than acute, of which it may either be a consequence, or it may exist as an original and independent disease. It is very common in dyspepsia, diarrhoea, dysentery, and infantile cholera, of which and of almost all protracted fluxes of the bowels, it is the principal cause, these affections themselves being merely the symptoms. Though not so immediately dangerous as acute inflammation, this disorder is usually very difficult to be dis- lodged from the stronghold which it takes on the part, and from the insidiousness of its attack, weeks and months sometimes elapsing be- fore it induces any decided constitutional disturbance. The anatomical characters of chronic inflammation differ, in many essential points, from those of the acute variety of the disease. As a general proposition, it may be stated that the appearances vary accord- ing to the duration of the malady, and the nature of the exciting cause, together with several other circumstances which it is unneces- sary to specify. Thus, when the disease is of recent standing, we usually find the mucous membrane of a dusky red, inclining to ma- hogany ; whereas, in the opposite state, especially when the attack is one of considerable intensity, it is of a livid, purple, or mulberry aspect. Though the discoloration is occasionally diffuse and uniform, yet in the great majority of cases it occurs in small patches, stripes, or bands, leaving the intervening surface of the natural hue. As in the acute form of the disease, so in this, the color, whatever be its nature, is closely identified with the mucous texture, and therefore always removable with much difficulty by maceration ; artificial injection, also, is no longer practicable, at least to any degree of minuteness. The ves- sels upon which this discoloration depends are generally disposed in arborescent lines, and, what is remarkable, and serves to distinguish this from mere congestive vascularity, is, that they cannot be traced to any particular trunks, but seem as if they were lost in the midst of the inflamed tissues. But it is not always that the diseased membrane is heightened in its color. Often, indeed, it is preternaturally pale, as if it had been bleached and drained of its fluids, and in such cases, also, it is generally very flabby and relaxed. Such an occurrence is by no means infrequent in chronic diarrhoea and infantile cholera. A very common appearance in this disease is a slaty, bluish, or black- 516 GASTRO-ENTERIC MUCOUS MEMBRANE. ish discoloration, occurring in spots, from the size of a five cent piece to that of a dollar. The parts in which it is most frequently met with are the colon and the rectum, where it is sometimes diffused over a large extent of surface. In the stomach and small bowel, where it is usually more limited, it is commonly most dictinct along the temporary folds and winking valves, for what reason it is not easy to determine. The discoloration, which runs through a great variety of shades, from light slate to jet black, is seldom witnessed except in cases of long standing, or in such as are characterized by a considerable degree of intensity, and probably always results from an extravasation of blood into the submucous cellular texture. Its seat, however, is not, as might be sup- posed, confined to this substance: often, indeed, it involves in a special manner the mucous membrane, the follicles, and even the villosities; and cases are not wanting, though they are uncommon, in which it penetrates all the tunics at the same time, tinging the tube externally of a greenish, brownish, or sooty dye. In chronic inflammation, the substance of the mucous membrane is generally thickened, and its density augmented, so that it can no longer be torn with the same facility as in the normal state. The mucous follicles are also more or less enlarged, forming, in many instances, hard, granular bodies, which project considerably above the level of the surrounding parts. Nor is the hypertrophy—for such it really is— always confined to these structures. The villosities, small as they naturally are, are often involved in the disease, and sometimes attain an astonishing development. Owing to these alterations, the surface of the mucous membrane is usually rough, and occasionally even cel- lulated, like a honey-comb. This, however, is by no means a uniform occurrence; for cases are frequently witnessed, and those even of long standing, in which the part is perfectly smooth and polished, not a gland or villosity being anywhere perceptible. In the stomach the thickening of the mucous coat is more usually uniform, and the tissue is frequently raised into folds separated by de- pressions. On this appearance, termed " mammillation" by the French pathologists, much stress is laid by some writers. It may, however, occur in health. Dr. Handheld Jones, in making minute examinations of the stomach, often met with this condition where the mucous mem- brane was nearly or quite healthy. In the depressed portions atrophy of the tubular glands is commonly found.1 The same writer has made some very interesting observations on the atrophy of the glandular tubes of the stomach in general. It would seem that they frequently become wasted, and replaced by a fibroid or granular matter. Yet, notwithstanding the changes in these important constituents, the organ does not, in general, seem to lose its power of digestion. When, as sometimes happens, the inflammation of the mucous membrane assumes a more acute form, the mucous texture undergoes still further changes, or, more correetly speaking, it assumes very dif- ferent characters. It loses its hardness and tenacity, and is converted into a soft, thick, pulpy substance, which is infiltrated with various * Observations on the Stomach. London, 1855. CHRONIC INFLAMMATION. 517 kinds of fluids, such, for example, as serosity, pus, or blood, either alone, or in combination. If the morbid action be of long continu- ance, the mucous tunic is apt to give way, and to form ulcerations, which extend, by degrees, to different depths in the tube. If, on the other hand, the disease retrogrades, the membrane, although it loses its dark complexion, remains preternaturally soft, spongy, and tumid. In chronic, as in acute inflammation, the vessels of the part always retain their unnatural volume for some time after the main disease has subsided; and cases are observed in which the veins have quite a tortuous and varicose disposition, forming thick whirls underneath the mucous tunic. This appearance is particularly liable to attend chronic inflammation of the stomach, colon, and rectum. Another effect of chronic inflammation of the stomach and intes- tines, especially of the latter, is a contraction of their cavities. The colon may be diminished to less than the size of a healthy ileum. The walls of the intestines are then denser and thicker, or softer, and even occasionally atrophied. An enlargement of the muciparous follicles, from partial closure of their orifices, and the consequent retention of their secretions, is an- other effect of chronic inflammation. In this manner little cysts are formed, from the size of a millet-seed to that of a pea. They are isolated, or grouped, transparent, elastic, rounded, or ovoidal, embed- ded in the submucous cellular tissue, and raised above the level of the villous membrane. Their surface is often pervaded by minute strag- gling vessels, the red color of which beautifully contrasts with the white appearance of the enlarged gland. Their contents are usually thick and glairy, like the white of eggs, but sometimes they are watery, or of a pultaceous consistence, like that of porridge or soft boiled rice. In old cases, the walls of these cysts are occasionally opaque, speckled, and transformed into a tough fibrous tissue. "Their most common seat is the large bowel, but they may occur in any portion of the sub- diaphragmatic portion of the alimentary canal. They are much less common in the human subject than in the horse, in which they may acquire the volume of an egg, or of an orange. Similar bodies have been found in dogs, sheep, and pigs. Finally, chronic inflammation of the mucous membrane may cause the formation of warty excrescences and hypertrophy of the sub- mucous cellular tissue. The secretions in this disease present several important varieties. Most generally they consist of a thick, ropy, inodorous mucus, dis- charged in considerable quantity by stool; not unfrequently, however, they are of a thin, gleety nature, and the cases are not uncommon wherein they are serous, sanious, purulent, or fibrinous. Occasionally, again, though this is rare, the evacuations are thin, greasy, and of a singularly cadaverous smell. 518 GASTRO-ENTERIC MUCOUS MEMBRANE. SECTION III. SOFTENING OF THE GASTRO-ENTERIC MUCOUS MEMBRANE. There are two kinds of softening of the mucous membrane of the alimentary tube, differing from each other widely in their nature, and therefore entitled to separate consideration. The one is caused by inflammation, the other by the action of the gastric juice. The former is usually limited to the mucous and submucous tissues, whereas the latter frequently produces extensive erosions and perforations of the canal. 1. Inflammatory Softening.—Softening of the mucous texture from inflammation is most commonly noticed in the lower third of the ileum, the ccecum, the right and left portions of the colon, the sto- mach, and the rectum, the frequency of its occurrence being very nearly in the order here enumerated. In the majority of cases, it is confined to particular parts of the digestive tube; but, in some rare instances, it extends through its entire length, from the cardiac orifice to the anus. Although the softening seems to be occasionally limited to the mucous corion, villosities, or follicles, yet most generally it occurs in all these structures at the same time, converting them into a pulpy, homogeneous substance. Under certain circumstances, it is possibly capable of invading all the tunics of the stomach or intes- tines, proceeding successively from the mucous membrane to the sub- jacent cellular texture, and from the latter to the muscular and serous layers, so as to give rise to perforations, with a discharge of the contents of these reservoirs. Inflammatory softening is usually somewhat gradual in its progress, running through several well-marked stages before it attains its full development. In the first stage, the mucous membrane is remarkably brittle, and breaks as soon as it is seized with the forceps, allowing itself no longer, as in the sound state, to be detached in small, narrow strips; in the second, the cohesive powers are so far destroyed that, by merely passing the finger over it, it may be converted into a soft, grayish pulp, very analogous to thick cream; and, in the last stage, the disorganization is such that the mucous membrane may be easily removed by a small stream of water poured upon it from the height of a few inches. When the softening has attained this degree of development, it is not uncommon to find considerable portions of the mucous membrane detached, by the passage simply of the fluid con- tents of the alimentary tube; and in this way may be produced nume- rous abrasions, of a circular, oblong, or linear configuration, from the size of a split pea to that of a dollar, or even the magnitude of the hand. The edges of these abrasions are generally clean and even, their surface being formed by the submucous cellular tissue, which is itself often in a state of partial disorganization. The denuded patches, especially when small and circular, have occasionally the appearance INFLAMMATORY SOFTENING. 519 of ulcers; but, in all cases of doubt, the handle of the scalpel, carried lightly over the part, will enable us to determine their true nature. If the membrane sloughs away to a very great extent, as sometimes happens, the margins of the sore, instead of being rounded, as in the former case, will be irregularly bevelled off, and run insensibly into the surrounding parts. In cases of this description, too, it is not unusual to find shreds of the mucous membrane stretched across the denuded surface, so soft as to render it impossible to lift them with the forceps. Considerable diversity prevails in respect to the color of the softened membrane, different shades of tint marking different cases, and even the same case in different regions. In general, the membrane is of a pale bluish aspect, one or two degrees lighter than in the normal state; and not unfrequently it is of a dead white, like milk or cream. This variety of softening is very common in consumption, in mesen- teric disease, and in all affections attended with much emaciation. It is the white or " pultaceous" variety of Louis and Cruveilhier, the latter of whom distinguishes from it that peculiar transparent gelati- form softening, whidi always proceeds from the interior to the exte- rior coat, invading layer by layer until the walls of the portion affected resemble jelly. The vessels around the softening mass are black. This kind of softening occurs both in the stomach and intestine, and especially in very young children, as a consequence of eruptive fevers, of cholera, and of hydrocephalus. Its causes are obscure. Eokitansky, noticing the frequent coexistence of this form of softening of the sto- mach with affections of the brain, concludes that it is owing to a faulty innervation of the organ produced by a morbid state of the pneumogastric nerve, and to an increased acidity of the gastric juice. It certainly does not seem to stand in the relation of inflammation. In other cases, again, the membrane presents various shades of red, brown, or purple, or, perhaps, even retains its natural hue. The dark color is probably owing to the presence of a large amount of blood in the softened tissue. This form is frequently observed in acute diseases. Occasionally the discoloration is rigidly limited to the part affected, especially in the pale variety; but in most instances it extends to the neighboring parts, which at the same time exhibit all the phenomena of ordinary hypersemia. The bloodvessels in this disease have a singularly flattened appear- ance, and many of them are partially obliterated, no doubt from their participating in the softening. Injecting matter can no longer be forced into them, and their contents often escape, so as to form small dark-colored ecchymoses, resembling the black spots observable in the stomach of those who die of yellow fever. The lesion now under consideration is exceedingly _ common. Although it is occasionally limited to some particular portion of the alimentary tube, yet, in by far the greater number of subjects, it occurs simultaneously in the stomach, the ileum, and large bowel. In some instances, it involves an immense extent of surface, as one-third, a half, or even two-thirds of the gastro-enteric lining. It may be the only disease, or it may exist with other affections, such as ulceration, 520 GASTRO-ENTERIC MUCOUS MEMBRANE. extenuation, or thickening; but, however this may be, the anatomical characters do not differ from those we have just pointed out. Inflam- matory softening of the mucous membrane is frequently witnessed in bilious and typhoid fevers, in dyspepsia, in phthisis, pneumonitis, diarrhoea, and dysentery. I have likewise noticed it repeatedly in infantile cholera, especially in the chronic form of that disease, of which it often constitutes the principal evidence. In nearly all the dissections which I have made of subjects who died of this malady, the softening was'particularly observable in the mucous lining of the colon and stomach. In a few instances it was also noticed in the lower half of the ileum. 2. Softening by the Gastric Juke.—The second species of softening is produced by the action of the gastric juice after death, and is there- fore most common in the stomach. The reason why this effect does not occur during life, is the constant resistance afforded by the vital principle. That it should take place after death is not surprising, when it is remembered that the gastric juice generally contains a cer- tain quantity of free muriatic acid, which must thus greatly increase its eroding properties. These properties are easily neutralized by magnesia, soda, and potassa, as has been proved by experiments on animals, and upon the human subject after death. It has also been ascertained that if gastric juice, however acid, be introduced into the stomach of a living rabbit, no sensible effect will result from its contact with the mucous coat of the organ, for the reason just men- tioned. With respect to its site, it is worthy of notice that this variety of softening always takes place at the great cul-de-sac of the stomach, in consequence of its depending position favoring the accumulation of the gastric acid, as well, perhaps, as from this fluid being secreted here in larger quantity than elsewhere. The only exception to this rule arises where there is an enlargement of the spleen, or some tumor pressing this part of the organ up, and thereby rendering the pyloric extremity the lowest point. When there is softening of the intestines, with erosion and perforation, it invariably occurs in the loups lodged in the epigastric region, in close proximity with the stomach. Under no circumstance, at least so far as my observation extends, has this variety of mollescence been noticed in the lower portions of the digestive tube, or in the urinary bladder. The extent of the lesion is very variable, being either limited to a small portion of the stomach and bowels, or occupying the whole surface of the former, with a considerable portion of the latter. Oc- casionally, it is observed entirely in the intestines, which can only be explained on the assumption that the gastric acid, having left the stomach, has accumulated in inordinate quantity in the latter organs. When the softening is accompanied with perforation, it may extend to the oesophagus, liver, spleen, diaphragm, and even the lungs, all of which viscera may therefore be affected in the same individual, and exhibit various degrees of dissolution. The form in which the softening presents itself varies in different parts of the digestive tube. When confined to the fundus of the SOFTENING BY THE GASTRIC JUICE. 521 stomach, the lesion generally occurs in irregular patches, varying much in size, the edges of which are formed by the mucous mem- brane, and their surface by the subjacent cellular texture. Very generally the margins of the erosions are thin, soft, ragged, and trans- parent. When the softening penetrates beyond the muscular tunic, the margins are bevelled outwards, and terminate in delicate and irregular processes, which exhibit a tattered, shred-like appearance on being immersed in water. The same form precisely is perceived when the lesion affects the peritoneum. This patch-like softening usually takes place whenever the mucous membrane happens to be stretched; but should it be thrown into folds, it will assume a different shape, and occur in stripes and bands of a light bluish tinge, forming thus a striking contrast with the sound surface, which is either of the natural color, rosaceous, or of a light vermilion. These stripes and bands, it should be stated, always correspond with the situation and direction of the mucous wrinkles, the intervals between them being very slightly or perhaps not at all changed in their consistence; a circumstance which may easily be recognized by floating the parts in clear water. Occasionally, though very rarely, the softened membrane is of a light orange hue; and the vessels traversing it, if there be any, which, however, is not always the case, are filled with black blood, which, as I have repeatedly witnessed, is insusceptible of any change upon ex- posure to the atmosphere. Eedness of the affected texture is never observed; its existence being incompatible with the chemical action of the gastric acid. The degree of softening presents several important varieties. At first the membrane has very much the same consistence as in mol- lescence from inflammation ; but, as the process advances, it is gradu- ally converted into a grayish, pulpy substance, which can be easily re- moved with a sponge or by a stream of water, leaving the submucous cellular tissue of a dark silvery color. Instances occur, especially in young children, in which the membrane is reduced to the consistence of a hot solution of starch, arrowroot, or isinglass. The rapidity with which softening, erosion, and perforation of the stomach may take place in the human subject, is well illustrated in a case which I had an opportunity of examining along with Dr. Mount. It occurred in a female infant, seven weeks old, who was found dead one morning in her mother's arms, having expired apparently without a struggle. A month previously, this child had had a severe cough, which continued for eight or ten days, when it gradually abated. It was also harassed, every evening for several weeks, with regular paroxysms of retching and vomiting, attended with occasional colicky pains, and latterly with diarrhoea. On inspection, nine hours after death, numerous apoplectic effusions, from the size of a currant to that of a pea, were discovered in the pulmonic tissue, which, together with the universal engorgement, the injected condition of the bronchia?, the distension of the right cavities of the heart, and the absence of any structural lesion, save a slight degree of hepatization of the inferior lobe of the left lung, made it sufficiently clear that the child had died of suffocation. In the great 522 STOMACH. cul-de-sac of the stomach existed a rounded opening, with ragged edges, about the size of a dollar, through which had escaped a small quantity of mucus and gastric acid. The concave surface of the spleen was of a pale color and macerated appearance; the contiguous portion of the omentum was slightly softened, and perforated at two places. The mucous membrane around the opening in the stomach was of the natural complexion and consistence, nor was there anywhere the slightest sign of disease. SECTION IV. DISEASES OF THE STOMACH. 1. That ulceration of the stomach should occasionally occur, is not surprising when we take into consideration the great extent of its surface, the delicacy of its organization, the variety of its functions, its important sympathetic connections with other organs, and the heterogeneous nature of its contents. Yet, that this event is much less frequent than was at one time supposed, is abundantly proved by the general experience of the profession; at least it is so in this country. Extensively as I have been engaged in pathological re- searches, I have seldom met with this lesion, notwithstanding I have used the utmost care in cleansing and inspecting the mucous coat. Ulcers of the mucous membrane of the stomach are seldom either large or numerous. Most generally, indeed, there is only a single one, which is then, perhaps, of considerable size. Occasionally, however, they are extremely numerous, as in the case of a man of thirty-three, in whom I counted upwards of sixty. When they are seated in the glands of Brunner, as happened in the instance just referred to, they are almost always much smaller than when they affect the intervening texture, their magnitude rarely exceeding that of a split pea. In the other variety, they often attain the size of a Spanish dollar, especially when solitary; and instances are not wanting in which they are much larger. Not less variable are the shape and depth of these erosions. Their most common appearance is that of depressed breaches of continuity of the mucous corion, of a roundish form, with edges slightly elevated above the level of the internal surface. Not unfrequently, however, they are remarkably irregular, their margins being hard, thick, fissured, and even granulated. Appearances like these are especially observable in old chronic cases, but are very rare in such as are recent. We often see the edges partially undermined, so that, upon being floated in water, they present the ragged, shreddy aspect, so com- mon in ulcers of the large intestine. The bottom of the ulcer may be formed by the cellular tissue, or it may extend through this and the muscular layer, so as to lie upon the peritoneal covering. In the latter case, it is not uncommon for per- ULCERATION. 523 forations to take place, and for the'contents of the stomach to escape into the abdominal cavity or into some one of the neighboring organs. Most generally a communication is established with the arch of the colon, the walls of which, as the erosive process extends, are firmly cemented with those of the stomach, by means of lymph. In this way, the individual may sometimes live for years, with very little inconvenience. Oftentimes the bottom of the sore is hard and thick- ened, from the hypertrophous condition of the subjacent textures, or, as more rarely happens, from a deposition of small patches of lymph. Its color is usually pale; but it may be of a light rose tint, brownish, or crimson. Under hardly any circumstances is the base of the sore of so deep a hue as the edges. It has been already mentioned that ulcers of this organ are occa- sionally followed by perforation. Of fifty-one cases of this accident, analyzed by Mr. Edward Crisp, of England, thirty-nine were females and twelve males. Of the former, twenty-one were between fifteen and twenty years of age; ten between twenty and twenty-five; five between twenty-five and thirty; one was forty, one fifty, and one sixty. Of the males, only one was under twenty years of age. The aperture in the majority of the female patients was situated in the smaller curv- ature of the organ, more frequently between the pyloric and cardiac orifices, but in many instances near the latter. In one case only was the perforation close to the pylorus. In nine examples, two ulcers were present, being situated opposite to each other; so that, when the stomach was in a state of collapse, the diseased parts were in contact. The period which intervened between the perforation and the death of the patient varied from twelve to thirty hours. In one instance, life was prolonged for nearly three days. The lesion usually occurred a short time after a meal. Not the least interesting circumstance connected with the history of ulcers of the stomach is that they occasionally undergo a process of repair similar to the cicatrization of ulcers of the skin. The pos- sibility of such an occurrence was long questioned, but has been abundantly established by modern observation. I have myself seen several well-marked cases of it; among others, that of a young female, who had been laboring for a long time under all the symp- toms of chronic gastritis, attended with extreme emaciation. In the posterior wall of the stomach, nearly midway between the great tube- rosity and the pyloric extremity, was an old ulcer, about the size of a five franc piece, the edges of which were puckered, thickened, and completely cicatrized. All the tunics were destroyed; and the con- tents of the organ were prevented from escaping only by the manner in which it was glued to the anterior surface of the pancreas, which thus formed the bottom of the erosion. The rest of the stomach was per- fectly sound, excepting that its coats were much thinner than usual, and remarkably blanched. Such a repair, however, is always difficult, from the surface of the sore being constantly exposed to the irritating contents of the organ, by which the salutary efforts of nature must be very frequently baffled. The first step in the process is an effusion of fibrin, by which the loose 524 STOMACH. margin of the ulcer is tied to the subjacent parts. By degrees, a similar substance is deposited upon the bottom of the sore, which, in time, is transformed into a granulating surface, bathed with a thin muco-purulent fluid. Thus, day after day, the process proceeds until the cicatrization is completed, the ulcer in the mean time diminishing in size, and acquiring a bluish, puckered appearance. The new pro- duct, however, although it occasionally attains the consistence and thickness of the natural membrane, is yet essentially different, being less smooth, less vascular, more easily destroyed by subsequent attacks of disease, destitute of follicles, and, therefore, incapable of secreting real mucus. No part of the stomach is exempt from ulceration. It would seem, however, to occupy the posterior surface more frequently than the anterior. In 220 cases, analyzed by Dr. Brinton,1 the ulcer occupied the posterior surface of the stomach in 86; in 55 its lesser curvature; in 32 its pyloric extremity; in 13 its anterior and posterior surfaces, often at two opposite places; in 10 its anterior surface only ; in 5 its greater curvature; in 4 its cardiac pouch. The exact cause of this lesion is still involved in obscurity. It is generally accompanied by chronic gastritis, and is supposed by some to commence with a circumscribed red softening of the mucous membrane, whilst others believe it to be merely the result of a defective local nutrition. I am accustomed to look upon it as the result of inflammation, although there is every reason to believe that this is very often not only re- markably tardy in its progress, but of an extremely low grade. Ulcers of the stomach affect more frequently the female than the male sex. They are rarely observed after the age of thirty-five, and occur more usually in the poor than in the rich. Needlewomen and maid- servants, between the ages of eighteen and twenty- five, seem to be particularly liable to them.2 Ulcers of the stomach may end fatally by inducing ex- haustion, hemorrhage, or perforation. Ulcers of the stomach are sometimes produced by the presence of a foreign body, as a needle, pin, or piece of bone, fixing itself in its coats. The ad- joining cut (Fig. 181), copied from a preparation in my cabinet, exhibits such an occurrence from the effects of a pin, which is seen lying across the ul- cer, which was of a circular shape, and hardly a line in diameter, with hard, almost callous, edges, well rounded off by the process of repair. The collection. ulcer had perforated the different tissues of the stomach, the contents of which were prevented from escaping by the adhesion of the organ to the colon. 2. Hypertrophy of the stomach is by no means so uncommon as was formerly supposed. Excepting the peritoneal, it may invade all the tunics simultaneously, or be confined to a single one, which is, in fact, Fig. 181. Ulcer from a From a of the stomach pin in its walls. specimen in my 1 Brit, and For. Med.-Chir. Review, January, 1856. 2 Budd on Diseases of the Stomach, London, 1855, p. 98 Am. ed. HYPERTROPHY. 525 most generally the case. Sometimes the enlargement mainly attacks the mucous follicles, giving the internal surface of the organ a rough, mammillated fulness, the widened orifices of the glands identifying the seat of the affection. This state of the mucous membrane of the stomach is caused by chronic inflammation, and is often observed in phthisis, in diabetes, and in chronic disease of the bowels. The mam- millated prominences, which are generally of a rounded, conical shape, and from the size of a large pin-head to that of a currant, strongly resemble the granulations of an old ulcer, and are occasionally sepa- rated by deep narrow grooves, running in different directions. Their length is subject to much variety. In some instances, it does not exceed half a line; in others, it is more than a third of an inch. In my own dissections, I have invariably found this mammillated appear- ance of the mucous coat most conspicuous in the inferior half of the organ. The mucous membrane in this affection is usually of a pale reddish tint, like the surface of an indolent ulcer; occasionally, it is almost white, grayish, or drab-colored. In most cases, it is abnormally firm and thick, allowing itself to be raised in large shreds. The villosities are also sometimes much augmented in size, and truly hypertrophous. To the same class of lesions are to be referred those singular look- ing warty excrescences which are sometimes observed upon the mucous membrane of the stomach. Their shape is generally rounded; their size is inconsiderable; and, in most cases, they adhere by a narrow foot- stalk, of considerable length. Much diversity prevails in regard to their internal structure, which is sometimes fibrous, sometimes fun- gous, sometimes vascular and erectile. Their color varies in-different cases, being for the most part grayish, but occasionally reddish, brown- ish, or blackish. Hypertrophy of the submucous tissue is characterized by consider- able thickening and induration, with or without change of structure of the other tunics: the areolar texture is destroyed, and replaced by a dense albuminous substance, which may be so firm as to prevent the stomach from collapsing when opened. There is some variety in the color of the affected part. Occasionally it bears some resemblance to a mixture of beeswax and tallow; more commonly, however, it pre- sents the appearance of a piece of well-boiled tripe, with some sections of it more transparent than others. The hypertrophy is not always limited to the submucous cellular tissue. Cases are frequently met with in which it involves the subserous substance, and even that be- tween the muscular fibres, rendering the latter pale and thin, or else remarkably large and distinct. Hypertrophy of the muscular coat varies in different cases. It may be very slight—perhaps hardly perceptible—or it may amount to an enormous degree, both as regards its thickness and the extent of sur- face which it occupies. It rarely pervades the whole organ; on the contrary, it usually occurs in considerable sized patches, either alone, or in union with hypertrophy of the cellular tissue. In this affection, the muscular fibres are uncommonly large and distinct, hard, more dense and florid than in the natural state, forming frequently thick, 526 STOMACH. membranous intersections, and producing an appearance not unlike that of the inner surface of the heart. The individual fasciculi are often several lines in diameter. In most instances of this species of hypertrophy, the patient labors under cancer, or some other disease which forces the organ habitually to reject its contents. It is also sometimes noticed in great eaters. 3. Atrophy of the stomach is usually caused by protracted absti- nence, cancerous affections, or protracted pressure, as from an en- larged spleen, liver, or omentum, thus impeding the process of nutri- tion and of innervation. It is characterized by remarkable pallor and attenuation of the organ, which is reduced to a soft, flabby sub- stance. The peritoneal covering seems as if it had been bleached; the muscular fibres are scattered, and almost colorless; and the mucous membrane is diminished in thickness, pallid, deprived of its villosities, and scarcely capable of being separated from the subjacent textures. A degree of atrophy like this, however, is extremely rare. Partial attenuation is more commonly observed at the great cul-de-sac than in any other portion of the stomach. In several instances, I have also seen it just below the cardiac extremity. 4. Dilatation of the stomach may arise from excessive gluttony, or from the effects of protracted disease, especially of the pylorus. The affection presents itself in various degrees, and may, or may not, be associated with hypertrophy or atrophy of the several coats of the organ. One of the most remarkable cases of dilatation of the stomach that I have ever witnessed came under my observation, in 1854, in a married lady, twenty-eight years old, where the immediate cause seemed to be paralysis of the muscular fibres, preventing the viscus from contracting upon its contents, and producing death by constitu- tional irritation. The patient had been long dyspeptic; and one day, soon after making a hearty meal upon strawberries, she was seized with violent colicky pains, attended with excessive nausea, but ina- bility to vomit. A large tumor existed in the epigastric region, extending over into the left side and nearly down to the umbilicus; it felt hard, and was quite tolerant of manipulation. The bowels were obstinately constipated. She expired in less than a week from the commencement of the attack. On dissection, the stomach was found to be immensely enlarged, and to contain upwards of a gallon of in- gesta. Its tunics were entirely free from inflammation, nor was there any evidence of disease in any of the other viscera. It is astonishing to what extent the dilatation of this organ may sometimes proceed. In a case observed by Dr. Yvan, of Paris, the length of the great curvature was three feet, the circumference at the widest part twenty inches, and the capacity nearly a gallon and a half. The muscular fibres, longitudinal as well as circular, although considerably attenuated, were quite distinct throughout the greater part of the viscus. The organ lay parallel to the axis of the body, and was of a constricted, hour-glass figure, one part being situated in the abdomen, the other in a large scrotal hernia. 5. Inordinate contraction of the stomach is occasionally met with, chiefly as a result of stricture of the oesophagus, or of the cardiac ex- TUMORS. 527 tremity of the viscus. Protracted abstinence may also induce it. The occurrence is usually associated with atrophy, and may be so great as to diminish very seriously the capacity of the organ for the reception of food and drink. 6. A part of the stomach is occasionally converted into a pouch, produced, apparently, by a rupture or separation of some of the mus- cular fibres, and a consequent protrusion of the mucous membrane. In this manner a sac may be formed, capable of holding several ounces, and looking very much like a supplementary reservoir. Such pro- ductions have no definite shape; they are met with chiefly along the great cul-de-sac of the organ, and their walls are usually very thin, consisting exclusively of the mucous and peritoneal investments. 7. Pieces of fibro-cartilage are sometimes found in the stomach, either between the mucous and muscular tunics, or between the latter and the peritoneal. Of a pale grayish, or bluish aspect, they are of a dense gristly texture, grating sensibly under the knife, of an irregular shape, and of variable extent, from that of a split pea to that of a twenty-five cent piece and upwards. Occasionally the new substance presents itself in the form of irregular nodules, projecting into the cavity of the reservoir beneath the lining membrane. In cases of long standing the deposit is sometimes partially ossified. 8. Various kinds of tumors, benign and malignant, occur in the stomach. The older writers have much to say about steatomatous growths of this organ, which they describe as being always encysted,. and as containing a semi-concrete substance, resembling suet, tallow, or soft wax. Few modern observers have met with such cases, and still fewer believe in their existence. Kuysch possessed a tumor which consisted of hair and teeth that had been taken, after death, from a cyst in the coats of a man's stomach. Polypoid growths of this organ are very rare. Of a reddish color and of a firm consistence, they are usually of an ovoidal figure, of a fibroid structure, somewhat rough on the surface, and from the size of a hazel-nut up to that of an orange; their attachment being generally effected by a short, slen- der pedicle. 9. The stomach is more liable to carcinoma than any other portion of the alimentary canal, except the rectum. The disease is al- Fig. 182. most peculiar to old age; and ,i 528 STOMACH. the original structure. In some instances the diseased mass exhibits a peculiar cauliflower arrangement, as in the accompanying cut, from the stomach of an old man of sixty-three, preserved in my cabinet. This form of cancer, however, is very uncommon. In the case adverted to the disease had existed nearly four years before it proved fatal. In general the malady appears in the form of distinct tumors, or nodules, varying in volume from a small nut to a goose's egg. With a surface that is often very rough, irregularly mammillated, or marked off into numerous lobules, they are found to exhibit a great variety of texture, some parts being fibrous, some fibro-cartilaginous, some osseous, some mammary or lardaceous, some fungoid, some medullary, some gelatiniform, and some haematoid. It is seldom, however, that these substances are thus combined. Commonly, indeed, not more than two or three coexist, and in many cases they occur separately. The most common form is the scirrhous or fibrous, next the medullary, or a mixture of the two; the least frequent of all being the colloid. The cancer often commences as a fibrous substance, and afterwards, as its development proceeds, other textures are superadded, or such as pre- viously existed are partially transformed. Cancer of the stomach is almost always a primary disease; the neighboring lymphatic glands and the pancreas may become secondarily involved. The first depo- sits generally occur in the submucous tissue, which is usually dense and of a dull color. The mucous membrane, in carcinomatous disease of the stomach, is variously affected. In general it is very much thickened—sometimes as much as a fourth of an inch—indurated, elevated into irregular masses, and of a light grayish color. Occasionally it is of a dull yellowish, greenish, or light mahogany tinge, soft, pulpy, or almost brain-like, vascular, ulcerated, or partly destroyed. Several of these morbid alterations are generally met with in the same specimen. The muscular fibres are unnaturally distinct; and the peritoneal tunic, although it does not always participate in the disease, is often much thickened, and almost of a gristly consistence. The various changes experienced by these structures are well illustrated in the adjoining cut (183). The stomach is com- FiS- 183- monly diminished in its capacity, and contains a very offensive gas, with a small quantity of dark colored fluid, like coffee-grounds. d <5!?^j^i(WBP decine, t. viii. p. 494; Andral, Path. Anat., vol. ii. p. 92. INTERNAL STRANGULATION. 551 Fig. 188. the patient dies with all the symptoms of strangulation from ordinary causes. b. Tumors are sometimes developed within the canal, and these, by obstructing the course of the feces, may lead to the same result as disease seated among the tunics of the bowel. A polype of the rectum has been known to produce death by arresting the contents of the tube,1 and similar effects occasionally follow the formation of an intestinal concretion. c. Mr. Howship2 relates a case in which the strangulation was caused by the pressure of an ovarian tumor upon the rectum, where the latter passes over the brim of the pelvis. The patient was fifty-two years old, and the tumor contained between six and seven pints of serum. The whole of the bowel above the seat of the obstruction was dilated, congested, and filled with fluid matters, as in strangulated hernia. d. It is not improbable that fatal obstruction of the bowel might be produced by a fibrous tumor of the uterus, or by the uterus itself, when much enlarged and partially dislocated, as in retroversion. Simi- lar effects might result from the presence of a morbid growth of the pelvis and from a distended Fallopian tube. Dr. Hoescher,3 of Hanover, has published a case of intestinal strangu- lation produced by hypertrophy of the pancreas. The organ had grown to the size of the head of a four months' foetus, and had so inclosed the duodenum for about three inches of its length that it would not admit of the passage of a goose-quill. VI. The sixth species of internal stran- gulation is produced by what is termed intussusception. This consists in the in- vagination of one portion of bowel within another, thereby filling up its cavity, and usually dragging along with it a portion of the mesentery. To this variety of internal strangulation belongs the very remarkable case recorded by Martin Solon," in which a coil of intes- tine was intercepted by getting into a perforation in another coil. Although there is, generally speaking, only one invagination, yet there may be as many as three or four. Much diver- sity obtains respecting the length of the included portion (Fig. 188). Most com- monly it does not exceed two or three inches; in other cases, however, it may be as much as one or two feet. Dr. Intussusception of the small bowel. From a preparation in my collection. 1 Voigtel's Handbuch der Path. Anatomie, B. ii. p. 649. 2 Op. cit., p. 257. 3 Hannoversche Annalen, Heft ii. 1840; Brit, and Foreign Med. Rev., xii. p. 538. 4 Bulletins de la Societe Medicale d'Emulation pour 1822. 552 SMALL BOWEL. Abercrombie makes mention of a case, in which the inverted intestine measured thirty-eight inches; and instances are to be found in which nearly the whole of the large bowel, together with a considerable por- tion of the small, was thus invaginated, the ileo-caecal valve descending as low as the anus. Sometimes, though very rarely, there is a double intussusception, one inverted portion of intestine slipping within another. The included portion of bowel may be variously affected, and give rise to the most disastrous results. In children, in whom this lesion is much the most frequent, the invagination is occasionally disentangled, either by the natural energy of the muscular fibres of the intestine, or by the influence exerted upon them by purgative remedies. When the incarceration continues for any length of time, the part usually manifests strong signs of inflammation, and either contracts adhesions to the surrounding gut, or else it dies, and is evacuated. In this way may be discharged large pieces of the alimentary tube, and the patient live for years afterwards, in the enjoyment of perfect health. In the former case, that is, when the bowel remains invaginated, its coats are very apt to become thickened, and to lay the foundation of permanent stricture. The length of the eliminated part is various. In my private collec- tion is a piece of the colon, twenty-nine inches long, which was pre- sented to me by Professor John Dawson, of Ohio, and passed by a child six years of age, who, notwithstanding, speedily recovered. In thirty-five cases, collected from different sources by Dr. William Thomson,1 the length of the evacuated pieces varied from six inches to upwards of three feet. They generally involved the entire cylin- der of the bowel, and nearly all had a portion of mesentery attached to them. The average duration of the disease was between four and five weeks. In twenty-two of the cases, the eliminated portion apper- tained to the small bowel, in the other, to the large, or jointly to this and to the former. The caecum alone was affected only in a single in- stance, the colon in two, the jejunum in three, the ileum in eleven. Intussusception may take place in any part of the alimentary canal, but is most common in the ileum, near its insertion into the colon, owing, doubtless, to the great difference of size between these two portions. Another fact deserving of notice is that the invagination does not always occur in the natural direction of the intestine, but sometimes from below upwards; which sufficiently disproves the theory, at one time so much in vogue, that this complaint is always caused by one part of the tube falling within another, simply by its weight. Concerning the proximate cause of this disease very little is known. It may be conjectured that it is in some way or other connected with inequilibrious action of the muscular fibres, by which one portion of bowel, contracting energetically, forces itself within another that is stationary, fixed, or passive. There is a species of intussusception very different from the one just described, inasmuch as it is entirely unattended by inflammation. J Edinburgh Medical and Surgical Journal, October, 1835. HERNIA. 553 I have repeatedly observed it in young children, as well as in adults; and, so far as I can judge, it appears to occur during the last struggles of life, from some irregularity in the peristaltic movements of the muscular fibres. The invagination in this variety of the lesion is always limited, according to my experience, to the small bowel. Of the great frequency of this occurrence some idea may be formed when it is stated that, out of three hundred children, opened at the hospital of Le Salpetriere in Paris, the great majority of them had three or four intussusceptions.1 No symptom of inflammation or other disease of the alimentary tube attended. The number of inva- ginations generally varies from two to five or six. In one instance, that of a child, eight years of age, I counted as many as eleven; and Mr. Burns, of Glasgow, on one occasion met with not less than forty- seven. From the fact that this affection usually occurs either just before death, in the act of dying, or within a few moments after dis- solution, before the muscular fibres have parted with their irritability, it may be denominated the cadaveric variety of intussusception, in contradistinction to the other, which is called the inflammatory. 14. Hernia.—Of hernia there are several distinct varieties, both as regards the contents of the tumor and its situation. The most com- mon place of rupture is at the inguinal and crural rings. Cases, how- ever, are often witnessed in which the bowel protrudes at the navel, or some other part of the abdominal wall; and, in a few rare instances, it has been known to pass into the thorax, through an opening in the diaphragm. There is also a species of rupture in which the intestine descends into the scrotum, in consequence of imperfect closure of the inguinal canal. This constitutes what is termed congenital hernia. The bowel in this case lies in the vaginal sac, and the manner in which it gets there may be easily explained by reference to what takes place in the descent of the testicle. Until the end of the seventh month of utero-gestation, this organ is situated in the pelvic cavity, immediately beneath the kidney. About this period it begins to advance towards the abdominal canal, along which it passes, until it finally reaches the scrotum, carrying with it a tubular process of peritoneum. As the descent is being completed, the serous sac is gradually obliterated, the communication between it and the abdomen being thus closed. This usually occurs a few weeks before the child attains its maturity. But it is not always that things proceed thus. In many cases the abdomino- scrotal sac remains open through life, and allows the bowel to pass down in contact with the testicle, forming the variety of hernia in question. To enter into a minute detail of everything relating to these dif- ferent varieties of hernial tumors, would be inconsistent with the scope of this work; I shall therefore limit myself to a few remarks respecting the morbid appearances which are usually witnessed in the protruded parts. In the congenital hernia, the mechanism of which has just been described, the intestine generally retains its natural characters, ' Dunglison's Commentaries on Diseases of the Stomach and Bowels of Children.— Amer. Med. Record., vol. viii. p. 139. 554 SMALL BOWEL. with the surrounding sac scarcely at all altered; and hence, when the patient assumes the recumbent posture, it always has a tendency to glide back into the cavity of the abdomen, descending again when he rises. In chronic cases, however, although the protruded parts them- selves may not be particularly affected, the sac, in consequence of the yconstant pressure that is exerted upon it, is apt to become indurated *and thickened, from the deposition of lymph. Shreds of the same substance occasionally adhere to the inclosed bowel, and, by gluing it fast, prevent its return into the abdomen. Similar appearances are sometimes witnessed in the other varieties of long-standing ruptures. In such cases, the sac is often as much as the eighth of an inch in thickness, and evidently consists of a number of well organized layers. The shape of the bag is either oval, rounded, or, more usually, pyri- form, the narrower part being above, the broader below. The neck is sometimes quite long, and so narrow as to allow only a small fold of intestine to pass out at a time. The outer surface of the sac is rough and irregular; the internal smooth, polished, and slightly lubri- cated by serosity. Such are the ordinary appearances to be observed in old and congenital ruptures. In recent ruptures, the sac is generally thin and opaque, differing very little from healthy peritoneum. When strangulation occurs, a new state of things supervenes. Fig-189- For not only does the sac evince signs of inflammation, but the protruded part, whe- ther it be bowel or omentum, is so excessively irritated that it frequently mortifies, whilst the patient either dies, or is doomed to drag out a wretch- ed existence with an artificial anus. 15. Abnormal Pouches.— Sac like tumors, cysts, or pouches are sometimes found in the bowel, caused by pro- trusion of the mucous and cel- lular tunics across the muscu- lar fibres, in the same manner as pouches are occasionally formed in the urinary bladder. Situated chiefly along the me- senteric border of the intestine, they are of a rounded, spherical shape, and vary from the size of a pea to that of a walnut. Some of the larger sacs are occasionally pyriform, or pediculated. Their number ranges from one to several dozens. Their contents are usually of a gaseous character, since their orifice of communication is rarely large enough to admit of the passage of fecal matter. These sacs may form in almost any portion of the intestinal tube. Professor J. B. S. Jackson, of Boston, informs me that he has met with WOUNDS. 555 Fiff. 190. Fig. 191. them most frequently in the large bowel, in aged and corpulent persons. Their development seems to depend upon some mechanical obstacle to the passage of the fecal matter, by which the muscular fibres are sepa- rated from each other so as to permit the mu- cous and submucous membranes to protrude through the resulting intervals. The accom- panying sketch (189), affords a good idea of the nature of this affection. 16. Wounds.—The first circumstance to be observed in a wound of the bowel is the eversion or protrusion of the mucous membrane (Fig. 190); this takes place in all injuries of this kind, and is similar, in its effects, to the contraction and retraction of the extremities of a divided artery. Its object evidently is to diminish the opening, and thus prevent fecal effusion. This eversion of the mucous membrane never occurs in ulcerative perforation of the bowel. In this affection the morbid action generally proceeds in a slow and gradual man- ner, at the expense mainly of the mu- cous and fibrous lamellae, which are always destroyed to a much larger extent than either the muscular or peritoneal. Hence, by the time the ulcer reaches the surface, it is impos- sible for the lining membrane to pro- trude across it, as it does when the bowel is wounded by a sharp instru- ment, a blow, or a kick. Another cir- cumstance which no doubt contributes to produce this result, is the indurated condition of the serous and muscular layers immediately around the perfo- ration, caused by the deposition of lymph during the progress of the ulce- rative action. If a small circular ligature be drawn firmly around the bowel of a dog, or other animal, the resulting effects will be very similar to those which attend the ligation of an artery. (Fig. 191.) The opposite surfaces will not only be forced into close contact with each other, but it will produce at the same time a complete division coat. If the cord be pulled very tightly, there will especially in young subjects, a partial separation of the cellulo-fibrous lamella and of the muscular fibres. These effects I have repeatedly witnessed in my experiments on dogs, and they may be readily pro- m of the mucous be, in addition. 556 SMALL BOWEL. duced in the human body after death.1 If a flat ligature be used, even when it is drawn with considerable firmness, the opposite surfaces of the tube are merely brought into contact, without any rupture of the substance of any of the tunics. The only exception to this is where the animal is very young and the parietes of the bowel are unusually tender; in which case there will be occasionally a slight division of the lining membrane, but not of the muscular fibres. When a nar- row ligature is used, the parts above and below it are so closely ap- proximated that they touch in the greater portion of their circumfer- ence ; a circumstance which must necessarily exert a most favorable influence over the reparative process and the re-establishment of the continuity of the canal. Soon after an operation of this kind, with a narrow circular liga- ture, inflammation is set up, plastic lymph is deposited upon and around the constricted parts, ulcerative action is established, and the cord at length works its way into the intestinal tube, where it is dis- charged along with the feces. The period required for the detach- ment of the ligature' is influenced by various circumstances, the principal of which are referable to the form and size of the foreign substance, together with the force with which it is applied, the thick- ness of the different tunics of the bowel, the age of the subject, and the state of the general health at the time of the operation, as well as immediately after. In a small but full grown dog, killed at the end of the third day after the experiment, the ligature, which was round and narrow, had found its way through more than one-half of the circumference of the tube; and in another animal of the same kind, which died from the effects of the operation thirteen hours later, the progress of the foreign body was still greater. In the latter, indeed, the cord had entirely disappeared, having lost its hold, and escaped into the bowel, in which, after a minute examination, it was discoverd at the distance of several feet from the seat of the injury, surrounded by fecal matter. In bothcases the continuity of the parts was thoroughly re-established by an abundant deposition of lymph, which, notwith- standing the brief period that had elapsed, exhibited already well- marked traces of organization. The bowel, however, presented in each instance a constricted appearance; and in one of the animals, that, namely, which was killed at the end of the third day, the opposed mucous surfaces were still in close contact, no attempt having appa- rently been made to restore that portion of the tube. In the other the parts were not only perfectly continuous with each other, as has just been intimated, but the cavity was partially re-established. In a third experiment, performed on a middle-sized dog, not more than eighteen months old, the ligature was found lying at the seat of the constriction, where it was retained by a layer of plastic lymph, which had sealed up, as it were, the surface of the fissure in the mu- cous tunic. The canal of the bowel was completely restored, and the bond of connection between the divided parts firm and organized. 1 See my " Experimental and Critical Inquiry into the Nature and Treatment of Wounds of the Intestines," Louisville, 1843. WOUNDS. 557 The animal was killed on the eleventh day. These appearances are exhibited in the subjoined cuts. Fig. 192 is the outer surface of the tube; Fig. 193, the internal, with the ligature in situ. Fig. 192. Fig. 193. Fig. 194. The lymph which is effused upon the external surface of the bowel, consequent upon the operation, gives the part at first a rough uneven appearance; but it gradually undergoes a sort of modelling process, and hence, if the animal survive several months, it is generally no easy matter to determine the seat of the injury. In a dog killed four months after the experi- ment, the reparation was so perfect that, had it not been for the attachment of a small pro- cess of omentum, it would have been im- possible, by mere external inspection, to dis- cover the place where the cord was originally applied, such were its smoothness and polish. Nor was this confined solely to the outer sur- face of the tube. Internally the cicatrization was almost as complete, the continuity of the mucous membrane having been everywhere re-established. There was the merest possible seam at the original seat of the constriction. (Fig. 194.) Effects similar to the above are produced when a ligature is applied around the edges of a small wound, that is, from two to three lines in diameter provided it be drawn with sufficient firmness not to slip off. The cord gradually cuts through the different coats of the bowel and the continuity of the canal is re-established by the effusion of plastic lymph upon the constricted part. The process of reparation, however, is not so speedily completed, owing to the breach being much wider than when a ligature is simply cast around the tube. _ In this case the mucous membrane is reproduced only after a long time, d the amount of lymph required is proportionally much greater. an The lio-ature is detached at a period varying from five to ten days. 558 SMALL BOWEL. Wounds and punctures of the bowel, unaccompanied by the effusion of fecal matter, heal, when left to themselves, either by the adhesion of their edges to the surrounding-parts, or by the deposition of lymph upon their surface and the gradual approximation of their lips. In the majority of cases the reparation is probably effected by the former method; since there is always a great tendency in the wounded struc- tures to attach themselves to those in their immediate vicinity. Even wounds of large size are occasionally repaired in this manner. In some instances, again, the breach is closed by a piece of omentum, which projects into it, and fills it up like a tampon. When this happens the serous membrane is firmly fixed to the edges of the opening, and the part which corresponds with the interior of the canal and assists in maintaining its continuity, is eventually absorbed; an occurrence which leads to the gradual approximation of the lips of the wound and their ultimate reunion. In mortification of the bowels, especially when occurring in small patches, the mode of reparation appears to be similar to that which takes place when a wound or puncture is left to itself. By the time the eschar is detached the edges of the breach will have formed ad- hesions to the circumjacent parts, by which the effusion of fecal matter will be effectually guarded against. Where this is prevented the pa- tient dies from peritoneal inflammation, or an artificial anus is esta- blished. When sutures are employed, the mode of reparation is essentially similar, whatever may be their form. The inflammation which is lighted up induces an effusion of lymph, which is speedily followed by adhesion of the injured coil to the neighboring structures, among which it is sometimes completely buried. At other times no such adhesion occurs, but the affected part throughout the entire line of suture is coated with a layer of plas- Fig- 195- tic matter, by which the continuity of the serous surface is finally re- established, and the threads used in sewing up the wound are concealed from view. In almost all cases— certainly in eight out of ten—there is an attachment of the omentum to the surface and edges of the wound, which thus assists, in a remarkable degree, in the process of restoration. (See Fig. 195.) This extraordinary tendency to adhesion in the external surface and edges of the wound to the parts around it, is nothing more than what might be expected when we reflect upon the nature of the peritoneum, and its invariable disposition, when inflamed, to pour out lymph. But it is otherwise with the mucous membrane. Here the process of reunion is not only much slower, but much less perfect; lymph is furnished very sparingly, or WOUNDS. 559 in quantities barely sufficient to fill the chasm between the margins of the wound; and, owing to the heterogeneous and irritating nature of the contents of the tube, a long time must necessarily elapse before it can become an organized or living intermedium. The little narrow band thus formed adheres firmly to the bottom of the wound, but very slightly, if at all, for some days, to its edges. Gra- dually, however, it becomes more and more dense; vessels extend into it from the circumjacent parts; its margins are flattened down; and, after a period varying from a few weeks to as many months, the adhesion is finally completed. Subsequently, or, indeed, while the changes just adverted to are still in progress, the new matter is nearly all absorbed, the wound greatly diminishes in width, and when the cicatrizing process is perfected, merely a small depression or seam remains, to indicate the original seat of the injury. The whole pro- cess may be compared to that which nature employs in the reparation of ulcers of the mucous lining of the small and large bowel. (See Figs. 196, 197.) Fig. 196. Fig. 197. This, however, is only one mode in which the restoration of the mucous surface is effected. Another, though by no means a frequent one, is by granulation. It has been already stated that, owing to the irritating and heterogeneous character of the contents of the bowel, the lymph which is deposited upon the wound is very tardy in becom- ing organized, and it may now be added that this process is occasionally entirely prevented, the substance in question being either destroyed or removed by the fecal matter, as it passes over the affected part. When this happens, nature makes an effort to repair the breach by the forma- tion of granulations, as in similar injuries of other textures. The process under these circumstances is generally much more tardy than in the previous case, the cicatrization is also less complete, and the tube is much more apt to be puckered immediately around the seat of the injury. From the foregoing observations it is evident that the process of reunion is the same, whether the bowel be encircled partially or wholly 560 SMALL BOWEL. by ligature, whether we employ sutures, or, lastly, whether the wound, provided it be not too ample, be entirely intrusted to the resources of nature. In each case the restoration is effected through the medium of plastic lymph, poured out as a consequence of inflammation, and undergoing, sooner or later, a certain degree of organization. The manner in which the ligatures are detached varies, according to the mode in which they are applied. Both in the interrupted and continued sutures, with their different modifications, the threads, if cut off close to the surface of the wound, invariably fall into the alimentary canal, along with the contents of which they are afterwards evacuated. This, indeed, may be laid down as a law, to which I have seen no exceptions in upwards of eighty experiments on dogs. The same circumstance, as was previously intimated, occurs when a ligature is cast around a loop of intestine, or when it is employed to encircle the margins of a small aperture, whether caused by injury or mortification. If, on the other hand, the extremities are permitted to hang out at the external wound, they will be discharged outwardly, instead of inwardly, as in the former case. 16. Artifical Anus.—Artifical, accidental, or preternatural anus may occur in any part of the abdomen; but, as it is generally produced by gangrene of the bowel, from the pressure which is exerted upon it by hernial stricture, it is by far most frequently met with in the inguinal, scrotal, femoral, and umbilical regions, particularly the first two. For the same reason we find that the small intestine is much oftener in- volved than the large, which is fixed or attached, while the former is loose, floating, and consequently more liable to protrusion. Occasion- ally, though rarely, the abnormal anus has its seat in the lumbar region, high up in the iliac, the hypochondriac, or even the epigastric. Three causes mainly give rise to this affection, namely, strangulated hernia, accompanied with mortification of the bowel, penetrating wounds, and stercoraceous abscess; the frequency of their occurrence being in the order here enumerated. The external orifice of an artificial anus exhibits no uniformity in respect to its size and configuration. In many cases it is rounded, in some ovoidal, and in most irregular. In its diameter it varies from a few lines to an inch and a half or even two inches; being usually smaller in traumatic cases, or in such as result from penetrating wounds, than in those which are produced by ulceration, abscess, and especially by gangrene. The margins of the opening are thick, bevelled, depressed, or inclined towards the centre, where they are in close contact with the mucous membrane of the two ends of the bowel, the junction between them being indicated by a reddish line; they have a raw, flesh-colored appearance, and are covered with numerous granulations, which are often very painful, and so irritable as to bleed upon the slightest touch. The depth of the outer orifice, or the distance between the skin and the bottom of the intestinal aperture, varies from three to twelve lines. It is always less when the disease is produced by a wound than when it is caused by gangrene; much will also depend upon the natural ARTIFICIAL ANUS. 561 thickness of the wall of the abdomen, and the degree of plumpness or emaciation of the individual. The external orifice is occasionally multiple; that is, instead of a single opening there are several. In this case there are usually fistulous tracks, which communicate with the main outlet, and some- times even writh each other. The union between the two ends of the bowel and the circumference of the outer orifice is effected through the medium of plastic matter, and constitutes an indispensable element of the lesion. The inflam- mation, preceding and accompanying the effusion, always begins in the serous surfaces of the parts, from which it gradually extends to the other structures, us the mucous membrane, the muscles, cellu- lar substance, and skin. The plastic matter, soft and glutinous at first, is soon organized, and thus opposes an effectual barrier to the effusion of fecal matter into the abdominal cavity. Subsequently it undergoes all the changes that lymph experiences, under favorable circumstances, in other situations. The extent of this adhesion varies, in different cases, from half a line to a line; it rarely amounts to half an inch, or, indeed, even the fourth of an inch, and in proportion as it is firm or otherwise will it be able effectually to resist the influence of such causes as have a tendency to separate the gut from the wall of the abdomen. When the artificial anus supervenes upon strangulated hernia, the formation of these adhesions usually precedes the death of the bowel; in the traumatic variety of the affection, on the contrary, they are established after the reception of the injury, and hence the greater frequency of fatal effusion in the latter than in the former. As the adhesions extend only a small distance along the gut, a cul-de-sac is formed, the opening of which looks towards the belly, and into which the abdominal viscera may protrude, so as to complicate the disease. Immediately around the inner margins of the outer Orifice are, as was previously stated, the two ends of the bowel; lying generally side by side, like the tubes of a double-barrelled gun. Each opens by a distinct orifice, of which the upper, in time, becomes much the larger; they are bounded by a sort of villous rim, are irregularly rounded in their form, and are separated from each other by a septum or partition. The upper orifice gives passage to the feces, and, as it is unprovided with a sphincter muscle, the patient has no control whatever over their escape. The lower orifice, of the same size at first as the upper, is generally very narrow, puckered up, and some- times even difficult to be found, especially when it has ceased for a long while to receive fecal matter. The upper opening is temporarily closed when the corresponding extremity of the bowel is touched with a probe or finger, or exposed to a few drops of cold water. When thus irritated it presents very much the appearance of the anus of the horse, the mucous lining being everted and corrugated by the peris- taltic action of the muscular fibres. The two ends of the bowel, at first similar in size, by degrees undergo important changes. The upper continually giving vent to feculent matter, bile, mucus, and even ingesta, receives a preternatural 36 562 SMALL BOWEL. quantity of blood, and henccgenerally acquires a considerable increase of volume and strength; its coats are thicker than in the normal state, the muciparous follicles are larger, the lining membrane is of a deeper red, and the peristaltic action is inordinately energetic. The lower extremity, on the contrary, having no longer any active function to perform, falls into a state of atrophy. Its tunics are pale, flaccid, and attenuated, its caliber is considerably diminished, though not obliter- ated, and its mucous glands are wasted and almost imperceptible. The canal contains a soft, whitish, gelatinous looking substance, which is evidently the product of an imperfect secretion, and which is voided by stool at intervals of two, three, or four months. The intestine, notwithstanding these alterations, still preserves its tubular form, however long the feces may have been discharged through the abnor- mal aperture. This atrophy or wasting is not confined to the lower portion of the bowel, but often affects the corresponding part of the mesentery and even the lymphatic ganglions. As might be supposed, it is always more marked in old than in recent cases. In artificial anus, caused by a gangrened rupture, the two ends of the bowel are surrounded and closely embraced by a sort of mem- branous pouch, to which the term funnel is applied. It is formed by the prolongation of the peritoneum which constituted the neck of the hernial sac, and varies very much in its shape, dimensions, and direction, its base being at the bowel, and the apex at the skin. It is generally very firm and dense in its structure, and from one to two lines in thickness, according to the extent of the previous inflam- mation; externally it is intimately united to the margins of the abnormal opening, and internally it presents a smooth, villous sur- face, not unlike that of an old fistulous track. The feculent matter from the upper orifice is poured into this cavity, and thence, when the artifical anus is closed, it is carried, after describing a half- circle, into the lower end of the canal. This membranous pouch is always wanting when the disease is the effect of a penetrating wound, and occasionally even when it is the consequence of a gangrened her- nia : in both cases the gut adheres immediately to the edges of the opening in the muscles and integuments. The most interesting cir- cumstance connected with this funnel-shaped cavity is the influence which it exerts upon the reparative process, or spontaneous cure, which is always so much the more prompt and perfect in proportion as it is larger and longer. Interposed between the two extremities of the intestine, and formed by the juxta-position of their sides, is what is technically called the ridge, septum, or partition, of the artificial anus. (Fig. 198.) It consists of two angular or crescentic folds composed each of four lamellae, of which the inner two are of a serous nature, and firmly united together by plastic matter, for an extent varying from one to six, eight, or even twelve lines. The outer layers are of a mucous character, and are continuous with the lining membrane of the tube, of which they form a part. Dividing the bottom of the funnel, where it is situated, into two unequal portions, this septum juts out nearer to the surface of the ARTIFICIAL ANUS. 563 abnormal opening in proportion as the loss of intestinal substance has been more considerable, and the change in the direction of the tube more marked. It is small, and scarcely perceptible, when the gut has Fig. 198. a a. Opening of the artificial anus, and point of union between the skin and the mucous membrane. b. Upper end of the intestine ; c. Lower end of the intestine ; d. The septum ep6ron, or ridge, formed ti- the walls of the two contiguous cylinders ; ee. Parietes of the bowel; /. The ligament or cord formed by the mesentery ; g. The cul-de-sac between the peritoneum of the intestines and of the abdominal walls, into which hernise occasionally protrude. been merely pierced by a wound, or slightly affected by an eschar, but large and prominent, when the lesion, whatever it may be, involves the whole circumference of the canal. In the former case, the two orifices of the bowel are separated by a kind of gutter or groove, which directs the transit of the fecal matter from the one to the other, and greatly facilitates the attempts at cure; in the latter, the septum forms a projecting angle or buttress, which conducts the contents of the upper orifice towards the abnormal outlet, and which nothing but art can break down or surmount. When the two lamellae of which this septum is composed are viewed posteriorly, or from within the belly, it is found that they gradually recede from each other, leaving thus a triangular interval between them the apex of which corresponds with the point of separation, and the base with the abdominal cavity. The surfaces of these lateral layers which are, in fact, nothing but the parietes of the affected cylinders of the bowel, are invested by a reflection of the peritoneum, and afford attachment to a process of the mesentery _ A very serious inconvenience to which persons laboring under arti- ficial anus are subject is the protrusion of the extremities of the gut. 564 SMALL BOWEL. This often amounts to a real prolapse, and is liable to occur, whatever may have been the cause of the disease. It may affect both ends, but the upper is more frequently involved than the lower. The extent of the prolapse varies, in different cases, from three to eight inches, as its minimum, to twelve or eighteen inches as its maximum. In its diameter the tumor seldom exceeds two and a half or three inches. It is more or less conical in its shape, contracted at the base, and per- forated at the extremity by an irregularly rounded opening. The everted mucous membrane is at first only preternaturally red and vas- cular ; by degrees, however, it becomes thickened, rugose, indurated, and completely hypertrophied. 17. Malformations.—Congenital development of the intestine some- times presents itself in the form of a diverticulum, as is seen in the adjoin- ing sketch (Fig. 199), from a specimen in my collection. The appendage, in this case, is fully three inches in length, by upwards of an inch and a third in diameter, and terminates in a conical extremity. In another preparation in my cabinet the length is somewhat less, but the diameter is quite equal to that in the other specimen. The most common situation of these appendages is the inferior portion of the ileum, but they have been seen in other parts of the alimentary canal, as the duodenum, jejunum, colon, and even the rectum. In all the cases that I have had an opportunity of examin- ing, I have found them to be of a cylinder figure, and to be composed of the same number of tunics as the portion of bowel with which they were connected, and of which they are, in fact, always merely so many lateral prolongations. The opening between them and the tube is of a circular shape, and destitute of valvular arrangement. Their length varies from a few lines to six inches, from two and a half to three inches being their average. Their extremity is generally free ; but now and then it is attached to a neighboring coil of intestine, and several cases are related where it terminated by a small orifice at the umbilicus. A diverticulum of this kind occasionally intercepts foreign substances, as peas, cherry-stones, and pieces of bone, and thus becomes the seat of violent inflammation, followed by gangrene, or by ulcera- tion and perforation of its walls. Diverticulum of the small bowel. From a preparation in my collection. INFLAMMATION — ULCERATION. 565 SECTION VII, DISEASES OF THE LARGE BOWEL. 1. Inflammation.—Inflammation of the large intestine is known, at least in one of its principal forms, by the name of dysentery. The main seat of the morbid process is, in the majority of cases, near the sigmoid flexure; occasionally the inflammation extends up to the ileo-caecal valve or even into the ileum. One of its first effects is to cause the epithelium to be cast off, which is seen lying in the shape of a distinct whitish layer on the mucous membrane, which becomes itself simultaneously injected, swollen, and softened. Subsequently an exudation of lymph occurs in the submucous tissue, giving rise to distinct solid protuberances. The follicles are swollen, filled with a thick secretion, and occasionally the seat of ulceration. The intestine is distended with gas, and the softened mucous membrane is covered with fecal matter, secretions from the glands, blood corpuscles and exuded lymph mixed up in a thick mass. The mucous membrane itself may ulcerate, and come off in shreds; the peritoneum loses its transparency, and its vessels are rendered preternaturally distinct. In some malignant forms of dysentery the mucous membrane sphacelates. The surface of the intestine around the disorganized mucous mem- brane is of a dark purple color; the submucous tissue is softened, disintegrated, and infiltrated with a purulent fluid. The softening may extend to the peritoneal coat, and perforation with fatal peritonitis result. In this form of dysentery, the mesenteric glands are of a bluish-red color, swollen, congested, and softened. When acute dysen- tery terminates in cure, the loss of membrane may be replaced by the formation of a new fibrous tissue; or when it assumes the chronic type, ulcers and abscesses may form in the intestine. 2. Ulceration.—Ulcers of the large bowel usually occur as the re- sult of chronic inflammation of the mucous membrane or of its glands. They closely resemble those of the small, except, perhaps, that they are more frequently of a linear shape. A good idea of the character of these ulcers may be obtained from the annexed cut (Fig. 200), from a specimen in my collection. The ulcers are large, numerous, deep, and several resting upon the muscular fibres. When beginning in the mucous follicles, they are more apt to be rounded. In this case, too, their edges are often remark- ably ragged, thin, and under- mined ; a circumstance which gives them the appearance of being much larger at the base than at the top. In such in- Fig. 200. Ulceration of the large b jwel. From a preparation in my collection. om LARGE BOWEL. stances, moreover, the glands are sometimes entirely removed, or por- tions of them are left in the midst of the ulcerated surface, in a state of induration. Occasionally nearly the whole of the large bowel is thus affected; but the sections most frequently diseased are the caecum and ascending colon, together with the right half of the transverse arch, whilst the rectum and the remainder of the gut are comparatively seldom implicated. In ninety-two cases of intestinal ulceration, re- ported by Andral, only one occurred in the rectum. The size of these ulcers is sometimes very considerable. I have repeatedly seen them of the diameter of an American dollar, and, on several occasions, between three and four inches in length by one and a half in breadth. When of these dimensions, the abrasions are gene- rally formed by the agglomeration of a number of smaller ones. In the linear varieties, I have, in a few instances, found the ulcers extend- ing almost completely around the circumference of the bowel, consti- tuting narrow grooves, of variable depths, with rough, elevated, and indurated edges. As in the rest of the alimentary tube, the ulcerative process may successively invade the different tunics, and finally lead to perforation; in which case the contents of the gut may be effused into the peritoneal sac, or else find their way into the surrounding hollow viscera. A fistulous opening sometimes forms through the walls of the abdomen, in the right iliac fossa, or in the groin, just above Poupart's ligament. In the cure of these ulcers nature may sometimes be detected, as it were, in the very act of reparation. Thus, in the ascending colon of a married woman, thirty-three years of age, who died, gradually ex- hausted, after an illness of nine weeks, I found the mucous membrane very much thickened, and of a dark red color, with a deep linear ulcer two inches and a half in length by three lines in width, the surface of which was covered with small masses of plastic lymph, so firmly adherent that it was difficult to scrape them away. In this case, it is obvious, there was an attempt at cicatrization ; and, had the patient lived long enough, it would, no doubt have gone on to comple- tion. In another instance, that of a man twenty-two years old, who died of chronic diarrhoea, a small circular ulcer existed in the sigmoid flexure, the centre of which was coated with a thick layer of lymph, which had evidently been deposited only a short time previously to death. An abscess sometimes forms between the coats of the large bowel. In my private cabinet is a preparation in which an abscess, of the ■size of a goose egg, existed in the submucous cellular tissue of the sig- moid flexure of the colon, near its junction with the rectum. The subject was a negro, twenty-nine years of age, who had labored for six weeks under all the symptoms of an ordinary remittent fever, with a pulse seldom lower than ninety-six in a minute. On inspec- tion, I found an excavation of the size of a walnut in each superior lobe of the lung, with numerous tubercles in other parts of the organ, and a large abscess between the serous and muscular tunics of the colon. It contained about half a pint of thick, offensive matter, and its walls were in such a state of softening as to yield to the slightest HYPERTROPHY. 567 traction. The abscess, in this case, was evidently tubercular, and such probably is always, in this situation, its most common character. 3. Hypertrophy.—Hypertrophy of the coats of the colon is rare, but by no means infrequent in those of the rectum, where it is occasionally conjoined with permanent stricture. The gut, for some distance above the constriction is usually considerably dilated, either with or without attenuation of its tunics, or the reverse. The extent to which the hypertrophy occurs, varies from a few inches to several feet; in a few instances, I have seen it involve the whole of the large bowel. The coats which are more particularly affected are the mucous and cellulo- fibrous, the latter of which especially is frequently from six to eight times the normal thickness : the muscular fibres are also apt to be- come very much altered, both as respects their size and color; but the serous texture rarely participates in the morbid derangement. When the hypertrophy is of long standing, the bowel almost always acquires an extraordinary degree of density, offering nearly as much resistance to the knife as fibro-cartilage, and emitting nearly the same creaking sound. Under this head may be described the wart-like excrescences which are occasionally met with in the colon and rectum, and which so closely resemble those which are so often seen on the female organs of generation. Of this lesion I have seen a number of well-marked examples. In a specimen (Fig. 201) preserved in my private collec- tion, the mucous membrane of nearly the whole of the large intestine is thickly Fig. 201. studded with these vegetations, the smallest of which are scarcely as big as a pin-head, whilst the largest are from three to eight lines in length, by two lines and a half in diameter. The former, which are much the most numerous, are, for the most part, of a spherical shape; the latter, on the contrary, have an elongated, conical ap- pearance, not unlike the nipples of some of the inferior animals. A few of the larger are bifid, and several adhere by a narrow pedicle, their free extremity being much broader than the attached. These singular excrescences are most abundant in the rectum and the sigmoid flexure of the colon, from which they gradually de- wan-iike vegetations of the m*. i ,i i . • -i cous membrane of the larsre bowel. Crease in number, though not in Volume, From a preparation in my cabinet. as they approach the cascum, where they are entirely wanting. Their surface is somewhat rough, as if covered with villi, and in the recent state they were all of a dark mulberry hue. The parietes of the bowel are very much thickened and indu- rated, especially in the inferior three-fourths of its extent; the caliber of the tube being greatly diminished throughout. The subject of this disease was a man sixty years of age, during the last four of which 568 LARGE BOWEL. he was constantly harassed with diarrhoea and intestinal pains, attended with gradual exhaustion and excessive emaciation. In another specimen of a similar nature, the walls of the colon are also very much thickened, though not so much as in the preceding case, and the inner surface, besides being cellulated, like a honey-comb, is covered with an immense number of soft, fungoid excrescences, some of which are nearly half an inch in length. In their shape they exhibit almost every variety, some being conical, some spherical, and some angular. Many of them arise by a common base, and, jutting out like little slender arches, unite at the top, leaving thus a number of intervening spaces which readily admit of the passage of a large probe. The structure of these vegetations seems to be very analogous to, if not identical with, that of the natural mucous membrane, upon which they grow, and of which they may, therefore, be regarded merely as so many prolongations. That this is the case is sufficiently obvious when we make a section of them. In the specimens in my possession, the inner surface of the colon and rectum presents thou- sands of hypertrophied villi, and similar bodies are plainly visible, even to the unassisted eye, on the warty excrescences. Thus, then, it may be concluded that these growths are neither villosities in a state of preternatural enlargement, nor new formations, but simply, as just intimated, so many prolongations of the mucous corion, folded over a small quantity of cellular substance. Their vascularity is sometimes very great, and there is reason to believe that they are susceptible of a species of erection. How these vegetations originate is still a mooted question. That chronic irritation has some agency in their production cannot be doubted, as we seldom, if ever, meet with an instance in which the bowels have not been seriously and for a long time deranged; but what the peculiar modification is, and why these bodies should exist in some cases and not in others, are problems which must, for the present, remain undetermined. In one of my cases, that of a young courtesan, twenty-three years of age, there had been well-marked signs of chronic colitis for several years, with occasional intervals of perfect health. She finally died of gangrenous inflammation of the vulva and vagina, having for the last few months suffered severely from disease of the bowels, the principal symptom of which was tor- turing pain in the umbilical region, with frequent slimy and bloody evacuations. So also in the other case I have mentioned, chronic inflammation had invaded nearly the whole of the large bowel, and had existed for nearly four years, having been engrafted upon a severe attack of Asiatic cholera. 4. Atrophy.—Atrophy of the large bowel may arise from various causes, as the pressure of an abdominal tumor, the constriction of a band of adventitious membrane, the lodgement of an alvine concretion, or the presence of a tumor, benign or malignant. Permanent obstruc- tion being thus occasioned, the tube below, pale and flabby, now only slightly stimulated by the transit of fecal matter, becomes gradually wasted, its caliber diminishing, and its coats assuming a thin, pale, POST-MORTEM CONTRACTION. 569 flabby appearance. In artificial anus, the result of strangulation, atrophy sometimes exists in a remarkable degree, especially in pro- tracted cases, the bowel below the abnormal orifice being reduced almost to a solid cord, perhaps hardly the size of a finger. 5. Heterologous Formations.—Tubercles of the colon and rectum are observed chiefly in phthisical subjects, in which they sometimes exist in immense numbers. The heteroclite matter is deposited in the mucous follicles, which, when the softening process occurs, are con- verted into small ragged ulcers, the edges of which are often greatly undermined, while the base is formed either by the submucous cellular tissue, or, in the advanced stages of the disease, even by the muscular fibres. The parts around the ulcers are generally abnormally dense and vascular; more rarely pale and softened. Melanosis is very rare, and occurs principally in small points, appa- rently seated in the mucous glands. Scirrhus, encephaloid, and col- loid, have their seat mostly in the ileo-caecal valve, the lower portion of the rectum, and at the anus. 6. Post-mortem Contraction.—In leaving this subject, there is one point upon which I deem it necessary to make a few comments. I allude to the singular contraction of the large bowel which is so fre- quently met with in post-mortem examinations. Every physician who is in the habit of making researches of this kind must have frequently observed this appearance. During the early period of my professional life, before I had much acquaintance with morbid struc- ture, I was inclined to look upon this contraction as the effect of dis- ease ; and as such, there is reason to believe, it is still regarded by many at the present moment. That this, however, is not the fact generally, my experience satisfies me; and, hence, in order to avoid mistake, I would suggest that, whenever this appearance is witnessed —as it will be, I feel confident, in nine cases out of ten—the bowel should be carefully opened with the scissors, and thoroughly scruti- nized, with a view of ascertaining the color, consistence, and other conditions of its several tunics. The parts of the large bowel most subject to this contraction are the left half of the arch of the colon, the descending portion, the sigmoid flexure, and the upper half of the rectum, the frequency of its occurrence being in the order enumerated. All these parts are often narrowed at the same time, and occasionally to such a degree that the caliber of the tube is nearly obliterated. To what this con- dition is owing it is difficult to conjecture; nor am I able to offer any opinion upon the subject, excepting that these parts of the ali- mentary tube, being less liable, during the last stages of our existence, to distension by fecal matter, the muscular fibres are enabled to contract with more energy than in the rest of its extent. 570 VERMIFORM APPENDAGE. SECTION VIII. DISEASES OF THE VERMIFORM APPENDAGE. The vermiform appendage, although in its structure closely resem- bling the rest of the intestinal canal, may, nevertheless, be considered as a distinct organ, possessing peculiar anatomical relations, and exe- cuting functions different from those of the rest of the alimentary tube. It is about three inches in length by three lines in diameter, slightly convoluted, and often considerably larger at some points than at others. Its coats are as thick as those of the caecum, and composed of the same tissues. Not a little variety exists in relation to the size and situation of this tubular diverticulum. Whilst occasionally it is very diminutive, I have seen it, at times, nearly half a foot long, and fully as large as the little finger, without any apparent disease. The appendage may be deficient, even when the rest of the bowel is per- fectly normal; and now and then it deviates remarkably from its accustomed position. In inflammation of the peritoneum it is often firmly glued to the neighboring organs, as the uterus and urinary bladder; and, under such circumstances, it has been known to pro- duce strangulation of the small bowel. The usual contents of the vermiform appendage are of a mucous nature, and of a soft, semi-fluid consistence. Fecal matter rarely finds its way into it; when it does, it is very apt to become impacted, and to produce mischief. Cases occur where the most violent inflamma- tion is thus induced, followed by gangrene of the tube and general peritonitis. But the most common cause of disease, undoubtedly, is the ingress of some foreign body, such as a bean, a cherry-stone, or a biliary concretion, producing local irritation, which rapidly spreads from the mucous to the other tunics. Severe peritonitis is soon lighted up, lymph is poured out, and the appendage speedily morti- fies. In another series of cases, the disease assumes a milder charac- ter, the serous membrane is comparatively little affected, there is scarcely any fibrinous exudation, and the inflammation finally passes into suppuration; or adhesions are formed between the caecal append- age and the adjacent parts, and the extraneous body, exciting ulcera- tion, at length escapes into some other situation. The insidious nature of this disease is well illustrated by the follow- ing case, communicated by my friend Dr. Richards, of Cincinnati, who had also the kindness to send me the diseased bowel. The patient, a gentleman, thirty-five years of age, had enjoyed good health up to the 24th of August, 1837, when he was attacked with bilious fever._ His tongue was considerably coated; there was headache, with pain in the back and limbs; the skin was hot and dry; the pulse ninety in a minute ; and there was, moreover, a slight hacking cough, which, however, had been present, at intervals, for the last ten months. Under a somewhat active course of treatment, these symptoms gradu- ANO-RECTAL REGION. 571 ally subsided, and, a fortnight from the invasion of the disease, the patient was apparently convalescent. On the evening of the same day, however, after partaking pretty freely of indigestible food, he was suddenly seized with severe pain in the abdomen, accompanied with slight distension of the hypogastric region, and great tenderness on pressure. The pulse was feeble, and one hundred and forty in the minute; the surface was cold, and bathed with profuse perspiration; and there was considerable embarrassment of breathing. These symp- toms gradually increased in severity until about forty-two hours from their first manifestation, when the man expired, in a state of complete collapse. On dissection, the omentum, with nearly the whole perito- neum, was found to be highly inflamed; the bowels were distended with gas, and extensively agglutinated by coagulating lymph; the pelvis was filled with fecal matter; and there was a large, ragged ulcer in the vermiform appendage, which had perforated all the coats. Through this ulcer the fecal matter had escaped, inducing violent and fatal peritonitis. The mucous membrane of the stomach was also much inflamed, as well as incrusted with patches of lymph, but that of the intestines was perfectly healthy, except immediately around the seat of the disease. SECTION IX. DISEASES OF THE ANO-RECTAL REGION. There are some organic lesions which are either peculiar to the rectum and the anus, or which occur so frequently in these situations as to render it proper that a short account of them should be pre- sented in this place. Of these affections, the most important are carcinoma, ulceration, stricture, hemorrhoidal tumors, polypes, fistule, and prolapse. 1. Carcinoma.—Carcinoma may exist as a primary affection, or be propagated from the surrounding organs, particularly the uterus and vagina. Its most common seat is from two and a half to three inches above the inferior outlet of the bowel, though occasionally it is much lower down, as well as higher up. In a case recently under my ob- servation, the disease involved both the margin of the anus and the lower portion of the rectum, the latter of which it encircled in the form of a dense, resisting ring, about four lines high, and more distinctly marked behind than in front, with a central opening hardly large enough to admit the middle finger. The anus was exceedingly dimi- nished in size by two scirrhous tubercles, one about the volume of an almond, the other of a pullet's egg. The latter was ulcerated upon its inner surface, and both were the seat of sharp, lancinating pains. The patient was a young man thirty years of age, and the disease was first noticed seven months before he came under my care. This affection presents itself either as a distinct tumor, or as an 572 ANO-RECTAL REGION. infiltration in the submucous cellular tissue, from which it gradually extends to the other tunics. Its anatomical characters are the same as those of carcinoma of the stomach and oesophagus; that is, it is either of a hard, dense, gristly consistence, with a rough, nodulated, and ulcerated surface; or it is of a soft and pulpy texture, like the medullary substance of the brain; or soft and gelatinous, like the matter of colloid. In fact, cases occur in which these heterologous deposits are intermixed, or where they form different and distinct portions of the morbid mass. The mucous and muscular coats of the bowel are usually very much thickened, the former being often thrown into large, irregular ridges, in the intervals of which it is not uncommon to find small fissures, chaps, or erosions. The fleshy fibres are at first very little changed, but as the disease progresses they lose their reddish color and soft consistence, and are trans- formed into pale, gristly bands, possessing all the properties of the new deposit, whether scirrhous, encephaloid, or colloid. When the affection is of long standing, the hemorrhoidal vessels are always much enlarged, sometimes quite varicose, and the surrounding cellular tissue is matted into a condensed mass, destitute, in great measure, of its primitive characters. When this disease affects the rectum, it usually terminates abruptly both above and below, but as it progresses its boundaries assume a more irregular form, and processes often extend in different directions. The degree of constriction varies from the slightest possible change of the natural caliber of the tube down to the size of a goose-quill. The bowel immediately above the seat of the disease is generally somewhat dilated, either uniformly, or, as is more commonly the case, at one or more points. Inferiorly, on the other hand, it is usually contracted; at times nearly obliterated. The height to which the disease extends varies in different cases from one to three inches. It has been known to be prolonged to the arch of the colon, transforming all the descending portion of that intestine into a scirrhous tube, the wall of which was upwards of two inches in thickness, and its caliber almost entirely obliterated, while the inferior third of the rectum had not experienced the slightest change of structure. There is reason to believe that the disease gene- rally, if not always, begins in the mucous follicles, from which it spreads with more or less rapidity to the other tissues. Like carci- noma in other parts of the body, it is most commonly observed in adult and advanced life, though instances of it occasionally occur at a much earlier period. It is met with in both sexes, but more fre- quently, according to my experience, in the female than in the male. 2. Fissure.—Fissure of the anus consists in an elongated, narrow ulcer, which commonly arises immediately above the internal sphincter, on the posterior surface of the gut, opposite the point of the coccyx, in consequence, frequently, of some mechanical cause. The bottom of the fissure, usually formed by the submucous cellular tissue, has a soft, spongy feel, but the edges are indurated and more or less prominent. The peculiar character of the disease is that it is invariably attended by spasmodic contraction of the sphincter muscles of the anus; owing SPREADING ULCER — ORGANIC STRICTURE. 573 to which the patient generally experiences the most horrible torture at every attempt at defecation. Occasionally considerable hemorrhage attends it. 3. Spreading Ulcer.—There is a species of ulcer of the rectum to which the term spreading may be applied, from the extensive ravages it is capable of committing; it is characterized by the complete removal of a considerable portion of the lining membrane, with a dense, indu- rated, and almost gristly state of the muscular tunic. It usually com- mences about half an inch within the anus, and terminates above by a rather abrupt but very irregular line of demarcation. The ulcer frequently extends around the whole bowel, and sometimes even high up towards the sigmoid flexure of the colon. 4. Sacs.—The pouches which naturally exist within the cavity of the rectum, between the external and internal sphincter muscles, are liable to enlargement, in consequence of the lodgement of fecal matter, and proba- bly also from other causes. The di- latation may affect only one sac, or several may be involved simulta- neously, or successively. In degree it varies from the slightest increase of the normal dimensions to the develop- ment of a cavity, half an inch or more in diameter. (Fig. 202.) The sac never extends above the margin of the internal sphincter, but it may de- scend so low as to project beyond the level of the verge of the anus, in the form of a soft, elastic tumor, as large as an olive. Its lining membrane may be natural, thickened, or attenuated, and usually fur- nishes an abundant glairy mucus. The disease is slow in its progress; and one of the earliest symptoms complained of is an extraordinary itching or sense of weight at the anus, to which is subsequently added violent smarting pain during every attempt at defecation. 5. Organic Stricture.—This disease consists in a thickened, indurated condition of the mucous and cellular textures, by which the caliber of the tube is more or less contracted. A smooth gristly ring is thus formed, from a few lines to half an inch in depth, above and below which the bowel commonly retains its natural structure. (Fig. 203). The thickening does not, however, always embrace the entire circumference of the rec- tum ; not unfrequently, indeed, it forms a mere segment of a circle, and is so arranged as to give the villous tunic in the immediate neighborhood a re- markably puckered appearance. When the ring is Complete, it Strongly re- Organic stricture of the rectum. Pouches of the rectum. From a preparation in my collection. Fis. 203. 574 ANO-RECTAL REGION. sembles a scirrhous pylorus. Hypertrophy of the muscular tunic is also occasionally observed, but the peritoneal is seldom implicated. The common seat of organic stricture is about three inches above the anal orifice. Cases, however, are frequently observed in which it is much lower down or higher up. The disease spares neither age nor sex. Whilst it is not usual about the meridian of life, it has been repeatedly witnessed in children as early as the eighth year, and in the old as late as the eightieth. The bladder is sometimes excessively irritable in this disease, from the pressure of the loaded gut; and occasionally fistules form in the nates and perineum. In the female, a communication frequently takes place between the rectum and the vagina; and in the male a similar passage may be established, though more rarely, between the rectum and the bladder. A spasmodic stricture of the rectum, caused by an irregular contrac- tion of the muscular fibres, is sometimes noticed. It is most common in the upper portion of the tube, and is probably dependent upon a vitiated state of the secretions. 6. Polypes.—Polypes of the rectum may occur at any period of life, but are most common in children under ten years of age. Occasion- ally they are observed soon after birth, and hence it has been inferred, and not without reason, that they may exist as a congenital vice. Almost always single, there are sometimes as many as three, four, five, or even half a dozen. Their ordinary situation is from one to three inches above the anus. When there are several such tumors they usually occupy different portions of the circumference of the gut, and the highest may then be entirely beyond the reach of the finger. In their shape they may be globular, ovoidal, pear-like, or vermiform; in their size they vary from that of a cherry to that of a hickory- nut, a hen's egg, or a small fist. They are of a soft spongy consist- ence, and of a pale rose color, bright red, purple, whitish, or dirty drab. Their attachment is usually by a narrow, slender pedicle. In one instance I saw a growth of this kind, not larger than a common hickory-nut, with a thin pedicle four inches in length. Fig. 204. Fig. 205. Polype of the rectum; Fig. 204 showing its external appearance ; and Fig. 205 its internal structure. They are composed of a cellulo-fibrous, fibrous, or gelatinoid texture, and are invested by a prolongation of the mucous membrane. Their surface, which is generally smooth and regular, is sometimes remarkably rough, knobby, mammillated, or tabulated, giving the part the appear- ance of consisting of several distinct masses. In a preparation, presented HEMORRHOIDS. 575 to me by Professor Hardin, of Kentucky, the tumor has a singularly porous appearance, very much like that of a sponge. The openings, which exist in immense numbers, freely communicate with each other, and vary in size from the smallest pin-head to that of a pea. The largest, as I have ascertained by a careful inspection, were filled with a white inspissated mucus, which was easily pressed out with the finger, and the removal of which was followed by a considerable dimi- nution of the tumor, originally about the volume of a hen's egg, and of an oblong reniform figure. It was of a bright red color before removal, bled freely at every point of its surface when touched or irri- tated, and was suspended by a rounded pedicle, two inches long by four lines in diameter. This pedicle took its rise a little above the sphincter muscle on the right side of the rectum, communicated to the finger a pulsation as strong as that of the radial artery, and was inserted into the centre of the tumor very much as the stem is into an apple. The subject, a boy ten years old, had* labored under the disease six years. The form and structure of the tumor are exhibited in Figs. 204 and 205. Owing to the constant contact of fecal matter, polypes of the rectum are liable to inflame, to ulcerate, and probably, also, to assume a ma- lignant tendency. When very vascular, they are apt to bleed freely, especially when they are roughly handled or irritated. The mucous coat immediately around them may be perfectly natural, or it may be thickened and changed in color. 7. Hemorrhoids.—Hemorrhoids may be distinguished into two varie- ties, one of which essentially consists in a varicose and erectile condi- tion of the vessels, the other in the formation of a small sac filled with blood. In the latter case, the disease presents itself in the form of one or more rounded, or ovoidal tumors, seated at the verge of the anus, or just within the external sphincter. In their size, they vary between a cherry and an almond (Fig. 206); they are of a soft, spongy consistence, and their color is either lilac, red, or livid, according to their age and the degree of pressure exerted upon them by the surrounding parts. When old, they often appear like hard, indurated knobs, quite pale, and almost devoid of sensibility. The manner in which these tumors are produced is easily explained. In straining at stool, or in riding on horseback, a he- morrhoidal vein gives way, and blood is extravasated into the connecting cellular tissue, where it forms a circumscribed swell- ing, covered partly by skin, partly by mu- cous membrane. The blood is at first per- fectly fluid, but in a short time it coagulates, and subsequently undergoes the same changes as in apoplexy of the brain. These circumstances satisfactorily account for the difference of color and consistence between a recent and an old hemorrhoidal tumor, as well as for the great facility with which the blood can be pressed Fig. 206. External hemorrhoids. From a preparation in my collection. 576 ANO-RECTAL REGION. out of the sac in the one case, and the great firmness with which it adheres to its walls in the other. The blood which is effused in this variety of the disease may be entirely absorbed; but more commonly it remains, and is gradually converted into a tough fibrinous substance, of a pale reddish or^ gray- ish color. Vessels extend into it from the parts by which it is covered, and in this manner it becomes at length inseparably united with the inner surface of the sac. These tumors are generally the cause of the pale, flabby, and corrugated excrescences, so frequently noticed at the verge of the anus, and the interior of which is occasionally of a hard fibrous consistence, similar to indurated cellular tissue. This variety of hemorrhoidal tumor differs remarkably from the one next to be described in that it never bleeds, and in being of a lighter color. It is most frequent after the age of twenty-five or thirty; but in a few instances I have met with it in very young children, without any assignable cause. It is exceed- ingly common in females, during the latter months of utero-gestation. The second form of hemorrhoidal tumor is produced by the dilatation of the capillary vessels of the mu- cous membrane, just above the in- ternal sphincter muscle. (Fig. 207.) The disease is generally slow in its progress, and often exists for a con- siderable period before it' is de- tected. Certain occupations pre- dispose to its occurrence, and it seems to be more frequent in the male than in the female. It seldom appears before the twenty-fifth year, and is most common after the age of forty. The tumors in this variety of the affection are of a soft, spongy con- sistence, erectile, and remarkably prone to hemorrhage, the blood often spirting from them in a full stream. In their color, they vary from a light red to a deep purple; their volume may equal that of a pea, a filbert, or an almond; their number seldom exceeds three or four, though I have counted as many as eight in the same subject. They are usually isolated, but now and then they are grouped together, so as to form a mass several inches in diameter. They may involve the entire circumference of the gut, or be confined to particular parts of it. Their surface is frequently incrusted with coagulating lymph, and the mucous membrane over them is liable to give way from the most trifling causes, followed by more or less hemorrhage. Sometimes the blood oozes out at numerous points, by a process of exhalation. The bleeding, however induced, may amount to several ounces a day, and is sure, if long continued, to be attended by an anaemic condition of the system, with partial or complete prolapse of the mucous mem- Internal hemorrhoids. From a preparation in my cabinet. VARICOSE ENLARGEMENT. 577 brane. To this form of the disease the term bleeding or internal piles is usually applied. Fig. 208 shows the spongy, porous structure of this form of the Fig- 208. disease. A tumor, very different in its character from the true hemorrhoidal, is sometimes met with at the verge of the anus, princi- pally as the result of severe straining at L "i n , . , i ° T The minute structure of an inter- stool, or of rough horse-back exercise. It nal hemorrhoidal tumor. consists of an effusion of serum in the sub- mucous cellular tissue, in the form of a rounded, or ovoidal elevation, from the volume of a cherry to that of a small hickory-nut; it is of a pale yellowish color, or nearly perfectly white, almost transparent, glossy, and very much like the vesicle of a common blister. It pits slightly under the finger, and generally attains its full size in ten or fifteen hours. A few delicate straggling vessels, the color of which beautifully contrasts with that of the other parts, may often be seen ramifying over its walls, or intersecting its substance. The tumor, although sometimes multiple, is almost always solitary. The disease is strictly analogous to oedema of the vulva and glottis. The warty excrescences, so frequently observed at the verge of the anus, may be the remains, as already stated, of shrunken hemorrhoids, or they may be formed by a dense, thickened, and hypertrophied condition of the common integuments and submucous cellular tissue. In the latter case, the tumors are external from their earliest development, which is caused either by continued friction, by habitual straining, or by want of cleanliness. They are of a flattened, oblong shape, mammillated, irregularly rounded, or conical, dense and firm in their consistence, in- dolent, or insensible, and of the same color pretty much as the skin, except when they are inflamed or highly congested, when they are red or purple, and extremely painful. Their number is variable, but there are seldom more than three or four. Excrescences of this de- scription may attain the volume of an almond or a small fig. They never bleed, but they may ulcerate, and become the seat of a purulent or thin sanious discharge. When very old they are generally of a hard, fibrous, or fibro-cartilaginous structure, from the effects of interstitial changes. The veins of the rectum, like those of the abdomen, the spermatic cord, and lower extremity, are liable to varicose enlargement. This state may exist alone, or in association with hemorrhoidal formations. The dilatation may affect a single trunk, or a considerable number, either simultaneously, or successively; and may extend as high up as the commencement of the sigmoid flexure of the colon. The veins are knotty, convoluted, thinner in some places than at others, and four or five times the natural size. Occasionally they are hard and firm, or soft and friable. The surrounding parts are thickened and oedematous. The cause of this affection is purely mechanical, and consists in what- ever has a tendency to interfere with the passage of the venous blood. The distended veins sometimes burst, and thus give rise to more or less hemorrhage. 37 578 ANO-RECTAL REGION. 8. Prolapse. Fig. 209. Of prolapse of the rectum there are two forms. In the first (Fig. 209), which may be termed the partial, the mucous membrane of the lower bowel alone is everted, so as to present the appearance of a ring. It is usually observed in the vigor of life, and very frequently depends upon the presence of hemorrhoids. In the second variety (Fig. 210), there is a descent of all the coats, the whole or the greater portion of the rectum falling through the external sphincter muscle. The ex- tent to which the protrusion occurs varies from a few lines to six or ten inches. In cases of the latter kind, it is probable that there is a real in- vagination of the sigmoid flexure of the colon; for it is difficult to conceive how the rectum could suffer the requisite displacement, even supposing that it possess- ed the necessary length. When the prolapse is complete, as in the form of the lesion now under review, the tumor is commonly of an irregularly globular figure, and varies from the size of an egg to that of the two fists, the mucous membrane being of a dark livid color, from the constriction of its capillary vessels, and affording a Fig. 210. Partial prolapse of the rectum. From a preparation in my cabinet. Complete prolapse of the rectum. thin, bloody secretion, not unlike red currant jelly, both in appearance and consistence. If the parts be allowed to remain long in this situa- tion, they become not only very much thickened, but gradually rough and callous. Protrusion of all the tunics occurs chiefly in children and aged persons, particularly in females of relaxed frame. 9. Fistule.—A fistule is a small narrow passage, which has one of its openings in the neighborhood of the anus, the other in the rectum; MALFORMATIONS. 579 in some instances, the upper extremity of the tube terminates blindly as a cul-de-sac. Its length varies from a few lines to several inches; its diameter generally equals that of a common probe, and occa- sionally that of a goose-quill. A channel of this kind is either straight or crooked; and when several coexist, they not unfrequently commu- nicate with each other. Internally, it is lined by a layer of adventitious membrane, the surface of which, usually somewhat rugose, is con- stantly bathed with purulent matter either alone, or mixed with feces. A fistule is always preceded by an abscess, and may therefore be con- sidered as a consequence of its imperfect restoration. The number of external openings varies in different individuals. Generally there is but one; but sometimes two, three, or even more exist. In a preparation in my possession, there are as many as seven, situated at various points of the nates. When the number of apertures is very great, the integuments have a cribriform or sieve-like aspect, the subjacent cellular substance is extensively destroyed, the surface is of a marbled or pale livid color, and there is a constant discharge of thin, sanious, and offensive fluid. This form of fistule is most frequently observed in phthisical subjects and habitual drunkards. When there are several orifices, the surround- ing parts are generally very callous, more or less red, and studded with fungous granulations, especially in cases of long standing. In regard to their shape, the external openings exhibit endless variety; being sometimes round or circular, but more frequently ragged and irregular. There is seldom more than one internal opening; sometimes, how- ever, there are two; and cases have been observed where there were as many as three. In a sailor, upwards of fifty years of age, on whom I operated for this disease before the medical class in the winter of 1843, there were not less than four internal orifices, situated within a short distance of each other. The aperture is usually soft and irregu- lar, rarely round, or callous. It is commonly situated at the side of the anus, seldom in front, and still more rarely behind. The precise point at which the internal orifice opens is worthy of notice. Until recently this was supposed to be high up, at the distance of two, three, or even more inches from the external outlet. It is now well ascertained that this is not the case, but that the orifice is generally very low down, that is, just above the point where the internal membrane of the rectum unites with the skin, sometimes a little higher up, but never more than five or six lines. I have never found the seat of the internal opening higher up than half an inch, and generally, indeed, not more than two or three lines. In all my operations for this disease, my practice, before dividing the parts, has been, for many years, to expose the internal orifice by means of a flexible director, brought out at the anus; a proceeding which could not be accomplished if the opening were situated at a considerable elevation. 10. Malformations.—Malformations, often incompatible with the perpetuation of life, are sometimes witnessed in the anus and lower extremity of the rectum. When the anus is absent, the large bowel is either partly or entirely deficient, or else opens in a cul-de-sac, 580 INTESTINAL WORMS. some distance above the usual place. Occasionally the aperture is closed simply by a thin fold of membrane, not unlike the female hymen, which may be easily divided with the knife, and the infant survive. Sometimes nearly the whole of the large intestine is wanting, as was the case with a foetus which I dissected a few years ago, in which the ileum terminated in a capacious cul-de sac, two inches and a half in length, which floated loosely in the pelvic cavity. At other times, again, the anus and rectum are natural, whilst the colon is either absent or so contracted as to render the continuance of life impossible. Instances occur, also, where the rectum opens into the urinary blad- der, the urethra, or the vagina; thus affording an approximation to the cloaca of birds, and of some fishes. SECTION X. INTESTINAL WORMS. Five species of worms inhabit the intestinal tube of the human subject, the lumbricoid, vermicular, trichocephaloid, the long tape, and the broad tape. These worms are not peculiar to man: they frequently occur in the inferior animals, and, as might be supposed, they all have a decided predilection for particular parts of the alimentary canal, some selecting the small, others the large bowel. How these parasitic beings originate is still a mooted point with pathologists: all are now agreed, however, in the belief that they must arise in one of two ways, either from the germs of animals, introduced into the body from with- out, or derived from the parent, or else by spontaneous generation. It does not accord with the plan of this work to enter into a detail of the various arguments that have been adduced by the advocates of these two questions: suffice it to say that the doctrine ascribing them to spontaneous generation occurring within the body, has now few followers. The most commonly received opinion is that these worms are developed from ova which may be introduced from without, but may also certainly be derived from the parent, as the circumstance that they have been repeatedly seen in the foetus amply proves. Kerk- ringius mentions the case of an immature foetus, in whose stomach he found several lumbricoid worms; and instances of tape-worms having been discovered under like circumstances are narrated by Pal- las, Heine, and other authors. Kudolphi and Bremser refer to nume- rous examples of worms existing in the foetuses of various quadru- peds, and also in those of birds which had just escaped from the shell. The lumbricoid worm (ascaris lumbricoides, lumbricus teres), as its name indicates, is of a cylindrical shape (Fig. 214), gradually tapering towards each extremity. It is marked by numerous circular ridges, and by four longitudinal lines, of which the dorsal and ventral are whitish, the two lateral ones dark and opaque. The head is tri-val- vular, without wings or processes; and the digestive tube, which runs INTESTINAL WORMS. 581 in a straight course, terminates a short distance from the tail in a transverse fissure. The length of this worm is from three to twelve Fig. 211. Fig. 212. Fig. 214. Ascaris lumbri- coides : a. Anterior extremity; b. Pos- terior ; d. Vulva; e e. Longitudinal lines. M 1, Penis of the ascaris lum- bricoides magnified; a. Ex. tremity ; 6. Base. Fig. 215. Bead and mout" of the ascaris ; a, b b. Tubercles ; c. Oval aperture. Fig. 212—Organs of the female ascaris: a. External tunic; b b. Muscular fibres ; d. Mouth ; e. (Esopha ■ gus ; /. Alimentary tube; k I m n. Generative organs. Fig 213.-Organs of the male ascaris : d. Mouth ; e. (Esophagus; h h. Generative organs ; /. Intestine g. Penis. 582 INTESTINAL WORMS. inches; its thickness about that of a goose-quill; and its color of a reddish-brown, bordering upon yellow. The male is much more slender than the female, from which it is readily distinguished by the singular curve of its caudal extremity, and by its forked penis. This species of worm exhibits a high degree of organization, being furnished with integuments, a muscular and digestive apparatus, and well-developed sexual organs, together, as is supposed, with a nervous and circulatory system. (Figs. 212, 213, 214, 215.) Its natural resi- dence is in the small intestines, where it often occurs in considerable numbers. It has also been found in the large bowel, in the stomach, biliary ducts, oesophagus, fauces, and even in the larynx. In the lat- ter situation it has been known to cause suffocation. The usual number of this species of worm ranges from one to two or three dozens. Occasionally, however, it Fig- 216. greatly exceeds this. Thus, Dr. Gilli,1 of Turin, saw a child who voided, in the course of eight days, five hundred and ten ; and a still more extraordinary case has recently been related by Dr. J. W. Hamilton, of Ohio, in the Western Journal of Medicine and Surgery. In this instance upwards of eleven hundred, from three to nine inches in length, were expelled in less than three months. About sixty, rolled up in a complete ball, came away at one time. The patient was between two and Fig. 217. three years of age. The lumbricoid worm sometimes twists itself into a knot; and, in a remarkable instance, of which the adjoining sketch (Fig. 216) is an accurate representation, an animal of this description became entangled in the eye of a button, which made two circular impressions, nearly an inch apart, upon its body. This anomalous specimen is now in my private collection. The vermicular species (ascaris vermicularis, oxyurus v., fusaria v.), is extremely small and delicate (Fig. 217), the male being not above the sixth of an inch in length, with a very thin, tapering body, of a whitish color. The mouth is of an orbicular shape, with a bladder-like, transparent membrane on each side: the tail is spiral and obtuse, and the sexual organ is contained in a sheath. The female is considerably larger, being from four to six lines long, and its tail is as fine as the most delicate needle. The heads of these worms are in constant motion, from which circumstance they are often called leap-worms: from the uneasy, gnawing sensation which they are supposed sometimes to occasion raisize. in the stomach, they have also received the name of maw- worms ; and, from their filiform configuration, they are vul- garly termed thread-worms. They are found only in the large intes- tines, especially in the rectum, where they are often collected in vast 1 Brit, and For. Med. Rev., vol. xv. p. 248. INTESTINAL WORMS. 583 multitudes, wrapped up in thick, viscid mucus. In females, these worms sometimes pass into the vagina, and give rise to much uneasiness. The trichocephaloid (trichocephalus dispar, trichuris, ascaris trichuria), hair-worm, or thread-worm (Fig. 218), as it has been variously denomi- nated, is principally found in the caacum, and is very common in the inhabitants of England, Ireland, France, Italy, and Germany. It is also frequently met with in the inferior quadrupeds, especially the monkey, dog, and fox. This species is from one and a half to two inches in length, with a white, cylindrical body, which is almost as thin as a horse-hair anteriorly, the remaining third being considerably stouter, and terminating in a rounded extremity. The mouth is Fig. 218. Fig. 219. *a. The head ; 6. Intestines ; c. Sheath ; d. Penis ; *, natural size. orbicular the head extremely slender, and the capilliform portion transversely striated: the alimentary tube runs in a straight course from before backwards, and terminates in the thick bulbous part, where it assumes a flat, spiral form. The male is the smallest, and is 584 -INTESTINAL WORMS. distinguishable from the female by the sexual organs, which are inclosed in a sheath, by the greater brevity of the anterior capilliform portion, and by the peculiar circular whirl of the tail. The long tape-worm (taenia longa, taenia solium, taenia cucurbitiva) naturally infests the small intestines; but it has also been observed in the stomach, colon, and rectum (Fig. 219). This species is of frequent occurrence in different sections of the United States and Europe; and, according to Hasselquest, it is also very common in many parts of the East, especially amongst the Jews at Cairo, large numbers of whom are affected with it. The long tape-worm is of a whitish color, from three to six lines in width, and of the average length of sixty feet. Occasionally the length is enormous. Bremser relates a case where it was one hundred and fifty feet, and others are given where it was above three hundred. Towards the anterior part, this worm suddenly tapers off into a very fine thread-like extremity, which is surmounted by a small hemispherical head, provided with four lateral suckers. The body is flat, rough, and composed of numerous joints, on one edge of which there is a slight projection, pierced by a minute aperture. The configuration of the articulations, their relative length and breadth, are much influenced by the movements of the animal, and cannot be specifically defined. The worm is rarely expelled entire: most com- monly it is voided in pieces several feet long, and not unfrequently it comes away in single joints, looking like so many gourd seeds. In its organization it seems to be greatly inferior to the preceding species, being a homogeneous cellulo-gelatinous mass, with an alimentary canal, but without distinction of sexes, or trace of a nervous system. This variety of tapeworm seems to be at once androgynous and herma- phrodite ; each joint contains male and female organs, filled with ova, so that impregnation occurs by means of the approximation of two individuals, or, as is more commonly the case, by that of the joints of the same animal. The broad tape-worm (taenia lata, bothriocephalus latus, taenia mem- branacea) seldom exceeds fifteen feet, though occasionally it attains a much greater length. It is white, flat, from six to ten lines in width at the broadest part, which is near the middle, and consists of a series of concatenated joints, the intervals between which grow successively longer the nearer they approach the tail. In its general fea- tures, it bears a pretty close resemblance to the long variety; but the articulations are comparatively larger and stronger; the flattened surface of each link is per- forated by a small hole, and the head of the animal (Fig. 220, a a), when seen by means of a lens, is found to be of an elongated, elliptical shape, with a large fis- sure on each side of it. Both extremities are remarkably attenuated, especially the anterior, which is often per- fectly thread-like for twelve or fifteen inches. This worm inhabits the upper portion of the small bowel and is very common in France, Switzerland, Poland, and Kussia, several of them often coexisting in the same individual. PERITONEUM. 585 CHAPTER XXI. PERITONEUM. Is liable to different forms of Disease.—Acute Inflammation.—Deposition of Lymph.—Effusion of Serum, Pus, and Blood.—Softening of Subserous Cellular Tissue.—Parts of the Membrane most apt to suffer.—Development of Vesicles.—Chronic Irritation.—Agglutination of the Bowels and formation of False Passages.—Ascitic Effusions.—Generation of Gas.—Tubercles. —Carcinomatous Growths. The lesion of the peritoneum may be referred to inflammation, tubercles, melanosis, and cancerous growths. A very brief description of these several pathological states must suffice. 1. Acute Inflammation.—The common characters of acute inflamma- tion are increased vascularity, opacity, exudation of lymph, and effu- sion of serous fluid. The redness is generally of a florid tint, and is either punctiform, arborescent, stellated, or oaten-like, being always most intense in those cases where there is teast secretion. Under opposite circumstances, indeed, the redness is sometimes scarcely per- ceptible, and may even be entirely absent; not so much, perhaps, from the reflux of blood from the capillaries during the agonies of death, as from the manner in which they are drained during the vio- lence of the inflammatory excitement. Occasionally small ecchymoses are observed; and, in almost all cases, the membrane loses a considerable FiS- 221- share of its transpa- rency, assuming an opaque, turbid, whitish, or milky aspect. Much has been said concern- ing the thickening of the peritoneum in this disease; but if this con- dition ever occurs, it must be very rare. By the time the red- ness is fairly established, the affected membrane throws out coagulating lymph and serum. Whether both these Substances are Separated False membrane of peritonitis. From a specimen in my cabinet. simultaneously, or one precedes the other, are points which are not fully settled. By some 586 PERITONEUM. it has been supposed that the lymph is deposited first; whilst others maintain that the priority, if any, is always determined by the intensity of the inflammation. According to this theory, when the disease is very mild, serum seems to be thrown out first; but, if the excitement is very acute, the earliest product is lymph. To me it appears more than probable that both substances are eliminated at one and the same time, as we have reason to believe they are in the pleura and pericar- dium. At first, the lymph has a soft, unctuous feel; but by degrees it be- comes dense, firm, and organized, vessels being either developed in its substance, or else shooting into it from the surrounding parts. The period at which it is vascularized varies in different cases, from thirty hours to several days, or weeks. Of the numerous forms which this matter assumes, the band-like is by far the most common. (Fig. 221.) Not unfrequently, however, we find it deposited in small amorphous masses, filling up the intervals between the convolutions of the intes- tines, and gluing them more or less closely together. In some in- stances, again, this substance covers and unites the abdominal viscera in one confused mass. When partial, these adhesions sometimes in- duce fatal mischief, by strangulating the bowel. The lymph is sometimes deposited in distinct layers, varying in thickness from the finest silk to the coarsest cassimere. Of a light grayish tint, they are perfectly smooth and transparent, and often con- tain long, slender vessels, filled with florid blood. Such adventitious membranes, from the manner in which they are attached to and spread over the surface of the bowels, may form small pouches, distended with serous fluid. The serum poured out in this affection varies in quantity from a few ounces to several pounds, being always much less than in chronic peri- tonitis. In its color, it differs in different cases. Sometimes, especially when the inflammation is partial, it is clear and limpid, like water; at other times, it is of a pale reddish hue, whitish, or milky; and not un- frequently it is mixed with flakes of lymph, or possesses all the sen- sible properties of pus. An effusion of pus is a frequent termination in fatal cases, and occa- sionally takes place at a very early period of the disease; but in gene- ral it is not considerable in quantity until the affection has existed for some time. There is no breach of continuity of the peritoneum in suppuration. The color and consistence of the pus are various, being white, greenish, milky, or reddish, with shreds of membrane, flakes of lymph, or dots of blood. In very violent grades of this disease, it is not uncommon to find an effusion of pure blood. It usually presents itself in the form of clots, without any breach of continuity or rupture of the vessels. The quantity is sometimes quite considerable, and in all the cases that I have seen the peritoneum exhibited evidence of high inflammation. Another effect of peritonitis is softening of the subserous cellular substance. This lesion, although principally observable in the acute form of the disease, is by no means peculiar to it. It is generally associated with sero-purulent effusion, and is particularly conspicuous CHRONIC INFLAMMATION. 587 in the pelvic portion of the peritoneum, in the persons of lying-in females, and in those who fall victims to injuries of the rectum and urinary bladder. The softening, which sometimes involves a large extent of surface, often amounts to such a degree as to permit the serous membrane to be peeled off with the greatest facility from the organs which it serves to envelop. A similar pathological condition is occasionally seen concurrently with the preceding, in the submucous cellular substance of the stomach and bowels, produced, in all proba- bility, by an extension of the irritation from the serous envelop. All parts of the peritoneum are not equally liable to inflammation, the portions most commonly affected being the broad ligaments of the uterus, and the covering of the small intestines, especially of the ileum, together with the tunic of the spleen and liver. The parietal part of the membrane is rarely implicated; and the same remark is applicable, in a still higher degree, to the serous envelop of the stomach. In- deed, serous gastritis must be regarded as an extremely infrequent disease. ^ In all my dissections, I cannot recall more than a few in- stances in which this portion of the peritoneum betrayed the least sign of acute inflammation. The organ, it is true, is occasionally found glued to the neighboring structures, as the spleen, diaphragm, or arch of the colon; but even this circumstance is far from affording conclusive evi- dence that it was the seat of the effusion which led to this pathological condition. Nor does the disease remain always confined to the original seat of the attack. Thus it often happens that the external coat of the bowel is inflamed in the first instance, and that the irritation is afterwards propagated, either rapidly, or step by step, as it were, to the other layers, or even to the wall of the abdomen. In puerperal peritonitis, the inflammation frequently commences on the internal surface of the uterus, and progresses until it reaches the peritoneal coat. From thence, the process may diffuse itself over the whole peritoneum, or remain confined to the portion covering the uterus and adjacent organs. A development of gas is sometimes noticed in this disease. It is more common, however, in chronic inflammation, attended with copious sero-purulent effusion, and is probably caused by the decomposition of this fluid. Another effect is the formation of little vesicles, produced by the presence of air in the subserous cellular tissue. It is an evi- dence of a high degree of morbid action. Acute peritonitis generally ends favorably or fatally in from five to ten days from its invasion. Occasionally it is disposed to run into gangrene. This termination, which is more liable to occur here than in any other serous texture, is anatomically characterized by the black grayish color of the affected part, by its soft, pulpy consistence, by its disagreeable, fetid odor, and by the facility with which it can be ^craped off from the subjacent structures. If there be any adventi- tious membrane, it usually participates in the disorganizing process, assuming the same appearances as the pre-existing texture. 2. Chronic Inflammation.—In chronic peritonitis, the affected part is of a dull, rather dark color, the vessels are more dilated, and the sub- 588 PERITONEUM. jacent cellular tissue is more dense and thick. The serous texture itself is sometimes hypertrophied, not uniformly, but in patches; this effect, however, is by no means so well marked as is asserted by patho- logists, and, in fact, is often entirely absent. Brownish, grayish, bluish, or dark slate-colored spots, are frequently observable in this affection, and might be mistaken by the young anatomist for gangrenous eschars; from which, however, they can be easily distinguished by their firm- ness, want of odor, and great extent, the whole peritoneum being occa- sionally marked with them. But we must not always expect to find the membrane discolored; for, in protracted cases, it is more common to witness the opposite state, the affected parts being unusually white and milky. The false membranes of chronic peritonitis are often very thick, forming large masses of fibro-cellular substance, by which the abdo- minal viscera are agglutinated into one general mass. When these structures ulcerate, their ordinary color is a dirty green; but they may also present various shades of yellow, gray, and brown, especially when, as sometimes happens, they are much impregnated with blood. Occasionally these membranes do not become organized, but have a friable, rotten aspect. Masses of this description have been found from one to two inches thick, overspreading the whole peritoneum like a poultice of mashed carrots. The plastic lymph which is thus poured out not only serves to agglu- tinate the abdominal viscera more or less firmly to each other and to the inclosing parietes, but it occasionally becomes the seat of fistulous tracks, having either the arrangement of a blind sac, or communicat- ing at each extremity with the intestinal tube. In the only instance m which I have observed this condition, the canals were of an irregu- larly cylindrical shape, from two to four lines in diameter, and from two to nine inches in length. The course of all, five in number, was remarkably tortuous. The principal one extended in an oblique direction over the anterior surface of the small bowel, from the sig- moid flexure of the colon towards the right side of the abdomen; where, after a distance of six inches, it terminated in two branches, each three inches in length; one of which opened into the upper part of the jejunum, the other into the upper part of the duodenum. The internal surface of these channels was somewhat rough and fleecy, as if lined by a mucous membrane; their parietes were of a fibro-cartila- ginous consistence and insensibly blended with the surrounding ad- ventitious textures. At the time of making the examination, they all contained a small quantity of fecal matter, of the same nature as that found in the small and large intestines. The manner in which these new channels are formed may be ex- plained in one of two ways. In the first place, we n»ay suppose that they are generated under the immediate influence of ulceration and perforation of the bowel. Under ordinary circumstances, the conse- quence of such an event would be an extravasation of fecal matter into the peritoneal sac, rapidly followed by fatal inflammation. But, in a case like that before us, no such occurrence, it is obvious, could possibly take place, owing to the manner in which the intestinal coils CHRONIC INFLAMMATION. 589 are tied together. Hence, when the bowel becomes perforated, its contents, instead of escaping into the abdominal cavity, find their way into the connecting adventitious substance, where they excite ulcerat- ive action, and thus gradually generate passages of communication between different parts of the alimentary tube. What countenances this view is the fact that, in the interesting case which fell under my observation, there were numerous ulcers both in the small and large bowel, and that the new channels all opened into these reservoirs. The patient was about twenty-eight years of age, during the four last of which he had been harassed almost incessantly with griping diar- rhoea, the relic, apparently, of a severe attack of Asiatic cholera, com- plicated with acute peritonitis. Latterly, whenever he took food, it would generally in a few minutes pass by the bowels, in the same state as that in which it was swallowed. All the abdominal viscera were firmly and inseparably matted together; and the caliber of the whole intestinal tube was contracted to nearly one-half the original volume. In different parts of its extent the new substance was stud- ded with hard, grayish, miliary tubercles, distinctly encysted, and many of them as large as a common pea. We may suppose, secondly, that these fistulous tracks are formed under the influence of purulent matter, poured out either simultane- ously with the plastic lymph in which they are situated, or subse- quently to the establishment of adhesions. The fluid which is thus accumulated, instead of being absorbed, or extravasated into the peri- toneal sac, works its way into the neighboring intestinal coils, through which it finds a ready outlet. In proportion as the contents of the abscess are evacuated, fecal matter passes in and supplies their place; for the opening in the bowel, being prevented from closing up, remains permanently patulous. According to this theory, the ulceration of the intestinal tunic, it will be observed, is supposed to be consecutive to the formation of the fistulous tracks. The serum in chronic peritonitis may be perfectly clear and limpid; more commonly, however, it is of a greenish tint, white or milky, and blended with purulent matter, or flakes of lymph, or both together. Occasionally we find it reddish, from 'the exhalation of blood. The accumulation of watery fluid is sometimes immense. Thus in a patient mentioned by Dr. Beall,1 of Missouri, the amount of fluid, evacuated within a few years, was two hundred and seventy-five gallons and a half, the first fifteen operations yielding an average quantity of twenty quarts! It is a singular fact that the water in ascites occasionally exerts such a degree of pressure upon the recto-vaginal portion of the peri- toneal sac as to make the perineum bulge out in the form of a tumor. The swelling varies in size between an orange and a foetal head, and is generally of an irregularly oval figure, like the urinary bladder: it fluctuates distinctly under the finger, and disappears temporarily on pressure. When large it is translucent, and projects forward so as to occlude the mouth of the vagina. The internal coat of the tumor is 1 Western Journal of the Medical and Physical Sciences, vol. x. p. 343. 590 PERITONEUM. formed by the peritoneum, the external by the perineum, which is sometimes inverted. The matter which attends this disease, sometimes works its way along the spermatic cord, and points externally; at other times it escapes at the umbilicus, and instances occur in which it finds an out- let through the urethra. A person thus circumstanced may live a considerable period with a fistulous opening, or fatal inflammation may arise from the ingress of air. Chronic peritonitis may exist as an intra-uterine disorder. The chil- dren are pale and emaciated, and thick, old membranes are found in the abdomen, agglutinating the viscera so firmly together that it is diffi- cult to separate them. Even tubercles have been detected in several instances in children that have died within a few hours after birth. 3. Gas.—The peritoneum, like the pleura and pericardium, may contain air, or gas, either introduced from without, or generated within. Usually the affection coexists with serous fluid, blood, lymph, or puru- lent matter; and hence it has been supposed that the gas was the result rather of a chemical than of a vital process. Be this as it may, there is reason to believe that, when the accumulation is of a spontaneous nature, it is generally connected with inflammation, subacute or chronic, of the serous membrane. When the air is introduced from without it usually finds its way in from the alimentary tube through an ulcer or perforation, which may be small and difficult of detection. The quantity may be very trifling, or it may be so great as to cause severe suffering and even death. The gas is occasionally very offen- sive, from the presence of sulphuretted hydrogen, and escapes, when the abdomen is punctured, with a loud hissing noise. 4. Cartilaginous and Osseous Concretions.—(Fig. 222.) These bodies, although unfrequent, are occasionally found in the peritoneal cavity, accompanied or not by lesion of the abdominal and pelvic viscera. Generally loose and floating, they are sometimes attached by a sort of footstalk to the free surface of the serous membrane, and at other times in- closed in the subserous cellular tissue. In their form they are irregularly rounded, oblong, flat- tened, or ovoidal, and in their volume they vary from that of a pea to that of a small walnut. Smooth and polished externally, they are com- monly composed of a mass of cartilage arranged around a bony nucleus; they are of a dull whit- ish, grayish, or pearly appearance, firm, compact, and occasionally, though not always, elastic. Their mode of formation is probably similar to that of interarticular bodies, to which they bear the greatest resemblance in their physical and chemical characters. 5. Tubercles.—Tubercles of the peritoneum are sufficiently common, both upon its surface and in the substance of its false membranes. In their size these bodies vary from that of a clover-seed to that of a mustard-seed, currant, or even a pea; and they are often so numerous Cartilaginous and osseous concretions of the peritoneum. From a preparation in my cabinet. CARCINOMATOUS FORMATIONS. 591 as to cover nearly the whole peritoneum, thousands being visible in every direction, both on the visceral and parietal portions of the mem- brane. Occasionally we may see them in every stage of change, from the consistence of recent lymph to that of fibro-cartilage. In many cases they are confluent, like the pustules of smallpox, and have vessels shooting into them from the surrounding parts, which are highly vas- cular, as well as considerably thickened. Although there is no part of the peritoneum which is entirely exempt from these heterologous bodies, yet they appear to be much more liable to occur in some situations than in others. In my own dissections, I have constantly found them more abundant, larger, and more distinctly developed, in the iliac and pelvic portions of the mem- brane than at any other points. They are also frequently seen on the mesentery, the omentum, and the serous coat of the spleen. In the early stage of their formation, they are so soft as to be easily wiped away; but they gradually increase in density, and may finally assume a cartilaginous, and even bony hardness. In some instances they have the consistence of putty, dry curds, or of semi-concrete mortar. The older ones are generally distinctly encysted, the enveloping mem- brane, which is very thin and delicate, being evidently of new forma- tion ; those, on the contrary, which are more recent, are unprovided with such a covering. In the generality of cases, they occur in scrofu- lous subjects, in connection with tubercles of the lungs, spleen, liver, and other organs. They almost invariably give rise to the signs of chronic peritonitis, of which they constitute a frequent form, so that,, in addition to these heterologous deposits, exudations of lymph and serum with adhesions are met with. 6. Carcinomatous Formations.—The peritoneum is liable to the carci- nomatous formations, especially the colloid and encephaloid. Of scir- rhus, properly so called, I have never seen an example in this mem- brane, nor do I know that it has ever been observed by others, except as a secondary growth, extending to it from the adjoining structures. Of colloid cancer of the peritoneum a remarkable case has been al- ready described in the chapter on this disease, and an instance, hardly less extraordinary, came under my notice in the winter of 1854, in a gentleman, forty-five years of age, who was seen several times in con- sultation by my late colleague, Professor Flint, of Buffalo. The duration of the disease could not be accurately ascertained, but it probably ex- tended over a period of upwards of two years, during the last of which the patient was nearly constantly confined to his bed. He finally died in a state of complete exhaustion. The peritoneal cavity was entirely obliterated, except at a small space over the right lobe of the liver ; and was occupied by an enormous tumor, extending from the neck of the bladder to the diaphragm, which was pushed high up into the chest. All the abdominal and pelvic viscera were involved in it, but free from colloid disease. The convolutions of the bowel, large and small, were inclosed in and compressed by it; the stomach was in the same condition, and was much reduced in size. The spleen, pancreas, gall- bladder, the greater portion of the liver, and the urinary bladder, were surrounded by the tumor. The colloid structure of this immense 592 PERITONEUM. mass was well characterized throughout, being composed of numerous cells, varying from the volume of a mustard-seed to that of a hazel- nut, and occupied by a pale greenish, jelly-like substance. The most ordinary form in which encephaloid occurs is that of small tumors, from the size of a bean to that of an egg. Their shape is either spherical or pear-like, and their number is often quite great, from twenty to a hundred being found in the same individual. They are generally of a dull white color, mottled with dark spots, are surrounded by a very delicate yet distinct membrane, and are pene- trated at different parts of their circumference by minute florid ves- sels, which thus supply them with blood. The contents of these tumors are subject to considerable variety; for, whilst some are composed almost wholly of cerebriform matter, others are made up of a soft grumous substance, or of a fluid closely resembling thin jelly or half- boiled arrowroot. On some occasions they are exceedingly vascular, exhibiting an appearance very much like that of the spleen. These heterologous growths are most frequently observed on the visceral portion of the peritoneum, and they generally coexist with similar formations in other parts of the body. A huge encephaloid tumor of the peritoneum was sent to me, some years ago, by Dr. George E. Conant, of Huntington, Ohio, and is now contained in my private collection. It was taken from the body of a little girl, five years of age, and weighed eleven pounds nine ounces. It occupied the whole abdominal cavity, extending from the ensiform cartilage low down into the pelvis, concealing the small bowels, and ad- hering to the great omentum—from which it seemed to have originated —the uterus, the urinary bladder, and the parietal portion of the peri- toneum. The tumor is of a whitish yellow color, tabulated, soft and doughy, with numerous vessels, of a large caliber, ramifying over its outer surface. Internally, it has a distinctly fibrous arrangement, and contains numerous little cells, some of which are filled with pus, some with a thin, turbid sanies, some with blood. This immense encepha- loid mass could be easily felt through the abdomen during life, and its presence occasioned, especially towards the last, the most frightful dyspnoea, together with great emaciation and gradual exhaustion of the powers of the system. Melanosis is sometimes found in the peritoneum, the form in which it is poured out being liable to considerable variety. It may occur as an infiltration in the connecting cellular tissue; but more commonly it is deposited upon the free surface of the serous mem- brane, and observes a punctiform, stratiform, or nodulated arrange- ment. The parts of the peritoneum most prone to melanosis are the great omentum and the epiploic appendages of the colon, from the predilection, probably, which this substance has for the adipose tissue. In the nodulated variety, the tumors, whether isolated or agglomerated, generally adhere by a broad base, and are sometimes enveloped by cysts of fine cellular tissue, furnished with delicate vessels. When occurring in layers this substance is covered by a thin film of mem- brane, and is liable to be confounded with common hemorrhagic effu- sions, altered in their color by the chemical action of certain acids and OMENTUM. 593 gases, developed either in the intestinal tube, or in the peritoneal cavity. _ Finally, the omentum, a process of the peritoneum, is subject to va- rious diseases, but the only one requiring any notice here is chronic enlargement, or hypertrophy. This affection is most common in old and large hernias, attended with the protrusion and long retention of this membrane. Under such circumstances, the omen- tum is very liable to contract adhesions to the hernial sac, by which it is rendered ultimately irreducible; but in addition to this, it always becomes more or less enlarged from interstitial de- posits, and ultimately entirely deprived of its primitive structure, being converted into a hard, dense, solid body, feeling more like a mass of fibro- cartilage than a fold of peritoneum. Its surface, at this stage of the affection, is generally very rough, and tuberculated, as if it were inlaid with cherry- stones, or small pebbles; it is of a reddish, or yellowish color, and distinctly creaks under the knife. Cases occur in which the degenerated mass contains serous cysts, colloid, or fibrous nodules. A change in the form of the membrane is always ■a striking phenomenon in the morbid appearance. Instead of being spread out, so as to cover the abdominal viscera, as it does in the healthy state, it is always contracted in every direction, forming a mass, perhaps, hardly the volume of an adult's hand. On the, other, it occasionally forms an im- mense tumor, literally filling the abdominal cavity, and imparting an appearance similar to that oc- casioned by an enlarged ovary, for which it has been known to be mistaken. A good specimen of such a mass is represented in the adjoining cut (Fig. 223), from Liston. The omentum is liable to the heterologous formations, all of which may originate in it, and pursue the usual course. 38 594 LIVER. CHAPTER XXII. BILIARY APPARATUS. I. The Liver.—Weight, Color, and Analysis.—Lesions.—Inflammation.—Suppuration and Ab scess.—Gangrene.—Softening.—Induration.—Hypertrophy and Atrophy.— Cirrhosis.—Tu- bercles.—Carcinoma.—Melanosis.—Hydatids.—Adipose Transformation.—The Liver Fluke, and other Worms.—Cartilaginous Degeneration.—Osseous Concretions.—Sanguineous Effu- sions.—Erectile Tumor.—Restorative Powers of the Liver.—II. The Gall-Bladder. Inflam- mation.—Ulceration and Rupture.—Atrophy and Thickening of its Coats.—Diseases of the Biliary Ducts.—Alterations of the Bile.—Gall-stones. SECTION I. LIVER. In its weight, the liver varies from two pounds and three-quarters to three pounds and a half; consequently, it may be said to constitute about the thirty-fifth part of the entire weight of the human frame. Its volume, however, is much influenced by the state of its own circu- lation ; a circumstance which might be anticipated from the immense quantity of blood which is continually poured into it by the hepatic artery and portal vein. Of the extent of this influence, a good idea may be formed by removing the liver from the abdomen and washing out its fluids, when its bulk will be found to be considerably dimin- ished, as is shown by its collapsed and wrinkled aspect. Nor is this all. Whatever has a tendency to retard, interrupt, or prevent the return of the blood from the hepatic veins to the right side of the heart, must induce congestion, with all its necessary evils, in the organ under consideration. Hence it is found that disease of the liver is often directly dependent upon lesion of the heart or large veins. That the color of the liver should be modified, and, if I may so ex- press myself, controlled by the amount of blood which it receives, no one can for a moment doubt. Accordingly, we find that in the foetus, in which the liver is always remarkably vascular, the color is much more florid than some time after birth, or in the subsequent periods of life. In the adult, it is generally of a reddish-brown, with spots of blue, particularly along the anterior margin and under surface. In persons who are hung, the liver is usually of a deep pink color, and sometimes even quite purple. In simple congestion, the hepatic tissue is generally of a florid red, the arteries and veins are preternaturally distended, and blood flows freely on making sections of it. By a careless observer this condition INFLAMMATION. 595 of the liver might be confounded with inflammation, but may be readily distinguished from it by the greater uniformity of its color, by its pervading the entire organ, and by the facility with which the blood may be squeezed from its vessels. It has been shown that, when the congestion results from the portal veins, the granules are the parts which are most vascular; whilst, when it is caused by the hepatic veins, it is most distinct in the intervening cellular tissue. When both systems are filled with blood, the redness will be equally conspicuous in both textures. The human liver has been analyzed by different chemists, with the uniform result of detecting the presence of a certain quantity of fat. One of the-fetest examinations is by Mr. Beale,1 of London, who, in two healthy subjects, obtained the subjoined results:— Water ........ Fatty matter ....... Extractive, soluble in water and alcohol Extractive, soluble in water only, and albumen Alkaline and earthy salts .... Matter insoluble in water, alcohol, and ether . 100.00 100.00 A knowledge of the situation of the liver, in respect to the neigh- boring parts, is of no little importance in reference to the diagnosis of some of its structural lesions. Such information will also be in the highest degree useful, as enabling us to comprehend how an enlarged liver may compress the stomach and interrupt its functions; how it may produce jaundice, by impeding the flow of bile; or dropsy of the abdomen, by obstructing the return of the blood to the heart; and how abscesses, originally formed in the hepatic tissue, may burst into the surrounding organs. The position of the liver is sometimes singularly altered, even al- though it may not have undergone any change in bulk. Thus, in hydrothorax, it may be prominently felt, not only in the epigastric region, where a part of it is naturally situated, but also in the umbi- lical and left hypochondriac. On the other hand, in copious ascitic effusions it may be forced so high up into the chest as to encroach seriously upon the right lung, producing atrophy of that viscus, and terrible dyspnoea. Sometimes, again, the liver is pushed over into the left hypochondriac region, by an encysted tumor, or by enlargement of the right kidney. All these facts should be borne in mind, as they have an important relation to the diagnosis of abdominal diseases. The lesions which will be treated of in the present chapter, are, inflammation, suppuration, gangrene, softening, induration, hypertro- phy and atrophy, tubercles, cancer, melanosis, hydatids, fatty degene- ration, worms, cartilaginous and osseous concretions, apoplexy, erectile tumors, and laceration. 1. Inflammation.—Inflammation of the liver may involve either the proper substance of this organ or its investing membranes, and, like ' Budd on Diseases of the Liver, p. 279. Philadelphia, 1853. 68.58 3.82 10.07 1.50 16.03 72.05 4.28 10.40 1.19 12.08 596 LIVER. the same disease in other organs of the body, it may be either acute or chronic. The acute form of the complaint is of rare occurrence in this country, but is sufficiently frequent in hot climates. In warm lati- tudes, there is always a high degree of nervous excitability of the chylopoietic viscera, and hence nothing is more common than to see a large proportion of the maladies of those regions characterized by a predominance of inflammation of the stomach, liver, bowels, or spleen. In our Southern States, almost all diseases assume a bilious type; but whether the liver labors under much irritation, or is merely sympathetically affected, are points which still remain undetermined. The term congestive, so much in vogue among the physicians of those regions, seems to me to be often used unmeaningly, certainly without a proper regard to the fundamental principles of pathology. That the internal organs, and especially the liver and spleen, are often inun- dated with blood in the intermittent and bilious fevers of those dis- tricts, may be readily supposed; but that this condition can last long without inflammation, is what very few will be willing to concede. Inflammation of the liver occasionally assumes an epidemic type, affecting a considerable number of persons at the same time. An instance of this tendency occurred in 1828, in Dublin, where, prior to that period, acute hepatitis was looked upon as a very rare disease, a case being seldom met with more than once in a year or two, in the largest hospitals. At the date here specified, however, every institu- tion of the kind in the Irish metropolis had a considerable number of individuals afflicted with it, and of these not a few died. The anatomical characters of acute hepatitis vary according to the intensity of the irritative action, and the length of time it has been in operation. In general, the first perceptible effect is an increase of the vascularity of the parenchymatous structure, which becomes en- gorged in circumscribed spots, of a light red color. The part affected is somewhat tumid, and bleeds freely on being incised, but is not changed in its consistence; the hepatic canals are distended with a viscid, yellow, brownish fluid; and the acini are of a florid tint, and increased in size, though sometimes the reverse is the case, these bodies being much less distinct than natural. In a more advanced stage, in addition to the vascularity, the hepatic structure becomes singularly softened, so that it may be reduced, by the slightest pressure of the finger, to a mere pultaceous mass. This state is analogous to the second stage of acute pneumonitis, and may, like it, be accompanied by the formation of pus, or a deposit of lymph upon the serous surface. In this respect, however, there is a wide difference between the liver and the lung, as we seldom meet with inflammation of the substance of the latter without pleuritis, while the reverse often obtains in acute hepatitis. In its transition from the first to the second stage, the inflammation often gives rise to various shades of color. Thus, the parenchyma may be of a deep red, disposed in arborescent lines; or the vessels may encircle the acini in the form of wreaths, freely anastomosing with each other. When the disease is very intense, it is not unusual to see a number of small ecchymoses, produced by a rupture of some of the ABSCESS. 597 capillary arteries or veins; and instances occur in which the affected part assumes a deep brownish, violet, or mottled aspect, the latter appearance being particularly liable to happen when the inflammation occurs in circumscribed spots. In such cases, the whole portal circle is gorged with black blood, the biliary ducts are deeply injected, and their contents, being of a sero-sanguinolent nature, have no longer the bitter taste and ropy feel which characterize healthy bile. The mucous coat of the duodenum, also, is more or less phlogosed, and the minute branches of the hepatic artery and portal vein no longer admit inject- ing matter. It is not often that the whole of the liver is involved in acute inflam- mation : most commonly it is limited to its surfaces, its borders, or to some of its deep-seated parts. In the latter case, the disease sometimes escapes the attention of the examiner, owing to the normal aspect of the exterior of the organ. Hence the necessity, in all our investiga- tions, of removing the liver from the abdomen, and cutting it into thin slices. In some cases, especially such as follow surgical opera- tions, the hepatic and portal veins are inflamed; and instances occa- sionally occur in which they are filled with pus or fibrinous concretions. AVhen the inflammation is seated in the investing membranes, they exhibit the same appearances as the fibro-serous textures generally. Numerous vessels pervade them, passing up from the parenchymatous texture, and they are thicker and more opaque than in the healthy state. Lymph is also commonly deposited upon their outer surface, either in narrow bands, in small patches, or in considerable masses. The organ being thus glued to the neighboring parts, is often com- pressed, and much restrained in its movements. In some instances it is literally buried in lymph, and its adhesions being strong, much dis- section is required to liberate it. The disease, however, is seldom thus extensive. Acute hepatitis may terminate in resolution, the formation of matter, gangrene, or softening. Not unfrequently it passes into the chronic form, when it is liable to give rise to induration and other structural lesions. There is reason to believe that chronic hepatitis sometimes exists as a primitive affection; its invasion being very gradual, and unaccompanied by any severe symptoms. It is a much more frequent complaint, in this country, than the acute form; yet it is not so com- mon, perhaps, as the term " liver disease," so generally used by the profession, would lead us to suppose. The anatomical characters of the disease may be collected from what we shall say concerning in- duration, hypertrophy, atrophy, and fatty degeneration of this organ. 2. Abscess.—Although suppuration of the liver occasionally follows chronic inflammation, yet this effect is much more frequently witnessed as the result of the acute variety of the disease. The pus may be diffused, occur in small points, or be collected into one or more ab- scesses. The number of these purulent deposits is often quite great, the liver being literally burrowed by them; sometimes they com- municate together by narrow fistulous passages, but in most cases they are separated by considerable intervals, or by thin partitions of hepatic substance. Occasionally the abscess is of extraordinary size, occupy- 598 LIVER. ing nearly the whole of one lobe, or the greater part of the organ. In this way quarts of matter are sometimes accumulated, and the hepa- tic textures are almost entirely wasted. When the quantity of fluid is great, or if it be long detained, even when small, it is apt to become encysted, the membrane by which it is inclosed, and which is suscep- tible of organization, varying in thickness from the fourth of a line to a quarter of an inch, and in consistence from the softness of lymph to the firmness of fibrous tissue. In other cases, especially in such as run a very rapid course, the matter lies in immediate contact with the hepatic tissue, which is itself usually in a state of purulent infiltration, or very much softened and altered in color. The matter of a hepatic abscess usually partakes a good deal of the nature of true pus, being of a thick, white, cream-like appearance. Sometimes it is thin and sanious, sometimes thick and curdy, some- times thin and brownish, like chocolate, and sometimes of the color and consistence of a decoction of unburnt coffee. In the generality of cases it is destitute of smell; but occasionally it is highly offensive and irritating. Now and then the fluid contains flakes of blood of a dark gray color; and instances occur in which it looks like the washings of flesh. Suppuration of the liver does not always prove fatal. In many instances the matter has a tendency to discharge itself externally, or to force its way into some one of the adjacent organs. The principal circumstances which appear to influence the point of communication are the seat of the abscess and the general volume of the hepatic tumor. In the abdomen, the opening usually takes place in the peri- toneal sac, the colon, duodenum, the stomach or gall-bladder; when the abscess points externally, the matter may find its way out at the epigastric region, the right loin, or between the false ribs, usually by a narrow, fistulous route. It is not improbable that the pus may sometimes pass into the bowels through the biliary ducts; and in- stances are mentioned in which it found an outlet through the right kidney. When the abscess is seated at the upper border or on the convex surface of the liver, it may break into the right side of the chest, where it either excites fatal inflammation, or it erodes the pul- monary tissue, and is finally discharged through the bronchial tubes, between the ribs, or even through the axilla. In one instance the matter was discharged into the vena cava. But the most extraordinary circumstance connected with this subject is, that the fluid sometimes works its way into the pericardium. Of this interesting cases have been reported by Mr. Knott, of India, Mr. Allen, of Mauritius, and by Professor Smith, of Baltimore. In the latter, the liver adhered closely to the upper part of the diaphragm, and was occupied by an enormous quantity of pus, about a quart of which had escaped into the pericardium. In a case detailed by Dr. Graves,1 of Dublin, the abscess opened both into the pericardium and the stomach. When the matter is discharged, the abscess sometimes heals, the process being Dublin Medical Journal, January, 1839. GANGRENE. 599 analogous to that which is observed under like circumstances in the lungs and other organs. Hepatic abscesses are very rare in the colder regions of this country, but sufficiently common in our southern latitudes. Some years ago there were, within the space of a few months, nearly a dozen cases of this disease, all from Louisiana, in the Louisville Marine Hospital. In Europe, abscesses of the liver are also extremely rare;' while in the East and West Indies they are very frequent. In acute hepatitis, pus usually begins to be deposited in the course of six or eight days from the commencement of the attack ; whereas, in chronic cases, months often elapse before the occurrence of this event. Abscesses of the liver are liable to be produced by irritation of the lungs; and in many instances they supervene upon injuries of the head, large wounds, and surgical operations. The matter in these cases is supposed by some to be transmitted with the blood through the veins, from remote and diseased parts; but the more plausible opinion ascribes its origin to inflammatory irritation of the substance of the liver, brought on by some inscrutable sympathetic action. That matter may be thus conveyed is probable; but that it should create irritation in one organ in preference to another, is a point in pathology which cannot be very easily comprehended. If it has any truth at all, it forms merely an exception to the general rule. To admit that abscesses may be thus produced in any organ, is to admit that such an organ has an elective attraction for the purulent fluid that shall be flowing in the circulating mass; or, on the other hand, that its tissues are so close and peculiar, its capillaries so exceedingly fine, as to entangle the matter, and retain it forcibly in its interior. To me the hypothesis appears not only objectionable, but very absurd. The mode of development of these metastatic abscesses, as they are denominated, is remarkably insidious, and is frequently connected with jaundice and phlebitis. Usually not larger than a hemp-seed, a pea, or a filbert, they are of an irregularly rounded shape, and much less perfectly circumscribed than when they are seated in the lungs. They may occupy any portion of the liver, but in most cases they are situated superficially; their number varies from one to several dozens, and their contents, which are commonly of a reddish, yellow- ish, or greenish color, are of a semi-concrete consistence, like that of a mass of fibrin. The hepatic tissue around these abscesses may be unaltered; but in general it is softened and preternaturally vascular. When they are seated superficially, the peritoneal covering is apt to participate in the morbid action. Commonly they succeed the original lesion on the tenth or twelfth day. 3. Gangrene.—The termination of acute hepatitis by gangrene is exceedingly rare. Baillie2 never witnessed an instance of it, and Annesley, although for many years an inter-tropical practitioner, and constantly in the habit of making examinations, declares he has not ' Andral's Pathological Anatomy, vol. ii. p. 373. 2 Morbid Anatomy, p. 136. I 600 LIVER. been more successful.1 In several thousand dissections made by An- dral,2 this lesion occurred only in a single case. The mortified part is very soft and lacerable, extremely offensive, of a dark color, and per- vaded with sanious fluid. 4. Softening.—Softening of the liver is a common and destructive affection in warm latitudes; but is very rare in the more temperate regions of America and Europe. That this is the case I am disposed to believe from my own experience, and from the few cases that are reported of this disease in our periodicals. The softening may present itself under two distinct forms, differing from each other both in their color and consistence, but resulting probably from the same cause, namely, inflammatory irritation. In the more common variety, which may be denominated brownish softening, the substance of the organ usually retains its normal color, but is broken down and friable, or has so far lost its cohesive properties that it readily yields to the force of the finger. In some instances, the affected part is infiltrated with thin, bloody, sanious, or puriform matter, and is converted into a soft, brittle mass, not unlike a rotten pear. When put in water, an im- mense number of small granules appear, resembling the seeds of a bunch of dried grapes: they are of a yellowish, brownish, or cinna- mon color, and are attached to the large vessels by delicate vascular pedicles. In other cases, maceration produces an appearance like the washings of half putrid flesh, the water becoming discolored, and the part exhibiting multitudes of shreds, the remains, probably, of vessels and fibrous filaments. This variety of mollescence is generally most remarkable on the convex surface of the liver, and occurs almost always in combination with disease of the other viscera, especially of the stomach, spleen and lungs. It appears to be frequently met with in India, in persons who are rapidly carried off by cholera, dysentery-, and malignant fevers. The second species of softening has received the name of black, and, from its close resemblance to gangrene, is probably the result of a higher grade of inflammatory action, disorganizing the parenchymatous texture. It commonly invades a large extent of surface, sometimes, indeed, almost the whole organ, which it reduces to a dark pultaceous mass, having the consistence and aspect of grumous blood, or of a black, softened spleen. In some instances, the affected part emits a remarkably fetid odor; a circumstance which, together with its color, has given rise to the belief that the disease is analogous to, if not identical with, gangrene. The size of the liver is commonly dimi- nished; it may, however, be perfectly natural, and occasionally it is considerably augmented. Softening of the liver may run a rapidly fatal course, with symp- toms of jaundice and of irritation of the brain. It is to this form that the term yellow atrophy of the liver has been applied. The organ is reduced in size and of an intensely yellow color. In the softened 1 Diseases of India, vol. i. p. 435. 2 Pathological Anatomy, vol. ii. INDURATION—HYPERTROPHY—ATROPHY. 601 parts, complete destruction of the hepatic cells has occasionally been noticed. The causes of softening of the liver are not well understood; but that it depends upon inflammation, either acute or chronic, is indis- putable. 5. Induration.—In induration the substance of the organ is unna- turally hard, firm, and dense, exhibiting, when torn, a singularly granu- lated surface. The volume of the gland may be unaltered, but in most cases it is much reduced, occasionally nearly one-half. The color varies in different instances, from a pale red to purple, nutmeg, brown, or lilac. A pale olive hue is sometimes met with. Induration commonly results from chronic inflammation, and is characterized by great thick- ening of the fibrous structure, and remarkable atrophy of the hepatic granules. In some cases, indeed, the granules seem to be entirely removed, their place being occupied by cellular tissue, very hard, and of a dull grayish color. The tunics of the liver usually participate in the condensation; the cellular substance accompanying the rami- fications of the hepatic artery and portal vein is frequently indurated ; and many of the excretory ducts are permanently obliterated, whilst others are thickened, and of almost gristly consistence. The induration is not always partial: we frequently see it pervade the entire organ, though in the majority of cases it occurs in patches, or is limited to particular parts. The right lobe and lobule of Spige- lius are perhaps more generally implicated than any other portions. Induration of the liver occurs in all cases of cirrhosis. 6. Hypertrophy.—Hypertrophy of the liver is a frequent affection, and in by far the greater number of cases, if indeed not all, it is combined with induration or softening. The color, size, and form of the liver in this affection vary infinitely, according to the period of its existence and the nature of the primary lesion. The most common tints are pale red, gray, brownish olive, dark green, mahogany, and nutmeg. These colors are frequently more or less blended, so as to impart a variegated appearance to the parenchymatous structure. The hypertrophy may be limited to a single lobe, or it may occur in all of them at the same time; most commonly, however, it attacks the right side. The shape of the liver may be variously affected; and the surface of the organ is frequently very rough, granulated, furrowed, notched, or mammillated. Hypertrophy of the liver results from slow and protracted inflam- mation. It is very common in young strumous subjects, in habitual drunkards, and in those whose constitution has been tainted by syphilis. The enlargement in these scrofulous livers would seem to arise from a deposition of albuminous material within the lobules. The liver is tough and of a light hue. A section is smooth and homogeneous, resembling bacon, whence it has been termed by some the lardaceous degeneration; whilst others, from its being almost uni- formly an accompaniment of a scrofulous diathesis, have described this form of hypertrophy by the name of scrofulous enlargement of the liver. 7. Atrophy.— Atrophy of the liver is much less frequent than hyper- 602 LIVER. trophy, and usually occurs in union with induration or mollescence. It often affects the whole organ; but it is much more common to find it limited to one of its lobes, and, what is rather paradoxical, the liver may not only be of its natural dimensions, but even enlarged. In speaking of induration, mention was made of the fact that the granular structure is sometimes entirely absorbed and replaced by dense cellu- lar substance. In this case, although there may be no diminution of bulk, there is yet an actual wasting of the hepatic tissue, the part affected being reduced, as it were, to its primordial framework. The color of an atrophied liver presents every variety of shade, from grayish-white to light brown or cinnamon. This state of the liver often occurs in persons who are in the con- stant habit of using ardent spirits. It is rarely seen before the middle term of life, and is most common in old age. The hepatic vessels are always much diminished in size, and the functions of the organ more or less impaired. Its cause is manifestly chronic inflammation, pro- ducing an effusion of lymph and a partial absorption of the granular tissue. The atrophy is frequently connected with ascites, either as cause or effect. 8. Cirrhosis.—When the inflammation has its main seat in the fibrous structure of the liver, it leads to a deposition of albumino-fibrinous matter, which is transformed into fibrous tissue, and by contracting around the hepatic parenchyma gives to it that peculiar granu- lated appearance known as hob- nail liver or cirrhosis. The tex- ture of the granulations is dense and compact, and exhibits a great variety of tints, being sometimes of a deep brownish red, sometimes of a tawny yellow, like beeswax, and not unfrequently of a pale cinnamon, pink, or lilac hue. When cut, they present a per- fectly flat surface; and, if further examined, are found to be in- vested by a dense cellulo-fibrous capsule, of a light grayish color, from which they can be easily removed by dissection, their principal bond of connection being a small pedicle, through which they receive their supply of vessels, nerves, and absorbents. The size of the granulations is extremely variable, even in the same liver. In general, they do not exceed a garden pea, and frequently they are not larger than a currant or a hemp-seed. In one case I found many of the granulations as large as a hazel-nut, as seen in Fig. 225. The liver weighed five pounds and a half. In their shape these bodies are mostly spherical, or irregularly rounded; not a few, however, have a compressed, flattened, or angular appearance. Some of the granulations become hypertrophied, others atrophied. Cirrhosis of the liver. From a specimen in my collection. CIRRHOSIS. 603 However this may be, they consist mainly of healthy liver paren- chyma. The secretory cells are unaltered. The vessels, especially the smaller ones, are obliterated, which may account for the atrophy of some of the granulations, whilst others which escape the con- striction and the diminution of their nervous and vascular supply, instead of becoming wasted, enlarge. What favors this view of the Fig. 225. Fig. 226. Hypertrophy of hepatic acini. From a preparation in my cabinet. subject is that the hypertrophied acini are all furnished with separate footstalks, which are easily demonstrated by the knife, and which serve to convey to them the vessels, nerves and lymphatics, which exist in them in the natural state, and which are now more or less enlarged. The atrophied acini, on the contrary, have no such provision, or, at all events, only a very slight and imperfect one; as the disease advances their vessels are obliterated, and their whole substance finally disappears. When these granules are very numerous, not large, and of a varie- gated brownish color, they give the liver a peculiar nutmeg-like appear- ance, as in Fig. 226. This state of the organ is most common in old dram-drinkers, as a result of repeated attacks of chronic irritation, or long-continued congestion. Indeed, whatever causes obstruction of the portal circle may give rise to it. In whatever form cirrhosis occurs, the surface of the liver generally presents a singularly mammillated aspect, as if it were raised into a multitude of spherical eminences; the peritoneal coat is thickened, opaque, and wrinkled; and the volume of the organ is either dimin- ished or augmented, seldom natural. In the former case, the hepatic texture is generally very dense, and almost destitute of moisture; in the latter, regarded by some as the first stage of the disease, it is usually somewhat soft, more or less vascular, and impregnated with a thin, bloody fluid, which can be easily squeezed out with the fingers. In both varieties, but more especially in the first, the hepatic tissue is often of a yellow tinge; and the bile being retained in the rootlets of the hepatic duct, exudes pretty freely on making sections of it. If, in this state, a 'portion of liver be macerated for ten or twelve days in water, the little granules will assume the appearance of adipocire, and may be easily washed out of their cellulo-fibrous capsules, leaving them in a soft, ftacculent condition. In the advanced stages of cir- rhosis, especially when there is great diminution with contraction of the liver, many of the vessels and ducts are obliterated, and the organ 601: LIVER. receives injecting matter with difficulty. Occasionally a collateral venous circulation is established by way of the diaphragm. Cirrhosis, although occasionally met with in children and young persons, is most common between the thirtieth and fiftieth years. I have repeatedly seen it in very old subjects. It rarely exists by itself, but is almost constantly associated with organic disease of other parts of the body, particularly of the heart, kidneys, and lungs. The most common complication is chronic lesion of the heart, which is often present, and frequently attains such a degree of development as to render it probable that it had preceded, if not actually given rise to, the disease of the liver. The morbid alteration of the kidney, known as Bright's disease, is also of common occurrence. Cirrhosis very rarely exists in connection with tubercles of the lungs. The fatty degeneration of the liver, on the contrary, is a frequent compli- cation of consumption. In the latter stages of the disease there is almost invariably ascites with auasarca, oedema of the lungs, hydro- thorax, pericarditis, purulent effusion into the peritoneal cavity, pneu- monia, pulmonary apoplexy, or intestinal hemorrhage. Occasionally several of these complications coexist. 9. Fatty Degeneration.—The liver is liable to the fatty degeneration, the new matter upon which this effect depends being either diffused through the whole organ, or limited to particular sections. The change is characterized by a pale yellowish, or light buff-color, by a diminu- tion of consistence, and by an unctuous feel, the part perceptibly greasing the finger or scalpel, and yielding, on boiling, a brownish oily fluid, varying in quantity, in different specimens, from twenty to sixty per cent, of the entire mass. The oily matter, of which there is always a small quantity in the healthy liver, presents itself in the form of globules, of various sizes, which occupy the hepatic cells, distend- ing their walls, and often obscuring their nuclei. Numerous globules, not inclosed in cells, are also seen under the microscope. A fatty liver is always larger than a healthy one, and its edges are generally somewhat knobby or obtuse. Its surface frequently exhibits small brownish spots, streaks, or lines, which, from the manner in which they are arranged, give it a very singularly mottled appear- ance, not unlike that of the liver of the shark, cod, and other oily fishes. When a section is made, the interior is found to be of a much more uniform color, being of a pale yellow, deep orange, or light olive. The hepatic substance is always diminished in specific gravity, and its vessels, although compressed, and scarcely perceptible, still retain their normal structure, being perfectly permeable, and trace- able to their minute divisions. The branches of the portal vein are engorged with black blood, and the excretory ducts contain unusually dark, fluid bile. The hepatic lobules are wasted, but the interstitial cellular tissue is remarkably distinct and abundant. The fatty degeneration occurs most frequently in drunkards and phthisical subjects. It has also been observed in chronic affections of the lungs, heart, brain, kidney, and bowels, and in certain forms of cancer, as scirrhus and melanosis; but whether as cause or effect is still undetermined. It is more common in women than in men, and CHANGE OF COLOR. 605 in the young than in the old. Indolence and huge feeding favor its development. Fatty degeneration of the liver has recently been de- scribed by several of our American pathologists as a constant lesion in yellow fever. Various hypotheses have been offered with a^view of accounting for this curious state of the liver; but the only explanation which seems to me to be at all tenable, is that which ascribes it to chronic inflam- mation, with venous engorgement, giving rise to an augmentation of the secretion of fatty matter, which is naturally contained in the organ, or to a fatty degeneration of the hepatic cells. This opinion derives support and illustration from what is observed in the inferior animals. In the goose and duck, an almost complete adipose transformation of the liver may be induced in a few weeks, simply by subjecting them to inactivity, withholding the light, and cramming their stomachs with paste made of barley-meal, mutton-suet, and coarse sugar, mixed with milk. This mode of fattening fowls has been pursued for many years in the neighborhood of London, and it has been found that if the repletion be kept up longer than a fortnight, so much structural lesion will be induced as to kill them, or render the meat unfit for the table, the liver being converted into a soft, red, oily mass. In the human subject, this change sometimes takes place very rapidly, as in the course of a week; and the organ is not unfrequently double the usual weight and bulk. The bile is variously affected in this disease, being at one time very thin and pale, at another thick and dark-colored, at another greenish, olive, or brownish, viscid, and full of carbonaceous granules. The addition of almost any of the acids frequently produces an intolerable stench. The urine, too, is often sensibly changed in its properties, being commonly of low specific gravity, quite neutral, and accompa- nied by an unusual quantity of mucus. 10. Change of Color.—The liver is sometimes remarkably changed in its color. Thus, it may be of a light drab, milky-white, dusky- brown, nutmeg, yellowish-gray, amber-yellow, bronze, olive, slate, jet- black, or purple. The alteration may be general or partial, superfi- cial or deep-seated, continuous or maculiform. A bluish, slate, or gray color is often present when the organ is apparently perfectly healthy. The livid or purple hue is most common in congestion of the portal circle; the different shades of drab and yellow, in the fatty degenera- tion ; the black, in acute hepatitis of tropical climates ; and the bronze, gray, and olive, in the remittent fever of the United States. Dr. Stew- ardson, formerly of this city, found this alteration so constantly in those who died of this disease under his care, that he is disposed to regard it as its essential anatomical characteristic. The color consisted of a mixture of gray and oli^e, bronze, or some shade of lead, which had entirely supplanted the reddish-brown, or left only faint traces of it. The alteration existed uniformly or nearly so throughout the whole extent of the organ, except in a single instance, in which a part of the left lobe retained its natural complexion. The liver was frequently enlarged, and its consistence generally diminished: the bile in the o-all-bladder was abundant and perfectly fluid: the spleen was soft- 606 LIVER. ened and enlarged in every instance. The discoloration described by Dr. Stewardson has been noticed by other observers; but the question is still unsettled whether it constitutes the distinctive anatomical fea- ture of remittent fever. Prof. Clark' ascribes the color in this fever to a deposit of pigment substance of varying shade and size. Some is of a transparent dark- brown, some red, orange, or jet-black. The coloring matter exists in the shape of globular particles, or in thin scales. The black pigment appears to be identical with the melanine described by Scherer and Robin. The adventitious matter is diffused through every part of the tissue; it occupies many of the secretory cells. The color of the liver is very much altered in yellow fever. Dr. Chisholm, in his dissections in the West Iudies, in 1793, found the organ of a color nearly approaching to buff, or a mixture of yellow and cineritious. The same appearance has since been noticed by Dr. Ruffz at Martinique. In the examinations of Louis at Gibraltar, the liver was invariably changed in its complexion. The most striking tints were those of fresh butter, straw, coffee and milk, mustard, orange, and buff. This alteration of color extended, in most cases, through the whole substance of the organ, although it was more prominent in the left than in the right lobe; and was associated with more or less anaemia and dryness of the hepatic tissue. Dr. Ashbel Smith, of Texas, found the liver of a light drab color, both externally and internally, in three cases out of seven. In one hundred and fourteen examina- tions by Dr. Dowler, of New Orleans, the organ was of a yellow, orange, lemon, straw, brass, gingerbread, or cork color in fifty-four; and in the remainder of the cases it presented various shades of yellow and milky, nutmeg and straw, brown and yellow, bronze and reddish, pale brown and mahogany, chocolate, mahogany and white, flaxseed, dark and greenish. It is to be regretted that this observer has not stated whether the discoloration noticed by him pervaded the entire organ, or was limited to particular parts of it. It has already been mentioned that the yellow color is presumed to depend on the fatty degeneration of the liver. The liver-cells are in many cases filled with oil-globules; but whether the degeneration of the liver is a con- stant and characteristic morbid change in yellow fever, has yet to be determined. Dr. Charles Frick, of Baltimore, recently communicated to me the particulars of a case in which the whole interior of the liver was uni- formly of a light apple or pea-green color, the outer surface of the organ being of a bronze hue, which also pervaded the entire skin. The patient, a man, aged twenty-five, had labored for a number of months under jaundice, and latterly, under ascites, hemorrhage, and black urine. The liver was cirrhosed, and one-third smaller than usual. Its fibrous structure was abnormally developed, and its lobu- lar arrangement very clearly defined. Under the microscope the hepatic cells were found to be filled with the same coloring matter that was so conspicuous upon its cut surface. The gall-bladder contained 1 La Roche on Yellow Fever, vol. i. p. 610, 1855. HETEROLOGOUS PRODUCTS — SCIRRHUS. 607 about half an ounce of light green bile. The abdominal cavity was distended with serum, and the intestinal canal was filled with dark fluid blood. The kidneys were congested and somewhat enlarged, but otherwise sound. The supra-renal capsules were perfectly normal. _ 11. Heterologous Products.—The liver is liable to tubercles, seated either in the substance of the organ, or scattered over its surface, giving it, in the latter case, a rough, mammillated appearance. Lying in close contact with each other, or separated, as the case may be, by- large intervals, these bodies are generally of a rounded shape, and consist of an opaque yellowish substance, in various degrees of matu- ration. Their size, although sometimes not exceeding that of a mus- tard-seed, is usually considerable, many of them being as large as a cherry or even a hazel-nut. When the liver is thus tuberculated, it feels much harder than natural, and its vessels are compressed and sometimes greatly reduced in volume, though the organ itself rarely deviates much from the ordinary standard. In some cases, the tuber- cles bear a strong resemblance to those of the lungs: they have the same size, form, and consistence, but are a little browner in their color. They are always connected with a scrofulous diathesis, as is manifested by their frequent coexistence with pulmonary phthisis, and by their contents being usually of a curdy nature. Scirrhus always occurs in distinct masses, the size, form, and con- sistence of which exhibit numerous diversities. The smallest are fre- quently not larger than a mustard- seed, but their volume may equal that of a chestnut, a walnut, or an orange. In a specimen in my private collec- tion, the tumors, two in number, are about the size of a common apple: they are of a spherical form, hard, dense, gristly, and situated in the very centre of the organ. The masses sometimes lie close together, and, by their agglomeration, form a tumor equal in size to a foetal head. These heterologous structures seldom occur singly. In the majority of cases, there are not less than six or eight; and I have seen instances where there were as many as two or three hundred. In their form, these tumors are generally spherical; and those which project beyond the surface of the liver, for which they have a great predilection, have often a white-grayish dimple in their centre, pro- duced probably by a condensation of the subserous cellular substance. The smallest, and those of recent formation, are of an opaque white appearance, and are intimately connected with the surrounding tissues; such, on the contrary, as are old, and of great magnitude, are often of a brownish color, with various shades of gray and black, and can be easily lifted from their situation. Vessels frequently shoot into them, sometimes so large that they can be filled with injecting matter: of the liver. From a specimen in my collection. 608 LIVER. they also no doubt receive nerves and absorbents, but their existence has not been demonstrated. To the touch they are hard and firm, like fibro-cartilage, the largest and densest yielding a slight creaking sound under the knife. The section generally displays a fibrous struc- ture, the fibres radiating irregularly from the centre towards the cir- cumference, like those of a turnip. In other cases, the tumor is lobu- , lated and internally areolar, filaments of a grayish, brownish, or yellow- ish hue intersecting it in every possible direction. A white, milky juice may be obtained from them by pressure, and, in the cellular variety, a substance of the consistence and color of thin putty, paste, or concrete lard. Small masses of blood are sometimes diffused through them; but this occurrence is rare, except in such as are old, or in a declining state. The hepatic substance in the immediate neighborhood of these bodies is, in most cases, perfectly sound; in others, it is indurated, softened, infiltrated with different kinds of matter, or partially ab- sorbed. Hypertrophy of the liver is sometimes observed; but a much more common occurrence is an extreme reduction of its weight and bulk. When the tumors are numerous, the larger vessels are apt to be compressed; and, as a consequence, the organ is often exsan- guineous. From the same cause may result obstruction of the hepatic duct, with retention of bile, and yellowish discoloration of the paren- chymatous texture. Encephaloid of the liver is occasionally observed, though, according to my observation, not so often as scirrhus, with which it probably has a similar origin. Like the preceding variety, this species of cancer occurs in various sized masses, of a grayish-white color, soft, compres- sible, and elastic, with considerable vascularity. They offer very little resistance to the knife, and are composed of an areolar meshwork, occupied by a soft, pulpy, brain-like substance, intermixed with fibri- nous concretions, and dark-colored clots. The intersections are com- monly of a lighter tissue, and, instead of being dense and thick, are eminently lax and delicate. Occasionally, though very rarely, the contents of these tumors are of the nature of hard jelly, constituting the gelatiniform sarcoma of some pathological anatomists, and the col- loid cancer of others. The liver is sometimes much enlarged, and presents a mixed mass of disease—carcinomatous, encephaloid, and melanotic—in various stages of maturation. The encephaloid matter is occasionally deposited in the portal and hepatic veins, so as to ex- hibit a ramiform arrangement. Melanosis of the liver exhibits the same characters as in the other organs. I have rarely seen this deposit in the human liver, but repeat- edly in that of the ox, in which it is by no means uncommon, especially in the South-West of the Union. In a specimen in my cabinet there are a great number of melanotic masses, arranged in the form of en- cysted tumors, varying in size from a small pea to a walnut. (Fig. 228.) In man, the matter either assumes the tuberiform arrange- ment, or is diffused throughout the parenchymatous structure as an infiltration. 12. Hydatids and Serous Cysts.—Hydatids of the liver may oc- HYDATIDS AND SEROUS CYSTS. 609 Melanosis of the liver. From a specimen in my col- lection. cupy the interior of the organ, or stud its surfaces. They may occur at any period of life, although they are most usually witnessed in adults, and in persons who have been addicted to intemperate eat- ing and drinking. Commonly of a globular shape, they are often closely clustered together, and are always contained in a cyst, form- ed of a dense, fibrous texture, and of a white, opaque appearance. In one of my cases the hyda- tids looked like spherical bags, the largest of which was about the size of an onion, whilst the smallest was hardly as big as a rifle-ball: their external tunic was dense, opaque, marked with nu- merous yellowish dots, and liber- ally supplied with vessels: their number did not exceed fifteen. The liver was much reduced in size, pale in color, and in many places so soft as to be unable to withstand the slightest pressure of the finger. When these bodies are large or numerous, they may perforate the liver, and escape into the peritoneal cavity, as I witnessed in a man, thirty-five years of age, whom I attended along with Dr. Richards. The hydatids were of a dirty yellowish color, opaque, and from the size of a marble to that of a pullet's egg. They had been contained in a large sac in the right lobe of the liver, the anterior surface of which had given way, and thus permitted them to pass into the abdo- minal cavity, where they speedily excited fatal inflammation. In some instances they escape into the alimentary canal, and are dis- charged with the feces. In the human subject, there are no mani- festations of the presence of these bodies during life, apart from those of chronic hepatitis. The disease may simulate ascites; and not a few cases are recorded in which the patient was actually tapped for this complaint. These parasites are not peculiar to the human subject; they occur also in the inferior animals, especially in the ox, hog, and sheep. In these quadrupeds, the organ is sometimes completely crowded with them, immense numbers being everywhere scattered through its sub- stance. Less complicated in their structure than hydatids are those serous cysts which are sometimes observed on the surface of the liver, and which constitute what writers have described under the name of en- cysted dropsy. The walls of these vesicles are generally transparent, smooth, polished, and supplied with numerous vessels, of the finest texture and most beautiful arrangement. Their contents, which are thin and limpid, like the water of ascites, are coagulable by heat, alcohol, and acids. In some cases these tumors hang from the con- 39 610 LIVER. Fig. 229. a. The mouth ; b. Suctorious disc ; c. Ge- nerative orifice. vex surface of the liver, in the form of globular bodies, about the volume of a walnut. Their most common size is that of a grape; but they may increase to a magnitude capable of holding many pints. 13. Worms.—The liver-fluke, the distoma hepaticum (Fig. 229), of helminthologists, although it has been several times seen in the human subject, is much more common in the inferior animals, as the sheep, horse, stag, and ox. It is also found in the gall-bladder; and Pallas mentions that he once detected it in the hepatic duct of a young female. Somewhat lanceolate in shape, it is of a yellowish color, obtuse at each extremity, and scarcely a fourth of an inch long by one line in breadth. It has two openings, one in front, which is directed obliquely inwards, and another behind and inferiorly, which is slightly prominent, and answers to the anus; the neck is rounded, and of a light brownish hue; the belly is marked by spots of an opaque dingy white. The worm is thought to have a distinct genital apparatus, with a vascular, and pro- bably also a nervous system. In animals, it is often an inch long, by nearly half an inch in breadth. Worms sometimes crawl from the duodenum into the liver, where they have been known to create profuse suppuration, followed by fatal irritation. They generally be- long to the lumbricoid species, and may be quite numerous, though ordinarily there is only a single one. They are always lodged in dis- tinct pouches, communicating with the hepatic and choledoch ducts, the parietes of which are much dilated and perforated in every direction. The parenchymatous substance around is in a state of disease, and the whole organ is frequently considerably enlarged, as well as exten- sively adherent to the surrounding parts. Lumbricoid worms are more common in the inferior animals than in the human subject. In the liver of the hog I have repeatedly seen both the vessels and excretory ducts of that organ filled with them, and I have also sometimes met with them in dogs, especially old ones. In examining, some years ago, the liver of a rat, I discovered a serous cyst, about the size of a small marble, on the under surface of the organ, which contained a taenia one foot in length by two lines in breadth. (Fig. 230.) The parasite was completely coiled up, and lived for upwards of an hour after its removal. The liver itself was per- fectly sound. The specimen is preserved in my private collection. 14. Transformations.—Deposits of cartilage are sufficiently rare in ^his organ; most frequently they are confined to the investing mem- branes, occurring in small patches, of a soft texture and grayish color. The deposits are sometimes entirely osseous, being composed essen- tially of carbonate and phosphate of lime, with a small quantity of animal matter. The individual concretions are of irregular shape, of a whitish or yellowish color, and of variable dimensions, from that of an American dollar down to that of a five cent piece. I have repeatedly met with very small osseous concretions (Fig. 231), HEMORRHAGE. — ERECTILE TUMORS. 611 in livers otherwise perfectly healthy. In one case there were alto- gether about fifteen, varying in volume from a mustard-seed to a Fig. 230. Fig. 231. Osseous concretions of the liver. From a preparation in my collection. currant. They were hard, somewhat gritty, of a yellowish hue, and most of them were distinctly encysted, the cap- sule, which was of a grayish color, and fibro-cartilaginous firmness, being from the sixth to the fourth of a line in thick- ness, and closely adherent to the surround- ing tissues. In another case, the concre- tions were only five or six in number, the largest of which was about the size of a common pea. They were also encysted, but of a light brownish color, and of great hardness. How these little bodies originate, can- not be very easily determined. In one of the cases referred to, it seemed to me that they were nothing but tubercles in a state of osseous degeneration; a supposi- tion which is favored by the fact that several of them, evidently less advanced than the rest, contained a minute quan- tity of curdy, friable matter. The indi- vidual, moreover, was of a decidedly scro- fulous habit, and numerous tubercles existed in different organs. 15. Hemorrhage.—Blood sometimes escapes into the substance of the liver, constituting what is called hepatic apoplexy. It generally proceeds from one or more ruptured vessels distributed through the parenchy- matous texture, and occurs in small spots, varying in density and color, according to the length of time they have existed, being always softer and darker the more recent they are. The disease is extremely rare, and is usually associated with other lesions. 16. Erectile Tumors.—Erectile tumors of the liver are of very rare occurrence, and have seldom been observed independently of the ex- 612 LIVER. istence of other disease. Embedded in the substance of the organ, from which, however, they usually project upon its surface, they are of an irregularly rounded shape, and vary in size from that of a small marble to a walnut. They are composed of an areolar, spongy struc- ture, the meshes of which are remarkably numerous, irregular in their form, and occupied by dark grumous blood, some being surrounded by a distinct fibrous envelop. A section of a mass of this kind bears the greatest possible resemblance to the cavernous body of the penis; whence the name of the disease. It is seldom we meet with more than one erectile tumor at a time. 17. Laceration.—Laceration of the liver is probably a much more frequent occurrence than is generally imagined. Only a few examples of it are, it is true, on record, but it is not unlikely that many happen which are never reported. The accident is always produced by exter- nal violence, as by a fall from a considerable height, or by the passage of the wheel of a carriage. It may take place without any mark of outward injury. In a great majority of cases, however, there is more or less contusion with ecchymosis of the skin, cellular tissue, and muscles, immediately over the affected organ. Along with this lesion there may be laceration of the spleen, intestines, kidney, and pancreas, with fracture of the cranium, ribs, sternum, spine, and other bones. The number, extent, situation, and direction of the lacerations vary in different instances, and do not admit of any definite statement. I give the following case in illustration of the subject: John Shidaker, a stout, athletic German boatman, twenty-three years of age, was ad- mitted into the Louisville Marine Hospital, June 29, 1841, for an attack of bilious remittent fever, under which he had labored for the last three days. On the 2d of July, in a paroxysm of delirium, he jumped over the portico upon the pavement below, a distance of fifteen feet, bruising the right hip, and wounding the forehead and right fore- arm. Death took place in about one hour after the injury. On examination, Dr. Pyles, the resident physican, who has furnished me with the particulars of the case, found the liver lacerated in not less than thirteen places. The largest rent, situated on the right lobe, towards its inferior margin, was rather more than six lines in depth, and ran in a crescentic direction for four inches from near the right border of the organ towards the left side. Two other fissures, both transverse, the one three, and the other two inches in length by eight lines in depth, existed above the preceding, together with two smaller, one of which looked more like a puncture than a laceration. The posterior surface presented eight rents, the largest of which, nearly three inches long, extended transversely across the organ, a little below its middle. The others ran in different directions, and, with the ex- ception of two, were perfectly distinct from each other. None of these rents, either on the anterior or posterior surface, extended through the whole substance of the liver, which was somewhat enlarged, softened, and of a dark-bluish color. The gall-bladder was distended with a thick, dark, grumous, tar-like substance. The spleen, which was very much enlarged and extremely soft, was ruptured on its convex surface, and a part of its contents had escaped into the peritoneal sac. The GALL-BLADDER. 613 right kidney was ecchymosed, and the small intestine extensively contused. The abdominal cavity contained upwards of eight pounds of fluid blood. None of the large vessels were injured. The brain and thoracic organs were healthy. The quantity of blood poured out in laceration of the liver varies from several ounces to six or eight pounds. The accident is always fatal, the patient, if he do not die immediately, seldom surviving more than a few hours. To this statement, however, a remarkable excep- tion is to be found in a case by Dr. Fazely, of Trinidad. The indi- vidual, a man, fifty years of age, survived the effects of the injury eight years, and finally died from a complication of disease. On exa- mination, it was found that the right lobe of the liver had been rup- tured throughout its whole length and thickness, from the anterior to the posterior part, and that the lacerated edges had perfectly reunited through the medium of a broad, thick cicatrice, of a hard, cartilagi- nous texture. In the interior of this cicatrice, at the depth of half an inch, a considerable cavity was seen, which communicated with the hepatic tissue, and contained about fifty biliary concretions. The surface of the liver adhered extensively to the walls of the abdomen. The gall-bladder was empty and flaccid, and the alimentary tube per- fectly sound. That such accidents are not so fatal as has been generally imagined, may be inferred from some experiments performed by Dr. Monro, of Edinburgh. He opened the abdomen of a living rabbit, and cut off one of the lobes of the liver. The divided vessels bled very profusely; but, by pressure, the hemorrhage entirely ceased in the course of three or four minutes. After the wound was sewed up, the animal appeared uneasy, but only for a short time, when it gradually recovered its spirits, and took food as before. During the five weeks that it was kept and closely watched by the experimenter, it was in perfect health, the digestion going on well, and the alvine evacuations being of the usual color, quantity, and consistence. In another experiment, also performed upon a rabbit, the results were precisely similar. The animal lived upwards of twelve weeks, when it was killed. On examination, the cut surface of the liver was found firmly glued to the walls of the abdomen, by means of lymph. The results of these experiments are extremely interesting, as show ing how large a portion of an organ, so important to life, may be ablated, and yet the animal perfectly recover. SECTION II. GALL-BLADDER. I. Inflammation of the gall-bladder is characterized by the same structural phenomena as inflammation in other mucous tissues, and may be produced by various causes, of which the principal are the retention of irritating bile, the presence of gall-stones, and external 614 GALL-BLADDER. violence. The disease, which may be acute or chronic, is often propa- gated from the duodenum along the cystic duct, and may lead to vari- ous consequences, as suppuration, ulceration, perforation, dilatation, or contraction, with hypertrophy or atrophy of its walls. Suppuration of the gall-bladder is an occasional consequence of typhoid fever, dysentery, external injury, or the pressure of some morbid growth, as an enlarged pancreas, lymphatic ganglion, or scir- rhous tumor. The pus is generally of a greenish tint, from the ad- mixture of bile, and of a thin consistence, its quantity varying from a few drachms to half a pint or more. It often contains flakes of lymph and shreds of mucus; it is sometimes very fluid, sanious, and fetid. When the accumulation is considerable, and is attended with obstruction of the cystic duct, the enlarged reservoir extends beyond the margin of the liver, forming a considerable swelling, which may sometimes be felt across the walls of the abdomen. The organ is also apt, under such circumstances, to contract extensive adhesions to the surrounding parts, at the same time that its mucous tissue exhibits all the evidences of high inflammation. When the excretory duct is free, the matter generally escapes into the duodenum, and so passes off along with the feces. Ulceration of the gall-bladder generally begins in the internal coat, being usually caused by the irritation of biliary calculi. In this man- ner extensive abrasions are sometimes produced, with hard, elevated edges; when there is obstruction of the cystic duct, the disorganiz- ing process may implicate the other tunics, and finally lead to perfo- ration and escape of the bile. The immediate effect of this accident is violent peritonitis, rapidly terminating in death. Perforation is most liable to happen from ulceration caused by the presence of biliary concretions, especially when they are very numerous, or when they block up the orifice of the excretory duct. The ulcers most frequently occur singly; but sometimes as many as six or eight small ones are found in the same case, giving the affected surface a peculiar sieve-like aspect. Dilatation of the gall-bladder is usually caused by obstruction of the cystic duct, and varies in degree from the slightest increase in the capacity of the reservoir to the most enormous distension. Thus Cru- veilhier met with an instance where, in consequence of the compres- sion of the choledoch duct by a mass of indurated absorbent glands, the organ was enlarged to the size of the urinary bladder. An equally astonishing case, in which it contained eight pounds of inspissated bile, is reported by Mr. Gibson, in the Edinburgh Medical Essays. When thus enlarged, the gall-bladder forms a pear-shaped tumor, which projects beyond the ribs, and sensibly fluctuates under the finger. A distended gall-bladder has been mistaken for a hepatic ab- scess; an opening has been made into it; bile has escaped instead of pus, and this, getting into the peritoneal sac, has speedily destroyed life. The coats of the gall-bladder are liable to oedema, from the infiltra- . tion of their connecting cellular tissue by sero-albuminous matter. When the quantity of fluid is considerable, the organ exhibits a whitish gelatinoid appearance, not unlike a common oyster, from three ATROPHY—TRANSFORMATIONS. 615 to six lines in thickness. Dr. Dowler, of New Orleans, by whom this lesion was first accurately described, states that it is very common in that city, especially in persons dead of yellow fever. I have rarely met with it in any of my dissections. The gall-bladder is usually diminished in size, and contains a thin watery fluid, with hardly any trace of bile. The parietes of the gall-bladder are sometimes hypertrophied by in- terstitial deposits, caused by chronic inflammation. The increase is generally most conspicuous in the cellular structure, but the different layers usually participate in it, and sometimes acquire an extraordinary degree of development, both as it respects their thickness and consist- ence. The gall-bladder may be affected with atrophy, accompanied by partial or total obliteration of its cavity. The most common cause of the occurrence is closure of the cys- "Pic 2^2 tic duct by calculi, destroying the „____ office of the organ, and reducing it by degrees to a mere fibrous mis- shapen nodule, not as large, perhaps, as an almond. (Fig. 232.) In this condition the gall-bladder might be easily Overlooked by a CareleSS Ob- Atrophy of the gall-bladder, with several server, thereby inducing the belief calculi in its interior- *r°m a Pr<>pa™tion m , . ■'. . , ° my collection. that it was entirely absent. The coats of the gall-bladder are subject to various transformations, as the fatty, fibrous, and osseous. Of these the first is the most com- mon, and is met with chiefly in advanced life, in huge eaters, and in persons of indolent habits. It may affect the entire organ, or occur at particular situations, without any other appreciable change, and often exists with a similar state of the arteries. The fatty degenera- tion of the gall-bladder derives it chief interest from the circumstance that it is always attended with an abundant deposit of cholesterine upon the mucous surface of the organ, followed by a tendency to the formation of at least one variety of biliary concretion. The fibrous and osseous transformations are occasional attendants upon protracted structural disease, resulting either in great wasting of the different tunics, or in their excessive expansion, in consequence of obstruction of the cystic duct. A deposit of earthy matter, chiefly phos- phatic, is sometimes witnessed upon the inner surface of the gall-bladder, where it has been known to form a kind of shell, from a quarter of a line to a line in thickness, and covered by a thin film of bile and mucus. Finally, the gall-bladder may be ruptured as a consequence of external violence. The accident, which, however, is exceedingly rare, is usually accompanied by extensive mischief in other parts of the body. Falls from a height, the passage of a carriage-wheel, and severe blows upon the right hypogastric region, are the most common causes of it. In a case mentioned by Alberti, it was produced by a kick in a scuffle. Death may succeed immediately to the injury that occasions the lacera- tion, or it may be postponed for a number of days and even weeks. II. The biliary ducts are liable to the same lesions as the gall-blad- 616 GALL-BLADDER. der, in whose structure they participate. Thus they may be affected with inflammation, acute or chronic, softening, induration, ulceration, and perforation. In the latter case the bile escapes into the peri- toneal sac, and induces disastrous results. The cystic duct is often obliterated and transformed into a dense, fibrous cord; similar lesions have occasionally been observed in the hepatic and choledoch ducts. The affection, however, I have reason to believe, is much more common in the former than in either of the latter of these tubes. Most gene- rally the obliteration arises from the irritation of a gall-stone, or from the pressure of some tumor, as the head of an enlarged pancreas or a scirrhous lymphatic ganglion. Fig. 233. Dilatation of these tubes, caused by some obstacle to the egress of the bile, is a common occurrence. (Fig. 233.) Both the hepatic and choledoch ducts are often much enlarged: a case has been recorded where the latter of these passages was of the size of the duodenum. " Instances of rupture of the biliary ducts are much rarer than those of rupture of the gall-bladder. M. Campaignac, however, has related a case in which a man, thirty-five years of age, who had received a violent blow from a carriage on the right hypochondrium, having died eighteen days after the accident, the left branch of the hepatic duct was found to exhibit, near the lobe of Spigelius, a longitudinal rupture, with unequal borders, capable of permitting the introduction of the end of the small finger. The abdomen contained six pints of a deep green fluid. The folds of the intestines were united to one another by a half organized false membrane, which lined also the ante- rior parietes of the abdomen, and other marks of inflammatory action were perceptible."1 1 Thomson, the Diseases of the Biliary Organs, p. 76. Phila., 1842. GALL-STONES. 617 III. Healthy bile is a greenish-yellow fluid, of a viscid, ropy consist- ence, readily miscible with water, of a peculiar sickening odor, and of a taste at first sweet, then bitter. From these normal states of the fluid, there may be numerous deviations, depending upon the condi- tion of the liver, or the period of its retention in the gall-bladder. Thus it may be unnatural in its color, augmented or diminished in quantity, unusually acrid or bland, uncommonly thin or viscid. In some diseases it is of a deep black color, grayish, or almost white. The light tints are most common in cases of long-continued obstruction of the cystic duct, being attended with absorption of the coloring principles of the bile. In addition to these tints, there are often numerous inter- mediate shades of green, reddish, brown, orange, and yellow. In warm weather, the quantity of bile is generally much greater than in cold, and the fluid is also more acrid and stimulating, frequently in- ducing diarrhoea, cholera-morbus, and spasmodic colic. Its consist- ence may be as thin as water, or as thick as molasses, tar, mucilage, or half-dissolved glue. In the diseases of tropical climates the bile is sometimes so hard and viscid that it can scarcely be forced along the excretory ducts. It is especially dense in cholera, in which affection and in Bright's disease it has been found to contain urea. In organic maladies of the liver, it is occasionally of the color and consistence of coffee-grounds; in chronic hepatitis I have seen the gall-bladder dis- tended with a thin reddish bile, not unlike the juice of the pokeberry. In some cases, if tasted, the fluid produces no particular inconvenience ; in others, it is so acrid as to cause severe irritation. These abnormal states of the biliary fluid are always attended with important altera- tions in its chemical constitution. Simply changing the food, or modifying the blood, enables us to alter at pleasure the composition of the bile. IV.' Gall-stones may form in the ducts of the liver, but they most generally originate in the gall-bladder, where they are often accumu- lated in large numbers (Fig. 234). The greatest number I have ever Fig. 234. Calculi in the gall-bladder. From a preparation in Dr. E. Wallace's possession. seen in one case was three hundred and four. John Hunter examined a case in which there were above a thousand; and Morgagni refers to one in which there were three thousand six hundred and forty-six. When thus numerous, they are commonly very small, frequently not exceeding a bird-shot; under opposite circumstances, however, they often attain a considerable magnitude. The largest I have ever seen was about the size of a walnut. They usually lie loose in the gall- 618 GALL-BLADDER. bladder, but I have seen them occasionally encysted, and in one in- stance I found several of considerable size, situated beneath the mu- cous membrane in separate sacs. Much diversity prevails in relation to the form and color of these concretions. When numerous, they are often perfectly smooth, and marked off into regular sides and angles, evidently occasioned by their mutual friction. In this manner they may assume various mathematical figures, as the tetrahedral and hexagonal. In the gall- bladder of a man of fifty, whom I examined in 1828, there were seventy-one of these six-sided concretions, none of which exceeded the dimensions of an ordinary pea ; they were of a deep brown color, and emitted, on exposure to heat, a peculiar fragrant odor, not unlike frankincense. When there is only one gall-stone, it is usually of an oval shape, with a rough, grooved, or tuberculated surface. The principal colors of these concretions are brown, cinnamon, and black; with numerous intermediate shades, which it is difficult to indicate. Sometimes they are semi-transparent, and of a white pearly lustre: when they are formed in the substance of the liver, it is not unusual to find them of a dingy black, not unlike grumous blood. Gall-stones often possess a considerable degree of solidity, and are commonly found to consist of a number of concentric laminae, placed around a radiating nucleus. This central structure is frequently much softer than the exterior, and is generally made up entirely of inspis- sated bile and mucus. The nature of these concretions has been investigated by numerous chemists. According to the analysis of Chevreul, gall-stones are mostly composed of the yellow coloring matter of the bile and cho- lesterine ; the latter generally predominating, and, in many instances, forming the entire concretion. Three varieties of gall-stones are usually described by chemists, the cholosteric, mellitic, and biliary. The first, as the name im- plies, is composed essentially of cholesterine; it is soft, smooth, and always of a polygonal shape, being generally composed of two tetra- hedrons, applied base to base, with their edges and angles rounded off. The mellitic calculus, by far the most common of all, derives its name from its dark honey-like color. Externally it consists of thin, con- centric layers of cholesterine, spread over a nucleus of indurated bile strongly resembling granulated honey. The third variety is very rare. It is made up entirely of inspissated bile, is of a yellowish cinnamon color, and of a semi-concrete consistence. Gall-stones, instead of passing off by the bowels, or of remaining harmless tenants in the parts in which they are originally developed, as they usually do, may produce ulceration and perforation, followed by their escape into the peritoneal cavity ; or, as occasionally happens, they work their way out through the walls of the abdomen. Of this mode of elimination I witnessed a remarkable case, in 1854, in a mar- ried lady, aged forty-one, whom I saw in consultation with my friend and former colleague, Professor Miller, of Louisville. She had suf- fered for several years from severe pain in the right hypochondriac region, preventing her from lying on her sides, especially the left. SPLEEN. 619 After some time, a hard, circumscribed swelling, about the size of an egg, appeared at the most tender part, and finally terminated in an abscess, which, "breaking externally, was followed by the discharge of thirty-six biliary calculi, not all at once, but several at a time, the period required for the extrusion being upwards of two months. The precise point of opening was five inches from the median line, on a level with the umbilicus. The concretions were of a tetrahedral figure, perfectly smooth, of a dark cinnamon hue, and about the volume of a medium-sized cherry. Gall-stones are more common between the ages of forty and fifty than at any other period of life. They are most frequently observed in persons of sedentary habits, and hence women- are more subject to them than men. It is stated that in England five-sixths of all the cases of this affection occur in the female sex. Whether the propor- tion is equally great in this country, I am unable to say. CHAPTER XXIII. SPLEEN. Relations, Weight, and Size.—Acute Splenitis.—Anatomical Characters.—May pass into Sup- puration or into Gangrene.—Softening.—Induration and Hepatization.—Hypertrophy and Atrophy.—Tubercles.—Calcareous Concretions.—Fibro-Cartilaginous and Osseous Matter.— Hydatids and Serous Cysts.—Sanguineous Deposits.—Laceration. The spleen is in relation with a number of highly important organs upon all of which it must encroach, to a greater or less extent, when in a state of hypertrophy. In case of excessive enlargement, it might sensibly interfere with the motions of the diaphragm, and thus cause difficulty of respiration; with the stomach, and thus occasion indi- gestion ; or with the colon and small bowels, producing displacement, together with difficulty of voiding the feces. The great vessels would also be apt to be compressed, and in this manner might result an un- equal distribution of the blood, some of the viscera being surcharged, others sparingly supplied with it. Moreover, by interfering with the ready return of this fluid from the abdomen and pelvis to the heart, as must necessarily happen whenever there is an obstruction in the ascend- ing hollow vein, ascites will be induced, generally of the most intract- able kind. Naturally, the spleen is attached in a loose manner by vessels and peritoneal folds; but in certain states of disease, it is more or less firmly agglutinated to the circumjacent viscera. The size of the spleen is subject to so much variety, even within the limits of health, as to render it impossible to lay down any definite rule concerning it. In the generality of cases, as I have satisfied my- self by personal observation, it is about five inches in length by three 620 SPLEEN. in width, and one and a half in thickness; but from these dimensions there are frequent deviations. Thus I have often seen perfectly healthy spleens that were not more than three inches in length by two in breadth; and, on the other hand, some that were from seven to nine inches long. and from four to five inches wide. Not less variable is its weight. In the average number of cases, it does not exceed eight ounces; but in one instance, that of an adult male subject, I found it range as high as fourteen ounces; and in another, that of a full-grown female, as low as three and a half. An additional spleen is occasionally found. This is more commonly the case, I believe, when the main organ is rather small. The greatest number of supernumerary spleens that I have ever seen was seven. Other writers have observed as many as ten, twelve, and even twenty. Of a rounded shape, they are about the volume of a nutmeg, and are usually situated in the gastro-splenic omentum, along the principal vascular trunks. The lesions of the spleen may be comprised under the following heads: 1, inflammation ; 2, suppuration; 3, gangrene; 4, softening; 5, induration ; 6, hypertrophy; 7, atrophy; 8, tubercles; 9, melanosis: 10, calcareous deposits ; 11, hydatids; 12, apoplexy. 1. Inflammation.—Inflammation of the spleen may be seated in its parenchymatous structure, or it may be limited to its envelops. In many cases the serous coat remains perfectly sound, but there are pro- bably few in which the fibrous is not more or less implicated, either primarily or consecutively. Acute splenitis is a very rare disease, both in this country and in Europe; but very common in the East Indies, and often runs its course in a very short time. In the milder grades of the disease, or in the early stages of its attack, the substance of the organ is of a red brownish color, verging upon livid, gorged with grumous blood, and somewhat indurated. It tears with more facility than in the healthy state, and is considerably swelled, the congestion frequently extending to the great omentum, stomach, and liver. At a more advanced period the spleen is reduced to a soft blackish mass, not unlike half-dissolved blood: it exhibits a homogeneous aspect, and readily breaks under the pressure of the finger. In very violent cases, lasting several days, deposits of fibrin or globules of pus are not unfrequently disseminated through the disorganized structure, or collected into little depots, which are either inclosed by a distinct sac, or surrounded by softened splenic substance. The peritoneal and fibrous coats are also more or less inflamed; and the organ is apt to become glued to the adjacent viscera, as the stomach, colon, and dia- phragm, by masses of lymph. The splenic artery no longer admits injecting matter, and the splenic vein usually contains black grumous blood, mixed with pus. This phenomenon, however, is far from being constant. 2. Suppuration.—Suppuration of the spleen is a very rare occurrence. The pus, although frequently of the creamy kind, is sometimes hard and flaky, or thin and dark-colored, like coffee-grounds. In most cases, it is collected into a distinct sac, around which the parenchymatous struc- ture is more or less softened, broken down, or altogether destroyed. METASTATIC ABSCESSES. 621 Occasionally the pus is infiltrated into the substance of the organ, or it presents itself in minute yellowish dots, intermixed with sanious matter. In quantity, it varies from a few ounces to several quarts. The coats of the spleen are almost always affected, and, together with the neighboring viscera, are covered with false membranes, which are sometimes perfectly organized. Cases occur in which the whole organ is converted into one great abscess, surrounded by a distinct pyogenic sac. The matter may find its way into the peritoneal cavity, the stomach, colon, or small intestine; or it may burst through the intercostal spaces, the loins, or the walls of the abdomen. Occasionally the spleen contracts adhesions to the diaphragm, and the matter is discharged into the left side of the chest. In this way it may get into the lung, and be finally expelled by coughing. I have seen but one case of abscess of the spleen. The patient was a young, robust farmer, who suffered immensely for a fortnight. The spleen gradually augmented in volume, and, at the expiration of this period, it projected over towards the umbilicus, forming a large rounded tumor, between the linea alba and the margin of the ribs. In a short time fluctuation was perceived, and, on introducing a trocar, about three pints of fetid, dark-colored matter issued from the incision. The wound was kept open for several days, by means of a tent; but in a short period it closed, and thence on, the patient's health began gradually to improve. The disease had supervened upon repeated attacks of intermittent fever, and was characterized by excessive irritability of the stomach, great pain and tenderness, and an impend- ing sense of suffocation, caused, no doubt, by the pressure of the en- larged organ upon the diaphragm. Metastatic abscesses of the spleen, consequent upon surgical operations and external injuries are of much rarer occurrence than in the lung, liver, and brain. They are also less numerous, but their volume is usually larger, and their contents resemble clots of blood interspersed with globules of pus. The tissues around the abscesses are usually inflamed, reddened, and softened. 3. Gangrene.—The termination of splenitis by gangrene is also very rare. Morgagni records only two examples of it, in both of which there was a similar lesion of the intestines. Modern authors, also, say very little upon the subject, and we have good reason to complain of the neglect with which it has hitherto been treated. The spleen, in this disease, is converted into a soft, diffluent mass, of a brownish, livid, or blackish color, and extremely offensive to the smell. 4. Softening.—A much more common effect of inflammatory irrita- tion of the spleen, is softening of its substance, or a conversion of it into a dark-colored, bloody colluvies. The disease is a very frequent attendant on intermittent and typhoid fevers, chronic diarrhoea and dysentery, and affections of the brain and liver. In some countries it is occasionally epidemic. The regions most remarkable, in this respect, are the marshy districts of Italy, Bengal, Denmark, La Vendue, the island of Walcheren, and East Friesland. Animals are often affected with it; and it is asserted, though I do not know upon what ground, 622 SPLEEN. that it is much more common in women than in men. In softening, the spleen may be enlarged or diminished, or it may retain its normal dimensions; its whole parenchymatous structure is broken down into a soft, blackish mass, not unlike grumous blood, thin tar, or currant jelly, surrounded by thickened and indurated coats. In the more aggravated forms of the complaint, the organ sometimes bursts spon- taneously without any violence on the part of the patient, and the matter, escaping into the peritoneal cavity, induces fatal inflammation. Occasionally, however, the shell which incloses it is so strong as to prevent this. This was evidently the case with a spleen in my private collection, in which the parenchymatous structure, although perfectly softened, is surrounded by a layer of lymph at least one-fourth of an inch thick. The cause of this disease is that of mollescence in general. Many pathologists attribute it to changes in the blood and in the nutrition of the organ; to me it seems to be produced by inflammatory irritation, breaking down the vascular and parenchymatous textures by a kind of molecular gangrene. This doctrine derives support from several cir- cumstances. In the first place, it may be alleged that the softening does not occur all at once, but obtains its perfection by degrees. In the incipient stage of the disease, the spleen is merely injected with dark, dirty-looking blood, its reticulated structure being not as yet very materially altered. Indeed, it is not until the disorder has existed for some time that the organ assumes that black, tar-like aspect which characterizes the softening when it has reached its full development. The disease, secondly, is often accompanied by inflammation of some of the other viscera, and by severe pain in the left hypochondriac region, corresponding to the seat of the spleen. Finally, cases occur in which it coexists with disease of the lung, stomach, liver, pancreas, kidneys, and intestines. In many of the subjects who died of the celebrated Walcheren fever, the spleen was greatly enlarged, often weighing from three to five pounds, and reduced to a mere bag, filled with a semifluid pulp, not unlike black currant jelly. In the malignant fever of Italy, Sar- dinia, Bengal, and Hungary, mollescence of this organ is a very com- mon affection; and the same change is generally witnessed in ordinary typhoid fever. In forty-six dissections of the latter, Louis found the spleen softened in three-fourths, and in a fifth part of these to such an extent as to be reduced to a pulpy mass with the greatest ease. In the Egyptian plague, the viscus is generally softened, and double its natural volume.1 In the remittent fever of Philadelphia, described by Dr. Gerhard and Dr. Stewardson, this alteration formed a constant and prominent feature. From all these facts, then, it may be justly con- cluded that mollescence of the spleen is uniformly dependent upon inflammation, sometimes of a high grade, but generally of a slow, chronic character. Softening of the spleen, hardly ever observed at a very early period 1 Clot-Bey on the Plague in Egypt: British and Foreign Medical Review, vol. i. p. HYPERTROPHY—ATROPHY. 623 of life, is very common in middle and advanced age. Its progress is often very rapid, reaching its height in the course of four or five days. Occasionally it assumes a chronic form. 5. Induration.—The spleen is sometimes indurated. This change is generally associated with hypertrophy, and is probably occasioned by chronic irritation, giving rise to congestion of the capillary vessels, and to effusion of lymph into the reticulated texture. The spleen seldom retains its natural color; most commonly it is of a light brownish hue, tears with a granulated surface, and imparts to the finger the same solid feel as the substance of the liver. When these characters are present, the organ is said to be hepatized; a phenomenon frequently witnessed in this country, in persons who die from the effects of in- termittent fever. Induration of the coats of the spleen will be spoken of in another paragraph. '6. Hypertrophy.—One of the most common affections of the spleen is hypertrophy, a state which I have observed in nearly three-fifths of all the examinations I have ever made. It generally occurs in connection with intermittent, remittent and typhoid fevers, and seems to depend chiefly upon mechanical congestion, exciting ultimately, perhaps, irrita- tive action. That this is probable is proved by the fact that the spleen is usually more or less indurated, and otherwise changed in its struc- ture. The enlargement is sometimes enormous. In many cases the organ is from ten to fifteen times the natural size; in an example re- corded by Lieutaud, it weighed not less than thirty-three pounds. The patient was an aged female, in whom the hypertrophy had been gradu- ally progressing for seventeen years. The hypertrophy is sometimes partial, occurring in the form of a tumor, from the size of a walnut to that of an orange. The hypertrophy may be of a mixed character, some parts of the spleen exhibiting a healthy aspect, whilst others are indurated, broken down in texture, or in a state of suppuration. The coats of the organ are usually hardened, opaque, and thickened, either by interstitial effusion, or by deposits of lymph upon their surface. Hypertrophy of the spleen is a very frequent, although by no means an invariable, accompaniment of the disease known as leucocythasmia, which consists in the presence in the circulating fluid of a large num- ber of white corpuscles, and of a diminution of the red. The size of many of the white corpuscles is greater than in health. Some look upon the enlargement of the spleen as the cause of this alteration of the blood; but this view remains to be proved, for cases of leucocytha?- mia have been observed without any change in the viscus. The organ next most commonly affected is the liver; enlargement of the lym- phatic glands is also frequently associated with this change in the constituents of the blood, sometimes with, sometimes without, simul- taneous hypertrophy of the spleen. 7. Atrophy.—Atrophy of the spleen is by no means so frequent as hypertrophy. Like the latter affection it varies in degree in different cases. The diminution in volume may be very slight, or so great as to give the organ the appearance of being almost annihilated. Professor Dunglison met with a case, not along ago, in which the spleen was re- 624 SPLEEN. duced to the size of a small almond; Portal refers to one where it was not larger than a nutmeg; and Cruveilhier has seen it scarcely weigh a drachm. In a case which fell under my notice, it was hardly as large as a billiard-ball. It was of a grayish color, rounded in figure, indu- rated, almost bloodless, and weighed only one ounce. Both coats were thickened, and the internal was partially converted into carti- lage. The patient, an old man of seventy-two, had died of tubercular phthisis. The atrophy is observed chiefly in connection with chronic affections of the alimentary tube, the liver, and kidneys, with ascites, and with profuse discharges of blood from different parts of the body. The lesion is sometimes partial, consisting apparently in a removal of the parenchymatous texture of the organ, leaving merely the original fibrous framework. 8. Lardaceous Degeneration.—An exudation of transparent amor- phous matter may take place into the structure of the spleen, giving rise to what has been variously named waxy, lardaceous, or colloid degeneration. This deposit produces slight enlargement of the organ and an increase in consistency; a section exhibits a smooth, shining, but not vascular surface. The morbid material may have its main seat in the Malpighian corpuscles, and then the spleen has the appear- ance of having little grains of sago scattered through its substance. This peculiar condition of the spleen is for the most part found asso- ciated with Bright's disease, chronic dysentery, and scrofulous or lardaceous liver. The exact nature of the exudation is not clear. It has been found to afford the reaction of cellulose, being rapidly colored violet when treated with iodine and sulphuric acid. 9. Tubercles.—Tubercles are not uncommon in the spleen, either as a result of rapid or gradual development. I have seen them repeatedly in this organ in children, but rarely in the adult, and never in the very aged. In one instance, I met with them in an infant only a few months old; they were very small, solid, and so numerous that the organ was completely crowded with them. Tu- bercles of the spleen seldom occur in clusters, and, excepting in adults, they do not often acquire a great size. Occa- sionally, they soften, and form numerous small abscesses, filled with thick, curdy matter. These little bodies are not pe- culiar to the human spleen; they have been repeatedly found in the horse, monkey, and other animals. They sel- dom lead to fatal results. In most cases they exist at the same time in the lungs. When large and numerous, they are apt to excite inflammation in the neighboring portions of the peritoneum, leading to ascites. Fig. 235 is a beautiful representation of encysted tubercles of the spleen, from a specimen in my cabinet. Fig. 235. Tubercles of the spleen. From a preparation in my collection. CARCINOMA — HYDATIDS—SEROUS CYSTS. 625 They are of large size, and of a pale yellowish color; some are par- tially softened, but most are in a crude state. 10. Carcinoma of this organ is exceedingly uncommon. In the many examinations I have made it has not fallen to my lot to meet with a solitary example of scirrhus, encephaloid, or colloid. In the case of general melanosis, described in the early part of the work, the spleen was free from that disease. 11. The spleen is not unfrequently the seat of calcareous concretions. They are always isolated, usually not larger than a grain of mustard, of a rounded shape, and of a whitish, or pale yellowish color. Their number is occasionally very great. In one case I counted upwards of fifty. The manner in which these bodies are formed is not well under- stood. My opinion, founded upon careful and repeated examination, is, that they are developed in the branches of the splenic vein; from which, as they increase in size, they gradually escape into the paren- chymatous substance. This view is countenanced by the fact that they are often seen in different stages of their formation, as the fibrous, fibro-cartilaginous, cartilaginous, and osseous. The splenic tissue around these concretions is always unchanged. There is a variety of osseous concretion of the spleen, which occa- sionally acquires a very large bulk. Its mode of origin is unknown. It is of a pale yellowish color, rounded, oval, or more or less angular in its shape, and either solid, or partly solid and partly porous. In one case a concretion of this kind weighed twenty-one drachms, and was arranged in concentric layers. 12. A very frequent affection of the spleen is a conversion of its tunics into a substance resembling fibro-cartilage, cartilage, or bone. The change generally begins on the convex surface, to which it either remains confined, or it gradually extends over the rest of the organ. The new substance commonly occurs in small, thin patches, separated by considerable intervals; but, in some instances, I have seen it quite thick, and spread over a large surface. This transformation is slow in its progress, and may affect one or both tunics. 13. Hydatids are occasionally found in the spleen. Their origin here is probably the same as in the liver, and they have hitherto been met with chiefly in persons of a cachectic constitution. The substance of the spleen immediately around these bodies is variously affected; in most cases it remains unaltered, but occasionally it is indurated, softened, and quite pulpy. The hydatids may be simply attached to the surface of the organ, grow between its tunics, or be developed in its parenchymatous structure. They are occasionally seen in the splenic veins, where they either float about, or adhere by delicate foot- stalks. Hydatids of the spleen cannot be diagnosticated during life. They occasionally attain a large size, and, by bursting into the abdo- men, may cause death. * 14. Serous cysts are sometimes met with in the spleen; they are generally of a globular shape, adhere to the surface of the organ by short, delicate pedicles, and contain a clear, limpid fluid, like spring- water. They rarely attain much bulk, and in some cases they are 40 626 PANCREAS. occupied by a sort of meliceric, atheromatous, or steatomatous sub- stance. Their mode of origin is very obscure. 15. The spleen may be affected with internal hemorrhage, so nearly resembling that of the brain that it may be designated by the term apoplexy. The blood is deposited at one or more points, commonly of a rounded shape, and of variable size, and is evidently the result of a laceration of some of the branches of the splenic vessels. When the hemorrhage is connected with softening of the organ, the fluid may accumulate in large clots, or it may burst the coverings of the spleen, and escape into the peritoneal sac. The changes which the apoplectic deposits exhibit are of the same nature as under similar circumstances in the brain and other organs. 16. The spleen, owing to its soft, brittle texture, is liable to lacera- tion from external violence, as a blow, a kick, a fall, or the passage of a carriage-wheel. In such cases the individual usually expires in a short time from hemorrhage, or shock. Occasionally, indeed, death occurs in a few minutes, or almost instantaneously. The rent, which may be single or multiple, oblique, transverse, or longitudinal, often extends from one surface, one edge, or one extremity to the other, and when it involves the splenic artery or some of its primitive divisions, it is always followed by copious hemorrhage, amounting sometimes to many pounds. When the spleen is very soft and pulpy, it may be ruptured from the most trifling causes, as an inadvertent movement of the body, violent straining, or inordinate contraction of the abdo- minal muscles. Of this occurrence, which, however, is extremely rare, an instance was observed, in 1842, by Dr. John Neill,1 of this city, in a black sailor, forty-two years of age. The spleen was of the natural form and shape, but exceedingly soft, and of a very dark color; the rupture was confined to the peritoneal covering, and the abdominal cavity was filled with blood, partly fluid and partly coagulated. CHAPTER XXIV. PANCREAS. Is liable to pretty much the same Diseases as the Salivary Glands.—Rarely the seat of Acute Inflammation.—Atrophy.—Hypertrophy.—Is sometimes affected with Scirrhus.—Encepha- loid.—Melanosis.—Fatty Transformation.—Serous Cysts.—Tubercular Deposits.—Sangui- neous Effusion.—Earthy Concretions. Excepting, perhaps, the'thymus gland, there is perhaps no organ in the body which is less frequently diseased than the pancreas. This exemption is probably owing, certainly in part, to the singular struc- ture of this viscus, to its concealed situation, and to the absence of everything like a proper envelop. 1 American Journal of the Med. Sciences, N. S., vol. iv. p. 369. PANCREAS — SOFTENING. 627 1. Occasionally the pancreas is attacked with inflammation, origin- ating either in its substance, or propagated to it from the surrounding organs, especially the duodenum, the lining membrane of which is re- flected into its interior along the rootlets of its excretory duct. In the acute form of this disease, the pancreas is of a light reddish color, and the interlobular tissue is infiltrated with serosity, by which the glandular texture is rendered unusually distinct. When the inflam- mation is violent, the color becomes more deep, not unfrequently of a faint brownish or mahogany tint, and the proper substance of the organ undergoes such a degree of softening that it may be readily torn. 2. Although acute pancreatitis generally terminates in resolution, yet occasionally it passes into the chronic form, or leads to suppura- tion. The matter, as in the other viscera, may be diffused through the interlobular cellular tissue, or be collected into an abscess. In the former case, the pancreas is generally very soft, and of a reddish- gray color; in the latter, a portion of the organ is usually broken down, and the matter ultimately bursts into the adjacent reservoirs, as the stomach, colon, or duodenum. In some instances, it escapes into the cellular tissue of the mesocolon, where it is either absorbed or erodes the lamina of this fold, and makes its way into the abdomi- nal cavity. In one case the abscess opened into the jejunum, the gland having been converted into a hard, reddish, friable mass, the interior of which was filled with drab-colored, fetid pus. I am not aware of any instance where the matter thus collected, discharged itself into the aorta or vena cava ; but I can readily conceive of the possibility of such an occurrence. The fluid is sometimes contained in a strong pouch, formed by the surrounding cellular tissue, either alone, or aided by a deposition of fibrin. There is considerable diversity in relation to the nature and con- sistence of the purulent matter. Most commonly it is thick, yellowish, and inodorous, as in healthy suppuration of other parts. In other cases, however, it is very thin, sanious, greenish, curdy, and highly offensive. The quantity of pus seldom exceeds a few ounces, though it may amount to several pounds. Suppuration of the pancreas is not unfrequently associated with other diseases, as gout and rheumatism, intermittent and typhoid fever, chronic diarrhoea, dysentery, dropsy, and hepatitis. Occasionally it has supervened upon surgical operations and external violence. Anthony Petit observed several cases in which it followed the extir- pation of the testicle and ligation of the spermatic cord. 3. Of softening of the pancreas very little is known. The lesion is very infrequent, and has been noticed chiefly in persons that have died of scurvy, smallpox, scrofula, and measles. It is characterized by loss of cohesion of the granular substance, and by inordinate humidity of the interlobular cellular tissue, with little or no change of color. 4. Acute pancreatitis has been known to terminate in gangrene; the occurrence is extremely rare, and I have never witnessed an in- stance of it. The event would, I suppose, be most likely to happen 628 PANCREAS. from an extension of inflammation from the neighboring structures, or as a consequence of external injury. However induced, it is gene- rally of limited extent, and is characterized by an increase of the normal color of the component tissues, by more or less softening, and by the exudation of a blackish fetid fluid on pressure. 5. Chronic inflammation is no doubt much more frequent than acute. Under the influence of this disorder, the pancreas becomes hard, firm, crisp, and of a dull reddish color, at the same time that it augments considerably in volume, from interstitial deposits. This increase of size, however, is far from being a constant phenomenon. Indeed, I am inclined to believe that, in very many cases, the organ experiences a real diminution, its lobules and granules becoming more closely aggregated than they are in the normal state. When the irritation is protracted, the pancreas often assumes a pale grayish aspect, and a hard, almost gristly, consistence. 6. Atrophy of the pancreas is most commonly induced by compres- sion of some of the neighboring viscera, as an enlarged spleen, a scir- rhous duodenum, or a hypertrophied liver. It may likewise be caused by enlargement of the right kidney, by a mass of diseased lymphatic ganglions, and by the pressure of a large aneurism of the ventral aorta. It might also result, I should suppose, from the contraction or partial obliteration of the splenic artery, interrupting the nutritive function of the component tissues of the organ. There is a species of atrophy in which the pancreas, in common with the salivary and other glandular viscera, loses its natural consistence, and is reduced in volume, as an effect purely of old age. The color and consistence of the affected organ may be natural, diminished, or increased. In a majority of cases the color is quite pale, from the diminished supply of blood, and the granular texture is unusually firm, from the absence of serosity and the condensation of the connecting cellular substance. The extent of the atrophy is extremely variable. It may be limited to one-fourth, or one-half of the gland, or pervade the entire organ. 7. Hypertrophy of the pancreas is still more rare than a diminution of its bulk. The best examples that I have met with were con- nected with scirrhus of the pyloric extremity of the stomach, caused by an extension of the morbid action along the pancreatic duct. In one case the lesion was associated with great enlargement of the liver, while in another it was evidently dependent upon caries of the spine and ulceration of the intervertebral fibro-cartilages. The increase of bulk is seldom very considerable, though the organ may be double, triple, or quadruple the natural size. The granular texture is remarkably close and firm, being intersected by opaque membranous bands, not unlike those of scirrhus. The connecting cellular substance is much condensed, and the gland is almost entirely deprived of moisture. The color may be natural, or augmented, but in most cases it is diminished, the enlarged part having a white, glossy appearance. When the hypertrophy, which is most common in the duodenal extremity of the pancreas, is considerable, the rootlets of the excretory duct are apt to be compressed by the indurated granules, SCIRRHUS—ENCEPHALOID. 629 leading to retentiorJ of the natural secretion, and to the formation of small cysts, filled with a turbid, viscid, reddish fluid. 8. Scirrhus of the pancreas may affect the entire gland, or be limited to particular sections of it, separated by parts which retain their normal structure and appearance. The portion most frequently impli- cated is the head or hepatic extremity. The diseased structure is usually of a whitish, grayish, or pale drab color, and of a dense, fibrous, or gristly consistence, emitting a grating noise when cut. In the more advanced stages, the granular texture is completely effaced, and the morbid mass is intersected by whitish or bluish bands, so characteristic of scirrhus in other glandular organs, as the mamma and testis. Now and then there is a singularly mixed state of disease, some parts being almost as hard as cartilage, others quite soft, or composed of alternate strata of white and yellowish matter. This disease frequently coexists with scirrhus of other parts of the body, particularly the stomach, duodenum, and liver. The pancreas may retain its natural form and bulk, or it may, as in fact it generally is, be irregularly tabulated and enlarged. The increase of size varies from a few lines to several inches, and may be so great as to equal the volume of a large fist. When the disease is chiefly confined to the head of the pancreas, the enlarged part may compress the duodenum and choledoch duct, impeding the passage of the food, and the flow of the bile. The stomach and large vessels may also be injuriously encroached upon. When the common gall-duct is obliterated, and the biliary fluid retained, extensive disorganization of the liver may be the result. The pancreatic canal itself may remain pervious, or it may be closed, and rendered turgid from retained secretion. When the patient survives the effects of this disease for several years, ulceration may take place, and thus a communication may be established between the tumor and some of the adjacent viscera, as the stomach, duodenum, or arch of the colon. In such cases life is sometimes destroyed, either suddenly or gradually, by hemorrhage from the perforation of a bloodvessel. Scirrhus of this organ is most common in old subjects, though it has been observed as early as the thirtieth year, and, in one case, in a child, immediately after birth. Whether it occurs with equal fre- quency in both sexes has not been ascertained. 9. Encephaloid disease of the pancreas is very rare, especially as a primary affection. Although it has been noticed as early as the six- teenth year, it is most common after the age of forty, and, like scirrhus, may appear simultaneously or successively in other organs. The tumor varies in size from a cherry to that of a full-grown foetal head, and exhibits the usual pale yellow, pulpy, and brain-like character of encephaloid in other situations. In the early stage of the disease the tuberoid nature of the tumor is well marked, but as the quantity of the heterologous matter increases, the pre-existing structures are changed, and ultimately entirely disappear. When ulceration occurs it pursues very much the same course as in scirrhus, that is, the erosive process extends to the stomach or bowels, and the patient is sometimes cut off by hemorrhage. 630 PANCREAS. 10. Of melanosis of the pancreas I have seen only one example, the subject being a man fifty-eight years of age, who hfid the same disease in nearly all the principal organs of the body. In the case alluded to the black matter existed in the form of small, hard, rounded nodules, with intervening healthy substance. Colloid of the pancreas is also very rare, and in the few examples of this formation which I have met with in the other organs of the body, it did not exist in this. 11. The extreme rarity of tubercles of the pancreas is well known. Rilliet and Barthez did not meet with them in a single instance out of 314 scrofulous children, nor was Louis more fortunate in his numerous dissections of phthisical subjects. I have witnessed the disease only in two of my examinations, once in a boy between eight and nine years of age, and once in a young man of twenty-two, both dead of pul- monary consumption. The deposit presented itself in the form of miliary bodies, of a firm consistence, and of a pale straw color, seated chiefly in the head of the organ, which was otherwise entirely sound. The heterologous matter occasionally occurs here as an infiltration. 12. Suety, atheromatous, and meliceric substances have been observed in the pancreas; and cases have occurred in which it had experienced the fatty degeneration. When thus affected, the organ is of a pale yel- lowish color, more or less soft, and indistinctly tabulated, and readily greases the scalpel. Its size is usually augmented, but its vessels are preternaturally small and brittle. This degeneration is rare, and the causes which give rise to it are still involved in obscurity. 13. Serous cysts are almost unknown in this organ. An instance is related by Bdcourt in which a tumor of this kind, as large as the head of a child four years old, existed in its substance; it had very thick, fibrous walls, and was filled with a thin watery fluid. In a few instances the organ has contained acephalocysts. Storck, in his Annus Medicus, gives a case in which a pancreas, weighing thirteen pounds, was converted into a membranous sac, full of blood, partly fluid, and partly laminated and organized, as in an old aneurism. The probability is that this immense effusion was caused by the rupture of an enlarged vessel in the interior of the diseased gland. 14. The pancreas, from the firmness of its structure, and thickness of the parts by which it is covered, appears to be less liable to laceration from external violence than any other abdominal organ. The acci- dent is always complicated with serious injury of other parts, as the liver, stomach, bowels, and ribs, and may therefore cause death in a very short time. 15. Finally, the duct of the pancreas, like that of the liver and gall- bladder, is liable to be choked up with tubercular matter, chalky powder, and earthy concretions. The latter vary in size between a small pea and a nutmeg, are of a whitish color, hard, friable, and of a spherical shape, with a rough, irregular surface. They are easily dis- solved by muriatic acid, and are composed chiefly of carbonate of lime, in combination with a minute quantity of animal matter. The number of these concretions is sometimes considerable, as many as a dozen having been found in a single subject. SUPRA-RENAL CAPSULES. 631 CHAPTER XXV. URINARY APPARATUS. I. Supra-renal Capsules.—II. The Kidneys. — Observations on their Congenital Vices.— Lesions of their Fibrous Covering.—Pyelitis, Acute and Chronic.—Nephritis, Acute and Chronic.— Abscesses.— Softening.— Induration.—Gangrene seldom or never observed.— Bright's Disease.—Scirrhus and Encephaloid.—Tubercles.—Melanosis.—Erectile Tissues.— Serous Cysts.—Hydatids.— Fibro-Cartilaginous, Osseous, and Fatty Degenerations.— En- largement and Atrophy.—Rupture.—Renal Calculi.—The Strongylus.—III. The Ureter.— Liable to Deposits of Tubercular Matter.—Effusion of Lymph, Thickening and Attenuation of its Parietes, with Contraction or Enlargement of its Cavity.—IV. The Urinary Bladder.— Is rarely affected with acute Inflammation, Suppuration, Softening, or Gangrene.—Hyper- trophy of the Mucous and Muscular Tunics.—Developments of Cysts.—Ulceration.—Ence- phaloid Disease. — Tubercle. —Neuralgia.—Rupture.—Worms.—Morbid Urine.—Urinary Deposits.—Calculous Concretions.—V. The Prostate Gland.—Is liable to various forms of Disease.—Inflammatory Abscess, Chronic Enlargement, Tubercles, Melanosis, Encephaloid, and Calculi. SECTION I. SUPRA-RENAL CAPSULES. The supra-renal capsule, situated at the upper extremity of the kid- ney, is seldom found diseased. In the adult it is always much smaller, relatively speaking, than in the infant, in whom it probably performs a very important function, though what that function is we are still ignorant of. As life advances, this body gradually diminishes in size, becomes indurated, brittle, and assumes a peculiar dark color. These changes, which are frequently noticed in young persons, are gene- rally very conspicuous in old age. The atrophy is sometimes very great, the organ scarcely retaining a vestige of its original shape and structure. Since the attention of the profession has been especially called by Dr. Addison to the diseases of the supra-renal capsules, several cases have been brought together in which the structure of these organs has been 'completely destroyed. Highly interesting cases of this kind are mentioned by Dr. Addison1 himself, in his valuable mono- graph, by Mr. Hutchinson,2 and by Dr. Taylor.3 One of the most interesting results of this inquiry has been to establish the fact that 1 On the Constitutional and Local Effects of Diseases of the Supra-Renal Capsules, London,1856. 2 Med. Times and Gazette, No. 297 and 299, 1856. 3 New York Journal of Medicine, Sept. 1856. 632 SUPRA-RENAL CAPSULES. a discoloration of the skin, of a bronzed hue, with angemia, and great languor and debility, are symptoms which permit, during life, the diagnosis of disease of these organs. Whether all affections of the supra-renal capsules give rise in any degree to these symptoms or not, is not yet ascertained; but as these bodies will now be more care- fully examined, we may soon expect not only to have this question settled, but also to learn much with regard to their physiology as well as diseases. The supra-renal capsule is subject to inflammation, but the changes induced by this disease have not been sufficiently studied to enable us to trace its history. In a few instances, I have seen it very red, in- jected, and softened, without, however, being able to satisfy myself.that it was inflamed. The disease, I suppose, rarely exists independently ; in most cases, it is no doubt propagated to it from the kidney or some other organ. Abscesses have been known to form in this viscus. Blasius1 mentions the case of a woman, fifty years of age, in whom the left supra-renal capsule was as large as a fist, soft, reddish, and filled with black puru- lent matter, mixed with sand and gravel; and Lieutaud2 has recorded an instance in which this organ contained two pounds of pus. The supra-renal capsule is liable, in common with other organs, as the heart and liver, to the fatty degeneration. The abnormal deposit occupies the granular cells, and occurs either in a crystalline form, or in the form of globules. The affected gland is of a brownish, pale yellowish, or cinnamon color, of a soft, doughy consistence, and variously altered in shape and size. Hemorrhage of this body is uncommon, especially as a simple, un complicated affection. The blood, which varies in quantity from a few drachms to several ounces, is red and fluid, black and coagulated, yellowish and firm, according to the length of time that has elapsed since it was effused, and is generally contained in one or more pouches, the walls of which are often quite tough and thick. The hemorrhage may occur at any period of life. It has been noticed in new-born infants, and in persons after the sixtieth year. Earthy concretions have occasionally occurred in the supra-renal cap- sule ; and in a few rare instances it has been observed to be changed into a substance like cartilage. Of tubercles of this organ, only two cases have come under my notice. In one of these, a young man twenty-seven years of age, the right supra-renal capsule was remarkably hard, dense, of a grayish mottled aspect, aud filled with-concrete tubercles, many of which were quite large. The left capsule was of a light slate color, and likewise contained several scrofulous deposits.3 In the other instance, that of a child of fifteen months, the formation was connected with pulmonary phthisis, and consisted of a large yellowish mass, of the consistence of soft putty. In both these cases, the affected organs appeared to be of the natural size. 1 Observ. Anat., p. 129. 2 Hist. Anat. Med., t. i. p. 357. 3 See Western Journal of the Medical and Physical Sciences, vol. xi. p. 21. MUCOUS LINING OF THE KIDNEY. 633 Of scirrhus of this organ no instance has ever fallen under my obser- vation, and I therefore infer that its occurrence is extremely rare. In the case of a man, aged fifty-eight, I found both capsules very much enlarged, changed in shape, and filled with melanotic matter, which existed at the same time in most of the other viscera of the body. The deposit may show itself here, as elsewhere, either as an infiltration or in the form of little tubercles, from the size of a millet-seed to that of a filbert. Encephaloid of the supra-renal capsule is also very infre- quent; and, as to colloid, I do not know that it has ever been observed here. SECTION II. KIDNEYS. I. Fibrous Covering of the Kidney.—The fibrous capsule of the kid- ney is seldom implicated in disease. Acute inflammation is very un- common; so much so, indeed, that in several hundred dissections I have never witnessed an instance. The reason why it so seldom occurs in this structure, probably is that it has no connection with the peri- toneum, as is1 the case, for example, with the spleen and liver, the en- velops of which are, as is well known, very prone to inflammation. Another reason, no doubt, is the fact that this membrane sends no pro- cesses into the glandular structure of the organ, the attachment between it and the outer surface of the kidney being effected by very short cellular tissue, which, we may suppose, rather prevents than admits of the propagation of diseased action from the one to the other. When inflamed, this membrane exhibits the same anatomical characters as other fibrous structures. In tubercular and scirrhous disease of the kidney, I have found the fibrous capsule very much thickened, opaque, preternaturally strong, and covered with patches of organized lymph. In the fatty degenera- tion, it is sometimes remarkably attenuated, and hangs almost loose around the organ, from the destruction of the connecting cellular tis- sue. It is occasionally partly ossified; and cases are seen where it is converted into a substance like cartilage. Not unfrequently it is glued to the surrounding organs by thick masses of lymph. II. Mucous Lining of the Kidney.—When the inflammation attacks the mucous membrane of the pelvis and calyces, it constitutes what is called pyelitis. This occurs at different periods of life, is induced by various causes, and is frequently associated with an albuminous state of the urine. It may affect the entire pelvis, or be limited to a par- ticular part of it, or even to a single calyx. The disease may exist simultaneously in both kidneys. The anatomical characters of acute pyelitis are increased vascularity, effusion of lymph or pus, opacity, softening, and alteration of the na- tural secretion. In the milder grades of the disease the vascularity of the mucous 634 KIDNEYS. membrane is of an arborescent character; but as the morbid action advances, the vessels exhibit a capilliform arrangement, and are so much distended as to give the part a tumid appearance. The dis- coloration varies from the slightest rose to the deepest purple, and is always in direct proportion to the intensity of the inflammation. Al- though it is sometimes spread over a considerable extent, it usually occurs in small, irregular patches, separated by narrow strips of sound membrane. In their size these patches range from a split pea to a dime; in their form they may be circular, oval, linear, or angular. When the inflammation is very high, the redness may not only be very intense, but is apt to be widely diffused. Minute spots, not larger generally than the head of a pin or a hempseed, are often observed, either in the substance of the membrane or in the submucous cellular tissue; they are evidently produced by the rupture of the capillary vessels, and constitute so many real ecchymoses. Connected with this augmented vascularity are, more or less opacity, softening, and depo- sition of lymph, in small, whitish, circumscribed spots, or in the form of a distinct lamella moulded to the shape of the cavity in which it is located. When the disease extends to the parenchymatous struc- ture, it is not unusual to find serosity or pus in the submucous cel- lular substance. Ulceration, gangrene, and perforation are exceed- ingly infrequent. When the morbid action is severe, the urine contained in the pelvis and calyces is invariably mingled with muco-purulent matter, pure pus, or pure blood. The presence of these adventitious fluids is not always visible to the naked eye, but may be easily detected with the microscope. In chronic pyelitis, the mucous membrane is of a grayish, dull-white, mottled, brownish, light slate, or pale mahogany tint, or entirely free from discoloration of any kind. It is opaque, thicker, and tougher than in the healthy state, rough, and incrusted with plastic lymph, firmly adherent to the surface on which it rests. In protracted cases, the excretory tubes are more or less dilated, and the veins on the sur- face of the kidney are enlarged, tortuous, and so arranged as to form a network. The kidney itself may be of the natural size, or it may be increased or diminished. Ulceration of the mucous membrane is infrequent, and when it does occur it rarely leads to perforation. When the effusion of lymph is very great, it may produce partial obliteration of the excretory passages, and so embarrass the flow of urine. III. Parenchyma of the Kidney.—The renal parenchyma itself is comparatively seldom diseased, which is surprising when we consider the great activity of its functions, and the facility with which its secre- tions are modified by the most trifling deviations from health. The principal affections of this gland may be referred to inflammation, sup- puration, softening, induration, fatty degeneration, scirrhus, encepha- loid, tubercles, serous cysts, hydatids, hypertrophy, atrophy, and earthy concretions. 1. Acute Inflammation.—Acute inflammation of the renal tissues is a very rare disease; it may affect the entire gland, or occur in circum- ABSCESS. 635 scribed patches, and is more frequent in the cortical than in the tubu- lar substance. The redness which accompanies it is generally limited, and varies from the slightest increase of the natural tints to a deep chocolate. This change is ordinarily combined with softening, slight intumescence, and sero-purulent infiltration. The discoloration is at first very trifling, and readily disappears under pressure and ablution. Subsequently it becomes deeper and more permanent. The injection on which the alteration of the color depends differs as it occurs in the tubular or cortical substance. In the former, it is striated; in the latter, capilliform, and disposed in beautiful wreaths. In both, it is frequently attended with small, red, black, or brownish points, not larger than a pin-head, and scattered in great numbers over the surface of the gland, or interspersed through its parenchymatous tissues. These little dots, which are merely so many ecchymoses, are sometimes sur- rounded by minute vesicles, which are distinct from the orifices of the divided vessels, and are nothing else than the corpuscles of Malpighi, encircled by a delicate vascular zone. In the cortical substance these little bodies are usually arranged in lines, groups, or little patches. In the more advanced stages of the disease, the affected part is of a deep red or purple color, the ecchymoses are larger and more nume- rous, the vessels are filled with black blood, the renal tissues are re- markably softened, and the section of the organ exhibits numerous purulent depots, hardly as large as a pin-head. These depots, which are most abundant in the cortical substance, often elude detection. In a small proportion of cases, globules of lymph are effused, of a pale straw color, not unlike the Malpighian corpuscles of the spleen. Nephritis may terminate by resolution, or it may relieve itself by softening, by passing into the chronic state, or by the formation of purulent matter. In the latter case, the pus, on inspection, will be found to be infiltrated into the glandular substance, or collected into an abscess. 2. Abscess.—When abscesses occur, they may be seated on the outer surface of the organ, just beneath its fibrous envelop, in the paren- chymatous texture, or in the pelvis and calyces. They may be nume- rous and very small, or few and large; in other words, they may vary in size from that of a millet-seed or a pea to that of a walnut, a fist, or a foetal head. When numerous or voluminous they may com- pletely destroy the glandular structure, and convert the organ into an immense purulent cyst. Very often the sac is thick, laminated, and multilocular; the intersecting bands being of a hard, fibro-cartilaginous consistence, and grating under the knife. When the pus is infiltrated into the parenchymatous substance, the fluid oozes out muddy and blood-tinged on pressure; and, when there is much softening, it sometimes gives the organ a dark pultaceous ap- pearance, like the lees of wine. The matter contained in these abscesses varies not a little in its physical properties. It may be a homogeneous fluid, like healthy pus ; or it may be heterogeneous, or intermixed with foreign ingredients. In the first case, the matter is opaque, of nearly uniform consistence, and of a yellowish-cream color, with small masses of coagulating 636 KIDNEYS. lymph; in the second, it is thin and serous, or sero-purulent, lactes- cent, whitish, or greenish-white, and thin or thick, viscid or curdy, like that of a scrofulous abscess. The fluid is also sometimes slightly reddish, or tinged with blood, and not unfrequently it contains sabu- lous matter, or even tolerably large concretions. It may be entirely inodorous, or quite fetid. Eenal abscesses generally open into the pelvis and ureter, their contents being thence discharged along with the urine. More rarely the matter finds its way to the external surface, into the cellulo-adipose tissue of the loins, or into the intestinal canal. It may also be evacu- ated into the peritoneal cavity, and in a few rare instances it has burst into the bronchial tubes, from which it was afterwards discharged by coughing. a. The most favorable direction in which the abscess can break is into the pelvis of the kidney, from which the matter may afterwards pass along the natural channels. When the accumulation is consider- able, a large quantity of fluid may thus be evacuated at once, or it may come away slowly and almost imperceptibly. The urine, in the former case, will be of a whitish, lactescent appearance, ropy, unnatu- rally thick, and more or less fetid; in the latter, it will be little, if at all, changed in its character, and deposit merely a slight sediment on cooling. b. The matter may escape externally by exciting ulcerative absorp- tion of the cellular tissue, muscles, and aponeuroses of the dorso-lumbar region. The progress of the fluid is indicated by excessive pain in the part, and a hard, prominent tumor, which, becoming red, soft, and fluctuating, finally gives way at one or more points. The opening thus produced frequently assumes a fistulous character, and may con- tinue to discharge pus, or pus, urine, and sabulous matter, for many months and even years. The kidney, in-this case, gradually wastes, and is ultimately reduced to a membranous bag, containing merely a little thin purulent fluid. If the matter cease to flow, a spontaneous cure may follow. c. The ulceration may take place through the ureter, pelvis, calyces, or renal parenchyma, and the contents of the abscess escape into the cellular tissue of the groin. The event is preceded by violent inflam- mation, generally terminating in extensive infiltration and mortifica- tion of the soft parts. The muscular fibres are more or less disor- ganized, the cellular tissue is converted into a dark slough, resemblino- wet tow, and the effused matter, which occasionally extends down to the thigh, and amounts to many ounces, is almost insupportably offensive. d. In the fourth place, the matter may be evacuated into the aliment- ary tube. The portion of intestine involved may be the ascending or descending colon, the transverse arch, or the sigmoid flexure. In inspect- ing the body of a boy four years and a half old, whom I had cut for stone eighteen months previously, I found a ragged, fistulous opening, about the size of half a dime, leading from the pelvis of the left kidney to the descending portion of the colon. He had labored under nephritic symptoms for several months, and had latterly voided purulent matter ABSCESS—SOFTENING. 637 both along the bowel and the urethra. It is not often that the small intestine or the cascum is the seat of the ulcerative perforation. In a case mentioned by Rayer1 a communication existed between the right kidney and the duodenum. e. The abscess may burst into the peritoneal cavity; but this oc- currence is so rare that some have even doubted the possibility of it. Mr. Howship,2 however, has recorded an instance in a boy seven years old, who had been affected with disease of the urinary apparatus from the age of eighteen months. Numerous abscesses existed in both kidneys, the largest of which, seated in the left organ, had discharged its contents into the abdominal cavity, where it produced violent peri- toneal inflammation, under which the patient rapidly sunk. /. Another mode in which the purulent matter may open a path for itself is through the diaphragm and pulmonary tissue. Of this occur- rence only three well-authenticated examples were, until recently, upon record, the first by Meckel,3 the second by De Haen,4 and the last by Rayer.* They all existed on the left side, and all terminated fatally, the kidney in each being dilated into a membranous sac without any trace of the original gland. The patients lived some time after the fistulous communication was established, and expectorated fetid, sanious, purulent matter. Finally, the matter, instead of finding a vent by some of the routes above specified, may be retained in the pelvis and calyces, in conse- quence of obstruction of the ureter, by adhesive inflammation, the presence of a renal calculus, or the deposition of tubercular matter. When this happens, the parenchymatous texture of the kidney is gradually destroyed, and the organ is dilated into a thick, tough, mem- branous pouch, capable of holding many ounces or even several quarts of purulent fluid. Abscesses of the kidney, in some instances, are connected with disease of the spinal marrow and the nerves which are detached from it. The subjects of them are usually affected with paralysis of the lower half of the body, with tenderness of the spine, pain in the loins, and irritability of the bladder. The kidneys are nearly always gorged with blood, of a dark color, remarkably flaccid, and infiltrated with purulent matter. 3. Gangrene.—The kidney is seldom affected with gangrene; indeed, I am not certain that it is susceptible of this occurrence, except as a consequence of traumatic inflammation. At all events, very little is known respecting it. In persons who die in this way, the kidney is tumid, softened, and pervaded by a foul, offensive serosity. Some parts occasionally lose their consistence to a much greater extent than others, being of a black, livid color, and converted into a shreddy, putrilaginous substance. 4. Softening.—Although inflammation sometimes produces softening 1 Traite des Maladies des Reins, PI. xx. 2 On the Urinary Organs, p. 39. 3 Voigtel, Handbuch der Path. Anatomie, vol. iii. p. 188. 4 Ratio Medendi, t. x. p. 103. 5 Traite des Maladies des Reins, PI. Ii. 638 KIDNEYS. of the renal tissues, yet this is unquestionably very rare. Of this affection there are two varieties. In one, the substance of the kidney is of a pale grayish tint, with small dot-like points, and the patient lives a long while without being sensible of any disease of the urinary apparatus; in the other, which is generally attended with serious de- rangement of the health, and which occasionally proceeds to a fatal termination, the renal tissues are converted into a soft, spongy mass, resembling, when shaken in water, the shaggy vessels of the placenta. The color in this species of softening may be red, gray, brown, or purple. The symptoms in both varieties are obscure, and consequently uncharacteristic. Like acute nephritis, of which this disease is com- monly the result, it rarely implicates the entire viscus. 5. Granular Degeneration.—Brighis disease of the kidney, the granu- lar degeneration, first pointed out by Dr. Bright, of London, is com- monly the result of chronic inflammation, although occasionally it assumes an acute character. It is not peculiar to any period of life, yet it is much more frequent in adults and old people than in chil- dren and'infants. It leads, as its main symptoms, to albumen and fibrinous casts in the urine, and to dropsical effusions in various parts of the body, especially in the cellular substance and peritoneal cavity. Opportunities very rarely present themselves for examining the kidney in the incipient stage of this malady, because few patients die during such attacks. At a more advanced period the anatomical cha- racters are so exceedingly variable that hardly any two writers are agreed respecting them. Thus they have been divided by authors into several forms; by Dr. Bright into three, by Solon into five, by Rayer into six, and by Rokitansky into eight. This excessive subdivision unnecessarily embarrasses the progress of pathological inquiry; for where is the necessity of making so many stages of the same morbid affection? On the other hand, several pathologists have of late years warmly maintained the view that entirely different diseases are included in Bright's disease, some of which may lead to the small contracted kid- ney, whilst others do not. I shall describe these affections as so many stages of a single morbid process. The kidney, in the earlier stages of the disease, is of a deep red, brownish, or modena color, engorged with blood, and unnaturally soft. The loss of cohesion, however, is inconsiderable. The outer surface of the organ is somewhat rough, and the vessels which are distributed over it are arranged in small tufts or clusters. The fibrous tunic is easily stripped off, and does not exhibit any change of structure. When divided longitudinally, the section is found to be of a brownish color in the cortical substance, and of a deep red, chocolate, or amber- brown in the tubular. The whole gland is hypertrophied, flabby, and very vascular. A microscopic examination shows the minute vessels, both arteries and veins, gorged with blood, and the uriniferous tubes filled with fibrinous deposits, but the renal epithelium is unchanged, although cast off from the sides of the tubes. This condition of the kidney is best marked in the more acute form of Bright's disease espe- cially after scarlet fever. Dr. George Johnson1 does not regard this 1 Diseases of the Kidney. London, 1852. GRANULAR DEGENERATION. 639 state as the first stage of the granular kidney, but describes it as a separate disease, as acute desquamative nephritis. The urine is dark, and of high specific gravity, and contains blood corpuscles, fibrinous casts, and epithelium. The casts are generally coated with epithelium or blood-corpuscles. At a later period, but before the degeneration has made much progress, the outer surface, though less deep in color, is still more irregular, from the presence of numerous elevations and depres- sions, the latter of which are remarkable for containing little clusters of red vessels. By the aid of the microscope, and sometimes with the naked eye, numerous solid corpuscles may be detected upon it, like grains of sand; they are extremely minute, of a rounded or globular shape, and of a pale grayish color. The cortical substance, in the in- terior, is of a lighter complexion than in the sound state, and generally exhibits some shade of drab, fawn, or yellow. Innumerable little bodies, similar to those on the surface, are everywhere visible, and impart to the section the characteristic granular appearance from which the disease derives its name. The tubular cones retain their natural color, or are dark, but are sensibly diminished in size, being encroached upon, flattened, and even notched. The organ may be of the natural volume, but in general it is hypertrophied, and one-fifth, a fourth, or a third larger than in the normal condition. In a small proportion of cases it is reduced in size. A minute examination of a kidney in-this stage exhibits, according to Frerichs,1 the Malpighian corpuscles covered with granules; its ves- sels are surrounded by a firm layer of fibrinous exudation mixed with numerous oil globules, and are filled for the most part with a dirty, brownish fluid. The corpuscles may be enlarged or of the normal size. The uriniferous tubes are enlarged and dilated, the wallsbeing frequently strictured. Their interior contains fibrinous casts and epithelium cells, sometimes very large, sometimes filled with oil drops, but more gene- rally imperfectly formed and broken up into a coarse granular mat- ter, all of which elements will be then found in the urine lying iso- lated or adhering to the fibrinous casts. The fatty degeneration of the deposit, which occasionally takes place to an extreme degree in this stage of the malady, gives rise to the yellow and slightly granular kidney, which, under the term granular fat kidney, is classed by some as a separate form of Bright's disease. In the more confirmed stages of the degeneration, the fibrous envelop is so strongly attached to the cortical substance that a portion of the latter comes off with it; it is tough, opaque, and unnaturally thick. In very young subjects it not unfrequently presents white milky-looking spots, of various size and shape. The surface of the kidney has a pecu- liar marbled or mottled appearance, and some parts of it are occasionally of a slate-gray or leaden-gray color; numerous vessels are seen upon it and the whole, or the greater portion of it, is moulded into large hollows and elevations, so as to seem tuberculated or mammillated, like the surface of a cirrhosed liver. The cortical substance is very much indurated and atrophied, and presents 'little or none of its stri- 1 Die Bright'sche Nierenkrankheit, p. 25. Braunschweig, 1£-">1. 640 KIDNEYS. ated character; its vessels are nearly all obliterated, and consequently incapable of receiving injection; its color is extremely variable, but the most common shades are buff, yellowish-gray, Sienna-yellow, or pale straw. The granulations, which exist in great profusion, are closely aggregated together, globular, or irregularly rounded in their. shape, of a pale yellowish or grayish color, and from the volume of a small pin-head to that of a millet-seed, or a grain of sago. When divided, they are found to be solid, firm, incompres- sible, and apparently homogeneous. The tubular cones are either very much atrophied, or entirely effaced by the pressure of the cortical prolonga- tions. The kidney itself is generally more or less deformed, considerably diminished in volume, and remark- Granular degeneration, in its incipient stage. nV)]v firm The renal arterV in this advanced stage is almost always very small, and some of its main branches are entirely obliterated, either by fibrinous concretions, or by the adhesion of their sides. The differ- ent appearances of the granulations, as occurring on the surface and in the interior of the kidney, are exhibited in the annexed wood-cuts (Figs. 236, 237, 238). Microscopically examined, many of the Malpi- ghian corpuscles and of the uriniferous tubes are found to be destroyed, whilst others are still dilated. The dilated tubes are especially marked Fig. 237. Fig. 238. Granular kidney, in its more advanced stages. Internal structure. Granular kidney, in its more advanced stages. External appearance. INDURATION—TRANSFORMATIONS. 641 in the granulations. Part of the exudation which takes place in the connecting cellular tissue leads, by being transformed into fibrous tissue, to contraction and to atrophy of the surrounding substance. In this respect the granular kidney is strictly analogous to cirrhosis of the liver, with which it often coexists. It is a further stage of degene- ration from the enlarged pale kidney above described, although the possibility of this conversion has been recently doubted, but not, as it appears to me, on sufficient grounds. 6. Induration.—Induration of the kidney, like mollescence, may be divided into two species, one being attended with increased vascula- rity, the other with remarkable pallor. In the former, the organ is generally enlarged; in the latter, diminished. In the pale indu- ration, the kidney occasionally retains its natural structure, except- ing that it is unusually firm; sometimes, indeed, as will be shown hereafter, it may even be of a fibro-cartilaginous consistence. When both organs are thus affected, very little urine will be secreted, and the patient will complain of the various symptoms which characterize chronic disease of the other viscera. 7. Hypertrophy and Atrophy.—Hypertrophy generally exists only in one kidney, the other being either reduced in volume, or else absent. It is recognized by the following characters: the kidney is one-fourth, one-third, or one-half larger than in the normal state; and its sub- stance is of a deeper color, more firm and compact. A development of this kind, under whatever circumstances it may occur, may be sup- posed always to depend upon an increased determination of blood to the sound organ. Hence we frequently find that the enlarged kidney is furnished either with two arteries, or with a single one of unusual size. In other cases, chronic irritation gives rise to this preternatural bulk of the organ, by keeping up habitual congestion. This state of the kidney, combined with augmented vascularity, is a common ap- pearance in diabetes. In atrophy of the kidney the size of the organ is much less than natural, its parenchymatous structure being pale, indurated, and shrivelled. As hypertrophy is the result of an unnatural supply of blood, so atrophy may be regarded as the consequence of a deficiency of this fluid. In some instances, this appearance is strictly congenital; but most commonly it is caused by an obstruction in the circulation of the blood, arising from the pressure of a tumor in its vicinity, an enlarged liver or spleen, or a collection of pus around its exterior, or from structural changes in the organ. I have a specimen of atrophy of the kidney in which the parenchymatous texture was nearly en- tirely destroyed by a number of serous cysts developed in its interior. Similar effects often follow the presence of renal calculi. 8. Transformations.—Under this head may be comprised the fibro- cartilaginous, osseous, and fatty transformations. I have seen the kidney converted into a substance resembling fibro-cartilage. In one case the organ was less than one-third the natural volume, remarkably white, dense, and fibrous, creaking sensi- bly under the scalpel. The fibrous capsule was inseparably adherent to the outer surface of the kidney, the ureter and funnel-shaped pro- 41 642 KIDNEYS. cesses were obliterated, and scarcely a trace remained of the tubular structure. The renal vessels were much diminished in size, and many of their larger branches, as well as nearly all the smaller, had disappeared. This transformation sometimes occurs in small patches, which are generally of a light bluish tint, and distinctly fibrous in their texture. The kidney may be partially ossified. The earthy matter is mostly confined to the uriniferous tubes, where I have seen it form narrow, slender pencils, running the whole length of the pyramids. The number of these lines, which are commonly of a pale yellowish color, is sometimes very considerable, hundreds of them occurring in a single specimen, perhaps in a single cone. In the cases in which I have carefully examined this lesion, it seemed to me that the earthy substance was deposited into the walls of the uriniferous tubes. A similar appearance is sometimes caused by ossification of the arterial tissues of the parts. The kidney is liable to the fatty degeneration. This occurrence, how- ever, is rare in the human subject. It is analogous to the adipose transformation of the liver, and is rarely attended with any serious symptoms. In many cases, indeed, it would seem to be compatible with the most perfect health. When this state is present, the kidney is of a pale, yellowish complexion, has a soft, fatty feel, and readily greases the scalpel. Instances occur in which the organ yields drops of oil under pressure. Such an event, however, is very rare. The fibrous capsule can always be peeled off much more easily than in health, and in most of the cases that have fallen under my observa- tion, the transformation was confined to the cortical substance, the pale tint of which strikingly contrasted with the fleshy red of the urin- iferous cones. In an advanced stage, the two structures are so much alike in color that it is no longer possible to distinguish them from each other. The fatty kidney rapidly putrefies, and yields a peculiar oily principle by boiling. There are, properly speaking, two varieties of form in which the fatty matter in this disease is deposited. In the one just described, it exists as an infiltration, which may be limited to a particular portion of the organ, or pervade its entire structure. In the other, which is very rare, the greasy matter, instead of being diffused through the renal parenchyma, is collected in little, rounded masses, either separated, or agglomerated, of a soft, jelly-like consistence, and of a pale, yel- lowish, or brownish color. Their number is generally small, and it is seldom that they involve the entire gland. The kidney, in both these varieties of form, may retain its natural shape and bulk; or it may be more or less disfigured, and diminished or increased in size. The cause of this degeneration is altogether unknown. Large quantities of fat are sometimes collected around the kidney, which, from the pressure thereby sustained, experiences a certain de- gree of atrophy. Similar accumulations are occasionally found around the pelvis and calyces, followed by similar results. 9. Serous Cysts.—Serous cysts in the human kidney are probably of less frequent occurrence than is supposed by pathologists. They are very common, however, in the hog, and it is here that the best oppor- SEROUS CYSTS. 643 tunity is afforded for examining them in the different stages of their development. In reference to their origin, these cysts may be arranged under three heads. Under the first are comprised the little vesicles which are developed upon the exterior of the kidney, immediately beneath the fibrous covering. At an early period they are exceed- ingly small, hardly as large as a mustard-seed; but as they increase in size they may acquire the volume of a cherry, a hazel-nut, a plum, or, in very rare cases, even of a child's head. Their number varies from one or two to several dozens, fifty, a hundred, or two hundred. I have repeatedly seen them scattered over the surface of the organ, so as to give it the appearance of being inlaid with them. They are of a spherical shape, and filled with a thin, pellucid fluid, which pos- sesses all the properties of the serum of the blood. Fig. 239, from a preparation in my cabinet, is a beautiful representation of this variety of the disease. Fig. 239 Serous cysts of the kidney. From a preparation in my cabinet. The cyst in this form of the disease consists of a single lamella, smoo,th and polished internally, and closely adherent by its outer sur- face to the cortical substance in which it is embedded, as well as to the fibrous capsule which is spread over it. This lamella is probably 644 KIDNEYS. of new formation, and, like similar structures in other situations, it is liable to become opaque, thickened, and indurated by inflammation. The fluid in this event also experiences certain changes; it loses its transparency, augments in consistence, and assumes a turbid, milky, reddish, or greenish aspect. It is seldom that this cyst is multilocular. Some pathologists believe that this nd the other classes of cysts have their origin in degenerating nuclei, the subsequent changes being due to an abnormal development. The second class consists of cysts which are developed deep within the cortical structure, or, more pro- perly speaking, in the granulations of Malpighi (Fig. 240). The cavi- ties become distended with serous fluid, which continues to accumulate until a distinct vesicle is formed, varying in size from a pea to that of a walnut, and the walls of which con- sist, for the most part, of a thin fibrous lamella. The pressure ex- erted by the effused fluid, gradually produces the absorption of the renal parenchyma, until at length the cyst approaches the surface of the kid- ney, where it generally presents it- self as a globular body, and receives an additional covering from the investing membrane of the organ. The contained fluid is not always of a serous character, but frequently possesses all the properties of urine, only that it is more limpid, and less strongly impregnated with saline matter. In the third class are included the serous bags which are formed in the uriniferous tubes, the calyces or pelvis of the kidney, in conse- quence of some obstruction to the free escape of the urine into the bladder. This is a very common variety, and the tumor is sometimes of considerable size. The manner in which it is formed is easily un- derstood. Let it be supposed that one of the calyces becomes closed by adhesive inflammation, and that the renal substance remains per- fectly sound. The cortical struc- ture will of course continue to perform its function, and the urine Cysts of the kidney. Fig. 241. Cysts of the kidney. External appearance. HYDATIDS. 645 that is secreted will be readily conveyed by the uriniferous tubes into the proper excretory duct. Here, however, its further progress will be resisted by the obstruction in question, and hence, as the accu- mulation increases, it will necessarily encroach upon the correspond- ing pyramid, and finally upon the cortical texture, destroying them by absorption. In this manner the renal parenchyma is sometimes com- pletely removed, the organ being reduced to a mere shell, of a dense, fibrous consistence, rough, and hilly externally, and intersected or not by membranous bands. If, at this stage of the disease, the tumor be carefully examined, it will be found to be highly vascular, and to be composed of three distinct layers, the internal of which corresponds with the mucous lining of the excretory canal, the second with the submucous cellular tissue, and the third with the fibrous capsule, the whole being intimately united by organized lymph. The annexed cuts, Figs. 241 and 242, exhi- bit the external and internal appearances of this form of renal change. The contents of these cysts, at first urinous and subse- quently of a serous character, may be clear, lactescent, red- dish, greenish, yellowish, or coffee-colored, and of a thin watery consistence, or thick, ropy, flocculent, and albumi- nous. In many instances they are purulent, sero-purulent, or sanguinolent. Occasionally, though rarely, they consist almost wholly of pure blood, partly fluid, and partly coagulated. The quantity of water varies from a few drachms to many ounces or pounds, according to the dimensions of the cystiform enlargement. Occasionally it is immense. A beautiful preparation, which represented the right kidney, and contained upwards of two gallons of pure pus, was shown to me, some years ago, by Dr. W. C. Sneed, of Frankfort, Kentucky. It was re- moved from the body of a man twenty-six years of age. The sac, which was exceedingly vascular, was about the thickness of the human skin, and was studded internally by a number of bony deposits, some of which were very firm and as large as a thumb-nail. The ureter was entirely closed, and the renal tissue was completely absorbed, the place of the papillae being occupied by seven digital pouches, isolated, and large enough to admit a finger. This variety of cyst constitutes what has been called renal dropsy. The disease is usually of slow formation, and may go on for years without seriously impairing the general health. It may exist in both kidneys at the same time, and be complicated with other affections, particularly of the bladder and urethra. 10. Hydatids.—Hydatids may be developed, first, on the external surface of the kidney, beneath its proper capsule; secondly, in its Internal structure of the cystic degeneration of the kid- ney. From a preparation in my cabinet. 646 KIDNEYS. parenchymatous substance; and, thirdly, in its excretory passages. In their size they vary between a hemp-seed and an orange; in num- ber, from one to several hundred. The older hydatids usually contain clusters of young ones, which either float about in the serous fluid, or are attached to their inner surface. The outer cyst often possesses the firmness of a fibrous membrane; it may also be incrusted with chalky matter, or partially transformed into bone. These changes are more frequent in the sheep and other animals than in the human sub- ject. When very large or numerous, which, however, is not often the case, the hydatids may destroy the parenchymatous substance of the kidney, and so give rise to the same morbid states as the serous cysts already described. They may remain pent up in the situation where they are originally developed, or they may escape into the excretory canals, and be evacuated along with the urine. In a few rare instances they have made their way through the lumbar region by inducing ulcerative absorption. 11. Heterologous Formations.—True scirrhus is extremely rare in this organ; and the same remark is applicable to colloid. Encephaloid, on the contrary, is not un- Fig. 243. common, especially in chil- dren, in whom it often ac- quires an enormous size. The heterologous matter usually makes its appear- ance in small whitish masses, which, increasing in volume and number, gradually coalesce, and at length transform the kid- ney into a soft, pulpy mass, of the color and con- sistence of the brain. (Fig. 243.) The tumor, in the advanced stage of the dis- ease, is irregularly tabu- lated, the fibrous envelop loses its identity, and the pelvis and ureter are oc- cluded by the cancerous substance. A section of the morbid growth occa- sionally presents a large clot, composed of loose, concentric layers, similar to those in a rapidly formed aneurism. Persons affected with this disease sometimes pass encephaloid matter with the urine which together with the pain and enlargement in the lumbar reoion, serves as an important diagnostic character of the nature of the morbid action. Melanosis of this organ has been found only in a few instances. Like tubercle, it rarely, if ever, exists except in association with simi- lar deposits in other parts of the body, as the skin, cellular tissue, lungs, liver, and serous membranes. It may present itself as an infil- Encephaloid of the kidney. From a preparation in my cabinet. MELANOSIS — TUBERCLES. 647 tration, but more commonly it occurs in small disseminated tumors, from the size of a pin-head to that of a hazel-nut, of an irregularly spherical figure, hard, of a black, brownish, or dark grayish color, and embedded in the cortical substance, immediately beneath the fibrous capsule. The heterologous matter is occasionally deposited in a dis- tinct cyst, filled with a liquid of the color and consistence of ink. When the new substance is very abundant, the kidney is usually somewhat augmented in volume, but in almost all cases it retains its normal bulk and form. It is of a spongy, vascular character, analo- gous to the cavernous body of the penis, and is formed by the inter- lacement of a great number of small veins, dilated at various points of their extent, and supported by delicate cellular substance. It is generally seated in the cortical texture of the kidney, and coexists with a similar alteration in other parts of the body. It is not often that tubercles occur in the kidney, and then only in connection with the same disease in other situations, particularly the lungs, lymphatic ganglions, liver, intestines, and genito-urinary apparatus. The heterologous matter may be deposited on the sur- face of the organ, in the cortical substance, or in the uriniferous cones, in the form of small disseminated masses, from the volume of a mustard-seed to that of a cherry or small marble, of a pale yel- lowish or whitish aspect, and of a firm, cheesy, almost fibro-cartila- ginous consistence. Their number is sometimes immense. Thus, in the right kidney of a young man, of twenty-seven, who died of psoas abscess, there were upwards of five hundred in the cortical substance, of all sizes between that of a mustard-seed and a cherry- stone. In some parts they were agglomerated, in others isolated. They were of a white opaque appearance, semi-cartilaginous in their consistence, and evidently organized, since, in cutting through some of them, I could distinctly trace the existence of vessels, the blood stand- ing upon the incised surface in minute dots. Externally Fig. 244. the organ had a dark mot- tled aspect, and in its inte- rior were two tubercular excavations; one, situated in the superior extremity of the gland, was scarcely larger than a hazel-nut; the other, which occupied the lower half of the viscus, was about the size of a turkey's egg, and filled with thin, ropy, whitish pus, destitute of smell. The abscess was lined throughout by a thick layer Of fymph, and inter- Tubercular excavations of the right kidney. From a SeCting it in different direC- specimen in my cabinet. tions were four rounded cords, the remains, probably of the tubular texture, which resembled 648 KIDNEYS. a good deal the fleshy columns of the heart, or the bands which we so often see in tubercular excavations of the lungs (Fig. 244). The kidney was very little enlarged: some tubercular matter was also found in the excretory passages, the cavity of the ureter having been nearly obliterated by it. In this case not a tubercle could be detected in the lungs. The}' were, indeed, perfectly sound, as were also the heart and brain, to- gether with most of the abdominal viscera. Strumous matter was abundantly contained in the lymphatic ganglions of the pelvis, and the seminal vesicles were completely distended with it. The tubercular matter is sometimes deposited upon the free surface of the calyces, pelvis, and ureter, either in small, circumscribed granu- lar masses, or in that of a continuous layer, of variable thickness, yel- lowish or grayish in its color, and more or less accurately moulded to the shape of the containing parts. The quantity of the effused matter may be very small, or so large as to lead to serious impediment to the passage of the urinary fluid. I have twice found it so great as to cause complete obliteration of the commencement of the ureter. The volume of the kidney may be natural or diminished, but most commonly it is somewhat increased. In cases in which the deposit takes place rapidly the kidney is generally very vascular. It has been said that both organs are usually attacked by this disease; an opinion which is disproved by the observations of Rayer, who found double tuberculization only in six cases out of sixteen. Of the remaining cases seven occurred on the left side. 12. Calculi.—Calculi of the kidney may be developed either in its parenchymatous substance, the calyces, funnel-shaped processes, or the pelvis of the ureter (Fig. 245), being in most cases the result of a pecu- liar.diathesis of the system. They generally consist of the same chemical Fig. 245. Calculi of tlie kidney and ureter. From a specimen in Profossor Willard Parker's collection. elements as those of the bladder. The commonest variety is the uric calculus, which is usually of a light brownish color, and of a spherical shape, with a perfectly smooth surface, Next in point of frequency is the oxalic concretion, of a dark complexion, and of an irregular oval figure, with a rough mulberry exterior. A third variety of'renal calculus is the ammoniaco-magnesian. This generally occurs in con- nection with one or the other of the preceding species, an external WORMS. 649 layer forming around them, varying in thickness from a line to half an inch or more. The phosphatic concretion is seldom met with in the kidney, and seems not to proceed from the urine, but from other secretions of the affected organ. Renal calculi may exist for a long time unsuspected. Most generally, however, they produce hemorrhage, inflammation, abscess, or ulcera- tion, with pain in the loins, obstruction to the flow of urine, uneasiness in the ureter and bladder, and constitutional disturbance. Should the concretion become immovably fixed in the excretory duct, the urine, which is still secreted, will accumulate in the passages above; and, by the pressure which it exerts upon the parenchymatous structure, it will gradually effect its absorption, until the organ is wasted to a mere remnant. At other times, the ureter bursts, as the urethra some- times does behind a stricture; or suppression of urine ensues, and the patient dies. 13. Worms.—The large strongyle (Fig. 246), a species of lumbricoid worm, has been observed in a few rare instances in the human kidney. It is oftener met with in the inferior animals, as the horse, ox, wolf, dog, otter, and raccoon, and is exceedingly common in the hogs which are brought to the slaughter-houses in the environs of Cincinnati, Louisville, and other western cities. The situations in which it is ordinarily found are the pelvis and infundibular prolongations of the ureter, in which it is frequently coiled up in considerable numbers. Occasionally it makes its way into the parenchymatous structure, where it produces suppuration, atrophy, and other mischief. Fig. 246. The strongyle is a very slender cylindrical worm, from two to three inches long, of a light grayish color, interspersed with dark spots; in some instances it has been known to attain the length of three feet, with a diameter of from four to six lines. The male is smaller than the female, and tapers slightly towards each extremity. The head is ob- tuse, and furnished with an orbicular mouth, encircled by six hemi- spherical papilla?: the body is transversely striated, and marked by two longitudinal impressions; and the tail, which is incurvated, ends 650 KIDNEYS. in a dilated pouch, from the base of which projects a single penis. In the female, the caudal extremity is less pointed than in the male, with the anus just below the apex; the vulva is situated at a short distance from the head, and communicates with a slender cylindrical vagina: the uterus, in the larger individuals, is about three inches long, and leads to a simple ovary, which is nearly four times the length of the body. A nervous system can be distinctly demonstrated in this para- site. It seems to consist of two delicate rings, one encircling the oeso- phagus, the other the anus, connected by a single cord running in a straight line along the middle of the ventral aspect. 14. Laceration.—The kidney, notwithstanding the firmness of its texture and the depth at which it is situated, is liable to laceration from external violence. The rupture may be confined to the cortical substance, or it may extend through this into the tubular, or even into the pelvis and calyces, though this is exceedingly rare. Occasion- ally it passes through the whole thickness of the organ, so as to divide it into two distinct parts, one of which is generally somewhat larger than the other. In its direction the fissure, crack, or rupture is usually transverse or oblique, seldom longitudinal. The number may be li- mited to one, or there may be as many as eight or nine, as in the interesting case narrated by Dr. Kirkbride,1 of this city, in which the principal rent was three inches and a half in length by nine lines in depth. Rupture of the kidney is usually attended with considerable effusion of blood into the surrounding cellular tissue, and sometimes also into the peritoneal cavity. It may occur alone, or be complicated with lace- ration of the liver, spleen, bowels, or urinary bladder, with fracture of the ribs and pelvic bones, and with contusion of the skin and muscles. It is worthy of note, however, that, in some instances, there is no mark whatever of exernal violence, not even the slightest ecchymosis. The accident is commonly produced by falls from a height, or by the body being pressed between two hard and resisting objects. It may also result from the kick of a horse, and, in one instance, it was caused by a blow with a bludgeon upon the right lumbar region.2 The patient generally voids more or less blood soon after the injury; the period at which death occurs varies from a few minutes to several hours, days, or weeks. The lesion, however, is probably not always fatal. In favorable cases, lymph is effused between the lips of the rupture, by which the breach is ultimately repaired, and the extravasation of urine into the retro-peritoneal cellular tissue prevented. 15. Malformations.—Considerable variety is observed in regard to the original conformation and situation of the kidneys. Xo well authenticated case has yet been recorded, I believe, of the complete absence of both these organs. One is sometimes absent, and then the other is generally unnaturally large, to compensate for the defi- ciency. It is not rare to see one of these viscera in front of the spinal column, 1 American Journal of the Medical Sciences, vol. xv. p. 359. 2 Morgagni, de Sedibus et caus. Morb., Epist. liv., § 15. URETER. 651 or in the cavity of the pelvis, the other Fig- 247. occupying its usual situation. Some- times they are joined together by a narrow isthmus. When this is the case, they lie close to the vertebrae, forming a kind of arch, with the con- cavity towards the diaphragm ; they are more compressed than usual, the fissure is absent, and the vessels enter lower down, generally at the anterior surface. The situation of the ureter is likewise different. (Fig. 247). Instances have been recorded of individuals who had three kidneys. In these cases, either two of the organs were on the same side, or they occupied their usual place, whilst the supernumerary one was situated in front of the spine, or within the pelvic cavity. Horseshoe kidney. From a specimen in my cabinet. SECTION III. URETER. The principal lesions of the ureter are deposits of tubercular matter, and lymph upon its surface, thickening and attenuation of its walls, with contraction or enlargement of its cavity. Dilatation (Fig. 248,) is gene- rally produced by the retention of a renal calculus, or by some tumor seated along the course of the tube, and interfering with the egress of the urine. In the male, it is sometimes caused by stricture of the urethra; in the female, by the pressure of a carcinomatous uterus. In a case of this description, which fell under my notice several years ago, the left ureter was fully as large as the thumb, with remarkably thin, transparent walls. Fig. 248. Dilatation of the ureter and pelvis of the kidney. From a specimen in my cabinet. 652 URINARY BLADDER. Small cysts, from the size of a pin-head to that of a pea, are some- times developed beneath the mucous membrane of the ureter, either singly or in groups. They are of a spherical figure, transparent, and occupied by a thin watery fluid, by inspissated mucus, or by a yellow- ish, semi-concrete substance, not unlike that of tubercle. Occurring sometimes simultaneously in the calyces, pelvis, and ureter, they are most common in the latter situation, and are probably nothing but mucous follicles, enlarged in consequence of the obstruction of their orifices. As they augment in size some of these cysts burst, appa- rently from over distension, and discharge their contents into the ureter, leaving a small ulcer, with thin, irregular, and inverted edges. Occasionally the duct presents a singularly sacculated arrangement, some portions of it being greatly expanded, others very much con- stricted. The ureters may be absent, and in some instances they have been known to terminate in a cul-de-sac. When the bladder is wanting, they open either into the urethra, the vagina, or the rectum. Occa- sionally, again, they are reduced to small, narrow, almost impervious cords; and when this happens, the pelves of the kidneys are generally dilated into large pouches, capable of holding many ounces of fluid. I have never seen valves in the interior of these tubes; but examples of this have been recorded by different writers, and are perhaps more frequent than is generally supposed. These folds, it may be remarked, are usually connected with a dilated and tortuous state of the ureters. SECTION IV. URINARY BLADDER. The bladder is liable to inflammation, suppuration, gangrene, soft- ening, ulceration, hypertrophy, hernial pouches, the heterologous forma- tions, rupture, worms, calculi, and congenital vices. 1. Inflammation.—The disease usually occurs in small irregular patches; and is anatomically characterized by increased vascularity, loss of transparency, softening, and deposits of lymph, with alteration of the natural secretion. The discoloration varies, according to the extent and degree of the morbid action, from the lightest rose to the deepest purple. It usu- ally displays itself in small and tolerably well-defined patches,, which are always most distinct at the centre of the inflamed part, from which they gradually diminish in intensity until they are insensibly lost in the surrounding healthy structures. In some cases, especially in such as run their course with great rapidity, blood is effused in the sub- mucous cellular tissue, and the part exhibits a truly ecchymotic aspect, similar to that which is seen in a bloodshot eye. This appearance existed, in a remarkable degree, in the bladder of a young man of SUPPURATION. 653 about twenty, whose body I examined a few years ago. Nothing was known of his previous history, but it was evident from the condition of his bowels, that he had died of colitis. The bladder contained about four ounces of dirty, turbid looking urine; and the mucous mem- brane, at the bas-fond, over a space of about three inches in diameter, was a deep cherry color, from the presence of extravasated blood in the submucous cellular tissue. A portion of the affected surface was incrusted with coagulating lymph, which had to be removed before the extent of the ecchymosis could be fully traced. There can be little doubt that this man had a violent attack of cystitis a short time before his death. The bloodvessels, in this disease, have either an arbore- scent or capilliform arrangement, according to the severity of the morbid action. More or less opacity almost always accompanies the discoloration; and when the disease is unusually violent, there is not only some degree of softening, but also considerable tumefaction of the mucous membrane. These changes are generally most conspicuous in those cases in which the inflammation has been somewhat protracted. A deposit of lymph is rather a rare phenomenon, and appears to occur chiefly as a result of external violence, the inordinate use of cantha- rides, or the irritation of a calculous concretion. The veins about the neck and bas-fond of the bladder are engorged with black blood, and the muscular tunic is preternaturally red, softened, and, in some places, almost gangrenous. When the inflammation has involved the peri- toneal investment, this part will be found abnormally vascular, in- crusted with lymph, and, perhaps, more or less adherent to the sur- rounding viscera. In some instances, minute abscesses are seen in the submucous cellular tissue, or in the substance of the muscular coat, and purulent matter in the veins of the neck of the bladder and of the prostate gland. These phenomena are most apt to occur in traumatic cystitis. At the commencement of the disease, the secretion of mucus is somewhat augmented in quantity, but thinner and less viscid than in the natural state. When at its height, it is almost entirely suppressed, and the membrane is consequently somewhat dry, just as in acute inflammation of the Schneiderian membrane; but as this period is always of short duration, the secretion is soon re-estab- lished, and often exists in great abundance, being of a thick, ropy consistence, and of a pale straw, grayish, drab, or greenish color. In the higher grades of the disease, the secretion, instead of being mucous, is puriform, or muco-purulent, and tinged with blood, which seems to be poured out, under these circumstances, in the form of exhalation, though occasionally it is no doubt caused by a laceration of some of the capillary vessels. 2. Suppuration.—The termination by suppuration is by no means infrequent. The matter, in most cases, is poured upon the inner sur- face of the bladder, where, mixing with the urine, it imparts to this fluid a peculiar lactescent aspect, and sometimes a very offensive odor. In other cases, the pus collects in the submucous cellular tissue, or be- tween the muscular and serous tunics, and finally escapes into the pelvic cavity. Occasionally the bladder contracts adhesions with the 651 URINARY BLADDER. rectum of the male or the vagina of the female, and the matter finds an outlet in this way. The quantity of pus seldom exceeds two or three ounces. 3. Gangrene.—Idiopathic gangrene of the bladder is extremely rare. It is most frequently seated at the neck of the viscus, and is remarked chiefly as a result of the protracted retention of urine. The eschars are of a dark, livid color, soft, easily torn, and bathed with a thin sanious fluid, of an exceeding fetid odor. 4. Softening.—It is very seldom, indeed, that the mucous membrane of the bladder is the seat of softening. When thus affected, it is of a dull white, pale gray, or drab color, devoid of vascularity, and so changed in its cohesive properties that it may be easily scraped away with the nail or the handle of a scalpel. It may retain its natural thickness, or it may exhibit a pulpy and infiltrated appearance, or it may be thin and withered. The softening may occur in patches of various shapes and sizes, or it may extend over the whole tunic, which, however, is extremely rare. In the few cases in which I have witnessed this lesion it was confined to the bas-fond of the organ, and was associated with other affections, as ulceration, tubercular deposits, hypertrophy of the prostate gland, or stricture of the urethra. In violent cystitis, the disease sometimes extends to the submucous cellu- lar tissue and muscular fibres, which are infiltrated with serosity, changed in color, soft, and lacerable. There is a variety of molles- cence of the urinary bladder which may be called idiopathic, as it is usually connected with a disordered state of the system, such as that arising from the excessive loss of blood, impoverished diet, or pro- tracted indisposition. The mucous membrane, in this case, is of a pale, milky hue, either uniformly, or in small strips or patches, and of the consistence of soft glue, isinglass, or jelly. 5. Ulceration.—Ulceration of this organ is uncommon. When of the simple kind, it is usually the consequence of ordinary inflamma- tion, of the bursting of an abscess, or of the pressure of a calculus. The erosions vary much in size, depth, shape, and number, in the appearance of their edges, and in their tendency to heal, which, owing to the irritating character of the urine, and the constant motion of the bladder, they rarely attain, or successfully accomplish. In stone of the bladder I have seen the mucous coat destroyed over a large extent of surface; but, in general, the ulcers are small, not exceeding a few lines in diameter, of an oval or circular shape, resting upon the sub- mucous cellular tissue, and having irregular and slightly undermined edges. In some instances they manifest a disposition to extend, the morbid action going on until a communication is established with the rectum, ileum, colon, vagina, or peritoneal cavity. 6. Chronic Inflammation and Hypertrophy.—Chronic inflammation is much more frequent than acute, of which it is sometimes the result, and gives rise to various alterations, among which the more important are, hypertrophy, the formation of cysts, and fungous excrescences, not unlike those that have been described as occurring in the large bowel. Hypertrophy, although it may be seated in any of the tunics, is most common in the muscular, which sometimes acquires the HYPERTROPHY. 655 thickness of nearly half an inch. The lesion is often partial, that is, it is limited to a small number of fleshy fibres, which are of a deep florid color, very strong, and collected into large bundles. When this happens, the inner surface of the organ becomes fasciculated, like the interior of the ventricles of the heart, and thus constitutes what is Fig. 249. Hypertrophy of the muscular fibres of the bladder. From a specimen in my cabinet. termed the columniform bladder. (Fig. 249). The accompanying wood- cut, which exhibits the various characters presented by this affection, is taken from a specimen in my collection. Hypertrophy of the muscular tunic, whether partial or general, is usually referable to obstruction at the mouth of the urethra, to over- come which it is obliged to make increased exertion; a larger flow of blood is invited, and excess of nutrition, with diminished capacity of the reservoir, is the consequence. This condition frequently coexists with vesical calculi, enlargement of the prostate gland, and stricture of the urethra. When the hypertrophy is seated in the lining membrane, or in the subjacent cellular substance, there is generally a great development of the mucous follicles, which, instead of being small and scarcely per- ceptible, as they are in the normal state, are rendered extremely promi- nent, and pour out an unusual amount of thick ropy fluid. In some instances we meet with well developed villosities, and, more frequently still, with pretty large, fungous-looking excrescences. These vegeta- tions, as they may be termed, are commonly of a light slate color, firm in their consistence, and of a pyriform shape, with a short, slender peduncle. Around their base are occasionally to be observed beautiful vascular wreaths, showing that they originate in inflammation. The mucous membrane at the neck of the bladder is sometimes ele- vated into one or more horizontal ridges, varying from one to two inches in length by three or four lines in width. The annexed draw- 656 URINARY BLADDER. ing (Fig. 250), from a beautiful specimen in my cabinet, represents two prominences of this description, both of large size. The prostate gland is very much increased in size, and the muscular coat is hyper- trophied throughout. The lesion is evidently the result of chronic irritation. Fig. 250. Hypertrophy of the bladder, exhibiting the corrugated appearance of its lining membrane, with a bar-like formation at its neck, and hypertrophy of the prostate gland. 1. Atrophy of the Bladder.—This affection is usually the result of long-continued compression, produced by the presence of a pelvic tumor, or some similar cause, interfering with the nutrition of the viscus. When this is carried to any considerable extent, the cavity of the bladder may be so much diminished as to be unable to hold more than a few ounces of urine, at the same time that its walls are pale and attenuated. Sometimes the atrophy is limited to the mus- cular fibres, as we see when the organ has been subjected for a long time to over-distension from paralysis. When this is the case, they have a pallid, wasted, straggling appearance, similar to what occasion- ally occurs in the coats of the stomach and bowels. 8. Sac-like Pouches.—A frequent consequence of hypertrophy of this viscus is a development of small sacs, caused by the outward pro- trusion of the mucous membrane, or by the interlacement of the mus- cular fibres. In the latter case, considerable cavities are sometimes intercepted, which become lined with a sheeting of lymph, and filled with different fluids, such as serum, urine, or pus. When the lining membrane is forced between the enlarged fascicules, it occasionally dilates into a large pouch, perhaps half as large as the bladder itself, HETEROLOGOUS FORMATIONS. 657 with which it communicates by a narrow aperture. (Fig. 251.) This appearance is generally observed near the fundus of the organ, and is much more common in the male than in the female, as in the Fig. 251. Section of the bladder and prostate, a. Mucous surface of the bladder. 5, 6. Lateral lobes of the pros- tate, c. Middle lobe. d. Large cyst or pouch, partially laid open, and communicating with the blad- der by a small orifice. From a preparation in my private collection. latter, from the peculiar construction of the urinary passages, there are fewer causes to produce it. The walls of these cysts are often much thickened by new deposits, and not unfrequently they contain calcu- lous concretions. The bladder, in this state, is almost always irritable, and admits of very little distension. The number of sacs varies from one to six or ten. 9. Heterologous Formations.—Encephaloid of the bladder seldom occurs as an original disease; most commonly it is propagated to it from the surrounding organs, as the rectum and the uterus. It appears to take its rise in the submucous cellular tissue; forming, as it ad- vances, a large tumor, which projects into the cavity of the organ, and greatly diminishes its capacity. In some instances it makes its way in other directions, passing outwards, and contracting adhesions with the sides of the pelvis, the uterus, or the bowels. Such growths are sometimes of a mixed character, scirrhous, cartilaginous, and fungous; and, occasionally, they are found studding the inner surface of the bladder in great numbers, being not larger than a common pea, and of a soft medullary texture. Scirrhus and melanosis of the bladder are extremely rare. In a case of general melanosis, described in the chap- ter on that disease, I observed five small, but well marked tubercles of this kind, seated at different points in the submucous cellular tissue. The occurrence of tubercle in the urinary bladder is much less fre- quent than in the larynx, trachea, and intestinal canal. Indeed, it is 42 658 URINARY BLADDER. among the rarest diseases to which this organ is liable. It is usually associated with tubercle of the kidneys, seminal vesicle, prostate gland, or other parts of the body, and is most common in persons be- tween twenty-five and fifty. The heterologous matter is deposited in small, discrete granules in the submucous cellular tissue, or in this substance and the mucous membrane, which is raised into little points, hard to the touch, and encircled by delicate vascular zones. The ulcers which are left by the softening of this matter are generally very small, and of an irregularly rounded form, with thin, ragged edges ; cases, however, occur where they involve the whole mucous lining, which is finally completely destroyed, the muscular fibres presenting the appearance as if they had been neatly dissected by the anatomist. 10. Neuralgia.—In persons of a nervous, irritable temperament, the bladder is sometimes the seat of severe pain, darting through the pel- vis in different directions, and recurring in regular paroxysms. In its nature, it is evidently neuralgic, and it is often associated with similar uneasiness in other parts of the body, especially the face and scalp. In some cases, it seems to be produced by sympathy with the kidney, by an altered state of the urinary fluid, and by the presence of a calculus. 11. Laceration.—Rupture of the urinary bladder, although certainly not common, is yet sufficiently frequent to render it an object of in- terest both to the pathologist and medical jurist. The causes which may give rise to this accident are, over-distension of the organ attended with softening of the mucous membrane and muscular fibres, gangrene and perforative ulceration, external violence, and, in the female, the pressure of the child's head during parturition. In whatever manner the laceration is induced, it is always followed by an escape of urine into the connecting cellular tissue, or peritoneal cavity, where its pre- sence soon excites fatal inflammation. The period at which death takes place varies from a few hours to as many weeks, but the great majority of patients perish within the first three or four days. When caused by external violence, the lesion may be complicated with fracture of the pelvic bones, rupture of some of the parenchymatous organs, as the kidney, liver, or spleen, contusion of the skin and abdominal mus- cles, and more or less effusion of blood into the peritoneal cavity. The blood poured out sometimes amounts to several pounds, and may proceed from the laceration of a great number of small vessels, or from the injury of a single large one. The size, situation, number, direction, and form of the accidental opening are extremely variable, and do not admit of any specific description. The ruptured organ is usually very much contracted, and rarely contains more than a few drachms of urine. When the lesion is the result of injury there is often no mark whatever of external violence, such as contusion or ecchymosis; a fact of great interest in a medico-legal point of view. This organ is sometimes lacerated by causes apparently the most trifling. Zivinger1 attended a young man whose bladder was torn by 1 Ephem. Nat. Cour., cent. vii.,obs. 30. MALFORMATIONS—WORxMS. 659 a severe blow on the lower part of the hypogastric region, unaccom- panied by the slightest appearance of external violence. A similar example is related by Zittmann.1 Montagu3 saw a case of rupture of this organ from a fall on the abdomen; and Dupuy tren3 met with one where the lesion was produced by a kick in a scuffle. In this case the patient survived until the seventeenth day. On dissection, marks of adhesion were seen between the intestines and bladder, on the ante- rior surface of which existed two rents, one of them an inch and a half in length. 12. Malformations.—The bladder is liable to various.malformations, a bare enumeration of which is all that my limited space will permit me to attempt. Total absence of the organ has been observed only in a few instances. When it exists, the ureters open either into the rectum, the urethra, or the vagina. In the former case, the arrangement resembles that of birds and reptiles, in the formation of a true cloaca. Secondly, the viscus is sometimes divided into several compartments, either congenitally, or as a consequence of disease. In either event, the cavities generally communicate directly with each other. Cases of this kind are described and delineated in my work on the urinary organs. Thirdly, the organ is deficient in front, constituting what is termed extrophy of the bladder. The malformation is always accompanied by imperfect development of the abdominal muscles, the pubic bones, and the genital organs. The posterior wall of the viscus is pushed forward into the vacant space, forming a hemispherical tumor, of a florid color,. which receives the orifices of the urethra, from which the urine con- stantly dribbles over the surrounding parts. The annexed cut (Fig. 252), copied from my treatise on the urinary organs, conveys an ex- cellent idea of the nature of this affection. 13. Worms.—The urinary bladder occasionally contains worms^ which are either of a distinct and specific character, such as are found in no other situation, or they creep into it from the rectum, colon, or small intestine. In nearly all the recorded instances of the lat- ter, the animal was of the lumbricoid or vermicular variety, which left its accustomed habitation, and passed into the urinary reservoir, either by perforating the coats of the alimentary canal, or, as more frequently happens, through an opening made by ulcerative action, from the irritation produced by an abscess, a piece of bone, or some extraneous body. Of the worms which naturally inhabit the urinary bladder, only two species, have hitherto been discovered, the one by Mr. William Lawrence, the other by Mr. T. B. Curling, of London. The animal described" by the first of these distinguished surgeons, is the spiroptera, of which, in the space of about two years, a young, unmarried woman. 1 Op. cit.. cent. v. obs. 22. 2 Medical Communications of London, vol. ii. obs. 23,. 1.790. 3 American Journ. Med. Sciences, vol. xii. p. 535. 4 Medico-Chir. Trans, of London, vol. ii. p. 385. 660 URINARY BLADDER. twenty-four years of age, voided not less than from eight hundred to a thousand. They varied in length from four to six inches, and were remarkably slender at the middle, from which they gradually increased Fig. 252. Extrophy of the bladder, a. Everted bladder. b, b. Orifices of the ureters, c. Penis without urethra. d, d. Pubic symphysis, e. Scrotum and testis. /. Congenital inguinal hernia. towards the extremities, which were small and tapering. One of the surfaces of the body exhibited the appearance of a double row of small protuberances, while the other was marked by a groove with two rising edges. They were soft when first voided, and of a yellowish color. The body seemed homogeneous throughout, and careful micro- scopical observation failed to throw any light upon their organization. The smaller worms, which were seen only on one occasion, were semi- transparent, and of a rounded form, with pointed ex- Fig. 253. Fig. 254. tremities. I am not acquainted with any instances in which this worm has been noticed in the human sub- ject by other observers. The worm discovered by Mr. Curling1 has been named by him dactylius aculeatus, from its peculiar ring-like appearance. It was voided with the urine, for a number of days, by a little girl, five years of age, who was affected with subacute pneumonitis, and who was also occasionally troubled with ascarides. The worm is of a light color, cylindrical in its form, annulated, and slightly tapering towards the extremities, particularly the anterior, which is the smaller. The female is four-fifths of an inch long (Fig. 1 Medico-Chir. Transactions of London, vol. xxii. p. 274. WORMS. 661 253), the male two-fifths (Fig. 254). The head is truncated; the mouth orbicular; the neck distinctly annulated; and the tail, also annulated, is obtuse. The tegument, of a: delicate transparent structure, and con- taining two layers of muscular fibres, one circular, and the other longitudinal, is armed with a number of sharp-pointed spines, arranged in equidis- tant rows, in clusters of three, four, or even five. They cover nearly the whole surface, and seem to be perfectly under the control of the animal, which has the power of protruding and retracting them at plea- sure. The alimentary canal commences at the mouth by three small convoluted tubes, which soon unite into a single one, which proceeds for some distance in a tortuous direc- tion, when it becomes saccu- lated, and, enlarging as it de- scends, terminates at the ex- tremity of the tail in a trilo- bular anus. The structure of the female is much more complicated than that of the male. The vulva is situated near the anterior extremity, about one-fifth of an inch from the head, and has the appearance of an opaque, mammillated process. The animal swells at this part, the tegument is thicker, there are no spines, and, for a short dis- tance above and below the vulva, the body is encircled by a series of regular, dark- colored fibres. About midway between the head and vulva, and on opposite sides of the alimentary canal, are two gra- Fig. 255. Fig. 255.—a. The head ; 6. The caudal extremity ; c. Sacculated alimentary canal; d. Dark lines at the junction of the ante- rior and middle third of the animal. Fig. 256.—a. Head, with the orbicular mouth ; b. Caudal extremity, with the labiated anus ; c. Vulva; d. The three tubes by which the alimentary canal commences ; e. Alimentary canal; /. Pulsating tube in the alimentary canal; g. Lobulated bodies round the commencement of the alimentary canal; h. Glandular bodies on the sides of the canal; i. Movable fimbriated bodies near the vulva; fe. Convoluted oviducts. 662 URINARY BLADDER. nular bodies, of an oval form, and just below these, two slightly con- voluted tubular processes. No genital apparatus was discernible in the male. Both sexes have a distinct vascular, and, doubtless, also a nervous system. The annexed wood-cuts represent the internal struc- ture of the worm. Fig. 255 is the male, Fig. 256 the female, both magnified ten times. Having thus briefly considered the several lesions of the bladder, I shall bring this section to a close by making some remarks on the morbid states of the urine, urinary deposits, and urinary calculi. 14. Morbid Urine.—Three varieties of urine, differing materially in their physical and chemical properties, are recognized by modern ob- servers. These are respectively denominated potous, chylous, and sanguineous. The first is that passed a short time after the free use of fluids, and is generally of a pale color; it is of low specific gravity, rarely exceeding 1.009, and contains comparatively little solid matter. In chylous urine, the product of the digestion of a full meal, the spe- cific gravity is generally considerably increased, and may be said to range between 1.020 and 1.030, the latter of which, however, it rarely attains. The sanguineous urine, the urine of the blood, or the morning urine, is the most elaborate variety of the three. It is of the average density of 1.015 to 1.025, and exhibits in perfection all the essential properties of this important fluid. The following is the average of three analyses of healthy urine by M. Lehmann:— Water..........934.567 Urea..........32.424 Uric acid ......... 1.064 Lactic acid ... . . . . . . . 1.520 Lactates.......... 1.565 Mucus .......... 0.107 Alkaline sulphates....... 7.308 Phosphate of soda ........ 3.806 Phosphates of lime and magnesia . . . . . 1.142 Chlorides of soda and ammonia ..... 3.653 Watery extract . . . . ' . . , . 0.614 Alcoholic extract ........ 10.267 The urine is greatly influenced by disease, diet, and other circum- stances. A brief outline of these changes is all that can be attempted in a work of this kind. 1. Water, being naturally present in greatest abundance, is more liable . to variation than any of the other constituents of the urine. In nerv- ous diseases, especially such as are of a hysterical character, this secretion is generally unusually copious as well as remarkably thin and limpid, looking more like well-water than common urine. In diabetes insipidus, the urine, which is often discharged in immense quantities consists almost wholly of water; the urea is entirely absent- and the fluid, on evaporation, deposits a yellow brownish syrup, in which there is no appearance of crystals, and which possesses a very feeble acid reaction. J Urea, next to water, exists more largely in healthy urine than any other ingredient. The quantity daily voided by a healthy adult varies from four to seven drachms; in the female, child, and did man man. URIC ACID — ALKALIES. 663 it is considerably less. It is influenced by different kinds of diet. Thus, M. Lehmann, in some experiments which he performed on him- self, obtained from the urine which he passed during twenty-four hours, the following interesting results :— Grains. After a non-nitrogenous diet......237.909 " a vegetable diet.......347.061 " an animal diet.......821.270 " a mixed diet........501.704 Urea is furnished sparingly in certain diseases, as in chronic inflam- mation of the liver, in granular degeneration of the kidney, in dyspepsia, pulmonary phthisis, gout, and intermittent fevers. Urea sometimes exists in excess. This state is usually combined with preternatural activity of the renal function, and can easily be recognized by mixing with the urine an equal quantity of nitric acid. Uric acid generally greatly predominates in arthritic affections, as is shown by the formation of the earthy concretions, which are so fre- quently seen in the joints of the extremities, and which seem to be composed principally of the urate of soda, with a small quantity of the urate of lime. Gravel commonly consists of uric acid, and it is well known that this substance forms the basis of one of the most common varieties of urinary calculi. In diabetes mellitus, this acid is entirely absent, no trace of it whatever being discoverable by the most delicate tests. In some instances, this substance occurs in a free state; but most generally it appears in combination with an alkali; and, so long as this is the case, it does not yield a crystalline deposit. A deficiency of phosphoric acid sometimes exists. When this is the case, the earthy materials are supposed to be converted into neutral salts, and then precipitated, so as to afford an opportunity for the for- mation of a stone. The alkalies which enter into the composition of this fluid are some- times secreted in excess, and, by combining with the acid ingredients, may form salts, which on being deposited in the bladder, give rise to calculous concretions. This is especially the case with the lime and ammonia, the soda and potash producing little or no inconvenience. Urine always contains, even in the healthy state, a small quantity of mucus, which, however, as it is perfectly transparent, does not be- come visible until after the fluid has stood some time in a tall, narrow glass vessel. It then presents itself near the bottom of the receiver, as a light but distinct cloud, which contrasts very strikingly with the clear supernatant fluid. It is always more or less transparent when moist, is not coagulable by boiling water, is soluble in caustic potash, and forms, on the addition of acetic acid, a thin, semi-opaque, corrugated, and characteristic pellicle. When dried, it has a peculiar shining aspect. Under the microscope, it is observed to have the same globular appearance as pus, but the particles are less numerous, and also less distinctly granular. They are suspended in a viscid, glairy fluid, sometimes combined with a minute trace of albumen. The urine with which the mucus is united is generally alkaline, and remarkably prone to decomposition, which not unfrequently takes place even in the bladder, especially if it be long retained. 664 URINARY BLADDER. The quantity of mucus is frequently much increased in disease. In cystorrhoea, for example, it is so abundant as to impart to the affection its distinctive character. An augmentation of quantity is usuall}' associated with an augmentation of consistence. In chronic cystitis, attended with a copious secretion of mucus, the fluid is generally exceedingly tough and viscid, adhering tenaciously to the bottom and sides of the receiver, and allowing itself to be drawn out in long, stringy threads. It is, also, under these circumstances, not unfrequently associated with phosphatic deposits. The lining membrane of the genito-urinary apparatus, like the ex- ternal surface of the skin, is constantly engaged in throwing off epithe- lial cells, of variable size, and of an oval, or irregularly angular and flattened configuration, each having a well- Fig- 25?. marked central nucleus; sometimes they are broken up, and arranged in scales, patches, or lamellated plates. (Fig. 257.) They fre- quently occur in combination with oxalate of lime, and in certain affections, especially in Bright's disease, they contain fat-globules. 2. The process of secretion, which is con- stantly going forward in the kidney, some- times proceeds to a morbid extent, in conse- quence of which substances are generated which do not naturally occur in the urine. pitheiium. rp^ mos^ important of these, in reference to the pathology and treatment of diseases, are albumen, fibrin, the coloring matter of the blood, and pus. Other substances are occasion- ally observed, which get into the urine accidentally, and impart to it their peculiar properties. Of this description are the yellow matter of the bile, asparagus, oil of turpentine, and most of the balsamic preparations. Cantu detected mercury in the urine of persons who had been subjected to frictions with that substance, in the form of oint- ment ; and the ferrocyanide of potash, tartaric acid, iodine, quinine, and a hundred other articles have been observed in this fluid after they had been used as medicines. In severe cases of jaundice, the bile passes from the blood into the kidneys, and communicates a yellow tint to the urine, at the same time that it renders it more acrid. The most delicate testof its presence is nitric acid, which causes either a green or brownish hue, according to the peculiar modification of the coloring principle of the foreign ingredient. Albumen is frequently present in certain diseases, in large propor- tion. In the granular affection of the kidney it generally exists in considerable quantities, though it cannot be regarded as pathognomonic of that lesion, as it has been repeatedly observed in pneumonitis, dropsy of the abdomen, tubercles of the lungs, prurigo, and typhoid fever. _ Albuminous urine is generally of low specific gravity, from defi- ciency of urea and salts, of a pale, opaline color, and readily coao-ula- ble on exposure to heat. The ferrocyanide of potassium, alum°and nitric acid will also curdle it. FIBRIN AND BLOOD. 665 The urine sometimes contains fibrin ; probably, indeed, more fre- quently than is generally supposed. It appears to be occasionally pre- sent when there is apparently no morbid action. It is now and then associated with certain forms of dropsy; but how it is produced it is impossible, in the present state of our knowledge, to determine, as nothing is yet certainly known respecting it. In general, however, it depends, there is reason to believe, upon some structural disease of the kidney, or upon inflammation of the bladder, ureters, prostate gland, or urethra. In some cases of this kind there are large cells, from ts'oo t° t^bo °f an mcn m diameter, full of granules, and with or without a distinct nucleus. These appearances are well represented in Fig. 258. Fig. 258. Fig. 259. Casts of the uriniferous tubes are also sometimes present in the urine; generally in combination with pus-corpuscles, epithelium, blood-disks, or oil-globules. Their appearance is usually denotive of serious or- ganic lesion of the renal tissues, especially when they are associated with fatty matter. The microscopic characters of these deposits are exhibited in the adjoining sketch (Fig. 259). The urine not unfrequently contains pure blood. This may be owing to various causes, the most common of which are external vio- lence, eventuating in a laceration of some of the vessels of the genito- urinary apparatus, the passage of a renal calculus, ulceration of the mucous surfaces, and the presence of encephaloid, fungous, or erectile tumors. Occasionally, though rarely, the fluid is the result of a process of exhalation. When the blood exists in large quantity, its presence is, in general, easily detected by the peculiar color which it imparts to the urine, by its tendency to subside to the bottom of the receiver, and by its alka- line properties. The readiest and most infallible mode, however, of discriminating between it and other substances is to examine it with the microscope. For this purpose, a minute portion of the suspected fluid is placed in a watch-glass in the field of the instrument. If it be of a bloody character, it will be found to contain a great number of corpuscles, which, although usually somewhat altered in shape, are yet sufficiently characteristic. When the blood is very recent, or has not been acted upon much by the urine, it generally retains its normal 666 URINARY BLADDER. appearance, and is consequently more easily distinguished. Fig. 260 represents the blood-corpuscles in an aggregated, and Fig. 261 in a separate state. Fig. 261. Fig. 262. Pus is a very frequent ingredient of urine, and is generally deno- tive of organic lesion of the genito-urinary apparatus. Its admix- ture may, however, be purely accidental, as when it is caused by the bursting of an abscess into the bladder, or the pelvis of the kidney. The urine with which the pus is combined always contains albumen, is indisposed to putrefy, and is gene- rally acid or neutral; when first voided, it is more or less turbid, but it soon assumes a pale appearance, though it never becomes perfectly transparent. By repose, the pus falls to the bottom of the receiver, where it forms a dense homoge- neous stratum, of variable thickness, and of a yellowish-white or greenish-yellow tint. Un- der the microscope, it exhibits the appearance of spherical corpuscles (Fig. 262), floating in an albuminous fluid, opaque, white, rough on the surface, and more than one-third larger than the red particles of the blood. By agitation it readily mixes with the urine, to which it imparts its peculiar color, but is not dissolved in it. A substance, termed kiesteine, is occasionally found in the urine. It was supposed, at one time, to be peculiar to pregnant women, but it has been ascertained to be generally present also during the early months of lactation, and sometimes also in the virgin state. When first observed it usually presents itself in the form of little, isolated patches, which gradually coalesce, and form a pellicle, from half a line to a line in thickness, of a whitish opaline tint, not unlike the greasy scum upon the surface of fat broth. Dr. Elisha K. Kane who care- fully investigated the physical properties of this substance, states that it occasionally makes its appearance in striated, irregular lines some- what similar to those of a spider's web, in rings, circles, trapeziums, and irregular figures of almost every shape, which become gradually obscured by the full development of the pellicle. It consists of a fila- mentous, flaky tissue, and is so coherent that it may occasionally be SPERMATOZOA — OIL, 667 lifted off entire from the fluid which it covers. A portion of this sub- stance commonly subsides, and forms a thin, bluish, or whitish layer at the bottom of the vessel. The urine sometimes contains seminal fluid. If a drop of it be placed under the microscope, it will be found to consist of numerous spermatozoa, which, however, rarely retain their vitality beyond a few minutes, inasmuch as the urine proves almost immediately fatal to them. These animalcules present themselves as minute ovate, semi- transparent bodies, having each a delicate hair-like tail (Fig. 263), which is capable of very brisk movements, and which becomes always much more dis- tinct when the urine is permitted to dry upon the object-glass. 3. In the third place, the urine may be altered by the ingress of substances which, so far as we know, are not naturally contained in the blood. Amongst these, the most com- mon are the cystic and xanthic oxides, oxalic acid, and a peculiar saccharine substance, like the sugar of grapes. The cystic and xanthic oxides are never observed in healthy urine; they form the base of several varieties of vesical concretions, but the causes which predispose to their development are still unknown. Oxalic acid is more frequently seen, and is often traceable to articles of diet which naturally possess a large quantity of this substance. An abundant secretion of sugar is a circumstance by no means uncommon. In diabetes mellitus, where it is generally present in large proportion, it forms the characteristic feature of the disease. The urine in this complaint is commonly of a pale straw-color, of a faint, whey-like odor, and of a decidedly saccharine taste; it has a greater specific gravity than in health, yields a syrup by evaporation, has little tendency to putrefy, and is susceptible of undergoing the vinous fermentation. Diabetic urine almost always contains the usual proportions of saline matters; but, in the majority of cases, there is a great deficiency of urea and lithic acid. Though oil is not contained in healthy urine, it is found in certain diseases. In one instance, Prout observed a substance like butter; and, in some cases, the fluid has the aspect of milk. The urine is occasionally of a bluish tint, owing to the presence of a peculiar coloring matter, which it holds in suspension. This sub- stance, whatever may be its nature, is slightly soluble in boiling water and alcohol, has neither taste nor smell, and is entirely destroyed by nitric acid. Exposed to heat, it yields carbonate of ammonia and an empyreumatic oil. The urine may likewise be of a black color, from the presence of melanic acid. When this substance is very abundant, the fluid has sometimes the appearance of black ink, or may be made such by the addition of an alkali. More frequently, a pink color is observed, owing to the presence of purpurine. Lastly, the urine may contain hairs, generally of a whitish color, 668 URINARY BLADDER. destitute of bulbs, and not more than a few lines in length. They may be soft or hard, straight or curled, abundant or few in number. 4. The urine is liable to vary very much in its quantity, color, and odor. The average quantity discharged in the twenty-four hours varies from 30 to 40 ounces. More is voided in cold than in warm weather. Huge feeders and drinkers pass more than the abstemious, and are, for this reason, more liable to renal disease. Severe exercise, and all inflammatory affeotions are attended with a diminished flow; the reverse being the case in repose, and in what are denominated nervous diseases, in which the quantity is often immense. In diabetes, from one to two gallons of urine are frequently voided, for weeks together, in the twenty-four hours. Diuretic medicines, as their name implies, act specifically upon the kidneys, and thus increase their secretion. It is worthy of remark that the approach of most inflam- matory maladies is accompanied by a diminution, and the decline by an augmentation, of the renal secretion. When the urine is unusually scanty, it generally contains a dispro- portionably small amount of water; its specific gravity is abnormally high, and its color is deeper than in the healthy state. It is well known that the urine is of a much higher color, as well as of greater specific gravity, in warm weather than in cold, and in strong, healthy, and robust persons than in such as are thin, feeble, and anaemic. During the heat of summer, the renal secretion is con- stantly counteracted, as it were, by the cutaneous, and the consequence is that it is not only considerably lessened in quantity, but materially heightened in color, the reverse being the case in cold weather. The urine is always of a deeper tint after severe exercise than after repose, after a hearty meal of meat than after one of vegetables, and after the use of brandy, wine, or malt liquors, than after the imbibition of water, tea, or milk. It is also of a higher color, generally speaking, in young and middle-aged persons, than in children and old subjects, in whom it is usually pale, dull, and cloudy. In inflammatory affec- tions, as the different forms of fever, gout, rheumatism, pneumonia, pleurisy, and erysipelas, the fluid is always abnormally red, and fre- quently also turbid, from the presence of animal and earthy matter. It has less water, but more lithic acid, is of higher specific gravity, and often contains a small quantity of albumen. The urine is generally clear, and even remarkably limpid in nervous affections, as in hysteria, epilepsy, and hypochondriasis. The quan- tity in attacks of this kind is often very great, and the fluid is gene- rally very thin and of low specific gravity. In diabetes, in which the urine is often thrown off in vast abundance, the color is usually very pale. J In jaundice, the urine often acquires a golden yellowish tint and a somewhat similar effect is produced by the use of saffron rhubarb and turmeric. Beet-root renders the fluid red; mulberries 'and black cherries dark; chalybeates, blackish. Infusions of madder, indio-o and logwood impart to the renal secretion their peculiar hue Urine de- positing cystine generally exhibits a pale yellow color, similar to that of honey. URINARY DEPOSITS. 669 The odor of the urine is liable to great variation, a circumstance deserving brief mention on account of its diagnostic bearing. In the healthy state, it is slightly aromatic, without acidity, alkalinity, or fetor of any kind; in facf, it strikingly resembles the odor of the per- spiration of a sound person. In certain diseases, on the contrary, it often becomes remarkably offensive, acquiring an ammoniacal odor, even before it is voided. Certain articles of diet exert a powerful influence upon the odor of the urine. It has long been known that asparagus, garlic, onions, cauliflower, and other vegetable substances have the faculty of impart- ing their peculiar odor to the renal secretion. Similar effects follow the exhibition of certain medicines, as oil of turpentine, copaiba, cubebs, fennel, valerian, castor, assafcetida, saffron, and other articles. Gin acts specifically on the kidney, and readily communicates its smell to the urine. The density of the urine is liable to be influenced by various cir- cumstances, as the age of the patient, the amount of perspiration, the nature of the diet, the state of the weather, and the character of the particular disease under which the individual may be laboring. 15. Urinary Deposits.—The urine is liable to various deposits, of which the most important are the lithic, oxalic, and phosphatic. I. The lithic deposit, as being the most common of all, may be con- sidered first. It derives its name from the circumstance that it enters largely into the composition of several varieties of urinary calculi. It is often called the uric deposit. Lithic acid is a peculiar animal sub- stance, which contains a considerable quantity of nitrogen, and is easily soluble in a solution of caustic potassa, but insoluble in water. It is dissolved by nitric acid with effervescence; and before the blowpipe it emits a disagreeable fetid smell, similar to that of burnt horn, with a combination of hydrocyanic acid. This is owing to the fact that it is always united in the urine with ammonia, with which it forms a salt, the superlithate of ammonia, the acid being in excess. In the natural state of the urine, the acid is held in perfect solution, but in certain morbid conditions of this fluid, or when the acid is secreted in excess, it is thrown down in the form of amorphous sediments, or crystalline salts. The urine depositing lithic acid always reddens litmus paper, and its specific gravity is generally over 1.020. It frequently contains an excess of urea, and when this is the case it crystallizes slowly when mixed with nitric acid in a watch-glass. Of the amorphous sediments, there are two, the yellow and the red, their names being derived from the peculiarity of their color. They consist of lithic acid in combination with ammonia, are readily dissi- pated by heat, and never appear in the urine until after it has cooled. The yellow sediment consists almost wholly of the lithate of ammonia, tinged with the coloring matter of the urine. In its complexion, it runs through almost every intermediate shade between a pale fawn and a deep orange. In some instances it is nearly entirely white. It is of very frequent occurrence, and often disappears with great rapidity, to reappear, perhaps, almost immediately from the slightest causes. Heat readily dissolves it; and the addition of a drop of nitric acid 670 URINARY BLADDER. causes a deposit of numerous crystals. The urine which furnishes this substance is of a pale amber tint, more or less acid, and clear when voided. Its quantity is commonly confined within the natural limits, and its specific gravity ranges from 1.015 to 1.025. The yellow de- posit is very common in children, and frequently alternates with the crystalline sediment. The red sediment is composed of lithate of ammonia, in union with a peculiar coloring pigment, to which Dr. Bird has applied the term purpurine. This coloring matter is of a highly carbonaceous character, and is always present in those states of the system which are attended with imperfect assimilation, or a want of proper aeration of the blood. This form of sediment varies in its tint from a pale pink to a deep pur- ple, according to the amount of purpurine present in the urine. A very frequent species is the lateritious, or brick-dust sediment, so com- mon in fever, rheumatism, and gout. The pink sediment is merely a variety of this; it is exceedingly rare. When there is an excess of purpurine, the deposit is sometimes of a deep purple color, not unlike that of the blood. The urine depositing this sediment is of a red, or brownish color, preternaturally acid, and of high specific gravity, ranging from 1.025 to 1.035. Its quantity is ordinarily considerably below the normal standard. By adding to it a drop of nitric acid, it generally becomes turbid, from the precipitation of lithic acid. The crystallized sediments, red sand, or gravel, consist of lithic acid, nearly in a pure state. They appear in the form of Fig- 264- minute particles, resembling very much, in shape, size, and color, the particles of Cayenne pepper. Heat does not dissolve them, as it does lithate of ammonia. Under the microscope, they are found to consist of exceedingly delicate crystals, most of which have the appearance of rhombic prisms, which may, therefore, be assumed as their normal form. The most perfect specimens are generally contained in the deposits of yellow sand in the urine of young infants. The crystals are sometimes nearly square; or they are very thin, and longer than broad, so as to represent square tables; or finally, they . are so thin as to appear merely like pale lozenge-shaped lamellae. Occasionally they lie across each other, and are firmly cohe- rent. These varieties are well shown in the adjoining cut. The color of this crystallized substance is subject°to considerable diversity. When the deposit is unaccompanied by fever it is usually more or less yellow; but when the reverse is the case, it is pale red ktentious brick red or brownish. A pink tint is exceedingly rare' The urine from which the matter is precipitated, is generally scanty deep-colored, acid, and of high specific gravity. The quantity of this deposit is sometimes astonishingly great. I have seen cases in which it was discharged to the extent of four or five drachms a day for many II. The oxalic deposit holds, in point of frequency, an intermediate TRIPLE PHOSPHATE. 671 rank between the lithic and phosphatic. It occurs in the form of a white, glistening powder, which is suspended in the urine, and manifests no disposition to precipitate itself, unless it Fig. 265. can attach itself to some substance capable of constituting ^^ 1 i\ a nucleus. Examined with the microscope, this powder "^ 4) is found to consist of beautiful transparent crystals, of an * octohedral figure, with sharp and well-defined edges and ^ 0 angles. Occasionally, though rarely, they are shaped like **. dumb-bells, or like two kidneys united at their concavi- —.^ ties, and so closely approximated as to appear almost cir- |pf| cular.1 (Fig. 265.) They vary much in their size, but in II general they are exceedingly minute. If they are sub- gp^ jected to ignition on platinum foil, the oxalic acid is de- ^^ composed, and a small quantity of carbonate of lime is left, which is readily dissolved with effervescence on the addition of dilute nitric acid. Oxalic acid sometimes occurs as a distinct deposit, in the form of a small concretion resembling a hemp-seed, which may be retained in the bladder, and go on gradually increasing until it con- stitutes a mulberry calculus. Urine containing oxalic acid is generally of a distinct amber color; occasionally it is preternaturally dark or pale. Its specific gravity, which is extremely variable, ranges from 1.015 to 1.025, and is usually greatest in night specimens. The fluid is always decidedly acid, and very frequently contains slight traces of lithic sediment, urate of am- monia, or triple phosphate. III. The phosphatic deposit is characterized by its whitish color, by its pulverulent arrangement, by its solubility in dilute hydrochloric acid, and by its insolubility in ammonia and solution of potash. It presents itself under three distinct varieties of form, the triple, the calcareous, and the mixed, each of which demands succinct notice in this place. 1. The triple phosphate consists of phosphate of ammonia and mag- nesia, on which account it is generally called the ammo- niaco-magnesian phosphate. It commonly occurs in minute white crystals, of a beautifully brilliant aspect, transparent or opaque, and remarkable for their sharp angles and edges. In their form, these crystals exhibit great diversity ; but in most cases they are prismatic. Occasionally they have a stellar, penniform, or foliaceous arrangement.2 (Fig. 266.) They often float on the sur- face of the urine, especially if it is partially decomposed, and look like an iridescent film of grease. The urine which accompanies this deposit is preternaturally co- pious, pale, or whitish, and of low specific gravity, rang- ing from 1.005 to 1.014. It has a faint, sickening smell, which soon becomes ammoniacal and offensive, is very feebly acid, and scarcely, if at all, reddens litmus paper. In some affections, the fluid is unna- 1 Bird, on Urinary Deposits, p. 184. Phila., 1854. 2 Bird, op. cit., p. 227. Phila., 1854. 672 URINARY BLADDER. turally dark, brownish, or greenish-brown, decidedly alkaline, and loaded with dense ropy mucus. The triple phosphatic deposit very often alternates with the yellow lithic or calcareous deposit. 2. The calcareous deposit is composed of phosphate of lime, and occurs in the form of an impalpable powder, of a whitish, grayish, or drab color. Occasionally it is more or less dark, from the admixture of the coloring matter of the urine. The urine, as in the triple variety, is pale, copious, and of low specific gravity, and readily decomposed by exposure to the atmosphere. 3. The mixed deposit, consisting of a combination of the two preced- ing, is very common, and is supposed to be the result of the joint agency of the kidney and the lining membrane of the urinary passages. The earthy matter is of a whitish color, partly amorphous, and partly crystallized, and is usually intermixed with mucus, which is often se- creted in large quantity, and of a ropy, viscid character. The urine is fetid, pale, and abundant, and deposits a thick mortar-like sediment upon standing. 16. Calculi.—The number of urinary calculi is extremely variable. Yery frequently there is only a single one, whilst at other times there are a great many. Sir Astley Cooper met with one hundred and forty- two; Desault with two hundred ; Boerhaave with three hundred ; Murat with six hundred and seventy-eight; and Physick with upwards of one thousand. This case occurred in the person of the late Chief Justice Marshall, and is perhaps the most remarkable of the kind on record. The concretions were all of an oval shape, and varied from the volume of a partridge-shot to that of a bean. When numerous, they are always more or less polished, from continued friction against each other ; and, although they generally lie perfectly loose in the bladder, they are sometimes encysted, impacted in the urethra, or lodged in the ducts of the prostate. These concretions are of all sizes, from a hemp-seed to that of the fist; in their weight, they vary from a few grains to a pound or more, their average being from two drachms to an ounce. Urinary concretions are generally classed under different heads, according to their color, consistence, and intimate characters. The subjoined arrangement includes the most important species that have hitherto been described. The uric calculus, the most common species of all, is of a brownish color, inclining to that of mahogany, of a flattened, oval shape, oc- casionally finely tuberculated on the surface, but most generally smooth, though not polished, unless there are several concretions at the same time, and from the size of a currant to that of a hen's eo-w. If it be divided with the saw, it will be found to consist of several layers arranged concentrically arouud a common nucleus the laminae being frequently distinguishable from each other by a slight difference in color, and sometimes by the interposition of other ingredients Water has but little action upon it; it is perfectly dissolved by caustic potash; and disappears with effervescence in hot nitric acid, the solu- tion affording, on evaporation to dryness, a bright carmine-colored residue; before the blowpipe, it becomes black, emits a peculiar CALCULI. 673 animal odor, and is gradually consumed, leaving a minute quantity of white, alkaline ashes. Fig. 267 shows the oval shape and finely tuberculated surface of the calculus; Fig. 268 the internal concentric layers. Fig. 267. Fig. 268. The uro-ammoniac calculus is a variety of the preceding. It is principally observed in children, and is so extremely rare that several distinguished chemists have been induced to deny its existence. It is generally of small size, with a smooth surface, of a clay color, and composed of concentric rings, which present a very fine earthy ap- pearance when fractured. Much more soluble in water than the uric calculus, it gives out a strong ammoniacal smell when heated with caustic potash, and deflagrates remarkably below the blowpipe. Next to the uric calculus, in point of frequency, is the oxalic, which is generally of a dark brown color, rough and tuberculated on the Fig. 269. Fig. 270. surface, very hard, compact, and imperfectly laminated, seldom larger than a walnut, spherical, and always single. Under the blowpipe, it expands and effloresces into a white powder; it dissolves slowly in 43 674 URINARY BLADDER. muriatic and nitric acid, provided it be previously well broken up. In the alkalies, it is perfectly insoluble. This species of urinary con- cretion, called by many the mulberry calculus, from its resemblance to the fruit of the mulberry, consists essentially of oxalate of lime. Figs. 269 and 270 show the external appearance and internal struc- ture of this concretion. A variety of this species of calculus has been described by the term hemp-seed, from some resemblance which it bears in color and Fig- 27L lustre to that substance. (Fig. 271.) It is always of small ®size, remarkably smooth, and generally exists in considerable numbers, being rarely, if ever, found alone. The phosphatic calculus (Fig. 272), is of a pale brownish color, and of a loosely laminated structure, with a smooth, polished surface, like porcelain. The shape is mostly oval, and the size, though generally small, is sometimes very considerable. It Fig. 272. whitens when exposed to the blowpipe, but does g?S8|llPm^fc not fuse; and readily dissolves in muriatic acid, with- ^^MS*®™^^ out effervescence. This calculus, composed essentially of phosphate of lime, is extremely rare, as forming entire concretions, but frequently constitutes alternate layers with other matters. It is sometimes called the bone-earth calculus, and occasionally contains small quantities of carbonate of lime. The next species is the ammoniaco-magnesian, so called from its being composed of the phosphate of ammonia and magnesia. (Fig. 273.) This mixed calculus is of a white color, friable, crystallized on the sur- face, and looks a good deal like a mass of chalk; its texture being never laminated, it easily dis- solves in dilute acids, but is insoluble in caustic potash; before the blowpipe, it exhales an ammo- niacal odor, and at length melts into a vitreous substance. This species of concretion sometimes attains an immense size. The fusible calculus consists of a combination of the last two. It is of a white color, extremely brittle, leaves a soft dust on the fingers, and is easily separated into layers; when broken, it presents a rao-o-ed, uneven surface. It is insoluble in caustic potash, but gives off am- monia ; and, under the blowpipe, it is readily converted into a trans- parent, pearly looking glass. This concretion is very common, and sometimes attains a very large size. It is frequently met with as an incrustation of foreign bodies. Figs. 274 and 275 exhibit the outer appearance and internal structure of this concretion. The cystic calculus is a very rare species of concretion so called from an erroneous supposition that it was peculiar to the bladder. It consists of a confused, crystallized mass, of a white yellowish color, with a smooth surface. The structure is compact and the frac- ture exhibits a peculiar glistening lustre, like that of a body havin^ a high refractive density. It exhales a strong characteristic odor under the blowpipe, and is very abundantly dissolved in acids and CALCULI. 675 alkalies, with both of which it crystallizes. This species is commonly of an irregular, spherical shape, and seldom attains a large volume. Fig. 274. Fig. 275. The external and internal appearances of the cystic calculus are shown in Figs. 276 and 277. The xanthic calculus is extremely rare. Its texture is compact, hard, and laminated: its color is of a cinnamon brown, its surface smooth, Fig. 276. Fig. 277. and its volume small. It dissolves very readily in acids and alkalies, and is gradually consumed before the blowpipe, leaving a minute quantity of white ashes. There is, lastly, what is called the fibrinous calculus. Like the pre- ceding species, this is also extremely rare, and appears to be composed principally of the fibrin of the blood, a property to which it owes its name, and by which it is characterized. It is of small size, of a sphe- rical or oval shape, and of a brownish color. When dried, it shrinks,. and loses some of its weight. Most calculi are formed in the kidneys, whence they descend into the bladder, where they gradually acquire the characters that have just been ascribed to them; but at other times they take their origin entirely in the urinary reservoir, and not unfrequently they grow 676 PROSTATE GLAND. around a foreign body as their central nucleus. A substance like mortar is occasionally contained in the bladder, filling up a large por- tion of its cavity. It is of a pale yellowish color; is composed prin- cipally of phosphate and carbonate of lime; and is usually connected with chronic inflammation of the lining membrane, leading to effusion of lymph. Hair is sometimes found in the softer varieties of urinary calculi, but this is very rare. The immediate cause of the formation of vesical calculi consists in the inordinate deposition of the earthy salts of the urine, which, instead of being discharged with that fluid, sink to the bottom of the bladder, and so become the nuclei around which the accretion gradually takes place. Almost any foreign substance, as a drop of blood, a mass of inspis- sated mucus, a shot, or a ball, may serve as a nucleus for calculous concretions. In my private collection is a specimen, presented to me by Dr. Jetton, of Tennessee, which contained three of the caudal bones of a squirrel. The supposition is that the man, who was thirty-five years of age, had been in the habit of exciting onanism with the tail of this animal, and that in one of these attempts a portion of it broke off, and slipped into the bladder. A considerable number of examples, in which bits of catheters, seeds of vegetables, fruit stones, pins, bodkins, and even needles, formed the centre of urinary calculi, are upon record. Such cases are, for obvious reasons, more frequent in the female than in the male. SECTION V. PROSTATE GLAND. 1. Acute inflammation of the prostate is a rare disease, especially in the young. Its anatomical characters are increased vascularity, slight discoloration, tumefaction, and preternatural lacerability. The swell- ing, in the milder forms, depends mainly upon an effusion of serum into the meshes of the cellular tissue of the organ, and upon the dilated condition of its vessels. When the inflammation is more violent there is, in addition, a deposition of coagulating lymph, of blood and even of pus. The latter fluid generally exists in minute, disseminated points, not larger than a pin's head, and of a pale straw color. They are most conspicuous in the cellular substance of the oro-an a section of which, when thus affected, bears a tolerably close resemblance to the pulmonary tissues in a state of grayish hepatization. The gland is red, and infiltrated, but still retains its cohesive pro- perties; it is only in the advanced stages of the disease that it becomes soft and friable. The mucous follicles are enlarged, injected and dis- tended with a thick ropy secretion; the excretory ducts on' the con trary, are generally diminished in size, and sometimes even obliterated by the adhesion of their side* Occasionally they yield, upon pressure, a thin, bloody, and slightly viscid fluid. The fibrous capsule is un ULCERATION—HYPERTROPHY. 677 naturally red and vascular, tense, and covered, here and there, with plastic deposits. The size of the gland varies, in different cases, from the slightest increase of the natural bulk, to the volume of a walnut, a hen's egg, or an orange. The swelling generally involves both the lateral lobes, though not in an equal degree. The middle lobe is also frequently much enlarged. The parts adjacent to the prostate usually participate in the morbid changes. Acute inflammation of the pros- tate may terminate in suppuration and ulceration, or pass into the chronic form. Of gangrene of this organ, as an idiopathic lesion, nothing is known. 2. Suppuration is commonly the result of acute inflammation, al- though occasionally it supervenes upon the chronic form of the disease. The matter, which is ordinarily of a thick, creamy consistence, and of a pale straw color, is either diffused through the substance of the gland, or, as more frequently happens, it is collected into little abscesses, which have a natural tendency to burst into the urethra, the bladder, or the rectum. In some instances the fluid finds an outlet through the perineum. Occasionally the abscesses attain a very considerable size, containing from one to three ounces of pus. Suppuration of the gland is seldom seen before the age of twenty; but from this period on it is not infrequent. 3. Ulceration of the prostate is uncommon. It is usually produced by the presence of calculous matter, lodged either in its own substance or at the neck of the bladder. The erosion, which varies in size and depth, is usually seated upon the vesical surface of the gland, and is characterized by great hardness and irregularity of its edges. When very extensive, it may become the seat of hemorrhage, more or less copious, and sometimes even exhausting. 4. Chronic inflammation of the prostate is much more common than the acute, of which it is occasionally a result. More frequently, how- ever, it is brought on by calculous disorders, stricture of the urethra, ex- cessive venery, or disease of the rectum and anus. However induced, it is very apt to be i „sily re-excited by the most trivial causes, resem- bling, in this respect, chronic inflammation of the tonsils. Its prin- cipal anatomical characters are increase of volume of the organ, and more or less induration of its component elements, phenomena which will claim special consideration under the head of hypertrophy, a not unfrequent product of this disease. 5. Hypertrophy of the prostate exists in various degrees, and may affect the entire organ, or only a part of it. In general, it involves both the lateral lobes, as they are termed, though rarely in the same degree. Occasionally, however, it is almost entirely limited to the third lobe. In the former case, the greatest increase of volume usually occurs in the long axis of the organ, in consequence, no doubt, of the want of resistance in this direction. Under these circumstances, the lateral lobes are of an elongated, oval shape, generally larger in the middle than at the extremities, convex in front, and rather compressed behind. (Fig. 278.) When, on the contrary, the hypertrophy advances equally in all directions, these bodies will be apt to be somewhat obround, or like the longitudinal section of an orange. Enlargement of the gland 678 PROSTATE GLAND. interval between them, representing the appearance, when the gland is laid open longitudinally along its pubic surface, of a median groove or gutter. When one lateral lobe is more enlarged than the other, the more bulky one frequently encroaches more or less upon the smaller one, and thus produces a lateral curvature, or a change in the direction of the neck of the bladder, and the commencement of the urethra. Again, it occasionally happens that one lobe projects over on one side, and the other on the opposite, giving rise thereby to two curvatures instead of one, as in the former case. Whatever may be the shape of the enlarged masses, or the direction in which the hypertrophy occurs, their surfaces, both external and in- ternal, may be perfectly smooth, or they may be more or less irregular, knotty, and even tabulated. Sometimes small prominences exist upon them, attached by a broad base, and evidently prolonged from their substance, which they resemble in color and structure. Fig. 279, from a specimen in my collection, exhibits this form of the enlargement. Several such bodies are occasionally found close together, thus pro- ducing a lobulated appearance. Cysts sometimes form in the enlarged masses, from the size of a pea up to that of a large marble, filled with serous fluid, and lined by a sort of false membrane. Finally, the sur- face of these bodies is occasionally excoriated, fissured, and even ulcerated. When the middle lobe is hypertrophied, it generally forms a sort of mammillary process, which is more or less vertical in its position and HYPERTROPHY. 679 varies in size from that of the female nipple to that of a pullet's egg. (Fig. 280.) The apex of the tumor is free and rounded, while the base is immovably fixed, and rests as it were upon the posterior extremity Fig. 279. of each lateral mass. Its position is usually median; but sometimes I have found it to project more to one side than the other, and thus create an additional impediment to the introduction of the catheter. Fig. 280. Fig. 281. Although the form of the third lobe, when hypertrophied, is generally as here represented, cases occasionally occur in which it is exceedingly irregular, setting everything like accuracy of description at defiance. 680 PROSTATE GLAND. Next to the mammillated variety, according to my observation, is the triangular, in which the tumor is large behind and narrow in front, terminating in a tolerably sharp crest. More rarely it is of a rounded shape, or broad and convex on its free surface, and adherent by a small pedicle. I have seen specimens in which the swelling consisted of three oblong bodies, placed side by side, as in Fig. 281, from a specimen in my private cabinet; and examples are recorded, in which there were as many as four and even five such lobes. Whatever be the form and volume of the tumor, it always projects towards the bladder, draw- ing up the prostatic portion of the urethra, and elongating the veru- montanum. The consistence of a hypertrophied prostate is liable to considerable diversity, and occurs under two very opposite forms, the hard and the soft. In the first, the more frequent of the two, the induration varies from the slightest increase of the natural consistence to the firmness of the fibrous tissue. It was owing, no doubt, to this circum- stance that the older pathologists were so constantly in the habit of considering this affection as being of a scirrhous character; an error, not perhaps entirely exploded at the present day. When the indura- tion exists in a high degree, the affected part tears with difficulty, and offers considerable resistance to the scalpel; but does not yield a cre- pitating sound. Interspersed through its substance are numerous granulations, of a grajnsh color, rounded or oval in their shape, and hardly as large as a millet-seed. They are inclosed each in a cellulo- fibrous capsule, to which they adhere by a delicate pedicle, and from which they may be easily enucleated. A section of the gland exhibits a rough, irregular surface, caused by the manner in which the granu- lations project from the cells or lodges in which they are naturally embedded. By pressure, a thin, milky fluid is obtained from it, which is probably merely the prostatic liquor, somewhat altered in its pro- perties and slightly increased in quantity. In the soft variety, the enlargement proceeds in a more uniform manner, and attains, as a general rule, a greater magnitude than in the hard. The affected tissues are more or less elastic, and yield readily under the pressure of the finger. The granulations, larger and more conspicuous than in the first variety, are of a soft, spongy texture, and of a whitish or grayish aspect. By a little care they can be easily separated from their cellulo-fibrous capsules, when it will be found that their principal bond of union is a delicate pedicle, through which they receive their bloodvessels, nerves, and lymphatics. Their shape is the same as in the hard variety, and the fluid which exudes from them, on pressure, is a little more abundant, and of an opaque, milky, yellowish, or brownish hue. The nature of the granulations above described is not well ascer- tained. It is highly probable, however, that they are nothing but the terminal follicles of the prostate, in a state of enlargement and partial occlusion. The capsules in which they are inclosed are of a dense, fibrous structure, and are evidently formed out of the natural fibrous element, very much hypertrophied. The lesion bears the greatest analogy to cirrhosis of the liver. FIBROUS TUMORS. 681 The color of the affected gland varies in the different periods of life, from circumstances directly dependent upon its nutritive functions. In senile hypertrophy, which generally takes place under the influence of causes operating in a slow and gradual manner, there is usually a diminution of color, in consequence, apparently, of the concomitant compression of the capillary vessels which ramify through the sub- stance of the organ. Hence, if a section be made of the parenchyma- tous structure, the surface will be seen to be of a dull grayish, light ash, or pale drab tint, and to emit hardly any blood on pressure. When the hypertrophy is produced and kept up by irritation, there is sometimes an increase of color, and an augmented capillary circulation. Under such circumstances, the parenchymatous substance may exhibit vari- ous shades of red and brown, and afford a considerable quantity of blood under pressure and maceration. Hypertrophy of this gland is one of the effects of old age. Hence it is generally known by the term senile. After the age of fifty, there are probably few persons who are entirely exempt from it. When dependent upon causes of this kind it generally advances very tardily, and, at times, even remains temporarily stationary. The inflamma- tory form, on the contrary, progresses more rapidly, and often attains a considerable bulk in a few months. 6. The prostate is liable to atrophy, sometimes as an effect of old age, but more generally as the result of mechanical compression, such, for example, as that produced by the presence of a calculous concretion. The extent of the atrophy varies; thus, it may involve the entire gland, one of its lobes, or only a part of a lobe. In extreme cases the proper structure is almost entirely effaced, and hardly anything remains but its fibrous capsule. In the more ordinary forms, however, the gland is only somewhat reduced in bulk, preternaturally firm, and of a paler color than in the normal state. The cellular element is wanting, being superseded by the fibrous. 7. Fibrous tumors of the prostate vary in their volume from that of a pea to that of a small almond; they are of a rounded, spherical, or ovoidal form, of a firm, dense consistence, and of a dull, grayish color. They are usually situated on.the outer surface of the gland, but occa- sionally they project inwards, so as to encroach upon the urethra and the neck of the bladder. In the few cases in which I have observed these tumors, they were solitary ; sometimes, however, there are as many as three or four. When they are seated upon the periphery of the organ, they give it a rough, knobby, or nodulated appearance. They usually grow from a broad base, which seems to be insensibly lost in the proper glandular substance. A section of these tumors displays a grayish or drab-colored tissue, of a tough, inelastic charac- ter, having little moisture, and but few vessels. Fibrous tumors of the prostate bear a strong resemblance, both in their situation and structure, to fibrous tumors of the uterus. They are always associated with hypertrophy of the gland, and are rarely found, except in old subjects, who have long labored under organic disease of the urinary apparatus. They are probably developed under 682 PROSTATE GLAND. the influence of chronic irritation, leading to irregular, local, or cir- cumscribed supernutrition of the parenchymatous structure^ 8. The prostate is occasionally the seat of tubercles. Of this disease I have seen but one example, in a young man who died of psoas ab- scess. There were eight small masses, of a pale yellowish color, and of a soft, curdy consistence, scattered through different parts of the gland, which was at the same time considerably reduced in size. The deposition of tubercular matter here is commonly associated with pul- monary phthisis; it seldom occurs under the age of forty-five or fifty, and appears to have a decided predilection, so to speak, for the folli- cular structure of the gland. 9. Cancer of the prostate gland is of singularly rare occurrence. Of scirrhus I have myself never seen a well-marked example. A few cases of encephaloid have been witnessed in this gland, mostly in old subjects. In a child, aged three years, whose history was kindly com- municated to me by Professor Bush, of Lexington, Kentucky, the prostate was enlarged to the size of a hen's-egg, and was completely transformed into medullary matter. Colloid has never been witnessed in this body, and of melanosis I know of but one example, and that occurred in my own practice in 1855, in a man fifty-eight years of age, who had the same disease in other organs. 10. Serous cysts occasionally exist in the prostate, occupied by a thin, watery, mucous or glairy fluid, of a spherical shape, and from the size of a millet-seed to that of a pea or a hazel-nut. 11. Earthy concretions of the prostate are not uncommon (Fig. 282). Their composition is invariably phosphate Fig- 282. 0f lime, with a little animal matter. In their size, they vary between a mustard- seed and a hazel-nut; they are of a rounded figure; their surface is smooth and polished; and their color is of a yellowish-brown. These bodies often exist in considerable numbers, being either imbedded in the substance of the gland, or situated in dilated ducts. In one case I found them of a regularly pyra- midal figure. Their existence may often be caicuii of the prostate. detected by the sound, or by the finger in- troduced into the rectum. 12. The excretory ducts of the prostate are liable to dilatation, forming small pouches, which may arrest the beak of the catheter, or become depots for calculi. The sacs, the number of which is varia- ble, are generally quite small, not exceeding the size of a cherry, but they may be as large as a marble; and cases occur in which the whole of one lobe, or even the entire organ, is converted into a thin, fibrous capsule, the proper substance of the gland being almost wasted. This lesion most commonly occurs in old persons, in connection with urinary calculi and chronic enlargement of the prostate. 13. Finally, the vessels of the prostate are liable to the formation of phlebolites. They are met with chiefly in old subjects who have Ion a- suffered under disease of the bladder and the associated organs. Their VAGINAL TUNIC. 683 number is usually small, their shape globular, their surface smooth, their color a pale grayish, their structure laminated, and their com- position carbonate and phosphate of lime, with a small quantity of animal matter. CHAPTER XXVI. MALE ORGANS OF GENERATION. I. The Testicle.—Weight and Volume.—Diseases of its Vaginal Tunic.—Inflammation.—Hy- drocele.—Haeniatocele.—Earthy Concretions.—Orchitis.—Malignant Affections of the Testi- cle.—Tubercles and Hydatids.—Hypertrophy and Atrophy.—II. The Spermatic Cord.— Encysted Dropsy.—Varicocele.—Neuralgia.—III. The Seminal Vesicles.—Their Lesions, few in number and still involved in obscurity.—Tubercles.—Earthy Concretions.—IV. The Scrotum.—Carcinoma.—Excessive Enlargement.—Is sometimes affected with a peculiar Sloughing Ulcer.—Contains Foreign Substances, such as Teeth, Hair, and pieces of Bone. —Earthy Concretions.—V. The Penis. — Gonorrhoea. — Gleet.—Chordee.—Organic Stric- ture.—Abscess along the Course of the Urethra.—Malformations of this Tube.—Imperfora- tion.—Morbid Erection of the Penis.—Degeneration of the Pectiniform Septum and Fibrous Sheath.—Carcinoma.—Syphilitic Ulceration.—Herpetic Affections.—Warty Excrescences.— Phymosis and Paraphymosis.—Sometimes Seat of Calculous Concretions. SECTION I. TESTICLE. The testicle, in the adult, is generally, according to my measure- ments, about twenty-two lines in length, by eighteen in breadth, and seven in thickness. Its medium weight I have found, in a consider- able number of subjects, to be about five drachms, the minimum being three and a half, and the maximum six and a half. The weight of the epididymis generally ranges from two to three scruples. The diseases of the testicle are numerous and important, and may be conveniently considered with reference, first, to its serous invest- ment, and, secondly, with reference to its proper parenchymatous texture. I. Vaginal Tunic.—The principal lesions of the serous membrane are inflammation, suppuration, hydrocele, induration, hsematocele, fungous growths, and various transformations. 1. Acute inflammation of the vaginal tunic exhibits the same phe- nomena as the serous textures in other situations. There is more or less redness, with effusion of serum, fibrin, pus, or blood; and the contiguous surfaces of the membrane not unfrequently coalesce by the adhesive process. The serum is either absorbed or it remains until it is drawn off. A secretion of pus is very rare, except as a consequence of hydro- cele and its treatment. The matter is generally of a yellowish straw 681 TESTICLE. color, and, when allowed to stand, separates into two parts, one being thin and watery, the other thick and purulent. Chronic inflammation of the vaginal tunic is of frequent occurrence in the inhabitants of warm climates, and in persons who suffer from disease of the urethra and prostate gland. It is characterized by opacity and thickening of the membrane, and by the effusion of dif- ferent kinds of fluids, especially serum and lymph. 2 The vaginal tunic is naturally lubricated by a thin vapor, just sufficient for the easy movement of the testicle. In inflammation this vapor becomes condensed, and thus leads to the formation of what is named hydrocele. Fig. 283 represents the appearance of a tumor of this kind from a preparation in my private collection. The quantity of fluid seldom exceeds eight or ten ounces; but may amount ,to several quarts. Gibbon, the historian, had a hydrocele which con- tained a gallon and a half, and an instance is recorded where it amounted to forty pounds. Fig. 283. From a table constructed by Dr. Dujat of 1,000 cases of this disease treated at the Native Hospital of Calcutta, it appears that the quantity of serum evacuated varied from less than ten to upwards of one hun- dred ounces. In 370 cases of dou- ble hydrocele the fluid was more abundant on the right side in 109, and on the left side in 128. Of the 630 cases of single hydrocele, the quantity of fluid in rather more than a third of the number, was under ten ounces; in two- sevenths it was from ten to nine- teen ounces; in nearly a third from twenty to forty-nine; and in eighteen cases from fifty to one hundred and twenty ounces. The appearance of the water varies a good deal according to the duration of the disease. In young subjects, and in recent cases, it is generally clear and limpid; but under opposite circumstances it is of a pale straw, yellowish, amber, or citron color, or of the color of pale sherry-wine. More rarely the fluid is of a red or brownish tint, from the admixture of haematosin. In some instances it is of a lactescent appearance, and a case has been observed where it was perfectly green. In its consistence it commonly resembles water, but it may be thick, and almost as firm as jelly. When the disease is of long standing, and dependent on organic lesion of the testicle, the Hydrocele of the vaginal coat From a prepara tion in my collection. HYDROCELE. 685 accumulated fluid is often purulent. In one case, I drew off nearly two quarts of pus and serum, of a very fetid character. White, flaky particles, soft, friable, and micaceous, or greasy, like adipocire, and composed of cholesterine, are likewise occasionally contained in the fluid of hydrocele. It has been suggested, with apparent probability, that these small particles are not the direct result of secretion, but the product of a chemical change in the effused liquid, similar to that by which adipocire is formed from flesh when subjected to protracted maceration in water. Spermatozoa are also sometimes found in this fluid. The water of hydrocele is usually devoid of odor, but has a marked saline taste, and is coagulable by heat, alcohol, corrosive sublimate, and the dilute acids; circumstances which clearly show its close affinity with the serum of the blood, from which it is derived. From the analysis of Dr. Bostock, it appears that 100.00 parts of the fluid of hydrocele, of the specific gravity of 1021, consist of Water .... 91.25 Albumen . . . . 6.85 Uncoagulable matter . . 1.1 Salts ..... .8 100.00 In recent hydrocele, the vaginal tunic is commonly unaltered; in old, on the contrary, it is apt to become hard, opaque, and thickened. Occasionally the inner surface has a rough, pitted aspect, from the effusion of lymph; and sometimes, though rarely, narrow bands ex- tend from it to the testicle. The membrane may be partially ossified, or transformed into a hard gristly substance, which generally pre- sents itself in the form of grayish, opaque patches, of various shapes and sizes. Loose bodies, of an oval figure, usually not larger than a pea, and of a fibrous, cartilaginous, or bony character, have been found in the sac; occasionally the fluid is contained in separate cells, or compartments, as in ovarian dropsy, and cases occur in which it is in- termixed with serous cysts. The albugineous coat is much less liable to suffer in hydrocele than the vaginal. It may, however, be variously affected, particularly in cases of long standing, or where the complaint is complicated with organic disease of the testicle. The most common changes are, in- creased thickness, induration, and the cartilaginous transformation. It has been found partially ossified, or studded with earthy concre- tions; it may also be the seat of fungous tumors, serous cysts, and warty excrescences. The testicle may be perfectly healthy, or it may be changed in its size, form, and consistence. In recent cases, when the accumulation is very small, the alteration, if any, is proportionably slight; but when the quantity of water is unusually great, the pressure which it exerts upon the gland may be so severe as to lead to considerable flattening, -softening,°and more or less atrophy. In some instances, in fact, the tubular "structure is nearly entirely absorbed. Hydrocele makes its appearance at all periods of life, in infancy, childhood adolescence, and old age. Children sometimes labor under 686 TESTICLE. this complaint, from the vaginal tunic continuing to communicate with the cavity of the abdomen, and allowing the water effused there to descend along the groin. This constitutes what is called congenital JlV(XT0C61€. In 1000 cases of hydrocele treated at the Native Hospital of Cal- cutta, the age in 41 cases was from 173 " 473 " " 257 " " 43 " 13 " 18 to 20 21 to 25 2(5 to 35 36 to 45 46 to 59 60 to 70' Fie. 284. Hydrocele is generally single, and the liability to the disease is nearly the same on both sides. 3. Hcematocele is a collection of blood in the vaginal sac, caused by mechanical violence, or inflammatory irrita- tion ; in the latter case it is ordinarily con- nected with hydrocele. The tumor is pyri- form, dark, compressible, and filled with thick, grumous blood, often of the color of coffee- grounds. The vaginal tunic is sometimes pre- ternaturally hardened, and its inner surface roughened with lymph. Sometimes the clots that are thus formed become organized, the vessels which they contain being susceptible of artificial injection. 4. Encephaloid, though occasionally found in the vaginal sac, is extremely rare. The mor- bid mass has a white, braindike aspect, and possesses all the characters of fungus hasma- todes. It is commonly connected with hydro- cele and thickening of the serous tunic. 5. Sometimes the vaginal tunic acquires a cartilaginous hardness; and portions of it have also been found in an ossified state. These transformations, which are occasional attendants on old hydroceles, ordinarily occur in small patches, of no determined shape; but some- times they grow from the free surface of the membrane in the form of little spicules, the attachment of which is effected by very slender footstalks. 6. In dissecting persons that have long labored under hydrocele, or other chronic affections of the serous covering of the testicle, we occa- sionally find small earthy concretions, either in distinct sacs, or ftaatino- about in the serum. Their number, though sometimes considerable3 seldom exceeds two or three ; their size varies from that of a shot to that of a pea; and they frequently have a peculiar pearly lustre. Some- times such bodies are partly osseous and partly cartilaginous; and now and then they are remarkably hard and gritty, like grains' of sand Their composition is carbonate and phosphate of lime, with about thirty-eight parts of animal matter in the hundred. Hematocele of the scrotum. Gazette Medicale de Paris, t. xvi. 1838, p. 561. CHRONIC INFLAMMATION". 687 Fig. 285. Acute orchitis. If. Testicle.—The testicle is liable to inflammation, abscess, scirrhus, encephaloid, tubercles, hydatids, and osseous degeneration. 1. The anatomical characters of acute orchitis are increased vascu- larity and thickening of the tubular structure, followed, when the dis- ease runs high, by deep redness and softening. The organ swells, becoming hard and rounded, and the vaginal sac is either distended with watery fluid, or lymph is poured out, by which the two contiguous surfaces of the mem- brane are permanently glued together. The epididymis is usually involved in the affection, and in many cases the irritation extends along the spermatic cord, rendering it tumid and painful. Although it generally terminates by resolution, it sometimes proceeds to suppuration, or it leaves the organ in a state of chronic enlargement, or, finally, it may give rise to hydrocele. 2. When suppuration is about to set in, all the symptoms become suddenly aggravated; rigors come on often, at- tended with slight delirium; and the part is so painful that the patient can scarcely tolerate the weight of the bedclothes. The pus, being generally mixed with seminal fluid, is seldom of a healthy cha- racter ; and, as it is confined by the albugineous coat, it is always along while in reaching the surface. The abscess often breaks at several places, thus leaving unhealthy sores, which it is difficult to heal, and which not uncommonly lead to a total disorganization of the tubular structure. Suppuration of the tes- ticle is most common in scrofulous subjects. The matter is sometimes encysted, as in Fio-. 286. 3. Chronic inflammation of the testicle is of rather frequent occurrence, especially in warm latitudes. It usually begins in hard- ness and swelling of the epididymis, whence it gradually extends to the body of the gland, the seminiferous ducts of which are dilated, indurated, and of a dark grayish color. At first, the organ, enlarged perhaps many times beyond its ordinary bulk, retains its natural smoothness, but by and by it be- comes knobby and irregular. This form of the disease is often accompanied by effusion of serum into the vaginal sac, by the deposi tion of purulent matter in the parenchyma- tous structure, and by enlargement and thickening of the spermatic cord. In obsti- Fig. 286. TESTICLE. nate cases, the gland is sometimes of a hard, compact consistence, grates under the knife, and is of a dark reddish color, not unlike half-boiled flesh. Cells are often found in its interior, containing different kinds of fluids. The disease occasionally affects both testicles. 4. Genuine scirrhus of the testis, such as is so often met with in the mammary gland, is an exceedingly rare disease. It is most common after the age of fifty. The affected gland is hard and knobby, of a whitish or grayish color, and intersected by dense fibrous bands, which pervade'it in different directions, and add very much to its firmness. It is seldom that the morbid mass is of the same uniform consistence throughout, but it is usually more compact in some places than in others. Cartilaginous and osseous deposits are occasionally observed in it, and instances occur in which it contains small cysts, filled with various kinds of substances, fluid, semi-liquid, or solid. The vaginal and albugineous tunics are more or less thickened, and the tubular texture is entirely destroyed. As the disease progresses the epididymis, and frequently, also, the lower portion of the sperma- tic cord experience the same changes, becoming hard, knotty, and painful. When ulceration sets in the adjoining glands become swollen, from extension of the morbid action. The disease may exist alone, or be associated with scirrhus, tubercle, or encephaloid in other parts of the body. 5. Encephaloid is the most common malignant disease to which the testicle is liable. Commencing in swelling and induration of the body of the gland, its progress, although sometimes slow, is generally so rapid that the tumor quickly attains a very considerable bulk, involv- ing the epididymis, and assuming a pyriform figure, with the base below and the apex above. In its first stages it consists of a soft, grayish, pulpy mass, looking very much like the cerebral tissue. It frequently contains serous cysts, coagulated blood, chocolate colored matter, or a dark creamy substance, more or less offensive to the smell. One portion of the tumour may be so firm as to creak under the knife, and to exhibit the appearance of fibro-cartilage, or hard cheese; another is perhaps quite soft and pulpy, and a third may be of the color and consistence of a clot of blood, or a piece of decom- posed flesh. In fact, there is no end to the diversified character of a tumor of this description. The tubular structure is generally entirely destroyed; the albugineous coat is very much thickened and indu- rated, or broken up and confounded with the diseased mass • and a considerable quantity of watery fluid, usually mixed with blood is almost always found in the vaginal sac. The tumor varies in volume from that of a fist to that of a foetal head. When very bulky, there is always a corresponding enlarge- ment of the vessels of the cord. The spermatic artery has been seen as big as the radial artery at the wrist. No period of life is exempt from this disease. It has been observed in children under twelve months of age, and in persons after eighty. The affection seldom occurs on both sides. When the morbid mass is removed the disease generally reappears either at the cicatrice, or in the lymphatic gan- glions of the groin, pelvis, or lumbar region. CYSTIC DISEASE. 689 6. Colloid scarcely ever attacks the testicle. A section of the mor- bid mass exhibits an immense number of small cells, cysts, or lodges, composed of fibrous walls, and occupied by different substances, as jelly, serosity, blood, and even pus. The proper structure of the testis is sometimes intact. 7. Of melanosis of the testicle our knowledge is exceedingly limited. I have myself not met with any examples of the kind, and very few -have been reported by authors. Cruveilhier1 has related the case of a man who died at the age of forty-six of melanosis of the lungs, heart, stomach, and other parts. The right testicle contained a small quantity of the same matter, and the left a deposit the size of a nut. 8. Tubercles are sometimes seen in the testicle, either in its paren- chyma, on its surface, or in the epididymis: they are of a pale yellowish color, spherical, Fig. 287. and about the size of a pea. Occasionally the scrofulous matter is infiltrated into the tubular structure; thus converting the gland into a curdy, friable, cheese-like body. The disease commences without local uneasiness, and is liable to cause ulceration, leaving thus a very unpleasant sore, which is of a pink color, fun- gous, irregular on the surface, and often highly sensitive. The deposit, which seldom takes place in both glands at the same time, generally begins at the epididymis, and thence extends to the body of the organ, the structure of which it sometimes entirely subverts. The matter is usually poured into the cellular tissue ; but, in some cases, it is deposited directly into the ex- cretory tubes. (Fig. 287.) 9. Cystic disease of the testicle is occasionally Tubercles of the testicle. met with, chiefly about the middle period of life. The cysts of which it is composed vary in size from that of a mustard-seed to the dimensions of a small grape, a marble, or a pigeon's egg; they are extremely delicate, highly vascular, gregarious, and filled with a thin, transparent, straw-colored fluid, analogous to the serum of the blood. They are developed in the substance of the testicle, which is ultimately entirely destroyed, and they often exist in immense num- bers, though in some cases there are not more than two, three, four, or, perhaps, half a dozen. Occasionally the coats of these cysts are very much indurated, if not partially transformed into cartilage or bone, and their contents are thick and glairy, like the white of egg, jelly, or inspissated mucus. In old cases large quantities of fibrin are sometimes effused, and the morbid mass is intersected by fibrous bands, which strikingly contrast with the other structures. Fig. 288, from Curling, is a section of a cystic tumor of the testicle, showing a multitude of cells of various shapes and sizes, with solid matter inter- 1 Anatomie Pathologique, livr. xix., pi. 3 and 4. U 690 TESTICLE. posed between them. The natural structure of the gland has entirely disappeared. The tumor is tardy in its progress, does not affect the general health, may attain the size of a common fist, and does not return after ablation. 10. Baillie1 met with a filaria medinensis, or guinea-worm, in a small, firm cyst, adherent to the testicle. Paullini2 saw a man whose left testicle contained an abscess, from which not less than fifty-seven small worms escaped. Morgagni found a small mass of fat between the epididymis and this organ, which was in other respects sound. The testicle has occasionally been the seat of acephalocysts. 11. Masses of fibro-cartilage are occasionally, though rarely, found in the testicle, either alone, or, as is more commonly the case, in union with other morbid pro- ducts. They may be situated between the vaginal and albu- gineous coats, or in the tubular substance of the organ, which, when they are large or nume- rous, may be in great measure destroyed by them. They are usually small in size, and of an irre- gularly oval shape, with a rough, uneven surface, elastic, homoge- neous, and of the consistence of fibro-cartilage. Sometimes they are partially ossified. When seated in the albugineous coat, or between this mem- brane and the vaginal, the new matter generally presents itself in the form of little patches, frequently not more than a few lines in diameter, and of a dull grayish color. 12. Ossification of the glandular structure of this organ is of very in- frequent occurrence. Examples, nevertheless, are recorded by a con- siderable number of writers. The deposit may take place in any part of the testis, but is most common towards its centre, and is generally accompanied with considerable enlargement. It is often of an earthy 1 Works by Wardrop, vol. ii. p. 313. London, 1825. 2 Miscel. Natur. Cur. Dec. ii. An. iv., append.' ob. 39. Cvstic testicle. Fig. 289. Calcareous matter in the testicle. From a preparation in my collection. TUMORS. 691 rather than a bony nature, being nearly destitute of animal matter, and closely resembling the earthy substance found in the lungs and bron- chial glands, as in Fig. 289. 13. The testicle may be transformed into a fibrous substance, not unlike that of a fibrous tumor of the uterus. The change probably begins in the internal cellular structure, which is gradually converted into white, grayish, or bluish filaments, narrow, dense, resisting, and in- terlaced in every conceivable manner. The new tissue interferes so much with the nutritive condition of the seminiferous tubes as to occa- sion, at first, a diminution in their size, and ultimately their entire de- struction. When the transformation is complete the morbid structure is firm, solid, almost incompressible, and inelastic; it creaks under the knife, possesses very little moisture, and is nearly destitute of cellular substance. Small cysts, containing serous fluid, are occasionally inter- spersed through it, and specimens are observed in which there are tole- rably large cavities filled with whitish, jelly-like matter. The tumor may be of the natural size of the testicle, or it may even be less, but in most instances it is as large as an orange or a fist. The vaginal and albugineous tunics generally preserve their natural characters. The disease has no tendency to return after removal. Tumors of the kind just described occasionally grow within the vaginal tunic, the testis retaining its integrity. Some years ago I operated upon a colored man, twenty-five years of age, removing from the left side a fibrous mass weighing nearly five pounds. It was of an ovoidal form, larger below than above, and was eight inches and a quarter in length by thirteen in circumference at its widest part. Its surface was perfectly smooth, and adherent, in the greater portion of its extent, to the vaginal tunic by loose cellular substance. The testicle was situated at the lower extremity of the tumor, and, with the exception of being slightly flattened, had under- gone no appreciable alteration. The vas deferens, also perfectly sound, ran along the posterior surface of the tumor. A section of the tumor exhibited a smooth, uniform surface, of a pale- grayish color. It was slightly elastic, almost incompressible, remarkably solid, and offered great resistance to the knife. A thin slice of it was opaque, and as tough as sole-leather. No cellular tissue could be detected among its component fibres, but here and there I could distinctly discern the orifice of a divided vessel. The tumor had been growing upwards of C J • 4.1, 1 I • Li Fibrous tumor oi the vaginal tunic. five years—during the last eighteen preparation m my collection. 290. 692 SPERMATIC CORD. months very rapidly—and caused no other inconvenience than what resulted from its weight and bulk. The spermatic cord, the skin of the scrotum, and the glands of the groin were perfectly healthy. The patient recovered from the operation, but died some months after- wards of pulmonary phthisis. Fig. 290 exhibits the form and struc- ture of the tumor; the testicle is seen at the base, to the left of the median line. 14. Hypertrophy of the testicle, without any appreciable change of structure, is very uncommon. The gland may attain the magnitude of a large fist. The general health is usually good; but the penis is sometimes incapable of erection, and the tumor incommodes by its weight. More commonly the hypertrophy is connected with indura- tion, and various other deviations from the normal state. 15. Atrophy of this organ seems to arise from chronic irritation, leading to absorption of the tubular structure. It may result, how- ever, from a great variety of causes, such as an abuse of venery, indulg- ence in masturbation, mechanical injury, obliteration of the spermatic arteries, and immoderate and long-continued use of iodine, opium, and other narcotics. In some instances it has been known to supervene upon injury or organic disease of the cerebellum; and, in the French soldiers, in Bonaparte's first campaign in Egypt, it was often produced, as was supposed by Larrey, by the employment of a species of brandy, manufactured from the date and laurel-berry. The wasting was gene- rally very gradual, commencing with a loss of sensibility of the organ, which became softened, and at length reduced to the size of a small bean. Contemporaneously with this structural lesion was an altered state of the voice, with cessation of the growth of the beard, and com- plete loss of sexual power. Another cause of this lesion is the mechanical pressure exerted upon the testicle by varicose tumors of the spermatic veins. The absorp- tion which is thus induced often proceeds with great rapidity, until the gland is reduced to a soft, pulpy mass, scarcely equal in volume to a Lima bean. Atrophy of the testicles occasionally exists as a congenital defect. I am acquainted with two young men in whom these organs are scarcely as large as a hazel-nut. One of them has never experienced the slightest sexual desire; the other has been married upwards of twenty years, but no offspring has followed the connection. Complete inaction of these organs, such as is observed in monks, is often attended with atrophy and impotence. SECTION II. SPERMATIC CORD. The spermatic cord, composed of the deferential duct of bloods sels nerves, and absorbents, all invested by a thin, fibrous sheath liable to encysted hydrocele, varicocele, and neuralgia ves- is ENCYSTED HYDROCELE — VARICOCELE — NEURALGIA. 693 1. Encysted hydrocele may be seated in the free portion of the cord, or it may occupy the part which lies in the inguinal canal. In the former situation, the nature of the swelling may be readily distin- guished by its globular figure, by its firmness, transparency, and diminutive size; in the latter, the diagnosis is often obscure, and the surgeon is liable to confound the disease with inguinal hernia. The fluid of a hydrocele of this kind is generally very thin and limpid, and the cyst consists of two layers, the external being formed by the spermatic fascia, the internal, which is almost always thickened, by the remains of the peritoneum. In the descent of the testicle, the cord, as is well known, is loosely invested by a prolongation of the serous membrane of the abdomen; this, after a time, contracts close adhesions around the cord, and in this way the communication between the peritoneum and the testicle is gradually destroyed. Occasionally, however, the union is incomplete, and, a space being thus left, a slight secretion goes on, eventuating in the development of an encysted hy- drocele. The tumor is commonly small, rarely exceeding the volume of a pullet's egg. 2. Varicocele is an enlargement of the spermatic veins, as they ex- tend from the testicle towards the groin. The vessels are convoluted, knotty, elongated, harder in some places than in others, and irregu- larly dilated, some of them being more than six times the ordinary volume. Their parietes are very thick, dense, and rigid at some points, and very brittle and attenuated at others. In cases of long standing, some of the vessels are completely obliterated by adhesive inflamma- tion, or by the formation of fibrinous concretions in their interior. Phlebolites are also occasionally found in them. The connecting cel- lular tissue does not experience any particular alteration, but the veins of the testicle itself are often considerably enlarged, as are also those which ramify between the vaginal and albugineous coats. The disease is most common between the ages of puberty and twenty-five, and is almost peculiar to the left side; owing, as Dr. Brin- ton, of this city, has satisfactorily demonstrated, to the absence of a valve at the mouth of the left spermatic vein, while such an arrange- ment exists on the right side. It is often met with in several mem- bers of the same family. Its progress is usually slow. One of the most unpleasant effects to which it gives rise is atrophy of the testicle and epididymis, produced by the pressure of the enlarged and dis- tended veins. 3. Neuralgia sometimes occurs in the spermatic cord, extending to the epididymis and body of the testicle. The affection, seated pro- bably in the nervous plexus around the spermatic vessels, is of the nature of tic douloureux, being characterized by unnatural sensibility of the affected parts, with excessive tenderness on pressure, and pain in the groins, sometimes darting into the back and thighs. The tes- ticle is but little swelled; the cord is not perceptibly altered; and, if the parts composing it be removed and carefully inspected, no lesion whatever is to be observed in them, excepting, in some rare cases, a slight thickening of the nerves. 694 SEMINAL VESICLES. SECTION III. SEMINAL VESICLES. Little is known respecting the lesions of the seminal vesicles. That they are liable to derangement is sufficiently obvious; but that their diseases are few and of rare occurrence, is equally certain. They have hitherto been almost entirely overlooked in our examinations; and to this omission, perhaps, more than to anything else, is to be as- cribed the meagreness of our information. Inflammation of the seminal vesicles rarely exists as a primary dis- ease ; most generally it is propagated to them from the urethra, blad- der, prostate gland, or testicles. In a few instances, pus has been detected in them ; and, on one occasion, I found the left in a fetid, gangrenous condition. The individual was fifty-eight years of age, and died of inflammation of the prostate, accompanied with complete retention of urine for nearly a week. The right vesicle was of a dark color, from the loaded state of its vessels; and its cavity was filled with a thick, muco-purulent fluid, mixed with a small quantity of semen. Collections of purulent matter in these reservoirs do not appear to be so uncommon as is generally supposed. The disease is usually, if not invariably, associated with, or, most probably, dependent upon, in- flammation of the prostate gland, the testicle, or the urinary bladder. Occasionally all these organs are involved at the same time, and the inflammation may even affect the ureters and Fig. 291. kidneys. The pus may discharge itself along the ejaculatory ducts, or it may make its way, by ulceration, into the urinary bladder or rec- tum. Tubercular matter is more rare in the semi- nal vesicles than in the testicles, uterus, or Fallopian tubes; I have witnessed only one example of it. The individual was twenty- seven years of age, for the last five of which he had labored under lumbar abscess, of which he finally died. Both reservoirs were remark- ably pale, of a fibro-cartilaginous texture, and reduced to less than one-half their natural size. Their sacculated arrangement had disappeared, and their cavities were distended with yellowish tubercular matter, of a semi-concrete con- sistence. (Fig. 291.) Small earthy concretions, of the same nature as those of the pros- tate, have been found in these reservoirs (Fig. 292). Their form is usually rounded, their surface smooth, and their color pale-gray- ish, white, or yellowish; their number varies from one to a dozen Tubercular matter in the semi nal vesicles. From a prepara tion in my cabinet. SCROTUM. 695 In a singular case mentioned by Mitchell,1 more than two hundred were contained in the right seminal vesicle. The patient died of pulmonary phthisis, and the pre- sence of the foreign bodies had not even been suspected during life. The seminal vesicles have been observed to be very much indu- rated, and more or less changed in their structure. The most com- mon transformations are the fibrous and fibro-cartilaginous. Occasionally their walls are of a dense, gristly nature, or partially ossified. Finally, these reservoirs are sometimes remarkably small, and occa- sionally one of them is absent. In some instances their ducts are wanting, and in others they are obliterated by inflammation, lymph, or tubercular matter, of which I have seen several examples. A case has been published in which both the excretory tubes terminated in a sort of flexuous cul-de-sac, which supplied the place of the seminal vesicles. Earthy concretions in a seminal vesicle. preparation in my collection. SECTION IY. Fig. 293. SCROTUM. The scrotum is liable to inflammation, cancer, and other diseases. Of these it is only necessary to notice a few of the more important. 1. Carcinoma of the scrotum is generally of the epithelial kind, and seldom occurs before the period of puberty. It is most common in chimney-sweepers; and hence it has by some been named the chimney-sweeper's cancer (Fig. 293). The affection generally begins at the base of the scrotum, in the form of a small, wart-like excrescence, covered by a thin, scaly crust. After this has continued for a time, the hardened cuticle sloughs off, leaving a superficial, painful, ill-looking ulcer, with indurated and everted edges. The surface of the sore has a red, excoriated aspect, and dis- charges a thin, sanguinolent fluid, often highly irritating and offensive. In this way the ulcerative process gradually ex- tends, until at length a large surface of the . ° . . . " . . An aggravated example of chimney- SCrotum, together With the Vaginal tuniC sweeper's cancer; much superficial and the exterior of the testicle, is involved texture destroyed. 1 Civiale, Traite sur les Maladies des Organes Genito-Urinaires, t. ii. p. 135. 696 SCROTUM. Fig. 294. in the disease. In this advanced stage, the cellular tissue around the sore is generally white and scirrhus; and the inguinal glands on one or both sides are enlarged, injected, and, in some instances, filled with cancerous matter. 2. The scrotum is sometimes transformed into a hard, fleshy mass, constituting what is termed sarcomatous enlargement (Fig. 294) _ The enormous magnitude which this dis- ease may attain is almost incredible. A surgeon of the Wrest Indies re- moved a tumor of this kind from the scrotum of a negro, which weighed seventy pounds; and Ba- ron Larrey has detailed the particu- lars of another, which was supposed to weigh one hundred and twenty pounds. In the medical museum at Montpelier, is a diseased mass of this character, which was amputated by Delpech, the weight of which is one hundred and sixty pounds. In my private collection is a specimen of this disease, presented to me by Dr. Bozeman, of Alabama, which weighs forty pounds. It began in early life, and grew until the pa- tient, a colored man, was twenty years old, when it was excised by that distinguished young surgeon. This disease is seldom observed in this country or in Europe; but in some parts of Asia and Africa it is not of infrequent occurrence, Hypertrophy, or elephantiasis of the scrotum, especially in persons afflicted with elephantiasis. Externally, the mor- bid growth is rough and fissured, and its surface, particularly in old cases, is covered with yellowish, scaly crusts, the detachment of which leaves so many small, herpetic sores, emitting a thin, ichorous dis- charge. The skin is very thick and indurated; the cellular tissue is firm and scirrhous, from the distension of its cavities with semi-con- crete, albuminous matter; and the bloodvessels of the part, instead of being large and varicose, as we find them in most other tumors, are remarkably small and contracted. The swelling is indolent and in- commodes rather by its weight and bulk than bv its pain. In its shape it is mostly pyriform, but sometimes ovoidal^ or globular. The testicle is not necessarily implicated in this disease nor is the matic cord so much indurated and enlarged as in some of the disorders of the genital apparatus. 3. A peculiar sloughing disease occasionally occurs in the scrotum of young children. In a case which I saw many years ago in an in- fant two weeks old, a slough, about an inch in diamete'r, suddenly sper- other CYSTS. 697 formed over the right testicle, leaving the vaginal tunic perfectly denuded, and producing an angry-looking sore with hard glossy edges, reposing upon black-colored cellular tissue. The spermatic cord was indurated, tumid, and remarkably tender on pressure. The constitu- tion did not seem to suffer much. In the course of twenty-four hours after these symptoms were discovered, the vaginal sac became dis- tended ; and, on puncturing it, a considerable quantity of sero-puru- lent fluid, of a yellowish color, followed the lancet. A small portion of the membrane now sloughed, leaving the gland quite bare; by touching the part with lunar caustic, and applying the yeast poultice, granulations gradually sprouted up, and the infant got well. 4. We sometimes find cysts in the scrotum filled with fatty matter, teeth, hair, or osseous fragments, or all these substances in a state of combination. In a case of this description, observed by St. Donat, a French surgeon, the tumor contained, among other pieces, two distinct frontal bones, the orbits of which were regularly hollowed out for the reception of two small, rudimentary eyes. In another example, the particulars of which have been published by Dr. Dietrich, Professor of Midwifery in the University of Glogau, the debris which was found in the testicle was composed of a pelvis and a lower extremity. A still more extraordinary instance was observed by Dr. Ekl.1 In this case, the scrotal tumor was formed by the ribs, the spinal column, the orbits, and the thigh bones of a foetus. A case has been reported by Dr. Andre', of Petronne, in which he discovered hair and teeth in the testicle of a boy seven years of age. But the most remarkable formation of this description is that men- tioned by Velpeau,2 and which this distinguished surgeon removed, in 1840, from a patient, twenty-one years old, in the Charity Hospital of Paris. The tumor, which had existed from birth, was of a rounded shape, of the size of a large turkey's egg, of a white color, insensible, and situated on the outer part of the right side of the scrotum; the corresponding testicle, epididymis, and cord being perfectly sound. At its posterior surface were three small openings through which fatty matter was occasionally discharged. A careful dissection showed the tumor to consist of two portions, one of which was solid, of a rosy tint, and made up of numerous pieces of bone, while the other, of a softer consistence, presented several cysts of different sizes and of variable contents. The largest cavity was occupied by a grayish fatty substance, composed of distinct portions connected by jelly-like mat- ter; the one next in size contained a similar substance, only of a darker hue, and having in its centre a quantity of very fine hair; the remainder were filled with a yellowish, stringy fluid, not unlike the vitreous humor of the eye. The solid part of the tumor was com- posed of different bones, variously arranged, articulated with each other, and surrounded by masses of fat; the whole being evidently the remains of a foetal skeleton. ' See the interesting treatise of Dr. OllMer, of Angers, entitled " Memoire sur la monstrosite par Inclusion," in which this and other cases are detailed. 3 New York Journ. Med. and Surg., July, 1840, p. 202. 698 PENIS. The above, and all similar formations, which, on the whole, are ex- tremely rare, bear the closest analogy to those of the ovary, and they can only be accounted for on the theory of monstrosity by inclusion. 5. Earthy deposits of the scrotum are rare. They may take place in the form either of sand-like granules, or in that of calculous masses, from the volume of a pea up to that of an almond. Their number, although generally small, sometimes amounts to several dozens ; they are of a dull whitish color, and of a cretaceous consistence, or even of the density and solidity of bone. Their chemical composition has not been ascertained; but, judging from what we know of these bodies in other situations, it is not improbable that they consist mainly of phosphate and carbonate of lime, cemented together by a small quan- tity of animal matter. Hitherto these concretions have been found exclusively in subjects past the middle period of life, in association with hypertrophy. Their formation is generally very tardy, and the irritation which they pro- duce sometimes leads to ulceration. In the interesting case observed by Professor Mott, the scrotum was nearly fifteen times the normal bulk, the patient was very far advanced in life, and the disease, which was removed by a surgical operation, had existed for upwards of twenty years. 6. Finally, the scrotum sometimes contains cysts communicating with the urethra, and filled with calculous concretions. The composition of the concretions is variable, but in general they consist of uric acid; they are usually quite smooth, ovoidal or spherical in their shape, and from the size of a millet-seed up to that of a Lima bean. Their number is sometimes remarkable, nearly as many as one hundred having been found in a single cyst. The cyst itself is commonly very thick, dense, and rough, especially in old cases. SECTION V. PENIS. The penis consists of several parts, differing from each other in their structure and functions, and liable therefore to dissimilar lesions. The cavernous bodies are rarely affected, whereas the urethra and the spongy texture around it are very liable to disease. Of the lesions of these different component elements, I shall notice only the more im- portant, commencing with those of the excretory duct. 1. Acute inflammation of the urethra, generally the result of impure connection, is marked by the same anatomical characters as acute in- flammation of the mucous textures generally: that is there is more or less redness, with opacity, and thickening of the lining membrane In three or four days after the infection—sometimes not under a week—- there is an increased discharge of mucus, followed in a short time by purulent matter, of a thick ropy consistence, and of a pale straw color. ORGANIC STRICTURE. 699 The quantity evacuated in the twenty-four hours varies from one to several drachms; and, in violent cases, it is not unfrequently extremely acrid, of a greenish cast, or tinged with blood. The morbid action is usually limited to the anterior extremity of the urethra, occupying the first two or three inches; but now and then it pervades the entire tube, from one end to the other. There is always a general turges- cence of the virile organ, with redness and swelling of the external orifice, the edges of which are often tender and pouting. Morbid erections are common, and the stream of urine is small and narrow, from the diminished calibre of the tube, caused by the turgid state of the lining membrane and the infiltration of the surrounding structures, especially the submucous. When the inflammation is violent, it is apt to extend to the neck of the bladder, the testicle, and spongy body of the penis, giving rise to effusion of lymph and the formation of abscesses. In ordinary cases, however, there is seldom, if ever, any breach of continuity. 2. When the disease assumes the chronic form, the discharge becomes more thin and limpid, bearing a greater resemblance to the white of egg than to real purulent matter. The quantity, also, is much less than in acute urethritis, and there is seldom much pain, scalding, or itching during micturition. The passage, however, usually remains somewhat contracted, from relaxation of the mucous lining, and the urine, in consequence, is always discharged in a narrow, tortuous stream. When the disease, now called gleet, is protracted, it often gives rise to stricture, by which the canal is permanently obstructed. A very frequent effect of gonorrhoea is the extension of the inflam- mation to the spongy structure of the penis, and the consequent effu- sion of lymph into its cells. This complaint, constituting what is called chordee, is characterized by abnormal erections, which are always most distressing during night, when the patient becomes warm in bed. The organ is curved downwards, from the spongy structure not admit- ting of so complete distension as the cavernous; and sometimes the cells are permanently obliterated, causing deformity of the penis, and imperfect erections. The effusion generally takes place about the middle of the organ, occupying occasionally a large extent of surface. In some cases, the deposition is effected at several points, though this is unusual. 3. Organic stricture of the urethra (Fig. 295) is the result of inflam- matory action, causing an effusion of lymph into the submucous cel- lular tissue and the interstices of the lining membrane. After some time, varying from a few days to several weeks, the effused fluid becomes organized, and thus forms a permanent obstruction, in front of which the passage is generally contracted, whilst behind it is dilated. The urethra is sometimes narrowed by a circular ring, not thicker than a thread, but more commonly the stricture occupies a consider- able extent of surface, from a line or two to an inch or more. Nor does it always surround the whole tube; in many cases, perhaps in most, it forms merely a segment of a circle. The bridle stricture, as it is called, consists of a dense band of organized lymph, stretched from one side of the urethra to the other. In old cases, the contracted 700 PENIS. part from repeated attacks of inflammation, is sometimes very elastic, firm and almost of the consistence of fibro-cartilage. The most com- mon seat of the disease is at the membranous portion, about seven Fig. 295. ¥%&£* Stricture of the urethra, with false passage ; enlargement of the prostate gland, and hypertrophy of the bladder. From a preparation in my collection. inches from the external orifice; the one next in point of frequency is at the junction of the posterior with the anterior two-thirds of the tube; and lastly, at the part immediately behind the neck of the penis. Besides the lesion now described, there is a variety of stricture, to which the term spasmodic is applied, as it is supposed to depend upon spasmodic action of the urethra. Every practitioner sees cases of this kind, in his attempts to pass the bougie. The obstruction is most common in the membranous portion of the tube, but I have seen it affect it in nearly its entire extent, the instrument being grasped with so much firmness as to require considerable effort to withdraw it. An irritable state of the lining membrane, alone or combined with mental agitation, is the most common exciting cause of the stricture; the im- mediate one being the contraction of the muscular fibres which sur- round the urethra. 4. One of the most distressing consequences of stricture is abscess, followed by fistule in the perineum, the rectum, or along the course of the urethra. (Fig. 296.) The canal, as was before stated, is generally more or less dilated behind the constricted part, forming a pouch for the lodgement of the urine. Occasionally calculi are retained here, and give rise to disagreeable symptoms. The suppuration is often very slow in its progress, and as the matter accumulates in the submucous texture, the lining membrane of the canal yields at one or more points, followed by the escape of the contents of the bladder into the surround- ing cellular substance, where they always produce considerable slough- ing. Extensive infiltration is sometimes prevented by the cellular tissue immediately around the abscess being so much condensed by the deposition of fibrin, as to present an effectual barrier to the diffu- sion of the fluid. The fistulous openings thus formed gradually diminish in size, and become incrusted by a layer of lymph, which in cases of long standing, sometimes degenerates into fibro-cartilage. The passage in front of the perforation being no longer needed for conveying urine, now contracts, and, unless means be used to dilate MALFORMATIONS OF THE URETHRA. 701 it, is finally much diminished. The number of these apertures is often considerable, the perineum being literally riddled with them. Fig. 297. Urinary fistules in the perineum. 5. Malformations of the urethra may, for practical purposes, be ar- ranged under the following heads: first, where the canal opens on the upper or lower surface of the penis; secondly, where it terminates in the perineum ; and, thirdly, where it opens in front of the abdomen, just above the pubes. In epispadias, as the first of these malformations is styled, the preternatural orifice usually exists about an inch and a half behind the extremity of the penis; but it may affect the whole dorsal surface, as in the adjoining sketch. (Fig. 297.) In hypospadias it may be situated at any point between the gland and the scro- tum, though its ordinary seat is opposite the neck of the organ, or just behind it. When the opening is in the perineum, the under surface of the penis is sometimes deeply grooved, the fissure extending down over the scrotum, and thus giving rise to an appearance of hermaphrodism, especially if, as occasionally happens, the testicles are retained in the abdomen, and the penis is very dimi- nutive. When the opening is placed far back the subject of the malforma- tion is generally impotent. To this rule, however, striking exceptions occur. Thus, I am acquainted with a colored man, who, although his urethra terminates at the scrotum, at least four inches from the ordi- nary point, is yet the father of five children. The urethra may be congenitally imperforate, and occasionally, though rarely, it has a double meatus. Baillie mentions an instance in which there were two canals, the one pursuing the natural course, while the other, which was about two inches in length, terminated at Epispadias. 702 PENIS. one extremity in a cul-de-sac, and at the other opened at the head of the penis, in the usual situation. When the tube is imperforate the obstruction may exist in any part of its extent, anteriorly, at the middle, or posteriorly, towards the neck of the bladder. The canal is sometimes entirely absent, at other times it is only partially deficient, and occasionally, again, the closure is produced by a sort of membrane, extending from one side to the other, in the form of a hymen. Cases have been observed in which the meatus was completely obstructed by the inflection of an elongated and adherent prepuce. The effect of this congenital obstruction, or obliteration of the ure- thra, is great distension of the urinary bladder, with enlargement of the ureters, and a peculiar cystiform dilatation of the kidneys. These changes also show, what has not been admitted by all physiologists, that micturition is naturally performed before birth, and that the secretion of urine may be carried on even after the renal tissues are almost entirely destroyed. 6. Morbid erection of the penis may be produced by inflammation, followed by an effusion of lymph into the cells of the cavernous bodies. I have never inspected a case of this kind after death, but observed one several years ago in a young mechanic, which lasted for nearly four weeks, in spite of the most rigid antiphlogistic measures. It came on soon after intercourse, and was attended with excessive pain, together with much constitutional disturbance. For several months after the violence of the disease had abated, the organ remained small, flaccid, and incapable of complete erection. Sometimes the priapism is caused by an effusion of pure blood, in which case, if the fluid is not absorbed, the.individual continues permanently impotent. 7, The pectiniform septum of the penis is liable to the cartilaginous transformation. I recollect a curious instance of this kind in a patient of the late Dr. George McClellan, of this city, for whose relief that gentleman was obliged to perform an operation. The man was be- tween fifty and sixty years of age; the disease had been coming on gradually; and the organ was curved towards the perineum to such a degree as to interfere materially with sexual intercourse. The ope- ration was entirely successful. Such a lesion, as the reader may readily conceive, might be a cause of impotence. The fibrous sheath of the cavernous body is sometimes affected in the same manner as the pectiniform septum. The transformation according to my observation, is most common in persons from thirty to forty years of age, and usually occurs in small patches, from the size of a three cent piece to that of a dime. Persons who indulge much in sexual intercourse are, I believe, most liable to it. When several such spots exist, they may interfere materially with the erec- tion of the penis. «. The penis is liable to carcinoma, chiefly of the epithelial form The disease usually begins as a little wart, tubercle, or fissure on the head of the penis, or the foreskin, from which it gradually spreads to the other structures, until the greater portion is destroyed The result ing ulcer is at first quite small and superficial; by and by however it SYPHILITIC ULCERS. 703 becomes broader and broader, and at last throws out a cauliflower-like fungus. There is now a profuse discharge of thin, sanious, and offen- sive matter, the inguinal glands rapidly enlarge, and the patient is harassed with severe lancinating pains darting up towards the abdo- men, his constitution being at the same time completely undermined by the local disease. Cancer of the penis is most common in old men. and its occurrence is generally supposed to be favored by the exist- ence of a long and tight prepuce. Of the truth of this opinion, how- ever, my own experience has not furnished me with any examples. 9. Syphilitic ulcers, generally known by the name of chancres, al- though they may occur on any part of the body, invade the mucous texture always in preference to the cutaneous. Indeed, before the latter can be involved, it must be deprived of epidermis ; for, so long- as this preserves its integrity, it is impossible for the venereal virus to produce its specific effect. Their most usual seat is the inner surface of the prepuce, together with the neck of the penis, the orifice of the urethra, and the sides of the frsenum. These ulcers vary ex- tremely, both in size and number, being sometimes quite small, and at other times forming large sores. In the plurality of cases, there are not more than two or three; but occasionally there are as many as six or eight, appearing either simultaneously or in pretty rapid succession. It is now well ascertained that all chancres of the mucous mem- brane of the genital organs, both in the male and female, are originally of a pustular form. The only exception to this law is where the virus is applied to an abraded surface, which modifies the appearance of the sore, converting it at once into a running ulcer. It is highly proba- ble that the matter, in ordinary cases, is deposited, in the first instance, in the mucous follicles, where it excites a specific inflammation, eventu- ating in the secretion of a fluid, which is capable, in its turn, of creat- ing a similar disease. What corroborates this opinion is the fact, just adverted to, that chancre always begins in the form of a pustule, and that it is most apt to be developed in those situations which abound in muciparous glands. The initial step of the disease is a small, reddish, indurated speck, the summit of which is speedily converted into a spherical vesicle, filled with a thin, colorless serosity. Its size scarcely equals that of a mustard-seed ; and its parietes, being formed by the mucous epithelium, are so excessively delicate as to break upon the slightest touch. Hence it is frequently ruptured before an opportunity is afforded of inspecting it, which is the reason, doubtless, why it so long escaped the notice of pathologists. On bursting, the vesicle leaves a small circular ulcer, with hard, jagged, and abrupt edges, as if they had been cut vertically. (Fig. 298.) The surface of the sore is gray, yellowish, or ash-colored, and the parts im- a venereal uicer on a corn- mediately around it are indurated, thickened, and ^J't' t?° tTT" J . , . -,. '. are chiefly those of the Hun- of a deep, florid hue, being formed into a distinct, teriaa chancre. After Ac. circumscribed tumor. The discharge is at first ton. 704 PENIS. of a foul, sanious, irritating character; but by degrees it assumes all the properties of laudable pus. The induration commences about the fifth day, and forms one of the most constant characters of chancre. It is about this period that the system begins to be in danger of con- tamination from the absorption of the virus. A chancre appearing on the cutaneous surface generally begins in the form of a pimple, which is surrounded by a red areola, and con- tains a thin serous fluid, which, on the fifth or sixth day, becomes purulent. The part about this period presents the aspect of a pustule, not unlike that of smallpox; the structures on which it rests being somewhat indurated and oedematous, from the effusion of coagulating lymph. In a few days more the matter becomes thick, the pustule shrinks, and a scab begins to form, which, on falling off, exposes a deep, rounded ulcer, encircled by a prominent, violet-colored ring. The scab, which is thick, and often of a truncated, conical shape, is soon succeeded by others; and thus the disease proceeds until the part either gets well, or yields to the devastating influence. Syphilitic ulcers are very apt to spread, and even to terminate in gan- grene. The slough is black, and at first small and circumscribed, but afterwards more or less extensive and ragged. The entire chancre is thus sometimes lifted from its place, leaving the surrounding tissues in an inflamed and infiltrated condition, with a sore that is easily healed. More generally, however, the ulcers assume a phagedenic character, and throw off fresh sloughs until, perhaps, the whole penis is involved in the mischief. Many chancres, after having persisted for a variable time, gradually exhaust themselves, and finally cease spontaneously, the event being announced by the secretion of laudable pus, and the development of healthy granulations. In whatever manner the reparation is effected, whether by art or the efforts of nature, there almost always remains a hard, gristly tumor, which is more or less tender on pressure, very slow in disappearing, and extremely prone to new attacks of ulceration. Indeed, so common is this, that chancre may be considered as a genuine phoenix, which springs from its own ashes, and furnishes the food for its own nourishment. So long as the disease is confined to the penis, it is strictly a local affection; but it has a tendency, sooner or later' to work its way into the system; the first evidence of which is gene- rally a swelling of one of the lymphatic ganglions of the groin, known by the name of bubo. Chancre alone can produce chancre. Inoculation has fully established the fact that the matter of gonorrhoea can no more produce chancre than the matter of chancre can produce gonorrhoea. It has also been ascertained that it is during the ulcerative stage that the sore yields its specific secretion; after this stage has passed, it loses its character its nature changes, and its poisonous property is destroyed. Dilution with other substances renders its operation not only uncertain but at times completely inert. The part to which it is applied must likewise be free from acute inflammation, from pus, and from unctuous matter Ine period of latency is uncertain. Occasionally the disease fol' PHYMOSIS. 705 lows inoculation in twenty hours; at other times—and this is most common—several days elapse; and, in some instances, it does not make its appearance under a few weeks. The nature of the part affected seems to exert considerable influence upon the production of chancre. Thus, the prepuce is more easily diseased than the gland, and the latter than the skin of the penis and scrotum. 10. Herpetic ulcers are chiefly observed in adults, on the inner sur- face of the prepuce, or at the junction of the skin and mucous mem- brane. They manifest themselves by inflamed spots, of a bright red color, varying in size from that of a millet-seed to that of a split pea. Small vesicles soon succeed, of a globular shape, remarkably transpa- rent, agglomerated, and containing at first a serous, and subsequently a puriform fluid. On the internal surface, these vesicles lead to the development of thin, flat scales which fall off about the fifth day, leaving a corresponding number of round, yellowish excoriations; on the external surface, rough, irregular scabs form. This disease is very apt to recur, and is usually attended with some itching, rarely with real pain. Friction and want of cleanliness are the principal exciting causes. By running together, these ulcers occasionally form one un- broken sore, occupying nearly the whole of the prepuce. 11. The psoriasic ulcer is most frequently met with in persons who have the foreskin unnaturally long, moist, and tender. It is an obstinate and painful disease, characterized by deep cracks, or fissures, on the edges of the prepuce, which becomes gradually thickened, hardened, and so corrugated as to occasion phymosis. The number of ulcers is sometimes quite considerable; they are very tender and unseemly; apt to bleed when injured; extremely difficult to heal; and, if large, attended with a copious, puriform discharge. Small, brownish-looking scales occasionally form on these sores. 12. The penis is liable to the development of warty excrescences (Fig. 299), as a consequence chiefly of gonorrhoea and syphilis. Although they may occupy any portion of the organ, they are most common around the neck and at the side of the fraenum, where they often occur in immense numbers, from the size of a pin-head up to that of a pea ; they are usually of a conical shape, with a rather small pedicle, rough, fissured, or tuber- culated, of a firm consistence, of a bright florid color, and of a fibrous structure. When these vegetations are very numerous they form a large tumor beneath the prepuce, which se- cretes an abundance of fetid pus. They fre- quently bleed on the slightest touch, and are always prone to recur after extirpation. Warts on tlie penis 13. Phymosis (Fig. 300) consists in a con- tracted and elongated condition of the prepuce, attended with an in- ability to uncover the head of the penis. It presents itself in two varie- ties of form, the congenital and the acquired. In the first, the narrowing of the prepuce depends chiefly upon the tightness of the mucous mem- 45 PENIS. brane, the other component parts retaining their natural character; in the other all the structures are condensed by inflammatory deposits, which in time often spontaneously disappear. 14. Paraphymosis (Fig. 301) is the reverse of phymosis, and is always an accidental occur- rence, causing a stricture just behind the head of the penis, which, in severe and neglected cases, may not only produce great suffering, but mortification of the strangulated tissues. 15. When the prepuce is very long and nar- row, it may become a receptacle for calculous concretions, of which some very curious examples are upon record. They are usually composed of uric acid, and vary in size from that of a mustard-seed to that of an almond. Cases have been witnessed in which there were as many as fifty, sixty, and even a hundred of these con- cretions. Their shape is spherical, or ovoidal, their surface rough or smooth, and their color grayish or pale ash. They are formed directly from the urine, which, in consequence of the difficulty of its escape through the narrow orifice of the prepuce, deposits its salts,in the phymotic pouch. UTERUS. 707 CHAPTER XXVII. FEMALE ORGANS OF GENERATION. I. The Uterus.—Observations on its Weight and Volume.—Liable to Malformations —Retro- version.—Prolapse and Inversion.—Is apt to suffer from Inflammation, both of its Lining Membrane, its serous Covering, and its proper Tissue.—Remarks on Uterine Phlebitis.— Softening.—Induration.—Atrophy.— Fibrous Tumors.—Different Species of Polypes.—Cal- careous Concretions.—Transformation of the Uterine Tissue into Cartilage and Bone.— Malignant Diseases.—Encephaloid and Scirrhus.—Tubercular Deposits.—Rupture.—Hemor- rhage.—Accumulation of Air.—Hairs.—Obstructions of the Mouth of the Womb.—Hydatids. —Uterine Moles. II. The Ovaries.—Their Disorders are numerous and important.—Osseous Transformations.—Serous Cysts and Hydatids.—Scirrhus.—Occasionally contain Teeth, Hair, and Fragments of Bone.—Hemorrhage.—Remarks on the Corpora Lutea. III. The Fal- lopian Tubes.—Are seldom affected with Disease. IV. The Vagina and Vulva.—Liable to the same kinds of Maladies as other Mucous Structures.—Polypes of the Vagina.— Varices.—Enlargement of its Mucous Follicles.—Vices of Formation.—The Great Labia.— Polypes.—Clitoris.—Nymphae, and Orifice of the Urethra. V. The Mammary Gland.— Is often the seat of Acute and Chronic Inflammation.—Its Diseases, in many respects, resemble those of the Testicle and Ovary. VI. Placenta.—Inflammation.—Suppuration.— Softening. — Cartilaginous Degeneration.—Ossification. — Fatty Degeneration. — Hyper- trophy.—Tubercles.—Sanguineous Effusions.—Umbilical Cord. SECTION I. UTERUS. The sexual system of the female consists of the uterus, Fallopian tubes, ovaries, vagina, vulva, and mammary glands. Previously to the age of puberty, these organs are extremely small, and as they do not exert any particular influence on the constitution, they are not at all prone to disease. When they have attained their full develop- ment, however, their importance is deeply felt by the system at large, and they then become subject to a great variety of morbid alterations, both of a functional and organic character, which either impair the general health of the female, or terminate in destructive mischief. The weight and dimensions of the uterus vary very much in differ- ent individuals, as well as at the different periods of life. In six specimens taken from young virgins, soon after the establishment of the menstrual function, I found the average weight to be one ounce and a half, the minimum one ounce, and the maximum one ounce and three quarters: the medium length was two inches seven lines; the breadth, from one Fallopian tube to the other, eighteen lines; and the thickness ten lines and a half. Of the neck, the length was fourteen 708 UTERUS. lines, the breadth eleven, and the thickness eight. The lips, which varied in thickness from three to four lines, were perfectly smooth and rounded, and enclosed a circular orifice scarcely a quarter of an men in diameter. In two of the specimens the aperture presented the appearance of a transverse slit. The horizontal diameter of the in- ferior extremity was eight, the antero-posterior, seven lines. The medium thickness of the parietes was five lines at the body, and four at the neck. The length of the fundus of the organ rarely exceeds the fourth of an inch. The dimensions of the virgin uterus are stated by Madame Boivin and Professor Duges to be the following:— Total length Breadth of the fundus Thickness Length of the cervix Breadth Thickness 26 lines. 17 13 H 7 Of the walls of the body of the organ the thickness, above, was five lines and a half, laterally five lines, posteriorly four lines and a half, and anteriorly four lines. The entire weight, without the append- ages, was five drachms. The woman, who was twenty-five years of age, had never been married; her stature was moderate, and the men- strual function had always been regular. In married women who have borne children, the same writers esti- mate .the weight of the uterus at from one ounce and a half to two ounces; the total length, at from two and a half to three inches. The length of the body is two inches; of the cervix, from thirteen to fifteen lines, the breadth of this portion being eighteen lines. The thickness of the body is fourteen lines, and sometimes much more; of the cer- vix, from eight to ten lines; of the contracted part, eight lines; of the parietes of the body, six lines. The breadth of the vaginal orifice is stated at six lines. 1. Malformations.—The uterus is liable to various malformations, of which the most common and important are, first, entire absence of the organ; secondly, deficient evolution; and, thirdly, increase of development. 1. Absence of the uterus is generally connected with absence of the ovaries and the Fallopian tubes. The vagina is also frequently want- ing; and the external parts of generation are either completely de- ficient, or represented as it were in miniature. When the ovaries are present, the vulvovaginal structures are more perfect, the mammary glands are more expanded, and the females possess more of the cha- racteristic attributes of their sex. 2. Cases also occur in which the womb is remarkably small or in which it exists only in a rudimentary state. Julius Cloquet1 has described the sexual organs of a woman, twenty-two years of a^e in whom the uterus was not larger than that of a child of twelve months The vagina was also very small; but the ovaries and Fallopian tubes 1 Journ. Gen. de Med., t. lxx. p. 274. MALFORMATIONS. 709 were well developed. Cases not unlike this are to be found in various periodicals. 3. There are other deviations from the normal standard which deserve brief notice here. These relate to the conformation of the uterus, and may be arranged under several heads. In the first place, the uterus may be double, as in Fig. 302. The organ is of an elongated, cylin- drical figure, and is divided, by a longitudinal septum, into two paral- lel canals, precisely alike in size and shape, and opening either into a separate or a common vagina. In the second variety, the uterus is also double, but instead of being united along the middle line, the two Fig- 302. Fig. 303. parts are free, except at their inferior extremity, where they are con- nected by a sort of isthmus. This may be named the bipartite uterus. It is well represented in the annexed cut. (Fig. 303.) It bears some resemblance to the tubular oviduct of birds, and each organ opens into the vagina by a distinct orifice. Fig. 304 illustrates an unusual species of malformation, consisting of two uterine bodies, one much smaller than the other, and terminating by a common mouth. The organ bears some resemblance to the womb of some of the inferior animals, both herbi- Fig. 304. Fig. 305. vorous and carnivorous. Finally, there is a variety of malformation, in which the cavity of the uterus is divided into two parts, by a longi - tudinal septum, which, however, is generally imperfect. The organ is 710 UTERUS. well formed externally, except that it is unusually large at the fundus. These appearances are well seen in Fig. 305. All these deviations from the normal formation are perfectly com- patible with impregnation. In some cases they are associated with absence or deficient development of the ovaries and Fallopian tubes; but, generally speaking, these structures are present, as in the natural state. In no instance, so far at least as my knowledge extends, were there two ovaries and two Fallopian tubes on each side, not even in the bipartite variety, the nearest approach to two separate wombs. In women who have borne children, the womb is always larger than in virgins, or than in those who are barren: its substance is also more dense and firm, its lips are more jagged and irregular, and sometimes, though rarely, the orifice of the organ is completely obliterated. Morgagni refers to a case where the closure was effected by an adven- titious membrane; and similar examples have since been recorded by others. The occlusion may also be produced by inflammation, attended with an effusion of plastic lymph. The orifices of the Fal- lopian tubes are also sometimes closed, either congenitally or as the effect of disease. In a few rare instances the uterus and vagina have been known to constitute one solid mass, without any cavity or opening in either; and occasionally, again, though this is also very infrequent, the cavity of the former is divided, by a transverse septum, into two chambers, one corresponding with its base, the other with its neck. This lesion is most common in very old females, and is generally, if not invariably, the result of inflammatory irritation, leading to adhesion of the isthmus of the organ. 2. Malpositions.—Of the various malpositions to which the uterus is liable, the most common are retroversion, anteversion, prolapse, and inversion. In retroversion (Fig. 306), the orifice of the uterus is tilted up against Retroversion of the uterus. Anteversion of the uterus. the pubic symphysis, and the fundus is thrown downwards and back- wards, so asto form a tumor between the vagina and the rectum Thus the axis of the organ is totally reversed relatively to its natural" MALPOSITIONS — INFLAMMATION. 711 Fit?. 308. situation within the pelvis. This species of displacement is most apt to occur between the third and fourth months of pregnancy; it may, however, take place at a much later period ; and, in some instances, it has been noticed soon after delivery. Its progress, though occasion- ally gradual, is generally rapid. Anteversion (Fig. 307) is a displacement precisely the reverse of the preceding, that is, the fundus of the womb is carried forwards on the urinary bladder, and the mouth backwards towards the rectum and the hollow of the sacrum. It rarely occurs during pregnancy, and is almost always associated with hypertrophy of the uterus. The anteversion is sometimes produced by morbid adhesions between the organ and the peritoneum, which have the effect of forcing it out of its normal position. The uterus is liable to prolapse. Notwithstanding that it has four ligaments which serve to maintain it in its natural position within the pelvis, it not unfrequently, both in its empty and gravid state, loses its hold, and falls down into the vagina, or even beyond the vulva. In the latter case, the organ forms a tumor between the thighs, with a small central aperture corresponding to the mouth of the womb, and the vagina is completely inverted, or pulled inside out. The accident is always attended with a thick muco-purulent discharge. In inversion of the uterus, the viscus is turned inside out. (Fig. 308.) It is gene- rally attended with more or less pro- lapse of the body of the organ, and sel- dom happens except during delivery of the after-birth, or the forcible removal of some tumor from its interior. Of this lesion there are three degrees. In the first, the fundus falls down nearly to the mouth of the womb, where it is arrested; in the second, it passes beyond this point for half or more of its length; in the third, the whole organ escapes at the inferior orifice. In the second case, it is obvious that the body and fundus may be compressed, or strangulated, by the contraction of the neck. 3. Inflammation.—The uterus is liable to inflammation, both in the married and in the single female, but much more fre- quently in the former than in the latter. The disease may attack any portion of the organ, or it may be limited to the lining membrane, the parenchymatous substance, or the peritoneal covering, or all these structures may be in- volved simultaneously, together with the venous and absorbent trunks. Inflammation of the lining membrane is characterized by the same phenomena that are observed in inflammation of the mucous textures in other parts of the body. The redness, which is of a deep shade, is Inversion of the uterus. From a pre- paration in Professor Meigs's collection. 712 UTERUS. often spread over a large extent of surface, and in violent cases it is not uncommon to meet with small ecchymoses, followed by an escape of blood on pressure. The mucous follicles, especially those about the mouth of the uterus, are in a state of enlargement, and there is usually, in the course of a few days, a great increase of the natural secretion. In some instances, pus is deposited, and continues to be discharged for a considerable period, as in inflammation of the mucous membrane of the vagina. Occasionally the inflammation of the lining membranes eventuates in an effusion of coagulating lymph. The occurrence is often seen in young females of a robust, irritable temperament, in whom it consti- tutes a frequent cause of dysmenorrhcea. The membranous concre- tion, which is seldom thick or firm, generally moulds itself to the inner surface of the uterus, and is sometimes expelled entire, though much more commonly in small pieces. The period required for the extrusion varies from a few hours to a number of days, and is always attended with much suffering. When the lymph extends into the Fallopian tubes, it may lead to sterility by occluding their uterine orifices. Inflammation of the body and serous covering of the uterus is most common in females during the first eight or ten days after parturition. It sometimes' betrays an epidemic tendency, and rapidly passes into suppuration, softening, or even gangrene. The pus that is poured out, in such cases, may be situated in the parenchymatous structure, in the uterine cavity, the subserous cellular substance, between the folds of the broad ligaments, or, finally, in the venous and absorbent trunks, or simultaneously in all these parts. In most of these locali- ties it occurs in the form of small yellowish-looking globules; but cases are observed in which the fluid is collected into distinct abscesses, which are never very large, and which manifest a disposition, sooner or later, to burst into the vagina, the rectum, pelvis, or urinary blad- der. The pus is generally blended with a good deal of lymph, and is sometimes highly offensive. The lesion may originate in, and be limited to, the veins; but, in the great majority of cases, the parenchymatous structure participates in the inflammation, assuming a dark livid aspect, at the same time that it loses its natural consistence. Serum and pus may also be found in the subserous cellular tissue; and the peritoneal investment is sometimes covered with thick patches of lymph. The veins them- selves are always much enlarged, and their cavities are filled with pus clots of blood, or plugs of adventitious membrane. The disease often extends along the venous trunks of the pelvis to those of the abdomen or even to those of the inferior extremities ; and very frequently the absorbent vessels are similarly circumstanced, being greatly augment- ed in volume, and infiltrated with enormous quantities of purulent matter. The causes of uterine phlebitis are not always very evident. In some cases, it appears to result from violence done in the extrac- tion of the placenta, while in others it may be traced to the effects of cold and moisture, irregularities of diet, or to some peculiar noxious condition of the atmosphere. The lesion is said to be more frequent ULCERATION — SOFTENING. 713 on the right side than on the left, and to be sometimes entirely limited to the veins in that situation. _ 4. Ulceration.—Ulceration of the uterus may occur at any period of life after puberty, but is most common between the ages of thirty and forty, in married women. It usually attacks the lips and neck of the organ, and exhibits every variety of form, from the slightest abrasion, merely involving the mucous lining, to a cavity several lines in depth. In its shape it may be circular, oval, or linear. In many cases it has the appearance of a crack, chap, or fissure, lying longitudinally or obliquely upon the surface of the affected lip or neck. Its edges are sometimes very abrupt, giving the part the appearance as if a depres- sion had been made into it with a punch. The bottom of the ulcer is smeared with unhealthy pus, incrusted with lymph, or studded with granulations, of varying size, color, and consistence. The surround- ing structures are red, tender, and often quite indurated. In cases of long standing, or unusual severity, the lower extremity of the uterus is excessively engorged, considerably enlarged, and greatly altered in its figure, often exhibiting a knobbed, clubbed, or pouting appear- ance. In some cases, the affected structures, instead of being indu- rated, are abnormally soft, or hard at one point and soft at another. In the more aggravated forms of ulceration, the organ increases in its weight, and thus becomes a cause of its own prolapse, by its dragging effects upon its ligaments. The discharge which accompanies the ulcerative action is subject to the greatest possible variety, both as it respects its quality and quantity. Thus it may be thick and yellow, thin and sanious, bland or irritating, scanty or abundant, free from odor or more or less fetid. In general, it is mixed with considerable mucus, of a thick, ropy character. Ulcers of the uterus may be acute or chronic, simple or specific. The simple ulcer usually arises without any assignable cause, and often continues for months and years, making, perhaps, in the mean- time, very little progress. The syphilitic ulcer is usually distinguished by its excavated character, its spreading tendency, and the copper- colored appearance of the adjacent parts. 5. Softening.—Softening of the uterus is generally the result of acute inflammation, as is evinced by the rapidity of its progress, the nature of its symptoms, and its anatomical characters. When it exists in a high degree, it may lead to rupture of the organ, or prove fatal by inducing gradual exhaustion. What is remarkable, the lesion is occasionally coetaneous with softening of some of the other viscera, especially the stomach, spleen, and heart. In most cases, it is confined to the neck or inner surface of the viscus, seldom penetrating to, or commencing in, its exterior. Here, as elsewhere, the mollescence presents several stages, running insensibly into each other. In the first stage, the uterine substance is preternaturally flaccid, lacerable, and infiltrated with sero- sity ; in the second, it readily yields under pressure, and may be broken up into a soft, stringy texture, like that of the spleen; in the third, when the disorganization is at its maximum, it is of a semifluid con- sistence, and scarcely retains any trace of its former character. The softened organ sometimes preserves its natural color, but more com- 714 UTERUS. monly it is remarkably pale, grayish, or brownish. Occasionally, as when the attending inflammation is violent, and runs its course very rapidly, the color is purple, slate, or black, and occurs in patches, vary- ing in diameter from a split pea to a twenty-five cent piece. 6. Induration.—Induration of the womb is most commonly met with as an effect of old age, or as a consequence of protracted chronic in- flammation. It is very different from scirrhus, with which, however, it is often associated, as it also sometimes is with encephaloid, fibrous tumors, and other morbid changes. It is characterized by unnatural paleness, and by a dense, firm, and almost incompressible state of the uterine tissues, many of the vessels of which appear to be obliterated. The womb, in this condition, may retain its normal size, or it may be diminished or increased. 7. Hypertrophy.—Hypertrophy of the uterus, as a result of healthy nutrition, is very rare. The affection is usually most conspicuous in association with fibrous tumors, in which it is sometimes truly enor- mous. Thus, in a specimen in my possession, the walls of the organ are nearly two inches in thickness, and of a firm, dense consistence, grating under the knife. Its cavity is of extraordinary size, and several small tumors are seen projecting from its outer surface. The hypertrophy is sometimes confined to the lips of the uterus, which, especially the anterior, become thick, dense, and stumpy. 8. Atrophy.—Atrophy of the uterus arises from various causes. It is by no means uncommon simply as an effect of old age. During the decline of life the viscus increases in density, and exhibits a propor- tionate diminution in weight as well as in volume; many of its vessels are obliterated, and its cavity is nearly, sometimes entirely, effaced. Prolonged inactivity will, even at a comparatively early period, cause atrophy of the uterus. In women who have never borne child- ren the organ is often considerably smaller than in those who have been repeatedly pregnant. The uterus, in such cases, is governed by the same laws as the other parts of the body, which are large or the reverse in proportion to the amount of their exercise and the conse- quent influx of blood. Continued pressure, as from the presence of a fibrous tumor, an en- larged ovary, or an exostosis of the pelvic bones, may produce this lesion. The proper substance, under these circumstances, is sometimes entirely removed, so that when the organ is distended with air it is almost as thin and diaphanous as a bladder. When the atrophy is carried to this extent, perforation may take place, and the secretions of the organ, if not suspended, be discharged into the peritoneal cavity. Atrophy of the uterus sometimes occurs during gestation; it may be very slight, or so great that the parietes shall not be more than a line or two in thickness. The causes of this form of atrophy are not understood. It may be accompanied by loss of color and cohesion* or the organ may retain its natural complexion and firmness. Gesta- tive atrophy of the uterus is frequently followed, especially during labor, by laceration. The mouth of the uterus is sometimes preternaturally small or so much contracted as scarcely to admit a silver probe or even a hoo-'s MUCOUS FOLLICLES — FIBROUS TUMORS. 715 bristle. This lesion is often congenital, but in other cases it is brought about by inflammatory irritation, in the same manner as stricture of the urethra. A similar condition is sometimes observed in the cavity of the neck of the uterus. The canal, in one of my specimens, is completely occluded, for the distance of nearly an inch, by the adhe- sion of its two walls. A stricture in either of these situations would be a cause of impotency and of the retention of the menstrual fluid. 9. Enlargement of the Mucous Follicles.—Chronic inflammation of the uterus is often attended with an extraordinary development of its mucous glands. The enlargement is most conspicuous about the mouth and lips of the womb, where the follicles are sometimes as big as a hemp-seed, a currant, or even a pea, dense, almost gristly, and of a white grayish color, as in Figs. 309 and 310. The parts between Fig 309. Fig. 310. them are generally tumid, red, morbidly sensitive, and disposed to bleed. In several cases, I have seen the enlarged glands transformed into considerable cysts, filled with a pale, tremulous substance, easily removed by pressure. It is in this manner, perhaps, that the greater number of diseases of the mouth of the uterus originate. 10. Fibrous Tumors.—One of the most common appearances observed in the uterus is the development of fibrous tumors (Figs. 311 and 312), Fig. 311. Fibrous tumor in the cavity of the uterus. From a preparation in my cabinet. 716 UTERUS. Fig. 312. occurring either in its substance, in its cavity, or on its outer surface beneath the serous coverings. Their shape is usually spherical; their diameter from the size of a hickory-nut to that of a melon; their structure firm, dense, opaque, and of a light grayish color, tearing into strong, concentric fibres. Such growths have sometimes a rough, granulated texture, and not unfrequently they contain small cavities, filled with earthy matter, or various kinds of fluids, as serum, jelly, blood, or pus. The calcareous matter, which, in some instances, almost encases these morbid growths, in the form of a thin, brittle shell, not unlike that of an egg, has been shown, by Dr. Bostock, to consist chiefly of the phosphate and carbonate of lime, together with a minute quantity of animal sub- stance. It is generally of a pale grayish color, very soft, and porous, like pumice-stone; but examples are recorded where it had the hard- ness of ivory, and admit- ted of a fine polish. Only one such tumor may exist in the uterus; or there may be a con- siderable number, per- haps as many as six, eight, ten, or a dozen. When large, they are usually irregularly lobu- lated, or divided by deep fissures; bloodvessels, of- ten of considerable mag- nitude, can be traced into their substance. They have no disposition to ulcerate, to become soft, or to assume malignant action; and,although they occur both in the married and the unmarried female, they seldom if ever, make their appearance before the age of thirty. When seated under the serous covering of the uterus, these tumors often hang by a very sjender neck, and they then assume a pyriform shape. They possess very little sensibility; and, so long as they remain small, they produce no change in the form of the uterus or local inconvenience; but, when they attain a large bulk, they often incommode by their weight, and, by the pressure which ihey exert upon the bladder and the rectum, may seriously interfere with the expulsion of the urine and feces. When these bodies are embedded in the walls of the womb, or spring from its inner surface, the subjects Fibrous tumors of the uterus—both internal and external. From a preparation in Professor Meigs's collection. POLYPES. 717 Fig. 316. of them are apt to be barren; or, if they conceive, the uterine tissue is unable to undergo the necessary expansion, and abortion results. Sometimes these tumors are attached to the base of the womb, and, by rising into the abdomen, may be felt movable in that cavity, and thus simulate pregnancy. When situated in the uterine cavity, they are occasionally expelled during labor, and the woman either recovers, or dies of the profuse hemorrhage that ensues. 11. Polypes.—Polypes of the uterus may be conveniently arranged, according to their anatomical characters, into four classes, namely, the fibrous, vascular, vesicular, and granular. The fibrous variety bears a strong resemblance to the fibrous tumor of the uterus, and is perhaps the most common of the four. Growths of this kind are of a fleshy consistence, firm, yet compressible, smooth, elastic, of a pale grayish color, and composed of dense filaments, which are so intimately interwoven with each other as to render it impossible to unravel them. In their shape, they are commonly globular or pyriform; in one instance, I found one that was of the figure of a mushroom, the rounded footstalk being attached to the neck of the uterus, the base projecting into the vagina (Fig. 313). The fibrous polype has few vessels and nerves, and is therefore little liable to bleed or to be attended with pain. Tumors of this kind have often a very rough surface, and they some- times contain considerable cavities filled with serum, jelly, pus, or earthy matter. The vascular polype is composed essentially of vessels and cellular tissue, the fibrous ele- ment being either entirely wanting, or existing only in a very limited degree. This species is extremely rare, and seldom attains a large size; it is of a red, florid color, of a soft spongy consistence, sensitive on pressure, erectile, and exceedingly prone to hemor- rhage. In respect to shape, it presents the same diversities as the other species. The vesicular, cellular, or gelatinoid polype holds a sort of intermediate rank between the two preceding, being softer than the fibrous and harder than the vas- cular. This species is readily distinguished by the following charac- ters:—It is semi-transparent, of a peculiar grayish complexion, com- pressible, glistening on the surface, and attached by a delicate pedicle, which renders it pendulous. Carefully examined, it is found to ex- hibit a shreddy, tremulous structure, interspersed with a few vessels, which are generally too small to emit much blood. The gelatinoid polype may acquire a large bulk, and is influenced by atmospheric vicissitudes, increasing in size when the weather is moist, and dimin- ishing when it is dry. The granular polype consists in an enlargement of one or more of the mucous follicles, situated at the mouth of the womb, and described Fibrous polype of the uterus. From a preparation in my col- lection. 718 UTERUS. by the older writers under the name of the ovules of Naboth. It almost always occurs in clusters, of a whitish or grayish color, com- monly about the size of currants or grapes, suspended by long, slender pedicles, and strongly resembling, in their general appearance, the surface of a cauliflower. When there is only one such tumor, it may attain the volume of a walnut, or of a hen's egg. It is invested by a smooth, delicate, vascular membrane, possesses little sensibility, and often contains a yellowish curdy matter, which is apparently nothing but inspissated mucus. The connection with the uterus is very slight, and its growth generally very tardy. Such are the distinctive characters of the four species of uterine polypes now described. To these it will be necessary to add a few remarks respecting certain features which they possess in common with each other. Uterine polypes are found of all sizes, from that of a bean up to that of a gourd. Fig. 314 represents a small tumor of this kind, of a pear-like, lobulated form, and attached to the base of the cavity of the womb by its footstalk. Their voldme, in some cases, is immense. Dupuytren saw one which weighed twenty-five pounds; and another, described by De Claubry, weighed thirty-nine pounds, and was nearly three feet in its vertical circumference. They occasionally extend far down into the vagina, and cases have been witnessed in which they reached more than ten inches below the vulva. (Fig. 315.) The shape Pisr. 314. Fig. 315. «f«^- Uterine polype attached to the base of the organ. Uterine polype hanging from the vulva. of these morbid growths is mostly pear-like; and, although they mav originate in any portion of the cavity of the uterus, they are most frequently attached to its neck. Many of them have a narrow slender TRANSFORMATIONS. 719 peduncle; and, in such as are of great size, it is not uncommon to see deep fissures, which give them a lobulated arrangement. They are all invested by a thin mucous membrane, which is more or less vascular, and merely a prolongation of that of the womb, immediately beneath which the morbid growth is developed. Uterine polypes often contain large cavities, filled with various sub- stances. Earthy concretions have been found in their interior, and some have pretended that they have detected tubercular matter. Waller alludes to cases in which they contained "hair. These tumors are most common in aged females. A notion, but a very erroneous one, was formerly entertained that they occurred most frequently in old maids; instead of this they are by far most common in married women, the mothers of children. Their presence often occasions alarming hemorrhage; and, when they become ulcerated, they may give rise to a copious discharge of irritating and offensive matter. 12. Transformations.—Calculous concretions sometimes occur in the uterus. Of these formations many cases are described by the older writers, and not a few by those of a more modern date. One of the most interesting examples, perhaps, on record, is that related by Louis, in the Memoirs of the Eoyal Academy of Surgery of Paris.1 It was observed in an old female, who was affected for a long time with diffi- culty in voiding her urine, and severe pain in the loins and perineum. The uterus, which was in a state of scirrhosity, and of extraordinary size, contained a hard, compact, and irregularly-shaped concretion of a< bony structure, which weighed five ounces and a half. Generally, how- ever, these heterologous formations are much smaller, not exceeding the volume of a grape, a pigeon's egg, or a walnut. Most of them are of a light grayish color, of an osteo-cretaceous character, and somewhat lamellated, with a rough, unequal surface. They all essentially consist of carbonate of lime, in union with a little animal matter. Concretions of this sort are sometimes surrounded by a delicate membrane provided with minute vessels; and they not unfrequently contain small nodules of cartilage. Although their most usual situa- tion is the cavity of the organ, yet they are occasionally developed in its substance, beneath its serous investment, or even in the uterine veins. When seated in the proper cavity of the womb, nature sometimes makes an attempt to expel them, which is almost always attended with considerable hemorrhage. At other times, though very rarely, their presence excites ulcerative action, leading to great local suffering and the formation of fistulous tracks between the uterus and the adjacent viscera. Calculous concretions are most commonly observed in advanced life; in a few instances they have been wit- nessed in young females, married as well as single, soon after the esta- blishment of the menstrual function. How these concretions are developed is still a litigated question. I have already described the formation of similar bodies in the plastic lymph of the serous membranes of the joints and of the visceral cavi- ties ; and it is not improbable that those under consideration have an 1 T. ii., 4to. edit., 1769. 720 UTERUS. analogous origin. It is well known that the uterus is liable, at all periods of life, but especially in old females, to the effusion of fibrin, either into its cavity, into its substance, or into the submucous cellular tissue. In either case, the fluid, if it be permitted to remain, becomes organized, and converted ultimately into an adventitious structure of a fibrous, fibro-cartilaginous, cartilaginous, or osseous character. It is possible that they may also be produced by the presence of coagula, formed during uterine hemorrhage; and it is probable, likewise, that in some rare instances the earthy matter is poured out without being preceded by any new growth, whether of an analogous or heterologous nature. This hypothesis derives support from the fact that these concretions are occasionally found entirely disconnected from the substance of the womb, lying perfectly loose in its cavity, or upon its outer surface. The uterine tissue may be partially transformed into cartilage, bone, or earthy matter. The foreign substance is generally seated in the proper texture of the organ, but occasionally it is lodged in the sub- mucous cellular tissue, and appears to be encysted. Louis, in his Essay on Calculous Concretions, previously alluded to, quotes an in- stance in which the parietes of the uterus were so completely ossified as to require to be broken with a hammer; the organ was of enormous size, and contained a considerable quantity of thick purulent matter. In another case, referred to by him, the internal surface of the womb was studded with numerous projections, of a yellowish color, and a firm, rock-like consistence, bearing a striking resemblance to stalac- tites. "I have seen a uterus," says Dr. Hooper,1 "the size of an adult head, irregular on its surface, and formed wholly of hard bony matter, surrounded by the expanded fibres of the organ, and in many parts covered only by the peritoneum." Such transformations are, however, extremely rare. They occur almost exclusively in females past the age of forty-five, and they appear to be produced by a perverted action of the uterine vessels, caused probably by chronic irritation. It would be interesting to ascertain, if this could be done, how far these deposits are connected with similar lesions of the arterial system. 13. Carcinoma.—The womb is often the subject of malignant disease, described by authors under the several denominations of scirrhus' fungus haematodes, cauliflower excrescence, corroding ulcer, and carci- noma. Scarcely any one of these appellations seems°to me'to be well chosen, as they have reference rather to certain states or appearances of the parts than to their true nature and constant anatomical charac- ters Not unfrequently all the conditions expressed by these terms are blended together, and, even when they exist separately, they have invariably the same tendency, namely, that of destroying the different textures of the uterus and the adjacent viscera. Malignant disease, be its nature what it may,'generally begins at the neck and lips of the organ, from which it gradually ascends to the other parts. So common is this mode of attack that it was once supposed to be invariable in its occurrence. Recent observations, however, ! Morbid Anatomy of the Hainan Uterus, p. 14. London 1832. CARCINOMA. 721 prove that there are numerous exceptions to this rule, and that in many cases the disease, instead of showing itself first in the parts just mentioned, commences at the base or body of the organ, thence spread- ing downwards so as to manifest itself last in its inferior extremity. The origin of cancer in the cavity of the organ is well shown in the adjoining sketch. Fig. 316. Incipient cancer beginning in the body of the uterus. From a specimen in my collection. The mouth of the womb in this affection usually becomes hard, thick, and irregular, the lips being everted, painful on pressure, and bleeding not unfrequently on the slightest touch. One, indeed, of the earliest symptoms is hemorrhage, not slight, but severe, long-continued, and recurring, with more or less frequency, throughout the whole progress of the malady. It is a symptom, therefore, of great diagnostic value, espe- cially in the inceptive stage of the complaint. After this state has continued for some time, ulceration takes place, a thin, sanious fluid, abundant in quantity and highly irritating in quality, oozes from the vagina, and all the textures of the affected part are completely de- stroyed. The base and body of the uterus, which are often much en- larged, also change their appearance; they become hard and firm, like fibro-cartilage, and are intersected by dense, grayish filaments running in a radiating direction. In some instances, the organ, when cut, has a raw flesh-colored aspect, like a slice of fresh pork; this is called the lardaceous degeneration of the uterus. In other cases, it has a gelatin- ous structure; and, in a third variety, as the softening and ulceration proceed, it assumes the color and consistence of encephaloid. The an- nexed cut (Fig. 317) affords an excellent illustration of carcinoma of the uterus beginning at the mouth and neck of the organ, and gradu- ally extending upwards towards its body. The brain-like variety of the disease generally occurs in the form of soft, lobulated masses, the interior of which contains clots of fibril 46 722 UTERUS. varying in color and consistence according to the length of time they have been deposited. Their size seldom exceeds that of an orange, but sometimes they are as large as a foetal head, of an irregularly glo- Carcinoma of the uterus beginning at the mouth and neck of the organ. From a preparation in Professor Meigs's collection. bular figure, and of a dark brownish complexion, caused by the secre- tion of melanotic matter. In other cases, again, though these are rare, the internal structure is of a deep red color, and composed essentially of anastomosing vessels. As the disease progresses, various morbid growths spring from the ulcerated surface, and fill up the vagina. These at length fall off by sloughing, and are either speedily succeeded by others, or they leave a deep excavated sore, with hard, irregular edges. In this stage of the complaint, there are generally copious discharges from the vagina, consisting of a thin, corroding sanies, serum, pus, or sero-purulent matter. In many individuals such discharges are exceedingly fetid, and at once serve to point out the true nature of the lesion. Carcinoma of the uterus is most common about the decline of the menses, in married females that have borne children. In 409 cases of cancer of the uterus, examined by Madame Boivin and Professor Dug^s,1 the period of life was as follows:— Under twenty years of age ••.... 12 From twenty to thirty . . . . . . .83 From thirty to forty.......102 From forty to forty-five . . . . . . .106 From forty-five to fifty . . . . . . .95 From fifty to sixty ....... 7 From sixty to seventy •••.... 4 409 Thus it would seem that nearly as many patients die between the ages of forty and fifty as in all the other periods of life conjoined. 1 Practical Treatise on Diseases of the Uterns, translated by Heming, p. 231. TUBERCLES — LACERATION. 723 Before the twentieth, and after the fiftieth year, the disease is very infrequent; owing, doubtless, to the want of activity of the uterine organs. The period at which carcinoma of the uterus proves fatal varies in different cases and under different circumstances. Of 120 cases, re- ported by Dr. J. C. W. Lever, of London, 107 died at an average period of twenty months and a quarter from the invasion of the malady. The shortest duration was three months, the longest five years and a half. Marriage and the previous state of the health did not appear to have exercised any particular influence upon the progress of the disease. 14. Tubercles—Tubercular matter, such as we find in the lungs, seldom occurs in the uterus, and then perhaps never before the age of puberty. It is usually deposited upon the inner surface of the organ, which is sometimes entirely incrusted with it, forming a layer a line or more in thickness. In some instances, though this is rare, the matter is deposited into the substance of the womb, or into the cellular texture between it and the peritoneum. 15. Laceration.—The uterus, like other hollow viscera, as the heart, stomach, and urinary bladder, is liable to laceration, both in the unim- pregnated and in the gravid state. The causes which predispose to this accident are wounds, such as are made in the Cesarean section, softening of the uterine tissue, irregular contractions, and various or- ganic degenerations, which, although they may increase the thickness of the parietes of the womb, render them more brittle, and thus diminish their power of resistance. The rupture, which may be partial or com- plete, transverse, oblique, or longitudinal, is most frequent during parturition, within twelve or fifteen hours after the commencement of labor, and most frequently affects the body, neck, and lower segment of the organ; very rarely the fundus or upper part. Of 230 cases of this lesion, related by Dr. Nevermann, 62 occurred during pregnancy, and 168 during labor. " Of the latter, eighty affected the body of the uterus, nine running in a transverse direction, and sixty-eight longitudinally, and extending backwards and to one side: in three cases the fundus was perforated partly by the feet of the child, partly by previous ulceration, and in one instance only the fundus was rent. In thirty-six cases the neck was torn longitudinally, and in fifteen transversely. In four cases the uterus was torn away from the vagina, and in twenty there was merely a small perforation of the body or neck. In the other cases the seat of the rupture is not mentioned." " The rupture does not always extend through the whole of the substance of the uterus. In four cases the peritoneum only was torn, and in five cases the uterus was torn and the peritoneum uninjured; and, in all these apparently slight cases, death ensued. The size of the lacerations varies much; some have been seen only a quarter or half an inch in length, others nine inches long, or even involving two thirds of the uterus. Sometimes the rupture is merely a small, round hole, through which fatal hemorrhage takes place." Fig. 318 is a lace- ration of the fundus of the uterus. The laceration, as just stated, is 724 UTERUS. sometimes limited to the peritoneal investment of the uterus, extending in an oblique, horizontal, or diagonal direction. It is most common at the postero-inferior surface of the organ, at the part which corresponds Laceration of the womb. From a specimen in the University of Louisville. with the promontory of the sacrum, and is apparently caused by the force in which the child, in the act of parturition, is impelled against this portion of the womb. All obstetricians bear witness to the rarity of this accident in first labors. Of 83 cases recorded by Collins, Eobertson, and McKeever, 10 only occurred under these circumstances. Dr. Nevermann finds, on a comparison of 406,081 labors, that the uterus was ruptured 85 times, or in the proportion of 1 to 4,777. 16. Hemorrhage.—Of hemorrhage of the uterus I shall speak only as it affects the organ in the unimpregnated state. Contemplated under this restriction, the occurrence is most common in married females, about the cessation of the menstrual function, and is observed in every state of constitution, in the strong and plethoric, as well as in the feeble and relaxed. A great variety of causes may give rise to uterine hemorrhage; but the most frequent by far is that peculiar state of the system which accompanies the disappearance of the menses, together with ulceration of the mouth of the womb, or the presence of some adventitious growth. Disease of the ovary also powerfully predisposes to this lesion; and there are some females who are naturally, or from habit, so prone to it that the most trifling exer- tion is sufficient to bring on an attack. The duration of the hemor- rhage varies from a few days to several weeks. When dependent upon structural disease, or the presence of a polypous tumor, the blood often comes away suddenly, in a gush, which continues, at intervals, for a few hours, and then ceases. The effused blood is generally of a dark red color, and comes away in coagulated masses, though occasionally, especially when the hemor- rhage is sudden and profuse, it is of a fluid consistence, as well as DROPSY — GAS—HAIR — HYDATIDS. 725 of a lighter tint. With regard to its quantity, it may vary from a few ounces to several quarts; and, although it is generally greatest when it proceeds from a ruptured vessel, it is often not less abundant when it has its source in exhalation of the mucous membrane. On dissection, we find the surface of the womb either of a uniform red color, or mottled with blackish spots, soft and corrugated, with here and there a submucous ecchymosis. The whole organ is commonly somewhat relaxed, and, on cutting through its substance, small clots of blood are occasionally observed, resembling apoplectic effusions of the brain. 17. Dropsy.—Large quantities of water—ten, fifteen, and even twenty quarts—have been known to accumulate in the cavity of the womb. The affection, however, is extremely rare, and is always connected with closure of the mouth of the organ, caused by previous inflammation, malignant disease, or some morbid growth. The fluid is generally clear and limpid like the serum of the blood, which it also resembles in its chemical properties. In some cases it is thick and turbid; it has also been .found of the color and consistence of coffee-grounds, from the admixture, probably, of sanguineous matter. The tumors thus formed often simulate pregnancy, are painful on pressure, and slightly fluctuate under the fingers. The disease, which is technically called hygrometra, is occasionally connected with utero-gestation, of which it forms one of the most distressing complications. Its true pathology is still involved in obscurity. In all probability it is de- pendent upon chronic inflammation of the lining membrane of the womb. 18. Collections of Gas.—Air now and then collects within the cavity of this viscus, constituting the disease which has been described by pathologists under the name of emphysema, physometra, and tympa- nites. How this is formed is still a litigated point. In many cases, it can be traced to the decomposition of effused fluids, as blood, serum, or pus; in others, it is not unlikely that it is the product of a true secretion from the uterine vessels, brought about by some morbid con- dition, the precise nature of which is unknown. These accumulations may take place at any period of life, in the married and single, the young and old. When considerable, they cause the womb to expand and rise up in the abdomen, as in pregnancy, with which it may be easily confounded. After the flatus has existed for several months, the uterus commonly makes an effort to dislodge it, expelling it with a noise somewhat similar to what is occasioned in eructation. 19. Hair.—The uterus has been known to contain hair, either by itself, or in union with other substances, as water, fat, decomposed skin, or pieces of bone. The subjects of this occurrence have always been married females, who were delivered some time previously of a dead child, from which the hair is doubtless derived, as it is impossible to conceive of such a formation independently of the process of im- pregnation. Hysterical women have been known to introduce hair into the vagina to excite the curiosity of their friends. 20. Hydatids.—We sometimes find hydatids in the uterus, though not so frequently as as has been generally imagined. The number 726 UTERUS. Fig. 319. of these bodies is often immense. In a specimen in my collection, notwithstanding a great many were lost during the delivery, there are at least ten thousand, of all sizes between an almond and a mus- tard-seed (Fig. 319). In their shape, these ,bodies are either globular, pear- like, or conoidal; and they are usually strung together by an intricate plexus of pedicles, which ramify in every di- rection, and are frequently not thicker than a common sewing-thread. The length of these stems varies from a few lines or less to several inches ; they are of an irregularly cylindrical figure, and from two to six are occasionally attached to the same vesicle; their strength is always very slight, so that they break with great ease; and many of them, though not all, are distinctly tubulated, being inflatable from the hydatids with which they are associated. The canal, however, does not generally extend through the whole length of the foot- stalk, but only a comparatively short distance; seldom, indeed, more than six lines or an inch. The larger hydatids have generally smaller ones attached to different parts of their surface, an arrangement not unlike what is observed in some tu- berous roots. From five to ten, not bigger than a grain of barley, are often seen sprouting out in this way, their connection with the parent parasite be- ing effected by means of a narrow, deli- cate stem, scarcely half a line in length. But, whatever may be their size or form, they all adhere, directly or indirectly, to one common stalk, exactly like a bunch of grapes, and which consists either of a portion of degenerated placenta, a fibrinous concretion, somewhat similar to an ordinary mole, a blighted ovum, or the remnants of the foetal en- velops. These are, I conceive, highly important circumstances in the history of these singular productions, inasmuch as they fully confirm the opinion, so warmly advocated by many writers, but so strenuously denied by others, that hydatids are never found except as the result of impregnation. When carefully examined, each vesicle is found to have three dis- tinct coverings, which may generally be separated without much diffi- culty with the knife, care being taken to hold the morbid growth under water during the dissection. The external tunic is extremely delicate, almost like a film, and of a pale cineritious color, which becomes more Hydatids of the uterus. From a prepara- tion in my collection. HYDATIDS. 727 perceptible when it is detached from the subjacent layer; it is easily lacerated, semi-transparent, and may be considered as a sort of decidu- ous membrane. The second lamella, on the contrary, is comparatively thick, firm, dense, and resisting; it has a whitish appearance, possesses the property, in some respects, of a fibrous texture, and serves at once to give shape and consistence to the vesicle which it assists in forming. Within the two coverings now described lies the hydatid, properly so called, which is generally so weak as to break under the pressure of the atmosphere, and which appears to consist merely of a thin, lymph- like sac, filled with serous fluid. In the recent state, this lamella is perfectly smooth and transparent; but, by immersion in alcohol, it speedily becomes opaque and corrugated. In most cases the parasite lies loosely within its envelops, but occasionally, especially when the vesicles are old or of large size, there is a pretty strong adhesion, by means of thread-like filaments, between them. Its contents are clear and limpid, like the purest spring water, slightly saline to the taste, and partially coagulable by heat, alcohol, and dilute acid. It has been already seen that the number of these bodies is some- times extremely great. By their agglomeration large masses are formed, the weight of which has been known to exceed ten pounds. These masses are generally expelled piecemeal, and they are rarely, if ever, enveloped by distinct foetal membranes, unless there are at the same time remnants of- a blighted ovum. The period of hydatic gestation, as might be supposed, is extremely variable. The following table, which I have compiled from Madame Boivin and other writers, gives an accurate view of the duration of this disease in forty-four cases, including five that have been commu- nicated to me by medical friends:— Duration of the disease. Number of cases. 3 months ........ 4 4 « ........3 5 ".........3 6 ".........5 7 .......... 6 8 " .'........? 9 ".........™ 10 ".........6 11 ".........1 13 14 44 From this table it appears that the number of hydatic births, if so they may be styled, is, within a fraction, twice as great after the sixth month as anterior to that period. Delivery never occurs, so far as my knowledge extends, before the expiration of the third month. The mean duration of this species of pregnancy, calculated from the above cases, is a little more than seven months, provided we receive as correct—which I am disposed to think we should not—the ex- amples of Baudelocque, Vernois, and others, where the female is said to have carried the morbid product more than a year. 728 UTERUS. It has been supposed that hydatids of the uterus are most common in women about the decline of the menses; but this opinion is evidently grounded upon superficial observation. Of thirty-one cases, in which the age is satisfactorily stated, I find that twelve occurred between the twentieth and thirtieth year: eight between the thirtieth and fortieth; and eleven between the fortieth and fiftieth, or rather between the fortieth and forty-sixth; for beyond this period I am not acquainted with a single well authenticated instance in which this degeneration was observed. The development of these parasites is generally, if not invariably, preceded by one or more normal gestations. In a case, the particu- lars of which were communicated to me by Dr. Dunlap, of Greenfield, Ohio, the woman, who was forty-six years old, and had always been in the enjoyment of excellent health, had given birth to eleven children. Occasionally these bodies form in several successive pregnancies; and in a few rare instances they have been observed in several members of the same family. The expulsion of the hydatids is almost constantly attended with more or less hemorrhage. To this statement, indeed, there are few exceptions. A discharge of blood frequently takes place at a very early period of gestation, and recurs at variable but generally short intervals, until the time of parturition. The quantity of blood lost is often so great as seriously to undermine the vital powers, or even destroy the patient. The expulsion of these bodies is always accom- panied by labor pains. As to the causes of these morbid growths, they are enveloped in complete mystery. It has been conjectured by many that they are occasionally an original production of the uterus; but there is no case on record, so far as I know, which warrants such a conclusion. In- deed, when we reflect upon the fact, already adverted to, that they always occur in association with mole-like concretions, the membranes of a blighted ovum, or some remains of the foetus itself, or finally, with portions of the placenta, in a state of degeneration, it must be conceded that they are invariably the result of impregnation. If this view be adopted, it follows, as a natural deduction, that the development of the new being is arrested and another action set up, under the in- fluence of which the bodies in question are created. What the nature of this action is, we cannot of course determine any more than that which presides over ordinary generation. 21. Moles.—The last subject to be discussed is that of uterine moles. _ Under this term authors have described different, and often very dissimilar products, which, after continuing for a variable period in the womb, are finally expelled with all the phenomena of ordinary labor. I shall divide uterine moles into two species, the fibrinous and the vascular. This arrangement, it will be perceived, altogether excludes uterine hydatids, which have been referred to this head by certain writers. •* The fibrinous mole (Figs. 320, 321, 322) is a much more interesting and intricate structure than we might be led to infer from the im- MOLES. 729 Fig. 320. Fig. 321. Exterior of a fibrinous mole. Mole cut open, showing its structure: o. Chorion ; b. Amnion. Fig. 322. perfect descriptions of it by authors. In its shape it is always, so far at least as reiterated inspection has enabled me to judge, more or less coni- cal, pyriform, or gourd-like; never, I believe, perfectly globular. Occasion- ally, though this is rare, it is somewhat lobulated or angular, either externally or upon the inner surface, or in both these situations at the same time. Its size and weight vary very much in in- dividual cases. In five specimens of this species of mole which I have examined with great care, the mean weight was a little more than one ounce, the maxi- mum two ounces, the minimum six drachms. The length, in the same cases, varied from two inches and a half to three inches and a quarter; the width, from one inch and a half to two inches and a quarter; and the thickness, from one inch and a half to two inches. The fibrinous mole, in the recent state, has very much the appear- ance of a mass of blood, being of a modena color, not uniformly, but darker in some places than in others. It is of a firm, solid consistence, requires a good deal of force to cut it, and emits a dull, creaking sound under the knife, like fibro-cartilage. The degree of induration, however, is not the same in all cases, or even in all parts of the same Mole with the cavity communicating externally. 730 UTERUS. specimen. When retained long, this species of mole sometimes par- tially degenerates into a hard, gristly substance, similar to certain transformations of the placenta. The adventitious product is invested by a grayish, fragile lamella, generally not more than the fourth of a line in thickness. It evidently serves to connect the mole to the inner surface of the uterus, and pos- sesses all the characters of the deciduous membrane. Not only does this lamella cover the exterior of this body, but it usually passes into the internal canal, which it thus lines throughout its whole extent. An instance has been recorded, where the mole was surrounded by an osseous covering, formed, doubtless, by a degeneration of the structure here described. On making a longitudinal section of this morbid growth, an internal cavity is found which is always remarkably small in proportion to the inclosing parietes. In most instances, it extends nearly from one ex- tremity to the other, at the larger of which, much more frequently than at the smaller, it has an external opening. To this law, which may be regarded as a very important one, I have met with only a single exception in a considerable number of specimens. To attempt to describe the shape of the internal canal would be idle, so much does it vary in different cases. Irregularity is its distinguishing character- istic. Very frequently it presents itself in the form of a fissure, which is sometimes cylindrical, sometimes angular. Equally irregular is the outlet of this canal; whilst in some instances it is small and tolerably well-defined, in others, and these are by far the most common, it is large, grooved, or slit-like. Occasionally it closely resembles ,the mouth of the unimpregnated uterus. But whatever may be the form and dimensions of the internal canal, or of its outlet, it is always lined by two short sacs, which, though intimately united, are perfectly separable by dissection, and which appear to correspond exactly to the natural envelops of the foetus. The outer layer is rough, flocculent, and loosely connected with the deciduous membrane, which, as was before stated, is always reflected into the mole when there is an open cavity; the inner, on the con- trary, is perfectly smooth and glossy, like the serous tissue in other parts of the body, and generally, though not always, contains a small quantity of transparent fluid, similar in every respect to the amniotic liquor. The parietes of the cavity just described are always exceedingly irregular, and vary in different parts of their extent from the twelfth of an inch to six or eight lines in thickness. They are composed principally, if not wholly, of the fibrin and coloring matter of the blood, cemented by plastic matter. On making a section of the mole in the direction of the long axis, the outer portion is observed to have an imperfectly lamellated arrangement, and also to be somewhat more compact than the internal parts, which are of a much darker complex- ion, homogeneous, much more friable, and almost entirely made up of coagulated blood. In some instances, the walls are essentially fibrous the fibres extending longitudinally from one extremity, or nearly so' to the other. Lying in close, parallel lines, they are very coarse easily MOLES. 731 torn, as well as easily separated from each other, and of a reddish-gray color, being darker at some portions than at others. These three varieties of structure are not unfrequently met with in the same tumor, the linear arrangement being seen at the apex, the lamellated at the external part of the body, and the uniform, homogeneous, or hematoid towards the centre. The cellular tissue entering into the composition of this variety of mole is usually very small in quantity, and is often so intimately in- corporated with the morbid mass as to be perceptible only after pro- tracted maceration. Its vessels, which are generally quite large, may be seen ramifying over its outer surface, running, for the most part, in the direction of its long axis. They enter the new product at various points, but none can be traced beyond the depth of a few lines: they are sometimes quite varicose, their parietes are remarkably brittle, and they have altogether much more of a venous than of an arterial cha- racter. The anastomoses which exist between these vascular trunks are commonly very imperfect; a circumstance which, with the delicacy of their structure, renders them exceedingly liable to congestion, rupture, and hemorrhage. The second species of mole may be called the vascidar (Fig. 323), in consideration of its structure, which, as the term imports, is essentially of that nature. It is much more rare than the preceding, but in what pro- portion it occurs we have no means to determine. In its shape, the vas- cular mole is generally globular, its diameter varying from one to four inches. Its weight, after the dis- charge of its contents, ranges from three drachms to one ounce, accord- ing to its dimensions, or the thick- ness of its parietes. In regard to its structure, this va- riety of mole may be said to bear a striking resemblance to the placenta. Like it, it appears to be essentially composed of bloodvessels, which freely anastomose with each other, and are bound together by delicate, cellular tissue, the whole forming a soft, spongy substance, the thick- ness of which rarely exceeds the sixth of an inch. In some instances, numerous intersecting filaments may be observed, which are either of a fibrous nature, or obliterated arterial and venous ramifications. The mole is covered by a thin, coriaceous lamella, which is much more delicate than in the fibrinous form; internally, it is furnished with two distinct membranes, one answering to the chorion, the other to the amnion. They are much more perfectly developed than in the preceding variety, as well as more easily separable from each other; and the latter always incloses a considerable quantity of watery fluid, occasionally, indeed, as much as three or four ounces. Such is a brief account of the two species of uterine moles. The 732 OVARIES. period during which they are retained in the womb is liable to some variation, but in the generality of cases it does not exceed three months. In a few instances I have known them to come away as early as the end of the tenth week, and on one occasion as late as tne middle term of normal gestation. Their expulsion is invariably accompanied with more or less hemorrhage, which is sometimes so profuse as to endanger life. The parturient efforts are usually very feeble, and often occupy from two to three days. The fibrinous mole has occasionally been observed in company with a healthy or diseased foetus; and I have a specimen of the vascular variety, in the interior of which are the remains of an umbilical cord. Like hydatids, these products may occur in several successive preg- nancies ; and they have been noticed at all periods, from the age of puberty to the decline of the menses. Their development is common- ly attended with the phenomena of ordinary gestation. It is supposed by many that these bodies are never formed except as a consequence of conception, an opinion which is in perfect ac- cordance with the result of my own observations. I speak now, of course, of what I consider to be the true genuine mole; that is, an organized body of a certain or determinate form and structure, having an internal cavity, either closed or open, and lined by two distinct mem- branes of the character here ascribed to them. Such a product, no matter whether it be fibrinous or vascular, I do not hesitate to say, on the authority of personal experience, is never developed in the virgin uterus. I have never seen an example of what some have called a spurious mole—a dense, compact, and amorphous mass, composed essen- tially of clotted blood—but such a substance might form, there is reason to believe, in females during the period which intervenes be- tween the establishment and the decline of the menses, without inter- course or the stimulus of conception, simply from the effusion and retention of a small quantity of organizable blood. Of the causes of the true mole we have no definite knowledge. We may suppose, however, in the absence of positive facts, that the uterus, instead of providiug for the growth and nourishment of the new beino-, as nature has designed it should, takes on inflammatory irritation, which is followed by the destruction of the germ, the effusion of blood, and the formation of an abnormal structure, which, as we have already seen, is sooner or later detached and expelled. SECTION II OVARIES. The ovaries are two small oblong bodies of a light grayish color and of the volume nearly of a common almond. With regard to their weight, much diversity obtains in the different periods of life as well in the single as in the married state. In eight young females INFLAMMATION 733 who died between the ages of seventeen and twenty-three, and in whom, from their previous health and moral habits, there was every reason to believe that the ovaries were perfectly natural, I found the mean weight to be one drachm and a quarter, the maximum one drachm two scruples and a half, and the minimum fifty-six grains. With respect to their dimensions, the mean length of the organs, measured in the same subjects, was seventeen lines, the breadth nine lines, and the thickness four lines and a half. In women who have borne children, the ovaries are generally about half a drachm heavier, and they are also broader and thicker, but seldom any longer. Their volume is always disproportionably great in early childhood; but from the eighth to the twelfth year they undergo little change in this respect; from this period on, however, they gradually augment in size, until puberty, when they attain their full development. The ovaries are subject to inflammation, suppuration, softening, tubercles, melanosis, scirrhus, encephaloid, fibrous growths, and serous cysts. Few of these affections occur before puberty, and they are much more common, as a general rule, in the married than in the single. 1. Inflammation.—The anatomical characters of acute ovaritis are increased vascularity, softening, and sero-purulent effusion. In vio- lent attacks, the organ is of a deep red color, much swelled, and gorged with blood. On cutting into the parenchymatous structure, it will be found succulent, and pervaded by globules of pus, or converted into a pulpy, disorganized mass. When the disease affects the albugineous and serous coverings, lymph is apt to be poured out, sometimes in great quantities, by which the ovary is embedded, and firmly attached to the adjoining viscera. In such cases the gland is liable to be per- manently fixed to the sigmoid flexure of the colon, the bladder, the body of the womb, and even the fimbriated extremity of the Fallo- pian tube. Ovaritis, especially the puerperal variety, sometimes passes into suppuration. The matter is commonly of a thick cream-like consist- ence, such as occurs in phlegmonous abscess, and it may be either infiltrated into the parenchymatous structure of the organ, or collected at one or more points. The quantity of fluid, though usually small, is sometimes almost incredible. In a case of chronic ovaritis, observed by Dr. Taylor, of this city, it amounted to sixteen quarts. The right ovary occupied the whole of the abdominal cavity, and was converted into a large vascular sac, weighing seventeen pounds after the removal of its contents. The matter thus formed may escape into the pelvic cavity, the rectum, vagina, or urinary bladder. In some cases it finds its way into the bowels; and occasionally it has been known to travel along the course of the round ligament of the uterus, down through the inguinal ring. Softening of the ovary is uncommon. It generally results from active inflammation, and occasionally coexists with puerperal perito- nitis. Under the influence of this disease, the organ becomes tumid, infiltrated with sero-purulent matter, extremely soft, and lacerable. In some instances, the entire structure of the ovary is reduced to a 734 OVARIES. dark-colored vascular pulp, in which it is impossible to perceive the slightest trace of its natural organization. In other cases, again, the organ is of a dark complexion, hard and friable, like a half-rotten pear. 2. Heterologous Formations.—The ovary is liable to the heteroclite formations, especially the encephaloid, the rest being comparatively infrequent. Tubercles of the ovary are met with chiefly in scrofulous females, after the decline of the menses. Louis found them in one-twentieth of his phthisical subjects. The most common form in which the heteroclite deposit occurs is the miliary, but it may also exhibit itself as an infiltration. Melanosis of the ovary is extremely rare, and perhaps never exists without similar disease in other organs. Scirrhus is more common, though, on the whole, it is a very rare affection. The new formation may occur by itself, constituting a hard, dense mass as large as a fist or even a child's head, of an irregular globular shape, of a whitish, grayish, or drab-colored aspect, and intersected by a great number of membranous filaments. The disease is most liable to show itself about the decline of the menses, and occasionally coexists with other morbid growths. The most common of the heterologous formations of this body is the encephaloid, which sometimes runs its course with frightful rapidity. It may occur at any period of life, soon after the appearance of the menses, and it seems, in some instances, to be called into activity by the process of impregnation. Generally the brain-like matter, which distinguishes this disease, is found in small, irregular masses, inclosed in distinct cysts, of a fibrous texture. These masses sometimes attain a very great magnitude. They are usually of different shades of color, being of a pale olive, brownish, or mahogany in some places, white, cream-like, or grayish in others. Branches of vessels may often be traced, in great numbers, into their structure; and not unfrequently they contain large cysts, filled with serum, pus, or sanious fluid. Colloid of the ovary may occur alone, or it may coexist with other morbid products, particularly the fibrous and encephaloid; it is capa- ble of attaining a large bulk, and exhibits the same structure as in other parts of the body. 3. Fibrous Tumors.—Fibrous tumors, similar in their texture to those of the uterus, are liable to form in the ovary. Varying in size between a hazel-nut and an orange, they are of a grayish color firm consistence, and usually attached by a long, narrow footstalk. Occa- sionally these tumors coexist with scirrhus, encephaloid, or serous cysts; and it is not uncommon to find in them small, irregular cavi ties, filled with a thick, dirty-looking fluid. Sometimes they are in- terspersed with cartilaginous, osseous, or earthy concretions These formations are particularly liable to occur in cases of long standing where the fibrous substance is occasionally almost wholly replaced bv them. Under such circumstances, indeed, large quantities of earthv matter may be deposited, weighing many pounds, of a whitish or Dale yellowish aspect, and so hard as to be divisible only with the saw SEROUS CYSTS. 735 The transformation is not always confined to the proper substance of the ovary, but may extend to its fibrous envelop, supplanting every vestige of the normal structure. 4. Serous Cysts.—There are probably no organs in the human body in which serous cysts are more frequently developed than in the ovaries. Assuming every variety of shape, they are most generally globular, ovoidal, or pyriform, and vary in size from the smallest nut to the magnitude of a large melon. Sometimes the whole ovary is converted into one enormous sac; at other times the cysts seem to be gregarious, or united into clusters, having no communication with each other. Occasionally the sac is multilocular, or divided into dis- tinct compartments. The annexed cut (Fig. 324) represents an ovarian cyst of large Fig. 324. Ovarian cyst. From a preparation in my cabinet. size. The uterus is seen to retain its natural form and volume. Attached to its left horn, at the origin of the Fallopian tube, is a small globular cyst, adherent by a short slender pedicle, and entirely uncon- nected with the ovary on that side. The contents of these cysts vary in color and consistence in different cases. In some, the fluid is thin, pale, and ropy ; in others, thick, and dark-colored, like coffee-grounds; in others, purulent, sero-purulent, sanious, meliceric, saponaceous, tar-like, greasy, or suety. The chemical constitution of the watery contents of these tumors varies in different cases, and even in different portions of the same sac, especially when it is of a multilocular nature. In general, it con- sists mainly of water, in combination with albumen and the earthy salts, along with a trace of fatty matter. In the multilocular form of ovarian dropsy it often happens that each cyst is filled with a peculiar product, aqueous or gelatinous, sanguineous, fatty, or even chalky. These substances are liable to become decomposed, when they exhale a putrid odor, and give rise to different kinds of gases. . . The brownish, turbid, or coffee-grounds-looking fluid, contained in 736 OVARIES. certain ovarian cysts, probably derives its color from the admix ur of blood, poured out by the vessels which are distributed through tne parietes of the main sac, or the internal septiform processes, and pro- bably undergoing a species of decomposition by long sojourn in tne tumor. Fontenelle ascertained that it is composed chiefly of albumen, with some fibrin, a concrete jelly, and earthy salts. In a woman, thirty-five years of age, whom I tapped twelve years ago, the fluid, amounting to between four and five gallons, was of the color and con- sistence of thin molasses. Ovarian cysts, especially the simple variety, are sometimes nearly entirely occupied by a yellow, granular substance, not unlike butter. The quantity varies from a few ounces to several pounds. This mat- ter has been analyzed by Dr. Bird,1 of London, who finds 100 parts to contain the following ingredients:— Butyrine, with butyric acid Elaine, with traces of margarine Margarine Fibrous mass Water 38- 24- 2-5 8-5 100 The quantity of fluid varies from a few ounces to many quarts. The largest quantity I have ever drawn off at one time was nine gal- lons and three-quarters. In a case reported by Dr. Hintze, of Balti- more, the cyst contained upwards of twenty-three gallons. It was nearly spherical in its shape, communicated with the urinary bladder and inferior portion of the colon, and was of a thick, compact, fibrous structure. Mead tapped a patient sixty-seven times in five years and a half, evacuating altogether two hundred and forty gallons of fluid. In the celebrated case of Martineau, paracentesis was performed eighty times in twenty-five years, and the entire quantity of water removed was eight hundred and twenty-eight gallons, three quarts, and one pint. The largest amount of fluid lost at one operation was fifty-four quarts. Thirty-nine quarts were evacuated after death, which occur- red three weeks after the last tapping. The whole of this enormous quantity of water was secreted by the left ovary, which was expanded into one vast sac, extensively ossified, and not very thick. Thus an ovary which, in the normal state, scarcely weighs two drachms, will expand, under disease, to a magnitude capable of hold- ing an immense amount of fluid. Externally, the sac is commonly smooth and polished; internally, it is rough and irregular, frequently sending off little septiform processes. In some instances it has a dense, cartilaginous feel; and occasionally it has been found partially ossified. These sacs, it may now be observed, constitute what is termed encysted dropsy of the ovary, and there is reason to believe that they often, if not generally, arise from a diseased state of the Graafian vesicles. The causes of ovarian dropsy are not understood. The disease is most common in married females, but is occasionally observed in old 1 London Lancet, for 1S42-3, p. 30, N. York edition. HYDATIDS — ATROPHY. 737 maids, and in young girls soon after the age of puberty. Its progress is usually tardy. Finally, ovarian tumors have been known to contain teeth (Fig. 325), Fig. 325. Fig. 326. Hair from an ovarian tumor. Teeth and pieces of jaw-bone. bones, cartilages, and hairs (Fig. 326), either inclosed in distinct cysts, or wrapped up in a peculiar saponaceous, fatty, or suety substance. The hairs are sometimes furnished with well-formed bulbs, and, like those of the head, to which they bear the greatest resem- blance in other respects, they exhibit every variety of color. These differ- ent products, which have occasionally been observed at a very early age, are doubtless always the result of concep- tion, the embryo beingdeveloped in the ovary instead of the uterus. When they occur in the young, immature female, without conception, their pre- sence can be accounted for only by the theory of monstrosity by inclusion. 5. Hydatids.—Hydatids are occasionally found in the ovaries. They vary in number from ten or a dozen to several hundred, and in volume between a pea and a hen's egg. Some adhere to the inner surface of the sac by narrow, slender necks; others are loose, and float about in the effused fluid, the quantity of which is often very great. They are generally, if not invariably, of the acephalocystic kind. 6. Atrophy.—Atrophy of the ovary is frequently observed in old females, after the cessation of the menses. The period for the exercise of the reproductive function being passed, the organ is no longer needed, and it accordingly, in many cases, greatly decreases in volume; the interior structure is dry, dense, and almost crisp, and the serous and fibrous envelops are remarkably rough and puckered. Similar phenomena are sometimes witnessed in women who are habitually barren. One of the ovaries is sometimes wanting, in which case the other is almost always considerably enlarged. I have met with several in- stances of this kind. Occasionally both organs remain in a rudi- mentary state, being scarcely as large as a bean, and of a dense, fibro- cartilaginous consistence. In such cases, of which a number have ^47 738 OVARIES. falleti under my observation, there is frequently an entire absence of the vesicles of De Graaf. „ 7. Hemorrhage.—-The ovary is sometimes, though rarely, the seat ot hemorrhage. This may occur in three distinct situations: 1, in the parenchymatous structure; 2, in the ovules of De Graaf; 3, imm ®' diately beneath the fibrous envelop. The blood is generally collected into irregularly rounded masses, varying from the size of a currant to that of a garden pea. It is either of a dark red color or almost black; coagulated, or partly fluid and partly solid. Ovarian hemorrhage is most common in young plethoric females, and usually occurs in combination with a highly congested state of the uterus, the Fallopian tubes, and broad ligaments. 8. Luteal Bodies.—In the ovaries of a woman who has recently been pregnant, we may observe, in addition to the ovules of De Graaf, a tender, friable, vascular structure, generally of an oval shape, but sometimes circular, somewhat convex on its surface, like the crystal- line lens, and, when fully developed, from four to six lines long, from three to four lines broad, and from one and a half to two lines and a half thick. This is called the luteal body, corpus luteum, or yellow body. Its color varies, however, according to the period at which it is examined. When quite young it is more or less red; by degrees, it assumes a dull yellowish aspect; after parturition, and sometimes even before, it becomes gradually more and more pale, and at length it loses its characteristic hue altogether. Its yellow color depends upon the presence of oil. The structure of the luteal body is found, when examined with a magnifying glass, to be convoluted, like that of the human brain, or glandular, like a section of the human kidney. It has a distinct, plicated wall. It is originally quite vascular, being surrounded by a large plexus of arteries and veins, branches of which penetrate it in every direction, and can be easily filled with injecting matter. As it grows older, however, its vessels gradually shrink, its structure be- comes more dense and firm, and, in time, it entirely disappears. The manner in which this body is formed admits of easy explanation. In the first place, there is a rupture of one of the larger vesicles of De Graaf, which are always situated superficially, and frequently from two to three lines in diameter. This rupture, being effected under sexual stimulus, is followed by an escape of the contents of the cyst, leaving thus a cavity which is immediately, or almost immediately, filled up with blood and lymph. This matter gradually acquires solidity, and receiving vessels from the surrounding parts, soon becomes an organ- ized structure, capable, for awhile, of withstanding the action of°the absorbents of the ovary. Ultimately, however, as already stated it yields to their influence, and entirely disappears, the process of decay beginning a short time prior to the close of pregnancy. At what period it completely vanishes is still a mooted question; but it mav be stated, as a general rule, to be from the fifth to the seventh month Ihe cicatrice which accompanies the formation of the luteal body differs essentially from this body itself, and owes its existence alto gether to the rupture of the vesicle of De Graaf, and of the overlyin* LUTEAL BODIES. 739 serous and fibrous envelops of the ovary. As the process of repair proceeds, the ragged and tattered edges of the oval or circular hollow, left by the escape of the contents of the cyst, are gathered in by the plastic matter which now occupies their place, the two becoming in time firmly and inseparably united, so as to leave merely a linear, radiated, or stellar depression. Ultimately, indeed, the parts are often so effectually rebuilt, if I may use the expression, as to render it im- possible to determine where the rupture occurred. The body now described should not be mistaken for the corpus luteum of menstruation, or ordinary sexual excitement. The discrimi- nation is of the highest importance in a juridical point of view, obser- vation having verified the fact that the former of these structures is always the result of pregnancy, whereas the latter sustains no such relations. The points of distinction have been well traced by Pro- fessor Dalton, of New York, in bis admirable " Prize Essay on the Corpus Luteum of Menstruation and Pregnancy," published in the fourth volume of the Transactions of the American Medical Association. I shall give his conclusions in his own language:— "The corpus luteum of pregnancy, then, differs from that which is merely the result of menstruation in several important particulars. "I. It arrives more slowly at its maximum of development, and afterward remains for a long time as a very noticeable tumor, instead of undergoing a process of rapid atrophy. " II. It retains a globular, or only slightly flattened form, and gives to the touch a sense of considerable resistance and solidity. " III. Internally, it has an appearance of advanced organization, which is wanting in the corpus luteum of menstruation. "IV. Its convoluted wall, particularly, attains a greater develop- ment, this portion measuring sometimes so much as three-sixteenths to one-fourth of an inch in thickness, while in the corpus luteum of menstruation it never exceeds one-eighth, and is almost always less than that. This difference in the thickness of the convoluted wall is one of the most important points of distinction. It will be much more striking when viewed relatively to the size of the central coagulum. " V. The color is not, by any means, so decided a yellow, but a more dusky and indefinite hue. " VI. If the period of pregnancy is at all advanced, it is not found, like the corpus luteum of menstruation, in company with unruptured vesicles in active process of development." The annexed cuts, taken from Professor Dalton's paper, convey a correct idea of the appearances of these two bodies. Fig. 327 exhibits the corpus luteum of menstruation about two weeks old; and Fig. 328, the corpus luteum of pregnancy at the end of the ninth month. Finally, it should be observed that the accompanying cicatrice, like the yellow body itself, is gradually effaced, generally within the first year after delivery, sometimes, indeed, several months sooner, but at other times, not until considerably later. Taken by itself, it affords no evidence of previous conception, inasmuch as it is impossible to distin- guish it from a cicatrice produced by the discharge of an abscess, a tubercular excavation, or a sanguineous effusion. The opinion, there- 740 FALLOPIAN TUBES. fore, that the scars remain for life, and exactly indicate the number of births, is erroneous. Fig. 327. Fig- 328- 9. Graafian Vesicles.—The Graafian vesicles are liable to morbid alterations. The fluid which they contain is often red, brownish, or even black, from the admixture probably of blood. Occasionally they are filled with purulent matter; they have been found perfectly dry and empty; they are sometimes absent as a congenital defect; and instances occur in which they are converted into cartilage and even bone. SECTION III. FALLOPIAN TUBES. The Fallopian tubes are liable to attacks of acute and chronic in- flammation,both in the virgin and in the gravid state. These diseases may be propagated to them from the uterus, or they may have an independent origin; they may be limited to one tube, or even to a part of that tube, or they may involve both ducts simultaneously. Inflammation is most apt to be present in dysmenorrhcea and puer- peral peritonitis, when the tubes are extremely vascular, and of a deep red color; and, in severe cases, they are closed up, either partially or entirely, with coagulating lymph, or distended with purulent matter In a case mentioned to me by the late Professor Harrison, of Cincin- nati, the left tube contained at least an ounce of thick laudable pus the right about three drachms; the mouth of the uterus was red and tumid, and the whole of its inner surface bathed with purulent matter When the accumulation is very great, the tube occasionally bursts' and the matter escapes into the pelvic cavity; at other times it dis- charges its contents through the rectum, the small intestines, the uri- nary bladder, or the uterus. ' In some instances, these tubes terminate in a cul-de-sac; and cases are witnessed in which their fringes are destroyed by ulceration or by adhesion to the ovaries and other organs. Thei/eanals^ are also FALLOPIAN TUBES. 741 sometimes obstructed by inspissated mucus, lymph, and scrofulous matter. In a young girl of ill-fame, whose case was communicated to me by Professor Harrison, the Fallopian tubes were very greatly dilated, and contained a thick, cheese-like deposit; to the outer surface of each were appended two small tumors, filled with a similar substance. Fibrous tumors sometimes grow from, sometimes within, the Fallo- pian tubes. They are usually of a rounded shape, very hard, and of the same appearance as fibrous tumors of the womb. Malignant dis- ease occasionally invades these passages, commencing in them either as an original affection, or extending to them from the uterus or ovaries. The true hydatid has never, I believe, been found here; but very often small cysts, filled with a thin, limpid fluid, are seen hanging from the fimbriated extremities of these tubes, and that some- times in women who have never borne children. Their size varies from that of a currant to that of a walnut, an orange, or even a small gourd. Fig. 329. Dropsy of the Fallopian tube. Dropsical accumulations are sometimes seen in the Fallopian tube. (Fig. 329.) The usual quantity is from one to two ounces; but 742 VAGINA. occasionally it amounts to many pints. In such cases, the tube com- monly assumes a pyriform shape, and greatly augments in thickness; a condition absolutely necessary to prevent its rupture. De Haen relates an instance in which the tube, weighing seven pounds, con- tained nearly four gallons of fluid; and a still more extraordinary one has been detailed by Madame Boivin. When the ovum is retained in the Fallopian tube, as occasionally happens, it generally grows until the third, fourth, or fifth month of gestation, and then makes its escape. In some instances, the escape is preceded by ulceration; but more commonly there is a rupture of the tube, its attenuated walls being incapable of further distension. Fatal hemorrhage almost always follows this accident. A very instructive case of this species of pregnancy was communicated to me some years ago by my friend, Yl„ 330. Dr. Kennedy, of Easton, Pennsylvania. In this case, the tube was ruptured in consequence of a blow on the abdomen, and the wo- man gradually sunk under the hemorrhage, having been pregnant about seven months. The annexed sketch (Fig. 330) repre- sents the foetus as occupy- ing the tube. SECTION IV. VAGINA, VULVA, AND URETHRA. I. Vagina— The vagina is liable to ordinary and specific inflamma- tion The disease is marked by the usual anatomical characters and is often attended with profuse discharges of purulent matter, of a'verv acrid nature, and mixed at times with blood. In bad cases abscesses are formed in the submucous cellular texture; and instances are witnessed where the parts are rapidly destroyed by gangrene A coating of adventitious membrane is sometimes observed, especially when the inflammation is connected with disease of the mouth and neck of the uterus. Ulcers of the vagina are generally referable to the syphilitic, cancerous, or scrofulous poison, and do not differ from the same class of sores in other regions of the body. There is a form of inflammation of the vulva wtaVh ™™.- • different periods of life, but especially in mStad "fornSTJ U principal seat in the mucous crypts. The disease usuallT hows itself in small patches, of a red, almost scarlet complexion ,tnddJI I minute points, which are slightly elevated aW th. J leyel, and perfectly distinct ^U^th^^JS POLYPES 743 points increase in volume, and ultimately coalesce, so as to impart to the surface a rough, granulated appearance. At this stage, and, in- deed, often before the morbid action has reached this point, some of the glands become ulcerated, the sore looking, at first, like a mere speck, but gradually growing larger and larger until it has acquired the size of a split currant or small pea, its edges being steep, ragged, and, perhaps, partially undermined. The affection is, in every respect, analogous to follicular ulceration of the bowel. These crypts are liable to chronic inflammation, attended with hypertrophy. When thus affected, they present the Fis- 331- appearance of little vesi- cles, charged with a thick mucous fluid, not unlike the white of eggs, or the contents of the enlarged follicles which we some- times see upon the lips of the uterus. These ap- pearances are well illus- trated in the accompany- ing cut (Fig. 331) from M. Huguier, who has pub- lished an excellent ac- count of the disease in the fifteenth volume of the Mem. de VAcad, de Chirurgie. A cystic tumor is some- times observed in this tube, consisting in a mor- bid enlargement of one of the mucous follicles. I once saw a swelling of this kind immediately beneath the orifice of the urethra of a young lady, the mother of four children. It was of a spherical shape, about the size of a walnut, and of a white, glossy appearance, with a rough, corrugated surface. It had been there for eight years. I opened the tumor with a lancet, and let out a considerable quantity of a viscid, glairy fluid, like the white of eggs. The fluid never reaccumulated. Polypes are occasionally, though rarely, developed in the walls of the vagina. Tumors of this description may attain a very considera- ble magnitude, so as not only to distend the whole tube, but project some distance down the thighs. Their weight has been known to exceed ten pounds. The vagina is sometimes covered with varicose veins, seated chiefly in the submucous cellular substance. They are spread out in an irre- gularly arborescent manner, and may be many times the natural size. The coats of the vessels may be entirely healthy, but more frequently they are diseased, being attenuated at one point, and thickened at another. In some cases the lining membrane becomes inflamed, 744 VAGINA. causing coagulation of the blood, and the formation of pus. During parturition the enlarged veins have been known to be ruptured by the pressure of the child's head, inducing copious hemorrhage^ Prolapse of the vagina is most common after middle age, m mar- ried females who have borne children, and who have long suffered under a relaxed condition Fig. 332. of the genito-urinary appa- ratus. The disorder may be limited to the anterior or posterior wall of the tube, or it may embrace its entire circumference. In the latter case, the vagina forms a large tumor, soft, elastic, and of a red, bluish, or lead color, passing beyond the vulva, and hanging down between the thighs, as in the annexed sketch (Fig. 332). In pro- lapse of the anterior wali, there is generally a descent of the bladder, which exhibits itself as a globular or ovoidal swelling at the upper part of the vulva, and which may be greatly reduced in size, if not entirely effaced, by catheterism. Occlusion of the vagina is liable to occur from inflammation, and the consequent effusion of fibrin into the submucous cellular tissue. In this way, not only the orifice, but the greater part of the tube, may be much diminished in size, either uniformly, or, as more frequently happens, at particular points. The stricture, though generally partial, occasionally completely encircles the vagina, presenting an appear- ance as if it had been surrounded by a ligature. The affected part feels firm, thick, and rigid, not unlike the mouth of the uterus, for which it has sometimes been mistaken during labor. The obstruction may be seated at any part of the length of the tube, but in most cases it is found within the first two inches of the lower outlet. The orifice of the vagina may also be closed up by an imperforate hymen, or by a dense, pale, gristly substance. The vagina is sometimes very short, not exceeding a few lines, half an inch, or an inch. When the defect is associated with absence of the urethra, the tube terminates in a cul-de-sac. Occasionally, the vagina is absent, greatly contracted, or converted into a solid, gristly mass; and cases have been noticed where, through accident or congenital deficiency, it communicated with the bladder and the rectum, at various distances from the anus. Sometimes again, the rectum opens into the vagina, and the vagina into the bladder. The vagina may be double. The septum sometimes extends the whole length of the tube, dividing it into two cylindrical canals each of which may terminate inferiorly by a separate aperture Callisen VULVA. 745 refers to two cases where the canals thus formed were closed each by a perfect hymen. In some instances, which, however, are extremely rare, the frsenum is situated transversely, constituting a sort of dia- phragm, which prevents the flow of the menstrual fluid. II. Vulva.—The great lips are liable to hemorrhagic infiltration from a rupture of some of the neighboring vessels, during or imme- diately after delivery. The lesion usually involves only one of these organs. The tumor which is thus formed is generally of an irregularly oblong shape, with a dark livid surface, more or less compressible, and about the size of a hen's egg. Occasionally, however, it is much larger, equalling the volume of a foetal head, and containing from ten to twenty ounces of blood. The effusion commonly takes place sud- denly, or in a very short time, and, when copious, it almost always makes its * escape spontaneously, by lacerating the superincumbent textures, or it remain's, and speedily induces gangrene. In the latter case, the blood is generally of a very black color, partly fluid and partly coagulated, and emits a highly offensive odor. The infiltrated tissues are sometimes frightfully lacerated, and converted into a dark, shreddy substance, without any trace whatever of their original cha- racters. The external lip may be the seat of different kinds of ulcers; and they are likewise liable to gangrene, and malignant disease. Mr. Kinderwood, many years ago, described a fatal disease of the vulva of young children, which, commencing at one or more points of the mucous surface, rapidly spreads over the nymphse, clitoris, and hy- men. Gangrenous spots appear in a very short time, and continue to enlarge until the parts are converted into dark-colored, fetid sloughs. Great prostration of strength, accompanied by fever and severe pain, is the most prominent symptom of the complaint. Warty excrescences are often seen within the vulva. In some in- stances they extend into the vagina, and down the perineum as far as the margin of the anus. Their number may be very great. In one case, that of a young girl of eighteen, I counted as many as sixty-five, of all sizes, from that of a mustard-seed to that of a raspberry. Usually they are of a pale florid color, of a fibro-cartilaginous consist- ence, rough on the surface, pediculated, and somewhat painful on pressure. Their origin, in most cases, is referable to gonorrhoea and syphilis. Polypes of the vulva are of very infrequent occurrence. They are generally of a pyriform figure, conical, or globular, and attached by a lono-, narrow pedicle. In their volume they vary between an almond and a°'child's head, though they rarely exceed that of the fist. Occa- sionally they are so large as to hang down between the knees. At an early period they are of a spongy consistence and of a bright florid color; but they are liable to become hard, and to assume a pale, mot- tled appearance, especially when they project beyond the vulva. Ulceration occasionally occurs, followed often by a copious discharge of bloody, fetid matter. Their structure is usually of a soft, fleshy nature, either uniformly, or interspersed with serous cysts, or masses of fibro-cartilage occasionally containing medullary matter. 746 URETHRA. The clitoris and nymphas are sometimes hypertrophied to such a degree as to require excision. In some countries these structures are naturally much larger than in America and Europe. In Persia and Turkey their development is often very great. The annexed cut (Fig. 333) from Churchill, affords a good idea of this affection. Fig. 333. III. Urethra.—The female urethra is rarely diseased. The principal lesions to which it is liable are, stricture, dilatation, and vascular ex- crescences. Fig. 334. Stricture is usually situated at the extremity of the tube, and may be so great as to produce much difficulty in making water. In some congenital malforma- tions, the orifice of the urethra opens into the vagina at some distance from the external aper- ture. Occasionally, as when the mouth of the vagina was closed up by a dense membrane, the urethra has been known to be so much dilated as to admit the male organ. Vascular excrescences sometimes spring from the female urethra, or are seated around its orifice (Fig. 334). They are of a bright scarlet color, exquisitely sensi- tive under pressure, and of a soft, spongy, erectile structure, with a MAMMARY GLAND. 747 smooth, fissured, or granulated surface. Their shape is generally pear-like, and in size they vary from a small pea to that of a horse- bean. The disease has been observed in young girls under seventeen, but is most common in adults. Its causes are unknown. Some years ago I assisted my friend Professor Willard Parker, now of New York, in removing a polype from the entrance of the ure- thra of a young lady of eighteen. It was of a conical shape, nearly an inch and a half in length by three-quarters of an inch in diameter, very sensitive, of a bright florid color, elastic, and compressible. On maceration for a few days it became perfectly white, and seemed to be composed essentially of soft cellulo-fibrous substance, pervaded by numerous bloodvessels. In the female, the parts most commonly attacked with chancre are, the edges of the pudendal lips, the nymphas, and the orifice of the vagina. In some instances the disease affects the perineum, the inte- rior of the vagina, and the mouth of the uterus. The ulcers ex- hibit the same characters as when seated on the penis; generally, however, their number is greater, and they are apt to produce more extensive devastation. SECTION V. MAMMARY GLAND. The mammary gland exists in the male, but only in a rudimentary state. Nevertheless, there have been instances in which it was quite large, and even secreted considerable quantities of milk. It has also been known, in a few rare cases, to be affected with carcinoma. Occasionally there is a supernumerary mamma, situated either in front of the chest, near the axilla, on the back, or on some other part of the body. Dr. Roberts, of Marseilles, has reported a case in which, in addition to the ordinary glands, a third occupied the left groin, and served to suckle several children. Examples of quadruple mamma? have been observed by Lynceus, Faber, Champion, Shannon, Lee, and others. In Dr. Lee's case the supernumerary breast was situated near the anterior margin of the axilla, and was about one-sixth the size of the other, from which it was separated by a deep, oblique depression. The nipple was small and flat, but when gently pressed yielded a milky fluid. Only one case has been recorded of five mammas in the human subject. In some women only one breast is developed. Supernu- merary nipples, capable of furnishing milk, are by no means uncom- mon. The lesions of the breast may be arranged under the following heads: inflammation, hypertrophy, atrophy, neuralgia, scirrhus, en- cephaloid, colloid, melanosis, tubercle, hydatids, serous cysts, fibrous transformation, apoplexy, milky accumulations, fistules, and earthy concretions. 748 MAMMARY GLAND. 1. Acute Inflammation.—Acute inflammation of the mamma occurs most commonly during lactation, being rarely observed at any other period. It usually sets in within the first fortnight after parturition, from the effects of cold, or, more commonly, from obstruction of some of the lactiferous ducts. The gland is hard, lobulated, enlarged, feel- ing as if it were composed of a number of separate masses. By and by, however, they become all united into one solid tumor, of great firmness, and grating under the knife, of a pale rose color, and per- vaded by numerous vessels, loaded with dark blood. If the gland be divided, and the section minutely examined, it will be found to con- tain a large quantity of fibrin, both in the proper mammary structure and in the connecting cellular tissue, thus affording an explanation of its increased size and hardness. The lactiferous tubes are enlarged, their walls being inflamed, and their interior filled with thick inspis- sated milk, intermixed, perhaps, with globules or flakes of lymph. The above changes may be considered as constituting the first stage of inflammation, which often disappears under mild treatment, or simply under the withdrawal of the milk, which distends the irritated tubes. If the disease, however, be permitted to progress, the morbid appearances become more profound. The gland enlarges in every direction, its substance is rendered more dense, firm, and vascular, the lactiferous ducts are obstructed by adhesive matter and occupied by an abundance of milk, and the surrounding cellular substance is infil- trated with inflammatory deposits. Such, in a few words, is the condition of the gland when the disease has reached its height. Under active treatment resolution is still possible, though not probable, its tendency being now to suppuration and the formation of abscess. This event usually occurs within a week or ten days after the commencement of the inflammation. The matter is ordinarily deposited at a single point; but sometimes the reverse is the case, suppuration occurring simultaneously in several lobules. Be this as it may, a large portion of the gland is often involved in the disease, it being sufficiently common, when several abscesses exist, to see them communicate with each other, and to open upon the surface by a single orifice. Not unfrequently, however, especially when the disease is of long standing, or has been neglected, the skin is perfo- rated at numerous points, giving it a riddled, sieve-like appearance. The matter which is formed in this disease is generally of a thick, cream-like consistence, and of a whitish or pale yellowish color. When thev inflammation has been very high it is apt to contain flakes of lymph and pure blood, the latter being usually in a state of coagula- tion. Milk is almost always a prominent ingredient. Even when it exists in so small a quantity as to be undiscoverable by the naked eye, its presence may, in general, be readily detected by the aid of the microscope. The quantity of pus varies from a few ounces to up- wards of a quart, the average being from four to eight ounces From a week to a fortnight is the time required by the abscess to work its way to the surface. The mammary gland is astonishingly exempt from gangrene Such an occurrence, indeed, is possible only in very unhealthy females, or CHRONIC INFLAMMATION — HYPERTROPHY. 749 in women who, in addition to scrofulous or syphilitic disease, have been suffering, at the time of the inflammatory seizure, under an im- poverished state of the blood. A few cases are upon record where gangrene of this gland was occasioned, in middle-aged females, by the protracted use of ergot. In erysipelas and carbuncle the cellular tissue around the gland sometimes mortifies, the mamma itself gene- rally escaping. 2. Chronic Inflammation.—Chronic inflammation of the mamma, al- though it may occur at any period of life, is most common between the ages of seventeen and thirty, during the period of the greatest func- tional activity of the organ. It often shows itself soon after the establish- ment of the menses in young girls apparently otherwise quite healthy. Invading usually only one or two lobules, it occasionally attacks the entire gland, the substance of which has a peculiar doughy feel, like that of a fatty swelling, and consists of a number of nodules, from the volume of a currant to that of a filbert; it is generally of a pale yellow- ish or pink hue; and its consistence ranges between fibrous tissue and fibro cartilage. The disease frequently continues for years; now indo- lent, now advancing a little, then halting, or even receding, and then, perhaps, again taking a new start. The breast sometimes acquires an enormous bulk, but never assumes any malignant action. The pre- cise character of the affection is not understood. The mamma is liable to chronic abscess. The disease is most com- mon in married females, between twenty-five and forty; but I have also met with it in young girls. The matter forms either in the gland itself, or, as is, perhaps, more frequently the case, in the cellular tissue around; sometimes without any assignable cause, but usually as the result of lactation, or disease in the sternum or in a rib. External violence may also induce it. The pus is usually deep-seated, and its formation is rarely attended with any of the ordinary symptoms of inflammation, a sense of un- easiness rather than of pain, and a feeling of distension being the most common attendants. The fluid is thinner than in the acute form of the affection, and of a color slightly bordering upon greenish;_ it usually contains small whitish flakes, like fragments of boiled rice, and is sometimes excessively fetid, especially when it has been long confined, or is seated near a diseased bone. It is commonly inclosed in a pyogenic membrane, similar to that which we find in chronic ab- scesses in other organs, and often exists in enormous quantities. The matter thus formed may remain penned up in the breast for months before it manifests any disposition to discharge itself. Gradually, however, as it approaches the surface, the skin becomes tense and glossy, and the subcutaneous veins assume a varicose and bluish ap- pearance, contrasting strikingly with the surrounding surface. 3. Hypertrophy and Atrophy.—Hypertrophy of the mamma is not uncommon, nor is it, as might be supposed, confined entirely to the female sex. I have repeatedly seen both breasts of the male enlarged many times beyond their normal bulk, and not a few cases are record- ed where they have freely, and for a long time, secreted milk. In women, the swelling is commonly associated with amenorrhcea; but 750 MAMMARY GLAND. it sometimes occurs during pregnancy, and disappears soon after de- livery. One of the most extraordinary examples of hypertrophy of the mamma, perhaps, to be found on record, occurred to Dr. S. C. Houston, in a colored girl, aged sixteen, in April, 1834. The left breast, which began to enlarge much earlier than the right, weighed twenty pounds, and measured forty-two inches around the base, form- ing an oviform mass, which extended from the lower part of the neck to some distance beneath the umbilicus. The other breast, which was of the same shape, was also enormously enlarged; yet, notwithstand- ing this, it was perfectly sound, presenting not the slightest structural lesion. Around both glands, the cellulo-adipose tissue was in a state of hypertrophy, and in neither could there be detected any trace of the nipple. The girl had menstruated, and enjoyed good health, until a few weeks before her death, which was occasioned by a contusion of the left mamma, terminating in gangrene. Mr. Hey, in his Practical Observations on Surgery, alludes to several cases of a similar nature, in all of which the hypertrophy was con- nected with suppression of the menses; in one the breast weighed fifteen pounds, and so greatly incommoded by its bulk as to require removal. Dorsten attended a young -lady in whom the enlargement was associated with the retention of the milk. Both breasts were pendulous and painful, and the left was found to weigh sixty-four pounds. No decided structural change could be detected in the gland, except the mere hypertrophy of the integrant cellular texture. Atrophy of the mamma is a natural effect of old age. When the menstrual function ceases, the gland begins to diminish in volume, and the wasting gradually progresses until at length the whole organ is reduced to a soft, flabby mass, of a dirty grayish tint, in which it is often difficult to detect any of the natural structure, except the lac- tiferous ducts, which are seldom completely effaced. Sometimes the gland shrinks early in life, particularly in married females who do not nurse their offspring. Atrophy of this viscus occasionally results from the effects of neuralgia, and other causes, as the use of iodine and hemlock. 4. Adenoid Tumor.—The breast is liable to a species of fibrous trans- formation similar to that occasionally seen in the testicle. The lesion, however, is very infrequent, and is observed chiefly in young, un- married females. The organ may retain its normal size, or it°may acquire a bulk equal to that of an orange, a fist, or even an adult head. The tumor is inclosed by a thin capsule of condensed cellular tissue, is firm and compact, and has a rough, granular, nodulated surface. Occasionally, however, it is perfectly smooth, compressible, and slightly elastic; but these are characters which are not essential to it. Its intimate structure consists of a pale grayish, pink, or bluish substance, nearly or quite homogeneous, friable, easily crushed, and very similar to that of a hypertrophied lymphatic ganglion. Hence, the term adenoid, now generally applied to this form of mammary tumor. Some parts of it may be so hard as to creak under the knife and specimens occur, possessing all the properties of old fibrinous concretions. Minute cells, variable in size and number, are occasion- ADENOID TUMOR. 751 ally scattered through it. The probability is that the transformation commences in the interlobular cellular substance of the organ, and that new fibrous tissue is developed, which, by its pressure, causes at first atrophy, and finally total destruction of the primitive glandu- lar texture. The disease is slow in its progress, and free from ma- lignancy. The adenoid mamma is occasionally filled with small nodules, of a rounded form, and from the size of a filbert to that of a common hickory-nut, hard, almost inelastic, movable, inclosed in cysts, and perfectly distinct from each other, the intervals between them being occupied by fibrous substance. In a specimen in my cabinet, removed in 1849, from a married but sterile female, aged thirty-three, each breast contains at least a dozen of such masses. The disease had been in progress for upwards of three years, and was attended with considerable enlargement of each gland, but there was an entire free- dom from pain, lymphatic involvement, and disorder of the general health. The organs were perfectly movable, and numerous nodules could be felt in their substance in every direction. The nipples were badly developed, but not more retracted than we often see them in women who have never borne children. Upon making, very recently, a careful examination of the little bodies above described, I found that they all consisted of a kind of cyst, inclosing a mass bearing a striking resemblance to a cauliflower, being composed of a fibrous membrane, of a white, glistening appear- ance, thin, and semi-transparent, folded like the ruffle of a shirt, and studded with an immense number of small delicate excrescences, look- ing very much like the warts which are so often met with upon the penis. They all adhered by a broad base or stem, and were made up each of a number of minute granules, resembling the eggs of certain insects. Under the microscope, Dr. Da Costa and myself found the stems to consist of fibrous tissue, while the granules were com- posed, for the most part, of rounded bodies, presenting a delicate fibrillated stroma, inclosing small ovoidal and spindle-shaped cells in varying pro- portion. The hard part of the mamma —that in which the nodules were de- veloped—consisted of bundles of very dense fibrous tissue, wavy, and ex- tremely distinct. Fat-cells were here and there embraced in its meshes. The adjoining cut (Fig. 335) repre- sents, though very imperfectly, the internal structure of these nodules. In an interesting paper by Mr. John Birkett, in Guy's Hospital Reports for 1855, a tumor of a similar kind has been described by this gentleman un- der the name of "adenocele." He considers, however, that the peculiar Fig. 335. Adenoid tumor of the mamma, exhibiting its cystiform arrangement and internal struc- ture. From a preparation in my collection. 752 MAMMARY GLAND. bodies which I have here pointed out, consist essentially of the cascal terminations of the lacteal ducts. He divides the disease into three great classes, each having a certain number of varieties. Further in- vestigation is required to establish the true pathological relations of this form of tumor. In the specimen here referred to there is certainly an entire absence of tubular structure. 5. Milk Tumor.—The lactiferous ducts, like other excretory canals, are liable to be permanently closed by causes which interrupt the pass- age of the milk, such as external tumors, or accidental products con- tained in their interior. Of these the most common, by far, is the effu- sion of plastic lymph produced by inflammatory irritation. The extent to which the tube is obliterated varies in different cases, from a few lines to an inch or more. The lesion generally arises within the first month after delivery; and, as the breast is then engaged in secreting milk, the portion of the tube behind the occluded part becomes dilated, forming a globular, ovoidal, or pear-shaped tumor, the volume of which rarely exceeds that of an orange. The swelling is usually attended with a peculiar sense of distension, and distinctly fluctuates under the finger. On cutting into it the con- tents are found to be of a whitish color, and of the consistence of milk, cream, or whey; the quantity ranging from a few drachms to several ounces. A remarkable case of this disease has been reported by Professor Willard Parker, of New York. The subject was thirty years of age, and the mother of five children, the youngest being nine months old. The swelling occupied the right breast, and was first noticed three months after her confinement. Three quarts of milk were evacuated at the first operation: in a week the fluid had reaccumulated to the amount of three pints. A still more remarkable instance is mentioned by Scarpa, of a young female, whose left breast, after her second con- finement, in the course of two months, acquired such a size that it measured thirty-four inches in circumference, and rested, when she was sitting, on the corresponding thigh. The skin presented no par- ticular alteration, except that it was rather tense and shining, the sub- cutaneous veins being dilated. A flow of pure milk followed the introduction of the trocar, ten pints of that fluid being drawn off in a continuous stream. 6. Butyrous Tumor—& peculiar form of tumor, termed butyrous, from the resemblance of its contents to butter, was first described by M. Velpeau. It evidently belongs to the class of swellings mentioned in the preceding paragraph. It is composed, essentially, of a yellow firm, concrete substance, of the appearance of cheese, butter, or coagu- lated caseum, and contained in the flattened and altered interlobular cellular tissue of the gland. Under the microscope it presents a multitude of globules analogous to those of milk, soluble, like them in ether and alcohol, insoluble in ammonia, and interspersed with the mucous globules and granular corpuscles of the colostrum It is not improbable that the milk in this disease is poured out into the con- necting cellular tissue of the gland, either as a secretion, or as a con- sequence of the rupture of some of the lactiferous ducts HYDATIDS—SEROUS CYSTS. 753 7. Hydatids.—Hydatids seldom infest this gland. In the examina- tion of a great number of breasts, I have not met with more than two cases. They always belong to the class of echinococci, and are most common between the ages of twenty-five and fifty. Varying in volume between a currant and an orange, they may occur in any portion of the organ, the proper substance of which they often completely destroy. They are of a globular figure, and present themselves either in clus- ters, or as bodies perfectly distinct from each other. When of con- siderable size, it is not uncommon to find within the old hydatids young ones, hanging by narrow footstalks, and having precisely a similar configuration and structure. The contained fluid is generally thin and limpid, but it may be thick and glairy, like the white of egg. In the older hydatids, especially such as are partially dead, there is sometimes an admixture of blood, pus, albumen, or curdy matter. These bodies may occur either alone, or in connection with other morbid products; and, when large and numerous, are productive of extraordinary enlargement of the breast, cases having been observed where the organ, from this cause, weighed from eight to ten pounds. 8. Serous Cysts.—Tumors of the breast, containing serous cysts, of a structure much more simple than that of the true hydatid, sometimes occur. The disease constitutes what is called cystic sarcoma, and the vesicles producing it are developed in the interlobular cellular tissue of the gland. They are of a spherical, ovoidal, or conical figure (Fig. 336), and vary in size between a hemp-seed and a marble. Some- Fis- 336- times they attain the volume of a hen's egg, a walnut, or an orange. Their number ranges from one to several hundred. At an early period they are smooth, transparent, elastic, vas- cular, closely adherent, and filled with a clear, watery fluid, slightly saline in its taste, and scarcely coagulable by heat, alcohol, or acid. Their parietes, however, are liable to become opaque and thickened, from the effects of inflammation, and the same cause generally induces remark - ble changes in the contained fluid, which may be lactescent, bloody, oleaginous, glairy, or gelatinous. Different cells of the same tumor often have dissimilar contents. The morbid mass is sometimes entirely composed of cysts; at other times a considerable proportion of solid matter is interposed between them, commonly of a tough, cellulo- fibrous character. The cystic tumor often acquires a large bulk. It is most common in young subjects, is tardy in its progress, and is not prone to degene- ration, or reproduction after removal. When fully formed, the mam- mary gland is generally completely annihilated. 48 Cystic disease of the breast. From a preparation in my cabinet. 754 MAMMARY GLAND. Cysts of large size, differing in structure from the preceding, some- times form in the mamma. They are generally unilocular, and are composed of a single membrane which bears a very close resemblance to the peritoneum and other serous textures, its inner surface being perfectly smooth and glossy, while the outer is intimately connected to the surrounding parts by short cellulo-fibrous tissue. _ Occasionally the cyst is intersected by membranous septa, separating it into a number of distinct compartments, of varying size and shape. When this is the case, the cyst is said to be multilocular. Various fluids are found in these sacs. Generally they are of a serous nature, more or less viscid, coagulable, of a saline taste, and of a limpid, or pale yel- lowish appearance; but cases occur in which they are of a reddish, olive, brownish, claret, or blackish hue. Last winter I saw an instance in which the fluid was of the color of the tincture of iodine. Some- times, again, it is of a lactescent nature, whey-like, or muco-albumi- nous. Finally, there are cases, although they are rare, in which the fluid contains cholesterine, flakes of lymph, and other substances. Cysts of the character now described often attain a large bulk, being capable of holding from twenty to forty ounces. Their progress is always tardy, they never manifest any disposition to take on malig- nant disease, and they are most common between the ages of twenty- five and forty. 9. Calcareous Concretions.—Calcareous concretions are met with in the breast, either in its substance or in the lactiferous ducts: they are commonly small, not exceeding an ordinary pea, and are observed chiefly in connection with fibrous and other tumors. I have seen these bodies only in two instances, in females far advanced in life. They were of a whitish color, irregularly spherical in shape, and of a hard, solid consistence, like dry mortar. A case has been described by Berard, in which the outer portion of the mamma was converted into a complete osseous shell. 10. Apoplexy.—The breast is liable to apoplexy, consisting in an effusion of blood into the connecting cellular tissue, resembling an ecchymosis produced by a blow or leech-bite. Generally there is only one such spot, but there may be several, coming on a few days before the menstrual period, and disappearing within the first week or two after; though sometimes they continue for more than a month. The disease seems to depend upon some sympathetic action between the uterus and the breast, causing a great determination of blood to the latter, eventuating in the rupture of some of its smaller vessels. The affected parts are always of a dark, livid hue, and are exquisitely tender on pressure, the pain sometimes shooting down to the ends of the fingers. 11. Fistules.—During lactation a galactophorous duct is sometimes included in a wound of the breast, and, unless the edges of the inte- guments be very closely approximated, a lacteal fistule may remain in the part. The same consequences may be produced by a rupture of the canal from the inordinate accumulation of milk. A more com- mon occurrence is the formation of accidental outlets, from the irrita- tion of multilocular abscesses. These passages are often of considerable NEURALGIA — HETEROLOGOUS FORMATIONS. 755 depth, tortuous, numerous, lined by an adventitious membrane, and attended with a great deal of induration of the surrounding parts. 12. Neuralgia.— Neuralgia of the breast may occur at any period after puberty, but is most common in young females from the age of fifteen to thirty. It is characterized by exquisite pain, darting through the part like electricity, and extending generally to the corresponding shoulder and axilla, sometimes down the elbow to the fingers. The suffering resembles that of tic-douloureux, often observes a regular periodicity, is very much increased prior to menstruation, and is sometimes so severe that the patient is unable to lie upon the affected side, or bear the weight of the bedclothes. The disease, although it may last for years, has no malignant tendency, and is met with mostly in persons of a nervous, irritable temperament, with deficient men- strual secretion. The disease is commonly confined to several of the mammary lobules, which either retain their natural bulk and appearance, or they are converted into small, solid tumors, distinctly circumscribed, movable, and highly sensitive to the touch. Occasionally these swellings seem to be seated in the connecting cellular tissue, rather than in the gland- ular structure; they seldom exceed the size of a marble, an almond, or a walnut; they never suppurate, and they sometimes disappear spontaneously. 13. Heterologous Formations.—All the heteroclite products, except- ing, perhaps, the tubercular, are met with in the mamma. The most common, by far, is the scirrhous, and next in point of frequency is the en- cephaloid, the colloid and melanotic being extremely rare. Scirrhus of the breast rarely appears before the age of thirty-five. It is most frequent about the period of the decline of the menses, and is witness- ed, relatively speaking, quite as often in old maids as in women who have borne children. AVrheu inspected after death, the mamma is found to be in- elastic, firm, dense, and crisp, like car- tilage, which it also resembes in color: sometimes it is of a dry, fibrous tex- ture, like the interior of an unripe pear, and of a light grayish tint, interspersed with yellowish lines, pro- bably the remains of lactiferous ducts; more rarely the organ is soft and suc- culent, presenting a considerable num- ber of small vessels, and yielding, upon pressure, a thin, opaque, serous fluid, occasionally blended with milk. These appearances frequently occur together, forming so many zones, Fig. 337. a. Section of a scirrhous nodule. 6. Scirrhous mamma laid open to show its lobulated structure. From a specimen in my cabinet. 756 MAMMARY GLAND. gradually and insensibly running into each other. In some instances, again, the tumor contains one or more cavities, filled with purulent matter, or with a viscid, ropy fluid, not unlike the synovia of the joints. The malady usually commences in a few lobules; but, as it pro- gresses, the whole organ becomes converted into a firm, solid mass, with a rough, tuberculated surface. In the annexed sketch (Fig. 337), taken from a specimen in my cabinet, a large number of nodules are seen, the largest of which, hard and crisp, like cartilage, and of an oblong, spherical shape, scarcely equalled the size of a pullet's egg. Before the gland was extirpated, it had an irregular, knobby feel, and could be freely moved in different directions. When the whole of the breast is not involved, the excepted part is generally somewhat changed in its color and consistence, being yellowish, firm, and coarsely granulated, so as to resemble the substance of the pancreas. Beginning usually with slight swelling, a circumscribed lump is soon perceived, hard and irregular to the touch, and somewhat tender on pressure. The induration gradually augments; and, as the turges- cence spreads, the whole gland becomes firm and knobby: in this stage, the organ is still movable, but by degrees it contracts adhesions to the pectoral muscle, so that it can no longer be pushed about with the hand. In the mean time the nipple is retracted ; the skin is puck- ered and discolored; the superficial veins enlarge, and assume a deep bluish tinge, and presently ulceration sets in, leaving one or more cir- cular sores, with hard, depressed, angry-looking edges, and a foul sloughy base. The discharge is thin, ichorous, offensive, and often so acrid as to corrode the healthy skin. Gradually the irritation extends to the neighboring lymphatic ganglions, which either become white, firm, and tumid, or they are rendered preternaturally soft and vascular, having often a bloodshot appearance. The retracted appearance of the nipple is well shown in the accom- panying cut (Fig. 338), from a patient at the College Clinique. It often begins early in the disease, and is produced by the manner in which the lactiferous tubes are compressed by the scirrhous matter. Scirrhus of this gland is sometimes invaded by gangrene, even be- fore ulceration has commenced. In a case of this kind, described in the chapter on scirrhus, the tumor was lifted completely out of its bed, the cavity being afterwards filled up with healthy granulations, though the disease returned subsequently in the neighborhood of the original affection. Although scirrhus generally commences in the glandular structure of the mamma, yet occasionally its primitive seat is in the common integuments and in the surrounding cellulo-adipose tissue. In the former case it usually presents itself in the form of a small rounded tubercle, scarcely larger than a shot, of a bluish color, firm, superficial, movable, and free from pain. This gradually increasing, finally in- volves the glandular structure; the skin, meantime, becoming hard, discolored, and intimately adherent to the subjacent parts. In the other variety of the disease, a firm, oblong, or spherical lump, of con- ENCEPHALOID. 757 siderable volume, is from the first felt deeply embedded in the adipose tissue around the organ, with which it has apparently as yet no con- nection. It may be readily lifted away with the thumb and finger, but it soon contracts adhesions, gradually contaminates the adjacent Fig. 338. Scirrhus of the mamma, showing the characteristic retraction of the nipple. From a patient at the College Clinique. structures, slowly approaches the surface, and at last breaks out into a foul, irritable, fungous ulcer. Scirrhus of the/breast sometimes remains stationary for a consider- able length of time, when it rapidly assumes the characters that have just been assigned to it. When removed, it is almost sure, after an interval of several months or years, to return, either in the cicatrice, or in the contiguous lymphatic ganglions. It has been known to occur in four or five members of the same family, and occasionally it coexists with scirrhus in other parts of the body. In a few instances it has been observed in the male. Encephaloid (Fig. 339) probably affects the mamma more frequently than any other organ in the body, excepting the eye, testicle, and lym- phatic ganglions. Its anatomical characters here are not different from what they are in other parts of the body. The tumor is seldom very uniform in its structure, but is generally very hard in some parts ; soft, spongy, and elastic in others. It not unfrequently hap- pens that one portion is fibro-cartilaginous, another pulpy and brain- like, and a third, perhaps, hsematoid or cystiform. Cavities or cells, containing different kinds of fluids, are often interspersed through it. Large clots of blood, sometimes of a black, brownish, or yellowish- buff color, and of varying degrees of consistence, are also sometimes 758 MAMMARY GLAND. Fig. 339. Fungus hsematodes of the mamma ; fungoid, bleeding, and blood-like. met with. The tumor has no capsule, except what is derived from the surrounding cellular tissue, which is occasionally considerably con- densed ; its surface is rough and Fig. 340. lobulated; and its substance is usually pervaded by numerous vessels, many of them of large size. Hence the frequent and ex- hausting hemorrhages after ulcer- ation has commenced. The vo- lume which the tumor attains varies, in different cases, from a fist to a man's head. The disease may occur at any period after puberty, but is most common after the thirtieth year. It sometimes coexists with encephaloid or scir- rhus in other organs. Fig. 340 affords a good idea of the hsematoid form of encephaloid of the mam- ma. The tumor from which the drawing was taken was removed from a negress, thirty years old, and was of very large size. The disease returned at the cicatrice, in less than three months after the operation. Colloid, alveolar, or gelatiniform cancer rarely attacks the breast The tumor advances slowly, and seldom exceeds the volume of the fist or of a foetal head. Externally, it is of a light-grayish color dense, firm, glistening, and irregularly lobulated; internally it is corn- Encephaloid of the mammary gland, of the haema- toid variety. From a specimen in my collection. PLACENTA. 759 paratively soft and succulent, yielding some moisture on pressure, and tearing into hard, jelly-like strings. The cellular arrangement, so well marked in alveolar cancer of the stomach, is seldom very distinct in that of the breast. Melanosis of the breast occurs either as an infiltration amongst the granules of the gland, or, as is most frequently the case, in the form of small spherical nodules, of a black, sooty color. Of this disease, I saw an interesting specimen, some years ago, in an old female who died of pulmonary phthisis, accompanied by scirrhus of the left mam- ma. The little tumors, which were five in number, were distinctly encysted, and contained a thin, ropy fluid, of the color and consistence of China ink. Tubercles of the mamma are very rare, or, more properly speaking, have, perhaps, never been witnessed. The lymphatic glands around the organ are, however, occasionally thus affected, forming hard, dense nodules, similar to diseased glands of the neck. SECTION VI. PLACENTA AND UMBILICAL CORD. Acute inflammation of the placenta is extremely rare; at any rate, such must be our conclusion when we reflect upon the few cases of it that are to be found on record. The disease is generally limited in its extent, and appears to terminate in one of three ways, in the effu- sion of lymph, in suppuration, or, finally, in passing into the chronic form. In the first case, the affected part presents all the characters of a hepatized lung; that is, it is dense, solid, easily crushed, and of a dark reddish color. When the lyrnph is poured out between the inner surface of the organ and the corresponding portion of the uterus, the two structures become so intimately incorporated as to render it frequently impracticable, when the period arrives for their separation, to detach them from each other. In this way, probably, usually arises what is called morbid adhesion of the placenta. Of suppuration of the placenta very little is known, except that the matter is commonly confined to one or more cotyledons, and is either diffused through their substance, or collected into little abscesses, varying in volume between that of a pea and a hazelnut. The pus is of a thick consistence, without any particular odor, and looks a good deal like softened tubercular matter. Softening of the placenta is doubtless caused by inflammatory irri- tation, and is often associated with the fibro-cartilaginous and osseous degenerations. Occasionally the softening affects the entire organ; but in general, it is confined to particular sections, occupying one- fourth, one-third or one-half of its extent. The volume of the placenta is seldom altered. 760 PLACENTA. Fig. 341. The most common disease of the after-birth is the cartilaginous degene- ration (Fig. 341). This generally occurs in small, circumscribed masses, from two to four lines in thickness, of a whitish, milk-like color, and of an irregularly oval shape. In their con- sistence, they vary from the softness of fibrous texture to the density of articular cartilage. In some instances, they are of a pale yel- lowish color, and partially transformed into osseous matter. In other cases, though this is not common, the masses are intersected by fibrous bands, constituting that form of the disease to which the older anatomists have erroneously applied the term scirrhus. Tn a third series of cases, the affected part has a re- markably granular appearance, being com- posed of an infinity of small, spherical bodies, of a reddish buff color, dense and firm in their consistence, and scarcely exceeding the volume of a millet-seed. This degeneration is generally associated with atrophy, and, as might be supposed, interferes more or less with the nutrition of the foetus. Another rather frequent lesion of the pla- centa is ossification. The degeneration may occur under two varieties of form. In one, the more frequent of the two, the ossification is confined exclusively to the smaller arterial branches, which assume an acicular arrangement, hundreds sometimes existing in a space not exceeding half a square inch. They are of a yellowish color, fragile, and particularly con- spicuous at the uterine surface of the organ. In this way whole cotyledons are occasionally transformed. This species of degeneration, which sometimes pervades the entire placenta, is analogous to senile ossification of the arteries. The larger arterial branches usually re- main sound, and the bulk of the organ is seldom materially diminished. In the second variety, the foreign matter occurs in the form of a distinct layer, varying in thickness from the fourth of a line to a quarter of an inch. In its diameter, it rarely exceeds a cotyledon, to the inner surface of which it closely adheres, the deposition commenc- ing apparently in its cellulo-fibrous envelop. In some instances, these plates are partly osseous, partly cartilaginous, and partly fibrous, according to the length of time they have been in progress of forming; their number is occasionally considerable; and they have been known to constitute a complete shell, accurately moulded to the uterine sur- face of the organ. A radiated arrangement is sometimes observable in these plates, not unlike that of the parietal bone of the foetus the osseous fibres extending from the centre to the circumference. The deposit consists of albumen, fibrin, phosphate of lime, phosphate of magnesia, and carbonate of lime. Tubercles of the placenta are very uncommon. In the few instances Fibro-cartilaginous degeneration of the placenta, causing the death of the foetus, which is in sitil. From a preparation in my cabinet. PLACENTA. 761 in which they have been observed they were associated with pulmonary phthisis, and presented themselves, at various parts of the organ, in the form of small discrete masses, of a pale straw color, and almost fibro-cartilaginous consistence. The placenta is liable to the fatty transformation. The degenerative process probably begins in a deposit of fibrin in the cells around the villi of the chorion, which become studded with innumerable oil- globules, and intimately adherent to each other, at the same time that they lose their natural consistence, and assume a pale, brownish hue. The chorion itself is considerably altered in character, being abnor- mally thickened and deprived of nuclei; and the cavities of the vessels are destitute of blood and fatty matter, though this substance is gene- rally contained in their tunics, as well as in the intervals between them. The placenta, like other organs of the body whose existence is of a less temporary nature, is liable to hypertrophy. When this happens, the weight and bulk of the viscus are variously augmented, its color is abnormally pale, and the parenchymatous structure is infiltrated with serosity, pitting on pressure, and being often very firm. Finally, the placenta is sometimes the seat of hemorrhagic effusions. The blood is poured into the parenchymatous substance of the organ, near its uterine surface, in the form of irregular masses, varying in vo- lume between a pea and a walnut. The number of depots is usually small, though occasionally every co- tyledon is affected. The fluid, at first of a dark color and soft con- sistence, becomes gradually lighter and more dense, until finally it pre- sents all the properties of an old apoplectic effusion of the brain. The surrounding textures are generally more or less altered, and many of the vessels are plugged up with fibrin. This lesion is occasionally connected with the fibro-cartilagi- nous degeneration. Nearly all the lesions above de- scribed are either directly hostile to the persistence of the placenta, or they interfere, to a greater or less extent, with the nourishment of the foetus. In the cartilaginous and osseous transformations, many of the vessels are either entirely obliterated, or their calibre is so much diminish- ed as to admit of a very imperfect circulation. Hence, atrophy of the placenta, and emaciation of the new Twisted and knotty umbilical cord. From a specimen in my collection. 762 PLACENTA. being, followed, when the lesions are extensive, by abortion. ^ Ossifica- tion of the placenta occurs occasionally in several successive preg- nancies. The placenta may adhere to any part of the uterus, but is usually found at the base. In twin cases, it is either double or bilobed, and furnished with two cords. Occasionally it is attached to the head of the infant.1 The umbilical cord presents some anomalies worthy of brief notice. It is occasionally double, and cases are recorded where it was inserted into the head, chest, and extremities. The length of the cord at birth is generally about twenty inches; but it may be much longer. In one instance I found it four feet and a half, and in another, men- tioned to me by Dr. Catlin, of Massachusetts, it was nearly six feet. Its veins are sometimes varicose; it is occasionally tuberculated, twist- ed, or knotted, as in Fig. 337 ; and, in a few rare instances, it has presented black nodosities, or been partially filled with serous cysts. Cases have occurred where there were two veins and but one artery, instead of one vein and two arteries. 1 Nouv. Bibliotheque Med., 1830. INDEX. Abscess, 73 ; of brain, 342 ; of liver, 599 ; of gums, 491 Absorption, how influenced by inflamma- tion, 46 Acephalocyst, 139 ; mode of reproduction, 140 ; of the brain, 355 Acne, 314 Adipose diathesis, 224 Adipose transformations; causes, 121; artificial; in old people, 122; effect of inflammation, 122 Adipose tissue, 223 ; wounds, inflammation and hypertrophy, 223 ; adipose tumors ; cases, 225 Albinism, 333 Amaurosis, 380 Ammoniaco-magnesian calculus, 674 Analogous tissues, 70 Anasarca, 60 Aneurism, 248 ; sacculated, 249 ; cylin- droid, 250 ; varicose, 250 ; dissecting, 250 ; spontaneous, 252 ; arterio-venous, 253 ; anastomotic, 254; termination of aneurism, 25(3 Anteversion of uterus, 711 Anthracion, 307 Anus, prolapse of, 577 Aponeurosis, inflammation of, 236 Apoplexy in hydatid, 142; of muscles, 234 ; brain, 350; lungs, 422 ; heart, 459 ; liver, 611 ; mamma, see Spleen, 626 Aqueous humor, 381 Aquo-capsulitis, 380 Arteries, wounds of, 239 ; arteritis, 240; suppuration, 124; gangrene, 201; ul- ceration, 241 ; gangrene, 241 ; softening, 242 ; atheromatous deposit, 246 ; carti- lage, 244 ; calcareous matter, 244 ; hy- pertrophy, 247; contraction, 248 Ascites, 589 Atrophy, general or partial, 111 ; causes ; senile atrophy, 112; of adipose tissue, 226 ; of muscles, 232 ; tendons, 235 ; bones, 291 ; hair, 336 ; brain, 352; spinal cord, 364; nerves, 369 ; thyroid body, 396 ; lungs, 426 ; heart, 459 ; tongue, 481 ; salivary glands, 483; stomach, 526; small bowels, 542 ; liver, 601; spleen, 623; kidney, 641; bladder, 656; testis, 692 ; uterus, 714 ; ovary, 737 ; mamma, 750 Auditory nerve, 390 Beard of females, 337 Bile-ducts, lesions of, 615 Bile, 617 ; gall-stones, 617 Biliary apparatus, 594 Blood, quantity and quality, how altered, 33 ; importance, 197 ; lesions, 198 ; want of coagulability from effects of lightning, disease, &c, 203; hemorrhagic diathe- sis, 203; causes, influence of nerves, 204 ; buffy coat, quantity of fibrin, 202 ; effects of ligature on the par vagum, 205 ; hematin, 207 ; its relative quantity in males and females, 206; in cholera, typhus, and plague, 206 ; serum ; milky serum, 208 ; general diseases of blood, 211; contaminated blood, effects of, 211; increased circulation, effects of; blood in cholera, fever, 213 ; yellow fever, 214; chlorosis, 216; jaundice,-scurvy, pul- monary phthisis, 216 Bones, 265 ; restorative process in, 276 ; fractures, 276 ; false joints, 278 ; osteitis, 279 ; suppuration, 280 ; caries, 280 ; ne- crosis, 282 ; exfoliation, 282 ; sequester, 283 ; regeneration, 284; softening, 285 ; rachitis, 286 ; induration, 287 ; fragility, 288 ; hypertrophy, 288 ; exostosis, 290 ; atrophy, 291 ; acephalocysts, 294 ; osteo- sanguineous disease, 294; cartilaginous tumors, 295 ; scirrhus and colloid, 296 ; encephaloid, osteo-sarcoma, 297-8 ; me- lanosis, tubercles, 298-9 Bowel, large and small. (See Larye and small bowel.) Brain, 335 ; wounds of, 338 ; inflammation, 339; yellow and red softening, 340; stages and progress, 340 ; suppuration, 341 ; abscess, 342 ; gangrene, 344; soft- ening, its progress and termination, 344; chronic inflammation, induration, 348; ulceration, 349 ; apoplexy, 350; tuber- cles, 353; melanosis, encephaloid, 353-4; cartilaginous and calcareous deposit, 764 INDEX. 354 ; cysts, 355 ; acephalocyst, adipose tumor, 355 ; hypertrophy, 352 ; atrophy, 352 Breast, female, inflammation, acute and chronic, 748 ; suppuration, 748 ; chronic inflammation, 749 ; hypertrophy and atrophy, 749; fibrous transformation, 750 ; milk tumor, 752; butter-like tu- mor, 752 ; hydatids, cystic sarcoma, 753 ; calcareous concretions, 754 ; apoplexy, 754; fistule, 754; scirrhus, 755 ; neu- ralgia, 755 ; encephaloid, 757 ; colloid, melanosis, tubercles, 759 Bronchia;, dilatation of, 406 ; obliteration, 407 ; ossification, 409 Bronchitis, 404 ; ulceration, 405 Bronchocele, 394 Bullar diseases, 322 Burses, synovial, 237 ; inflammation, 237; hydatids, 238 ; hypertrophy, 238 Calcareous matter in arteries, 244; in brain, 354 Calculi, pancreatic, 630; salivary, renal, urinary, 672 Capillaries, structure, 46 ; two kinds, not equally abundant in all parts, 47 ; con- dition in inflammation, 49 Carcinoma of the uterus, 720; of nerves, 368 , of maxillary sinus, 477 ; of mouth, 478 ; scrotum, 695 ; penis, 702 ; stomach, 527 Carditis, acute, 454 Cartilaginous transformations, 119 Cartilages, articular, 269 ; loose cartilages of joints, 273 Caries of bones, 280 ; of teeth, 485 Cataract, 384 Caverns, tubercular, 163 Cellular texture, 218; ossification, 119 ; lesions, 218 ; acute inflammation, 218; gangrene, chronic inflammation, 220; induration, 220 ; morbid growths, 221; infiltration, 221; hemorrhage in, 221; emphysema, foreign substances, para- sitic animals, 222 Cellular transformations, 117 Chalk-stones, 274 Charbon, 307 Chaussier, case of tubercles in foetus, 151 Chlorosis, blood in, 216 Cholera, saline injections in, 207 Choroid coat, 379 Chordee, 699 Cicatrice, 102 Cicatrization, stages of, 102 Cirrhosis, 602 Congestion, causes of, 53 Coagulability of blood, want of, 203 Conjunctiva, 373 ; suppuration, 373; vesi- cles, 374 ; granulations, 374; pterygium, 375 Conjunctivitis, 373 Contaminated blood, effects of, 211 Contractility of muscles, 228 Contraction of arteries, 248 Cornea, 375 ; corneitis, suppuration, 375 ; ulceration, cicatrization, opacity, fatty degeneration, ossification, 377; fleshy excrescences, 378 Corpora lutea, 738 Crude tubercle, 157 Crusta lactea, 317 Crystalline lens, capsule of, 383 ; situation and structure, 383 ; cataract, 384 Cupped blood, 201 Cutaneous and mucous tissue, their mutual transformations, 118 Cutaneous system, 302. (See Skin.) Cylindroid aneurism, 250 Cysts, simple, 144; multilocular, 145 ; in- cluded, 145 ; inflammation of, 146 ; of brain, 355 Cysticercus, organization and situations of, 136; five species of; cellular, vesicular, dicystic, speckled, Fischerian, 137 Diabetes mellitus, 767 Demours, membrane of, 380 Diceras, 138 Diffuse inflammation, 219 Discoloration after death, 54 Disease, what; functional or organic, 36 ; result of inflammation, 36 ; modified by age, sex, climate, 37 Dropsy, 60 Da Hamel, case of malignant pustule, 212 Dupuy on experiments on the pneumo- gastric nerve, 205 ; on transfusion, 212 Duodenum, inflammation and ulceration of, 530 ; perforations, 531; rupture, car- cinoma, 532 Dura mater, inflammation of, 356 ; suppu- ration, fibrous tumors, 356 ; ossification, 357 ; Pacchionian glands, 357 Ear, 387 ; polypes, 387 ; tympanum, 388 ; Eustachian tube, labyrinth, 389 ; vesti- bule, auditory nerve, 390 Echinococcus, 138 Ecthyma, 315 Eczema, 324 Edson, Calvin, living skeleton, 226 Eiloid, 303 Elephantiasis, 326 Emphysema, of cellular texture, 222; lungs, 420 : vesicular, 420 ; interlobular, 421 Encephaloid, 177 ; seat and forms, 177; color and consistence, 178; structure, 179; origin; a disease of early life, 183 ; progress and termination, 185 ; in the muscles, 232; lymphatic glands, 267 ; brain, 354 ; bones, 296 ; skin, 304 ; eye, 385 ; lungs, 424; pleura, 447 ; heart, 457; peritoneum, 592 ; liver, 608 ; kid- ney, 646 ; prostate, 682 ; bladder, 657 ; testicle, 688 ; uterus, 721; ovary, 734; mamma, 757 Encysted tubercle, 154 INDEX. 765 Encephalitis, 339 Endocardium, 468 Endocarditis, characters, 468 ; effects, 470 Ephelis, 333 Epispadias, 749 Epulis, 491 Ergot, a cause of gangrene, 92 Erysipelas, 313 Erythema, 312 Exanthems, 311 Excavations, tubercular, 162 Exfoliation, 283 Exostosis, 290 Extrophy, 659 Eye, 371; ball of, 373 ; conjunctivitis, 373 ; | suppuration of conjunctiva, 373; vesi- ! cles, 374 ; granulations, 374; pterygium, 375 ; cornea, 375; corneitis, 375 ; sclero- tica, 379 ; choroid, 379 ; retina, 380 ; op- tic nerve, 380 ; aquo-capsulitis, aqueous humor, 381; filaria papillosa, 381; iritis, 381; capsular cataract, 383 ; lens, 384; lenticular cataract, 384; vitreous humor, 385 ; encephaloid, 385 ; melanosis, 386 Fallopian tubes ; inflammation, 740; wa- tery fluids in, 741 Fatty discharges from bowels, 544 Fibrinous calculus, 675 Fibrin, chemical composition, disposition to become organized, 66 ; mode of or- ganization, 67 ; tissues resulting from it, 70; its importance in producing union, 71; want of coagulability, 203 ; quantity of in health and disease, 204 Fibrous transformations, 118 j Filaria medinensis, 223 ; papillosa, 381 Fistules. Definition, situation, extent, 114; orifices, direction, formation, nature of discharge, state of surrounding tissues, 116 ; causes, 116 Fistule in anus, 578 Fluids and solids, 33 Fluke in liver, 610 Follicular enteritis, 513 Foy, analysis of melanosis, 165 Fractures, mode of union, 279 Fragility of bones, 288 Frambcesia, 327 Frontal sinus, 477 Fusible calculus, 674 Gall-bladder, inflammation of, 613 ; ulcer- ation, 614; dilatation, oedema, 614; sup- puration, 614; rupture, atrophy, 615; ducts, lesions of, 615 ; bile, 617 Gall-stones, 617 ; symptoms, 618 Ganglia, nervous, 367 ; lesions, 367 Ganglions, lymphatic, 265 Ganglion of tendons, 236 Gangrene, 89 ; characters and seat, 89 ; causes, 91; senile gangrene, 94 ; cellu- lar tissue, 218 ; bones, 282 ; skin, 307 ; brain, 344; nerves, 368; lungs, 416; heart, 455 ; teeth, 485 ; gastro-enteric mucous membrane, 514; liver, 599; spleen, 621 ; rare in the kidneys, 637; also in bladder, 654 Gastro-enteric mucous membrane, its or- ganization, 500 ; glands of Brunner, 502; color ; color in foetus, and during diges- tion, 501 ; color, influenced by the kind of death, 502 ; acute inflammation, 503 ; redness, 504; arborescent and capilliform injection, 505 ; speckled appearance, 505; vascularity, 507; transparency, 508 ; dryness, thickness, softening, 508 ; vesi- cular eruption, 509 ; plastic exudations, 509 ; suppuration and effusion of blood, 510; rice-water secretion, 511; follicular enteritis, 513 ; gangrene, 514 ; chronic inflammation, 515 ; its characters, 515; softening, stages of, 518 ; color of, do. 519 ; softening, by the gastric juice, 520 Gendrin, experiments on transfusion, 211; Generation, organs of, in male, 683 ; in fe- male, 707 Gibson, Dr., remarkable case of fragility of bones, 288 Glands, lymphatic, 265 ; of Peyer, 533 Gleet, 699 Glossitis, 479 Goitre, 394 Graafian vesicles, 740. Granulations, 98; structure and sensi- bility, 100 ; absorb and secrete; their importance, 101 Granulated kidney, 638 Granulated liver, 602 Gubernaculum testis, transformation, 117 Guinea worm, 223 Gums ; epulis, 491; ulcerative absorption, 489 ; abscess, 491 Hsemophthalmus, 381 Haemoptysis, 441 Hair, lesions of, 335 ; Polish plait, 335 ; atrophy, hypertrophy, 336 ; other lesions, 337 Heat of inflammation, experiments on, by Hunter, Home, and Huber, 42 Heart, situation, 453 ; weight and dimen- sions, 453 ; carditis, 454 ; suppuration and ulceration, 455 ; gangrene, 455 ; soft- ening, 455 ; induration, cartilaginous and osseous transformations, 456 ; scir- rhus, encephaloid, 457 ; fatty transfor- mation, 457 ; apoplexy, atrophy, 459 ; dilatation, 462; passive aneurism, sac- culated aneurism, 462 ; rupture, 463 ; tubercles and melanosis, 457; serous cysts and hydatids, 457; hypertrophy, 459 Hematosine, relative quantity in males and females, 206 ; is slowly reproduced when removed, 206; its condition in cholera, typhus, and plague, 206 ; effects of dividing the pneumogastric nerve on, 207 Hemorrhage, causes of, 82 ; most frequent seat, 84; different kinds of, 84; quan- / 766 INDEX. tity, 86; remarkable case of, following | extraction of a tooth, 203; hereditary j cases, 204; how arrested by nature, 239; from the skin, 310 Hemorrhagic diathesis, 204; causes, 204 Hemorrhoids, two varieties of, 575 Henry, Dr., on the composition of melano- sis, 165 Hepatitis, 596 Hernia, varieties of, 553 Herpes, 326 Heterologous formations; classification, 147 ; duration and origin, 148 Horny excrescences, 305 Hughes, Dr., cases of hereditary predis- position to hemorrhage, 204 Hunter, John, experiments on heat, 42 Hydatids, seat of; met with in nearly all animals, 135 ; organization and classi- fication, 135 ; origin, 140; how nourished, 141; mode of termination, 142; apo- plexy of, 142 ; in muscles, 233 ; burses, 238 ; bones, 294; brain, 355 ; lungs, 425 ; liver, 608 ; spleen, 625 ; kidney, 645 ; testicle, 689 ; uterus, 725 Hypertrophy, causes, 108 ; general or lo- cal, 109 ; color, weight, and volume, 110; its nature, 110 ; hypertrophy of the adi- pose tissue, 225 ; muscles, 232 ; arteries, 247 ; lymphatics, 266 ; bones, 288 ; skin, 304; nails, 334; hairs, 336; brain, 352 ; spinal cord, 364; nerves, 369; thymus gland, 392; thyroid gland, 394; lungs, 426; heart, 459 ; tongue, 480; salivary glands, 483 ; tonsils, 493 ; stomach, 524 ; small bowels, 542 ; liver, 601; spleen, 623 ; kidney, 641; bladder, 654 ; pros- tate, 677; testis, 692; clitoris and nymphse, 746 ; mamma, 749 Hypospadias, 701 Ichthyosis, 329 Impetigo, 316 Induration, 104 ; color and degrees of in- duration, 105 ; period necessary for its production, causes, 106 ; termination and results, 107 ; of cellular tissue, 220; muscles, 229 ; arteries, 244; brain, 349 ; spinal cord, 364 ; heart, 456 ; liver, 601; spleen, 623 ; kidney, 641; uterus, 714 Infiltration, tubercular, 154 Inflammation, originally local; modified by age, sex, climate, 37; acute and chronic, 38; its frequency in different organs variable, 38; common and spe- cific, 39 ; its nature and symptoms, 39- 46 ; its seat, 46 ; agency of the vascular end nervous systems, 49 ; condition of the capillaries, 49 ; theories of Boer- haave, Cullen, and others, 57 ; termina- tions of inflammation, 58 ; buffy coat of blood in, 200 ; cellular texture, 218 ; adi- pose tissue, 223; muscles, 228 ; tendons, 235 ; aponeuroses, 236 ; burses, 237; ar- teries, 238; veins, 257; lymphatics, 263; lymphatic glands, 265 ; joints, 269 • synovial membrane, 272; liga- ments, 275 ; bones, 279 ; periosteum, 3(10 • dura mater, 356 ; arachnoid, 358 ; pia 'mater, 362 ; brain, 339 ; nerves,. 368 ; lachrymal gland, 371; conjunc- tiva 373; cornea, 375 ; sclerotica, 379 ; choroid, 379; retina, 380; iris, 381; tympanum, 388 ; thyroid gland, 393; larynx, 397 ; trachea, 403 ; bronchia, 404; lungs, 410 ; pleura, 442; pericar- dium, 448 ; heart, 454; endocardium, 468 ; nasal cavity, 473 ; maxillary sinus, 476; frontal sinus, 477 ; tongue, 479 ; salivary glands, 482 ; teeth, 486 ; tonsils, 492 ; pharynx, 495 ; oesophagus, 496 ; gastro-enteric mucous membrane, 503 ; duodenum, 530; vermiform appendage, 570 ; peritoneum, 585 ; liver, 595 ; gall- bladder, 613 ; spleen, 620; pancreas, 627 ; kidney, 634 ; bladder, 652 ; pros- tate, 676 ; testicle, 683; seminal vesicles, 694 ; penis, 698 ; uterus, 711; ovary, 733; Fallopian tubes, 740; vagina and vulva, 742 ; mamma, 748 ; placenta, 759 Intestinal worms; lumbricus, 580 ; trico- cephaloid, 583 ; tape-worm, 584 Intussusception, 551 Inversion of uterus, 711 Iris, inflammation of, 381 ; prolapse of, 382 ; pupil, alterations of, 382 Itch ; itch insect, 325 Jaundice, state of blood in, 216 Joints, 269 ; inflammation, softening, sup- puration of cartilages, 270 ; ulceration, 270 ; ossification, 271 Keloid, 302 Kentucky giant, 224 Kidneys ; congenital vices, 633; lesions of their fibrous covering, 633; acute in- flammation of, 634 ; granular degenera- tion, 638 ; induration, 641; hypertrophy and atrophy, 641; encephaloid, 646 ; tu- bercles, melanosis, 647; serous cysts, 642; hydatids, 645 ; ossification and fatty de- generation, 642 ; laceration, 650; concre- tions, 648 ; strongyli, 649 Labyrinth of the ear, 390 Lachrymal apparatus, 371; gland, inflam- mation of, 371; scirrhus, serous cysts of, 372; excretory ducts, dilatation of, inflammation of, 372; lachrymal sac, 373 Lamellated transformation, 119 ; tubercu- lar deposit, 154 ; melanosis, 167 Lambert, Daniel; hypertrophy of adipose tissue, 224 Lardaceous tissue, 172 Large bowel, ulceration of, 565; cicatriza- tion, 566; vermiform appendage, dis- eases of, 570; hypertrophy of coats of the colon, 567 ; excrescences, 567 ; gene- INDEX. 767 ral diseases of mucous membrane, 568 ; carcinoma, 571 ; organic stricture of the rectum, 573 ; spasmodic stricture, 574 ; polypes, 574; hemorrhoids, 575 ; vari- cose enlargement of veins of rectum, 577 ; prolapse of anus, 578 ; fistule, 578 ; malformations, 579 Larynx, inflammation, 397 ; oedema of glot- tis, 398 ; membranous croup, 398 ; ulcer- ation of larynx, 400 ; osseous transfor- mations, 401; polypes, 401; warty ex- crescences, tubercles, hydatids, 402 ; en- cephaloid, 402 Lens, crystalline, 383 Lenticular cataract, 384 Lentigo, 332 Lepoides, 303 Lepra, 328 Lichen, 321 Ligaments, lesions, 275 ; mode of repara- tion, inflammation, 275; atrophy, cal- careous concretions, 276 Lips, encysted tumor of; hare-lip, 478 Liver, weight, color, and analysis of, 595; situation, 595 ; inflammation, 595 ; ana- tomical characters of, 596 ; suppuration, 597; gangrene, 599; softening, 600; in- duration, 601; hypertrophy, 601; atrophy, 601 ; granulated, 602 ; nutmeg liver, cir- rhosis, 602; tubercles, 607 ; scirrhus, 607 ; encephaloid, gelatiniform sarcoma, 608; melanosis, hydatids, 608 ; serous cysts, 609; fatty liver, 604; parasites, 610 ; osseous and. cartilaginous deposits, 610 ; erectile tumors, rupture, 611 Lombard, Dr., on relative frequency of tu- bercles in different organs of young sub- jects, 150 Louis, on site of tubercle in adults, 150 Lumbricoid worm, 580 Lungs, lesions of, 409 ; acute inflammation, stages of, 410; symptoms of inflamma- tion, 410; terminations, 414; chronic inflammation, 418 ; oedema, 419 ; em- physema, 420 ; apoplexy, 422 ; encepha- loid, 424; melanosis, 424 ; serous cysts, hydatids, 425; calcareous concretions, 425 ; hypertrophy, atrophy, 426 ; tuber- cles, 427 ; varieties of tubercular depo- sit, 427 ; cicatrization of tubercular cavi- ties, 433; haemoptysis, 441 Lupus, 327 Luteal bodies of the ovaries, 738 Lymph, uniformly the result of inflamma- tion, 63 ; forms of, 66 ; chemical compo- sition, 66 ; organization of, 67; tissues resulting from it; analogous tissues, 70 ; importance of in the union of divided parts, 70 Lymphization, 63 Lymphatics, lesions of, 263 ; inflammation, 263 ; suppuration, tubercles, ossification, dilatation, 264 ; aneurism, 264; oblite- ration of thoracic duct, 264 Lymphatic glands, 265; inflammation, 265 ; suppuration, gangrene, hypertrophy, 266; scirrhus, encephaloid, 267; tubercles, ossification, 268 Male organs of generation, 683 Malignant pustule, 307 Mammary gland, inflammation, acute and chronic, 748 ; adenoid tumor, 750 ; milk tumor, butyrous tumor, 752; scirrhus, 755; encephaloid, 757 ; hydatids, tuber- cles, colloid, 758 ; cystic sarcoma, 753; hypertrophy, atrophy, 749; calcareous concretions, 754; melanosis, 759 ; neu- ralgia, 755 ; apoplexy, 754; obstruction of ducts, 752 Mammary sarcoma, 753 Maxillary sinus, 476; carcinoma, exosto- sis, 477 Medullary membrane of bones, 301; in- flammation of, 302 Melanosis, 164; found in man and lower animals ; chemical analysis of, 165 ; co- lor and forms, 166; most common seat, 168; causes, 169; muscles, 231; lym- phatics, 267 ; bones, 298 ; periosteum, 301; skin, 304; brain, 353; eye, 386; lungs, 424; heart, 457 ; small bowels, 543; peritoneum, 592; liver, 608; pan- creas, 630; kidney, 646; mammary gland, 752 Miliaria, 324 Miliary tubercle, 153 Milky serum, case of, 208 ; characters of, 208 Moles, 728 Mucous membrane, gastro-enteric, see gas- tro-enteric mucous membrane. Mucous transformations, 118 Multilocular cyst; most frequent in the brain; is found in the ovaries, 145 Mumps, 482 Muscular system, 227; mode of union, 227; acute inflammation, suppuration, 228; gangrene, chronic inflammation, ulceration, softening, induration, 229; ossification, fibrous transformation, 230; fatty degeneration, tubercles, melanosis, scirrhus, encephaloid, colloid., 232; hy- pertrophy, atrophy, parasites, 233 ; apo- plexy, 234 Naevus, 254 Nails, 334; hypertrophy, 334; onyxitis, 335 Nasal sinus, 473; inflammation, 473; ozoena, epistaxis, polypes, 474 Necrosis, 282 Nephritis, 635 Nerves, restorative power, 367; neuritis, 367 ; suppuration, 368; ulceration, gan- grene, carcinoma, hypertrophy, tuber- cles, atrophy, 369; tumors, 369 ; en- largement of ganglia, 370 Nervous system, 338 ; influence of, on the blood, 207 768 INDEX. Neuritis, 367 Nigritism, 333 Nutrition, how affected by inflammation, Obesity, 224 OEdema, 60 ; of cellular texture, 221 Oesophagus, inflammation of, 496 ; ulcera- tion, abscess, 497; softening, stricture of, 498; dilatation, 498; carcinoma, 499 ; laceration, 499 ; malformations, 499 Oil, in serum, 208 Onyxitis, 335 Optic nerves, diseases of, 380 Organs of generation in male, 683 ; in fe- male, 707 Osseous transformations, 119 ; three varie- ties of; of the dura mater, 120; most common seat and mode of formation, 120 .Osseous system, 276 (see bones) Ossification, is it always preceded by car- tilage ? 119 ; of muscles, 230; tendons, 235 ; lymphatics, 263; lymphatic glands, 268 ; cartilages of joints, 271; perios- teum, 301 ; dura mater, 356; of the laryngeal cartilages, 401; tracheal rings, 404; pleura, 446; heart, 456; endo- cardium, 469 ; peritoneum, 596 ; liver, 610; gall-bladder, 615; spleen, 625; kidney, 642; uterus, 720; placenta, 760 Osteitis, 279 Osteo-sanguineous disease, 294 Osteo-sarcoma, 298 Ovaries, weight and dimensions, 732 ; in- flammation, 733; suppuration, soften- ing, tubercles, melanosis, scirrhus, 734 ; encephaloid, colloid, fibrous tumor, 734 ; serous cysts, 735 ; hydatids, 737 ; teeth in, 737 ; atrophy, 737 ; hemorrhage, 738 ; luteal bodies, 738; their structure and mode of formation, 738 Oxalic acid calculus, 673 Palate, soft; polypes, 494; split palate, uvula, hypertrophy of uvula, 495 Pancreatic scirrhus, 172 Pancreas, diseases of, 627 ; softening, gan- grene, chronic inflammation, 628 ; atro- phy, hypertrophy, 628; scirrhus and encephaloid, 629; fatty degeneration, serous cysts, tubercles, melanosis, 630 ; laceration, calculi, 630 Papillas of skin, 304; of tongue, their dis- eases, 481 Papular diseases of skin, 321 Paraphymosis, 706 Parotid, inflammation of, 482 Pellagra, 330 Pemphigus, acute and chronic, 322 Penis, acute inflammation of urethra, 698 ; chronic do., gleet, chordee, stricture of urethra, 699; abscess, malformations of urethra, 701 ; morbid erection, pectini- form septum, carcinoma, 702 ; chancres, 703; herpetic ulcers, 705 ; psoriasic ul- cers, 705 ; phymosis and paraphymosis, 705 Pericarditis, 448 ; hydro-pericardium, effu- sion of pus, 449 ; effusion of blood., air in, serous cysts in, 451 Pericardium, 448 Periosteum, lesions of, 300 ; inflammation of, 300 ; ossification, melanosis, 301 Periostitis, 300 Peritoneum, acute inflammation of, 585 ; adhesions, 586; pus in cavity of, 586; gangrene, chronic inflammation, 587; false membranes, fistulous openings, 5^8 ; tubercles, ascites, 590 ; melanosis, scirrhus, and encephaloid, 592 Peyer's glands, 533 Pharynx, inflammation of, 495 ; abscess of, sacculated, 496 Phlebolites, 260 Phlegmonous inflammation, 219 ; erysipe- las, 313 Phosphatic calculus, 674 Phthisis, 427 ; miliary tubercle, 428 ; gray granulation, 427 ; stratiform, 428 ; ca- verns and excavations, 429; cicatriza- tion, 433; sex, influence of, 435 ; age, 436; duration of phthisis, 436; is it contagious ? 436 ; disease of pleura in phthisis of air-passages, heart, 437; spleen and liver, 438 ;, stomach and in- testines, 439 ; anal fistule an infrequent attendant on phthisis, 440; disease of lymphatics, brain, 440 ; nature of phthi- sis, 440; haemoptysis, 441 Phymosis, 705 Pityriasis, 328 Pia mater, inflammation of, tubercles, ossi- fication, cysts in, 362 Piles, two varieties of, 575 Placenta, inflammation of, 759; softening, suppuration, cartilaginous degeneration, ossification, 760; fatty transformation, 761; hypertrophy and sanguineous effu- sions, 761 Pleura, 442; acute inflammation of, 442; gangrene, 443 ; concretions, formation of gas, 445; ulceration, ossification, tuber- cles, scirrhus, encephaloid, 447 ; chronic inflammation, 444 Pleurisy, 442 (see pleura) Plica polonica, 335 Pneumatosis, history, frequency, names by which it is known, form, 122; extent, physical and chemical properties, causes, 123; effects on neighboring organs, most frequent in females, 126 ; duration, 127 • termination, 127 Poisons, acrid, effects of on the gastro- enteric mucous membrane, 506 Pneumonia, acute, 410; stages of 410- terminations, 414 ; gangrene, resulting from, 41b ; chronic pneumonia, 418 INDEX. 769 Polycephalus, characters and situation of, 137 Polypes, situation, not peculiar to human subjects, number, 128 ; size, form, struc- ture, varieties, 129 ; degeneration, 131; period of life, sex, effects, 132; true character, 133 ; of the ear, 387; larynx, 401; nasal cavity, 474; maxillary sinus, 477 ; pharynx, 496 ; uterus, 717; va- gina, 743 Porrigo, 316 Prolapse of rectum, 578 ; uterus, 711 Prostate gland, 676 ; acute inflammation of, ulcerations, chronic inflammation, hy- pertrophy, 677 ; atrophy, fibrous tumors, 681; tubercles, calculi of, 682; phlebo- lites, 682 Prurigo, 322 Psoriasis, 329 Pterygium, 375 Pupil, lesions of, 382 Pulmonary apoplexy, 422 Punctiform melanosis, 167 Pus, 77 ; healthy, 80 ; scrofulous, sanious, fibrinous, contagious, muco-purulent, 80; characters and mode of production, 81 Pustular diseases of skin, 314 (see skin) Pustule, malignant, 307 Pyelitis, 633 Redness as a symptom of inflammation, 41 Regeneration of bones, 284 Rectum, organic stricture of, 573; spas- modic stricture, 574 Red particles of blood, their physical and physiological characters, 198 Respiratory apparatus, 397 Retina, 380 Retroversion-of the uterus, 710 Rives, tubercles in an infant, case of, 151 Roseola, 312 Rubeola, 312 Rupia, 323 Saline injections in cholera, 207 Salivary glands, inflammation of, 482; suppuration, gangrene, 483; atrophy, hypertrophy, scirrhus, fatty degenera- tion, salivary calculi, ranula, 484 Salts of blood, abstraction of, 207 Sanguineous liquor, 199 Scabies, 325 Scaly diseases of skin, 327 Scaly tetter, 329 Scarlatina, 313 Scirrhus, 170; varieties of; tuberoid, infil- trated, stratiform, 171; mammary, pan- creatic, lardaceous, 172 ; reticular carci- noma, 172; chemical composition, 173 ; influence of age and sex, 173 ; most com- mon situation, 174; causes, 175 ; changes, 176 ; muscles, 232; bones, 297; lachrymal gland, 372; thymus gland, 393; thyroid gland, 396 ; heart, 457 ; parotid, 483; oesophagus, 499; pylorus, 529 ; perito- neum, 591; liver, 607; kidney, 646; 49 prostate gland, 682; testicle, 688 ; womb, 720; ovary, 734; breast, 755 Sclerotica, diseases of, 379 Scrotum, cancer of, sarcomatous enlarge- ment, 695 ; sloughing, concretions in, 698 Scurvy, 216 Sebaceous follicles, diseases of, 309 Seminal vesicles, diseases of, 694 Sequester, 283 Serous cysts, 143; seat and structure, 143 ; multilocular, 145 ; included cysts, 145 ; in brain, 355; lachrymal gland, 372; lungs, 425; pericardium, 451; spleen, 625 ; pancreas, 630; kidney, 642 ; ovary, 735 Serum, effusion, 59 ; color, consistence, and chemical composition, 60 ; causes, 61; serum of the blood, 208 ; milky serum, 208 ; causes of, 208 ; serum in inflamma- tion and other diseases, 209 Sheaths of tendons, 236 Skin, 302; unclassifiablc lesions of, 302; keloid, 302; eiloid, lepoid, 303; mela- nosis, 304; encephaloid, scirrhous tu- mors, 304; hypertrophy, 304; corns, 305 ; verruca, horns, 305 ; gangrene, 307 ; ma- lignant pustule, 307; white gangrene, sebaceous follicles, diseases of, 309 ; in- flammation, 309; hemorrhage, 310; class- ifiable lesions, exanthems, 311; roseola, urticaria, erythema, 312 ; rubeola, 312 ; scarlatina, 313 ; erysipelas, 313 ; pustu- lar diseases, acne, 314; sycosis, 315 ; ecthyma, impetigo, 316; porrigo, 316 ; crusta lactea, 317; vaccinia, 317 ; va- riola, 319; varicella, 321; papular dis- eases, lichen, prurigo, 321; bullar dis- eases, pemphigus, 322; rupia, 323 ; ve- sicular diseases, eczema, 324; miliaria, scabies, 325 ; herpes, 326 ; tubercular diseases, elephantiasis, 326 ; framboesia, lupus, 327; scaly diseases, lepra, pityri- asis, 328 ; ichthyosis, psoriasis, 329 ; pel- lagra, 330 ; syphilitic diseases, exanthe- matous, vesicular, 330; pustular, tuber- cular, papular, 331 ; scaly, 332; stains, lentigo, ephelis, albinism, 333 ; nigritism, 333 Small bowel, ulceration, 533; disease of glands in typhoid fever, 534; hypertro- phy, atrophy, 542 ; contraction and dila- tation, 542; tubercles, 542; carcinoma, melanosis, 543 ; concretions, fatty dis- charges, 544 ; laceration, 545 ; internal strangulation, 547 ; intussusception, 551; hernia, 553; abnormal pouches, 554; wounds, 555 ; artificial anus, 560 Softening, 87 ; causes, 88; of tubercles, 161; bones, 285 ; brain, 344-348 ; spinal cord, 364; heart, 455 ; oesophagus, 497 liver, 600; spleen, 621; pancreas, 627 kidney, 637 ; uterus, 713 ; ovaries, 733 gastro-enteric mucous membrane, 518 do. after death, 520 Solids and fluids, 33 770 INDEX. Spermatic cord, encysted hydrocele, vari- I cocele, 692 ; neuralgia, 693 Spicular transformation, 120 Spinal cord, inflammation, suppuration, softening, 364 ; induration, hypertrophy, atrophy, hydrorachitis, 365 Spina bifida, 365 ; analysis of fluid con- tents, 366 Spleen, 619 ; inflammation, 620 ; suppura- tion, 620 ; abscess, 621 ; gangrene, 621; softening, 621; induration and hepatiza- tion, 623 ; hypertrophy, 623 ; atrophy and tubercles, 624; lardaceous degene- ration, 624 ; calcareous matter, ossifica- tion, and hydatids, 625 ; fibro-cartilagi- nous, 625 ; serous cysts, apoplexy, 626 ; laceration, 626 Stains, 332 Stratiform tubercular deposit, 154; scir- rhus, 171; encephaloid, 178 Stomach and bowels, 500 Stomach, ulceration of, 522; perforation, 523 ; hypertrophy, 524 ; warty excre- scences, 525 ; hypertrophy of submucous tissue, 525; of muscular coat, 525 ; atrophy, 526 ; dilatation, 526 ; contrac- tion, 526 ; tumors, carcinoma, 527 ; lace- ration, rupture, 529 Stricture of urethra, 699 Strongylus, 649 Suggillations, 222 Suppuration, a result of inflammation, 72; muscles, 229 ; veins, 258 ; lymphatics, 263 ; joints, 270 ; synovial membrane, 273 ; bones, 280 ; dura mater, 356; brain, 341; spinal cord, 364; nerves, 368 ; tym- panum, 388 ; thyroid gland, 394; lungs, 415 ; pleura, 443 ; heart, 455 ; gums, 491; oesophagus, 497 ; gastro-enteric mucous membrane, 511; peritoneum, 586 ; liver, 597 ; spleen, 620 ; kidneys, 635 ; testicles, 687 Supra-renal capsules, 631 Sycosis, 315 Syphilitic diseases of skin, 330 ; exanthe- matous, vesicular, 331; pustular, tuber- cular, papular, 332; scaly, 332 Synovial membrane, 272 ; inflammation of, 272 ; suppuration, 273 ; ulceration, 273 ; chalk-stones, 274 Taenia solium, 584; lata, 584 Tape-worm, 584 Teeth, caries of, 485 ; gangrene, inflamma- tion, 486 ; exostosis, 487 ; calcareous con- cretions, 488 ; effects of age on, 488 ; in ovaries, 737 Tendons, mode of union when divided, 234 ; regeneration, inflammation, 235 ; ossification, atrophy, ganglions, 236 Tetter, 239 Testicle, weight and volume, 683 ; vaginal sac, hydrocele, 683 ; hsematocele, 686 ; concretions, acute and chronic inflamma- tion of testicle, 687 ; scirrhus and ence- phaloid, 688 ; colloid, cancer, melanosis, tubercles, 6S9 ; hydatids, 689; cartilage, ossification, 690 ; hypertrophy and atro- phy, 692 Thoracic duct, aneurism of, obliteration, 264 Thymus gland, 391; diseases, 391 Thyroid gland, 393 ; diseases, 393 Tissues, formation and combination of, 34 ; cellular tissue, 218 ; adipose, 223 ; mus- cular, 227 Tongue, inflammation of, 479 ; ulceration, aphtha?, hypertrophy, 480; of mucous membrane, 481 ; papillae, atrophy, vesi- cles, cancer, malformation, 482 Tonsils, inflammation, 492; suppuration, gangrene, ulceration, hypertrophy, 493 ; scirrhus, encysted tumor, tubercles, en- cephaloid, 494; calcareous concretions, 494 Trachea, trachitis, ulceration, 403 ; dilata- tion, laceration, ossification, stricture, 404 Transformations, 117 ; cellular, 117 ; mu- cous, fibrous, cartilaginous, 119 ; osseous, 119; adipose, 121 Transfusion, experiments on, 211 Trichina spiralis, 233 Tricocephaloid worm, 583 Tubercle, 148 ; seat of, how influenced by age, 149 ; comparative frequency in dif- ferent organs, 150; most frequent be- tween 20th and 40th years ; occurs at all periods of life; met with in lower animals, 151; composition, 152 ; miliary tubercle, encysted, 153 ; tuberculous in- filtration, stratiform do., 154 ; gray gran- ulation, 155; origin and nature, 156; organization, 156; microscopical ele- ments, 160 ; softening of, 161; calcare- ous degeneration, 163 ; muscles, 231; lymphatics, 263; bones, 299 ; of brain, 353 ; thyroid gland, 396 ; lungs, 427 (see phthisis) ; small bowels, 542; perito- neum, 590 ; liver, 607 ; spleen, 624 ; pan- creas, 630; kidney, 647 ; testicle, 689 ; seminal vesicle, 694; uterus, 723 Tubercular diseases of skin, 326 Tuberoid transformations, 120 ; melanosis, 166 ; scirrhus, 170 ; encephaloid, 177 Tympanum, inflammation, 3 8 8 ; suppura- tion, 388 Ulceration, 95; causes, 96; nature, 97. (For ulceration, see the different organs.) Ungueal matrix, 335 Union by first intention, 71 Ureter, 651 Urethra, male, inflammation of, 698 ; stric- ture, 699 ; malformations, 701; urethra of female, 746 Uric calculus, 672 Urinary apparatus, 631 Urinary bladder, 652 ; inflammation, sup- puration, softening, hypertrophy, gan- INDEX. 771 grene, 654; atrophy, cysts, ulceration, encephaloid, 657; neuralgia, tubercle, rupture, 658 ; worms, 659 ; calculi, 672 ; uric acid, 672 ; uro-ammoniac, 673 ; ox- alic, phosphatic, ammoniaco-magnesian phosphate, 674; fusible and cystic cal- culus, 674; xanthic oxide, fibrinous, 675 Urine, analysis of, diseases, 662 ; diabetes insipidus, 662 ; excessive secretion, 662 ; kiesteine, diabetes mellitus, 667 ; oil in urine, 667 ; bluish and black, 667 ; hairs in urine, 667 ; quantity, color, and odor, 668 ; density, 669 ; lithic deposit, 669 ; yellow and red amorphous sediments, 670 ; crystallized sediments, 670 ; oxalic and phosphatic deposits, 671 Urticaria, 312 Uro-ammoniac calculus, 673 Uterus, weight and volume, 707; malfor- mations, 708 ; malposition, 710; retrover- sion, anteversion, 711; prolapse, inver- sion, 711; inflammation, 711; ulceration, softening, 713; induration, hypertrophy, atrophy, 714 ; contraction of mouth, 714 ; enlargement of mucous follicles, 715 ; fibrous tumors, 715 ; polypes, 717 ; trans- formations, 719; malignant disease of uterus, 720; tubercles, 723; rupture, 723 ; hemorrhage, 724 ; water, air, 725 ; hair, hydatids, 725 ; moles, 728 Uvula, fissure of, 495 ; hypertrophy, 495 Vaccinia, 317 Vagina, inflammation, polypes, obstruction of, 742 ; prolapse, 744; short, double; bloody infiltration, ulcers, excrescences, 743 Varicella, 321 Varicose aneurism, 250 ; veins, 259 Variola, 319 Veins, inflammation, suppuration, 257; ulceration, chronic inflammation, 258; dilatation, hypertrophy, 259 ; oblitera- tion, calcareous deposits, phlebolites, 260 ; admission of air into veins, 261 Vermiform appendage, inflammation and ulceration of, 570 Verruca, 305 Vesicular diseases, 323 Vestibule, 390 Vitreous humor, 385 Wardrop on want of coagulability of blood, 203 ; hereditary case of, 204 Warts, 305 Worms, intestinal, 580 Xanthic calculus, 675 Yaws, 327 Yellow fever, blood in, 214 THE END. / BLANCHARD & LEA'S MEDICAL AND SURGICAL PUBLICATIONS. TO THE MEDICAL PROFESSION. In the present catalogue we have affixed prices to our publications, in obedience to the repeated requests of numerous members of the profession. While books, like all other articles, must necessarily vary somewhat in cost throughout the ex- tended territories of this country, yet our publications will generally be furnished at these rates by booksellers throughout the Union, who can readily and speedily procure any which they may not have on hand. To accommodate those physicians who have not convenient access to bookstores, or who cannot order through merchants visiting the larger cities, we will forward our works by mail, free of postage, on receipt of the printed prices in current funds or postage stamps. As our business is wholesale, and we open accounts with book- sellers only, the amount must in every case, without exception, accompany the order, and we can assume no risks of the mail, either on the money or the books; and as we only sell our own publications, we can supply no others. Physicians will, therefore, see the convenience and advantage of making their purchases, when- ever practicable, from the nearest bookseller. We can only add that no exertions are spared to merit a continuance of the gratifying confidence hitherto manifested by the profession in all works bearing our imprint. BLANCHAKD & LEA. Philadelphia, May, 1857. *3-* A copy of our new Illustrated Catalogue, 80 pages, octavo, will be sent free to any address on receipt of nine cents in postage stamps. Catalogues of our nume- rous publications in miscellaneous and educational literature forwarded on application. TWO MEDICAL PERIODICALS, FREE OF POSTAGE, FOR FIVE ©OULAISS PEK AWWUJfl. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to postage, when not paid for in advance,.......$5 00 THE MEDICAL NEWS AND LIBRARY, invariably in advance, - - 1 00 or, both periodicals furnished, free of postage, for Five Dollars remitted in advance. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. D., is published Quarterly, on the first of January, April, July, and October. Each number contains at least two hundred and eighty large octavo pages, handsomely and appropriately illustrated; wherever necessary. It has now been issued regularly for more than thirty-five years, and it has been under the control of the present editor for more than a quarter of a century. Throughout this long period, it has maintained its position in the highest rank of medical periodicals both at home and abroad, and has received the cordial support of the entire profession in this country. Its list ol Collaborators will be found to contain a large number of the most distinguished names of the pro- fession in every section of the United States, rendering the department devoted to ORIGINAL COMMUNICATIONS full of varied and important matter, of great interest to all practitioners. As the aim of the Journal, however, is to combine the advantages presented by all the different varieties of periodicals, in its REVIEW DEPARTMENT will be found extended and impartial reviews of all important new works, presenting subjects of novelty and interest, together with very numerous BIBLIOGRAPHICAL NOTICES, including nearly all the medical publications of the day, both in this country and Great Britain, with a choice selection of the more important continental works. This is followed by the 2 BLANCHARD & LEA'S MEDICAL QUARTERLY SUMMARY, being a very full and complete abstract, methodically arranged, of the IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES. This department of the Journal, so important to the practising physician, is the object of especial care on the part of the editor. It is classified and arranged under different heads, thus facilitating the researches of the reader in pursuit of particular subjects, and will be found to present a very full and accurate digest of all observations, discoveries, and inventions recorded in every branch oi medical science. The very extensive arrangements of the publishers are such as to afford to the editor complete materials for this purpose, as he not only regularly receives ALL THE AMERICAN MEDICAL AND SCIENTIFIC PERIODICALS, but also twenty or thirty of the more important Journals issued in Great Britain and on the Conti- nent, thus enabling him to present in a convenient compass a thorough and complete abstract of everything interesting or important to the physician occurring in any part of the civilized world. An evidence of the success which has attended these efforts may be found in the constant and t-teady increase in the subscription li>t, which renders it advisable for gentlemen desiring the Journal, to make known their wi>hes at an early day, in order to secure a year's set with certainly, the publishers- having frequently been unable to supply copies when ordered late in the year. To their old subscribers, many of whom have been on their list for twenty or thirty years, the publish- ers feel that no promises are necessary; but those who may desire for the first time to subscribe, can rest assured that no exertion will be spared to maintain the Journal in the high position which it has occupied for so long a period. By reference to the terms it will be seen that, in addition to this large amount of valuable and practical information on every branch of medical science, the subscriber, by paying in advance, becomes entitled, without further charge, to THE MEDICAL NEWS AND LIBRARY, a monthly periodical of thirty-two large octavo pages. Its "News Department" presents the current information of the day, while the " Library Department" is devoted to presenting stand- ard works on various branches of medicine. Within a few years, subscribers have thus received, without expense, the following works which have passed through its columns :— WATSON'S LECTURES ON THE PRACTICE OF PHYSIC. BRODIE'S CLINICAL LECTURES ON SURGERY. TODD AND BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. 724 pnges, with numerous wood-cuts, being all that has yet appeared in England. WEST'S LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. MALGAIGNE'S OPERATIVE SURGERY, with wood-cuts. SIMON'S LECTURES ON GENERAL PATHOLOGY. BENNETT ON PULMONARY TUBERCULOSIS, with wood-cuts, WEST ON ULCERATION OF THE OS UTERI, and BROWN ON THE SURGICAL DISEASES OF FEMALES, with wood-cuts. While in the number for July, 1856, was commenced a new and highly important work, which is continued throughout 1857. WEST'S LECTURES ON THE DISEASES OF WOMEN. Part I.—Diseases of the Uterus The very favorable reception accorded by the profession to the valuable "Lectures on the Diseases of Children," by the same author, which likewi; .__.wise appeared in this periodical, has in- duced the publishers to secure the present work for their subscribers, from advance sheets supplied by the author. The very high reputation of Dr. West, and the unusual clinical advantages which he has enjoyed, sufficiently indicate the practical value of a systematic work from his pen important a subject. The publishers, therefore, trust that its appearance in the " News" will entire satisfaction to their numerous subscribers, who will thus receive it free of all expen^ H3T For a more extended advertisement, see p. 32. which on so afford It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber will obtain a Quarterly and a Monthly periodical, EMBRACING ABOUT FIFTEEN HUNDRED LARGE OCTAVO PAGES, mailed to any part of the United States, free of postage. These very favorable terms are now presented by the publishers with the view of removing all difficulties and objections to a full and extended circulation of the Medical Journal to the office o every member of the profession throughout the United Slates. The rapid extension of manfheih ties will now place the numbers before subscribers with a certaintv and diJrmtnh n«t h . ? attainable; while by the system now proposed, every subscriber™WoS ^uSi^DSS &"e3Se g'at the V6ry re3S0nable pHCe °f FiVC D°UarS &t^!SriSd"3^!£l Those subscribers who do not pay in advance will bear in mind that their subscription of Fiw Do lars will entitle them to the Journal only, without the News, and that they w"ll be Tt he exnen^ of their own postage on the rece pt of each number. The advantage „f t L™A I expense ing the Journal will thus be apparent. numDer- iJie advantage of a remittance when order- As the Medical News and Library is in no case sent without advance payment its suh^riho™ will always receive it free of postage. payment, ns subscribers Remittances of subscriptions can be mailed at our risk, when a certificate i« taL-«n master that the money is duly inclosed and forwarded. certificate is taken from the Post- Address BLANCHARD & LEA, Phoammphia. AND SCIENTIFIC PUBLICATIONS. 3 ALLEN (J. M ), M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. THE PRACTICAL ANATOMIST; or, The Student's Guide in the Dissecting. ROOM. With 266 illustrations. In one handsome royal 12mo. volume, of over 600 pages, lea- ther. $2 25. (Now Ready.) In the arrangement of this work, the author has endeavored to present a complete and thorough course of directions in a clearer and more available form for practical use, than has as yet been accomplished. The chapters follow each other in the order in which dissections are usually con- ducted in this country, and as each region is taken up, every detail regarding it is fully described and illustrated, so that the student is not interrupted in his labors, by the necessity of referring from one portion of the volume to another. However valuable may be the " Dissector's Guides" which we, of late, liave had occasion to notice, we feel confident that the work of Dr. Allen is superior to any of them. We believe with the author, that none is so fully illustrated as this, and the arrangement of the work is such as to facilitate the labots of the student in acquiring a thorough practical knowledge of Anatomy. We most cordi- ally Tecommend it to their attention.—Western Lan- cet,Dec. 1856. We believe it to be one of the most useful works upon the subject ever written. It is handsomely illustrated, well printed, and will be found of con- venient size for use in the dissecting-room.—Med. Examiner, Dec. 1856. From Prof. J. S. Davis, University of Va. I am not acquainted with any work that attains so fully the object which it proposes. From C. P. Fanner, M. D., Demonstrator, Uni- versity of Michigan. I have examined the work briefly, but even this examination has convinced me that it is an excellent guide for the Dissector. Its illustrations are beau- tiful, and more than I have seen in a work of this kind. 1 shall take great pleasure in recommending it to my classes as the text-book of the dissecting- | room. ANALYTICAL COMPENDIUM OF MEDICAL SCIENCE, containing Anatomy, Physiology, Surgery, Midwifery, Chemistry, Materia Medica, Therapeutics, and Practice of Medicine. By John Neill, M. D., and F. G. Smith, M. D. New and enlarged edition, one thick volume royal 12mo. of over 1000 pages, with 374 illustrations. $W See Neill, p. 24. ABEL (F. A.), F. C.S. AND C. L. BLOXAM, HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical; with a Recommendatory Preface by Dr. Hofmann pages, with illustrations. $3 25. It must be understood that this is a work fitted for the earnest student, who resolves to pursue for him- Belf a steady search into the chemical mysteries of creation. For such a student the ' Handbook' will prove an excellent guide, since he will find in it, not merely the approved modes of analytical investi- gation, but most descriptions of the apparatus ne- ill one large octavo volume, extra cloth, of 662 cessary, with such manipulatory details as rendered Faraday's ' Chemical Manipulations' so valuable at the time of its publication. Beyond this, the im- portance of the work is increased by the introduc- tion of much of the technical chemistry of the manu- factory.—Dr. Hofmann's Preface. ASHWELL (SAMUEL), M. D., Obstetric Physician and Lecturer to Guy's Hospital, London. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised London edition. In one octavo volume, extra cloth, of 528 pages. (Lately Pub- lished.) $3 00. The most useful practical work on the subject in the English language. — Boston Med. and Surg. Journal. The most able, and certainly the most standard and practical, work on female diseases that we have yet seen.—Medico-Chirurgical Review. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- tions. $2 50. __________________ BUDD (GEORGE), M. D., F. R. S., Professor of Medicine in King's College, London. ON DISEASES OF THE LIVER. Second American, from the second and enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- fully colored plates, and numerous wood-cuts. pp. 468. $3 00. p nv vears Dr Budd's work must he the I the subject has been taken up by so able and experi- authoritv of the great mass of British practitioners enced a physician.—British and Foreign Medico- ot the hepatic diseases; and it is satisfactory that I Chirurgical Review. BY THE SAME author. (Now Ready.) ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. In one neat octavo volume, extra cloth. $1 50. style, the subjects are well arranged, and the practi- cal precepts, both of diagnosis and treatment, denote From the high position occupied by Dr. Budd as a teacher a writer, and a practitioner, it is almost Ledless to s7ate that the present book may be con- wtted with great advantage. It is written in an easy the character of a thoughtful and experienced phy- sician.— London Med. Times and Gazette, Dec. 1855. 4 BLANCHARD & LEA'S MEDICAL BROWN (ISAAC BAKER), Surgeon-Accoucheur to St. Mary's Hospital, &c. ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- MENT. With handsome illustrations. One vol. 8vo., extra cloth. (Now Ready.) $160. Mr. Brown has earned for himself a high reputa- tion in the operative treatment of sundry diseases and injuries to which females are peculiarly subject. We can truly say of his work that it is an important addition to obstetrical literature. The operative suggestions and contrivances which Mr. Brown de- scribes, exhibit much practical sagacity and skill, and merit the careful attention of every surgeon- accoucheur.—Association Journal. We have no hesitation in recommending this book to the careful attention of all surgeons who make female complaints a part of their study and practice. —Dublin Quarterly Journal. BENNETT (J. HUGHES), M.D., F. R. S. E., Professor of Clinical Medicine in the University of Edinburgh, &c. THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken for or associated with, Phthisis. In one handsome octavo volume, extra cloth, with beautiful wood-cuts. pp. 130. (Lately Issued.) $1 25. BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Fourth American, from the third and revised London edition. To which is added [July, 1856), a Review of the Present State of Uterine Pathology. In one neat octavo volume, extra cloth, of 500 pages, with wood-cuts. $2 00. The addition of the " Review" presents the most recent aspects of the questions discussed in this well-known work, bringing it down to the latest moment. This edition has been carefully revised and altered, | When, a few years back, the first edition of the and various additions have been made, which render ! present work was published, the subject was one al- if, more complete, and, if possible, more worthy of I most entirely unknown to the obstetrical celebrities the high appreciation in which it is held by the I of the day ; and even now we have reason to know medical profession throughout the world. A copy , that the bulk of the profession are not fully alive to should be in the possession of every physician.— the importance and frequency of the disease of which Charleston Med. Journal and Review. j it takes cognizance. The present edition is so much We are firmly of opinion that in proportion as a enlarged, altered, and improved, that it can scarcely knowledge of uterine diseases becomes more appre- I be considered the same work.—Dr. Banking's Ab- ciated, this work will be proportionably established ^ract. as a text-book in the profession.—The Lancet. ALSO, for sale separate, A REVIEW OF THE PRESENT STATE OF UTERINE PATHOLOGY. 1 small vol. 8vo. 50 cents. BIRD (GOLDING), A. M., M. D., &c. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. A new and enlarged American, from the last improved London edition. With over sixty illustrations. In one royal 12mo. vol, extra cloth, pp. 372. $ L 30. It can scarcelybe necessary forus to say anything extension and satisfactory employment of our thera- peutic resources. In the preparation of this new edition of his work, it is obvious that Dr. Golding Bird has spared no pains to render it a faithful repre- sentation of the present state of scientific knowledge on the subject it embraces.— The British and Foreign Medico-Chirurgical Review. of the merits of this well-known Treatise, which so admirably brings into practical application the re- sults of those microscopical and chemical researches regarding the physiology and pathology of the uri- nary secretion, which have contributed so much to the increase of our diagnostic powers, and to the BY THE SAME AUTHOR. ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Intro- ductionto the Physical Sciences. Illustrated with nearly four hundred wood-cuts. From the third London edition. In one neat volume, royal 12mo., extra cloth, pp. 402. $1 25. BILLING'S PRINCIPLES OF MEDICINE.— Second American, from the Fifth and Improved London edition. In one handsome octavo volume, extra cloth. 250 pages. $125. BLAKISTON'S PRACTICAL OBSERVATIONS ON CERTAIN DISEASES OF THE CHEST, and on the Principles of Auscultation. In one vol., cloth, 8vo pp. 384. $1 25. BURROWS ON DISORDERS OF THE CERE- BRAL CIRCULATION, and on the Connection between the Affections of the Brain and Diseases of the Heart. In one 8vo. vol., extra cloth with colored plates, pp. 216. $1 25. BEALE ON THE LAWS OF HEALTH IN RE- LATION TO MIND AND BODY. A Series of Lettf rs from an old Practitioner to a Patient In one volume, royal 12mo., extra cloth, pp 296 B0 cents. B vI^etaIlf^tpp^1^0?^ °,f AN1MAL a™ FunrHo^ »rS pk **'' a X °Pular Treatise, on the nn- I h d Phe?omena of Organic Life. In one handsome royal 12mo. volume, extra cloth with over 100 illustrations, pp. 2™'. 80 cent.i ' BUCKLER ON THE ETIOLOGY PA TROT nrv AND TREATMENT OP FIBRO-BRONmT' TIS AND RHEUMATIC PNEUMONIA In one 8vo. volume, extra cloth, pp.150. $125. BmHN A^UTiUiR,IrN?(MANUALS ON). BY JOHN WILLIAM GRIFFITH G owvivr REESE AND ALFRED MARKWICK? o£ ZLvt™h*V^mo->extra cloth- ** B GERY'S1 v^«ICAIl L,ECTURES ON SUR- IjfcKY. 1 vol. 8vo., cloth. 350 pp. $125. AND SCIENTIFIC PUBLICATIONS. 5 BARLOW (GEORGE H.)f M. D. Physician to Guy's Hospital, London, &c. A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. F. Condie, M. D., author of " A Practical Treatise on Diseases of Children," &c. In one hand- some octavo volume, leather, of over bOO pages. (A new work, just ready, 1856.) $2 75. The position of the author as physician to Guy's Hospital and other large public institutions, is a sufficient guarantee of the extent and value of the experience which is here systematically re- corded and condensed. His aim throughout has been to produce a practical work, on which the student can rely as a guide, and to which the practitioner can refer with confidence. The additions by the editor comprise chapters on Cerebro-spinal Meningitis, Cholera Infantum, and Yellow Fever, besides numerous notes wherever the diseases or practice of this country seemed to render them necessary or desirable. We most emphatically commend it to the attention of the profession, as deserving their confidence—a depository of practical knowledge, from which they may draw wiih great benefit.—Cincinnati Med. Ob- server, Mar. 1850. The student has long been in want of a gocd ele- mentary work on the Practice of Medicine. In Dr. Barlow's Manual that want is supplied; and we have no question that it will at once be installed as the favorite text-book in all Medical Schools.— Medical Times and Gazette. We recommend Dr. Barlow'sManual in the warm- est manner as a most valuable vade-mecum. We have had frequent occasion to consult it, and have found it clear, concise, practical, and sound. It is eminently a practical work, containing all that is essential, and avoiding useless theoretical discus- sion. The work supplies what has been for some time wanting, a manual of practice based upon mo- dern discoveries in pathology and rational views of treatment of disease. It is especially intended for the use of students and junior practitioners, but it will be found hardly less useful to the experienced physician. The American editor has added to the work three chapters—on Cholera Infantum, Yellow Fever, and Cerebro-spinal Meningitis. These addi- tions, the two first of which are indispensable to a work on practice destined for the profession in this country, are executed with great judgment and fi- delity, by Dr. Condie, who has also succeeded hap- pily in imitating the conciseness and clearness of style which are such agreeable characteristics of the original book.—Boston Med. and Surg. Journal. Feb. 1856. BARTLETT (ELISHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATE6. A new and revised edition. By Alonzo Clark, M. D , Prof. of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, &c. In one octavo volume, of six hundred pages, extra cloth. (Now Ready.) Price $3 00. The position which this work has obtained as one of our medical classics, renders unnecessary any remark further than to say that the editor, in executing the task assigned to him by the late author, has endeavored to render the work a faithful exposition of the subject in its most advanced condition. To effect this, a considerable amount of matter has been introduced, but by a slight enlargement of the page it has been accommodated without unduly increasing the bulk of the volume. The reputation of the editor as an accurate observer and philosophical writer is sufficient guarantee that, in his hands, the work will fully maintain its former character. The masterly and elegant treatise by Dr. Bartlett is invaluable to the American student and practi- tioner.—Dr. Holmes''s Report to the Nat. Med. Asso- ciation. We regard it, from the examination -we have made of it, the best work on fevers extant in our language, and as such cordially recommend it to the medical public.—St. Louis Medical and Surgical Journal. Take it altogether, it is the most complete history of our fevers which has yet been published, and every practitioner should avail himself of its con- tents.—The Western Lancet. BOWMAN (JOHN E.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Second Ame- rican, from the third and revised English Edition. In one neat volume, royal 12mo., extra cloth, with numerous illustrations, pp. 288. (Now Ready, 1856.) $ 1 25. Presenting, in a condensed and convenient form, at a very low price, the applications of Chemistry to the practical purposes of Clinical Medicine, this work supplies a want which has long been telt by the physician. The numerous editions which have been called for both in England and this country, sufficiently attest the success with which the author has carried out his plan. BY the same author. (Now Ready.) INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS. Second American, from the second and revised London edition. With numerous illus- trations. In one neat vol., royal 12mo., extra cloth, pp. 350. $1 25. CURLING (T. B.), F. R.S., Surgeon to the London Hospital, President of the Hunterian Society, &c. A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- TIC CORD, AND SCROTUM. Second American, from the second and enlarged English edi- tion In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. (Now Ready, 1856.) $2 00. In the revised English edition, of which this is a reprint, the author, for want of space, omitted the Anatomical Introduction. By a more condensed style of printing, room has been found in the present volume to retain this important portion without rendering the work inconveniently large. Some of the notes of the former American editor have also been incorporated, and a number of new illustrations introduced. With these improvements, and the thorough revision which it has enjoyed at the hands of the author, it will be found fully worthy to retain the authoritative position which it has acquired with regard to this class of affections. G BLANCHARD & LEA'S MEDICAL CARPENTER (WILLIAM B.), M. D., F. R. S., &.C., Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from the la, M. D., Professor of Surgery in the University of Heidelberg, &c. A SYSTEM OF SURGERY. Translated from the German, and accompanied with additional Notes and References, by John F. South. Complete in three very large octavo volumes, of nearly 2200 pages, strongly bound, with raised bands and double titles. $10 00. s BLANCHARD & LEA'S MEDICAL CONDIE (D. F.), M. D., &c. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fourth edition, revised and augmented. In one large volume, 8vo., leather, of nearly 750 pages. $3 00. From the Author's Preface. The demand for another edition has afforded the author an opportunity of again subjecting the entire treatise to a careful revision, and of incorporating in it every important observation recorded since the appearance of the last edition, in reference to the pathology and therapeutics of the several diseases of which it treats. In the preparation of the present edition, as in those which have preceded, while the author has appropriated to his use every important fact that he has found recorded in the works of others, having a direct bearing upon either of the subjects of which he treats, and the numerous valuable ob>ervations—pathological as well as practical—dispersed throughout the pages of the medical journals of Europe and America, he has, nevertheless, relied chiefly upon his own observations and experience, acquired during a long and somewhat extensive practice, and under circumstances pe- culiarly well adapied for the clinical study of the diseases of early life. Every species of hypothetical reasoning has, as much as possible, been avoided. The author has endeavored throughout the work to confine himself to a simple statement of well-ascertained patho- logical facts, and plain therapeutical directions—his chief desire being to render it what its title imports it to be, a practical treatise on the diseases of children. Dr. Condie?s scholarship, acumen? industry, and practical sense are manifested in this, as in all his numerous contributions to science.—Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the great- est satisfaction.—Western Journal of Medicine and Surgery. One of the best works upon the Diseases of Chil- dren in the English language.—Western Lancet. Perhaps the most full and complete work now be- fore the profession of the United States; indeed, we may say in the English language. It is vastly supe- rior to most of its predecessors.—Transylvania Med. Journal. AVe feel assured from actual experience that no physician's library can be complete without a copy of this work.—N. Y. Journal of Medicine. A veritable paediatric encyclopaedia, and an honoT to American medical literature.—Ohio Medical and Surgical Journal. We feel persuaded that the American medical pro- fession will soon regard it not only as a very good, but as the very best " Practical Treatise on the Diseases of Children."—American Medical Journal. We pronounced the first edition to be the best work on the diseases of children in the English language, and, notwithstanding all that has been published, we still regard it in that light.—Medical Examiner. CHRISTISON (ROBERT), M. D., V. P. R. S. E., &c. A DISPENSATORY; or. Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the most important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. It is not needful that w«. should compare it with this branch of knowledge which the student has a right to expect in such a work, we confess the omis- sion has escaped our scrutiny. We cordially recom- mend this work to such of our readers as are in need of a Dispensatory. They cannot make choice of a better.—Western Journ. of Medicine and Surgery. the other pharmacopoeias extant, which enjoy and merit the confidence of the profession : it is enough to say that it appears to us as perfect as a Dispensa- tory, in the present state of pharmaceutical science, eould be made. If it omits any details pertaining to COOPER (BRANSBY B.), F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, extra cloth, of 750 pages. $3 00. COOPER ON DISLOCATIONS AND FRAC- TURES OF THE JOINTS —Edited by Bransby B. Cooper, F. R. S., &e. With additional Ob- servations by Prof. J. C. Warren. A new Ame- rican edition. In one handsome octavo volume, extra cloth, of about 500 pages, with numerous illustrations on wood. $3 25. COOPER ON THE ANATOMY AND TREAT- MENT OF ABDOMINAL HERNIA. One large volume, imperial 8vo., extra cloth, with over 130 lithographic figures. $2 50. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty-five Miscellane- ous and Surgical Papers. One large volume, im- perial 8vo., extra cloth, with 252 figures, on 36 plutes. $2 50. ' COOPER ON THE STRUCTURE AND DIS- EASES OF. THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial 8vo., ex- tra cloth, with 177 figures on 29 plates. $2 00. COPLAND ON THE CAUSES, NATURE AND TREATMENT OF PALSY AND APOPLEXY In one volume, royal 12mo., extra cloth, pp. 326 80 cents. CLYMER ON FEVERS: THEIR DIAGNOSIS PATHOLOGY, AND TREATMENT In one octavo volume, leather, of 600 pages. $1 50. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Ad- ditions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, oc- tavo, leather, with numerous wood-cuts. pp. 720. CARSON (JOSEPH), M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvanm SYNOPSIS OP THE COURSE OF LECTURES ON MATERIA' MEDICA AND PHARMACY, delivered in the University of Pennsylvania. Second an,! revved e£ tion. In one very neat octavo volume, extra cloth, of 208 pages. (Now Ready) $1 50 AND SCIENTIFIC PUBLICATIONS. CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American, from the last and improved English edition. Edited, with Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 139 illustrations. In one very handsome octavo volume, leather. pj).510. $3 00. To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be- found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Gazette. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. The most popular work on midwifery ever issued from the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but one work on midwifery, and permitted to choose, we would unhesitatingly take Churchill.—Western Med. and Surg. Journal. It is impossible to conceive a more useful and elegant manual than Dr. Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on the subject which exists.—N. Y. Annalist. No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.—Monthly Journal of Medical Science. The clearness and precision of style in which it is written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this departmentof medical science, — N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for the frequent consultation of the young practitioner.— American Medical Journal. BY THE SAME author. (Now Ready, 1856.) ON THE DISEASES OF INFANTS AND CHILDREN. Second American Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating?, M. D. In one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, $3 25. In preparing this work a second time for the American profession, the author has spared no labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, while every portion of the volume has been subjected to a severe scrutiny. The efforts of the American editor have been directed to supplying such information relative to matters peculiar to this country as might have escaped the attention of the author, and the whole may, there- fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- rican Profession. By an alteration in the size of the page, these very extensive additions have been accommodated without unduly increasing the size of the work. A few notices of the former edition are subjoined :— The present volume will sustain the reputation acquired by the author from his previous works. The reader will find in it full and judicious direc- tions for the management of infants at birth, and a compendious, but clear account of the diseases to which children are liable, and the most successful mode of treating: them. \Ve must not close this no- We regard this volume as possessing more claims to completeness than any other of the kind with which we are acquainted. Most cordially and ear- nestly , therefore, do we commend it to our profession- al brethren, and we feel assured that the stamp of their approbation will indue time be impressed upon it. After an attentive perusal of its contents, we hesitate not to say, that it is one of the most com- prehensive ever written upon the diseases of chil- dren, and that, for copiousnessof reference, extent of research, and perspicuity of detail, it is scarcely to be equalled, and not to be excelled, in any lan- guage.—Dublin Quarterly Journal. tice without calling attention to the author's style, which is perspicuous and polished to a degree, we regret to say, not generally characteristic of medical works. We recommend the work of Dr. Churchill most cordially, both to students and practitioners, as a valuable and reliable guide in the treatment of the diseases of children.—Am. Journ. of the Med. After this meagre, and we know, very imperfect ■ sciences. notice of Dr. Churchill's work, we shall conclude by saying, that it is one that cannot fail from its co- piousness, extensive research, and general accuracy, to exalt still higher the reputation of the author in this country. The American reader will benarticu- larly pleased to find that Dr. Churchill has done full justice throughout his work to the various American authors on this subject. The names of Dewees, Eberle, Condie, and Stewart, occur on nearly every page, and these authors are constantly referred to by the author in terms of the highest praise, and with the most liberal courtesy.— The Medical Examiner. We know of no work on this department of Prac tical Medicine which presents so candid and unpre- judiced a statement or posting up of our actual knowledge as this.—N. Y. Journal of Medicine. Its claims to merit both as a scientific and practi- cal work, are of the highest order. Whilst we would not elevate it above every other treatise on the same subject, we certainly believe that very few are equal to it, and none superior.—Southern Med and Surgical Journal. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50. 10 BLANCHARD & LEA'S MEDICAL CHJJRCHILL (FLEETWOOD), M. D., M. R. I. A., &.C. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condie, M. D., author of << A Practical Treatise on the Diseases of Children." With mime rous iXstrations. In one large and handsome octavo volume, leather. (Now Ready, May, 1857.) S3 00. This "edition of Dr. Churchill's very popular treatise may almost be termed a new work so thoroughly has he revised it in every portion. It will be found greatly enlarged, and thoroughly brought up to the most recent condition of the subject, while the very handsome series of illustra- tions introduced, representing such pathological conditions as can be accurately portrayed, present anove" feature/and afford valuable assistance to the young practitioner. Such additions as ap- peared desirable for the American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone. A few notices of the former edition are subjoined :— larity. This fifth edition, before us. is well calcu- lated to maintain Dr. Churchill's high reputation. It was revised and enlarged by the author, for his American publishers, and it seems to us that there is We now regretfully take leave of Dr. Churchill's book. Had our typographical limits permitted, we should gladly have borrowed more from its richly stored pages. In conclusion, we heartily recom- mend it to the profession, and would at the same time express our firm conviction that it will not only add to the reputation of its author, but will prove a work of great and extensive utility to obstetric practitioners.—Dublin Medical Press. Former editions of this work have been noticed in previous numbers of the Journal. The sentiments of high commendation expressed in those notices, have only to be repeated in this; not from the fact that the profession at large are not aware of the high merits which this work really possesses, but from a desire to see the principles and doctrines therein contained more generally recognized, and more uni- versally carried out in practice.—N. Y. Journal of Medicine. We know of no author who deserves that appro- bation, on " the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and stu- dents as a masterpiece in its particular department. The former editions of this work have been com- mended stronglv in this journal, and they have won their way to an extended, and a well-deserved popu- scarcely any species of desirable information on its subjects that may not be found in this work.—Th* Western Journal of Medicine and Surgery. We are gratified to announce a new and revised edition of Dr. Churchill's valuable work on the dis- eases of females We have ever regarded it as one of the very best works on the subjects embraced within its scope, in the English language; and the present edition, enlarged and revised by the author, renders it still more entitled to the confidence of the profession. The valuable notes of Prof. Huston have been retained, and contribute, in no small de- gree, to enhance the value of the work. It is a source of congratulation that the publishers have permitted the author to be, in this instance, his own editor, thus securing all the revision which an author alone is capable of making.—The Western Lancet. Asa comprehensive manual for students, or a work of reference for practitioners, we only speak with common justice when we say that it surpasses any other that has ever issued on the same sub- ject from the liritish press.—The Dublin Quarterly Journal. DICKSON (S. H.), M. D., Professor of Institutes and Practice of Medicine in the Medical College of South Carolina. ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- peutics, or the History and Treatment of Diseases. In one large and handsome octavo volume, of 750 pages, leather (Lately Issued.) $3 75. As an American text-book on the Practice of Medicine for the student, and as a condensed work of reference for the practitioner, this volume will have strong claims on the attention of the profession. Few physicians have had wider opportunities than the author for observation and experience, and few perhaps have used them better. As the result of a life of study and practice, therefore, the present volume will doubtless be received with the welcome it deserves. This book is eminently what it professes to be; a distinguished merit in these days. Designed for Teachers and Students of Medicine," and admira Uly suited to their wants, we thin kit will be received, on its own merits, with a hearty welcome.—Boston Med. and Surg. Journal. Indited by one of the most accomplished writers of our country, as well as by one who has long held a high position among teachers and practitioners of medicine, this work is entitled to patronage and careful study. The learned author has endeavored to condense in this volume most of the practical matter contained in his former productions, so as to adapt it to the use of those who have not time to devote to more extensive works.—Southern Med. and Surg. Journal. We can strongly recommend Dr. Dickson's work to our readers as one of interest and practical utility, well deserving of a place in their libraries as a book of reference; and we especially commend the first part as presenting an admirable outline of the princi- ples of medicine.—Dublin Quarterly Journal, Ftb. 1850 This yolume, while as its title denotes it is a compendious view, is also a comprehensive system of practice, perspicuously and pleasantly written, and admirably suited to engage the interest, and in- struct the reader.—Peninsular Journal of Medicine, Jan. 1850. Prof. Dickson's work supplies, to a great extent, a desideratum long felt in American medicine.—N. O. Med. and Surg. Journal. Estimating this work according to the purpose for which it is designed, we must think highly of its merits, and we have no hesitation in predicting for it a favorable reception by both students and teachers. Not professing to be a complete and comprehensive treatise, it will not be found full in detail, nor filled with discussions of theories and opinions, but em- bracing all that is essential in theory and practice, it is admirably adapted to the wants of the American student. Avoiding all that is uncertain, it presents more clearly to the mind of the reader that which is established and verified by experience. The varied and extensive reading of the author is conspicuously apparent, and all the recent improvements and dis- coveries in therapeutics and pathology are chroni- cled in its pages.— Charleston Med. Journal. In the first part-of the work the subject of gene- ral pathology is presented in outline, giving a btau- tiful picture of its distinguishing features, and throughout the succeeding chapters we find that he has kept scrupulously within the bounds of sound reasoning and legitimate deduction. Upon the whole, we do not hesitate to pronounce it a superior work in its class, and that Dr. Dickson merits a place in the first rank of American writers.—Weste m Lancet. AND SCIENTIFIC PUBLICATIONS. 11 DRUITT (ROBERT), M.R. C.S., &c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American, from the improved London edition. Edited by F. W. Sargent, M. D., author of " Minor Surgery," &c. Illustrated with one hundred and ninety-three wood-engravings. In one very handsomely printed octavo volume, leather, of 576 large pages. $3 00. Dr. Druitt's researches into the literature of his subject have been not only extensive, but well di- rected; the most discordant authors are fairly and impartially quoted, and, while due credit is given to each, their respective merits are weighed with an unprejudiced hand. The grain of wheat is pre- served, and the chaff is unmercifully stripped off. The arrangement is simple and philosophical, and the style, though clear and interesting, is so precise, that the book contains more information condensed into a few words than any other surgical work with which we are acquainted.—London Medical Times and Gazette. No work, in our opinion, equals it in presenting so much valuable surgical matter in so small a compass.—St. Louis Med. and Surgical Journal. Druitt's Surgery is too well known to the Ameri- can medical profession to require its announcement anywhere. Probably no work of the kind has ever been more cordially received and extensively circu- lated than this. The fact that it comprehends in a comparatively small compass, all the essential ele- ments of theoretical and practical Surgery—that it is found to contain reliable and authentic informa- tion on the nature and treatment of nearly all surgi- cal affections—is a sufficient reason for the liberal patronage it has obtained. The editor, Dr. F. W. Sargent, has contributed much to enhance the value of the work, by such American improvements as are calculated more perfectly to adapt it to our own views and practice in this country. It abounds everywhere with spirited and life-like illustrations, which to the young surgeon, especially, are of no minor consideration. Every medical man frequently needs just such a work as this, for immediate refer- ence in moments of sudden emergency, when he has not time to consult more elaborate treatises.—The Ohio Medical and Surgical Journal. The author has evidently ransacked every stand- ard treatise of ancient and modern times, and all that is really practically useful at the bedside will be found in a form at once clear, distinct, and interest- ing.—Edinburgh Monthly Medical Journal. Druitt's work, condensed, systematic, lucid, and practical as it is, beyond most works on Surgery accessible to the American student, has had much currency in this country, and under its present au- spices promises to rise to yet higher favor.—The Western Journal of Medicine and Surgery. The most accurate and ample resume of the pre- sent state of Surgery that we are acquainted with.— Dublin Medical Journal. A better book on the principles and practice of Surgery as now understood in England and America, has not been given to the profession.—Boston Medi- cal and Surgical Journal. An unsurpassable compendium, not only of Sur- gical, but of Medical Practice.—London Medical Gazette. This work merits our warmest commendations, and we strongly recommend it to young surgeons as an admirable digest of the principles and practice of modern Surgery.—Medical Gazette. It maybe said with truth that the work of Mr. Druitt affords a complete, though brief and con- densed view, of the entire field of modern surgery. We know of no work on the same subject having the appearance of a manual, which includes so many topics of interest to the surgeon ; and the terse man- ner in which each has been treated evinces a most enviable quality of mind on the part of the author, who seems to have an innate power of searching out and grasping the leading facts and features of the most elaborate productions of the pen. It is a useful handbook for the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinion, it is admirably adapted to the wants of the student.— Provincial Medical and Surgical Journal. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. *ifc* This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine I titioner. This estimate of it has not been formed extant; or, at least, in our language.— Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner.—Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.—Medical Examiner. We rejoice that this w6rk is to be placed within the reach of the profession in this country, it being unquestionably one of very great value to the prac- from a hasty examination, but after an intimate ac- quaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many of the most eminent professors and teachers of London, Edinburgh, Dub- lin, and Glasgow. It is, indeed, the great merit of this work that the principal articles have been fur- nished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them, and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it, stamps their own doctrines with high and just authority.—American Medical Journ. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's last improvements and corrections In one octavo volume, extra cloth, of GOO pages. $320. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD- REN. Tenth edition. In one volume, octavo, extra cloth, 518 pages. $2 80. DEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo, extra cloth, 532 pages, with plates. $3 00. DANA ON ZOOPHYTES AND CORALS. In one volume, imperial quarto, extra cloth, with wood- cuts. SI5 00. Also, AN ATLAS, in one volume, imperial folio, with sixty-one magnificent colored plates. Bound in half morocco. $30 00. DE LA BECHE'S GEOLOGICAL. OBSERVER. In one very large and handsome octavo volume, ex- tra cloth, of 700 pages, with 300 wood-cuts. $1 00. FRICK ON RENAL AFFECTIONS; their Diag- nosis and Pathology. With illustrations. One volume, royal 12mo., extra cloth. 75 cents. 12 BLANCHAKD & LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Obstetrics, Medical Jurisprudence, &c. With the French and other Synonymes; Notices of Climate and of celebrated Mineral Waters; Formulae for various Officinal, Empirica , and Dietetic Preparations, etc. Thirteenth edition, revised, is now ready. In one very thick octavo volume, of over nine hundred large double-columned pages, strongly bound in leather, with raised bands. $4 00. Everv successive edition of this work bears the marks of the industry of the author, and of his determination to keep it fully on a level with the most advanced state of medical science. Thus nearlv fifteen thousand words have been added to it within the last few years. As a complete Medical Dictionary, therefore, embracing over FIFTY THOUSAND DEFINITIONS, in a 1 the branches of the science, it is presented as meriting a continuance of the great favor and popularity which have carried it, wilhin no very long space of time, to a thirteenth edition. Every precaution has been taken in the preparation of the present volume, to render its mecha- nical execution and typographical accuracy worthy of its extended reputation and universal use. The very extensive additions have been accommodated, without materially increasing the bulk ot the volume by the employment of a small but exceedingly clear type, cast for this purpose. The press has been watched with great care, and every effort used to insure the verbal accuracy so ne- cessary to a work of this nature. The whole is printed on fine white paper; and, while thus exhi- biting in every respect so great an improvement over former issues, it is presented at the original exceedingly low price. We welcome it cordially; it is an admirable work, and indispensable to all literary medical men. The labor which has been bestowed upon it is something prodigious. The work, however, has now been done, and we are happy in the thought that no hu- man being will have again to undertake the same gigantic task. Revised and corrected from time to time, Dr. Dunglison's " Medical Lexicon" will last for centuries.—British and Foreign Med.-Chirurg. Review. The fact that this excellent and learned work has passed through eight editions, and that a ninth is rendered necessary by the demands of the public, affords a sufficient evidence of the general apprecia- tion of Dr. Dunglison's labors by the medical pro- fession in England and America. It is a book which will be of great service to the student, in teaching him the meaniiiL' .>r all Ihe technical terms used in medicine, and «-nl be of no less use to the practi- tioner who desires to keep himself on a level with the advance of medical science.—London Medical Times and Gazette. In taking leave of our author, we feel compelled to confess that his work bears evidence of almost incredible labor having been bestowed upon its com- position.—Edinburgh Journal of Med. Science. A miracle of labor and industry in one who has written able and voluminous works on nearly every branch of medical science. There could be no more useful book to the student or practitioner, in the present advancing age, than one in which would be found, in addition to the ordinary meaning and deri- vation of medical terms—so many of which are of modern introduction—concise descriptions of their explanation and employment; and all this and much more is contained in the volume before us. It is therefore almost as indispensable to the other learned professions as to our own. In fact, to all who may have occasion to ascertain the meaning of any word belonging to the many branches of medicine. From a careful examination of the present edition, we can vouch for its accuracy, and for its being brought quite up to thedate of publication ; the author states in his preface that he has added to it about fouT thou- sand terms, which are not to be found in the prece- ding one. — Dublin Quarterly Journal of Medical Sciences. On the appearance of the last edition of this valuable work, we directed the attention of our readers to its peculiar merits; and we need do little more than state, in reference to the present reissue, that, notwithstanding the large additions previously made to it, no fewer than four thou- sand terms, not to be found in the preceding edi- tion, are contained in the volume before us.— Whilst it is a wonderful monument of its author's erudition and industry, it is also a work of great practical utility, as we can testify from our own experience; for we keep it constantly within our reach, and make very frequent reference to it, nearly always finding in it the information we seek. —British and Foreign Med.-Chirurg. Review. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references. The terms generally include short physiological and pathological descriptions, so that, as the author justly observes, the reader does not possess in this work a mere dictionary, but a book, which, while it instructs hirn in medical etymo- logy, furnishes him with a large amount of useful information. The author's labors have been pro- perly appreciated by his own countrymen ; and we can only confirm their judgment, by recommending this most useful volume to the notice of our cisat- lantic readers. No medical library will be complete without it.—London Med. Gazette. It is certainly more complete and comprehensive than any with which we are acquainted in the English language. Few, in fact, could be found better qualified than Dr. Dunglison for the produc- tion of such a work. Learned, industrious, per- severing, and accurate, he brings to the task all the peculiar talents necessary for its successful performance; while, at the same time, his fami- liarity with the writings of the ancient and modem " masters of our art," renders him skilful to note the exact usage of the several terms of science, and the various modifications which medical term- inology has undergone with the change of theo- ries or the progress of improvement. — American Journal of the Medical Sciences. One of the most complete and copious known to the cultivators of medical science.—Boston Med. Journal. The most comprehensive and best English Dic- tionary of medical terms extant.—Buffalo Medical Journal. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $6 25 Upon every topic embraced in the work the latest information will be found carefully posted up.__ Medical Examiner. The student of medicine will find, in these two elegant volumes, a mine of facts, a gathering of precepts and advice from the world of experience, that will nerve him with courage, and faithfully direct him in his efforts to relieve the physical suf- ferings of the race.—Boston Medical and Surgical Journal. It is certainly the most complete treatise of which we have any knowledge.—Western Journal of Medi- cine and Surgery. One of the mos lelaborate treatises of the kind we have.—Southern Med. and Surg. Journal. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, leather, of about 1500 pages. (Just Issued, 1856.) $7 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled ; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated, and the work in every respect has been brought up to a level with the present slate of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. A similar improvement will be found in the typographical .execution of the volumes, which, in this respect, are superior to their predecessors. A large number of additional wood-cuts have been introduced, and the series of illustrations has been greatly modified by the substitution of many new ones for such as were not deemed satisfactory. By an enlargement of the page, these very considerable additions have been accommodated without increasing the size of the volumes to an extent to render them unwieldy. It has long since taken rank as one of the medi- cal classics of our language. To say that it is by far the best text-book of physiology ever published in this country, is but echoing the general testi- mony of the profession.—N. Y. journal of Medicine. There is no single book we would recommend to the student or physician, with greater confidence than the present, because in it will be found a mir- ror of almost every standard physiological work of the day. We most cordially recommend the work to every member of the profession, and no student should be without it, It is the completest work on Physiology in the English language, and is highly creditable to the author and publishers.—Canadian Medical Journal. The most complete and satisfactory system of Physiology in the English language.—Amer. Med. Journal. The best work of the kind in the English lan- guage.—Silliman's Journal. The most full and complete system of Physiology in our language.— Western Lancet. BY THE SAME AUTHOR. GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. Fifth edition, much improved. With one hundred and eighty-seven illus- trations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. As a text-book for students, for whom it is par- ticularly designed, we know of none, superior to it.—St.Louis Medical and Surgical Journal. It purports to be a new edition, but it is rather a new book, so greatly has it been improved, both in the amount and quality of the matter which it contains.—N. O. Medical and Surgical Journal. We bespeak for this edition, from the profession, elapsed since the issue of the first, that has escaped an increase of patronage over any of its former the careful search of the author. As a book for | oneBj on account of its increased merit. — N. Y. reference, it is invaluable.— Charleston Med. Jour- | journal of Medicine. nal and Review. It may be said to be the work now upon the sub- | We consider this work unequalled.—Boston Med jects upon which it treats.—Western Lancet. \ and Surg. Journal. In this work of Dr. Dunglison, we recognize the same untiring industry in the collection and em- bodying of facts on the several subjects of which he treats, that has heretofore distinguished him, and we cheerfully point to these volumes, as two of the most interesting that we know of. In noticing the additions to this, the fourth edition, there is very little in the periodical or annual literature of the profession, published in the interval which has BY THE same author. (A new Edition.) NEW REMEDIES, WITH FORMULA FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. (Just Issued, May, 1856.) $3 75. Another edition of the "New Remedies" having been called for, the author has endeavored to add everything of moment that has appeared since the publication of the last edition. The chief remedial means which have obtained a place, for the first time, in this volume, either owin- to their having been recently introduced into pharmacology, or to their having received novel applications—and which, consequently, belong to the category of "New Remedies -are the fol- l° ADMl~Oaffein, Carbazotic acid, Cauterization and catheterism of the larynx and trachea, Cedron, Cerium', Chloride of bromine, Chloride of iron, Chloride of sodium, Cinchonicine Cod-liver olein, Con-elation Eau de Pagliari, Galvanic cautery, Hydnodic ether, Hyposulphite tf soda and silver, function, Iodide of sodium, Nickel, Permanganate of potassa, Phosphate of hme Pumpkin Qu.nidia, Sne Saccharine carbonate of iron and manganese. Santonin, Tellurium, and Traumatic.ne. The articles treated of in the former editions will be found to have undergone considerable ex- pansion in this, in order that the author might be enabled to introduce as far as practicable the re-uIts of the subsequent experience of others, as well as of his own observation and reflection; and o make the work still more deserving of the extended circulation with which the preceding editions have been favored by the profession. By an enlargement of the page, the numerous addi- euuioii. ««" v7. ... ...____,i„ ^s.-oo^mn- ihu Kn lr nf thf> vn iimfi.—Preface. Shave been incorporated without greatly increasing the bulk of the volume.-Preface. The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable, has enabled One of the most useful of the author's works.— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to enhance its value.—New York Med. Gazette. him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire to examine the original papers.—The American Journal of Pharmacy. 14 BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, &c. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries, Diseases, and Operations. Edited by John H. Brinton, M. D. Illustrated with three hundred and eleven engravings on wood. In one large and handsome octavo volume, of over nine hundred closely printed pages, leather, raised bands. $4 25. It is, in our humble judgment, decidedly the best hook of the kind in the English language. Strange that just such books are notoflener produced by pub- lic teachers of surgery in this country and Great Britain Indeed, it is a matter of great astonishment. hut no less true than asionishing, that of the many works on surgery republished in this country within the last fifteen or twenty years as text-books for medical students, this is the only one that even ap- proximates to the fulfilment of the peculiar wauls of young men just entering upon the study of this branch of the profession.— Western Jour, of Med. and Surgery. Its value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering- his noviliate of practice, we regard it the most serviceable guide which he can consult. He will find a fulness of detail leading him through every step of the operation, and not deserting him until the final issue of the case is decided For the same, rea- son wo recommend it to those whose routine of prac- tice lies in such parts of the country that they must rarely encounter cases requiring surgical manage- ment.—Stethoscope. Embracing, as will be perceived, the whole surgi- cal domain, and each division of itself almost com- plete and perfect, each chapter full and explicit, each subject faithfully exhibited, we can only express our esiimate of it in the aggregate. We consider it an excellent contribution to surgery, as probably the best single volume now extant on the subject, and with great pleasure we add it to our textbooks.— Nashville Journal of Medicine and Surgery. Prof. Erichsen's work, for its size, has not been surpassed ; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes; and will prove a reliable resource for information, both to physician and surgeon, in the hour of peril.— iV. 0. Med. and Surg. Journal. We are acquainted with no other work wherein so much good sense, sound principle, and practical inferences, stamp every page.—American Lancet. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one neat octavo volume, extra cloth, of 296 pages. (Lately Issued.) $1 75. After an examination of the new matter and the alterations, we believe the reputation of the work built up by the author, and the late distinguished editor, will continue to flourish under the auspices of the present editor, who hus the industry and accu- racy, and, we would say, conscientiousness requi- site for the responsible task.—Am. Jour, of Pharm. It will prove particularly useful to students and young practitioners, as the most important prescrip- tions employed in modern practice, which lie scat- tered through our medical literature, are here col- lected and conveniently arranged for reference.— Charleston Med. Journal and Review. FOWNES (GEORGE), PH. D., &.c. ELEMENTARY CHEMISTRY; Theoretical and Practical. With numerous illustrations. A new American, from the last and revised London edition. Edited, with Addi- tions, by Robert Bridges, M. D. In one large royal 12mo. volume, of over 550 pages, with 181 wood-cuts. (Lately Issued.) In leather, $1 50; extra cloth, $1 35. We know of no better text-book, especially in the difficult department of organic chemistry, upon which it is particularly full and satisfactory. We would recommend it to preceptors as a capital "■ office book" for their students who are beginners in Chemistry. It is copiously illustrated with ex cellent. wood-cuts, and altogether admirably "got up."—N. J. Medical Reporter. A standard manual, which has long enjoyed the reputation of embodying much knowledge in a small space. The author hasachieved the difficult task of condensation with masterly tact. His book is con- cise without being dry, and brief without being too dogmatical or general.— Virginia Med. and Surgical Journal. The work of Dr. Fownes has long been before the public, and its merits have been fully appreci- ated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.—Lon- don Journal of Medicine. A work well adapted to the wants of the student. It is an excellent exposition of the chief doctrines and facts of modern chemistry. The size of the work, and still more the condensed yet perspicuous style in which it is written, absolve it from the charges very properly urged against most manuals termed popular.—Edinburgh Journal of Medical Science. FERGUSSON (WILLIAM), F. R. S.. Professor of Surgery in King's College, London &c A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third X^^^^^^J^z^^: bsuSul,y printed octav° voiume> °f ab°ut ™> The most important subjects in connection with practical surgery which have been more recently brought under the notice of, and discussed by, the surgeons of Great Britain, are fully and dispassion- ately considered by Mr. Fergusson, and that which was before wanting has now been supplied, so that we can now look upon it as a work on practical sur- gery instead of one on operative surgery alone. Medical Times and Gazette. No work was ever written which more nearly comprehended the necessities of the student and practitioner, and was more carefully arranged to that single purpose than this.—N. Y. Med. Journal. The addition of many new pages makes this work more than ever indispensable to the student and prac- titioner.— Banking's Abstract. Among the numerous works upon surgery pub- lished of late years, we know of none we value more highly than the one before us. It is perhaps the very best we have for a text-hook and for ordi- nary reference, being concise and eminently practi- cal.— Southern Med. and Surg. Journal. AND SCIENTIFIC PUBLICATIONS. 15 FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, &c. (An Important New Work.) PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. (Now Ready.) f 3 00. The author has aimed in the present work to supply a vacancy in medical literature, viz: "a work limited to diseases affecting the respiratory organs, treating inextenso and almost exclusively of the principles and practice of physical exploration, as applied to the diagnosis of those affections." The intricacy and importance of the subject demand a fuller and more detailed exposition than has been accorded to it in any volume as yet accessible to the American profession ; while the high re- putation which the author has acquired by his researches in kindred topics sufficiently manifests his ability to render the present work a text-book of great practical utility for the student, and a source to'which the practitioner can at all times refer with certainty. A very condensed summary of the contents is subjoined. CONTENTS. INTRODUCTION. Section I. Preliminary points pertaining to the Ana- tomy and Physiology of the Respiratory Appara- tus. Section II. Topographical Divisions of the Chest. PART I. Physical Exploration of the Chest. Chap. I. Definitions—Different Methods of Explora- tions—General Remarks. Chap. II. Percussion. Chap. III. Auscultation. Chap. IV. Inspection. Chap. V. Mensuration. Chap. VI. Palpation. Chap. VII. Succussion. Chap. VIII. Recapitu- latory Enumeration of the Physical Signs fur- nished by the several methods of Exploration. Chap. IX. Correlation of Physical Signs. PART II. Diagnosis of Diseases Affecting the Respira- tory Organs. Chap. I. Bronchitis, Pulmonary or Bronchial Ca- tarrh. Chap. II. Dilatation and Contraction of the Bronchial Tubes—Pertussis—Asthma. Chap. III. Pneumonitis—Imperfect Expansion (Atelec- tasis) and Collapse. Chap. IV. Emphysema. Chap. V. Pulmonary Tuberculosis — Bronchial Phthisis. Chap. VI. Pulmonary (Edema— Gan- grene of the Lungs—Pulmonary Apoplexy—Can- cer of the Lungs—Cancer in the Mediastinum. Chap. VII. Acute Pleuritis—Chronic Pleuritis— Empyema—Hydrothorax—Pneumothorax—Pneu- mo-hydrothorax--Pleuralgia--Diaphragmatic Her- nia. Chap. VIII. Diseases affecting the Trachea and Larynx — Foreign Bodies in the Air-passages. Appendix. On the Pitch of the Whispering Souffle over Pulmonary Excavations. GRAHAM (THOMAS), F. R. S., Professor of Chemistry in University College, London, &c. THE ELEMENTS OF CHEMISTRY. Including the application of the Science to the Arts. "With numerous illustrations. With Notes and Additions, by Robert Bridges, M. D., &c. &c. Second American, from the second and enlarged London edition. PART I. (Lately Issued) large 8vo., 430 pages, 185 illustrations. $1 50. PART II. (Preparing) to match. GRIFFITH (ROBERT E.), M. D., &c. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- tists. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume, extra cloth, of over 600 pages, double columns. (Just Issued.) $3 00; or bound in sheep, $3 25. It was a work requiring much perseverance, and | tioner can possibly have in his possession.—Medical when published was looked upon as by far the best work of its kind that had issued from the American press. Prof Thomas has certainly "improved," as well as added to this Formulary, and has rendered it addiiionillv deserving of the confidence of pharma- ceutists and physicians.—Am. Journal of Pharmacy. We are happy to announce a new and improved edition of this, one of the most valuable and useful works that have emanated from an American pen. It would do credit to any country, and will be found of daily usefulness to practitioners of medicine; it is better adapted to their purposes than the dispensato ries.— Southern Med. and Surg. Journal. A new edition of this well-known work, edited by R. P. Thomas, M. D., affords occasion for renewing our commendation of so useful a handbook, which ouH.t to be universally studied by medical men of every class, and made use of by way of reference by office pupils, as a standard authority. It has been much enlarged, and now condenses a vast amount of needful and necessary knowledge in small com- pass. The more, of such books ihe better for the pro- fession and the public— N. Y. Med. Gazette. It is one of the most useful books a country practi- Chronicle. The amount of useful, every-day matter, for a prac- ticing physician, is really immense.—Boston Med. and Surg. Journal. This is a work of six hundred and fifty one pages, embracing all on the subject of preparing and admi- nistering medicines that can lie desired by the physi- cian and pharmaceutist — Western Lancet. In short, it is a full and complete work of the kind, and should b^ in the hands of every physician and apothecary. O. Med. and Surg. Journal We predict a great sale for this work, and we espe- cially recommend it to all medical teachers.—Rich- mond Stethoscope. This edition of Dr. Griffith's work has been sreatly imnrove.d by the revision and ample additions of Dr. Thomas, and is now, we believe, one of the most complete works of its kind in any language. The additions amount to about seventy pages, and no effort has been spared to include in them all the re- cent improvements which have been published in medical journals, and systematic treatises. A work of this kind appears to us indispensable to the physi- cian, and there is none we can more cordially recom- mend.— N. Y. Journal of Medicine. BY THE SAME AUTHOR. MEDICAL BOTANY; or, a Description of all the more important Plants used in Medicine, and of their Properties, Uses, and Modes of Administration. In one large octavo volume, extra cloth, of 704 pages, handsomely printed, with nearly 350 illustrations on wood. $3 00. 16 BLANCHARD & LEA'S MEDICAL GROSS (SAMUEL D.), M. D., « Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE UEINARY BLADDER, THE PROSTATE GLAND, AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- four illustrations. In one large and very handsome octavo volume, of over nine hundred pages. (Just Issued.) In leather, raised bands, $5 25; extra cloth, $4 75. The author has availed himself of the opportunity afforded by a call for a new edition of this work, to thoroughly revise and render it in every respect worthy, so far as in his power, of the very flattering reception which has been accorded to it by the profession. The new matter thus added amounts to almost one-third of the original work, while the number of illustrations has been nearly doubled. These additions pervade every portion of the work, which thus has rather the aspect of a new treatise than a new edition. In its present improved form, therefore, it may confidently be presented as a complete and reliable storehouse of information on this important class of diseases, and as in every way fitted to maintain the position which it has acquired in Europe and in this country, as the standard of authority on the subjects treated of. A volume replete with truths and principles of the utmost value in the investigation of these diseases.— American Medical Journal. On the appearance of the first edition of this work, the leading English medical review predicted that it would have a " permanent place in the literature of surgery worthy to rank with the best works of the present age." This prediction has been amply ful- filled. Dr. Gross's treatise has been found to sup- ply completely the want which has been felt ever since the elevation of surgery to the rank of a science, of a good practical treatise on the diseases of the bladder and its accessory organs. Philosophical in its design, methodical in its arrangement, ample and sound in its practical details, it may in truth be said to leave scarcely anything to be desired on so im- portant a subject, and with the additions and modi- fications resulting from future discoveries and im- provements, it will probably remain one of the most valuable works on this subject so long as the science of medicine shall exist.—Boston Med. and Surg. Journal. "Dr. Gross has brought all his learning, experi- ence, tact, and judgment to the task, and has pro- duced a work worthy of his high reputation. We feel perfectly safe in recommending it to our read- ers as a monograph unequalled in interest and practical value by any other on the subject in our language.—Western Journal of Med. and Surg. Whoever will peruse the vast amount of valuable practical information it contains, and which we have been unable even to notice, will, we think, agree with us, that there is no work in the English language which can make any just pretensions to be its equal.—N. Y. Journal of Medicine. BY the same author. (Just Issued). A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. $2 75. A very elaborate work. It is a complete summary conclude by recommending it to our readers, fullv of the whole subject, and will be a useful book of \ persuaded that its perusal will afford them much practical information well conveyed, evidently de- rived from considerable experience and deduced from an ample collection of facts. — Dublin Quarterly Journal, May, 1855. by the same author. (Preparing.) A SYSTEM OF SURGERY; Diagnostic, Pathological, Therapeutic, and Opera- tive. With very numerous engravings on wood. by the same author. (Preparing.) ELEMENTS OF PATHOLOGICAL ANATOMY; illustrated by several hun- dred wood-cuts. New edition, thoroughly revised. In one very large and handsome octavo vol ume. reference.—British and Foreign Medico-Chirurg Review. A highly valuable book of reference on a most im- portant subject in the practice of medicine. We GLUGE (GOTTLIEB), M. D.. Professor of Physiology and Pathological Anatomy in the University of Brussels &c ANt^ASK°? PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva- nia In one volume, very large imperial quarto, extra cloth, with 320 figures, plain and colored on twelve copperplates. $5 00. bult-i F"»" »"u coiorea, GARDNER'S MEDICAL, CHEMISTRY, for the use of Students and the Profession. In one royal 1.2mo. vol., ex. cloth, pp. 396, with illustrations $1 00. HARRISON'S ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM. In one octavo volume, leather, 29a pages. $1 50. H£?,£E™ cl'IN'CAL INTRODUCTION TO THE PRACTICE OF AUSCU L.TA I ION AND mnKPSlOF PHYSICALDlAGNoi^ IN DISEASES OF THE LUNGS AND HEART] becond American, from the second London edition. I vol. royal 12mo., ex. cloth, pp. 304. $1 00 In one handsome HAMILTON (FRANK H.), M. D. Professor of Surgery, in Buffalo Medical College, Sec A TREATISE ON FRACTURES AND DISLOCATIONS octavo volume, with numerous illustrations. (Preparing.) The numerous improvements which this imnnrtant hmn^h ^r 0.,-,™ u and ingenuity of American surgeons renderpaS^ has received from the skill systematic original work on the3 subject^ TheSavs^ whichTSl w Va Uab1^ a comP'^ and kindred topics are already widely and favoraoTy know^n^ give ea nesMha"? hTf ^b P°b,-i8hed T will prove indispensable, both as a te*t-book for the ^^^^^^SSSSJ0'1" AND SCIENTIFIC PUBLICATIONS. 17 HOBLYN (RICHARD D.), M. D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. By Richard D. Hoblyn, A. M., &c. A new American /rom the last London edition. Revised, with numerous Additions, by Isaac Hays, M. D., edfror of the "American Journal of the Medical Sciences." In one large royal 12mo. volume, leai&er, ot over 500 double columned pages. (Now Ready, 1856.) $ 1 50. .' If the frequency with which we have referred to this volume since its reception from the publisher, two or three weeks ago, be any criterion for the future, the binding will soon have to be renewed, even with careful handling. We find that Dr. Hays has done the profession great service by his careful and industrious labors. The Dictionary has thus become eminently suited to our medical brethren in this country. The additions by Dr. Hays are in brackets, and we believe there is not a single page but bears these insignia; in every instance which we have thus far noticed, the additions are really needed and ex- ceedingly valuable. We heartily commend the work to all who wish to be ait cnurant in medical termi- nology.—Boston Med. and Surg. Journal. To both practitioner and student, we recommend this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for ordinary consultation.—Charleston Med. Journ. and Review. Admirably calculated to meet the wants of the practitioner or student, who has neither the means nor desire to procure a larger work. — American Lancet. Hoblyn has always been a favorite dictionary, and in its present enlarged and improved form will give greater satisfaction than ever. The American editor, Dr. Hays, has made many very valuable additions. —N. J. Med. Reporter. To supply the want of the medical reader arising from this cause, we know of no dictionary better arranged and adapted than the one bearing the above title. It is not encumbered with the obsolete terms of a bygone age, but it contains all that are now in use ; embracing every department of medical science down to the very latest date. The volume is of a convenient size to be used by the medical student, and yet large enough to make a respectable appear- ance in the library of a physician.—Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions we have, and ought always to be upon the student's table.— Southern Med. and Surg. Journal. **"■ HOLLAND (SIR HENRY), BART., M.D.,F. R. S., Physician in Ordinary to the Queen of England, &c. MEDICAL NOTES AND REFLECTIONS. From the third London edition. In one handsome octavo volume, extra cloth. (Now Ready.) $3 00. As the work of a thoughtful and observant physician, embodying the results of forty years' ac- tive professional experience, on topics of the highest interest, this volume is commended to the American practitioner as well worthy his attention. Few will rise from its perusal without feel- ing their convictions strengthened, and armed with new weapons for the daily struggle with disease. HUNTER (JOHN). TREATISE ON THE VENEREAL DISEASE. Dr. Ph. Ricord, Surgeon to the Venereal Hospital of Paris. F. J. Bumstead, M. D. In one octavo volume, with plates. Also, HUNTER'S COMPLETE WORKS, with Memoir, Notes, &c. &c volumes, leather, with plates. $10 00. With copious Additions, by Edited, wilh additional Notes, by $3 25. %3T See Ricord. In four neat octavo HORNER (WILLIAM E.), M. D., Professor of Anatomy in the University of Pennsylvania. SPECIAL .ANATOMY AND HISTOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, extra cloth, of more than one thousand pages, handsomely printed, with over three hundred illustrations. $6 00. This edition enjoyed a thorough and laborious revision on the part of the author shortly before his death, with the view of bringing it fully up to the existing state of knowledge on the subject of general and special anatomy. To adapt it more perfectly to the wants of the student, he introduced a large number of additional wood-engravings, illustrative of the objects described, while the pub- lishers have endeavored to render the mechanical execution of the work worthy of its extended reputation. JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, &c. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and ten illustrations. Second American from the second and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills' Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. (Now Ready.) $1 50. We are confident that the reader will find, on perusal, that the execution of the work amply fulfils the promise of the preface, and sustains, in every point, the already high reputation of the author as an ophthalmic surgeon as well as a physiologist and pathologist. The book is evidently the result of much labor and research, and has been written with the greatest care and attention; it possesses that best quality which a general work, like a sys- tem or manual can show, viz : the quality of having all the materials whencesoever derived, so thorough- ly wrought up, and digested in the author's mind, as to come forth with the freshness and impressive- ness of an original production. We entertain little doubt that this book will become what its author hoped it might become, a manual for daily reference and consultation by the student and the general prac- titioner. The work is marked by that correctness, clearness, and precision of style which distinguish all the productions of the learned author.—British and For. Med. Review. 18 BLANCHARD & LEA'S MEDICAL HANDFIELD), F. R. S., & EOWARn H. SIEVEKING, M Assistant Physicians and Lecturers in fct. Mary's Hospital, London. JONES (C A MANUAL OF PATHOLOGICAL ANATOMY D., Revi beau First American Edition, ised. With three hundred and ninety-seven handsome wood engravings.^ In one large and itiful octavo volume of nearly 750 pages, leather. (Lately Issued.) $3 75. Asa concise text-book, containing, in a condensed form, a complete outline of what is known in the domain of Pathological Anatomy, it is perhaps the best work in the English language. Its great merit consists in its completeness and brevity, and in this respect it supplies a great desideratum in our lite- rature. Heretofore the student of pathology was obliged to glean from a great number of monographs, and the field was so extensive that but few cultivated it with any degree of success. As a simple work of reference, therefore, it is of great value to the student of pathological anatomy, and should be in every physician's library.—Western Lancet. We urge upon our readers and the profession gene- rally the importance of informing themselves in re- gard to modern views of pathology, and recommend to them to procure the work before us as the best means of obtaining this information.—Stethoscope. In offering the above titled work to the public, the authors have not attempted to intrude new views on their professional brethren, hut simply to lay before them, what has long been wanted, an outline of the present condition of pathological anatomy. In this they have been completely successful. The work is one of the best compilations which we have ever perused.—Charleston Medical Journal and Review. We have no hesitation in recommending it as worthy of careful and thorough study by every mem- ber of the profession, old or young.—N. W. Med. and Surg. Journal. From the casual examination we have given we are inclined to regard it as a text-book, plain, ra- tional, and intelligible, such a book as the practical man needs for daily reference. For this reason it will be likely to be largely useful, as it suits itself to those busy men who have little time for minute investigation, and prefer a summary to an elaborate tieatise.—Buffalo Medical Journal. KIRKES (WILLIAM SENHOUSE), M. D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. A MANUAL OF PHYSIOLOGY. Second xYmerican, from the second and improved London edition. With one hundred and sixty-five illustrations. In one large and handsome royal 12mo. volume, leather, pp. 550. $2 00. In the present edition, the Manual of Physiology has been brought up to the actual condition of the science, and fully sustains the reputation which it has already so deservedly attained. We consider the work of MM. Kirkes and Paget to constitute one of the very best handbooks of Physiology we possess —presenting just such an outline of the science, com- prising an account of its leading facts and generally admitted principles, as the student requires during his attendance upon a course of lectures, or for re- ference whilst preparing for examination.— Am. Medical Journal. We need only say, that, without entering into dis- cussions of unsettled questions, it containn all the recent improvements in this departmerl cf medical science. For the student beginning this t.,udy,and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know, without special details, which are read with interest only by those who would make a specialty, or desire to possess a criti- cal knowledge of the subject.—Charleston Medical Journal. One of the best treatises that can be put into the hands of the student.—London Medical Gazette, Particularly adapted to those who desire to pos- sess a concise digest of the facts of Human Physi- ology.—British and Foreign Med.-Chirurg. Review. We conscientiously recommend it as an admira- ble "Handbook of Physiology."—London Journal of Medicine. KNAPP'S TECHNOLOGY; or, Chemistry applied to the Arts and to Manufactures. Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson. First American edition, with Notes and Additions, by Prof. Waltee R. Johnson. In two handsome octavo volumes, extra cloth, with about 500 wood- engravings. S6 00. LALLEMAND ON SPERMATORRHOEA. Trans- lated and edited by Henry J. McDougal. In one volume, octavo, extra cloth, 320 pages. Second American edition. $1 75. LUDLOW (J. L.h M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Designed for Students of Medicine throughout ihe United States. Third edition, thoroughly revised and greatly extended and enlarged. Wilh three hundred and seventy illustrations. In one large and handsome royal 12mo. volume, leather, of over 800 closely printed pages (Now Ready.) $2 50. The great popularity of this volume, and the numerous demands for it during the two years m which it has been out of print, have induced the author in its revision to spare no pains to render it a correct and accurate digest of the most recent condition of all ihe branches of medical science. In many respects it may, therefore, be regarded rather as a new book than a new edition, an entire section on Physiology having been added, as also one on Organic Chemistry, and many portions having been rewritten. A very complete series of illustrations has been introduced, and every care has been taken in the mechanical execution to render it a convenient and satisfactory booh for study or reference. The arrangement of the volume in the form of question and answer renders it especially suited for the office examination of students and for those preparing for graduation. LARDNER (DIONYSIUS), D. C. L., &c. HANDBOOKS OF NATURAL PHILOSOPHY AND ASTRONOMY. Revised, with numerous Additions, by the American editor. First Course, containing Mecha- nics, Hydrostatics, Hydraulics, Pneumatics, Sound, and Optics. In one large royal 12mo. volume, of 750 pages, with 424 wood-cuts. $1 75. Second Course, containing Heat, Electricity, Magnetism, and Galvanism, one volume, large royal 12mo., of 450 pages, with 250 illustrations. $1 25. Third Course (now ready), containing Meteorology and Astronomy, in one large volume, royal 12mo. of nearly eight hundred pages, with thirty-seven plates and two hundred wood-cuts. $2 00. The whole complete in three volumes, of about two thousand large pages, with over one thousand figures on steel and wood. $5 00. Any volume sold separate, strongly bound in leather. AND SCIENTIFIC PUBLICATIONS. 19 LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by • .°i,ROmE", D1Y! M- D-' F- R> S-' &c' edited bY R- E- Rogers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, wilh illustrations selected from Ua k j ° Physiolo?lcat Chemistry, and an Appendix of plates. Complete in two large and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- trations. (Just Iss?ied.) $6 00. y ° This great work, universally acknowledged as the most complete and authoritative exposition of the principles and details of Zoochemistry, in its passage through the press, has received from 1 rolessor Kogers such care as was necessary to present it in a correct and reliable form. To such a work additions were deemed superfluous, but several years having elapsed between the appear- ance in G-ermany of the first and last volume, the latter contained a supplement, embodying nume- rous corrections and additions resulting from the advance of the science. These have all been incor- porated in the text in their appropriate places, while the subjects have been still further elucidated by the insertion of illustrations from the Atlas of Dr. OttoFunke. With the view of supplying the student with the means of convenient comparison, a large number of wood-cuts, from works on kindred subjects, have also been added in the form of an Appendix of Plates. The work is, therefore, pre- sented as in every way worthy the attention of all who desire to be familiar with the modern facts and doctrines of Physiological Science. Already well known and appreciated by the scien- tific world, Professor Lehmann's great work re- quires no laudatory sentences, as, under a new garb, it is now presented to us. The little space at our command would ill suffice to set forth even a small portion of its excellences. To all whose studies or professional duties render the revelations of Physio- logical Chemistry at once interesting and essential, these volumes will be indispensable. Highly com- plimented by European reviewers, sought for with avidity by scholars of every nation, and admirably written throughout, it is sure to win a welcome and to be thoroughly studied.—Boston Med. and Surg. Journal, Dec. 1855. The most important contribution as yet made to Physiological Chemistry.—Am. Journal Med. Sci- ences, Jan. 1856. The present volumes belong to the small class of medical literature which comprises elaborate works of the highest orderof merit.—Montreal Med. Chron- icle, Jan. 1856. The work of Lehmann stands unrivalled as the most comprehensive book of reference and informa- tion extant on every branch of the subject on which it treats.—Edinburgh Monthly Journal of Medical Science. All teachers must possess it, and every intelligent physician ought to do likewise.—Southern Med. and Surg. Journal, Dec. 1855. BY THE SAME AUTHOR. (Just Issued, 1856.) MANUAL OF CHEMICAL PHYSIOLOGY.» Translated from the German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Samuel Jackson, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania. With illustrations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. The original of this work, though but lately issued by its distinguished author, has already assumed the highest position, as presenting in their latest development the modern doctrines and discoveries in the chemistry of life. The numerous additions by the translator, and the Introduc- tion by Professor Jackson will rentier its physiological aspect more complete than designed by the author, and will adapt it for use as a text-book of physiology, presenting more thoroughly than has yet been attempted, the modifications arising from the vast impulse which organic chemistry has received within a few years past. From Prof. Jackson'''s Introductory Essay. In adopting the handbook of Dr. Lehmann as a manual of Organic Chemistry for the use of the students of the University, and in recommending his original work of Physiological Chemistry for their more mature studies, the high value of his researches, and the great weight of his autho- rity in that important department of medical science are fully recognized. The present volume will be a very convenient one I densed form, the positive facts of Physiological for students, as offering a brief epitome of the more Chemistry.—Am. Journal Med. Sciences, April, 1856. elaborate work, and as containing, in a very con- j LAWRENCE (W.), F. R. S., &.C. A TREATISE ON DISEASES OF THE EYE. A new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather with raised bands. $5 00. This work is so universally recognized as the standard authority on the subject, that the pub- lishers in presenting this new edition have only to remark that in its preparation the editor has carefully revised every portion, introducing additions and illustrations wherever the advance of science has rendered them necessary or desirable, constituting it a complete and thorough exponent of the most advanced state of the subject. This admirable treatise—the safest guide and most j octavo pages—has enabled both author and editor to comprehensive work of reference, which is within the reach of the profession.—Stethoscope. This standard text-book on the department of whieh it treats, has not been superseded, by any or all of the numerous publications on the subject heretofore issued. Nor with the multiplied improve- ments of Dr. Hays, the American editor, is it at all likely that this great work will cease to merit the confidence and preference of students or practition- ers. Its ample extent—nearly one thousand large do justice to all the details of this subject, and con- dense in this single volume the present state of our knowledge of the whole science in this department, whereby its practical value cannot be excelled. We heartily commend it, especially as a book of refer- ence, indispensable in every medical library. The additions of the American editor very greatly en- hance the value of the work, exhibiting the learning and experience of Dr. Hays, in the light in which he ought to be held, as a standard authority on all sub- jects appertaining to this specialty.—N. Y. Med. Gaz. 20 BLANCHARD & LEA'S MEDICAL LA ROCHE (R.), M. D., &c. YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination of the connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. (Just Issued.) $7 00. From Professor S. H. Dickson, Charleston, S. C, September 18, 1855. A monument of intelligent and well applied re search, almost without example. It is, indeed, in itself, a large lihrary, and is destined to constitute the special resort as a book of reference, in the subject of which it treats, to all future time. We have not time at present, engaged as we are, by df),y and by night, in the work of combating this very disease, now prevailing in our city, to do more than give this cursory notice of what we consider as undoubtedly the most able and erudite medical publication our country has yet produced But in view of the startling- fact, that this, the most malig- nant and unmanageable disease of modern times, has for several years been prevailing in our country to a greater extent than ever before; that it is no longer confined to either large or small cities, but Senetrates country villages, plantations, and farm- ouses; that it is treated with scarcely better suc- cess now than thirty or forty years ago; that there is vast mischief done by ignorant pretenders to know- ledge in regard to the disease, and in view of the pro- bability that a majority of southern physicians will be called uponto treat the disease, we trust that this able and comprehensive treatise will he very gene- rally read in the south.—Memphis Med. Recorder. This is decidedly the great American medical work of the day—a full, complete, and systematic treatise, unequalled by any other upon the all-important sub- ject of Yellow Fever. The laborious, indefatigable, and learned author has devoted to it many years of arduous research and careful study, and the result is such as will reflect the highest'honor upon the author and our country.—Southern Med. and Surg. Journal. The genius and scholarship of this great physician could not have been better employed than in the erection of this toweringmonument to his own fame, and to the glory of the medical literature of his own country. It is destined to remain the great autho- rity upon the subject of Yellow Fever The student and physician will find in these volumes a rtsumi. of the sum total of the knowledge of the world upon the awful scourge which they so elaborately discuss. The style is so soft and so pure as to refresh and in- vigorate the mind while absorbing the thoughts of the gifted author, while the publishers have suc- ceeded in bringing the externals into a most, felicitous harmony with the inspiration that dwells within. Take it all in all, it is a book we have often dreamed of, but dreamed not that it would ever meet our waking eye as a tangible reality.—Nashville Journal of Medicine. We deem it fortunate that the splendid work of Dr. La Roche should have been issued from the press at this particular time. The want of a reliable di- gest of all that is known in relation to this frightful malady has long been felt—a want very satisfactorily met in the work before us. We deem it but faint praise to say that Dr. La Rcche has succeeded in presenting the profession with an able and complete monograph, one which will find its way into every well ordered library.— Va. Stethoscope. Although we have no doubt that controversial treatises on the mode of origin and propagation of the fever in question will, as heretofore, occasionally appear, yet it must be some time before another sys- tematic work can arise in the face of so admirable and carefully executed a one as the present. It is a mine of information, quite an encyclopaedia of refer- ences, and risumi of knowledge relative to what hag been recorded upon the subject.—London Lancet. A miracle of industry and research, constituting a complete library of reference on the disease of which it treats.—Dublin Quarterly Journal. BY THE SAME AUTHOR. PNEUMONIA; its Supposed Connection, Pathological and Etiological, with Au- tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. $3 00. A more simple, clear, and forcible exposition of I Thiswork should be carefully studied by Southern the groundless nature and dangerous tendency of | physicians, embodying as it does the reflections of certain pathological and etiological heresies, has I an original thinker and close observer on a subject seldom been presented to our notice.—N. Y. Journal peculiarly their own.—Virginia Med. and Surgical of Medicine and Collateral Science. I Journal. LAYCOCK (THOMAS), M. D., F. R. S. E., Professor of Practical and Clinical Medicine in the University of Edinburgh, &c. LECTURES ON THE PRINCIPLES AND METHODS OF MEDICAL OBSERVATION AND RESEARCH. For the Use of Advanced Students and Junior Prac- titioners. In one very neat royal 12mo. volume, extra cloth. Price $1 00. (Now Ready.) Though addressed more particularly to the student, this little volume will be found of much use to all members of the profession who aim at rendering their practice a science rather than a routine. The importance of the development and application of principles, and the exercise of correct and logical reasoning from clinical observations are beginning to be generally recognized and in furtherance of this object, a wide circulation of the present volume cannot fail to exercise a most beneficial influence. The object and scope of the work may be gathered from the following .condensed summary of the contents :— Lecture I. General Principles of Observation and Inquiry—Nature and Acquisition of Experi- ence in Medicine—Combination of Experience with Theory and Observation, with illustrations of the Fallacious use of Theories. Lect. II. General Methods and Objects of Clinical Study. ™l-}l Meth°ds of'Clinical Examination—Clinical Observations of General or Constitutional Morbid Slates. Lect. IV. On Prognosis, and the Order of Succession of Morbid Phenomena. Lect. V On the Due Estimate of Treatment-Management of the Case. Lect. VI. Numerical Method of Research in Medicine. Lect. VII. Analogical, Philosophical, or Purely Inductive Method of Research-Practical Examples of the Conduct of an Analogical Investigation-Examples of its Applications to Anatomy, Physiology, and Histology. P MULLER (PROFESSOR J.), M. D. PRINCIPLES OF PHYSICS AND METEOROLOGY. Edited, with Addi- tions, by R Eglesfeld Griffith, M. D. In one large and handsome octavo volume, extra cloth, with 550 wood-cuts, and two colored plates, pp.636. $3 50. voiume, esira AND SCIENTIFIC PUBLICATIONS. 21 MEIGS (CHARLES D.), M. D., Professor of Obstetrics, &c. in the JefTerson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Third edition, revised and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. $3 75. (Now Ready.) The rapid demand for another edition of this work is a sufficient expression of the favorable verdict of the profession. In thus preparing it a third time for the press, the author has endeavored to render it in every respect worthy of the favor which it has received. To accomplish this he has thoroughly revised it in every part. Some portions have been rewritten, others added, new illustrations have been in many instances substituted for such a< were not deemed satisfactory, while, by an alteration in the typographical arrangement, the size of the work has not been increased, and the price remains unaltered. In its present improved form, it is, therefore, hoped that the work will coniinue to meet the wants of the American profession as a sound, practical, and extended System of Midwifery. by the same author. (Lately Issued.) WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Lec- tures to his Class. Third and Improved edition. In one large and beautifully printed octavo volume, leather. pp. 672. $3 60. The gratifying appreciation of his labors, as evinced by the exhaustion of two large impressions of this work within a few years, has not been lost upon the author, who has endeavored in every way to render it worthy of the favor with which it has been received. The opportunity thus afforded for a second revision has been improved, and the work is now presented as in every way superior to its predecessors, additions and alterations having been made whenever the advance of science has rendered them desirable. The typographical execution of the work will also be found to have undergone a similar improvement, and the work is now confidently presented as in every way worthy the position it has acquired as the standard American text-book on the Diseases of Females. It contains a vast amount of practical knowledge, by one who has accurately observed and retained the experience of many years, and who tells the re- sult in a free, familiar, and pleasant manner.—Dub- lin Quarterly Journal. There is an off-hand fervor, a glow, and a warm- heartedness infecting the effort of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in The instructive and interesting author of this work, whose previous labors in the department of medicine which he so sedulously cultivates, have placed his countrymen under deep and abiding obli- gations, again challenges their admiration in the fresh and vigorous, attractive and racy pages before us. It is a delectable book. * * # This treatise upon child-bed fevers will have an extensive sale, being destined, as it deserves, to find a place in the library of every practitioner who scorns to lag in the rear of his brethren.—Nashville Journal of Medi- cine and Surgery. MAYNR'S DISPENSATORY AND THERA- PEUTICAL REMEMBRANCER. Comprising the entire lists of Materia Medica, with every Practical Formula contained in the three British Pharmacopoeias. Edited, with the addition of the Formulae of the U. S. Pharmacopoeia, by R. E. Griffith, M.D. 112mo. vol. ex. cl.,300 pp. 75 c. such bold relief, as to produce distinct impressions upon the mind and memory of the reader. — The Charleston Med. Journal. Professor Meigs has enlarged and amended this great work, for such it unquestionably is, having passed the ordeal of criticism at home and abroad, but been improved thereby ; for in this new edition the author has introduced real improvements, and increased the value and utility of the book im- measurably. It presents so many novel, bright, and sparkling thoughts; such an exuberance of new ideas on almost every page, that we confess our- selves to have become enamored with the book and its author; and cannot withhold our congratu- lations from our Philadelphia confreres, that such a teacher is in their service.—N. Y. Med. Gazette. This book will add more to his fame than either of those which bear his name. Indeed we doubt whether any material improvement will be made on the teachings of this volume for a century to come, since it is so eminently practical, and based on pro- found knowledge of the science and consummate skill in the art of healing, and ratified by an ample and extensive experience, such as few men have the industry or good fortune to acquire.—N. Y. Med. Gazette. MALGAIGNE'S OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French by Frederick Brittan, A. B., M. D. Withnumerousillustrationson wood. In one handsome octavo volume, extra cloth, of nearly six hundred pages. $2 25. by the same author. (Lately Published.) ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. $2 50. BY THE SAME AUTHOR , WITH COLORED PLATES. A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style of art. In one handsome octavo volume, extra cloth. $4 50. 22 BLANCHARD & LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto. With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. $11 00. %* The size of this work prevtnts its transmission through the post-office as a whole, but those who desire to have copies forwarded by mail, can receive them in five parts, done up in stout wrappers. Price $9 00. of keeping up his anatomical knowledge.—Medical Times. The mechanical execution cannot be excelled.— Transylvania Medical Journal. A work which has no parallel in point of accu- racy and cheapness in the English language.—N. Y. Journal of Medicine. To all engaged in the study or practice of their profession, such a work is almost indispensable.— Dublin Quarterly Medical Journal. No practitioner whose means will admit should fail to possess it.—Ranking's Abstract. Country practitioners will find these plates of im- mense value.—N. Y. Medical Gazette. We are extremely gratified to announce to the profession the completion of this truly magnificent work, which, as a whole, certainly stands unri- valled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand.—The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. We know of no other work that would justify a stu- dent, in any degree, for neglect of actual dissec- tion. Jn those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory.—The Western Journal of Medi- cine and Surgery. One of the greatest artistic triumphs of the age in Surgical Anatomy.—British American Medical Journal. Too much cannot be said in its praise ; indeed, we have not language to do it justice.—Ohio Medi- cal and Surgical Journal. The most admirable surgical atlas we have seen. To the practitioner deprived of demonstrative dis- sections upon the human subject, it is an invaluable companion.—N. J. Medical Reporter. The most accurately engraved and beautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.—Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, and so useful a work, is offered at so moderate a price.—Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond the reach of competition.—Medi- cal Examiner. Every practitioner, we think, should have a work of this kind within reach.—Southern Medical and Surgical Journal. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given.—Boston Medical and Surgical Journal. As a surgical anatomist, Mr. Maclise has proba- bly no superior.—British and Foreign Medico-Chi- rurgical Review. Of great value to the student engaged in dissect- ing, and to the surgeon at a distance from the means ESP The very low price at which this work is furnished, and the beauty of its execution, require an extended sale to compensate the publishers for the heavy expenses incurred. MOHR (FRANCIS), PH. D., AND REDWOOD (THEOPHILUS). PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood. $2 75. MACKENZIE (W.), M.D., Surgeon Oculist in Scotland in ordinary to Her Majesty, &c. &c. A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, &c. izc. In one very large and handsome octavo volume, leather, raised b-,nds, with ..plates and numerous wood-cuts. {Now Ready.) $5 25. The treatise of Dr. Mackenzie indisputably holds the first place, and forms, in respect of learning and research, an Encyclopaedia unequalled in extent by any other work of the kind, either English or foreign. —Dixon on Diseases of the Eye. Few modern books on any department of medicine or surgery have met with such extended circulation, or have procured for their authors a like amount of European celebrity. The immense research which it displayed, the thorough acquaintance with the subject, practically as well as theoretically, and the able manner in which the author's stores of learning and experience were rendered available for general use, at once procured for the first edition, as well on the continent as in this country, that high position as a standard work which each successive edition has more firmly established, in spite of the attrac- tions of several rivals of no mean ability. This, the fourth edition, has been in a great measure re-writ- ten ; new matter, to the extent of one hundred and fifty pages, has been added, and in several instances formerly expressed opinions have been modified in —Dublin Quarterly Journal accordance with the advances in the science which have been made of late years. Nothing worthy of repetition upon any branch of the subject appears to have escaped the author's notice. We consider it the duty of every one who has the love of his profes- sion and the welfare of his patient at heart, to make himself familiar with this the most complete work in the English language upon the diseases of the eye. —Med. Tunes and Gazette. The fourth edition of this standard work will no doubt be as fully appreciated as the three former edi- tions. It_is unnecessary to say a word in its praise, for the verdict has already been passed upon it by the most competent judges, and " Mackenzie on the Eye" has justly obtained a reputation which it is no figure of speech to call world-wide.—British and Foreign Medico-Chirurgical Beview. This new edition of Dr. Mackenzie's celebrated treatise on diseases of the eye, is truly a miracle of industry and learning. We need scarcely say that he has entirely exhausted the subject of his specialty. AND SCIENTIFIC PUBLICATIONS. 23 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, &c. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume, leather, of 700 pages, with two hundred and forty exquisite illustrations on wood. (Just Issued, 1S56.) $3 75. The extended reputation enjoyed by this work will be fully maintained by the present edition. Thoroughly revised by the author, it will be found a clear and compendious exposition of surgical science in its most advanced condition. In connection with the recently issued third edition of the author's " Practice of Surgery," it forms a very complete system of Surgery in all its branches. The work of Mr. Miller is too well and too favor- ably known among us, as one of our best text-books, to render any further notice of it necessary than the announcement of a new edition, the fourth in our country, a proof of its extensive circulation among us. As a concise and reliable exposition of the sci- ence of modern surgery, it stands deservedly high— we know not its superior__Boston Med. and Surg. Journal. It presents the most satisfactory exposition of the modern doctrines of the principles of surgery to be found in any volume in any language.—N. Y. Journal of Medicine. The work takes Tank with Watson's Practice of Physic; it certainly does not fall behind that great work in soundness of principle or depth of reason- ing and research. No physician who values his re- by the same author. (Lately Published.) THE PRACTICE OF SURGERY. Third American from the second Edin- burgh edition. Edited, with Additions, by F. W. Sargent, M. D., one of the Surgeons to Will's Hospital, &c. Illustrated by three hundred and nineteen engravings on wood. In one large octavo volume, leather, of over 700 pages. $3 75. putation, or seeks the interests of his clients, can acquit himself before his God and the world without making himself familiar with the sound and philo- sophical views developed in the foregoing book.— New Orleans Med. and Surg. Journal. Without doubt the ablest exposition of the prin- ciples of that branch of the healing art in any lan- guage. This opinion, deliberately formed after a careful study of the first edition, we have had no cause to change on examining the second. This edition has undergone thorough revision by the au- thor; many expressions have been modified, and a mass of new matter introduced. The book is got up in the finest style, and is an evidence of the progress of typography in our country.—Charleston Medical Journal and Review. No encomium of ours could add to the popularity of Miller's Surgery. Its reputation in this country is unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to which no conscientious surgeon would be willing to practice his art. The additions, by Dr. Sargent, have materially enhanced the value of the work.— Southern Medical and Surgical Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the " Principles" and the " Practice" of Surgery by Mr. Miller—or so richly merited the reputation they have acquired. The author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it.—Kentucky Medical Recorder. By the almost unanimous voice of the profession, his works, both on the principles and practice of surgery have been assigned the highest rank. If we were limited to but one work on surgery, that one should be Miller's, as we regard it as superior to all others.—St. Louis Med. and Surg. Journal. The author, distinguished alike as a practitioner and writer, has in this and his " Principles," pre- sented to the profession one of the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding the attention; indeed, he appears to make the very process of condensation a means of eliminating attractions. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recommend- ed.— Southern Journal of Med. and Phys. Sciences. MONTGOMERY (W. F.), M. D., M. R. I. A., &c, Professor of Midwifery in the King and Queen's College of Physicians in Ireland, &c. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OP PREGNANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. In one very handsome octavo volume, extra cloth, of nearly 600 pages. (Now Ready, 1857.) $3 7o. The present edition of this classical volume is fairly entitled to be regarded as a new work, every sentence having been carefully rewritten, and the whole increased to more than double the original size The title of the work scarcely does justice to the extent and importance of the topics brou-ht under consideration, embracing, with the exception of the operative procedures of mid- wifery almost everything connected with obstetries, either directly or incidentally; and there are few physicians who will not find in its pages much that will prove of great interest and value in their daily practice. The special Essays on the Period of Human Gestation, the S,gns of Delivery, and the Spontaneous Amputation and other Lesions of the foetus in Utero present topics of the hi°-hest interest fully treated and beautifully illustrated. In every point of mechanical execution the work will be found one of the handsomest yet issued from the American press. A book unusually rich in practical suggestions.— Am Journal Med. Sciences, Jan. 1857. These several subjects so interesting in them- selves, and so important, every one of them, to the most delicate and precious of social relations, con- trolling often the honor and domestic peace ot a family1! the legitimacy of offspring, or the life of its parent are all treated with an elegance of diction, fulness of illustrations, acuteness and justice of rea- soning, unparalleled in obstetrics, and unsurpassed in medicine. The reader's interest can never flag, so fresh and vigorous, and classical is our author's stvle'- and one forgets, in the renewed charm of every'page, that it, and every line, and every word has been weighed and reweighed through years of preparation; that this is of all others the book of Obstetric Law, on each of its several topics; on all points connected with pregnancy, to be everywhere received as a manual of special jurisprudence, at once announcing fact, affording argument, establish- ing precedent, and governing alike the juryman, ad- vocate, and judge. It is not merely in its legal re- lations that we find this work so interesting. Hardly a page but that has its hints or facts important to the general practitioner ; and not a chapter without especial matter for the anatomist, physiologist, or pathologist. —N. A. Med.-Chir. Review, March, 1857. 24 BLANCHARD & LEA'S MEDICAL NEILL (JOHN), M. D., Surgeon to the Pennsylvania Hospital, &c; and FRANCIS GURNEY SMITH, M.D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with three hundred and seventy-four illustrations on wood. Strongly bound in leather, with raised bands. (Now Ready, 185b.) $3 00. The very flattering reception which has been accorded to this work, and the high estimate placed upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex- hausted two large editions, have stimulated the authors to render the volume in its present revision more worthy of the success which has attended it. It has accordingly been thoroughly examined, and such errors as had on former occasions escaped observation have been corrected, and whatever additions were necessary to maintain it on a level with ihe advance of science have been introduced. The extended series of illustrations has been still further increased and much improved, while, by a slight enlargement of the page, these various additions have been incorporated without increasing the bulk of the volume. The work is, therefore, again presented as eminently worthy of the favor with which it has hitherto been received. As a book for daily reference.by the student requiring a guide to his more elaborate text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate examination, or as a source from which the practitioners of older date may easily and cheaply acquire a knowledge of the changes and improvement in professional science, its reputation is permanently established. In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of. Tlie newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though concisely, laid before the student. Of course it is useless for us to recommend it to all last course students, but there is a class to whom we very sincerely commend this cheap book as worth its weight in silver — that class is the graduates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not exactly now what it was when they left it off.—The Stethoscope We recommend it to our readers as the best work of the kind with which we are acquainted.—Med. Examiner, April, 1850. Having made free use of this volume in our ex- aminations of pupils, we can speak from experi- ence in recommending it as an admirable compend for students, and as especially useful to preceptors who examine, their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined. A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them; and this is unquestionably the best of its class.—Transylvania Med. Journal. NEILL (JOHN), M. D., Professor of Surgery in the Pennsylvania Medical College, &c. OUTLINES OF THE VEINS AND LYMPHATICS. With handsome colored plates. 1 vol., cloth. $ 1 25. OUTLINES OF THE NERVES. With handsome plates. 1 vol., cloth. $1 25. NELIGAN (J. MOORE), M. D., M. R. I. A., &c. (A splendid work. Now Ready.) ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of disease. $4 50. This beautiful volume is intended as a complete and accurate representation of all the varieties of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the profession some years since. The publishers feel justified in saying that no more beautifully exe- cuted plates have ever been presented to the profession of this country. The diagnosis of eruptive disease, however, under all circumstances, is very difficult. Nevertheless Dr. Neligan has certainly, "as far as possible," given a faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the " Atlas" we have been induced to examine also the " Practical Trea- tise," and we are inclined to consider it a very su- perior work, combining accurate verbal description, with sound views of the pathology and treatment of eruptive diseases.—Glasgow Med. Journal. The profession owes its thanks to the publishers of Neligan's Atlas of Cutaneous Diseases, for they have placed within its reach and at a moderate cost a most accurate and well delineated series of plates illus- trating the eruptive disorders. These plates are all drawn from the life, and in many of them the daguer- reotype has been employed with great success. Such works as these are especially useful to country prac- titioners, who have not an opportunity of seeing the rarer forms of cutaneous disease, and hence need the aid of illustrations to give them the requisite infor- mation on the subject. With these plates at hand, the inexperienced practitioner is enabled to discri- minate with much accuracy, and he is thus, com- paratively speaking, put on an equal footing with those who have had the opportunity of visiting the large hospitals of Kurope and America.—Fa. Med. Journal, June, 1856. BY THE SAME AUTHOR. In one A PRACTICAL TREATISE ON DISEASES OF THE SKIN neat royal 12mo. volume, extra cloth, of 334 pages. $1 00. EST The two volumes will be sent by mail on receipt of Five Dollars. OWEN ON THE DIFFERENT FORMS OF I One vol roval12mn „f,„ „i„«, tv THE SKELETON, AND OF THE TEETH. | illustrations? S'C)0Jl'&h Mmet°U! AND SCIENTIFIC PUBLICATIONS. 25 (Now Complete.) PEREIRA (JONATHAN), M. D., F. R. S., AND L. S. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; including Notices of most of the Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages, on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with raised bands. $9 00. Gentlemen who have the first volume are recommended to complete their copies without delay. The first volume will no longer be sold separate. Price of Vol. II. $5 00. When we remember that Philology, Natural His- tory, Botany, Chemistry, Physics, and the Micro- scope, are all brought forward to elucidate the sub- ject, one cannot fail to see that the reader has here a work worthy of the name of an encyclopaedia of Materia Medica. Our own opinion of its merits is that of its editors, and also that of the whole profes- sion, both of this and foreign countries—namely, " that in copiousness of details, in extent, variety, and accuracy of information, and in lucid explana- tion of difficult and recondite subjects, it surpasses all other works on Materia Medica hitherto pub- lished." We cannot close this notice without allud- ing to the special additions of the American editor, which pertain to the prominent vegetable produc- tions of this country, and to the directions of the United States Pharmacopoeia, in connection with all the articles contained in the volume which are re- ferred toby it. The illustrations have been increased, and this edition by Dr. Carson cannot well be re- garded in any other light than that of a treasure which should be found in the library of every physi- cian.—New York Journal of Medical and Collateral Science. The third edition of his "Elements of Materia Medica, although completed under the supervision of others, is by far the most elaborate treatise in the English language, and will, while medical literature is cherished, continue a monument alike honorable to his genius, as to his learning and industry.— American Journal of Pharmacy. The work, in its present shape, forms the most comprehensive and complete treatise on materia medica extant in the English language. — Dr. Pereira has been at great pains to introduce into his work, not only all the information on the natural, chemical, and commercial history of medi- cines, which might be serviceable to the physician and surgeon, but whatever might enable his read- ers to understand thoroughly the mode of prepar- ing and manufacturing various articles employed either for preparing medicines, or for certain pur- poses in the arts connected with materia medica and the practice of medicine. The accounts of the physiological and therapeutic effects of remedies are given with great clearness and accuracy, and in a manner calculated to interest as well as instruct the reader.—Edinburgh Medical and Surgical Journal. PEASLEE (E. R.), M. D., Professor of Physiology and General Pathology in the New York Medical College. HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology; for the use of Medical Students. With over four hundred illustrations. In one handsome octavo volume. (Nearly Ready.) The author's object in this work has been to give a connecled view of the simple chemical ele- ments, of the immediate principles, of the simple structural elements, and of the proper tissues entering into the composition of the fluids and the solids of the human body; and also, to associate with the structural elements and tissues their functions while in health, and the changes they un- dergo in disea-e. It will, therefore, be seen that the subject of the volume is one, the growing importance of which, as the basis of all true medical science, demands for it a separate volume. The book will therefore supply an acknowledged deficiency in medical text-books, while the name of the author, and his experience as a teacher for the'last thirteen years, is a guarantee that it will be thoroughly adapted to the use of the student. PIRRIE (WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hospital, &c. In one very handsome octavo volume, leather, of 780 pages, with 316 illustrations. $3 75. We know of no other surgical work of a reason- able size, wherein there is so much theory and prac- tice, or where subjects are more soundly or clearly taught.— The Stethoscope. There is scarcely a disease of the bones or soft parts, fracture, ordislocation, that is not illustrated by accurate wood-engravings. Then, again, every instrument employed by the surgeon is thus repre- sented. These engravings are not only correct, but really beautiful, showing the astonishing degree of perfection to which the art of wood-engraving has arrived. Prof. Pirrie, in the work before us, has elaborately discussed the principles of surgery, and a safe and effectual practice predicated upon them. Perhaps no work upon this subject heretofore issued is so full upon the science of the art of surgery.— Nashville Journal of Medicine and Surgery. One of the best treatises on surgery in the English language.—Canada Med. Journal. Our impression is, that, as a manual for students. Pirrie's is the best work extant.— Western Med. and Surg. Journal. PARKER (LANGSTON), Surgeon to the Queen's Hospital, Birmingham. THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- MARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi- lis by a safe and successful method. With" numerous Cases, Formula?, and Clinical Observa- tions- From the Third and entirely rewritten London edition. In one neat octavo volume, extra cloth, of 316 pages. (Just Issued.) ' 75. 26 BLANCHARD & LEA'S MEDICAL \ PARRISH (EDWARD), Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, &c. AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many For- mulae and Prescriptions. In one handsome octavo volume, extra cloth, of 550 pages, with 243 Illustrations. (Just Issued.) $2 75. A careful examination of this work enables us to speak of it in the highest terms, as being the best treatise on practical pharmacy with which we are acquainted, and an invaluable vade-mecum, not only to the apothecary and to those practitioners who are accustomed to prepare their own medicines, but to every medical man and medical student. Through- out the work are interspersed valuable tables, useful formulas, and practical hints, and the whole is illus- trated by a large number of excellent wood-engrav- ings.—Boston Med. and Surg. Journal. This is altogether one of the most useful books we have seen. It is just what we have long felt to be needed by apothecaries, students, and practitioners of medieine, most of whom in this country have to put up their own prescriptions. It bears, upon every page, the impress of practical knowledge, conveyed in a plain common sense manner, and adapted to the comprehension of all who may read it. No detail has been omitted, however trivial it may seem, al- though really important to the dispenser of medicine. —Southern Med. and Surg. Journal. To both the country practitioner and the city apo- thecary this work of Mr. Parrish is a godsend. A careful study of its contents will give the young graduate a familiarity with the value and mode of administering his preset iptions. which will be of as much use to his patient as to himself.— Va. Med. Journal. Mr. Parrish has rendered a very acceptable service to the practitioner and student, by furnishing this book, which contains the leading facts and principles of the science of Pharmacy, conveniently arranged for study, and with special reference to those features of the subject which possess an especial practical in- terest to the physician. It'furnishes the student, at the commencement of his studies, with that infor- mation which is of the greatest importance in ini- tiating him into the domain of Chemistry and Materia Medica; it familiarizes him with the compounding of drugs, and supplies those minutiae which but few practitioners can impart. The junior practitioner will, also, find this volume replete with instruction. —Charleston Med. Journal and Review, Mar. 1856. There is no useful information in the details of the apothecary's or country physician's office conducted according to science that is omitted. The young physician will find it an encyclopedia of indispensa- ble medical knowledge, from the purchase of a spa- tula to the compounding of the most learned pre- scriptions. The woikis by the ablest pharmaceutist in the United States, and must meet with an im- mense sale.—Nashville Journal of Medicine, April, 1856. We are glad to receive this excellent work. It will supply a want long felt by the profession, and especially by the student of Pharmacy. A large majority of physicians are obliged to compound their own medicines, and to them a work of this kind is indispensable.—N. O. Medical and Surgical Journal. We cannot say but that this volume is one of the most welcome and appropriate which has for a long time been issued from the press. It is a work which we doubt not will at once secure an extensive cir- culation, as it is designed not only for the druggist and pharmaceutist, but also for the great body of practitioners throughout the country, who not only have to prescribe medicines, but in the majority of instances have to rely upon their own resources— whatever these may be—not only to compound, but also to manufacture the remedies they are called upon to administer. The author has not mistaken the idea in writing this volume, as it is alike useful and invaluable to those engaged in the active pur- suits of the profession, and to those preparing to en- ter upon the field of professional labors.—American Lancet, March 24, 1S56. RICORD ( A TREATISE ON THE VENEREAL With copious Additions, by Ph. Ricord, M. D, M. D. In one handsome octavo volume, extra Every one will recognize the attractiveness and value which this work derives from Ihus presenting the opinions of these two masters side by side. But, it must be admitted, what has made the fortune of the book, is the fact that it contains the ''most com- plete embodiment of the veritable doctrines of the Hopital du Midi," which has ever been made public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted, are inconlestably dominant, have heretofore only been interpreted by more or less skilful P.), M. D., DISEASE. By John Hunter, F.R.S. Edited, with Notes, by Freeman J. Bumstead, cloth, of 520 pages, with plates. $3 25. secretaries, someiimes accredited and sometimes not. In the notes to Hunier, the master substitutes him- self for his interpreters, and gives his original ihoughts to the world in a lucid and perfectly intelligible man- ner. In conclusion we can say that this is incon- lestably the best treatise on syphilis wilh which we are acquainted, and, as we do not often employ Ihe phrase, we may be excused for expressina: the hope that it may find a place in the library of every phy- sician.— Virginia Med. and Surg. Journal. BY THE SAME AUTHOR ILLUSTRATIONS OF SYPHILITIC DISEASE. Translated by Thomas F. Betton, M. D. With fifty large quarto colored plates. In one large quarto volume, extra cloth. $15 00. LETTERS ON SYPHILIS, addressed to the Chie! Editor of the Union Medicale. Translated by W. P. Lattimore, M. D. In one neat octavo vol- ume, of 270 pages, extra cloth. $2 00. RIGBY (EDWARD), M. D., Senior Physician to the General Lying-in Hospital, &c A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. BY THE SAME AUTHOR. (Now Ready. ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. The following condensed summary of the contents will show the topics treated in this little volume. The aim of the author has been throughout to present sound practical views of the im- portant subjectsunder consideration ; and without entering into theoretical disputations and disqui- sitions to embody the results of his long and extended experience in such T condensed form as would be easily accessible to the practitioner. Chapter I. Amenorrhcea.—II. Dysmenorrhea.—III. Menorrhagia.—IV. Uterine and V»«nnnl D^harges.-V. Inflammation of the Os and Cervix.-VI. Ulceration of the oTand Cervix- VII. Displacement oftheLleruj..-VIII. Retroversion.-IX. Anteversion -X. Prolapsus Ve"o'« -XI. Prolapsus Uten.-XII. Fibrous Tumor of ihe Uterus.-XIII. Mali-nant°DiP«eaJ of}ih* Uterus.-XlV.-Caulilh.wer Excrescence of .he Os.-XV. Corroding UlSer of U e O*-XVf Pruritus Pudendi.—XVII. Vascular Tumor of Orifice of Urethra.—XVIII Ovarian AffeptuW -XIX. Displacement of the Ovary.—XX. Ovarian Tumors. ovarian Affections. AND SCIENTIFIC PUBLICATIONS. 27 RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY", in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. With Additions by W. V. Keating, M. D. In one large and handsome imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty- four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly two hundred large and beautiful figures/ (Lately Issued, 1856.) $5 00. In calling the attention of the profession to the new edition of this standard work, the publishers would remark that no efforts have been spared to secure for it a continuance and extension of the remarkable favor with which it has been received. The last London issue, which was considera- bly enlarged, has received a further revision from the author, especially for this country. Its pas- sage through the press here has been supervised by Dr. Keating, who has made numerous addi- tions with a view of presenting more fully whatever was necessary to adapt it thoroughly to American modes of practice. In its mechanical execution, n like superiority over former editions will be found. From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulation will, 1 trust, be extensive throughout our country. The publishers have shown their appreciation of the merits of this work and secured its success by the truly elegant style in which they have brought it out, excelling themselves in its production, espe- cially in its plates. It is dedicated to Prof. Meigs, and has the emphatic endorsement of Prof. Hodge, as the best exponent of British Midwifery. We know of no text-book which deserves in all respects to be. more highly recommended to students, and we could wish to see it in the hands of every practitioner, for they will find it invaluable for reference.—Med. Gazette. • But once in a long time some brilliant genius rears his head above the horizon of science, and illumi- nates and purifies every department that he investi- gates ; and his works become types, by which innu- merable imitators model their feeble productions. Such a genius we find in the younger Ramsbotham, and such a type we find in the work now before us. The binding, paper, type, the engravings and wood- cuts are all so excellent as to make this book one of the finest specimens of the art of printing that have given such a world-wide reputation to its enter- prising and liberal publishers. We welcome Rams- botham's Principles and Practice of Obstetric Medi- cine and Surgery to our library, and confidently recommend it to our readers, with the assurance that it will not disappoint their most sanguine ex- pectations— Western Lancet. It is unnecessary to say anything in regard to the utility of this work. It is already appreciated in our country for the value of the matter, the clearness of its style, and the fulness of its illustrations. To the physician's library it is indispensable, while to the student as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior.—Ohio Med. and Surg. Journal. We will only add that the student will learn from it all he need to know, and the practitioner will find it, as a book of reference, surpassed by none other.— Stethoscope. The character and merits of Dr. Ramsbotham's work are so well known and thoroughly established, that comment is unnecessary and praise superfluous. The illustrations, which are numerous and accurate, are executed in the highest style of art. We cannot too highly recommend the work to our readers.—St. Louis Med. and Surg. Journal. ROKITANSKY (CARL), M.D., Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, &c. A MANUAL OF PATHOLOGICAL ANATOMY. Four volumes, octavo, bound in two, extra cloth, of about 1200 pages. Translated by W. E. Swaine, Edward Sieve- king, C. H. Moore, and G. E. Day. (Just Issued.) $5 50 To render this large and important work more easy of reference, and at the same time less cum- brous and costly, the four volumes have been arranged in two, retaining, however, the separate paging, &c. The publishers feel much pleasure in presenting to the profession of the United States the great work of Prof. Rokitansky, which is universally referred to as the standard of authority by the pa- thologists of all nations. Under the auspices of the Sydenham Society of London, the combined labor of four translators has at length overcome the almost insuperable difficulties which have so long prevented the appearance of the work in an English dress, while the additions made from various papers and essays of the author present his views on all the topics embraced, in their latest published form. To a work so widely known, eulogy is unnecessary, and the publishers would merely Mate that it is said to conlain the results of not less than thirty thousand post-mortem examinations made by the author, diligently compared, generalized, and wrought into one com- plete and harmonious system. The profession is too well acquainted with the re- putation of Rokitansky's work to need our assur- ance that this is one of the most profound, thorough, and valuable books ever issued from the medical press. It is sui generis, and has no standard of com- parison. It is only necessary to announce that it is issued in a form as cheap as is compatible with its size and preservation, and its sale follows as a matter of course. No library can be called com- plete without it.—Buffalo Med. Journal. An attempt to give our readers any adequate idea of the vast amount of instruction accumulated in these volumes, would be feeble and hopeless. The effort of the distinguished author to concentrate in a small space his great fund of knowledge, has so charged his text with valuable truths, that any attempt of a reviewer to epitomize is at once para- lyzed, and must end in a failure.—Western Lancet. As this is the highest source of knowledge upon the important subject of which it treats, no real student can afford to be without it. The American publishers have entitled themselves to the thanks of the profession of their country, for this timeous and beautiful edition.—Nashville Journal of Medicine. As a book of reference, therefore, this work must prove of inestimable value, and we cannot too highly recommend it to the profession.— Charleston Med. Journal and Review, Jan. 1856. This book is a necessity to every practitioner.— Am. Med. Monthly. ROYLE'S MATERIA MEDICA AND THERAPEUTICS; including the Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, M. D. With ninety-eight illustrations! In one large octavo volume, extra cloth, of about 700 pages. $3 00. 28 BLANCHARD & LEA'S MEDICAL SMITH (HENRY H.), M.D., Professor of Surgery in the University of Pennsylvania, &c. MINOR SURGERY; or, Hints on the Every-day Duties of the Surgeon. Illus- trated by two hundred and forty-seven illustrations. Third and enlarged edition. In one hand- some royal 12mo. volume, pp. 456. In leather, $2 25; extra cloth, $2 00. A work such as the present is therefore highly useful to the student, and we commend this one to their attention.—American Journal of Medical Sciences. And a capital little book it is. . . Minor Surgery, we repeat, is really Major Surgery, and anything which teaches it is worth having. So we cordially recommend this little book of Dr. Smith's.—Med.- Chir. Review. This beautiful little work has been compiled with a view to the wants of the profession in the matter of bandaging, &c.,and well and ably has the author performed his labors. Well adapted to give the requisite information on the subjects of which it treats.^— Medical Examiner. The directions are plain, and illustrated through- out with clear engravings.—London Lancet. One of the best works they can consult on the Bubject of which it treats.—Southern Journal of Medicine and Pharmacy. No operator, however eminent, need hesitate to consult this unpretending yet excellent book.^ Those who are young in the business would find Dr. Smith s treatise a necessary companion, after once under- standing its true character.—Boston Med. and Surg. Journal. No young practitioner should be without this little volume; and we venture to assert, that it maybe consulted by the senior members of the profession with more real benefit, than the more voluminous works.— Western Lancet. BY THE SAME AUTHOR, AND HORNER (WILLIAM E.), M.D., Late Professor of Anatomy in the University of Pennsylvania. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $3 00. These figures are well selected, and present a complete and accurate representation of that won- derful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratu- late the student upon the completion of this Atlas, as it is the most convenient weak of the kind that has yet appeared ; and we must add, the very beau- tiful manner in which it is "got up" is so creditable to the country as to be flattering to our national pride.—American Medical Journal. SARGENT (F. W.), M..D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. Second edition, enlarged. One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood- cuts. (Just Issued, 1856.) Extra cloth, $1 40; leather, $ 1 50. This veryuseful little work has long been a favor- ite with practitioners and students. The recent call for a new edition has induced its author to make numerous important additions. A slight alteration in the size of the page has enabled him to introduce the new matter, to the extent of some fifty pages of the former edition, at the same time that his volume is rendered still more compact than its less compre- hensive predecessor. A double gain in thus effected, which, in a vade-mecum of this kind, is a material improvement.—Am. Medical Journal. Sargent's Minor Surgery has always been popular, and deservedly so. It furnishes that knowledge of the most frequently requisite performances of surgical art which cannot be entirely understood by attend- ing clinical lectures. The art of bandaging, which is regularly taught in Europe, is very frequently overlooked by teachers in this country; the student and junior practitioner, therefore, may often require that knowledge which this little volume so tersely and happily supplies. It is neatly printed and copi- ously illustrated by the enterprising publishers, and should be possessed by all who desire to be thorough- ly conversant with the details of this branch of our art.—Charleston Med. Journ. and Beview, March, 1856. A work that has been so long and favorably known to the profession as Dr. Sargent's Minor Surgery, needs no commendation from us. We would remark however, in this connection, that minor surgery sel- dom gets that attention in our schools that its im- portance deserves. Our larger works are also very defective in their teaching on these small practical points. Tins little book will supply the void which all must feel who have not studied its pages — West- ern Lancet, March, 185G. We confess our indebtedness to this little volume on many occasions, and can warmly recommend it to our readers, as it is not above the consideration of the oldest and most experienced—American Lan- cet, March, 1856. SKEY'S OPERATIVE SURGERY. In one very handsome octavo volume, extra cloth, of over 650 pages, with about one hundred wood-cuts. $3 25. S™Nl,'£Y'S TREATI»E ON DISEASES OF IHh BONES. In one volume, octavo, extra cloth. 286 pages. SI 50. ' SOLLY ON THE HUMAN BRAIN; its Structure, Physiology, and Diseases. From the Second and much enlarged London edition. In one octavo cuir 88lio* Cl°th' °f 5°° PilgeS' WUh UQ WOod- SIMON'S GENERAL PATHOLOGY, as conduc- ive to the Establishment of Rational Principles for the prevention and Cure of Disease. In one neat octavo volume, extra cloth, of 212 pagea. STILLE (ALFRED) M D PRINCIPLES OF GENERAL AND SPECIAL" THERAPEUTICS handsome octavo. (Preparing.) vyx^oj xi.i£*ix±\.irib\j llL/fci In SIBSON (FRANCIS), M. D. Physician to St. Mary's Hospital ' "EE^S^ S^Ef^fes,mcture'mi Position °f th° To much "Macli«'« Surgical .Wmy."rlnl Jft^S"".' ™"h *l,len