A MANUAL PATHOLOGICAL ANATOMY. B7 CARL ROKITANSKY, M.D., CUBATOB OF THE IMPEBIAL PATHOLOGICAL MUSEUM, AND PBOFESSOE AT JI tJMVEKSITY OF VIENNA, ETC. TRANSLATED FROM THE LAST GERMAN EDITION BY WILLIAM EDWARD SWAINE, M.D., CHARLES HEWITT MOORE, EDWARD SIEVEKING, M.D., GEORGE E. DAY, M.D., F.R.S. FOUR VOLUMES IN TWO. VOLS. I. II. PHILADELPHIA: BLANCHAED & LEA. , 1855. C. SHERMAN & SON, PRINTERS, 19 St. James Street. A MANUAL PATHOLOGICAL ANATOMY. BY CARL ROKITANSKY, M.D., THE IMPERIAL PATHOLOGICAL MUSEUM, AND PROFESSOB AT THE CMYEKSITY OF VIENNA, ETC. VOLUME I. GENERAL PATHOLOGICAL ANATOMY. TRANSLATED FROM THE GERMAN, BY WILLIAM EDWAKD SWAINE, M.D., FELLOW OF TEE ROYAL COLLEGE OF PHYSICIANS; PHYSICIAN EXTRAORDINARY TO H. R. H. THE DUCHESS OF KENT. PHILADELPHIA: BLANCHARD & LEA. 1855. \ 10 BIOLOGY LID" -' AMERICAN PUBLISHER'S NOTICE. THE numerous unsuccessful attempts which have been made to present the following work in an English translation, sufficiently attest the very general estimation in which it is held, as well as the difficulty of the undertaking. The task having at last been executed by the united labors of four gentlemen, each well qualified for the portion intrusted to him, the American publishers take much plea- sure in presenting to the profession of the United States, this great store-house of pathological knowledge, in a convenient and accessible form. The world-wide reputation of the author and of his work render eulogy superfluous, while the appearance of the translation under the auspices of the Sydenham Society is a guarantee of its fidelity. Under these circumstances, and as subsequent papers and researches of the author have been introduced in their appro- priate places by the translators, it has not appeared to the publishers that additions were necessary or desirable to such a work or to such an author, and they have consequently endeavored simply to secure an accurate reprint. For greater convenience of reading and refer- ence, and to lessen the cost, the four volumes have been bound in two, the paging, titles, &c., rendering each complete in itself. The volumes of the English Edition were not published in their regular sequence, Volume n. being issued first, and Volume I. last. The reader is therefore referred to Dr. Sieveking's Preface to Volume n., as well as to Dr. Swaine's Preface to Volume L, for some expla- nation of the work, and of the manner and auspices under which it has appeared. PHILADELPHIA. August, 1855. EDITOR'S PREFACE TO VOL. I. IN issuing this portion of Rokitansky's " Pathological Anatomy," it is necessary to offer, on behalf of the Council of the Sydenham Society, some apology for the delay which has attended the com- pletion of this important and voluminous work. In his interest- ing preface to the second volume, Dr. Sieveking has recorded one reason for the order in which the volumes have been pub- lished; but he has not adverted to the main consideration by which the Council was influenced, namely, the apparently well-founded hope that they might be enabled to' present the Association with the histological portion of the work in a new and revised edition. Encouraged from time to time in this hope by the author him- self, the Council did not hesitate to defer, from year to year, the publication of the first volume, until they felt that it would be improper to tax the patience of the members any further. The new edition is still promised, but with no surer pledge for its early completion than heretofore! The editor has, however, availed himself to a considerable extent of certain papers read by the author before the Imperial Academy of Sciences at Vienna ; namely, On the Structure and Growth of Cyst and of Cancers, &c. He has even found it not at all incompatible with the gene- ral unity and concordance of the work to substitute, almost bodily, the author's more recent essay on " Cyst and Alveolus," for the comparatively brief and imperfect article on the same subject in the original. These papers, there is reason to believe, contain the principal results of the author's more recent investigations, and therefore, in all probability, the most important of the additions that might be anticipated in a new edition. The Council has also sanctioned the introduction of two plates in illustration of the newly added matter. At the conclusion of the work will be found a copious Index to the four volumes collectively. To this each editor has contributed his respective share, thus offering to the English reader facilities altogether wanting in the original work. viii EDITOR'S PREFACE. On the other hand the editor has felt the necessity of abridging somewhat the author's general introduction, partly because, totally unlike the general tendency of the work, it is of too " transcen- dental" a character either to suit the English language or to har- monize with English ideas; but more particularly because it is interwoven with a train of speculative reasoning upon the relation between power and matter, which might, in this country, very possibly give rise to misinterpretation and rebuke. "What Dr. Sieveking justly alleges of the general peculiarities of Rokitansky's style, and of the difficulty of rendering his writings intelligible in English, is, by all who are conversant with the origi- nal, admitted to apply with especial force to the first volume. Upon this ground the editor ventures to urge his claim for a fair measure of indulgence on the reader's part. In conclusion, the editor, having been disappointed of a promised autobiographical sketch, takes leave to subjoin a few extracts from a short account of the career of this great pathologist, copied by a friendly hand from the last edition [1854] of Brockhaus's " Conver- sations Lexicon." ^ " Charles Rokitansky, the founder of the German [it should rather have been called Austrian] medico-anatomical school, was born at Konigsgraetz, in Bohemia, was educated at the Gymnasium of Leitneritz, and graduated, at Vienna, in 1828. Shortly afterwards he was appointed Assistant in the pathologico-anatomical department of the University, and, in 1834, Professor of Pathological Anatomy. At the same time he was instituted Prosector at the General [united Civil and Military] Hospital at Vienna, and also sole medico-legal Anatomist for the examination of all doubtful cases of death through- out that metropolis. " The immense fund of materials thus placed at his disposal [the number of corpses dissected by him is summed up at 30,000] was almost entirely reserved for the elaboration of that grand work on pathological anatomy, which, in the consciousness of having thoroughly mastered the subject, he gave to the world between the years 1842 and 1846 ; which has passed, unaltered, through three reimpressions ; and which, under the auspices of the Sydenham Society, has been translated into the English language." " In 1849, Eokitansky was appointed Dean of the Medical Faculty, and, in 1850, Eector of the University, of Vienna." YORK, January, 1855. AUTHOR'S PEEFACE. THE appearance of this first volume brings the publication of my " Pathological Anatomy" to a close. As was the case with the earlier volumes, the completion of this one has been delayed by lack of leisure, and especially by long and repeated attacks of illness. Whilst engaged in working out the design of this Pathological Anatomy, I have throughout endeavored to act the part of a clinical teacher; and I believe that, in so doing, I have apprehended the requirements of our day, and usefully disposed of the colossal materials within my reach. The same self-reliance that characterized the commencement of my pathologico-anatomical studies, has stood by me whilst engaged in observing and interpreting the facts of which the said materials are composed : for, each individual discovery encouraged me more and more to pin my faith upon ^Nature alone. Still I have never failed to watch and to appreciate the achievements of other men. The present work will at any rate tend to show, how thorough is my conviction that Pathological Anatomy must constitute the groundwork, not alone of all medical knowledge, but also of all medical treatment ; nay, that it embraces all that medicine has to offer of positive knowledge, or at least of what is fundamental to it. Its domain will here, however, be found more extended, and more nearly approximated to the confines of Pathological Chemistry than has generally been the case in pathologico-anatomical writings. Upon individual sections of the work I must confess to have exercised a certain favoritism ; and I have striven to cultivate and to carry out some important general views, with a well-tested conviction X AUTHOR S PREFACE. of their truth. Amongst these views I may here single out for exemplification the doctrine of a primitive diversity in blastemata, as the only tenable basis for a humoral pathology. From a comparison of the antecedently published volumes on special pathological anatomy with the present one, it will be /'seen that the former furnish the groundwork of the views here pro- pounded, and that my convictions, upon the whole, remain un- changed. THE AUTHOR VIENNA, July, 1846. CONTENTS OF VOLUME I. PAGE EDITOR'S PREFACE, ........ vii AUTHOR'S PREFACE, ........ ix INTRODUCTION, . . . . . . . . .17 CHAPTER I. ANOMALIES IN RESPECT OF THE NUMBER OF PARTS, . . . .35 CHAPTER II. ANOMALIES OF SIZE, ........ 42 Abnormal Magnitude, ....... 42 Hypertrophy, ........ 42 Abnormal Diminutiveness, ...... 50 Atrophy, ......... 51 CHAPTER III. ANOMALIES OF FORM, ........ 54 CHAPTER IV. ANOMALIES OF POSITION, . . . . . . . .57 CHAPTER V. ANOMALIES OF CONNECTION. ....... 59 CHAPTER VI. ANOMALIES OF COLOR, ........ 64 Xll CONTENTS. CHAPTER VII. PAGE ANOMALIES OF CONSISTENCE, ....... 68 CHAPTER VIII. SEPARATIONS OF CONTINUITY, ....... 69 CHAPTER IX. ANOMALIES OF TEXTURE, ....... 70 I. Organized New growths, .- . . . . . 72 A. Of Organized New growths in general, . . . . .72 Blastema and its Metamorphoses with an especial reference to Fibrin, 78 Coagulated Fibrin, . . . . . . .82 Metamorphoses of Blastema, . . . . . 86 Hypersemia, ........ 91 Hemorrhage, ....... 93 Anaemia, ........ 98 Inflammation, Phlogosis, . . 4 . . . 98 Varieties of Inflammation, . . . . . .105 Relation of the Inflammatory Process to Crasis, . . . 107 Exudation, . . . . . . . .109 Pus, Ichor, . . . . . . . 115 Issues of Inflammation, . . . . . . .124 Gangrene, Necrosis, . . . . . . . 128 Characteristic of Inflammatory Textures and Diagnoses of Inflammation in the Dead subject, . . . . . . .132 Corollary, ........ 133 Deposits, Metastasis (so called), ..... 134 B. Organized New growths, Specially considered, . . . . . . .136 Areolar-tissue Formations, ...... 137 Fibroid Texture, . . . ' . . .138 Gluten yielding Fibroid Tumor, . . . . . 141 Elastic Tissue and Texture of the Annulo-fibrous Membrane of Arteries, 142 Cartilaginous Growths, . . . . . . 143 Bone Formation, ....... 144 Growth of Bloodvessels, ...... 149 Fat Formation. Fatty degeneration, ..... 154 Fat Textures, . . . . . . . 154 Normal Fat, . . . . . . .154 Abnormal Fat, . . . . . . . 155 Free Fats, . ..... 156 Epidermidal and Hair Formations, . . . . . 159 Pigment Formation, ....... 160 Colloid, 166 Cyst and Alveolus, . . . . . . .168 Sarcoma and Carcinoma, . . . . . . 189 a. Sarcomata, 190 CONTENTS. Xlll PAGE Cysto-sarcoma, .... . Appendix, ..... 194 0. Cancer. Carcinoma, . . . 196 Colloid, Gelatinous Cancer. Alveolar Cancer (C. areolaire), . . 202 Fibro-carcinoma (Simple Carcinoma), .... 204 Medullary Carcinoma, . . . . . .207 Cancer Melanodes, . . . . . 213 Typhous Substance, ... . .215 Villous Cancer, . .... 216 Epithelial Growths, Epithelial Cancer, . . . .217 Carcinoma Fasciculatum, . . . . . . 219 Cysto-carcinoma, . . . . . .219 Appendix, .... .219 Tubercle. Tuberculosis, ... . .223 Albuminous Tubercle (Acute Tuberculosis), . . . 245 Albuminous crude Blastemata, ...... 247 II. Unorganized New growths, ...... 248 A. Of Unorganized New growths in general, .... 248 B. Of Unorganized New growths in particular, . . . 250 First Series, . . . . . . . .252 Second Series, . . . . . . . 253 CHAPTER X. ANOMALIES OF CONTEXTS, . . . . . . 254 A. Pneumatoses and Dropsy, . . . . . . 254 B. Foreign Bodies, ........ 257 c. Parasites, . . . . . . . . 257 I. Parasite Plants (Epiphytes, Entophytes), . . . .258 1. Fungi within and upon the common Integument, . . 258 2. Fungi upon Mucous Membranes, . . . . .259 II. Parasite Animals (Siebold), ..... 259 1. Infusoria, ........ 260 2. Insects, ........ 260 3. Arachnida. Acarina, . . . . . .261 4. Intestinal Worms. Helminthes. Entozoa, . . . 261 Nematoidea. Round Worms. Thread Worms, . . 263 Trematoda. Suction Worms, . . . . 265 Cestoidea. Tape Worms, . . . . .265 Cystica. Vesicular Worms, .... 266 Spurious Parasites, . . . . . . . . 271 Blood Diseases. Dyscrases, . . . . . . 271 1. Fibrin-erases, . . . . ... . 274 a. Simple (Organizable, Fibrinogenous) Fibrin, . . 278 b. The Croupous Crasis (Piorry's Hasmitis), . . .278 Croupous Crasis (), . . . ., . 279 " " (/), 280 " " GO, 281 c. The Tubercle Crasis, ...... 282 Pyaemia. Pus-blood, . . . . . . 285 2. Venosity. Albuminosis. Hypinosis (Simon), . . . 288 XIV CONTEXTS. PAGE a. Plethora, ....... 289 6. The Typhus-crasis, ....... 289 c. The Exanthematous Crasis, . . . . . 292 d. Hypinosis in Diseases of Nerves, ..... 295 e. The Drunkard's Dyscrasis, . . . . . 295 f. The Crasis of Acute Tuberculosis, ..... 297 g. Cancer Dyscrasis, . . . . . . 298 3. Hydramia : AnaBmia, . . . . . .301 a. The Serous Crasis. Hydramia, . . . . 301 5. Anaemia, ........ 301 4. Decomposition. Putrid, Septic Crasis. Sepsis of the Blood, . 302 Independent Anomalies of the Blood-Corpuscles, . . . 305 EXPLANATION OF THE PLATES. PLATES I. AND II. FIGS. 1 and 4 represent proliferous cyst-formations from the cortical substance of the kidney, as a sequel to Bright's disease. The two figures, 1 and 4, illustrate well Roki- tansky's history of proliferous cyst-development, and at the same time what he under- stands by the often-occurring expression, "alveolar type or arrangement." In fig. 1 we have the cyst in all its phases, a is a simple cyst, arising out of the expansion of the elementary granule, first into the nucleus, from this into the cell, and progressively into the cyst. But it has remained barren, and contains only a diaphan- ous, viscid serum within a simple cyst-membrane, b represents a parent-cyst, the early history of which accords with that of the barren cyst ; within it, however, new granules have formed, and gradually become developed into vesicles or cysts containing other nuclei, until the parent-cyst has become replete with them, and from being spherical, they are rendered polyhedrical by mutual compression. In an adjoining parent-cyst, many of the filial cysts have remained barren, others contain nuclei in the act of splitting, c, c. c, c, represent another form of development of the parent-cyst. Here, again, the parent- cyst has gone through the same phases, from the elementary granule upwards. But, as the cell dilates into the cyst, a granule forms centrally to the latter and expands into a filial cyst, centrally to which a third granule opens out in the same manner ; and so on. These intra-cystic cysts in their dilatation ultimately close upon the parent-cyst, forming secondary, tertiary, and ulterior layers, to which an external, fibrous layer is generally added out of the surrounding blastema. Or this fibrous coat accrues in the alveolar shape. Fig. 1 affords several examples of this. It is, however, better seen in Fig. 4. a is the fibrous sheath in progress of development out of d, the elongated and caudate nuclei coursing around the parent-cyst or aggregation of parent-cysts. They eventually break up into the requisite fibres, e is to represent the point-molecule, within an amorphous blastema, out of which the nuclei (6) form. They are at first sphe- rical, afterwards elongated, and ultimately broken into fibrillation. This constitutes what the author designates as the " alveolar type or arrangement." It is, however, still better defined in, Fig. 2. which represents cyst-formation in a medullary carcinoma. From the carci- nomatous framework a bulb-like excrescence is thrown out, within the extremity of which a parent-cyst forms and becomes replete with filial cysts, each containing a cen- tral nucleus. This parent-cyst surrounds itself with a broad marginal area of blastema, within which elongated, caudate nuclei course round the cyst in several tolerably regu- lar circles or series the rudiments of a dense fibrous envelope. Such is the " alveolar type," which applies to the fibrous fabric of follicle walls as well as to those of cyst- formations. (See " Cyst and Alveolus.") Fig. 3 represents a transverse section of a colloid cancer, a is an older portion of densely fibrillated fibro-membranous structure, c is a transverse section of a more recent fibro-membranous stroma; &, a transverse section of the colloid warp which intertwines with the said fibro-membranous stroma. (See p. 220.) xvi EXPLANATION OF THE PLATES. Fig. 8 represents the multilocular, fibre-membranous stroma of colloid cancer deprived of its colloid contents. (See p. 221.) Figs. 5, 6, and 7, represent so many stages of the development of medullary carcinoma. They are severally described in the same order in which they are here numbered, at pp. 220 and 221. Figs. 1, 2, and 4 are magnified by 90 diameters, the five remaining figures by 400 diameters. Several of the figures here given are embodied from Rokitansky's " Essays," in Mr. Paget's admirable " Lectures on Surgical Pathology," vol. ii. Figs. 1, 2, and 4, are derived from Rokitansky's Essay on " Cyst and Alveolus," read before the Imperial Academy of Sciences, at Vienna, in 1849 j figs. 3 and 8 from his Essay on " Colloid Cancer," published in 1852 ; figs. 5, 6, and 7, from a thesis of his on " Cancer-stromata," also published in 1852. PLATE I. Fig. 1 PLATE II. Fig. 5. Fig. G. Fig. 7. INTRODUCTION. PATHOLOGICAL ANATOMY may be said to be a modern science. It is indeed only of late years that it has assumed the dignity of an inde- pendent science at all. Although, according to Pliny, dead bodies were examined in Egypt at the time of the Pharaohs, that is to say, many centuries before Galen, with a view to detect the seats of disease ; the result of those researches has remained unrevealed to us. Even upon Greek medicine the pathologico-anatomical observations made by its founders and scholars have been without material influence. They were indeed gra- dually lost sight of in the medical schools, which arose out of the suc- cessive systems of philosophy of a later period. Not until the commencement of the sixteenth century the period of the regeneration of anatomy does the epoch begin of an occasional, fragmentary, indeterminate study of pathological anatomy. Still, Eustachius, the rival of Vesalius, must have been deeply impressed with its importance ; for, towards the close of his life he expresses his regret that he had not rather bestowed upon pathological anatomy that time and attention which he had devoted to physiological anatomy. The first who dedicated himself in an especial manner to pathological anatomy was Antony Benivieni, who wrote, at Florence, " De abditis morborum causis" (1507). He was followed by Mathieu-Reald Co- lumbus, the protector of Vesalius (1590), Volcher Goiter, a disciple of Fallopius (1573), Salius Diversus (1584), Marcellus Donatus (1588). Johannes Schenkins collected the observations made up to his time (1584). Johannes Wierus (1569), Felix Plater (1614), Fabricius Hil- danus (1606), Tulpius (1672), Vesling (1664), Thomas Bartholin (1654- 1675), Stalpaart van der Wiel (1677), Daniel Sennert (1676), Friedrich Ruysch (1691), cultivated pathological anatomy after their own fashion. Their observations, although partially of great interest, often bear the impress of superstition, and are disfigured by the fanciful way in which they are interpreted. Since the time of Harvey, the discoverer of the circulation, who, in denominating our particular science, medical anatomy, showed how fully he comprehended its import, various physicians have worked out sundry branches of pathology anatomically. Amongst them are Thomas Willis (1677) and J. J. Wepfer (1658-1727). Others, as Fernel (1679), F. Sylvius (1734), Baillou (1735), have, in their com- VOL. I. > 9 a 18 INTRODUCTION. pendia of pathology, adopted pathological anatomy for their ground- work. Bonnet was, however, the first who compiled an ample repertory on this subject (" Sepulchretum," 1679) ; and even this work unites to the imperfections of earlier observations the lack of a standard physio- logical principle, and of a definite practical tendency. The same applies equally, if not more forcibly, to Blankaard's "Anatomia prac- tica" (1688). Above both these above all that had been previously accomplished stands pre-eminent, Morgagni and his work, " De sedibus et causis morborum" (1767). Notwithstanding its defects, this book remains a model of industry and perseverance, of method and arrangement, of breadth and perspicuity, and, lastly, of originality, for all time. In the same century, special investigations, not unworthy of record, were made by J. Moritz Hofman, Walter, Albinus, Vater, Levret, W. Hunter, Senac, Meckel, Bbhmer, Van Doeweren, Camper, Bleuland, and others. In a work containing a vast number of facts (" Historia anatomico- medica," 1768), the purpose attained by Morgagni, failed in Lieutaud's hands, through lack of detail, of analysis, of a practical generalization of facts. On the other hand, Sandifort (" Observ. anat. path., 1777) merits, for the richness and solidity of his writings, to be classed along with Morgagni. 4 The compendia published in 1785, by C. T. Ludwig, and in 1796, by Conradi, and even the greater work of Voigtl (1804), so marked by literary industry and so serviceable withal, have not advanced science, either by aptness of discrimination, by a judicious selection of matter, nor yet by any remarkable progress in the method of anatomical research. Mathew Baillie's anatomy of morbid structures (translated into Ger- man by Soemmering, in 1794) is distinguished by greater depth of research into the fabric of organs, and both by its generalizing tendency and its physiological character. These latter qualities are, however, still more decidedly impressed upon the aphorisms from pathological anatomy published at Vienna, by Velter, in 1805. The most decided impulse was given to a right conception and appli- cation of pathological anatomy by Bichat in his general anatomy. Bichat founded upon the latter an especial physiology, or rather, blended the two. Pathologists, imitating this, endeavored to recon- struct their science upon an anatomical basis. France was the country in which this attempt was made in the most effectual manner ; not that it was exactly the cradle of pathological anatomy, but that it was the land of all others, in which men sought and found in it a solid foundation for medical knowledge. Such men were, amongst others, Bayle, Corvisart, Laennec, Dupuytren, Broussais, Cruveilhier, Rochoux, Lallemand, Eiobd, Andral, Louis, Gendrin, Bouillaud, Billard, Rayer. 4 It is true that one of these, namely, Broussais, disseminated an error from which his pupils cannot yet disentangle themselves, an error in which Brunonianism seemed once more to be trying its strength upon novel ground. On the other side, however, Laennec invented and carried out a method which insures to INTRODUCTION. 19 him and to his work the acknowledgment and admiration of future ages. In England many have, up to our own day, worked in a similar spirit. Amongst these, we may mention the names of Abernethy, Charles Bell, Astley Cooper, Hodgson, Farre, Wardrop, Howship, Baron, Hodgkin, Hope. In Italy, on the contrary, and in Germany if we except the impulse so decisively given in the same direction by the ingenious Reil patho- logical anatomy has been upon the whole less cultivated, and has exer- cised less influence upon medicine. Accordingly, Germany and Italy have but few men to place in parallel with those of France ; few to add to the names of Scarpa, Malacarne, Paletta of J. F. Meckel, Otto, and (in industry and method, the essentially German) Lobstein. It was reserved for Germany, at the present day, to establish a pathological anatomy and a method of working it out, partly indepen- dent, partly framed according to the best models of France. Under the auspices of German universality and analysis, this renovated science', emancipated alike from the systems of a bygone age and from a vain eclecticism, has begun to incorporate itself with pathology in a way that promises both durability and brilliant progress, more especially in its natural alliance with German physiology, and under a consistent and rational standard of pathological chemistry. Classification. Just as there is a general and a special anatomy, physiology, pathology, so there must in like manner be a general and a special pathological anatomy. The former treats of general anomalies of organization, the latter of the special anomalies of individual tex- tures and organs. All anomalies of organization involving any anatomical change manifest themselves as deviations in the quantity or quality of organic creation, or else as a mechanical separation of continuity. They are reducible to irregular number [deficient or excessive formation], irre- gular size, form, position, connection, color, consistence, continuity, texture, and contents. They relate to the physical properties of the animal body and of its organs. The chemical properties, although not strictly pertaining to the field of anatomy, are too intimately connected with the physical, to be suffered to remain in the background at the present day. The animal fluids bear a similar relation to anatomy. Their anomalies will be taken into account, so far as it may appear needful, under the appropriate heads. Those of the sanguineous fluid will, however, demand a separate chapter. This will come in at the conclusion of the general anatomy, in which a frequent reference to them will have previously demonstrated the indispensable nature of the inquiry, as a sort of connecting link between general and special anatomy. "We shall thus have to discuss, in ten separate chapters, the anomalies of organization. There are, however, a few general points which require some previous explanation. 20 INTRODUCTION. I. The said anomalies, being simple alterations of the normal being and of its parts, appear as abnormal conditions, excluding the idea of an independent parasitic organism of disease. II. No formation is incapable of becoming diseased in one or more ways. Several anomalies coexisting in an organ commonly stand to each other in the relation of cause and effect. Thus, deviations in tex- ture very frequently determine deviations in size, in form, and these again deviations in position. Deviations in position give rise to anoma- lies of volume and of texture. III. Pathological anatomy, proximately concerned with anomalies of individual organs and systems with local anomalies has often reserved for it the task of revealing by experiment and deduction the existence of general disease, as also of establishing the mutual relations which exist between the two. The seat of general diseases may now be refer- red, almost without exception, to the blood [the fluids]. They appear, therefore, as anomalies of admixture or crasis, either primary or secon- dary. IV. This demonstration of general disease is indeed a step in advance for pathological anatomy. It threatens, however, to mislead us into the error of exclusive, transcendental, all-pervading humoralism into the error of denying all local disease, by deducing the latter in every in- stance from a corresponding general affection, not but that many dis- eases really are but the localization of a pre-existent general disease. V. The existence of purely local independent of general disease, from the simplest inflammation from blennorrhoea, to tubercle and cancer, we look upon as grounded (a.) In the self-vitality of organs, and their independent relations to the external world. (b.) In the local influence of direct or reflected stimulation. Either directly, or through the medium of the nervous system, stimuli effect a local modification in the vital processes of absorption and secretion in the interchange of matter, an anomalous reciprocity between bloodves- sels and their contents on the one side, and the parenchyma-engendering products, abnormal both in quantity and in kind, on the other. Normal nutrition and secretion are no doubt mainly dependent upon a normal crasis ; but they are also based upon the perfection of the spe- cific vital action proper to individual parenchymata. Anomalous secre- tions often arise out of influences which modify the vital action of the parenchyma, and consequently its reciprocity with the unchanged gross material, the blood: as, for example, augmented or otherwise altered secretion of milk, produced by local irritation or by anomalous innerva- tion, the effect of mental operations. In like manner, local diseases are but a consequence of qualitative and quantitative alienation of the tex- tures and organs, the formative material (the blood), notwithstanding its reciprocity with the latter, not becoming sensibly contaminated. Influences, especially of a mechanical kind, are often so strictly local, that it would be far-fetched to derive all local disorder from a general causal disease. Even the latter would be but secondary, a mere transfer of the alienation locally produced. INTRODUCTION. 21 The existence of local diseases is further shown (c.) By direct evidence, where local disease is established, of the ab- sence of any disease of the blood crasis. (d.) In the curableness by topical remedies extirpation, isolation, &c. of local diseases, without their recurrence either on the same spot or elsewhere. The cure may even involve the simultaneous removal of a general disease consequent upon the local one, this having possibly acted as an anomalous instrument for the elimination of certain elements from the blood, exhausting it of certain essential constituents. VI. Local disease extends beyond its original seat in various ways : 1. By contiguity. The affection spreads to the immediate vicinity of its original seat. This extension is favored (a.) By uniformity of structure. (5.) By intensity of disease. (c.) By the nature of the malady. Certain diseases, such as tubercu- losis and cancer, in their extension, spare no texture, whilst the typhous process upon the intestinal mucous membrane always finds an arresting formation in the sub-mucous areolar tissue. 2. The disease extends to remote formations, both similar and dis- similar. This mode of diffusion does not imply concurrent general dis- ease, but proceeds, according to tolerably constant laws of sympathy, through the mediation of the nerves. It is greatly promoted, however, by a concurrent general disease, kindred in character with the local, causing it to increase, and multiplying the seats of the disease, as, for instance, in inflammation. VII. The originally mere local is enhanced into a general disease of the same nature, or gives rise to one of different attributes. The former contingency may arise from the alienation of the peripheric nerves, pro- ductive of the local anomaly, being transmitted to the nervous instru- ments presiding over the circulation, in other words, to the nervous centres, and in particular to the spinal cord and the ganglia. Or else the conversion assumes the substantive form of infection, the noxious matter evolved by the original local disease, or its products, being re- ceived into the circulation. This last event occurs where the products of the local disease exhaust the blood of certain ingredients, for in- stance, of fibrine, of albumen, of serum, of salts. To this class belong, in like manner, the anomalies occasioned by mechanical disproportion, such as the venous diathesis, cyanosis dependent upon disease of the heart or lungs, &c. VIII. The presence of general disease may be the more safely inferred : 1. The more widely extended is the local disease over several uniform or dissimilar formations, and the greater its intensity. 2. The less the products of the local process are conformable with the character of the normal structures ; 3. The less the extent and nature of the local disease, or of the struc- tures involved, however important in the organism, suffice to account for the general appearances during life and after death ; 22 INTRODUCTION. 4. The more anomalous, compared with the alienation of the solids, are the secretions and excretions ; and, 5. The more the totality of the organism, in the absence of actual anatomical disturbances, seems cachectic and impaired. 6. The more marked is some anomaly in the circulating fluid, with respect to the quantity or quality of its component parts. IX. General disease engenders in the most various organs and tex- tures, according to their innate general or individual tendencies, either spontaneously or by dint of some overpowering outward impulse, a local affection which reflects the general disease in the peculiarity of its pro- ducts. The general disease becomes localized, and, so to speak, repre- sented, in the topical affection. X. A general disease not unfrequently finds in its localization a per- petual focus of derivation, with seeming integrity of the organism in other respects. Recovery may, after a lengthened process, eventually take place through the exhaustion of materials at the local vent. Forced extirpation, on the contrary, or insulation of the locality, generally aggravates to a high degree the general disease, multiplying its points of localization. XI. The disease has, even anatomically speaking, its stages of inci- piency, increment, acme, and decline. - XII. The terminations of disease are, in like manner, subjects for anatomical research. 1. The issue of local disease in health consists either in the perfect re-establishment of the normal condition, or else in partial recovery ; more or fewer important residua and sequelae of the disease, not incom- patible with a tolerably fair state of health, remaining entailed. Thus the previously diseased organ may have lost substance, or more or less its natural texture ; or it may have suffered changes in form or in posi- tion, or interruptions of continuity. 2. The issue of one general disease in another general disease [metaschematismus] is frequent. Anatomical research proves, and che- mical analysis will still more clearly demonstrate, that it is far more fre- quent and varied than would appear from mere clinical observation. This is taught in an especial manner in the mutual exclusion of different morbid processes, which seem to succeed each other, when in full vigor, sometimes almost by a necessary sequence. Thus dropsy may succeed to the exhaustion of fibrine and the excretion of albumen, cancer to tubercle, &c. 3. Transition by so-called metastasis often becomes the subject of the scalpel. It comprises various conditions : (a.) The localization of a general disease at an unusual spot. It has the character of a vicarious or supplementary crisis. Instances are afforded in skin eruptions, and especially in the secondary typhous processes. (b.) Topical processes constituting the localization of a metaschema- tism, with which, as in the former instance, a general disease concurs. Such metastases occur more particularly in the sequel of typhus, and in the shape of inflammation, suppuration, gangrene, in both external and INTRODUCTION. 23 internal organs. They represent the localization of a general disease consecutive to the original typhous process. (c.) Local processes, with the development of which the general dis- ease is essentially abated, or thoroughly exhausted and extinguished. They are frequent, and deserve alone to be designated as metastases, metastases in a restricted sense. They are either just sufficient vents for the general disease, and are only cured when the latter is subdued ; or they heal spontaneously, the dyscrasis having, through their agency, become exhausted. (d.) When, owing to whatever cause, a local disease has been checked in its development, it subsides only to reappear in another part, often with augmented force, and with the supervention of a new general dis- ease, or the aggravation of one already existent. 4. Issue in death. Diseases are mortal for the most part, (a.) Through exhaustion of power and of organic matter, tabescence, loss of fluids. (b.) Through the suspended function of organs essential to life; through palsy ; through sudden and extensive displacements ; through hypertrophy, atrophy, diseases of texture. (c.) Through vitiation of the blood and palsy of the nervous centres arising out of the conflict between contaminated blood and nervous medulla. XIII. Where several diseases coexist in an individual, they are in part primary, in part secondary and subordinate to, although homolo- gous with, the former. Again, they are partly sequelae and residua of antecedent disease, as in the case of atrophy of the brain consequent upon apoplexy, upon encephalitis. XIV. Very dissimilar anomalies may coexist in one individual, as mere local affections or complications. Combination or exclusion result only in the case of heterogeneous diseases founded in or determining a dyscrasis : for example, cancer and tubercle, organic heart disease and tuberculosis. The study of these two relations opens a rich field of promise for the furtherance of accuracy in diagnosis. XV. The import of a disease bears a direct ratio to the worth of the organs attacked: take, for example, hypertrophy in different muscular organs. XVI. With reference to the period during which anomalies originate, we have to distinguish congenital, or such as have become established during intra-uterine life, and acquired, or such as have arisen during extra-uterine life. The former comprehend primitive anomalies. XVII. Primitive anomalies comprise malformations. These are de- viations of the organism, or of an organ, so intimately blended with its primary development, as to occur only at the earliest periods of embryonic life, or at any rate before that of mature foetal existence. Malformations, when inconsiderable and harmless to the individual, are termed lusus naturce, variation, defect of formation, malformation; when more marked, deformity ; when excessive, misbirth, monstrosity, monster. 24 INTRODUCTION. Despite some progress made in this field of late years, the genesis of malformation is still veiled in much obscurity. The opinions of modern physiologists on this point may be collected under two heads. Accord- ing to the one section, the malformations are referable to a primitive malformation of the germ. According to the other, to various influences affecting the germ in the progress of development. The former opinion resolves itself into that of the ovists and that of the spermatists. Those believed in the foreshadowing of the malforma- tion in the ovum ; these regarded it as dependent upon the spermatozoa as embryones. At this day both theories are rejected as inapplicable to a vast num- ber of malformations which unquestionably do originate during the de- velopment of the germ. Still the malformation might be founded in the nature of the ovum and of the sperma, although neither of these constitutes the embryo. The frequent recurrence of the same malfor- mations out of the same parents, and the hereditary character of these anomalies, render this not improbable. We might further advert to the nature of certain malformations inversions, duplicate formations, for instance in which the fusion of two germs, and the bisection of a single germ, during their development, are neither of them quite conceivable. The second of the aforesaid propositions embraces several hypotheses. (a.) The oldest and most popular ^attributes the malformation to a sudden and forcible impression wrought upon the mother (Yerschen). The question whether mental emotions do influence the development of the embryo must be answered in the affirmative. Instances undoubtedly have occurred of such maternal impressions fright more particularly when violent, giving rise to malformations. Seeing that many malfor- mations originate in an arrest of development, and how frequently the former bear a certain resemblance to various animals, it is just conceiv- able that the development of the embryo may be so arrested by mater- nal emotions as accidentally to occasion a likeness between the object that produced the impression and the resulting malformation. (6.) A second doctrine derives malformation from external mechanical influences, such as a blow, a thrust, a fall, &c., suffered by the mother ; mechanical obstacles to the passage of the ovum through the Fallopian tubes, and to its growth in the womb ; excess or deficiency of liquor amnii ; restriction of space for the foetus ; the formation of false mem- branes within the cavity of the amnion, &c. Although F. Meckel dis- sents from this doctrine, we are not quite prepared to relinquish it our- selves. (.) The lack of sufficient moisture, of water, in the blastema, is alleged as the condition upon which tuberculization depends. To this we reply that tubercle-blastema exudes under all conditions, and, not at all rarely, with a considerable amount of water, of blood- serum. A primitive lack of moisture in the entire exudate cannot there- fore determine the tuberculization, the tuberculous nature, of its coagu- lable, solidifying portion. If perfected tubercle be poor in water, it is so obviously in consequence of the high degree of solidification of its blastema. This, therefore, namely, its high degree of coagulability, might be the cause of the tuberculous nature of the exudate, of its per- sistence at its primitive stage of crudity. This, again, might be the reason why the tuberculous exudate takes the form of granulation. In- flammatory products, like blastemata generally, seldom exude pure. Inflammatory products of a tuberculous nature are, therefore, ordinarily alloyed with others of a different kind. Hence, portions of the former emerging, by reason of their transcendent coagulability, from their com- binations with the latter, appear to the eye in the shape of roundish coagula, in a word, of tubercle. But, again, it will be necessary to ask, whereupon does this high grade of coagulability depend ? It can but be founded in an as yet unknown dyscrasial constitution of the fibrin, as tubercle-blastema. There are blastemata dry from primi- tive poverty in serum ; and also others which, parting with their serum and passing into a high degree of condensation, nevertheless do not tuberculize, but become developed into textures, in the plenitude of their mass. It would appear evident, therefore, that the tuberculous nature of a blastema must be indwelling, be acquired either during the local process (inflammation) or in the general blood-disease which preceded and prepared its exudation. Accordingly, tubercle would, as once be- fore stated, have to be interpreted, now as a local, now as a general affection. This general character of tubercle is the more marked in proportion as its mass as an exudate is considerable ; as its diffusion through the organism is extensive ; as* its characters are impressed upon any spon- taneous coagula formed within the vascular system; and, lastly, as the organism in its totality reflects and manifests the tuberculous habit. Let us now, as a sequel to the foregoing, discourse respecting that anomaly of the crasis upon which tubercle is based. With a view, how- 236 TUBERCLE. ever, to establish a suitable groundwork for the exposition of the tubercle crasis, we would first add a few supplementary remarks concerning tubercle itself. The tubercle crasis is, without doubt, a fibrin-crasis fibrinosis. It is not this in respect to quantity alone hyperinosis but also, and this is the more important side of the anomaly, in respect to quality. This is clear even from that varied constitution of tubercle upon which we have founded our classification of fibrin-tubercle. Besides this, the fibrin must have become impaired in a particular way, in order to qualify the tubercle, which, in the one case, as simply fibrinous, cornifies ; in the other case, as fibrino-croupous, does not undergo the rapid process of dis- solution (puriform liquefaction) proper to croupous fibrin. This peculiar vitiation of the fibrin may itself become somewhat modi- fied, or admit of some accessory impairment. And this may operate as the cause of many differences in tubercle, recognized to this day only by deviating physical properties ; those, for instance, of coloration and lustre, of consistence, external form, mode of aggregation of the granu- lations. &c. Thus, the gray tubercle-granulation is distinguished at times by its dingy bluish coloration, by a grayish lustre, by its aggrega- tion in sharply defined spheres thinly scattered through the pulmonary texture; the yellow tubercle by a lardaceous aspect. The croupous tubercle effused into the lung during the inflammation and ichorous off- throwing of cancers, is, owing no doubt to the fundamental cancerous vitiation of the fibrin, remarkable for its whitish coloration, its softer glue-like consistency, its liquefaction to a whitish, cream-like ichor. A point of great moment, in relation to the crasis, is the recognition of an impress upon general nutrition indicative of a predisposition to tubercle, and consisting in certain developmental proportions of textures and organs; in a word, the "tuberculous habit." Another point of equal interest is the relation of tubercle to other morbid processes, bound up with primitive or consecutive anomalies of the crasis. There exists undeniably a habit, expressed in a delicate construction of the soft parts, in imperfect development of the muscular, with prepon- derance of the vascular, system, and especially in a so-called phthisical build of the thorax, commonly deemed ominous of pulmonary tubercle. It is essential, however, that this build should not, according to the vulgar notion, be imputed to smallness of the lungs within a seemingly insufficient thorax, but rather to very voluminous lungs within a thorax, the obvious narrowness of which, in its antero-posterior diameter, is amply compensated for by its length, with a relatively small abdominal cavity, and small abdominal viscera. Nevertheless, tubercle does not always, nor exclusively, thrive upon a substructure like this. The tuberculous crasis, like the local tuberculosis of an organ, may become acquired in an individual of quite a different habit, as a consequence of surpassing external and internal mischief. With reference to the second point, namely, the relation of the tubercle to other morbid processes, no disease offers so much that is in- teresting, that is corroborative of views already set forth, that is practi- cally serviceable and inductive of ulterior research, as tubercle. It is TUBERCLE. 237 especially distinguished by its exclusive relation towards several morbid processes. The sum of an immense range of experience in point is to the follow- ing effect : 1. Cyst-formation, as a new growth, is rarely found concurrent with tubercle, either in the same organ or in the same organism generally. In this sense the proliferous cyst-formations are distinguished. Where their seat is in the abdominal cavity, as for instance in the ovary, the immunity against tubercle is augmented by an accessory circumstance, in itself most important, namely, the coarctation of the thoracic space by pressure from beneath. Experience seems to show that it is more common for cyst-formations to succeed to the extinction of tuberculosis, than the converse. A comparison of the occurrence of both in the various organs esta- blishes, as the extreme points of the scale, the well-known great frequency of tubercle against the extreme rarity of cyst-formation in the lungs, and the reversed proportion of the two in the ovaries, and next to these in the salivary glands. This relation seems highly important in refer- ence to the affinity which cyst-formation bears to sarcoma and carcinoma. 2. A similar antagonism, as shown from still more numerous observa- tions, prevails between tubercle and carcinoma. Whenever their general correlation is susceptible of proof, cancer has seemed to succeed to tuberculosis, tubercle rarely to become developed after the extinction of cancer and its crasis. Moreover, it must be repeated that to cancer, and in particular to inflamed and ulcerating cancer, there is sometimes superadded, more especially in the lungs, a tubercle, marked by a whitish coloration, a softish glue-like consistence, and a tendency to resolve itself into a whitish cream-like ichor. It has the import of tuberculo- croupous impairment of a carcinomato-dyscrasial fibrin. A corresponding result of much interest is afforded by a comparison of the scale of frequency of cancer and tubercle, as well as of several special local relations of both. They are diametrically opposed to one another, as thus : FREQUENT. RARE. Lung tubercle. Lung cancer. Ovarium cancer. Ovarium tubercle. Salivary gland cancer. Salivary gland tubercle. Stomach cancer. Stomach tubercle. (Esophagus cancer. (Esophagus tubercle. Rectum cancer. Rectum tubercle. Ileurn tubercle. Ileum cancer. &c. &c. Again, the special localities present many differences of their own. Thus, in the uterus, the vaginal portion and cervix become affected with cancer, whilst tubercle fastens upon the mucous membrane of the body of the womb, and generally stops short at the internal orifice. The epididymis becomes primarily and essentially tuberculous ; the testis, can- 238 TUBERCLE. cerous. In the lungs the upper section is peculiarly obnoxious to tubercle, whilst cancer occurs at every part of the lung-parenchyma. In fine, cancer and tubercle possess a different import in the most vari- ous organs according as the one or the other is primitive or secondary. Thus, cancer of the liver is not rarely a primitive, tuberculosis of this organ almost invariably a secondary affection, if not a mere participa- tion of general tuberculosis. 3. Typhus and Tuberculosis. Typhus associates itself with tubercu- losis only under the influence of very intense epidemics ; in other words, it very seldom attacks tuberculous individuals. On the other hand, a fibrino-croupous tubercle-crasis developes itself not unfrequently in the sequel to typhus, and with it local inflammation with fibrino-croupous exudation of a tuberculous nature. This occurs in the shape of inflam- mations of the lungs, and also of such follicles of the ileum as have escaped the typhous process. This determines, from the softening of the tubercle around the typhous loss of substance, a combination of the so-called typhous with the tuberculous intestinal ulcer. This tuberculosis in the sequel to typhus is without doubt based upon the not unfrequent conversion of the typhous to the fibrino-croupous crasis. The conversion takes place at different periods, but frequently at a very early stage of the retrogressive typhous process. There is a similar relation of tuberculosis to the acute exanthemata ; especially to scarlatina and measles. The tuberculosis following them is, for the most part, fibrino-croupous, and dependent upon a similar conversion of the exanthematous crasis. 4. Intermittent Fever and Tuberculosis. The experience of foreigners places their incompatibility with each other beyond any doubt. 5. Bronchocele and Tuberculosis. Although within the range of our own observation a moderate degree of sporadic goitre has not seemed necessarily to possess an exclusive relation towards tubercle, the obser- vations of foreigners as to the exclusive relation of endemic goitre to tuberculosis merit, nevertheless, to be noticed here. Apart from the affinity in the structural relations of the enlarged thyroid gland, goitre presents, in the outpouring of colloid, important points of analogy with cysts, sarcomata, and cancers, in which colloid often constitutes an essential ingredient. It would seem that, in endemic goitre, it is not the mechanical hinderance to respiration that occasions consecutively, but an anomaly of the crasis connected with the secretion of colloid in the thyroid gland, that determines primitively the exclusion of tuber- culosis. (See Colloid.} This is betokened by the alienation of the general habit contracted with goitre, and still more by the fact that, in districts where goitre is endemic, tuberculosis does not occur, even in individuals unaffected with the prevailing deformity. 6. Rickets and Tuberculosis do not readily combine. Nay, rachitic deformity and coarctation of the thorax are scarcely ever found com- plicated with tuberculosis. It is, as yet, undecided whether, or what degree of, exclusiveness towards tubercle absolutely belongs to rickets ; and, again, whether the latter owe not its immunity to a consecutive disproportion of its own creation, namely, the deformity the narrowing of the thorax. TUBERCLE. 239 7. Even the arterial disease upon which spontaneous aneurism depends, and which consists in the endogenous exudation and strati- fication of a fibrinous substance upon the internal bloodvessel membrane (see Abnormal Conditions of the Arteries) is, in its more highly deve- loped grades, very rarely associated with tuberculosis. The immunity is, perhaps, based upon an exhaustion of the materials for tubercle, due to the deposition of a solidifying blastema out of arterial blood. A more decided immunity is brought about by aneurisms, or by a single extensive aneurism, in the proximity of the heart, involving the endo- genous coagulation of great fibrinous masses, and a consequent hydrse- mia through defibrination of the blood. 8. The relation to tubercle of venosity (that is, an habitual prepon- derance of venous blood in the system) and of cyanosis, as resulting from mechanical hindrance at the centres of the organs of circulation and of respiration, is of paramount interest and even of great practical importance. The remarkable exemption from tubercle brought about by these conditions induces us to set forth the relevant facts, as nearly as may be, in their natural order. They determine the venous consti- tution in various ways, generally conforming in this, that they prevent the arterializing of a sufficiency of blood ; whilst they engender cyanosis by hindering the return of blood to the right chambers of the heart, the said blood being arrested in the veins, and consequently in the capil- laries generally. The relevant facts, ranged in a twofold series, accord- ing as the venous habit and cyanosis are dependent upon the heart or the lungs, are as follows : (a.) The first place is due to the fact, confirmed by daily experience and convenient as a starting-point for the ensuing considerations ; namely, that persons laboring under enlargement (dilatation, hyper- trophy, and their complications) of the heart, whether primary or super- induced by mechanical obstruction at its orifices, do not contract tuber- culosis. (b.) Nor does tuberculosis co-exist with such congenital vices of formation in the heart or the great arterial trunks [absence, insuffi- ciency, coarctation of either, persistence of ductus arteriosus, &c.] which, with their complications, result in venosity and cyanosis, and, as the anatomical measure of their significance, in augmented volume of the heart. (c.) Next in the series we have to mention the immunity afforded by many acquired anomalies of arterial trunks, which resemble congenital vices of formation, such as coarctation from compression, obstruction, obliteration, or again by large aneurisms in the vicinity of the heart. Apart from what has already been said on this point, the immunity is due to the mechanical impediment which the overpowering blood-column in the dilated aortal trunk opposes directly to the emptying of the left ventricle, and indirectly to the influx of venous blood into the right heart. The same immunity is attained in venosity and cyanosis owing to hindrance to the pulmonary circulation; more especially where the impediment reveals its serious character by a dilatation of the right heart. 240 TUBERCLE. We may here further adduce : (d.) The observation that the increased density of the lungs produced by coarctation of the thoracic spaces, in higher grades of lateral curva- ture of the spine, or in the rickety chicken-breast, excludes tuberculosis. Nay ! it is an important fact that, with the establishment of a deformity of the spine in the shape of gibbosity, even when owing to tuberculous caries of the vertebrae, the tubercle-crasis is forever rooted out in con- sequence of the narrowing of the thoracic spaces. (e.} The fact that the compression exercised by pleural effusion, and a consecutive, abiding increase of compactness of the one lung, as denoted by a sinking in of the thorax, in like manner extinguishes the tendency to tuberculosis. This effect is the more surely produced, the greater the mechanical obstruction, and the consequent disproportion between the blood-mass and the lung-capillaries pervious to it ; and the less competent the other (vicariatmg) lung is to carry on the function of arterialization. (/.) The fact that pregnancy arrests the progress of an established tuberculosis ; or, as we would correct and extend this proposition, the fact that advanced pregnancy not only arrests a tuberculosis already in being, but also obviates the formation of tuberculosis generally. It is the effect of that embarrassment of the thoracic spaces, and of that resulting condensation of the lung-parenchyma occasioned by upward pressure from the abdomen ; in other words, it is based upon a venosity brought about by mechanical means. It is probably for similar reasons that the placenta very rarely, the foetus perhaps never, becomes tuber- culous. This relation derives further interest from the rapidity with which, after child-birth, that is, after removal of the conditions which prevailed during advanced pregnancy, fibrin-erases with their respective exuda- tory processes, and amongst them the tubercle-crasis and tubercle- deposits, take place, more particularly through the medium of inflam- matory stasis. (g.) To the same class is to be referred the immunity from tubercle arising from every enlargement of the abdominal space, and the conse- quent narrowing of the thoracic cavity. The exemption allotted to patients afflicted with vast ovarian cystoids probably partakes of this nature. (h.) Again, the fact that even congenital smallness of the pleural sacs, paired with primitive smallness of the lungs, and, as it mostly is, with an inverse ratio of the development of the abdomen and its viscera, serves as a protection against tuberculosis. (i.) That in the earliest childhood (with closed foetal passages), owing to a condensed state of the lungs caused by predominant abdomen, tuberculosis occurs, if at all, very rarely. (k.) The exemption apportioned to those who labor under chronic catarrh, under vesicular emphysema of the lungs, or under bronchial dilatation, was recognized even by Laennec. The empirical recognition of this relation has even led to attempts to cure tuberculosis by the forcible production of those conditions. The real preservative point was, however, overlooked, both here and in another mode of cure aimed TUBERCLE. 241 at by others, namely, that of closing cavities in the lungs by forcible compression of the thorax. The protective and curative impulse con- sists, even here, in venosity. And this venosity is a consequence of the destroyed function, the collapse and eventual wasting of numerous pulmonary lobules, through obstruction of their bronchia with muco- purulent secretion ; in bronchial dilatation, through the concomitant obliteration of considerable portions of the lung ; in emphysema, through lost contractility of the pulmonary texture for expiration, and conse- quently embarrassed respiration, more especially, however, through the destruction of extensive ranges of the lung-capillaries. (I.) It will be readily understood that the dropsical crasis, especially when resulting from venosity, excludes tubercle. It will now become necessary to inquire how certain exceptional cases are to be explained. Individual cases of the kind are represented in tu- bercle associated with cancer, or with venosity mechanically brought about. (1.) The conditions mentioned as excluding tubercle, operate thus only in so far as the latter is based upon a hyperinotic crasis an excess of fibrin. This does not, however, prevent the small fund of fibrin accom- panying those conditions from being, under favorable circumstances, ex- pended upon tubercle formation, which then becomes localized in a pro- cess of exudation. (2.) The tubercle may be the product of a local inflammation, in which the fibrin becomes tuberculous. (8.) The entire mass of fibrin may suffer a morbid change, effecting, as intercurrent disease, a consecutive tubercle crasis, which becoming exhausted by a corresponding exudation, again gives way to the original crasis. It is thus that genuine tubercle, when concurrent with cancer, may be interpreted; and this the more readily, that true hyperinoses and fibri- nous exudates not unfrequently do co-exist with cancer. The tubercle may be merely local, and the cancer no less so. It may, however, be local, and yet the cancer be a general disease. Or, again, it may be the product of an intercurrent primitive tubercle-crasis, or of a consecutive one derived from a local process, and co-ordinate with those hyperinoses and fibrin-exudations which not rarely supervene upon inflamed and ulcerated cancer, reflecting a secondary crasis. (4.) As to the exemption afforded by venosity, there is no doubt that, to render it complete, a high degree of the latter is requisite. Since, however, we possess no scale whereby to ascertain directly the grade of a protective crasis, and to illustrate the exceptions, we must inquire whether it be not possible to arrive indirectly and approximative^ at this recognition. In the absence of such a scale, certain anatomical changes must serve as the measure, so to speak, of the anomaly. They consist in the degree of heart affection (dilatation) present, this furnishing an available criterion for the amount of the impediment to the circula- tion, and therefore for the grade of the venosity. This approximative index with the aforesaid inferences, will be especially applicable where the precise extent of the impediment is not to be immediately summed up from anatomical data, as in lung affections, like catarrh and bronchial dilatation, emphysema, and preternatural density of the lungs. VOL. I. 16 242 TUBERCLE. We attach importance to this relation of tubercle to the venosity resulting from mechanical impediments in the heart and lungs, as affording not alone proof of the fibrin-crasis being the foundation of tubercle, but also valuable indications for medical treatment. We have now to consider the relative occurrence of tubercle in the different organs and textures, and its peculiar processes of repair. It will be expedient, however, as a preliminary point, to determine what is signified by scrofula, what is the distinction if there be any between scrofulous and tuberculous substance. For our own part we hold tubercle and scrofula to be identical tuber- culosis and scrophulosis to be one and the same disease ; and this upon the following grounds, namely : (a.) One and the same elementary composition, both anatomical, and, so far as investigation has gone, chemical also. This applies with especial force to scrofulous substance, as compared with yellow tubercle. Jb.) Both are subject to the same metamorphoses, namely, softening cretefaction. ( belongs to the genus Oidium (Linck), and according to Muller greatly resembles the oidium aureum of wood. Or, according to Corda, it may, together with all thread-fun- guses, which fructify by simple separation of their links, and in which every link may become a spore, be taken, along with yeast funguses, into the great genus Torula. 1 [It is now, however, pretty generally admitted to be an alga. ED.] PARASITE ANIMALS. 259 There is as yet no certainty as to the part played by these thread- fimguses. Attempts at inoculation have hitherto failed, with the excep- tion of one experiment made by Remak. (b.) Fungi in the root-sheath of the hair in sycosis [mentagra, Gruby]. They collect around the hair itself within the root-sheath, and are marked by redundant spore-formation. The spores are spherical and the thallus-threads frequently contain in their interior little granules. (c.) Fungi in the interior of the hair-roots [Gruby]. In alopecia cir- cumscripta, areata [porrigo decalvans], the falling out of the hair is caused by a thread-fungus, called by Gruby, on account of the minute- ness of its spores, microsporum. (d.) In plica Polonica, Giinsburg has detected, in the hair-bulbs, a fungus which differs from that of favus. (e.) In Pityriasis versicolor, Eichstedt has discovered a thread-fungus. Fuchs, Klenke, Helmbrecht, have observed a fungus formation in lepra alphoides, and inoculated it with success. Langenbeck met with a fungus in crusta serpiginosa. Finally, the mould formations upon sloughing ulcers, and in senile gangrene, come under this head. They are both frequent and copious. 2. FUNGI UPON MUCOUS MEMBRANES. These are very often found upon the mucous membrane of the mouth, the pharynx, the oesophagus, the intestinal canal, that is to say in fibrino-croupous, and especially in corroding, aphthous exudates. Aphthae and diphtheritis of the mouth and throat ; croupous exudates in the same localities, in florid phthisis ; croupous exudates in the larynx, oesophagus, &c., in the sequel to typhus. They are assuredly not the morbific agent. The croupous exudates upon which they vegetate are cognizable to the naked eye, for those familiar with the subject, by a peculiar character, consisting in a viscid, curdlike turgescence, dingy yellow or tawny discoloration, and a broken or jagged aspect. The fungi resemble those of favus. The thallus-threads are, however, mostly much longer, more slender, and have frequently at their free ex- tremity protuberances replete with minute granules (spores). They often form very compact, felt-like tissues. Amongst these funguses are, no doubt, to be counted the fungus Noma, of Klenke ; those found by Bennett in the sputa and lungs, in a case of pneumo-thorax, as also in the black sordes upon the teeth, in typhous patients ; again, those seen upon so-called typhus-ulcers in the intestines ; lastly, the mould such as we ourselves once observed upon an old blood-clot, unattached within a bronchial sac. II. PARASITE ANIMALS (Siebold). Parasite animals are divisible, although not strictly so, into ecto-para- sites (epizoa), and into ento-parasites (entozoa). The former infest the surface of the body, the latter its different cavities and parenchymata. Some of them are parasitic during their entire existence ; others only 260 INFUSORIA. INSECTS. at certain periods of it. For this purpose the latter migrate, and enter into various metamorphoses. Some of them inhabit exclusively certain definite parts of the body, both cavities and parenchymata, others on the contrary occur in various regions of the body, and in great numbers all at once. All this is con- tingent upon their habitudes, and perhaps still more upon the mode in which they obtain access to their place of abode. With regard to the difficult question of their origin and propagation, modern researches in the least promising domain, namely, of the helmin- thes, have pretty well succeeded in subverting the older doctrine con- cerning the generation of parasites, and their relation to the animals which they infest. They get introduced into the organism as ova, as larvae, or even as developed creatures ; and wherever they meet with a nidus congenial to their nature, live and thrive upon it. For this habitation to last, how- ever, a peculiar disposition on the part of the subject is no doubt indis- pensable. In the different parasites this sort of predisposition differs materially. Much is assuredly not required to incur a visitation of ascarides. On the other hand, notwithstanding the extensive dissemina- tion of the ova of the helminthes, the disproportionately small number of persons affected with worms ; the circumstance that, under certain conditions (for example, disease), worms for the most part, if not alto- gether, abandon the individual they had infested ; and lastly, the fact that different kinds of worms are proper to different animals ; testify to the necessity of the peculiar disposition adverted to, existing in persons affected with worms. 1. INFUSORIA. The most frequent are the vibriones, in purulent and other protein- fluids in the progress of decomposition. Donnd has detected a vibrio in the pus of chancre, and rated it beyond its worth. In pus, the vorticella, and also the colpoda cucullulus (Yogel) occur. The trichomonas vaginalis, detecting by Donne in the vaginal mucus of syphilitic females, is probably not an infusorium, but a misshapen ciliary cell from the uterus or the tubes. Lastly, we have to cite the hcematozoa occurring in the blood ; if they be not rather the embryones of worms, which is probably the case with many of them. 2. INSECTS. Besides the various flies which infest putrid ulcers with their ova and maggots, and the exotic [still problematic] oestrus hominis, we have the flea, the lice, and the bug. (a.) Pulex irritans, the common flea. (b.) Pulex penetrans, the sandflea, common in the West Indies and in South America. The impregnated female burrows into the skin, especially beneath the toe nails, where the brood gives rise to malignant sores. INTESTINAL WORMS. 261 Of lice there are (a.) Pediculus capitis, the head-louse. (b.) Pediculus pubis, the crab-louse, infesting, the scalp excepted, every hairy part, and penetrating the skin with its head. (c.) Pediculus vestimenti, the clothes-louse, infesting parts of the body devoid of hair, and uncleanly vestments. (d.) Pediculus tabescentium, the louse of wasting disease, in which it occurs in great multitudes. The notion, however, that there is a disease in which lice are generated beneath the skin, is without doubt fallacious. Of bugs, we have only to mention the ordinary bed-bug, cimex lectu- larius. 3. ARACHXIDA, ACARINA. (a.) The itch-mite, acarus scabiei, sarcoptes hominis, punctiform, from a quarter to half a millimetre long, ovoid, garnished with trans- verse, bandlike, dorsal striae, and with central, acuminate warts ; ante- riorly a bristled proboscis, prolonged inferiorly to a band upon the thorax ; four bristly fore-feet terminating in disk-plate, whilst the four hind-feet taper into lengthy bristles. , It burrows in the epidermis, often boring beneath it a canal several lines long, at the termination of which the acarus is, on a narrow inspection, discoverable as a minute whitish speck, marked with a brown point. When the said canals penetrate to the cutis, they engender the itch-vesicles and pustules. Researches into the natural history of this mite, together with the results of extended experience, prove beyond a doubt its relation to itch as its sole cause. The follicle mite, acarus commedonum sive folliculorum, an elon- gated acarus, from one-fifth to one-third of a millimetre long, and about one-twentieth broad, the head having two lateral antennae and an intermediate proboscis. The head passes immediately into the anterior part of the body, which occupies about one-fourth of the entire mite. From it project four pair of very short, thick, conoid, three-jointed feet, each furnished with three toes. The anterior body passes without break into the posterior, which gradually tapers, but is rounded off at the extremity, is transversely striated, and contains a finely granular, brownish mass. It inhabits singly or numerously the hair sacs and sebaceous follicles on various parts of the person. Amongst other anomalies, it occa- sionally displays only six feet, which no doubt implies an earlier state of its development. Its presence is probably often of little moment. Occasionally, however, it may, by stimulating the secretion, engender commedones, or set up inflammation, and thus give rise to the acne pustule. 4. INTESTINAL WORMS. HELMINTHES. ENTOZOA. Restricting ourselves here to the consideration of such as are peculiar to man, we would preface our special description of them with the fol- lowing general remarks : 262 INTESTINAL WORMS. (a.) Intestinal worms, in their consummated development, are all provided with organs of generation. Those in which the latter have not been demonstrated, are propagated by buds or by offshoots, if they be not imperfect, that is, either larvae or diseased animals. As opposed to the doctrine of equivocal generation, these facts are important, if we consider : (b.) The migrations and the attendant metamorphoses of the hel- minthes. The migrations of the helminthes consist, first in the search for a suitable animal to inhabit, and in introducing themselves into it, when found, through channels formerly unthought of. Secondly, they consist in abandoning the animal dwelt in, for the purpose of casting their ova under favorable conditions, then in passing through one of their meta- morphoses, and lastly in searching for another animal for their habita- tion. They pass, under various phases of development, for the most part through natural orifices of the body, more especially into and out of the intestinal canal. Their occurrence, however, even in the paren- chymata, is intelligible upon grounds of direct experience. As illus- trative of this, the larvae of cercarioid trematoda, and of the tetrar- hynchi, have been observed to migrate through the parenchymata of mollusca and fishes. It is also deserving of notice, in this place, that helminthes may reach, and settle in any parenchyma through the circu- lating channels, probably by boring for themselves a passage into the bloodvessels of the intestinal canal. This applies to the nematoid, thread-like animals found by Valentin, Vogt, Gruby, Ecker, and others, in the blood of frogs, dogs, and ravens, and probably representing the embryones of helminthes. This migration of the helminthes may involve frequent aberrations, and these in their turn many phenomena, which an extended inquiry will perhaps correctly set down to a morbid condition. We refer more particularly to the encysting, the atrophy, and the deformity of certain helminthes ; amongst others, of the trichina spiralis, and the taenioid cystica. (c.) The metamorphoses of the helminthes, coincident with their migrations, are of the greatest interest. They constitute a circle of generations, which Steenstrupp, following up the investigations of other naturalists, has pointed out in the trematoda (as in the medusae, bulb- polypi, and salpse). A parent animal produces a brood altogether dissimilar to itself, nor identified with it until after three or four gene- rations. These intervening generations of larvae these pro-nutrices and nutrices form without sexual mediation, and are the source of the numerous fallacies taught by the older helminthologists. (d.) All this accords perfectly well with the strict limitation of certain worms to particular countries. The most striking example is afforded in those two riband-worms, the botryocephalus latus, of Russia, Poland, Prussia up to the Vistula, and Switzerland; and the taenia solium of the remainder of Europe. (e.) On the other side, the doctrine of the origin of the helminthes out of intestinal mucus and the like, has not a single point of real evi- dence in its favor. A disposition to worms exists only in so far as an NEMATOIDEA. 263 organism abnormally nourished offers to helminthes, introduced into it from without, a nidus well adapted for their development. In mankind the following helminthes occur : NEMATOIDEA, ROUND WORMS, THREAD WORMS. Filar ia medinensis, the thread or Guinea-worm, of about the thick- ness of packthread, whitish, from half a foot to several feet long, j^t the broader end obtunded, terminating behind in a pointed curve. Peculiar to tropics of the Old World, but especially to Guinea ; inhabits the sub- cutaneous areolar tissue, especially of the lower extremities, but occa- sionally also of the scrotum, the trunk, and the throat. Having spent its earlier period out of the body, it burrows beneath the skin, where it tarries in the areolar tissue for a considerable time (several months), after which it again perforates the skin from within, in order to dis- burden itself of its offspring, or in order, it may be, to migrate for this purpose altogether. These proceedings are attended with inflammation and ulceration, and great caution is recommended, in any attempt to extract the worm, to avoid tearing it ; either the elapsing brood or other contents of the worm, having an erosive property which tends to aggra- vate the said processes. It would seem that, as yet, none but females have been observed. Accordingly these must have introduced them- selves in the impregnated state. Trichoceplialus dispar, the hairhead or whip- worm ; filiform ; the anterior part hair-like, the posterior part considerably thicker ; from one and a half to two inches long ; of distinct sexes. The male is, at its posterior part, spirally convoluted, and its penis contained in an elongated, funnel-shaped, violet-colored sheath. The posterior part of the female is not spiral. It infests the caecum, singly, and also frequently in multitudes [espe- cially, it is true, in the dead bodies of persons who have died of pro- tracted typhus or similar diseases], without occasioning any extraordi- nary symptoms. The females are loaded with ova, which are, however, not developed in this locality. Ascaris lumbricoides, the cylinder worm, a widely disseminated intes- tinal worm, from five to twelve inches in length, cylinder-shaped, taper- ing towards both extremities, especially towards the anterior; having four longitudinal striae, two of which are more strongly pronounced ; densely marked with transverse striae : semi-diaphanous, so that the intestinal canal and the organs of reproduction are transpicuous. The head, divided from the body by an annular groove, displays three little nodules, or rather valves, which encircle the mouth. . The caudal extre- mity, especially in the male, is incurvate. Sexes distinct, the male being smaller and narrower, and having at the caudal extremity a thin, capillary, sometimes double penis. The female is larger, and exhibits at its upper third a fissure from six to eight millimetres long, as the orifice to the organs of generation, which contain ovaries and oviducts of enormous length. It infests the ileum, often in extraordinary number, in groups and con- glomerate masses. A brood is never met with ; the ova, therefore, be- 264 NEMATOIDEA. come hatched extraneously to the human body, to remigrate thither after- wards, as the living brood. It gives rise to the well-known worm symp- toms. The perforation of the intestine, however [migration extraneous to the intestinal membranes], and its sequelse are, to say the least, ex- tremely rare. Oxyuris vermicularis (the Ascaris vermicularis of Rudolphi), the hook-tail, maw-worm ; a little, thin, white worm. Sexes distinct. The male very rare and small, from one to one and a-half millimetres long, with spiral convoluted tail : annulate ; with a tail terminating in a fine transparent point. The head of either displays a transparent swelling, which under the microscope appears as a wing-like membrane. It inhabits the colon and especially the rectum, occasioning both here and in the vagina, into which it creeps, an intolerable itching. As it is never accompanied by a brood, it probably migrates as the impreg- nated female. Strongylus gig as [Pallisadenwurm]. Giant strongle ; a very large, cylindrical worm,\of from five inches to three feet long, and from two to six lines in thickness ; when recent, of a fine red color. Sexes dis- tinct ; the male smaller, more tapering towards both ends ; annulate, with shallow, longitudinal grooves ; head obtuse, with six papillae ; at the tail extremity, a funnel-shaped pouch, out of which protrudes a very thin penis. The female, larger, with o*btused caudal extremity, and near it the vulva. Inhabits the kidneys ; is rare both in man and in brutes [found in the dog, the wolf, the marten, the horse, &c.] To these may be added the following nematoda and nematoid pseudo- parasites, some of them being very rare, or even but once met with. ^\\.Q filaria broncliialis. \_Hamidaria lympliatica, Treutler H. sub- compressa B., once seen by Treutler in a degenerated bronchial gland in the human subject.] Filaria oculi humani [in the liquor Morgagni and in the cataractous lens, Gescheidt, Nordmann]. The filaria in the blood [Klenke] ; the ancliylostoma duodenale [Dubini, in the duode- num] ; the spiroptera hominis [Barnett, in the urine] ; the dactylius aculeatus [Curling, in the urine]. Finally the encysted nematoda. Trichina spiralis, an incarcerated worm, which one might be tempted to class intermediately between the nematoda and the cystica, were it not extremely probable that it is only a strayed nematodon which, with- out coming to maturity, encysts itself, perishes, and cretifies within a second cyst thrown out from the textures. The worm is enclosed within a double cyst, an external one, mostly lemon-shaped, and an inner, oval one ; the space of the first, at its two ends, being filled up with very fine dark granules. Both consist of a homogeneous, faintly granular structure ; the former being about one fiftieth of an inch long, and one ninety-fifth broad, the latter one seventy- seventh long. In the inner cyst, amidst a more or less granular, viscid, transparent fluid, lies the worm, perfectly free, and generally rolled up in two and a half spiral convolutions. When extended it is from one twenty-fifth to one thirtieth of an inch long, and about one six-hundredth broad, lumbricoid, thread-like at both extremities, although more pointed at the one than at the other. It possesses internally a winding canal. CESTOIDEA. 265 interpreted as intestine, and a granular organ, the designation of which, as an ovary, is without doubt erroneous. Occasionally the cyst contains two, or even three, worms. The Trichina spiralis inhabits the voluntary [striated] muscles, and always in vast multitudes, the muscles appearing to the naked eye studded with little white specks. The cysts always lie with their long diameter parallel to the course of the muscles. [Hilton, Owen, Blizzard, Henle, and others.] TREMATODA, SUCTION-WORMS. Especially characterized by their peregrinations and metamorphoses. Distoma hepaticum, and D. lanceolatum, Liver-fluke ; flat, melon- seed or lancet-shaped, soft worms, of a yellowish-white color, with two suction pores ; one of which is seated at the head extremity ; the other, which terminates cgecally, at the belly. Between the two is the sexual orifice. They are hermaphrodites. The Distoma hepaticum is the larger, being from four to eight or to fourteen lines long, and from one and a half to six broad, with a branched intestinal canal. The Distoma lanceolatum, as the smaller, is from two to four lines long and about one broad. Its intestinal canal is bifurcated. Both infest the liver of the herbivora, rarely of man. The D. lanceola- tum has only once been met with in the latter. In brutes they occur in great multitudes, obstructing and dilating the gall-ducts. Distoma oculi liumani. A minute distoma, once met with in a child between the cataractous lens and its capsule. Polystoma pinguicola, Hexathyridium pinguicola (Treutler). An inch long and from two to three lines thick, oval, superiorly convex, in- feriorly depressed worm, with six pores at its head extremity, and a larger abdominal aperture anterior to the tail. Pound once by Treutler in the fat of an ovarian fat-cyst. Polystoma venarum, HexatJiyridium venarum (Treutler), probably a pseudo-parasite. CESTOIDEA TAPEWORMS. These are characterized by their enduring growth, and by the great length to which they attain. They consist of a succession of linked joints, of which the fully developed, sexually mature, hindmost ones be- come cast off in greater or lesser series ; whilst at the neck, fresh joints are continually being reproduced. As in these, again, a brood is rarely seen associated with the old individuals, whilst the separated, sexually mature joints so frequently become ejected, it is probable that the em- bryones become developed externally to the animal they infest, to re-im- migrate subsequently. In mankind there occur : The Tcenia solium, T. vulgaris, T. cucurbitina, the ordinary tape- worm, long-jointed tape-worm, chain-worm ; a white, or yellowish-white worm, twenty feet long and beyond it, anteriorly thin, roundish, pos- 266 VESICULAR WORMS. teriorly flat, and from three to six lines broad, -jointed. The joints are flat, square, towards the distal end more and more oblong-square, re- sembling gourd-seeds with truncated apices. At the right or left margin, often alternately, is seen a wartlike projection marked by a pore with a raised brink. This is the orifice of the sexual organ, which represents a cavity dendritically branched throughout the joint. The head constitutes at the very thin anterior termination, a nodule-like intumescence, with four lateral, black points in relief. There are four suction pores ; and, between them is seated upon a slightly raised circle a double coronet of booklets. The annulate neck is studded with numerous lime-corpuscles of the most various size (vide Cystica). Inhabits the small intestine in man, almost in all districts, except where the botryo-cephalus occurs. The belief that it only occurs singly in man is quite adverse to experience. We have discovered nine of them in the corpse of a lad. It occasions the well-known annoyances, but no visible anatomical mischief. Botryo-cephalus latus, tcenia lata, the broad or broad-jointed tape- worm, resembles the last in many points, equalling it in length, and being in like manner jointed. Its joints are usually broader than those of the T. solium ; this alone, however, cannot pass for a diagnostic mark. The wartlike projections are not, as in the other worm, seated at the margin, but at the centre of tlie ventral surface. Their pore leads to a branched rosette-shaped, sexual organ. The head, differing from that of the T. solium, exhibits no suction-pores, but two longish grooves. Inhabits the small intestine in man, but is strictly limited to Russia, Poland, Prussia [trans Vistulam], Switzerland, and to the South of France. If it occur elsewhere it is assuredly imported from one of those countries. It rarely parts with single joints or links, but usually with a greater or %esser chain of them. CYSTICA. VESICULAR WORMS. In the formation of their head, these resemble tape-worms to such a degree, that even in 1836 Johannes Muller proposed to unite them in a single order, with two subdivisions. Light has, however, been since thrown upon the subject, which warrants us in going a step further, pro- nouncing these cystica with tape-worm heads to be in truth nothing more than errant cestoda, which, owing to their deviations, have sickened, de- clined, and remained sexless. The lime corpuscles found upon them, and especially upon the cysti- cercus, are the same as those occurring upon tape-worms. They have been erroneously held to be ova, and in reality rather represent an outer skeleton formation. These cystica, within textures, are almost always distinctly encysted ; that is, shut up within a capsule effused from the textures. In free spaces, for example in the ventricles of the brain, this is not the case. This adventitious outer cyst is not to be confounded with the cyst proper to the animal itself. They frequently perish, espe- cially through inflammation of the external cyst, being either mechani- VESICULAR WORMS. 267 cally crushed by, or corroded and destroyed in, the product. In the sequel, the complicated contents of the outer cyst, after having suffered many changes, progressively thicken, and eventually cretify, en masse, within the shrivelled capsule. The unequivocal proof of the previous existence of an animal in such obliterated cysts is furnished by ddbris of the animal cyst ; by booklets, from the coronet of booklets, which have resisted the corrosive agency ; and lastly, by the presence of the lime corpuscles before alluded to. In man occur : The cysticercus cellulosus, consisting of a conical, snow-white, trans- versely rugous body, and of a vesicle which constitutes its caudal ex- tremity. The vesicle is oval, spherical or square, in muscles, cylindrical, parallel to the muscular fibres, and of the size of a pea or a haricot bean, in rare instances, for example, in the ventricles of the brain, of a hazel-nut. When the animal is retracted into this vesicle, it appears as a white, spherical, solid body, seated somewhat eccentrically on its inner surface, whilst upon the vesicle itself is observable, externally, a delicate point-like fold or depression at the same spot. When the animal is external to the vesicle, a condition easily brought about by puncturing the vesicle, and pressing the hardish spherical body between the finger and thumb, a pore becomes perceptible which leads to the interior oT the animal pouch. Taking the size of the caudal vesicle at the ordinary one of a pea, the animal itself, that is the trunk, would about equal the diameter of the vesicle, both together measuring from six to twelve lines in length. The neck is short, very thin, and, like the body, wrinkled. Upon it is seated the largish, bulb-shaped, or rhomboidal head, upon which there is at each angle a circular suction-cup ; and midway between these a proboscis, cone-shaped in its protruded state, with, at its ex- tremity, a coronet of booklets consisting of a double row [about thirty- two in all], which, when retracted, pack up into a funnel-shaped cup. The two circles of booklets are identical in shape ; those of the outer circle are however much smaller than the others, whilst both are so dis- posed that the larger and smaller booklets alternate with each other. The above-mentioned transversely wrinkled, anterior portion of the creature appears as an almost structureless, feebly striated membrane, to which a profusion of fine, black-contoured molecule adheres. It is, moreover, studded with a multitude of roundish or oval, whitish, smooth, sharply contoured, shining, lesser or bigger corpuscles, of from one- eightieth to one-thirtieth of a millimetre in diameter. They are most numerous about the middle part ; near the neck and head their number greatly diminishes, whilst, close to the caudal vesicle, they suddenly and entirely disappear. They lie superimposed in several layers, those of the outer stratum being only loosely adherent to the animal, so that they may be very easily scraped away. Treated with hydrochloric or with acetic acid, they dissolve under the copious development of carbonic acid, leaving an organic base-substance behind. In the solution, oxalic and sulphuric acids create a precipitate. The caudal vesicle consists of the same homogeneous, indeterminate, granulated mass, besprinkled with countless small and larger fat-molecules. The contents of the caudal vesicle consist of a watery, neutral fluid, holding but a scanty portion of albumen. 268 VESICULAR WORMS. Wherever the cysticercus occurs in textures, it is inclosed within a second cyst of fibrous texture. When magnified it appears as a deli- cately-fibred membrane, permeated by delicate blood-vessels, and easily rendered transparent by acetic acid. Where the cysticercus occurs free within a cavity, as within the ventricles of the brain, it is uninvested, showing the outer cyst, in other localities, to be adventitious. When the creature perishes, as frequently happens from disease of the outer cyst, the caudal vesicle becomes semi-opaque, collapsed, its contents turbid, displaying the said lime-corpuscles and booklets, which, together with a granulate mass, are found floating in its fluid. The entire crea- ture softens and liquefies, afterwards condenses, and eventually settles into a cretaceous concrement. Meanwhile the outer cyst shrivels and dwindles into a thick-membraned capsule, for the isolation of the said concrement. The cysticercus cellulosus occurs in the brain, in the striated muscles, including the heart, and in the areolar tissue. It also occurs, free, without its outer envelope, in the ventricles of the brain, and in the chambers of the eye. It sometimes occurs in the muscles and brain simultaneously, in great multitudes. Even in the brain it is usually borne imperceptibly. When present there in great numbers, however, it often occasions vertigo, and the case has happened of its proving fatal by setting up inflammation in its vicinity. Ecliinococcus hominis aceplialocystis (Laennec). The relation of both to each other, and the import of the last-named animal in particular, will become manifest from the following description : (a.) Echinococcus. Within a sac of fibroid texture is inclosed a soli- tary, independent, thoroughly distended vesicle, containing a limpid, serous fluid ; or else inclosing, as a parent vesicle, other similar vesicles of various size, in various numbers, spherical or flattened by mutual com- pression, either floating at large in the contained fluid, or sessile upon the inner membrane of the said parent. Its size varies from that of a vesicle just cognizable, and as big as a poppy- or a millet-seed, to the magni- tude of a goose's egg and more. In number it may amount to hundreds, so that the serous contents of the parent vesicle are reduced to a mini- mum. Generally speaking, the lesser filial vesicles are sessile, whilst the larger ones are free. In very voluminous sacs it is common to find that the parent vesicle appears to be wanting. Either it is mixed up with the younger vesicles, split up, collapsed and dissolved into scattered shreds, or else it has dis- appeared in the excessive attenuation consequent upon its enlargement. In their unimpaired vegetation, these vesicles are filled to distension, are elastic, and impart to the touch a sense of tremulous fluctuation, as does the parent cyst replete with them [hydatid tremulousness]. They consist of a substance resembling coagulate albumen, separating into several layers, partly diaphanous, partly white and opaque, frequently accumulated in the inside to considerable thickness, and into gibbous projections. Moreover, they contain a limpid serosity identical with the contents of the parent cyst. When the vesicle is punctured, this fluid gushes forth in a column, and on an incision being made, the parietes of VESICULAR WORMS. 269 the vesicle become suddenly inverted. The substance of the latter is a stratified, homogeneous, very fine-granular, structureless mass, whilst their contents exhibit a few lustrous fat-drops, some scattered or agglo- merate, elementary granules, and glebous coagula. These vesicles occasionally contain others similar, of a third, and the latter again in rare instances of a fourth generation. On a narrower inspection of the inner surface of these vesicles, we perceive in many of them, a whitish, opaque, gritty efflorescence, whilst with the aid of the microscope we here discover densely-nestled animal- cules, which prove, by the most various changes of shape, that they long continue to live on in the dead subject. A few of them are even found free in the above-mentioned fluid. This entozoon is from one-ninth to one-third of a millimetre long, and from one-twelfth to one-fourth of a millimetre broad. It has a tsenioid head, with four lateral suction-pores, and a proboscis garnished with a double coronet of booklets. The head is distinguished from the thicker, spheroid trunk, by an annulate indentation. From the proboscis a longi- tudinal stria tion runs to the posterior part, and, commencing from these striae, the body of the creature is transversely striated. The posterior termination is a transverse cleft, in which is inserted a cordlike forma- tion, by whose means the creature maintains its seat upon the vesicle. Between the striae of the trunk are spherical or oval, limelike corpuscles, resembling those upon the cysticercus. In its developed state the creature appears in the above form. It is met with, however, under various other shapes. Thus it appears as an elongated sphere, in the centre of which the coronet of booklets appears perspicuous when the head is retracted. Or it assumes the shape of a heart, or of a pitcher, or even of a horse-shoe. The abode of this echinococcus in mankind is, according to our own experience, invariably internal to, and never external to, the vesicles. (b.) Acephalo-cyst. Under this term we at this day understand no- thing beyond those vesicles which we have just described as being inha- bited by the echinococcus, but which are in some instances sterile. The above name has been given to this formation in order to designate that supposed independent vitality which the absence of organs still renders problematical. The Acephalo-cyst, which Blainville reckons amongst the "monadaires," and Kuhn compares to Agardh's protococcus, with its multiplication by buds, is in our own opinion not to be held separate from the echinococcus, although the precise relation between the ani- mal and the vesicle is by no means clear. The relation of the primary acephalo-cyst [the echinococcus-vesicle] to the outer cyst, is analogous to that of a new growth incapsuled by exudation from the surrounding textures. 1. "W. Griffith has examined acephalo-cysts and their contents. The transparent fluid, of 1-008 sp. grav., coagulated readily by heat or nitric acid, and contained an inconsiderable amount of fat. A thousand parts yielded fifteen parts of solid ingredients, principally common salt. They left 0-85 per cent, of this salt, a little sulphate of soda, a trace of phos- phate of lime, and some albuminous extractive matter, but neither choles- terine nor alkaline phosphates. The envelopes of the hydatids left, when 270 VESICULAR WORMS. dried, a brown residuum, which dissolved with a deep brown color when boiled with hydrochloric acid, but was not again precipitated on the ad- dition of an alkali. When moist, they dissolved in hydrochloric and in nitric acid, but the solutions were precipitated neither by ferro-cyanide of potassium, nor by tincture of galls. Nothing was dissolved by boiling them in water, for neither by tannic nor by nitric acid was either any precipitate formed, or the fluid gelatinized. When boiled with carbonate of potash, the dried membranes were dissolved with brown coloration, but without any accompanying development of sulphuretted hydrogen, nor any precipitation on the addition of an acid. Acephalo-cysts, together with the creatures that infest them, are ex- tremely liable to destruction, through hypertrophy, atrophy and conse- quent perforation of their external coat ; but most particularly through inflammation of the latter with its products. It is not a rare thing to find, within a sac, individual vesicles imper- fectly filled, or collapsed, with walls transparent, tumefied, gelatinized, or even degraded to a smeary mass. The contents of such vesicles are turbid. They consist partly of fat-globules with a fine pulverulent point- molecule in great abundance, and the ddbris of broken up echinococci. Occasionally this conversion affects most, if not all of the vesicles. They burst or rather open out, owing to the increasing tendency to dis- solution, until at length the entire contents of the parent cyst are ren- dered turbid. The inflammation of the outer sac, a frequent occurrence, is impor- tant. It bears the character of inflammation of a sero-fibrous mem- brane, and throws its products, for the major part, upon the inner surface and into the cavity of the cyst. It is in many instances to be regarded as a fortunate event, leading as it does to the disruption and extinction of the acephalo-cyst, with its in- habitant animalcules, and in due time to the shrivelling and decay of the entire sac. The contact of the acephalo-cysts with exudate, and the re- ception of the latter through endosmosis into the walls and cavity of the acephalo-cysts appear to be amongst the most ordinary causes of their dissolution. After the effusion, gradual resorption of a portion of the contents that is, of the original serous fluid, and of the exudate fol- lows, whilst another portion thickens to a grayish, unctuous chalk-pap, and eventually cretifies altogether. The sac shrivelling commensurately with the diminution of its contents, becomes obliterated in such wise as ultimately to inclose a mass consisting of variously superimposed residua of acephalo-cysts (echinococcus-vesicles) and of the said chalk-pap or con- crement. It is not unfrequent for an intense inflammation to terminate in ulce- ration of the sac, so that an abscess, inclosed within the implicated paren- chyma, takes its place. This, together with consecutive suppuration in neighboring textures, may lead to the opening of the sac into another adjoining one ; or to its opening externally : or into one or other of the great serous sacs ; into the intestinal canal ; into the urinary cavities or passages ; the gall-ducts, &c. The direction in which such an abscess empties itself decides the question as to the favorable or the unfavorable issue of the case. BLOOD DISEASES. 271 The echinococcus and acephalo-cyst are particularly frequent in the liver, less and less so in the subperitoneal, areolar tissue, and in the peri- toneum, in the omentum, in the striated muscles, including the heart, in the brain, in the spleen [mostly in concurrence with others in the liver], in the kidneys ; very rare in the lungs and bones. Not unfrequently they occur in several organs simultaneously. Thus they will infest in vast numbers both the peritoneum and the abdominal viscera. In magnitude the sacs may attain, or even exceed the diame- ter of a foot. The echinococcus-cysts may become perilous through their volume ; and, when present in great numbers, prove fatal through exhaustion and general wasting, as also through the aforesaid inflammatory and suppu- rative processes. SPURIOUS PARASITES. As such are to be reckoned all those foreign bodies reputedly or really, accidentally or designedly, conveyed upon or into the human body ; but which are proved either not to infest it in reality, or to be of a nature even manifestly to preclude a parasite existence. We have to bring into this account not alone animal creatures, and various parts of animals and of plants ; but also misshapen, diseased tex- tural parts of the organism, or products of disease. Such are : 1. Animals and parts of animals dead or alive, really voided by stool or rejected by vomiting, such as the larvae of flies received into the stomach with food in a state of decomposition, or accidentally or design- edly added to the matter so evacuated. 2. A great variety of other bodies of the descriptions adverted to. Amongst the spurious parasites of the present day we may 'cite (a.) The trichomonas vaginalis of Donne*, probably a misshapen ciliary cell. (b.) Diceras rude (Rudolphi), repeatedly recognized as the undigested seeds of mulberries. BLOOD DISEASES DYSCRASES. Humoral pathology is simply a requirement of common practical sense; and it has always held a place in medical science, although the limits of its domain have, no doubt, been variously circumscribed or interpreted at different times. Of late years it has met with a new basis and sup- port in morbid anatomy, which, in the inadequacy of its discoveries in the solids to account for disease and death, has been compelled to seek for an extension of its boundary through a direct examination of the blood itself. Not alone has pathological anatomy demonstrated the existence of blood diseases in unlocked for detail ; it has at the same time solved a problem of the weightiest import. It has, we think, decided in favor of 272 BLOOD DISEASES. a humoral pathology, by demonstrating a primitive anomaly of blaste- mata ; by demonstrating the endogenous impairment of the blood within the vascular system, in the inflammatory process, as the basis of the varia- tions in exudates [blastemata] ; lastly, by demonstrating the dependence of local morbid action upon pre-existent impairment of the general circula- tion. Our attention will be here directed to diseases of the blood in its totality, and to local dyscrasial processes, with inflammation at their head, only in so far as these offer the basis and starting-point for consecutive disease of the entire blood-mass. It is remarkable, however, and no less important for practice than for science, that the essential forms of these local dyscrasial processes, perhaps of all local dyscrasial disease, occur, likewise, as primitive affections of the entire blood-mass. This is proved by the varied character of the products of the inflammatory dyscrasial process, and a comparison in detail of these products with anomalies of the general blood-crasis. Thus, primitive pyaemia, fibrin- crasis, sepsis of the blood, severally occur independently of all local beginning, and of all infection. There are, indeed, two ways of investigating and recognizing blood- diseases : first, the anatomical examination of the blood in the dead sub- ject, or of blood obtained during life through spontaneous or artificial hemorrhage ; and secondly, chemical analysis. Both kinds of investi- gation should be supported, and the results controlled, by a concurrent examination of the secretions and excretions, of the general condition of the solids, and of new-formations, especially of such exudates as are the offspring of inflammation. In fine, both kinds of research should go hand in hand. For, although a deeper insight into the changes suffered by the blood may be reserved for chemistry, it must needs be based upon sound anatomico-humoral premises. Up to the present day chemistry has not taken this duly into consideration, so that as yet this science cannot be said to have far ex- celled the achievements of a circumspect anatomical survey, notwithstand- ing the limited resources at the disposal of the latter. Upon the chemical pathologist we would strongly urge an unremitting prosecution of his researches. We would recommend him to direct his labors more particularly towards ascertaining the precise character of the impairment suffered by the proximate ingredients of the blood, and of the anomalies impressed upon its elementary composition. The inte- rests of hsemato-pathology would after all, perhaps, be best served by the examination, in the above sense, of blood taken from the dead subject, the diagnosis of the case having previously received the light of a general post-mortem examination. Our own task in these pages will be limited to establishing a purely anatomical pathology of the blood ; we shall therefore restrict ourselves, as nearly as possible, to anatomical facts, although without neglecting to avail ourselves of the collateral support of such chemical data as may be relied upon at the present hour. It is the business of pathological anatomy to determine both the phy- sical properties of the blood in its totality, and also the relative quantity, and more especially the quality, of its more immediate components. BLOOD DISEASES. 273 The two main components which come peculiarly within its province are, first, those essential form-elements, the blood-globules ; and secondly, the spontaneously separating, coagulating, solidifying fibrin, that compo- nent which, owing to its varying tendency to become organized, is, in an anatomical sense, the most important of all. We will here summarily refer to ivhat has been said in the introduction to the doctrine of blaste- mata and to the section on exudates, and then proceed to treat of blood diseases in what would appear to be their most natural order. The sub- ject is, however, so intimately allied to that treated of in the chapters referred to, that a certain amount of repetition will, perhaps, be unavoid- able in the following pages. Affections of the blood are, like those of the solids, either primitive or consecutive. And again, the former, equally with the latter, suggest an inquiry as to whether they result from an immediate influence of the morbific agent upon the blood, or are determined by the nervous system, as the actual percipient, alienated both in matter and in function. This question can, however, hardly affect us in this place, since the latter view mainly rests on speculative grounds, and upon the fact that obvious injury to, or sensible anatomical disturbance of, the nervous system sooner or later results in disease of the blood. The latter are determined in very different ways by anomalies in the solids. Thus, the hindered eliminating activity of an organ occasions retention of effete matter in the blood ; an abnormal plastic process influ- ences the blood crasis, directly or indirectly, through the anomaly in the interchange of matter. Take for example, the infection of the blood within the range of an inflammation. To diseases of the solids, as local morbid processes in the broadest sense, affections of the blood stand in a twofold relation : 1. The anomalous crasis is a pre-exist ent one the primitive affection ; the local disease a localization thereof the secondary affection. The point of localization, apart from the effect of concurrent external influ- ences, is determined by a specific relation of the crasis to certain organs presided over by the nerves. The forms it assumes are chiefly those of hypergemia and stasis inflammation, absolute stasis, exudation, or, without the latter, a product-formation completed within the bloodves- sels ; for instance, spontaneous coagulation of diseased fibrin, pus-forma- tion within a greater bloodvessel or within the capillaries of an organ. The relation of the various erases to the organs and textures, nay, even to particular sections of organs, is manifold. Thus, the croupous fibrin- erases evince a very marked preference for the mucous membrane of the air-passages, and for the lungs themselves ; the typhus-crasis, for the mucous membrane of the ileum ; the exanthematous erases, for the com- mon integument and for mucous membranes. 2. The anomaly of the general crasis is consecutive ; that is, the con- sequence of a local disease, and especially of local dyscrasial processes, whereof the products are taken up into and affect the general blood-mass. This happens (a.) Through resorption of the effused products by means of the lym- phatics, or immediately into the veins. VOL. i. 18 274 FIBRIN-CRASES. (&.) Through reception into patent bloodvessels. This process includes the reception of products thrown out into the cavity of larger bloodves- sels, pus, for example. ( Fatty liver, the adipose metamorphosis, morbid accumulation of fat in the liver. A well-marked case is distinguished by the following ana- tomical characters : the liver is enlarged, the increase of size taking place chiefly in a lateral direction ; its edges are flattened and swollen, the peritoneal covering is smooth, shining, transparent and tense ; the organ is soft and pits on pressure ; its color, internally and externally, is uni- formly yellowish-red or light yellow, resembling that of autumnal foliage ; it is pale and exsanguine, and contains a large amount of fat, as evidenced by the greasy deposit when cut with a dry warm blade, or as proved by submitting the liver to high temperatures. The disease consists in a deposition of free adipose tissue to such an extent as not only to replace the true glandular structure, but to penetrate the entire parenchyma to the exclusion of the vascular tissue. In the earlier stages of the affection the various signs alluded to are less marked. Two conditions chiefly favor its production : In the first instance it very commonly accompanies tubercular phthisis ; and, according to the researches of Louis, is found in two-thirds of all cases of phthisis. Andral has explained this occurrence on the ground of impeded secretion of hydrogen by the lungs ; but extended investigation allows us to conclude that this impediment, which is not even demon- strable, is not the cause of the deposit ; but that it is an essential consti- tuent or pathognomonic combination of the tubercular dyscrasia, inasmuch as it allies itself with tubercular affections of every kind, with tubercle of the intestinal mucous membrane, of the bronchial glands, the serous membrane, the bones, &c. Secondly; The fatty liver is also developed independently of tubercle in consequence of a luxurious and indolent regimen, in children that have been gorged with food, and especially as a result of dram- drinking. In this case it is accompanied by accumulations of fat in the omentum, the mesenteries, the pericardium, the heart, and the subcuta- neous cellular tissue, by fatty degeneration of the muscular fibres of the gall-bladder, and even of the muscular tissue of the heart ; the common integument has a leaden hue, and the perspiration has a greasy appear- 100 ABNORMITIES OF ance and a peculiar odor. The fat bears throughout a resemblance to tallow. The waxy liver is a variety of the fatty liver ; it is distinguished from the latter by a color resembling that of beeswax, by its greater consist- ence, dryness, and brittleness ; and these qualities depend upon a peculiar modification of the infiltrated fat, which, although accumulated to a con- siderable amount, leaves but few traces on the scalpel. Occasionally the tallow is seen deposited at a few points only, or it accumulates at particular spots. They are commonly superficial, though they are also seen in the deeper parts in the shape of irregularly-circum- scribed maculae, which are the more conspicuous by their change of color the less the other portions of the liver are involved in the disease, and the darker they are. o. Lardaceous (speckig, baconny) liver. Next in order to the fatty liver are the infiltrations of the hepatic parenchyma by a coarser, gray, sometimes transparent, albuminous, lardaceous, or lardaceo-gelatinous, substance. This affection is found concurrent with constitutional disease of the vegetative system, especially with scrofulous and rickety disease, with syphilitic and mercurial cachexia, and it may consequently be con- genital. It appears that it is occasionally developed as a sequela of in- termittent fever in cachectic subjects. The following are its anatomical characters : considerable increase of size and weight, with remarkable lateral development and flattening of the organ ; smoothness and tenseness of*the peritoneal investment, a cer- tain degree of doughy consistency combined with hardness and elasticity, anaemia, pale, watery, portal blood ; gray, grayish-white, or grayish-red color, tinged with yellow or brown ; the surface of a section being smooth, and homogeneous, resembling bacon, and leaving but a slight fatty stain on the scalpel. Sometimes, however, there is an adipose deposit in the entire liver, or in certain parts of the organ, and the blade of the scalpel then shows the fatty appearance when a section is made. In many cases the foreign substance is also deposited in the shape of white lardaceous spots, the edges of which are not distinctly circum- scribed. The spleen is very commonly affected in a corresponding manner ; it is found much enlarged, and infiltrated by a similar substance (vide Spleen). Bright's disease of the kidneys and analogous renal affections are also very often complicated with the lardaceous and fatty liver. b. Atrophy. Atrophy of the liver, independent of the marasmus senilis of the organ, appears in various forms. We first draw attention to two distinct forms which have not been remarked hitherto, and which, similarly to the hypertrophic affections, are the expressions of a consti- tutional malady, and have their immediate origin in anomalies of the blood. Owing to their distinctive coloring, they may be appropriately termed yellow and red atrophy. a. Yellow atrophy. This affection is characterized by the saturated yellow color, owing to a diffusion of bile throughout the tissue, by extreme flabbiness and pulpiness, loss of the granular texture, extreme rapidity in the reduction of size, which chiefly affects the vertical diameter, and consequently induces a flattening of the liver. It occurs chiefly in the : ; i -^ '. THE LIVER. '''-' early years of life, during puberty, and in the prime ; it is remarkable for the rapid course it runs, for extreme tenderness of the liver, nervous attacks, and jaundice ; it terminates fatally with febrile symptoms of a disorganized state of the blood, irritation of the brain and its membranes, and hydrocephalic softening of the former, and with symptoms of exuda- tion and suppuration generally, and especially of the mucous membrane, pneumonia, &c. The blood contained in the large vessels of the liver, and even that contained in the trunk of the vena portae, is reduced in consistence, and of a dirty reddish-brown color ; and the coats of the latter vessel are tinged with bile. This points to the fact that the portal blood itself con- tains such an excess of biliary constituents, that they are separated here, and still more in the capillaries, and thus fill the entire vascular and biliary system ; the coats of the vessels and their cellular strata thus absorb bile by exosmosis, the true glandular tissue fuses, is lost in the biliary colliquation, and disappears. The immediate consequences of this condition are that the blood in the vena cava is infected and overcharged with bile, causing intense jaundice ; when this has reached a certain point, the above symptoms terminate in a rapid consumption of the blood and in exhaustion. We commonly find biliary matter of a deep yellow color, or if the disorganized blood has exuded through the mucous mem- brane, a black tarry substance in the intestine. ,?. Red atrophy. This is distinguished from the former by its dark- brown or bluish-red color ; the liver is gorged with blood, and presents a spongy elastic consistency ; there is an absence of granulation, and a section offers an appearance of perfectly homogeneous texture ; the organ is reduced in size, though its thickness preponderates over the other dimensions. The disease is chronic, and is always accompanied by torpor of the abdominal ganglia, venous plethora of the abdominal viscera, and by the formation of brownish-black, or greenish-black, tarry bile, and faeces of a similar constitution. By itself it rarely proves fatal, though death may ensue from the marasmus brought on by the enduring congestion of the portal system. In addition to these two forms, we consider Y. Laennec's cirrhosis in its advanced stage, a chronic affection which resembles acute yellow atrophy, but besides being chronic, is distinguished from the latter by the liver being firm, or, if flabby, very tough. Granular liver is a variety of this species ; it appears essentially as secondary textural degeneration, and although commonly treated of as atrophy, and from ignorance of the above described forms as the only variety of atrophy, we refer for a minute examination to a subsequent portion of this work. Finally, we have o. Atrophy of the liver from obliteration of the ramifications of the vena, porta (vide, the acquired Lobular Form of the Liver, p. 103). 3. Abnormities of Form. 1 These abnormities are either congenital, and are then in part foetal conditions of the liver, in part acquired. To the former belong the round, the unlobulated, or but slightly lobulated (embryonic) liver, the semiglobular, the broad, the flattened, the trian- gular and quadrangular, and multilobular liver. 1 Oestr. Jahrb. xx. 4. 102 ABNORMITIES OF The acquired irregularity of form is either the result of external influ- ences, or it depends upon an affection of the tissue of the liver. The former consists in a flattening of the liver anteriorly, in indentations or furrows, produced by contractions or deformities of the thorax, by stays, exudations, enlarged viscera, or morbid growths. The latter are of pecu- liar interest, as the nature of the hepatic malformation, taken in connec- tion with the increase or diminution of size, is characteristic of the inter- nal affection of the viscus. We shall devote some further consideration to this class. Malformations of the liver must be considered in reference : Firstly, To the relation of the vertical to the longitudinal and trans- verse diameters, or the circumference of the edges ; Secondly, To the condition of the edges, which may be bevelled off, thinned, acuminated, or thickened, enlarged, and rounded ; Thirdly, To the state of the surface, which may be variously smooth and level, or as variously uneven. With reference to the first variety, we are able to affirm that the de- velopment of the vascular tissue generally, is connected with swelling and enlargement of the liver and with a preponderance of the vertical diameter (thickness) ; that the so-called development of the yellow tissue (infiltra- tion) is complicated with lateral enlargement, or increase of size with flattening, and corresponding diminution of the vertical diameter. In reference to the edges, we have to remark that in the last-named states, at least in their advanced degrees, they are absolutely thickened and rounded. We find the following irregularities of form to occur more particularly in connection with the above-mentioned varieties of enlargement. 1st. When the increase of size is the result of congestion, or of tempo- rary hypersemic turgor, the liver retains the general outline of its normal condition : but if this affection becomes permanent, the vertical diameter soon predominates considerably. This is still more the case in genuine hypertrophy. 2d. The nutmeg liver, the fatty and waxy and lardaceous liver, induce a lateral enlargement of the organ : the vertical diameter diminishes, and the liver is flattened : this becomes more apparent when, as in the higher degrees, there is at the same time, an increase in the substance of the edges, i. e. when the latter become thicker and globose. An evident exception occurs when this condition takes place in early life, or when it is congenital. The above-mentioned irregularity of form is in that case less marked, as the preponderance of the vertical diameter of the liver is normal in the foetal state and during the first years of life. Even in the varieties of atrophy of the liver, the remarks made as to the alterations of form, are confirmed in the main ; in the yellow variety the liver is generally reduced in its vertical diameter, whereas in the red variety, the decrease is chiefly perceptible at the edges, and the vertical diameter consequently predominates ; in the former case the organ pre- sents a disk-like shape, in the latter that of a hemisphere or ball. The irregularity of form consequent upon that textural disease which is called the granular liver, is very remarkable. It is almost always THE LIVER. 103 accompanied by a considerable diminution of size ; the granulations and the atrophy generally commence at the edges, and the latter attains its extreme development at this point ; the edges consequently appear very much thinned, and at last form a mere seam, consisting of cellule-fibrous tissue, which is contained between two condensed laminse of peritoneum, and reflected over the convexity, or inverted into the concavity of the liver. The left lobe of the liver is frequently shrunk into a very small, flattened, cellulo-fibrous appendix, and the thick hemispherical or globu- lar mass of the right lobe represents the entire organ. Occasional exceptions arise from the granular disease being developed in a liver that was previously affected by some other disease, as by the fatty degeneration ; in this case the reduction in size only takes place very slowly, and the edges instead of being thinned down, are often thickened and rounded. The more violent inflammations of the hepatic peritoneal lamina, affect the surface-layer of the liver, and thus induce changes in form, that vary in proportion to the intensity of the inflammation. Thus the liver is not unfrequently converted into a thick cake with rounded edges, if the in- flammation has been uniform, or it may be converted into a globular mass, compressed into a small space by peritoneal investment, which, in conse- quence of repeated attacks of inflammation, is transformed into a fibro- cartilaginous tissue. A malformation which we shall have occasion to revert to subsequently (superficial lobulation) results from an intense development of this process in detached spots. The surface of the liver offers several points for consideration. Hypersemic turgor, and still more all the varieties of hepatic infiltra- tion, are distinguished by their producing a smooth surface. Unevenness of the surface is produced in various forms and degrees ; the chief forms are the racemose and the lobulated. The racemose form appertains to the granular liver ; it depends upon the granulation of the peripheral layer, and appears delicately or coarsely moulded, of partial or uniform occurrence, in proportion to the develop- ment of the acini. The lobulated liver is either a congenital abnormity or an acquired malformation. The congenital form of this affection is owing to an arrest of develop- ment ; the liver is divided into several lobes, and this division may pro- ceed so far as to present several small livers which are only connected with the main organ by peritoneal folds and the vessels enclosed in them. This condition is not accompanied by any perceptible shrivelling or con- densation of the peritoneum in the fissures or sulci, and still less by a condensation of the parenchymatous cellular tissue, or an obliterated state of the vessels. We may assume d priori, and experience confirms the view, that the lobulation commences and is chiefly, if not exclusively, developed on the concave surface of the liver, as the natural point of departure for the fissures. Acquired lobulation of the liver presents itself in various degrees, and depends upon various causes. We base our division upon the latter, and thus arrive at their chief varieties, which at the same time, represent as many degrees. 104 ABNORMITIES OF Very superficial tabulation, one of which there is a mere indication, is occasionally the result of superficial inflammations affecting the hepatic sheath. These induce fibrous condensation of the parenchymatous cellu- lar tissue, and cicatriform contraction of the investing peritoneum, be- yond which the neighboring parenchyma projects in the shape of shallow, convex, and smooth protuberances, circumscribed by slight furrows. A second form, in which the tabulation is more marked, is developed in the granular liver. In the same manner as the granulations may produce a racemose appearance of the hepatic surface, they may, when several of them are grouped together, produce larger protuberances, or lobes ; if the interstitial cellular tissue is much condensed, the peri- pheral groups may become pediculated, so as to resemble mere appen- dices. The third form and highest degree, which bears most resemblance to congenital tabulation, results from the obliteration of one or more branches of the vena port93, from inflammation and the consequent shri- velling and atrophy of the hepatic sections supplied by their ramifica- tions. These sections shrink in the direction of the obliterated trunk, the peritoneum generally follows, the surface is affected, and fissures re- sult, which run in various directions, and above which the healthy tissue projects in the shape of large rounded protuberances. The enlarge- ment of these protuberances appears to be encouraged by the additional labor thrown upon them, and still more so if these portions have become the seat of fatty and other infiltrations.* Irregularities of the hepatic surface of a different kind are induced by the development of adventitious products, such as cancer in the liver ; but these will be discussed hereafter. 4. Abnormities of Position. Abnormities of position are either congenital or acquired. To the former belong the abnormal position of the liver, external and internal to the abdominal cavity ; as in cases of fissure of the abdominal parietes and eventration, of deficient diaphragm, of congenital umbilical hernia, of lateral transposition of the viscera. In the latter case, the entire relations of the organs have undergone a corresponding change, the large right lobe now being on the left side, and vice versa, and the vesical fossa to the left of the umbilical fissure. Some of the acquired malpositions of the liver resemble the former, as in the case of extensive wounds of the abdominal parietes, and of the diaphragm, and of certain rare anomalies, resulting from acquired um- bilical hernia. A more common occurrence is the abnormal position of the liver within the abdominal cavity, in consequence either of pressure exerted by other viscera, or of a change in the size and weight of the organ. We find the liver and the neighboring organs pushed out of their proper place by distortions of the spine ; by hypertrophied neigh- boring viscera, e. g., the right kidney, by expansions of adjoining cavities, as of the pericardium, but more especially of the right pleura. In the latter case it is forced down into the mesogastric region by the dia- phragm which is depressed by the accumulation of gases or fluids in the pleura ; and as the pressure especially affects the right lobe, this portion occupies the lowest position, and comes to be placed under the left lobe. THE LIVER. 105 The liver may be pushed upwards into the concavity of the diaphragm and into the thorax, by gaseous accumulations in the abdominal cavity, by ascites, by peritoneal effusion, and by tympanitic distension of the intestines. It is as variously affected by partial exudations and by morbid growths, and the change of position corresponds to their seat and magnitude. The spontaneous change of position which the liver undergoes in con- sequence of increase in size and weight, is invariably a descent to a lower region of the abdomen, and it follows from the anatomical rela- tions of the parts that it must be the right lobe which is peculiarly involved. 5. Changes of Consistency. As these changes are always allied to other anomalies of more importance, and have therefore been already alluded to, or will be subsequently considered, we here only advert to the diminution in the consistency of the organ which takes place without any change in the hepatic tissue, in all dyscrasic processes accompanied by decomposition or subsequent to excessive elimination of the fibrine of the blood, as occurring in typhus and typhoid states, in purulent in- fection of the blood, and acute tuberculoses, or subsequent to extensive exudation on serous membranes, and especially in puerperal fever. The liver appears flabby, collapsed, and pultaceous ; its parenchyma is soft- ened and infiltrated with serum, generally very pale and exsanguine, or containing only pale, thin, and watery blood. 6. Diseases of the Tissues, a. Hypercemia, apoplexy, anaemia of the liver. Hypergemia of the liver appears in three forms : as active hypersemia, resulting from idiopathic or consensual irritation ; as passive hyperaemia, dependent upon torpor in the portal vascular system ; and lastly, as mechanical hypersemia, chiefly induced by obstacles in the circulation through the heart and lungs ; the last form is one of very frequent occurrence, and is marked by the intensity and extent to which it affects the entire viscera. In rare cases an anomalous anasto- mosis of the epigastric cutaneous veins with the umbilical veins which have remained permanently open, gives rise to persistent hyperaemia of the liver. (Vide Veins.) The anatomical signs are congestive turgor of the viscus, increase of size, especially in the vertical diameter, but without any further change of form, dark-red color, and obliteration of the yellow substance, soften- ing of the parenchyma, and a large supply of blood. In habitual, and particularly in permanent mechanical hypenemia, the vessels in the liver, as well as the trunk of the vena portse, and the branches from which it arises, are found dilated and varicose. Habitual hyperaemia of the liver is apt to be followed by hypertrophy ; and as a consequence of an increased production of portal blood, and an exaggeration of its peculiar qualities, the nutmeg-liver may result, which again, may give rise to granular degeneration of the organ. Apoplexy of the liver is a very rare occurrence ; it results from con- gestion which has rapidly attained a very high degree, and undoubtedly commences as capillary hemorrhage ; an apoplectic spot is thus caused, 106 ABNORMITIES OF which may enlarge and induce a rupture of larger vessels. According to the seat of the hemorrhage we find two varieties, viz., peripheral or deep-seated hemorrhage ; both may however occur simultaneously. In the former, the hepatic peritoneum, especially that investing the convex surface of the right lobe, is detached in a varying extent, and under- neath it is found fluid or coagulated blood to a larger or smaller amount. These hemorrhages occur chiefly in infants, as a consequence of impeded respiration and pulmonary circulation, from suffocative catarrh. The hepatic peritoneum may become ruptured, and thus cause an effusion of blood into the abdominal cavity. The liver is in a state of permanent congestive tumefaction, and being overcharged with blood, presents a dark-red color, and looseness of texture. We are reminded by these effusions of the analogous bleedings at the cranium, accompanied by a detachment of either the pericranium or the dura mater, which consti- tute the so-called thrombus or cephalhgematoma. In the second variety, apoplectic spots of various forms and sizes are found in the parenchyma ; there are generally several of them dispersed through the organ. This variety is found more frequently in adults than the former, but the two may take place at the same time. If a cure follows, a cellulo-fibrous callous cicatrix remains. Anaemia of the liver is the result of hemorrhages, exhaustion, or a reduction of the mass of blood by extensive exudative processes, and is accompanied by a diminution of the consistency of the liver. It is also constantly associated with many hepatfo diseases, such as the fatty, the lardaceous, and waxy liver, to which we have already adverted. b. Inflammation of the Liver (Hepatitis). Although inflammation of the liver may not be a very rare affection, it is certain that the intense degrees, which terminate in suppuration and abscess, do not occur very frequently with us. We may remark that the most various diseases of the hepatic tissues are at the bedside taken for hepatitis. If we sum up the observations of solitary instances of well-marked hepatitis, taken in connection with the condition of the hepatic tissue surrounding wounds and recent abscesses of the liver, we find the fol- lowing to be the anatomical signs of hepatitis previous to its termination in suppuration : Inflammation never attacks the entire organ, but occurs in one or more patches. Commonly there is but one spot, but it may vary in ex- tent, and the process is here found developed in various degrees. The viscus is swollen in proportion to the number and size of the inflamma- tory patches, and this tumefaction is particularly perceptible when a section is made, the turgid tissue rising above the edges of the incision and the peritoneal sheath. The parenchyma is loosened and lacerable, and the structure becomes more apparent from the enlargement of the acini, which gives the broken surface a granular appearance ; the acini become altered in shape, and assume an oval form ; their circumference becomes transparent, so that each acinus seems imbedded in a gray or grayish-red layer of gelatinous matter, with which it is however inti- mately blended. In the advanced stage of inflammation, the granulated structure disappears, the tissue seems perfectly uniform, and the broken surface has a laminated appearance. The organ has a paler color, and THE LIVER. 107 it is almost uniformly brown, or grayish-red in some parts, or yellowish- red or pale-yellow in others. The capillary vessels are filled with albu- minous and fibrinous coagula. If the process extend to the circumference, the peritoneal investment becomes opaque, thickened, and is easily detached ; in many cases it is inflamed, and covered by an exudation of varying thickness. Acute inflammation frequently leads to suppuration of the parenchyma and to hepatic phthisis. We then find small spots of pus occurring here and there in the infiltrated tissue, which gradually increase, coalesce, and form an hepatic abscess. The large abscesses found in the dead subject may almost always be proved to have resulted from a union of several smaller spots, by the remains of the fistulous passages that con- nected them, by the sinuous shape of their circumference, or by the debris of the former partitions. The size of hepatic abscesses varies. They are often of the size of a fist, or a child's head, and may even occupy an entire lobe. The seat of the abscess corresponds with the seat of the previous in- flammation ; it therefore most commonly occupies the right lobe, is gene- rally found in the deeper parenchyma, and is often accompanied by an abscess in the left lobe, or extends into the latter. The recent abscess represents an irregular cavity with uneven parietes, which are infiltrated with pus and consequently very friable ; prolonga- tions of the same tissue project into the cavity. The abscess increases by fusion of the adjoining tissue, and thus as- sumes a round form, which becomes sinuous if a communication is esta- blished with other abscesses. When the suppurative process has reached the boundary of the original inflammation, it meets, if no further inflammatory reaction is established in the vicinity, with infiltrated, tumid, and discolored parenchyma. In this manner the abscess may remain passive for a considerable period, retaining the shape and other characters above described. It is com- monly lined by a suppurating and loosely-attached membrane. In refe- rence to its contents, the hepatic abscess presents considerable differences at different periods, depending in part upon the communication established with the biliary vessels. The pus contained in the recent abscess is mixed with little or no bile, as the acini and the capillary gall-ducts have be- come obliterated by the inflammation ; the bile contained in them at the commencement of the inflammatory attack, is at most found in combina- tion with the pus. A large abscess of long standing, invariably contains pus mixed with a considerable amount of bile, which arises from the com- munication established between the cavity and larger gall-ducts. These are, like the bronchi, affected by a continuation of the suppurative process, and are generally eaten across in a transverse or slanting direction ; and in exceptional cases only, and in very large abscesses, are they attacked and opened laterally. The pus contained in old abscesses is always dis- colored, generally greenish, and possessing a strong ammoniacal odor : we must undoubtedly attribute to it the extensive discoloration of the surrounding parenchyma. The bloodvessels opening into the abscess are blocked up, so that hemorrhage very rarely occurs. Before a fatal issue takes place, the hepatic abscess may discharge its 108 ABNORMITIES OF contents in different directions, and with various results. The dis- charge is very rarely effected into the peritoneal sac, as from the perito- neal investment having been either primarily or secondarily involved in the inflammatory process, adhesions will have been formed, which pre- vent this occurrence. We have to notice the. following modes of dis- charge : a. The hepatic abscess induces suppuration in and between the thoracic and abdominal parietes, and after a communication has been established between the former and the superficial abscess, it discharges externally by straight or sinuous, narrow or wide passages ; and by this means a cure is sometimes brought about. /5. The diaphragm may be perforated, and a discharge be effected into the right pleura, where, sooner or later, fatal inflammation is set up ; or if the lung had previously been agglutinated to the diaphragm, suppura- tion of the pulmonary lamina of the pleura follows, and an opening being effected into the bronchi, pneumonia and pulmonary abscess supervene. Y. The hepatic pus may be eliminated by the bronchi. d. The contents of the abscess may be discharged into the stomach, the duodenum, and the colon ; and in these cases the hepatic abscess is reported to have healed. e. A discharge may take place into the gall-bladder, or more frequently into one of the larger branches of the hepatic duct, the hepatic pus is conveyed to the intestine by a longer passage, and thus escapes. C. Cases in which the central aponeurosis of the diaphragm is perfo- rated, and the pus discharged by longer or shorter sinuses into the peri- cardium, inducing pericarditis, are very rare. They have been observed by Smith and Graves, and once by ourselves. 7). Finally, very rare cases have occurred in which the hepatic abscess has discharged itself into large vessels, such as the vena cava ; we have observed a case in which a communication was established between an hepatic abscess and the vena portse and duodenum. A cure of the hepatic abscess is effected after the pus has been dis- charged by one of the above-described methods, or it may result without this occurrence from more or less complete absorption of the pus by the cellulo-vascular membrane investing the sides of the abscess ; for, as soon as that portion of the parenchyma which has undergone purulent infiltra- tion is entirely broken down, the abscess comes in contact with a surface of tissue which is in a less inflamed state, or which does not put on any reaction till now. This, however, gives rise to an exudation, which in- vests the smoothed surfaces of the abscess, and after being repeatedly redissolved, at last forms a permanent coating. The subjacent layer in the interim has been converted into fibro-cellular tissue, and the cellulo- vascular investment becoming incorporated with the former, induces a gradual absorption of the enclosed pus, the walls of the abscess gradually approach one another, and at last unite to form a callous cicatrix. Not unfrequently a remnant of pus, which is converted into a cheesy concre- tion, and gradually becomes cretified, may still be found locked up in the tissue of the cicatrix ; the parenchyma, lying above the situation of the original abscess, is found collapsed ; and if the abscess extended to the THE LIVER. 109 circumference, the hepatic peritoneal lamina forms a cicatrized, dense, shrivelled covering. The true glandular tissue of the acini, and the interlobular tissue, are undoubtedly to be considered as the seat of the inflammation we have just examined ; it must be carefully distinguished from inflammation of the capillary gall-ducts, as well as from abscess resulting from suppura- tion in the latter, which is characterized by its large admixture of bile. We shall advert to this form in connection with diseases of the gall- ducts. In the same manner we have to distinguish between the hepatic abscess above described, and secondary or metastatic purulent deposits. Induration and obliteration of the hepatic parenchyma are the more frequent result of slight and chronic inflammatory attacks. The product of inflammation solidifies, and the hepatic parenchyma becoming oblite- rated, is converted into a cellulo-fibrous callosity, which gradually con- tracts, and induces a collapse at the surface of the liver proportionate to its vicinity to the surface. If this occurs simultaneously at several points, the surface of the organ obtains an uneven, undulated, and slightly lobulated appearance. These accumulations of cartilaginous tissue are to be distinguished from the obliterations and atrophy which affect the hepatic tissue, as a result of obliteration of the portal ramifica- tions consequent upon phlebitis. The investigation of true chronic inflammation of the liver offers still greater difficulty, inasmuch as, in the dead subject, we generally have to deal with its products only, in various degrees of development ; many cases of the so-called granular liver are probably referable to this head. At the bedside, the most heterogeneous conditions when accompanied by tedious and oppressive morbid sensations and by painful symptoms, espe- cially by enlargement, are diagnosed as chronic inflammation of the liver. c. Inflammation of the vena portce. This is, under all circumstances, a very important affection. It occurs both in a primary and in a secon- dary form, and may in either lead to obliteration or suppuration, and may attack the trunk and the ramifications of the vessel, or the latter only. Inflammation ending in obliteration of the branches of the vena portae within the liver demands a special notice, as it occurs very frequently, although we rarely have opportunities of investigating it in the dead sub- ject otherwise than in its termination and its consequences. It would appear to be owing to an anomalous condition of the portal blood, and to belong to the adhesive form. Several cases that we have observed, in which irregular anastomoses were discovered between the portal and the general venous system, by means of the patulous umbilical vein, seem to authorize this view. Under certain indented and contracted parts of the surface of the liver, we discover an accumulation of cellulo-fibrous callous tissue, which, on*more minute examination, is found to conduct to a larger or smaller portal branch, with which it is connected. The vessel itself is converted into a ligamentous cord, or it is plugged up with a fibrinous, cheesy, or calcareous deposit. The consequences of the obliteration are, atrophy of that part of the 110 ABNORMITIES OF \ liver which is supplied by the ramifications of the vessel, lobulation of the liver, as described at page 103, and in extreme cases, ascites. d. Deposits, metastases in the liver. Metastases occur in the liver under the same conditions under which they take place in the lungs. They are, however, much less frequent in the former than in the latter and in the spleen ; and the so-called hepatic abscess, more especially consequent upon important surgical operations, wounds and injuries of the cranium, is found much more rarely than has been hitherto supposed. Besides, we always simultaneously discover deposits in other organs, par- ticularly in the lungs and the spleen. We are unacquainted with the special conditions which give rise to a predominant deposit in the liver, with the exception of those cases in which the source of the poisoning of the blood is within the compass of the portal system. The deposit in the liver is also caused by the deposition or exudation of fibrin through the coats of the capillaries into the tissue, or by the coagulation of the blood in the capillary rete of vessels. In both cases metamorphoses may ensue which vary according to the nature of the morbid essence absorbed into the blood ; occasional induration and shrivel- ling are induced, with consequent obliteration of the parenchyma and the capillaries ; more frequently purulent or ichorous fusion result, and then either suppurative inflammation of the surrounding parenchyma is established, or a solution of the coats of the capillary vessels is effected. The deposit presents, as in the lungs, the appearance of a circum- scribed nodulated accumulation, of a dark-red or brownish-red color, which, as it approaches the state of fusion, is converted into a dirty yellow or greenish color. The deposit has a rounded form, varying in size from that of a pea to that of a walnut ; it is found in considerable numbers, and is commonly seated in the peripheral layer, where it gives rise to inflammation of the hepatic peritoneal lamina. This is a guide to distinguish it from the ab- scess which originates in idiopathic inflammation of the liver; the diag- nosis is also aided by the acute course of the affection, by its origi- nating in another morbid affection, by the typhoid symptoms, by the occurrence of similar processes in other organs, more especially in the lungs and the spleen, by the disorganization of the blood, and the re- sulting jaundice. e. G-angrene of the liver. Gangrene of the liver is very rare, in fact Ferrers and Brard deny its occurrence, but we have seen it in one well-marked case, associated with pulmonary gangrene. It is developed in parts affected with inflammation and suppuration, not so much as a result of intense inflammation as of certain peculiar conditions, which cause a tendency to gangrenous degeneration. It occurs in more or less circumscribed spots, in which the parenchyma is dissolved into a brown or greenish-black pulp, which diffuses the characteristic odor of sphacelus. We find suppuration in the vicinity, which is the product of reactive inflammation, and which defines the boundaries of the mortified part.* /. Granular liver. Granular liver is one of the most important, though in many respects, and especially in reference to its pathogeny, one of the most enigmatical affections of the liver ; it is termed by Laenncc cirrhosis : older authors have considered it identical with or related to THE LIVER. Ill scirrhus ; and if viewed in reference to its termination only, it may be called induration of the liver. It undoubtedly presents many degrees, which merge into one another ; from the very unsatisfactory state of our knowledge, however, in refer- ence to the elementary process and fundamental nature of the disease, we consider it necessary to sketch the affection as seen in a marked case, without any further complication, and subsequently to state what is known of the earlier stages of the disease, and of the later metamorphoses of the organ. In a case of the kind alluded to, the yiscus appears considerably dimi- nished in size, and this decrease is accompanied by a characteristic change of form. The margins are thinned down to such a degree, as to repre- sent a cellulo-fibrous seam, which is folded upon the remainder of the organ ; the vertical diameter of the liver has increased, and is found to consist chiefly of the hemispherical or globular right lobe. (Vide p. 103.) The external surface presents a granular, warty, racemose appearance, -which results from the projection of the peripheral so-called granulations, of the liver. These granulations may all have the same size, e. g. that of a hemp-seed, and the surface then is uniformly racemose : or they vary in size, and the surface is then unevenly racemose. The hepatic surface intervening between the granulations is of a dull white color, tendinous, shrivelled, and contracted ; the granulations are thus circumscribed, separated from one another, and even occasionally pediculated. The viscus, when it has this appearance, is to a certain extent elastic and tough, and even indurated, so as to offer a cartilaginous resiliency ; it cannot be broken, as it possesses the tenacity of leather. The scalpel itself confirms the fact of induration, as the instrument meets with a scirrhoid substance, which may even cause a crunching sound. A section shows the above-mentioned granulations to be either isolated or grouped together ; an accumulation of dirty white, dense, resilient cel- lular tissue, which is almost destitute of bloodvessels, and which forms a nidus for the former, is seen between them. The color of the organ is variously modified ; being dependent upon the color, either of the granulations, which we shall have still further to examine, or of the intervening fibro-cellular tissue. The liver is frequently attached to adjacent parts, especially to the diaphragm, by means of cords or laminae of new matter; the adjoining peritoneum, and especially the peritoneal covering of the gall-bladder, and the folds which leave the liver, are opaque, shrivelled, and tendinous. The granulations have given rise to the name of granular liver ; and from the coexisting atrophy and diminution of size, the affection is also termed granular atrophy of the liver. The granulations are the most prominent sign in the sketch we have given, and the question arises as to their nature. Laennec viewed the granulations as an adventitious product, and as his specimens offered a yellow color, he termed it cirrhosis (xtpfos, fulvus). One may easily be convinced of the incorrectness of this view, as a 112 ABNORMITIES OF careful examination at once proves that the granulations consist of no- thing but hepatic parenchyma, which, however, as we shall subsequently have occasion to show, is variously modified. It follows from our demonstration that in granular liver the hepatic parenchyma has become reduced to the granulations, and that the por- tion which has disappeared, has been replaced by fibro-cellular tissue. The desire to obtain more accurate views as to the nature of the granu- lations and their mode of origin, has caused the promulgation of various doctrines which are untenable or incomprehensive in proportion as their authors attached too much importance to the ideas of hypertrophy and atrophy and their combination, or attempted to construct a theory from isolated observations, or because they did not sufficiently distinguish be- tween the diseases of the hepatic parenchyma preceding the formation of granulations, and those affecting the granulations themselves, and other morbid conditions not essentially connected with them. According to Bouillaud, with whom Andral coincides in the main, the granulations are the result of hypertrophic development of the so-called white or secreting substance, accompanied by obliteration and gradual atrophy of the red or vascular tissue. Cruveilhier advocates a different opinion. He thinks that cirrhosis consists in the atrophy of a considerable number of the hepatic acini, accompanied by hypertrophy of the remainder, which, as it were, take the place of the former. We pass over the unsatisfactory and erroneous doctrines of other writers, which are based upon investigations of solitary cases, or of ano- malies in the elementary tissue, and merely remark, that we do not adopt any one of the above views exclusively, as they do not appear to us to embrace the entire characters of granular liver. Granular liver presents considerable varieties. The granulations themselves offer numerous variations in reference to texture, number, size and form. With regard to their texture, we sometimes find that they consist of normal, or at least tolerably normal, hepatic parenchyma. Commonly, however, this is not the case ; the parenchyma of the granulations is itself abnormal, and variously diseased ; such cases render the analysis of the hepatic granulations difficult, and cause errors in the conclusions arrived at, as not sufficient attention is paid to the distinction between the essential and non-essential characters of the abnormity. The altera- tions of tissue in the granulations are either such as constitute the causa proximo, of the entire metamorphosis, i. e. they are essential, or they are mere accidental complications, which may either precede or accom- pany the formation of granulations. As we shall subsequently have to show the development of the granulations from the former, and as we are also compelled to examine into the complications of granular liver, we here give a summary of the abnormal conditions, without reference to the above distinctions. Firstly. The parenchyma of the hepatic granulations occasionally pre- sents a coarse-grained hypertrophy of the acini, the granulations pro- THE LIVER. 113 jecting on a sectional surface in the shape of dark reddish-brown and elastic points. Secondly. It frequently appears in the various degrees of the nutmeg liver (Laennec's cirrhosis of a low degree). Thirdly. The granulations appear in the shape of rounded or lobular convolutions of dilated, turgid, yellow, gall-ducts, the red vascular sub- stance in the vicinity having disappeared. This yields one of the com- monest and most exquisite forms of the granular liver ; it is genuine cirrhosis, which originates in the first variety of the nutmeg-liver, de- pendent upon stasis and dilatation of the biliary ducts. The majority of authors have evidently taken their description of granular liver from specimens of this kind. Fourthly. The parenchyma of the granulations is frequently infiltrated with fatty matter or similar products, and the granulation then presents on a small scale all the signs discussed at page 98. Gluge has evidently employed a specimen of this description for his investigations. Fifthly. We occasionally find the granulations in the condition of what we have termed yellow acute atrophy ; they are then yellow through- out, and appear at the surface and on section as pulpy, collapsed, friable, yellow masses. Sixthly. The parenchyma of the hepatic granulations frequently pre- sents symptoms of an inflammatory condition ; it then appears pale, of a homogeneous structure, with obstruction of the small biliary canali- culi, commencing induration and obliteration. The granulations vary much as to number, and are either uniformly distributed through the surrounding cellulo-fibrous tissue, or they coa- lesce into groups of various extent. The more numerous they are, the less the hepatic parenchyma is destroyed ; the number of the granula- tions therefore indicates the degree of atrophy that has taken place, and, if we take the quality and quantity of the textural changes into consideration, the stage of the disease generally. The size of the granulations varies from that of a pin's head to that of a horse-bean, according as a single acinus, or an entire lobule, or a large portion of the organ is affected ; they are generally of a rounded form, though they are very frequently of an irregular and especially of a lobu- lated shape. In the majority of instances we find one size and form to prevail. The cellulo-fibrous tissue intervening between the granulations, is either diminished or increased in amount. There is generally an inverse ratio between this tissue and the number of granulations ; but we find exceptional cases in which the granulations are very numerous, and the interstitial cellular tissue is also much increased. The latter varies much as to density, resiliency, vascularity, succulence, and color. Sometimes it is loose, friable, vascular, more or less reddened, and succulent ; at other times it is tough, less succulent, of a dirty gray or greenish color, at others again, dense, indurated, dirty white, of fibro-cartilaginous, scirrhoid, resiliency and elasticity, crepitating when cut, &c. Having discussed the two constituent parts of granular liver, we must now examine into the origin of the metamorphosis. We have seen that in granular liver the granulations represent the VOL. II. 8 114 ABNORMITIES OF persistent hepatic tissue, and that the parenchyma which has been re- moved is replaced by cellulo-fibrous tissue. The question arises whether this reduction is primary or secondary, and supposing the latter case, which is the primary anomaly ? It is commonly set down as mere atrophy, in consonance with the view of the French observers above quoted. We are not of opinion that granular liver always takes its origin in the same fundamental affection ; we are inclined to adopt two morbid states as the essential and original anomalies, which give rise to granu- lations in the hepatic parenchyma as a secondary affection. a. In one case there is a morbid development of the capillary gall- ducts (the so-called secreting tissue) ; an accumulation of the secretion, and probably also a hypertrophy of the parietes of those vessels giving rise to the nutmeg liver, and to an obliteration of the capillary blood- vessels, the so-called vascular substance. We then have to do with the gradual reduction of the organ, already described under the head of Atrophy, as an advanced stage of cirrhosis ; in this condition granular liver takes its origin, for the granulations are formed by the biliary ducts coalescing into rounded fasciculi or coils of the size of a pin's head or hemp-seed. They are more or less of a yellow color, containing fat, and either solitary or collected into lobular groups ; they are surrounded by a spongy, cellular, soft, succulent, red, and vascular tissue, from which they can only be separated by rupture of the latter and of its vessels. This anomaly is commonly met with in * various degrees of development at different parts of the viscus ; it is generally more advanced in the peripheral portions, the deeper portions presenting at the same time the appearance of the nutmeg degeneration ; the liver is frequently enlarged, but certainly not diminished in size, and preserves the thick, massive edges peculiar to the nutmeg liver. A secondary metamorphosis now gradually supervenes, the stage of obliteration and atrophy. The interstitial tissue gradually loses its vascularity, its red color, succulence, and spongy texture ; it becomes more and more pale, of a grayish-red, and dirty white color ; it shrivels up, and becomes denser and drier, coriaceous, and even of scirrhoid hardness ; and it presents a cellulo-fibrous, fibro-cartilaginous structure. The granulations at the same time undergo important modifications. The obliteration of the interstitial tissue not only destroys the vascular connection between the latter and the granulations, but, as their nutri- tion becomes impaired, their secreting power also ceases. We now find the granulation enclosed in a cellulo-fibrous case, from which it may be easily removed, as it is only connected with its investment by a few de- licate cellular threads, or is even quite detached, with the exception of a single vascular pedicle ; it is found collapsed, pulpy, of a dirty yellow color ; it gradually diminishes in size, the surrounding tissue also becom- ing atrophied ; it soon appears only as a minute yellow or greenish spot, and at last vanishes entirely. In exceptional cases, in which the liver has become so much indurated as to be incapable of further condensa- tion, the tissue surrounding the individual granulations is converted into a cyst with a serous lining, in which the granule floats, attached only by a vascular footstalk, and surrounded by a yellowish or pale green, watery, THE LIVER. 115 or gelatinous fluid. In consequence of the vascular obliteration, it is gradually so much reduced as at last to present nothing but a minute nodule attached to the internal surface of the cyst, which is now entirely filled with the fluid. In this variety, therefore, the original anomaly consists in the hepatic parenchyma being gradually reduced to the capillary gall-ducts which have assumed the shape of the granulations ; and in so far as this is genuine cirrhosis of the liver, it certainly bears some resemblance to the pulmonary cirrhosis described by Corrigan. The secondary metamor- phosis causes a gradual atrophy of the granulations, accompanied by a predominance of the interstitial cellulo-fibrous tissue, and a uniform diminution of the entire organ. The degree attained by the metamorphosis is proportionate to the number of obsolete granulations, or to the amount of parenchyma re- maining capable of performing its functions ; the organ decreases in pro- portion to the shrivelling and condensation of tha interstitial, cellulo- fibrous tissue ; and it often appears reduced to one-quarter, or even one- sixth, of its ordinary size. The condensation of the cellulo-fibrous tissue, as it gives rise to a decrease of the organ, also induces a corruga- tion and shrivelling of the peritoneal investment. The latter will be more or less opaque, and thickened ; and, being retracted between the projecting granulations, these not unfrequently appear to have a neck- like contraction. These changes in the hepatic peritoneal covering take place without any symptoms of inflammatory action. The secondary metamorphosis chiefly affects the margin of the liver, and more particularly the left lobe. The organ very commonly appears to have been almost or entirely deprived of parenchyma, and to consist exclusively of fibro-cellular tissue, the edges more particularly being thinned off and turned back upon the body of the organ, the left lobe of which is converted into a mere appendix of fibro-cellular structure, of the size of a hen's egg or a walnut. Not unfrequently the granulations assume, in the advanced stages, and after a long duration of the disease, a bluish or dark-green color, which particularly affects those seated at the concave surface of the liver. This form of cirrhosis of the liver undoubtedly originates in hypenemic states, a view that is confirmed by their frequent connection with organic disease of the heart : its frequent occurrence in drunkards also points to a peculiar anomaly in the constitution of the portal blood. /5. In the second case, the original affection of the hepatic parenchyma in granular liver is proved, by the post-mortem appearance of the granu- lations, to consist in a slow chronic inflammation. This induces a gradual obliteration of the parts attacked, and their conversion into fibro-cellular tissue, the amount of which varies in proportion as the processes of ab- sorption or of organization predominate in the inflammatory product. This secondary metamorphosis, from not occurring uniformly, results in a subdivision of the organ into larger or smaller scattered compartments, which present the characteristic rounded form of the granulations in the same ratio as they correspond to single hepatic lobules. Their paren- chyma is frequently found in the original state of chronic inflammation, 116 ABNORMITIES OF but it may be unchanged, or it may offer one of the other accidental ano- malies alluded to. It is intelligible that the diminution of size in this variety is often in- considerable, that the organ may even be enlarged, and that the fibro- cellular tissue is accumulated in such a manner as to preponderate over the parenchymatous cellular tissue. A marked decrease of size occurs when the obliteration is extensive and the cellule-fibrous tissue has shrunk ; and as this decrease advances, the pressure exerted by the shri- velled tissue upon the parts not originally affected by the anomaly, in- duces an atrophy in them ; they fade, and put on a rusty or dark yellow color. Granular liver frequently presents an abnormity which appears peculiar to this variety. We allude to the presence on the condensed peritoneal investment of pseudo-membranous formations, of a cellular or cellulo- fibrous texture, which generally extend to the diaphragm in the shape of corded adhesions. They are the result of inflammatory processes, which have become extinct long before the occurrence of the secondary metamorphosis, and which appear to afford evidence of the inflammatory nature of the hepatic disease itself. Besides these two modes of development of granular liver, the affec- tion may also be viewed as a retrograde process, manifested in deposi- tions or infiltrations of the hepatic parenchyma, arising from an anoma- lous state of the blood. In reference to the external conformation of granular liver, we have still to advert to a variety which is characterized by the hepatic paren- chyma not being reduced to granulations, but continuing in large masses, the more superficial of which are pushed out by the shrinking interstitial tissue, and being more or less contracted at their base, cause the entire organ to appear lobulated. Granular disease of the liver is found complicated with all the essential or accidental anomalies which we have described as occurring in the paranchyma of the granulations, and these anomalies may either precede the granular disease or supervene after its development. The complica- tions may be hypertrophy, nutmeg liver, cirrhosis, adipose and other in- filtrations, acute yellow atrophy, inflammatory and other hepatic diseases. The granular disease arising from one of the essential anomalies, e. g. from inflammatory causes, is more particularly liable to combine with another essential anomaly, as, for instance, with true cirrhosis. The complication with adipose deposit is peculiarly interesting. The latter may, Firstly, be the primary affection upon which the granular disease is grafted in the shape of cirrhosis. As the cirrhosis advances, the reduc- tion of the organ generally, but more particularly of the marginal por- tions which have been infiltrated with fat, is impeded, and the atrophy that does take place is characterized by its affecting the margin much less than in the uncomplicated form. Secondly ; the adipose deposit may supervene upon a granular state of the liver ; and if it does so before the secondary metamorphosis has advanced very far, and whilst the granulations are still very numerous, it may prevent the liver from assuming the form peculiar to the granular THE LIVER. 117 condition. If it occurs at a later period, it need not modify the cha- racteristic form of the organ. Thirdly ; the cirrhotic and shrinking granulation which is cut off by dense cartilaginous interstitial tissue may degenerate into a flabby, dirty yellowish-brown fat-lobule, the degeneration apparently proceeding from the confined biliary matter. A similar relation exists in regard to the modifications of form be- tween the granular condition and other infiltrations of the hepatic paren- chyma. Granular liver is also very frequently coincident with the most various morbid affections of the heart, which give rise to congestion in the vena cava and in the portal system; of these, hypertrophy, dilatation, and valvular disease are the most common. Disease of the heart must be considered as an important momentum in the origin of the hepatic dis- ease. The symptoms resulting from the granular state of the liver bear a ratio with the degree of its development ; the impermeability and oblitera- tion of its secreting tissue induce, on the one hand, congestion in the portal system, hyperaemic states of the intestine and of the peritoneum, a blennorrhoic condition of the former, tumefaction of its membranes, and ascites ; on the other, dyscrasic conditions of the blood allied to scurvy and frequently accompanied by icterus, an inclination to exuda- tive processes, with an especial proclivity to hemorrhage, anasarca, and anaemia. We cannot admit that the relation existing between Bright's disease of the kidneys and granular liver, though the two often coexist, has been accounted for. In one set of cases both affections would seem to have originated in common causes ; in another, Bright's disease is evidently of more recent date, and has supervened upon the existing granular state of the liver ; but whether in this case it is due to a separate cause, or is owing to the dyscrasia accompanying the hepatic disease, we are unable to determine. Granular liver is invariably a chronic affection, which may often be arrested in its development for a short time, but never permanently. It terminates fatally by inducing anaemia and tabes complicated with dropsy ; by disorganization of the blood, by exhausting and paralyzing exuda- tions on the serous membranes, and especially on the peritoneum. It rarely occurs before the prime of life, but we have seen one case of it at the age of seventeen. g. Adventitious growths. . Anomalous production of fat. This occurs in two distinct forms. We have already become acquainted with one in the shape of adipose deposition, or infiltration of the hepatic tissue with free fatty matter ; the second is very unusual, and appears as a lipomatous morbid growth of a rounded or lobulated form, and rarely larger than a pea. /9. Cavernous tissue. This is remarkable from its frequent occurrence in the liver. It resembles the tissue of the corpora cavernosa, and is commonly found in the peripheral substance of the liver only ; from its dark-blue color it shines through the peritoneum, and the affection is therefore recognized on the external examination of the organ. It varies 118 ABNORMITIES OF in size, from that of a hemp-seed or pea to that of a hen's egg, and more ; is generally irregular in form, and its cells contain a large quan- tity of dark blood ; a connection may be always traced between the latter and some larger portal vessel. According to the amount of blood con- tained in the compartments, these are found in the dead subject project- ing beyond the surface of the liver, or collapsed and sunk. Sometimes they are single, sometimes numerous. Y. Cysts. The liver is more liable to the formation of encysted tumors than any other parenchymatous organ ; and we repeat that the rarity of tubercular deposit in the liver enhances the importance of the hydatid theory. We find in the liver aa. The simple serous cyst, a serous sac containing a clear watery fluid ; this is not met with as often as PP. The acephalocyst of Laennec ; which in the first instance is merely a serous, but from acquiring a fibrous investment, is converted into a nbro-serous sac, containing, besides serum, the so-called acephalocysts ; these are small bladders (hydatids), formed of coagulated albumen and filled with an albuminous fluid ; they vary in size and number, and are either attached to the parietes of the former or float in the serum. The acephalocyst generally attains a considerable size in the liver. We have several extraordinary specimens in the Viennese museum, and there is one of a foot in diameter. In proportion as the heterologous growth increases, the hepatic parenchyma gives way, and the nearer the former originally was to the surface, the sooner will it reach the peritoneal investment; it then projects above the*liver, with a larger or smaller segment of its circumference. Under these circumstances the peritoneum invariably inflames, and the consequence is a thickening of the latter upon and in the vicinity of the acephalocyst ; an investment of pseudo- membranous cellular tissue is formed, by which the viscus becomes attached and agglutinated to adjoining organs. Sometimes there is but one, sometimes there are several of these cysts ; in rare cases, the entire liver appears converted into an aggregation of larger or smaller sacs. In the latter instance, two or more are often found to communicate with one another ; either in consequence of atrophy of their parietes from pressure, of rupture from inflammation, or from a sudden increase in their contents. The right lobe of the liver is the ordinary seat of the acephalocysts ; the largest are always found at this part. Acephalocysts are liable to inflammatory attacks, which entirely re- semble those of normal serous and fibro-serous membranes, both in regard to the exudations they give rise to, as to their terminations and consecu- tive results. They may, by causing suppuration and obliteration, de- troy the vitality of the acephalocysts, and thus bring about a cure. The hepatic acephalocyst may discharge its contents in various direc- tions ; the portion that projects above the surface of the organ, and has lost the support it previously received from the surrounding parenchyma, may become atrophied and thinned, or its tissue be weakened or destroyed by inflammation and suppuration, and thus communicate directly with the abdominal cavity ; or having first become agglutinated to neighboring THE LIVER. 119 viscera, it may perforate the latter and discharge externally, or into other cavities and canals. The contents may thus make their way Into the right pleura, or into a pulmonary abscess, and be removed by the bronchi : Into the intestinal cavity, and especially into the duodenum and transverse colon, so as to pass off by vomiting or defecation : Into the gall-ducts, i. e. into a large branch of the ductus hepaticus, by which passage they may ultimately be conveyed into the intestine ; though the protrusion of the acephalocyst more frequently induces dangerous obstruction of the biliary passages : In rare cases, into a neighboring bloodvessel, and lastly : Into a neighboring circumscribed abscess, resulting from peritoneal inflammation. Occasionally the acephalocyst opens in various directions at once. After the discharge of its contents, obliteration of the sac and cure, sometimes follow. The contents of the sac are discharged unaltered or changed, accord- ing to the process accompanying its perforation ; the products of inflam- mation in the matrix, or of the parietes of other cavities (e. g. the pleura), the bile, the intestinal secretions, &c., are particularly prone to induce a maceration and complete solution of the acephalocyst. On the other hand, not only the parietes of the investing sac are often found saturated with bile, but the bile extravasated from large gall-ducts is frequently mixed with its contents, and its parietes are incrusted with inspissated bile. In the same manner we may now and then discover blood in the cyst, which has been discharged from neighboring vessels. The hepatic parenchyma is forced out of its position in proportion to the size and number of the cysts ; if otherwise affected, it presents the nutmeg degeneration. Acephalocysts in the liver are frequently complicated with affections of the same kind in other organs, as the lungs, spleen, and kidneys ; the disease is also complicated with cancerous affections in other organs. Large acephalocysts of the liver give rise to ascites or peritonitis, and may thus prove fatal. In reference to the etiology of these growths, it appears, according to some observations, that mechanical injury of the liver and intermittent fevers may influence their development. They seem not to occur before puberty. (5. Tuberculosis of the liver. Contrary to the received opinion, we assert that the liver is rarely the seat of tubercular disease. It scarcely ever occurs in this organ as a primary affection, but is not unfrequently found as a secondary complication of advanced primary tuberculosis in another organ, or of universal tubercular disease. It must, therefore, almost always be considered as the expression of advanced tubercular cachexia. Hepatic tubercle occurs in the shape of semi-transparent, grayish, crude, miliary granulations ; in which case it is more especially the pro- duct of acute tuberculosis ; or as yellow, cheesy, adipose deposits, of the size of a hemp-seed, or pea, or more. It is consequently often larger 120 ABNORMITIES OF than pulmonary tubercle ; but, on the other hand, with the exception of very rare cases, is much less extensively disseminated than the latter. Hepatic tubercle is not limited in its seat to a particular section of the viscus, but attacks all portions indiscriminately, and the more so, the acuter its course. The tubercular matter is deposited in the parenchymatous cellular tissue of the organ, and especially in that pertaining to the biliary capil- laries. It very frequently surrounds a minute gall-duct, and thus pre- sents a central canal, which gives rise to a biliary discoloration of the nucleus. When the liver is attacked by acute tuberculosis, its appearance resembles the parenchyma of other organs similarly affected ; it is in a peculiar state of turgescence, the tissue is relaxed, friable and pale, and gorged with a serous or sero-sanguineous fluid. All this will be the more evident, the more rapidly the tubercular deposit is effected, and the more the universal cachexia is developed. The conditions under which hepatic tubercle occurs, render it apparent that it rarely passes into the stage of softening, and scarcely ever into that of cretification ; the constitutional affection generally proves fatal from its violence and diffusion, before the tubercles of the liver have undergone these metamorphoses. Still we do occasionally find that, from the very violence of the constitutional affection, a solution of hepatic tubercle is effected ; and then it is probably the yellow variety which is converted into a primary hepatic vomica, and which offers no peculiar characters beyond the biliary discoloration of its contents. We do not, however, meet with a condition accompanying tubercular suppuration in the liver which may be considered analogous to pulmonary phthisis. This vomica requires to be the more carefully distinguished from morbid dilatation of the gall-ducts, as the latter not only occurs frequently or almost invariably, in combination with hepatic tubercle, but is not unfrequently coexistent with tubercular disease of other organs. In this case small cavities, of the size of a millet-seed or a pea, filled with viscid, muco-bilious, dirty green matter, with flaccid parietes, are found scattered through the liver, which on close examination are found not to be tuber- cular, but to be dilatations of capillary gall-ducts. The hepatic tubercles exist at the same time, and at various distances ; a tubercle may occa- sionally be found near one of these cavities, but it is not characterized by the symptoms of secondary deposit accompanying the fusion of tuber- cular matter. The conditions of their origin, and their connection with the constitu- tional disease, have not been as yet ascertained ; but we are warranted by numerous observations in stating, that they invariably indicate a high degree of the constitutional affection ; and a tendency to universal tuber- cular deposition, and especially in the abdominal viscera. Hepatic tubercle may be complicated with tubercular affections of almost all organs, as might be assumed from its originating in an advanced stage of tubercular dyscrasia ; however, the abdominal organs are found chiefly implicated, viz. the abdominal lymphatic glands, the spleen, the peritoneum, and the intestinal canal. THE LIVER. 121 e. Carcinoma of the liver. Carcinoma of the liver is a disease of much greater importance than tubercular deposition, as it occurs very frequently and is often a primary affection. Although we do not coincide "with Cruveilhier, as to the frequency of its occurrence, it still must be considered as a common affection, and we would give its numerical relation to carcinoma of other organs as one to five. The greater frequency of its occurrence, as compared with tubercle of the liver, and considered in reference to the frequency of both affec- tions in other organs, and especially in the lungs, and to the facts con- nected with the formation of cysts in the lungs and the liver, is a matter of particular interest. These remarks apply to carcinoma of the liver generally, but not to its different varieties ; of these, some are frequent, some occur less fre- quently, some very rarely. Four varieties of carcinoma are found in the liver, which we will examine in succession. aa. Areolar cancer. This form occurs so rarely, that it is never de- scribed among hepatic affections. One case of very extensive areolar cancer has come under my notice. ,5,5. Carcinoma fasciculatum sive hyalinum (Muller). Although not as frequent as the following, it undoubtedly occurs often. It is generally taken for medullary carcinoma, and the mistake is accounted for by the fact that the two often coexist. It forms masses of the size of a filbert to that of a man's fist, which are surrounded by an investment of delicate cellular tissue ; though the surface is uneven and lobulated, the general outline is round ; its consistency varies, being sometimes but slight, at others almost cartilaginous ; its color a pale yellowish-red, and generally of almost vitreous transparency. The carcinomatous masses are com- monly found in considerable numbers, and like medullary cancer, they cause rounded protuberances of the viscus, and produce an increase in its weight and size. 77. Medullary carcinoma. This is the most common form of hepatic cancer, and almost all investigations that have hitherto been made in reference to this subject, treat of this variety only. It occurs either in the shape of detached masses, or as an infiltration of the hepatic parenchyma. aaa. The detached masses occur as tumors, which offer many peculiar features. Their general form is spherical, though their surface not unfrequently is slightly racemose or lobulated. Those which have been developed in the peripheral portion of the organ, and are therefore in contact with the peritoneum, present a flattened, or even an indented surface, and the indentation may extend to the very nucleus of the morbid growth. The peritoneal lamina in the indentation is opaque and thickened, owing, not as is commonly thought, to cartilaginous induration, but to an homolo- gous cancerous degeneration of the serous and subserous tissue. This condition of the peritoneum is analogous to the relation the common integument bears to subjacent cancerous growths. In size the medullary cancer varies from that of a millet- or hemp-seed to that of a man's fist, a child's head, and more. In most instances mor- 122 ABNORMITIES OF THE bid growths of various sizes are found in the same individual. The larger those are which occupy the peripheral portion of the organ, the more prominent will be the protuberances on the surface. The number of these adventitious products varies equally ; sometimes there are but few, or even only a solitary one is found ; at others they are very numerous. The greater the number of those occupying the peripheral portion of the organ, the more numerous will be the protube- rances on the surface. When the morbid growths are numerous and large, two or more often coalesce. We are unable to discover any peculiarity in reference to their posi- tion ; they commence equally in the peripheral and in the deeper-seated portions of the intestine. They commonly make their first appearance in the right lobe. As regards consistence, we find two varieties which have also been considered as differing in texture. They do not, however, constitute essential distinctions, but are merely different degrees of development of the same morbid growth. One is of the consistency of bacon, and presents on section a smooth homogeneous, shining surface, of a dull white color, and without a trace of bloodvessels. On pressure, a small quantity of a thick creamy fluid exudes from the meshes of a dense fibrous structure. These growths are not detached from the adjoining hepatic tissue without considerable diffi- culty ; and a distinct cellular investment can scarcely be demonstrated. The growths belonging to this variety, when coexisting with the second, are always the smaller of the two. The second presents the physical characters of true encephaloid dis- ease ; its general color is milk-white, it is more or less vascular, and consequently in part gray, yellow, brownish, red, or even dark red ; it is very spongy, and on pressure yields a large quantity of a thin milky fluid, which is contained in the meshes of a friable, fibrous tissue. The tumors are invested by a delicate cellulo-vascular sheath, and are easily detached from the hepatic parenchyma. When occurring simultaneously with the first variety, they generally form the large morbid growths. The latter evidently represent an advanced stage of the morbid growth, as appears not only from the foregoing remarks, but also from the rela- tions of the primary cell. (Vide vol. i.) /W. Infiltrated medullary cancer is analogous to the other infiltrations of the hepatic tissue, which we have already discussed. It always con- tains obliterated and obsolete bloodvessels and gall-ducts, which are gra- dually absorbed. The infiltration attacks larger or smaller segments of the viseus ; it does not present distinct boundaries, but insensibly passes into the normal parenchyma. It rarely occurs without nodulated cancer. The carcinomatous mass presents the same two varieties in reference to consistence and to its elementary constitution. We find a transition from the diffused to the circumscribed form in the fact, that the nucleus of the latter is sometimes infiltrated hepatic tissue, which becomes en- dowed with independent growth, and merely forces the parenchyma out of its place. The larger and the more numerous the carcinomatous masses are, the BILIARY PASSAGES. 123 more extensive the cancerous infiltration, the more does the viscus in- crease in size and weight. The extracancerous tissue presents the nutmeg and adipose degeneration. Medullary cancer is here, as elsewhere, the seat of hemorrhages, which are proportioned to the rapidity of its growth and the looseness of its tex- ture. In rare cases it penetrates through the peritoneal investment of the liver, its development then proceeds with extreme energy, and it in- duces exhausting hemorrhages. In other cases it perforates the coats of large gall-ducts within, or of the biliary passages external to the liver, and grows into their cavities. In the infiltrated form we not unfrequently find extravasations of bile to a greater or less amount. Medullary cancer rarely passes into suppuration, as it generally termi- nates fatally by inducing universal cachexia and exhaustion. Its fusion is still more rarely found to take place within a fibrous sheath, as is com- paratively oftener the case in the spleen. Occasionally nature seems to attempt an arrest of the morbid growth, by a conversion into fat or adipocire. Hepatic cancer undoubtedly very often occurs as the first of a succes- sive series of cancerous deposits ; yet, in the dead subject, it is commonly found combined with carcinoma of the lymphatic glands, that are seated near the biliary passages and in the lumbar region, with cancer of the stomach, of the intestine (especially of the rectum), of the peritoneum, of the kidneys, and with universal cancerous infection. It is often developed with remarkable rapidity after the extirpation of cancerous growths, and is then generally accompanied by cancer in the lungs. 777. Medullary carcinoma not unfrequently occurs in the liver in the shape of cancer melanodes (melanosis), and equally as an infiltration, or in circumscribed masses. We find the most varied combinations of its elementary molecules with those of pure medullary cancer. A common result of hepatic cancer making its way outwards, is inflam- mation of the peritoneum ; the carcinomatous liver is consequently often found agglutinated to neighboring parts by means of cellular or cellulo- fibrous tissue, which may in its turn be subjected to cancerous degenera- tion. SECT. II. ABNORMITIES OF THE BILIARY PASSAGES. We now come to the consideration of the diseases of the gall-bladder and its efferent duct, those of the ductus communis choledochus, of the ductus JiepaticuS) and of the branches and ultimate distribution of the latter. We include the entire apparatus under one head, though we shall devote a special consideration to the peculiar characters exhibited by separate sections. 1. Excess and Defect of Formation. In rare cases a congenital absence of the gall-bladder has been noticed, an anomaly which must not, however, be confounded with obliteration of the gall-bladder which is frequently consequent upon inflammation. When there are two livers, the gall-bladder and the entire apparatus correspond ; but we also find, without any further anomaly, a twofold instead of a single common 124 ABNORMITIES OF THE duct ; the two ducts then either both open into the duodenum, or one communicates with the duodenum, and the other with the stomach. 2. Irregularities of the Biliary Passages with reference to Calibre. Independently of congenital enlargement or diminution of these parts, we find important acquired anomalies in the shape of dilatation or con- traction. Dilatation either affects the entire apparatus from the duodenal orifice to the capillary gall-ducts equally or almost equally, or it only affects larger or smaller portions, whilst the remainder retains its ordinary size. The gall-ducts are capable of extreme distension. We find that dilatation of the passages is caused by habitual accumu- lation of inspissated bile, and by everything that impedes the progress and the discharge of the secretion. We allude to compression of the biliary passage within and external to the liver by morbid products or enlarged lymphatic glands, to diminution of their calibre by tumefaction of the coats, by cicatrices or unusually large folds or valves of the mucous membrane ; to obturation by biliary calculi, by morbid growths projecting into the cavity of the biliary passages, by catarrhal or croupy secretions. Some of these obstacles occur mainly in one, others in another portion of the apparatus. If the impediment occupies the ductus choledochus, the dilatation gradually extends over the entire ap- paratus ; but it must be observed that the dilatation of the gall-bladder does not in general correspond with the dilatation of the other portions, as its efferent duct (ductus cysticus), 4from opening into the common duct at an acute angle, is compressed by the enlarged ductus chole- dochus. The more completely the calibre is obstructed, the more com- plete is the capillary distension ; the more rapidly it ensues, so as not unfrequently to induce rupture. The ductus choledochus is either found compressed by disorganized, and especially by cancerous, lymphatic glands, or by the pancreas, or the passage is narrowed by the tumefied mucous membrane or by the tumefied valve, or it is closed up by a biliary calculus or a carcinomatous tumor from without. Occasionally it is so enormously dilated as to ex- ceed the diameter of the small intestine ; the slower this effect is pro- duced, the more marked will be its active character ; and the distension extends upwards, passing by the gall-bladder, as above observed, to the hepatic duct and its ramifications. The channel of the ductus cysticus is found impaired by unusual flexures, or large and numerous mucous folds, consequent upon previous elongation and distension, by cicatrices and cancerous degeneration ; it may become perfectly obliterated by the same means, or by biliary calculi, which are impacted in the neck, and more particularly in a lateral dilatation of the gall-bladder. Enormous dilatations of the latter result, which in the course of time induce an entire change in the tissue and the functions of the mucous membrane of the gall-bladder. After this occlusion has been rendered complete, the residuary bile in the gall-bladder is absorbed ; the mucous membrane secretes mucus more copiously, in proportion to the irritation exerted upon it by the stagnating mucus left after the removal of the specific contents of the bladder. The secretion gradually accumulating, the gall-bladder extends, and BILIARY PASSAGES. 125 its mucous membrane becomes converted into a serous membrane, which secretes a serous, albuminous fluid, resembling synovia ; this is at first opaque, and subsequently becomes clear, and we detect in it, with the assistance of the microscope, nothing but solitary flocculi of pigmentary matter, and a few crystals of biliary fat. This affection of the gall- bladder is termed hydrops cystidis felleae, and the bladder resembles the sound of fishes, being converted into a tense capsule, a condition similar to that developed under analogous circumstances in the Fallopian tubes, the ureters, the pelves and calices of the kidneys, and even in the vermiform process. The new lining membrane of the gall-bladder is subject to all the dis- eases to which serous membranes and their cavities are liable ; inflamma- tions occur very frequently, giving rise to the most various exudations, and terminations as various. Among the latter, we allude especially to shrivelling of the gall-bladder, accompanied by diminution of its con- tents. These become inspissated, so as to form an adipose chalky pulp, or chalky concretion, with a subsequent ossification of the parietes. The dilatation of the biliary ducts in the interior of the liver is either uniform, and affects the entire organ or certain portions only, or it occurs as a partial saccular dilatation of one or more of those ducts. In the former case the cause is generally to be found in an obturation of the biliary channels within or external to the liver, by means of concretions, cancerous growths, or croupy exudation ; and the dilatation very fre- quently extends from the ductus choledochus to the biliary passages within the liver. In well-marked cases the entire capillary network be- longing to this apparatus is dilated and gorged with bile ; the paren- chyma of the liver may be saturated with bile, and present a dark yellow or green color ; the viscus is turgid, though pulpy and friable, resembling the condition of yellow atrophy ; the larger ducts contain bile in a dis- organized state, and not unfrequently blood in a similar condition. This affection invariably proves fatal with symptoms of biliary infec- tion of the blood, and consequent cerebral disease, which is often combined with exudation on the arachnoid, with intense icterus and extreme pain in the liver. The capillary ducts are occasionally rup- tured, and this gives rise to larger or smaller accumulations of bile in the deep-seated portions of the organ ; or the rupture may occur in the peripheral layers, at spots where patches of dilated gall-ducts form rounded, fluctuating projections on the surface of the organ ; in this case the hepatic peritoneum frequently becomes involved, and extravasation may take place into the abdominal cavity. Finally, the bile that transudes through the coats of the gall-ducts may, if it reaches the peri- toneum, induce peritonitis, which in its turn predisposes to rupture of the serous covering investing the approaching biliary abscess. The second or saccular form of dilatation of the biliary ducts is generally the result of a catarrhal or blennorrhoic condition. Capsules varying in size from a pin's head to a hen's egg, with a loose mucous lining that forms valvular folds, are found scattered through the liver, and they contain a liquid consisting of blennorrhoic or purulent mucus and bile, which deposits a sediment or incrustations. The character of the investing membranes affords a sufficient distinction from other cavi- 126 ABNORMITIES OF THE ties containing a similar fluid ; but the afferent and efferent canal is not easily discoverable, even with the assistance of injections. These dilata- tions undoubtedly originate in an accumulation of catarrhal secretion, and are generally accompanied by a dull pain in the liver. Contraction of the biliary passages is induced by the above-mentioned circumstances, and may advance to adhesion and obliteration, as is especially the case in the gall-bladder. 3. Anomalies in the Form and Disposition of the Biliary Pas- sages. Among these we reckon the various congenital malformations of the gall-bladder, in which it presents an intestinal, cylindrical, extended, twisted, pyriform, or phial-shaped appearance, or in which it seems divided longitudinally or transversely, owing to a rigid condition of the internal folds. To this class also belongs the anomalous insertion of the ductus choledochus into the duodenum or stomach. The acquired mal- formations consist in contraction, obliteration, or dilatation of the gall- bladder ; in change of position of the biliary passages, owing to pressure exerted upon them by enlarged lymphatics, morbid growths, &c. 4. Solutions of Continuity. We regard as peculiarly interesting the spontaneous ruptures occurring in the biliary passages external and internal to the liver as a consequence of excessive dilatation, which is generally preceded or accompanied by inflammatory action. "We have also to cite the perforations of the biliary passages external to the liver, resulting from suppuration of their cyats, and the abnormal passages subsequently established between the biliary ducts and the stomach and intestinal canal ; as well as certain abscesses produced by suppuration of the capillary gall-ducts within the liver, of which we shall have occasion to speak more fully in the sequel. (See Textural Diseases of the Biliary Passages.) 5. Textural Diseases, a. Inflammation. We often observe catar- rhal inflammation occurring in the biliary passages, with various termi- nations and results. Like catarrhs of other mucous membranes, it not unfrequently is a primary affection, and becomes chronic, or it as often is propagated from the intestine to the gall-ducts ; but it often evidently has its origin in the irritation caused by an accumulation or an altera- tion in the composition of the bile, and especially by biliary calculi. At the bedside the affection is undoubtedly often mistaken for irritation and inflammation of the hepatic parenchyma. Owing to the paralytic state induced in the contractile and irritable layer of their coats, and to the accumulation of bile, the gall-ducts become distended, their mucous membrane relaxed and tumid, and the muscular coat hypertrophied ; within the liver saccular dilatations are formed ; the catarrhal disease induces a stagnation of bile, which gives rise to calcu- lous concretions, and occasionally suppuration and perforation of the gall- ducts follow. In the range of the biliary capillaries it most probably causes, in the manner just described, the formation of peculiar accumula- tions (abscesses), which are remarkable for the blennorrhoic pus and the bile they contain, and are thus distinguished from the products of paren- chymatous inflammation of the liver. BILIARY PASSAGES. 127 Inflammation originating in irritation, caused by biliary calculi, de- serves a special consideration, on account of its terminations and its con- sequences ; it occurs chiefly in the gall-bladder. Occasionally and par- ticularly when brought on by an accumulation of bile from obturation of the neck of the bladder or of the ductus cysticus, it runs a very rapid course, attacking the submucous tissue of the gall-bladder, and terminat- ing in rupture and effusion of its contents into the peritoneal cavity. At other times it proceeds more slowly, and after repeated relapses, induces suppuration and ulcerative perforation of the gall-bladder. The latter is most liable to occur at the dependent portion, which is chiefly exposed to irritation, viz. the fundus of the bladder ;' and as previous peritoneal exudation will have agglutinated it to adjoining viscera, the suppuration extends to them, giving rise to abscesses in the liver itself above the gall- bladder, or in the lesser omenturn ; or establishing fistulous passages through the abdominal parietes, or communications between the gall- bladder and the pylorus, the duodenum and the transverse colon. Lastly, in favorable cases, the coats of the gall-bladder may be converted into a fibrous, callous tissue ; its contents are discharged by the normal or by the above-described anomalous passages, and the organ represents a thick- coated hollow capsule, with or without cicatrices on its inner surface, and containing, according to the condition of the mucous membrane, a mucous or serous fluid, and not unfrequently one or more calculi. This is the so-called obliteration or atrophy of the gall-bladder. The calculous inflammations of the biliary passages are followed, though less frequently, by similar results, viz. rupture, suppuration, gangrenous perforation, cal- lous induration, and obliteration. b. Croupy inflammation is of very rare occurrence. We have ob- served it in the mucous membrane of the gall-ducts in the liver, accom- panying cholera-typhus and ileo-typhus. It gives rise to tubular exuda- tions, in which the bile forms branched concretions which block up the passages, and thus cause dilatation of the capillary gall-ducts. We have already noticed the occurrence of the secondary and gangre- nous typhous process on the mucous membrane of the gall-bladder. c. (Edema of the coats of the gall-bladder. Serous infiltration of the coats of the gall-bladder occurs in general dropsy, and especially in ascites, and also in the shape of subserous infiltration in inflammation of the peritoneum. d. Adipose deposits in the coats of the gall-bladder. An excessive deposit of fat under the peritoneal investment of the gall-bladder only occurs as an accompaniment of general adipose accumulation, or at least of accumulation of fat in the abdomen. Its occurrence is of some inte- rest, inasmuch as, like the fatty deposit in the heart, it is likely to in- duce fatty degeneration of the muscular layer. 6. Adventitious Products, a. Fibroid tissue. Under this head we class the textural alteration occurring in atrophy of the gall-bladder after inflammation. b. Anomalous osseous deposit ossification, as elsewhere in mucous canals, takes place only as a consequence of previous textural alteration of another kind. Thus we find subserous osseous lamellae formed in the parietes of the gall-bladder, after it has been converted into a sero- 128 ABNORMITIES OF THE fibrous capsule, in hydrops cystidis ; or the fibroid tissue which is deve- loped in the parietes of the gall-bladder, as a consequence of inflamma- tion and partial suppuration, may ossify. c. Tubercular deposit in the biliary passages is of very rare occur- rence. d. Carcinoma of the biliary passages is chiefly met with as a compli- cation of cancer of the liver, but also of the lumbar lymphatic glands, and of the stomach. It occurs either as an idiopathic nodulated deposit in the submucous tissue, in rare cases giving rise to annular stricture and degeneration of the entire bladder into a cancerous capsule, or as can- cerous infiltration of the mucous membrane ; or, as is more commonly the case, the biliary passages are attacked from without, cancerous growths in the vicinity perforate the parietes, and push their way into the cavity. The gall-bladder is most frequently attacked by hepatic cancer ; the ductus choledochus by carcinoma of the lymphatic glands. Obtura- tion of the passages and hemorrhage are common consequences of the affection. 7. Anomalous Contents of the Biliary Passages. The most remark- able are those entirely abnormal contents of the biliary passages, which are either the product of textural changes and morbid processes in their coats, or which after being generated externally, are conveyed into the cavity by various passages. We allude to the sero-albuminous fluid of dropsy of the bladder, to mucus, to pus that has been formed in the biliary passages, or in hepatic abscessed, to blood derived from cancer- ous growths, to acephalocysts from the liver, lumbrici from the intes- tine, &c. The bile itself presents great varieties as to quantity, but more still as to quality ; in the majority of instances the anomaly has its origin not so much in disease of the liver, as in morbid conditions of other organs, especially of the intestine and of the portal blood. As regards quantity, the bile is found accumulated to a large amount in the biliary passages and intestine, or it is remarkably scanty. It is to be observed that in the latter case the deficiency is sometimes compen- sated by the saturated condition of the fluid. The qualitative anomalies of the bile are more numerous and impor- tant, and affect both its physical and its chemical constitution. The color of the bile varies extremely : it may be pale yellow, ochrey, orange-colored, yellowish-brown, blackish-brown, black, or of all the different shades and tints of green. The consistency of the bile gene- rally increases in a ratio with the increased depth of color, varying from the fluidity of water to the density of tar and of calculous concre- tions. In taste it varies as to the amount of bitterness, but it may also be more or less, or entirely, saccharine, saline, sour, alkaline, acrid, or insipid. In reference to its chemical constitution, the bile presents, as might be inferred from its physical qualities, numerous deviations from the correct standard ; the chief constituents vary in their relative proportions, or they are replaced by new anomalous substances. The biliary calculi are of considerable importance. They originate in BILIARY PASSAGES. 129 a morbid constitution of the bile, which may be abnormal when secreted, or subsequently become so from stagnation and retention. They occur in the biliary passages external to and within the liver, but more espe- cially in the gall-bladder. Here too we find numerous variations with regard both to physical qualities and to chemical composition. They vary in size from a millet-seed to a hen's egg, and more. We generally find the largest to be formed by several materials disposed in layers, with a preponderance of fatty matter. The larger they are, the less numerous will they be ; sometimes several hundreds of small calculi are discovered in the gall-bladder. Their form and surface vary much. Single calculi are commonly round, oval, or cylindrical ; when very large, so as to occupy the entire cavity of the gall-bladder, they are frequently slightly curved ; if several are present at the same time, they mutually prevent their enlargement, and in consequence of the friction and pressure they exert upon one another, they assume cubical, tetrahedric, prismatic, or irregularly poly- hedric shapes, with convex or concave surfaces. The calculi found in the ducts are generally cylindrical, occasionally branched, or entirely amorphous. Their surface may be smooth and unc- tuous to the touch, or rough, racemose, uneven, of a mulberry appearance, crystalline, or branched. The texture of the calculi may be uniform or varied, in proportion as they consist of one substance, or of several layers. Many show no dis- tinct arrangement ; some have an earthy pulverulent fracture, or a fibrous, striated, laminated, micaceous texture, presenting a glassy, silky, or asbest-like gloss on fracture, as is particularly observed in calculi consisting of cholesterine. Generally speaking, they are not very hard, and may, when first re- moved from the body, be easily compressed between the fingers. On drying, they crack and fall to pieces, and j at last become pulverulent, which is particularly the case with those concretions which consist of in- spissated bile or biliary resin. In color they vary considerably ; they may be milk-white, bluish, chalky, light or dark-yellow, brown, black, or colorless, or transparent, with a slight yellow or green tinge. Those of an ochrey, red, green, and blue (bronzed) color are unusual. Sometimes we find them spotted, and either of a uniform color throughout, or varying in layers, or at least containing a differently colored nucleus. Chemical analysis shows the biliary calculi to consist mainly of in- spissated bile, biliary resin, coloring and fatty matter, and the calculus may be either formed of one of these substances or of a mixture of several. In the latter instance they either interpenetrate one another, or are disposed in distinct layers, which are distinguishable by their color or texture. Large biliary calculi generally contain but a small portion of inspis- sated bile ; the latter often forms small irregular concretions in the gall-bladder, or larger cylindrical and branched concretions in the gall- ducts, or it serves as a nucleus to the various calculi of the gall-bladder. The resin and pigmentary matter of the bile enter into the composition VOL. II. 9 130 ABNORMAL CONDITIONS of the majority of gall-stones, and that frequently to a considerable extent. Cholesterine almost always preponderates ; it frequently occurs in a pure state as a white, mother-of-pearl like, shining, or opaque fatty in- vestment, or in distinct layers of a striated texture, which are separated by colored resinous layers ; it may also exist in an isolated form, depo- sited round a colored nucleus, and give rise to translucent calculi of a striated and distinctly crystalline texture. In the latter case we gene- rally find that small solitary calculi, in the former very large calculi result. Picromel commonly occurs but in minute quantities, in biliary calculi; the various salts they contain form but a small proportion compared to the amount of the above-named constituents. Those concretions in the gall-ducts which are found to consist of carbonate of lime, are not pro- ducts of the bile, but of the blennorrhoic mucus and pus of the gall- bladder. The calculi found in the same gall-bladder generally resemble one an- other in composition, shape, and size ; although we meet with occasional exceptions from this rule. Thus in dropsy of the gall-bladder, we often find, beside the calculus which closes up the cystic duct, and which is of an old date, and of complicated structure, a second crystalline calculus, of more recent formation, which consists of pure cholesterine. The calculi are either unattached or sessile. In the latter case they may be grasped and retained by a portion of the bladder, or be aggluti- nated to its internal surface by exudation, or they may be included in compartments, formed by an inspissated albuminous product of the gall- bladder, o%by organized lymph which has been converted into fibrous tissue. Small calculi are also occasionally formed within small saccular dilatations of the biliary mucous membrane, and may appear to lie ex- ternal to the cavity of the bladder. Biliary calculi frequently cause irritation, inflammation, and subse- quent suppuration of the coats of the gall-bladder, which may terminate in various ways. Cicatrices are often left, which more or less diminish the cavity. They may induce complete occlusion of the biliary pas- sages, followed by dilatation and retention of bile. We must, however, observe that sometimes, owing to the extreme distension which the biliary passages are capable of, calculi of the size of a hen's egg are enabled to pass. Biliary calculi are of common occurrence. We have observed that their formation is peculiarly coincident with excessive deposit of adipose tissue and with carcinoma. The entozoa occurring in the human gall-bladder are the endogenous acephalocyst of the hepatic parenchyma and the distoma hepaticum. SECTION III. ABNORMAL CONDITIONS OF THE SPLEEN. 1. Defect and Excess of Formation. The spleen is generally absent in acephalous monsters, together with other organs of the abdomen and thorax. Occasionally it is found wanting, together with the stomach or the fundus of the stomach, in subjects that are otherwise well developed, OF THE SPLEEN. 131 or it exists in a rudimentary state, whilst the stomach is in a normal condition. The explanation of these phenomena is to be sought in the history of the development of the embryo. The spleen is found double in biventral monstrosities. The multipli- cation of the spleen, in the shape of lienes succenturiati, is not to be viewed as an increase, but as a subdivision of the organ, which does not affect its individuality. We not unfrequently find, besides the main organ, small accessory spleens (lienes succenturiati) seated in the omen- turn and ligamentum gastrolienale. They vary in size from that of a millet-seed to that of a walnut, and in number from one to twenty. They are round, present the same structure as the spleen, and are mor- bidly affected at the same time, and in a similar manner as the latter. The marginal indentations of the spleen, or the complete separation of a portion of the organ by a horizontal fissure, form transitions to this abnormal condition. 2. Deviations of Size. Deviations of size consist either in an abnor- mal increase or diminution of the organ. The former is of particular importance, and those tumors afford a special interest, which depend upon congestion caused not by mechanical impediments, but by the peculiar relation of a morbid state of the blood to the spleen. With the rare exceptions of those cases in which, like analogous states of the liver, they are congenital, these conditions are acquired. They are either acute or chronic : in the former case they accompany other acute diseases, either during their entire course, or only during single stages ; in the latter, the tumefaction results from dyscrasiae or cachectic con- ditions, which induce congestion, induration, and hypertrophy of the spleen. These terms, however, from referring mainly to external ap- pearances, are apt to cause the real nature of the disease to be over- looked. It is unnecessary to enter more fully into the consideration of these changes affecting the splenic parenchyma, which are evidenced by tume- faction, as it will be more appropriate to treat the subject under the head of Textural Diseases. We merely add the following remarks : a. Acute tumefaction is generally accompanied by considerable soften- ing of the splenic parenchyma ; chronic tumefaction by increase in the consistency of the organ. It is questionable whether the hypertrophy affects the elementary tissue and constitution of the spleen : this is a point which requires to be elucidated by further research ; but there is no doubt of the fibrous trabeculae of the spleen and its fibrous capsule becoming hypertrophied in old chronic tumors. When we have suc- ceeded in reducing an acute or chronic tumor, or even a mere hyperaemic state of the spleen, we often find the sheath of the spleen thickened, opaque, corrugated, and relaxed after death a fact which may serve as a useful indication. b. The size attained by chronic tumors of the spleen is often very considerable. The spleen not unfrequently measures sixteen inches in its long, seven inches in its short diameter, and four inches in thickness ; its weight may amount to thirteen pounds and a quarter, and, according to the observations of others, even to twenty and more pounds. 132 ABNORMAL CONDITIONS Diminution of the spleen is characterized by shrivelling of the fibrous tissue, which prevents the vessels from being injected ; and is peculiar to genuine cholera (cholera algida), or it occurs as atrophy, in conse- quence of a special change in the fluids at large. Under this head we must class numerous obscure cases of permanent diminution of the spleen in individuals who in no way resemble each other, of the reduction of the spleen observed by some pathologists as resulting from the use of steel, and of the senile involution of the spleen. Atrophy varies in degree ; it occasionally advances to such an extent during the involution of the organ, as to reduce it to the size of a hen's egg or walnut. The spleen in these cases is paler than usual, its consistency is in- creased or diminished, the organ may assume the toughness of leather, or become soft, friable, and pultaceous. Senile atrophy may be charac- terized in the following manner : the spleen is considerably reduced in size, and flabby ; its sheath is opaque, corrugated and thickened, but at the same time softened and easily ruptured ; the parenchyma consists of a pulp which is of the color of rust or the lees of wine, and which is en- closed in dense and equally friable, fibrous tissue. We not unfrequently find the sheath of the spleen indurated and cartilaginous, or ossified, and at the same time, ossification of the arterial ramifications and free calcareous concretions (phlebolithes) in the veins of the organ. 3. Deviations of Form. We not unfrequently meet with a tongue- or platter-shaped, almost cylindrical, globular, or angular spleen ; its edges may be more or less notched, which is particularly the case with the anterior margin ; and the indentation may extend so far as to cause a transverse division of the organ. These furrows are not to be con- founded with the contractions that are occasionally produced by inflam- mation and metastasis, and which very much resemble the former. 4. Deviations of Position. The congenital anomalies that come under this head consist in the spleen occupying a place external to the abdominal cavity, when the latter is fissured, in its being placed in large umbilical hernise, and in the left thoracic cavity when the dia- phragm is absent, and in a varying position, consequent upon an anoma- lous congenital elongation of the peritoneal attachments. Acquired deviations of position consist in a descent of the spleen, when forced down by enlargement of the left side of the thorax, or in its being pushed up by dropsical and ascitic accumulations, or by a tympani- tic state of the intestine ; in its dislocation by various turners, or in its descent from increase in size and weight. Enlarged spleens sink ver- tically into the left mesogastric region, or raise the diaphragm, or they descend to the ileum, and in the case of a still further increase of size, slide off from the latter, so as to occupy a diagonal position in the hy- pogastrium, and extend over the right ileum. There is no doubt that the spleen occasionally presents very loose attachments, and remains freely movable, even after it has been reduced from a hypertrophied state to its normal size, in consequence of the previous traction exerted upon its ligaments. OF THE SPLEEN. 133 5. Solutions of Continuity. Under this head we class injuries of the spleen inflicted by cutting instruments, rupture consequent upon blows or knocks received in the region of the spleen, contusions, as in being run over, concussions, as in a fall, and spontaneous ruptures. The latter are of peculiar interest, as they are the result of acute and vio- lent tumefaction of the organ, proceeding to a most intense degree. We are able to confirm the fact observed by other authors, of the occurrence of spontaneous rupture in typhus, in typhoid cholera, and in the hot stage of ague, and the consequent fatal termination from hemorrhage. 6. Diseases of Texture. The chief diseases that appertain to this class, the hypercemire, the so-called infarction and hypertrophy, and in- flammation of the spleen, require, in order to be duly appreciated, not only anatomical proof of the existence of the disease, based upon a clear notion of the structure of the organ, but more especially an advance in our knowledge of the pathology of the blood and the serum. Numerous diseases, and more particularly the simplest derangements, as many cases of hypenemia, can only be elucidated by attending to these points. These diseases of the spleen are probably but rarely idiopathic ; they almost always arise from certain anomalies of the blood and the serum, or from certain dyscrasise, which, though little known, and as little un- derstood, bear a remarkable and positive relation to the spleen. The spleen may in fact be considered as the most sensitive test for a variety of dyscrasic states of the fluids. An acquaintance with this connection may serve to lift the veil which still conceals the true function of this organ. We shall now resume the consideration of tumefaction of the spleen, upon the basis of the above remarks, and enter into a more minute investigation of the subject than we could adopt in the previous general outline. The main points relating to deviations of consistency will at the same time be adverted to. 1. Bypercemia, anaemia. Hypersemia of the spleen arises either from a mechanical impediment in the circulation of the blood, or from the pe- culiar relation alluded to as existing between the spleen and certain anomalous conditions in the fluids. The first variety occurs in organic diseases of the heart and in hepatic obstructions, though not, especially in the former, to the extent, nor as frequently, as might be expected from obstacles or stasis affecting the entire system of the vena cava and venae portoe. The deranged circu- lating fluid appears to have no affinity for the tissue of the spleen, and to be thus in part carried off, and in part mechanically retained. This latter portion, in the first instance, induces a hyperaemic turgor of the organ, and gives it a dark-red color, and subsequently, as is generally the case in these hypersemise, induces hypertrophy of the fibrous tissue and of the pulpy parenchyma of the spleen. The organ is more consis- tent, indurated, and dense. The second form accompanies various dyscrasic conditions of the fluids, and in proportion to their duration induces an acute or chronic tumor of the spleen, which differs in appearance, and in its primary and secondary constitution, according to the nature of the cause. The hypenemioe affecting the peripheral portion of the organ not un- 134 ABNORMAL CONDITIONS frequently degenerates into inflammation of the peritoneal investment of the spleen ; the resulting exudations are converted into the cellular, cellulo-fibrous, or cartilaginous tissues and adhesions, so often found upon spleens that have formerly been tumefied. Anaemia of the spleen occurs in connection with the above-mentioned reductions in size. 2. Tumors of the Spleen. We have already discussed the tumors of the spleen arising slowly or rapidly from hyperaemia, and from the con- gestion of dyscrasic blood, as far as regards the mere increase of volume. We have now to examine them more closely in other points of view. These tumors are observed in typhus, and in many typhoid states, as in cholera typhus, in pyaemia, and in anomalous exanthematic processes, as occurring from disorganization of the blood after erysipelas, scarlatina, miliaria, or rheumatism, as found in drunkards, and in acute tubercular affections ; they occur as a result of suppressed menstrual or hemor- rhoidal discharge, of intermittent fever, of rickets, of lues and mercurial cachexia, and of many dyscrasic tubercular affections. These tumors differ in character, and are owing partly to the hyper- aemia, partly to the deposition of an anomalous fibrous product in the parenchyma of the spleen. We find the greatest difference in the consistence of the tumors ; but the chronic indurated tumors, are undoubtedly soft at first, and subsequently attain greater hardness, according as the deposit is more or less coagulable. The same remark applies to the color of the tumor, which at first is undoubtedly red, but sub- sequently becomes paler in proportion as the coloring matter is absorbed, and the hyperaemia is forced to yield to the compression exerted upon it by the deposit. We find, as regards other qualities, that the morbid product offers very prominent varieties, which we will examine in the analysis of the chief tumors that follows ; the finer, though not less different characters we leave to another department of science, which, though not yet cultivated, promises many and very important results. a. Among the tumors which accompany acute diseases of the blood, those of typhus are distinguished by their rapid and extensive increase, by their lax tissue, both of which circumstances sometimes predispose to rupture, and by the dark-red color of the parenchyma. This variety originates in stasis affecting the vascular system of the fundus ventriculi, and in the deposition of a very lax, pultaceous, semi-fluid, blackish-red, dirty violet, or lighter-colored purplish mass, varying in amount, and re- sembling the pulpy medullary matter found in the typhous mesenteric tland. If this substance is deposited rapidly to a large amount, the brous trabeculae of the spleen are rendered soft and friable by exten- sion ; and if the deposit is very soft, the viscus presents fluctuation. The tumors occurring in the other acute dyscrasiae above alluded to, are more or less allied to this one. When accompanying universal acute tuberculosis, the eliminated mass, partially at least, at once as- sumes the characters of tubercle. The spleen may increase from a slight enlargement to three, four, five, and six times its normal size. Tumors occurring after suppression of the above-mentioned hemor- rhages do not generally become a subject of anatomical research until they have attained a very considerable size. They are most probably OF THE SPLEEN. 135 the result of repeated typical (typische) hyperaemiae, and would be found at their commencement to be of slight consistency, and of a red color. A coagulable fibrinous deposit, however, takes place, and the tumor, therefore, in proportion to the amount of coagulation, becomes hard, elastic, and indurated, the parenchyma is reddish-brown, of the color of fresh muscle, and presents on section a fleshy (sarcomatous) appearance ; by degrees the coloring matter is absorbed, the organ then presents a pale red, yellowish, or reddish-white appearance, and resembles fibrine that has been washed. During the hyperaemiae the fibrous trabeculse also increase in quantity and toughness, so that the tumor becomes more re- sistant ; the fibro-serous capsule is also rendered more opaque, and is thickened ; it is invested with a cellular pseudo-membrane, resulting from peritoneal inflammation, and is thus attached to the abdominal parietes. The deposit gradually increases to such an extent as to induce a compres- sion of the vascular portion of the spleen, and to render it impermeable to injections ; for the same reason, the tumor gradually becomes paler, and a vicarious development of the vessels at the fundus of the stomach ensues. The third variety of splenic tumors bears a general affinity to those accompanying the above-named cachexiae, but the deposit that occurs in them and is substituted for the parenchyma of the organ much resembles bacon in consistency and appearance ; the organ on section offers a very smooth surface, a dull, lardaceous (speckig, baconny), waxy gloss, and its superficial layer appears partially transparent ; the spleen is hard, but breaks with a peculiar fracture ; it presents a color varying from dark purple to pale red, and the blood contained in the vessels is pale and seroUvS ; this variety of splenic tumor is often coincident with the analo- gous lardaceous infiltration of the liver (vide p. 100) : it may, however, occur in an isolated form, or complicated with a similar affection of the kidneys (a variety of Bright's disease). Like the other varieties, this tumor may attain an extreme size, and dropsy, and especially ascites, are common results. b. We have lastly to advert to the fact that many cases of swelled spleen depend upon the formation of certain corpuscles, in addition to the coexisting hyperaemia. These small bodies are quite distinct from the Malpighian corpuscles, found in the spleens of some graminivora ; they are minute grayish-red, or grayish-white, opaque, soft, deliquescent, vesicular substances, of the size of a millet-seed, which occupy the paren- chyma of the spleen. They accompany a morbid development of the ab- dominal lymphatics, and especially of the follicular apparatus of the intestinal mucous membrane, with turgescence of the mesenteric glands, occurring in those affections of children and young subjects, which we have spoken of at page 61 ; they are also found in typhous affections of these organs, and of the spleen, and indicate a predominance and quali- tative derangement of the lymphatic system. They are consequently also found complicated with acute and chronic tumors of the spleen, and are not to be confounded with acute tuberculosis of that organ. The consistency of the spleen, as may be gathered from the above re- marks, depends almost entirely upon the state of aggregation of the parenchyma, or of the morbid product which has replaced the latter. The condition of the fibrous tissue also influences it to a certain extent, 136 ABNORMAL CONDITIONS but it varies much even within the limits of its physiological condition. The two extremes constitute softening and induration of the spleen, which we have already examined in their strict sense. In very rare cases, the black softening of the tissues of the fundus ventriculi, is accompanied by a similar affection of the splenic tissue, which is converted into a black, carbonaceous, tarry, semi-fluid mass, originating in the vascular system. 3. Inflammation of the Spleen. The very important conclusions to be derived from pathological anatomy in reference to inflammation of this organ, and with regard to its influence upon sanguification, will be self-evident. We cannot doubt that the pulpy substance of the spleen may be the original seat of inflammatory action ; the fact has not, however, been as yet anatomically demonstrated ; in the same manner it is not improbable, though by no means proved, that many acute and chronic tumors of the spleen may be the product of inflammation. The variety of inflammation for which pathological anatomy affords an explanation is, to name it from its seat, phlebitis, i. e., an inflamma- tion of the numerous anastomosing and tortuous venous canals of the spleen. In fact, we have only to apply the doctrines promulgated with regard to inflammation of a vein to a venous ganglion, in order to obtain a correct picture of inflammation of the spleen ; that which elsewhere takes place in a simple vascular tube is here found in a complicated venous apparatus. This inflammation of the spleen occurs as a primary or as a secondary affection. Whilst the former is as rare as spontaneous primary inflam- mation of a vein, the latter is as frequent as secondary phlebitis. Primary inflammation of the spleen, if not early combated, or unless ending in resolution, gives rise to an exudation of laudable pus or fibrine. In either case the circulating fluid may become infected, and coagulation be produced in the most various regions of the vascular, and especially in the capillary system. This is an explanation of so-called metastases. However, this is unusual in the case of fibrinous exudation, as the in- flamed vessels are closed by the coagula, causing obliteration and subse- quent conversion of the inflamed part of the spleen into a fibro- cellular callus, which may even ossify. In the case of purulent exudation, inflammation of the spleen passes into suppuration, and abscesses form. In a favorable case, the abscess may be circumscribed by adhesive inflammation, and, being enclosed in a sac formed by obliterated parenchyma, which has been converted into fibrous tissue, may be borne for a long period]; a partial absorption of the pus may take place, and the remainder becoming inspissated be reduced to a calcareous greasy pulp, or even to a hard concretion. The more common case is that the parietes of the abscess also put on inflammatory action, and suppurate, in consequence of which the abscess generally en- larges very rapidly, with symptoms of violent and universal reaction in the shape of hectic fever. We then have a case of florid (floride) splenic phthisis. If the inflammation extends to the sheath of the spleen, inflammation of the splenic and neighboring peritoneal surface ensues ; an occurrence which is analogous to the communication of disease from an inflamed OF THE SPLEEN. 137 vessel to the tissues in its vicinity : the inflammation is not, however, apt to spread far. The splenic abscess not unfrequently discharges, Firstly, Into the abdominal cavity; the pus is then often enclosed by the product of circumscribed peritonitis, -which causes the formation of a sac, bounded by the external wall of the abdomen and the diaphragm, the fundus ventriculi, the colon, and its mesentery ; the entire spleen is thus occasionally destroyed by suppuration. Secondly, Into the left thoracic cavity, after suppurative destruction of the diaphragm, or, Thirdly, Into the cavity of the transverse colon, and into the stomach. Secondary inflammation of the spleen is of frequent occurrence in all cases in which the blood is poisoned by the absorption of an inflamma- tory product, or has become affected in an analogous way spontaneously, a fact which indicates the delicate reaction of the spleen to a morbid con- dition of the blood. We then see the formation of inflammatory spots, which are in every way remarkable. They are well defined; they always occupy the peripheral portion of the organ, and generally pre- sent a cuneiform shape, the base being at the surface, the apex being directed towards the interior ; there are often two, three, four, and more of these foci present at the same time ; they vary in size from that of a pea, to that of a hen's egg, and in rare cases involve an entire third of the viscus. The substance of the spleen appears considerably darker at these spots, from the commencement, and also denser and more resistant ; it subse- quently assumes a reddish-brown color, and its density also increases, so that the affection' may be at once identified, even externally ; its limits are now well defined, and reactive inflammation is set up in the adjoining tissue. The process may terminate in various ways : in favorable cases, especially when a benignant fibrinous exudation has been absorbed into the blood, as frequently occurs in inflammation of the internal mem- brane of the bloodvessels, and particularly of the endocardium, the dis- eased tissue is converted into a cellulo-fibrous callus, which contracts and causes a cicatrix at the surface, by drawing the sheath of the spleen in- wards. The more common case is that pus or ichorous matter is absorbed, and that the inflamed portion is converted into a puriform, creamy mass, or into a sanious, greenish, greenish-brown, or chocolate-colored pulp ; in the latter instance, the conversion is often effected with very violent symptoms, without previous induction of the paleness above described. The entire process is a detailed repetition of that occurring in secondary phlebitis, and is nothing more than the metamorphosis of an infected coagulum within the channels of a vascular ganglion. When the disease affects the peripheral portions of the organ, peri- tonitis frequently supervenes, and an eschar having formed in the sero-fibrous sheath, a discharge into the abdominal cavity is not rarely effected. This secondary inflammation of the spleen is a very frequent compli- cation of inflammation of the internal vascular coat, and particularly of endocarditis. Of all organs that are affected in a similar manner, by the absorption of a product of inflammation into the blood, the spleen is the 138 ABNORMAL CONDITIONS OF THE SPLEEN. most liable to be attacked. When occurring as a result of spontaneous disorganization of the blood, it is particularly important in complication with croup, as also with exudative processes on mucous and serous mem- branes, particularly with pneumonia, and, lastly, with the analogous process of tubercular disease. 4. Grangrene of the Spleen. Gangrene is as rare an occurrence in the spleen as in the liver ; we have had an opportunity of observing it once in a chronic tumor of the spleen, affecting the organ to a conside- rable extent. 5. Adventitious growths, a. Anomalous, fibrous, and fibro-cartila- ginous tissue. This tissue occurs a. Very often upon the surface of the organ underneath its peritoneal sheath, in the shape of smooth and level, or tuberculated plates, of vary- ing thickness and size. It occurs in this shape at advanced periods of life, as a result of the congestion to which the parenchyma and the in- vestment of the organ have been exposed. It is not very unusual to find these laminse of such an extent as to invest the entire convexity of the spleen, and to present a thickness of several (two, three, and five) lines. fi. It occurs very rarely in the shape of fibroid tumors of the paren- chyma of the spleen. b. Anomalous osseous groivths. We find them occurring . As ossification of the fibroid laminae just described, of the same extent and thickness as the latter ; they are rarely found except in very old people ; /9. As cretified fibrine in the cellulo-frbrous callus, subsequent to pri- mary and secondary inflammation of the spleen ; Y. As round unattached concretions, or phlebolithes, in the venous channels of the spleen. c. Formation of cysts. Encysted tumors of the spleen are very re- markable, and as unusual as cancer, a fact which is interesting on account of the contrast with the frequency of tubercle. The acephalocyst is either found in the spleen alone, or concurrently with one in the liver ; it rarely attains the size it reaches in the latter organ, but is otherwise not dis- tinguished by any peculiarity. Cysts with other contents are still less frequent. d. Tubercle. Tubercular disease affects the spleen only less frequently than the lungs and the lymphatic glands. It always characterizes an advanced stage of tuberculosis, which had previously only appeared as chronic disease in some other organ, as the lungs, the brain, or the lym- phatic glands, or had merely existed in a latent form, and is now con- verted into acute general tuberculosis. Splenic tubercle is consequently always complicated with tubercle in the most various organs, and very frequently with universal tubercular deposit. Tubercle of the spleen, when acute, commonly appears in the shape of numerous densely-sown granulations of the size of a pin's head or millet- seed, resembling gray transparent vesicles, or of an opaque white color ; or as yellow cheesy masses, varying in size from a millet-seed to a pea. When chronic, it presents the shape of crude, originally gray, granula- tions of the size of a millet- or hemp-seed, which subsequently are con- verted into a cheesy substance. ABNORMITIES OF THE PANCREAS, ETC. 139 The parenchyma of the spleen is the seat of tubercle ; we not unfre- quently find a small central cavity within the tubercle, and the latter is occasionally surrounded by a cyst or capsule of fibro-lardaceous texture, a fact which demands special investigations for its elucidation. For the same reasons that apply to hepatic tubercle, tubercle of the spleen scarcely ever passes beyond the stage of commencing rarnollisse- ment. The spleen appears swollen in proportion to the quantity, and also to the size of the tubercles : in acute tuberculosis its turgescence and the relaxation of its parenchyma strongly resemble the typhous condition. e. Cancer. Cancer occurs very rarely ; we have as yet only met with the medullary variety in combination with cancer of other organs, espe- cially of the liver and the lumbar glands. The structure of the spleen appears to afford a satisfactory explanation of the fact, that cancer oc- curring in it is frequently invested by a fibrous sheath, within which it passes into a state of ichorous solution. The sheath is formed by the displaced fibrous tissue of the spleen, which, in the case of the adventi- tious growth attaining a considerable size, is strengthened by the fibrous investment of the spleen. SECT. IV. ABNORMITIES OF THE PANCREAS, AND THE OTHER SALIVARY GLANDS. We shall first examine the abnormities affecting the parenchyma of the above-named glands, and then proceed to examine those of their efferent ducts, and of their contents. We may observe, generally, that these organs are not very liable to become diseased. 1. Abnormities of the Pancreas and the Salivary Glands. 1. De- fect and excess of formation. Absence of the pancreas and the salivary glands is only observed in very imperfect monstrosities ; salivary glands sometimes present an arrest at a very low stage of development, inas- much as they may be blended with one another and with the thymus and thyroid glands, so as to form one mass. Excess of development occurs very rarely in the shape of a double pancreas, or of an extravagant de- velopment of accessory appendages. 2. Deviation in size. Enlargement of the above-named glands, in consequence of hypertrophy, is altogether unusual; but when it does occur it affects not so much the acini themselves, as the interstitial cellular tissue. The gland therefore almost invariably becomes more compact and drier, and then presents simple non-malignant induration. A diminution of the pancreas is the result of atrophy. Occasionally, and particularly at an advanced age, this takes place spontaneously, or it may be induced, secondarily, by other anomalies, such as chronic in- flammation and adipose infiltration, or the deposition of calcareous matter in the efferent ducts. The atrophic state is accompanied by variations of consistency, the organ sometimes presenting coriaceous tenacity, at others a lax and pultaceous condition. 3. Deviations of consistency. We meet with the most various degrees of consistency in the pancreas. The two extremes only come within the 140 ABNORMITIES OF range of pathology ; they are on the one hand extreme cartilaginous dry- ness of the tissue, and induration which is generally coupled with en- largement ; on the other extreme softening, relaxation, and succulence of the tissue. 4. Diseases of the tissues, a. Inflammation. Inflammation of the salivary glands is either acute or chronic, and it is either primary or secondary ; in the latter case it is metastatic. Inflammation of the pan- creas, at all events in the acute form, is extremely rare : this is not the case with the other salivary glands, especially with the parotis ; here the inflammation is very pften primary, and still more frequently metastatic. The acute form is characterized in the following manner : in the first instance there is tumefaction of the gland, reddening, congestion, relaxa- tion, and succulence, i. e. infiltration of the interstitial cellular tissue ; in the progress and in the higher stage of the disease, a sarcomatous condensation of the cellular tissue follows as a consequence of plastic exudation into its areolae ; the congestion and reddening attack the acini, which appear to be fused with the former, and the entire gland is enlarged and indurated. Unless the inflammation pass into resolution, small punctiform abscesses result, which enlarge, become more numerous and coalesce ; the gland, and particularly the cellular tissue, is now found uniformly infiltrated with yellow pus, which exudes from it as from a sponge, whilst the acini appear as small, red, lax, friable corpuscles, which fuse at a later period ; or suppuration is established at distinct spots so as to form an abscess, which may discharge itself in various di- rections, subsequent to the destruction tff the adjacent tissues. Chronic inflammation induces condensation, induration of the cellular tissue, obliteration of the acini, and either permanent enlargement or subsequent atrophy of the gland. The metastatic forms of inflammation not unfrequently pass rapidly from the stage of hypersemia with livid redness, into sanious ulceration, with sudden disappearance of the turgor. b. Adventitious growths. The salivary glands are not very subject to the formation of morbid growths ; tubercle is never discovered in them, and carcinoma rarely attacks them primarily. We find the pancreas liable to a. Excessive accumulation of fat, which may terminate in a conversion of the entire organ into one mass of fat. This affection rarely occurs without a coincident accumulation of fat in the abdomen. The disease proceeds from without inwards, and in very obese persons a direct com- munication may be traced between the surrounding fat and the pancreas ; the cellular tissue gradually absorbing the lax greasy fat, the acini, which are of a dirty yellow color, being reduced and gradually disappearing. When the disease has attained its extreme limits, a mere pultaceous strip of fat retaining the general outlines of the gland is found in its place ; only scattered remains of the acini are discoverable, and in the delicate and thinned duct there is a whey-like fatty fluid. The disease occurs fre- quently in drunkards, associated with fatty liver and the formation of biliary calculi. ft. Cysts. Serous cysts are occasionally formed in the pancreas, as THE PANCREAS, ETC. 141 well as in other salivary glands. They are to be carefully distinguished from dilatations of the ducts and their terminations, which put on a similar appearance. . Y' Fibrous tissue, cartilaginous and osseous growths. Tumors of this description occur but very rarely in the parotid. d. Carcinoma. Carcinomatous disease occurs, in the pancreas and sali- vary glands, and especially in the parotid, in the shape of scirrhus and medullary cancer. In the parotid it sometimes appears as a primary disease ; in the pancreas we have only found it, and even then exclusively at its duodenal end, as a complication of extensive carcinoma of numerous other organs. The secondary affection of the salivary glands by an ex- tension of the disease from adjoining organs, and in the case of the pan- creas especially, by an extension from the scirrhous pylorus, is very common. Cancer appears in the shape of infiltration of the interstitial cellular tissue of the gland or of nodes. Dr. Berg has, during his resi- dence in Vienna, discovered carcinomatous induration of the entire pan- creas in a new-born child. 2. Abnormities of the different Ducts and of their Contents. Next to salivary fistula subsequent upon injuries and ulcerative destruction of the tissues, which occurs chiefly at the ductus stenonianus, but which we have also seen in the shape of pancreatic fistula (see p. 39) discharging by a perforating ulcer of the stomach, we find dilatation of the excretory ducts and of the ductuli salivales to be the chief and most frequent affec- tion that has to be noticed under this head. Dilatation depends mainly upon retention and accumulation of the se- cretion, and may either affect the entire duct or one portion uniformly, or small detached points, so as to form saccular or varicose dilatations ; in the latter case, again, the duct may present single fusiform or vesicular dilatations at intervals, or numerous closely-set expansions, which are partially separated from one another by valvular folds formed by the coats of the duct. The coats may be either considerably thickened or considerably attenuated. The cause is generally to be found in some mechanical impediment, such as compression and complete obliteration of the duct external or internal to the gland by morbid growths of various descriptions. In the pan- creatic duct it may be induced by gall-stones occupying the orifice of the ductus choledochus, by a sudden curve or angle of the duct brought on by cancerous induration and shrivelling of the normal tissue, with change of position, such as we often observe in the pancreatic duct near the head of the pancreas. It may be induced by tumefaction of the internal mem- brane, by a mucous plug, and especially by calcareous concretions (sali- vary calculi). In rare cases the dilatation of the pancreatic duct is, like that of the bronchi, brought on by induration and atrophy of the gland. In morbid softening of the gland, and especially in the adipose meta- morphosis, the duct is deprived of its contractility, and dilatation with a marked attenuation and relaxation of its parietes ensue ; lastly, dilata- tions of the duct may take place without any mechanical obstruction, in consequence of scirrhoid disease of its duodenal end ; the duct in this case fuses with the scirrhous portion of the gland ; it is thus fixed, the 142 ABNORMITIES OF THE PANCREAS, ETC. scirrhus involves its tissue, whereby its vital contractility becomes im- paired, and the secretion is allowed to stagnate in its cavity. The dilatations of the pancreatic duct enlarge to the size of a goose's or swan's quill ; the saccular expansions may reach the size of a hazelnut or pigeon's egg. -In Wharton's duct the dilatation occurs in the shape of a fluctuating tumor, and is known as ranula. Dilatation of the ductuli and their terminations sometimes puts on the shape of serous cysts. The contents of the salivary ducts, i. e. the saliva of the mouth and stomach, occasionally offer rather remarkable anomalies in reference to quantity, color, consistency, and probably, as indicated by the taste, and especially by its acid or alkaline reaction, in reference to chemical con- stitution. Not unfrequently calculous concretions, the so-called salivary calculi, are generated in the saliva, and this is more especially the case in the ducts of the sublingual gland and the pancreas. They are white, friable, and either round, oblong, cylindrical, or obovoid ; in size varying from that of a millet-seed or a pea, to even that of a hazelnut ; they are either solitary, or if small, frequently very numerous (twenty and more) ; and they are composed of phosphate and carbonate of lime, held together by animal matter. These calculi give rise to obturation of the ducts, and consequent accumulation of the secretion and dilatation. At times, blood, pus, cancerous sanies, is found in the salivary ducts ; bile is not unfrequently discovered in the pancreatic duct ; in one case of migration of lumbrici into the biliary vessels, two were found to have crept into the latter. PART II. ABNORMITIES OF THE URINARY ORGANS. PAKT II. ABNORMITIES OF THE URINARY ORGANS. UNDER this head we comprise the morbid anatomy of the kidneys and the efferent apparatus, viz. the calices, the bladder, and the urethra ; the two are of course very intimately related to one another. The abnor- mities of the suprarenal capsules will be considered in an appendix. SECTION I. ABNORMITIES OF THE KIDNEYS. 1. Defect- and Excess of Formation. The urinary apparatus is very rarely entirely deficient ; it is generally found even in very imperfect monstrosities. One kidney is frequently absent, or individual portions of the system are, as we shall have occasion to see, more or less imper- fectly developed. When one kidney only is present, it is important to distinguish between the unsymmetrical and the solitary kidney. The former is represented by a right or left kidney, which is normal in regard to position and con- formation, and occasionally rather enlarged, its fellow being deficient. The solitary kidney is the result of a fusion of the two organs, and therefore offers the characters peculiar to this arrangement in a greater or less degree. The lowest degree of fusion is seen in the horseshoe kidney (ren unguliformis) ; the two kidneys are united at their inferior portions by a flat, riband-like, or rounded bridge of tissue, which crosses the ver- tebral column. In the higher degrees the two lateral portions approach one another more and more, until they reach the highest degree, in which a single disk-like kidney, lying in the median line and provided with a double or a single calyx, represents complete fusion. The more intimate this union is, the more the hilus of the kidneys is directed forwards, so that whereas, in the lowest degree, it is indicated by an evidently in- creased development of the posterior labium of the hilus, the hilus of the solitary kidney occupies the anterior surface. The more considerable the fusion is, the more the kidneys descend along the vertebral column, and the solitary kidney is commonly situated at the promontory, or even at the concavity of the sacrum. In exceptional cases only the solitary kidney is placed, like the unsymmetrical kidney, at the side of the verte- bral column, on one side of the median line. Excess of development occurs very rarely, except in the case of biven- tral monsters, in the shape of a third kidney, situated in the median line, and generally placed at the promontory ; or in the shape of a single symmetrical kidney, which is composed of two kidneys united into one. VOL. II. 10 146 ABNORMITIES OF 2. Deviations of Size. The kidneys are found enlarged or dimi- nished in various degrees, and under various circumstances. 1. Enlargement is observed Firstly. Occasionally in one kidney, after its fellow has been deprived of its functions ; this is a case of hypertrophy which may be considered as analogous to the increase of size in the unsymmetrical kidney ; Secondly. As congestive turgor ; Thirdly. As inflammatory swelling ; Fourthly. As a consequence of infiltration of the renal tissue induced by or independent of inflammation ; various forms of Bright's disease belong to this subdivision ; Fifthly, as arising from morbid growths, in which case the enlarge- ment corresponds to their number and size ; Sixthly. As originating in dilatation of the pelvis and calices of the kidneys; the greater in this case the increase of size, the more will the renal substance become atrophied in consequence of pressure from within. Rayer states the left kidney to be normally of greater weight and larger dimensions than the one on the right side. Abnormal smallness is either congenital, or the result of atrophy. Spontaneous and primary atrophy occurring independent of contraction, or complete occlusion of the artery, is very unusual, and belongs almost exclusively to old age ; secondary atrophy, resulting from and compli- cated with disease of the tissues, is much more frequent. In the case of extreme dilatation of the renal pelves and calices atrophy and enlarge- ment appear combined. 2. Atrophy may affect the two substances of the kidney uniformly ; or it may involve the cortical substance only ; the latter is the more frequent case in secondary atrophy, on account of the greater proclivity to disease in the cortical substance. The tissue is rendered pale, or it may be distinguished by its darker color, and the vessels are often found varicose. We very often find an unusual amount of fat accumulated round the atrophic kidney. We shall have occasion to enter more fully into the subject of secon- dary atrophy, at a future period. 3. Deviations of Form. Besides the anomalous forms of the kid- neys, resulting from fusion of the two organs, which we have already described, we may point to the lobulated kidney as an interesting con- formation. It occurs as an arrest of development in the foetal state, or if acquired, as atrophy of the cortical substance, accompanied by dilatation of the calices. There are other congenital malformations of the kidneys, which are of less importance, as, for instance, the elongated kidney, which appertains to the foetal state, the round, prismatic, trian- gular, cylindrical kidneys, the kidneys with a transverse furrow (sepa- ration into an upper and lower half) ; and also various acquired mal- formations, which are caused by external pressure, by partial loss of substance, and atrophy. 4. Deviations of Position. Here too we must first point to an anomaly resulting from the various degrees of fusion of the two organs, THE KIDNEYS. 147 i. e. the descent of the kidneys to a lower part of the abdomen. This may, however, occur independently of the malformation alluded to, and we sometimes find one, sometimes both kidneys, as low down as the brim of the pelvis, or even as the hollow of the sacrum. The anomalies in the origin of the renal vessels which correspond to the original devi- ation of position deserve attention, as well as the increase in their num- ber and the diminution of the ureter in proportion to the descent of the kidney. The kidneys, and especially the right one, may be depressed by an enlarged liver, and the consequence is, that the hilus of the former is turned upwards, as the upper portion of the kidney is necessarily most depressed. We have lastly to allude to the occasional movability of the kidneys, which is owing to insufficient fixation by means of the adipose fascia, and apparently also to an elongation of the vessels ; we sometimes find that the kidneys may be moved from one to two inches along the spinal column. 5. Deviations of Consistency. The kidneys sometimes offer a dimi- nution of consistency, or relaxation, or an increase of resistancy or tough- ness, without any apparent change of texture. The former occurs con- currently with a similar condition in other parenchymatous organs, and is the result of cachexia, anaemia, and marasmus, and of defibrination of the blood, from excessive exudations ; the organs, in this case, are very pale and friable. Both an increase and a diminution of consistency are much more frequent as complications of textural alterations, and we shall examine them more in detail under this head. Genuine softening of the entire kidney, or of a portion of the organ, in the shape of spots of vari- ous sizes, of a dirty brown, chocolate-colored, rusty pulp, is a very rare- occurrence. 6. Solution of Continuity. This is produced not only by cutting- in- truments, but may occur in the shape of rupture, from concussion, or in consequence of falls or blows, received in the region of the kidneys. After a fall from a considerable height, rupture of the kidneys is very fre- quently complicated with laceration of other abdominal viscera. It gives rise to hemorrhage, inflammation, and suppuration ; the latter terminates in the manner that we shall have occasion to delineate when speaking of renal abscess. Concurrent injury of the calices and of the pelvis of the kidney, causes extravasation of urine into and beyond the adipose cover- ing of the kidneys : if the peritoneum has also suffered, a fatal termina- tion ensues rapidly ; if not, a permanent or temporary cure, with a resi- duary fistula, may follow. 7. Diseases of the Tissues. 1. Hypercemia, apoplexy, ancemia. Hypersemia of the kidneys not unfrequently occurs in the active form accompanying an exaltation of the renal functions ; or as passive conges- tion in consequence of general marasmus, and especially in consequence of paralysis of the spinal and ganglionic nerves, such as we find in the torpid condition of the sympathetic in the insane, connected with abdo- 148 ABNORMITIES OF minal plethora and congestion, and in paraplegic cases ; it also, occurs in the mechanical form as a consequence of impeded circulation in con- nection with hypersemia of other organs. The effects, are swelling of the organ (congestive turgor) and increase of size, greater depth of color of the tissues, increased density and resistancy, and loose attach- ment of the fascia propria. In children the tubular portion is frequently the chief seat of hyperagrnia. When it has reached a high degree, it is apt to give rise to spontaneous hemorrhage (renal apoplexy), which, both in children and adults, has its main seat in the pyramids. We then find in the place of the pyramids, a spot of various dimensions, which has pushed aside a proportionate amount of parenchyma, and contains besides coagulated dark blood, the broken-up remains of the tubular sub- stance. A cure undoubtedly ensues occasionally ; the effusion gradually loses its color, and assumes a rusty and a yellow tint ; it is then absorbed, and the calyx becoming obliterated, a fibro-cellular cicatrix closes up the cavity. Minute hemorrhagic spots, in the shape of ecchymoses of the tissue resulting from an acute disorganization of the blood, as well as small extravasations under the tunica albuginea, are of much more frequent occurrence. Hyperssmia accompanied by increase of size (hypertrophy), is, accord- ing to the few cases we have been able to examine, the only anomaly of the kidney, demonstrable in diabetes by the pathological anatomist. Anaemia of the kidneys occurs not only in connection with general impoverishment of the blood, but it is found as a more or less character- istic symptom, in all those cases in which the renal parenchyma has become impermeable from being infiltrated with coagulable matter, either owing to inflammation or deficient nutrition ; this is particularly the case in that disease which is commonly cited as the type of the class, Bright's disease of the kidney. 2. Inflammation. Inflammation of the kidneys is either primary, secondary, or metastatic ; in the first case it results from injury, concus- sion of the intestines, cold, or specific irritation (turpentine, cantharides, &c.) ; in the second it follows acute or chronic diseases, and it then pre- sents a more or less remarkable type, corresponding to the general dyscrasia ; in the third instance it arises chiefly from inflammations of the pelvis and calices, or from inflammations of the fascia adiposa and adjoining organs. The inflammation runs an acute or a chronic course ; the idiopathic variety being particularly liable to the former. The cortical substance is the chief seat of the first two varieties, as of textural alterations generally ; when the inflammation commences at the pelves of the kidneys, the tubular substance is naturally implicated also. In the former case we often find one or both kidneys, either simultane- ously or in rapid succession attacked throughout their substance ; whereas the latter commences in spots from which it extends through the renal tissue. . The following are the anatomical characters of acute inflammation of the kidneys, modified of course by the degree and the acuteness of the affection. Hyperaemic tumefaction and redness of the organ are followed by a uniform discoloration of the parenchyma which appears of a dirty THE KIDNEYS. 149 brown or purple color, and filled with a dark sanguinolent fluid ; it is either turgid and resistant, or collapsed, flabby, and very friable ; or it may be turgid and friable, and the discoloration less uniformly grayish- red, or dirty white, accompanied by infiltration of a denser, coagulable, fibrinous substance, the texture is granular, the surface scattered over with an injected, asteroid, and polyhedral vascular network, and the fractured surfaces or sections made in the direction of the hilus, are streaked with striated vessels. The general result of the infiltration is, that the organ is more or less swollen and discolored, and that its consistency is variously diminished. In accordance with what has been above remarked, we find the cortical substance chiefly affected ; the affection is general or partial, and in the latter case it occupies particularly the superficial layer ; in the first in- stance the swollen cortical substance is found to have forced its way into the basis of the pyramids, between the fasces of the tubuli, and they consequently appear unravelled and fimbriated. The process not unfrequently extends to the tubular portion itself, or the latter is involved in the inflammation propagated from the pelvis. The pyramids then appear enlarged, swollen, pale ; their color changed to a dirty brown, or grayish-red, and softened or indurated according to the nature of the inflammatory products ; the inner membrane of the calices and pelvis is in both cases injected as in catarrhal inflammations, reddened and relaxed, and filled with an opaque, flaky, grayish, or yellowish-brown fluid. Externally we find the fascia propria, and even the adipose covering of the kidneys involved in the inflammatory process : the former is easily detached from those portions of the surface which present the vascular injections above spoken of, its tissue is more or less injected and tume- fied ; the latter is infiltrated with serum, and softened. This inflammation occasionally affects one kidney only, but very often both are simultaneously attacked : in the latter case, especially, it is liable to terminate fatally, in consequence of paralysis of the renal func- tion with typhoid symptoms, resulting from retention of the urea in the blood ; this is frequently complicated with serous effusion into the ventri- cles of the brain, or into the pulmonary tissue, followed by putrescence ; or if the inflammation reaches a certain degree of intensity, suppuration, or an excessive retrograde process, or atrophy may result ; or, lastly, the affection may become chronic. Suppuration is not a frequent consequence. The inflammatory pro- duct which has been infiltrated in detached sections, or uniformly throughout the organ, is converted at first into small punctiform or millet-sized spots of white, creamy, or yellow pus, which subsequently coalesce into a small abscess. In its vicinity a renewed reactive pro- cess is set up, and we find a red injected halo, varying in size, which gives rise to a similar fusible product leading to an extension of the abscess. The original small abscesses are sometimes found scantily dis- persed through the kidney, at others they are grouped together, at others, again, they are thickly sown through the entire kidney ; they are then characterized by the surrounding inflammatory halo, and this renders them conspicuous though individually almost imperceptible. 150 ABNORMITIES OF They are always incomparably more numerous in the cortical substance ; they here generally retain their rounded shape, even whilst enlarging, whereas in the tubular substance they are converted into elongated striated abscesses. In the manner just described, as well as by the coalition of several abscesses, we see an extensive purulent accumulation brought about, which may increase so as to occupy one-half or two-thirds, or more, of the kidney. Moreover, there may be one or more of these accumula- tions, and their existence establishes phthisis renalis. Renal abscess extends in the most various directions from the inflam- mation and suppurative fusion spreading through the kidney, and even beyond its sheath ; we most frequently find it presenting excavations or sinuses, backwards and downwards ; it causes death by exhaustion, or if the progress of the fusion is stopped, the surrounding parenchyma may become obliterated, or in the case when suppuration has extended be- yond the latter, the fasciae of the kidney may become converted into cartilaginous tissue, and the abscess thus be enclosed and be borne for a long period ; it may be reduced in size, and may even heal up, leaving a cicatrix ; this is particularly liable to result after an opening and a dis- charge have been effected in a favorable direction. This discharge may take place : Firstly, into the cavity of the renal pelvis ; the pus is then discharged by the urinary passages ; Secondly, into the peritoneal cavity ; Thirdly, externally in the lumbar region, by means of sinuses of various dimensions ; Fourthly, after previous agglutination of the intestine to the walls of the abscess and perforation, into the cavity of the former ; it is evident that the ascending and descending colon, and the sigmoid flexure, are particularly liable to be thus involved, and in second order the duo- denum. Fifthly, renal abscess has also been seen to communicate with the lungs after perforation of the diaphragm ; its contents are then expecto- rated in the shape of urinous-purulent sputa. These discharges may sometimes take place in various directions at once ; a combination of the discharge into the urinary passages with elimination of urine by a false passage renal fistula, is of especial interest. Termination in gangrene or gangrenous suppuration is extremely rare ; it is more usual to find acute inflammation passing into the chronic form. Chronic inflammation of the kidney either commences in that form, or is the result of acute inflammation, or, as is most frequently the case, it is the consequence of inflammation of the urinary passages, and espe- cially of the calculous variety. It is distinguished from acute inflamma- tion by a lower intensity of the symptoms, by its smaller extent, and by the variety of stages presented by the coexisting and consecutive inflam- matory spots. Chronic inflammation also not unfrequently terminates in suppuration, which is particularly the case with the variety originating in calculous irritation of the renal pelvis ; it also frequently terminates THE KIDNEYS. 151 in induration and obliteration of the parenchyma, or induces atrophy of the kidney. In the former case the coagulable portion of the infiltrated and accu- mulated product of inflammation is converted into a whitish, fibro-larda- ceous, cartilaginous callus, in which the renal parenchyma has entirely disappeared. The kidney is often found increased in bulk, and appears altered in shape, from the irregular accumulation of the product, giving rise to various tuberculated projections. This tissue may here, as else- where, subsequently become shrivelled and condensed, and is also, in a few cases, the seat of bone-earth deposit, osseous transformation, ossification. Chronic inflammation is, like the acute form, frequently followed by atrophy of the kidney ; inasmuch as not only its product but the original tissues themselves become absorbed. This secondary atrophy attacks either the entire kidney or sections of the organ, and the consequence is, accordingly, a uniform reduction of its size, or a partial contraction, which gives the kidney a shrivelled and uneven, lobulated surface. The contraction sometimes advances to such a degree, that the kidney appears reduced to the size of a hen's or even a pigeon's egg, it is surrounded by the tunica albuginea, that has become thickened by the inflamma- tory deposit, and by contraction, and forms a callous sheath of several lines in thickness ; on closer examination we find the cortical substance reduced to a mere vestige ; the pyramids are diminished to a size corre- sponding to the dimensions of the organ ; the tissue generally is of a pale-red, or here and there of a slate-gray color, denser, tough, and fibro-cellular ; occasionally, however, it is unusually dark-red, vascular, and congested, and all the vessels dilated. The calices and pelves are uniformly enlarged, the ureters contracted, their parietes shrivelled and thickened, and here and there approaching to obliteration, or actually obliterated. Inflammation of the kidneys, with its consequences, has occasionally been discovered in new-born infants ; but its frequency and importance are much more considerable at maturity and at the advanced periods of life. 3. Bright* s Disease of the Kidney. This affection of the kidneys, which has been named after its discoverer, Bright, and has of late been extensively investigated, is of extreme importance. It has been termed granular degeneration, by Christison, and nephrite albumineuse, by Rayer. "We treat of it in connection with inflammatory affections of the organ, for reasons which will appear in the sequel. It is generally a chronic disease ; however there are numerous cases that incline to an acute course, and some equal, or even exceed, acute inflammation in rapidity. It assumes very different forms, which have reference either to the degree and rapidity of the disease, or to its stage of development ; the former bear a close relation, first, to the amount of local reaction in the renal tissue, and, secondly, to the dyscrasic state of the blood. We shall commence by describing the various phases which the disease pre- sents as distinct forms ; we shall then, examine its complications, their course, stages, degrees, and transitions, and lastly, arrive at a general analysis of the disease. 152 ABNORMITIES OF The cortical substance is that which is primarily and chiefly affected ; in the course of the disease, however, the tubular substance also becomes involved in the manner which will be immediately delineated. First form. The kidney appears enlarged, swollen, heavier ; the cor- tical tissue is almost uniformly infiltrated with dirty brownish-red, turbid fluid, and the bloodvessels, with the tissue immediately surrounding them, are delineated on this background in the shape of spots, or streaks of a darker red. Other red spots may be visible, which are owing to extra- vasations of blood into the tissue, ecchymoses. The pyramids, how- ever, present a similar though darker discoloration, with dull-red striae. The entire parenchyma, but more especially the cortical substance, is peculiarly pulpy and friable, and the surface, presented by section or fracture, yields a reddish-brown, limpid, delicately flocculent and opaque, sanguinolent and slightly viscid fluid. The organ generally is charac- terized by a turgid though flabby state. The fascia propria, from the injected state of its vessels, but more from the exudation of blood into its tissue, is of a dirty red color, and is easily detached ; the mucous membrane of the calices and pelvis is similarly reddened and tumefied ; and their cavity contains a thin, muco-sanguinolent, turbid, urinous fluid. Second form. Besides the increase in size and weight found in the first variety, the cortical substance presents an infiltration of a grayish or grayish-red, or yellow, viscid, and turbid fluid, which pervades it uni- formly or in diffused spots ; the color of the tissue corresponds, and if more carefully examined, an indistinct, dotted, or linear arrangement is perceived. At the same time, small punctiform or striated ecchymoses are found, which are the more conspicuous the paler the color of the in- filtrated tissue. The tissue frequently presents the infiltrated and pallid appearance in some parts, whilst the hypersemia and ecchymoses predo- minate in others ; this constitutes the combination of partial anaemia and hypersemia, alluded to by authors as a special variety. The organ appears of diminished firmness, but this character is less marked here than in the first form. The renal fascia observes the same bearing, the mucous membrane of the pelvis and calices of the kidney is of a roseate hue, and tumefied ; and the latter contain a flocculent, turbid, yellowish or reddish-white fluid. Third form. There is considerable enlargement and increase in weight ; the cortical substance is completely anaemic ; and only a few solitary dilated vessels, bearing an asteroid, convoluted, or striated ap- pearance, are seen in it. The cortical portion presents an increase in diameter of from five to nine lines ; its surface is smooth and slightly glossy; it is tense, friable, and infiltrated with a large quantity of opaque, milky-white, or yellowish fluid. The superficial layer more par- ticularly, but also the deeper-seated parts, are found to be made up of white or yellowish-white, loose, tense granules (Bright's granulations), of the size of a poppy-seed, or a pin's head ; in the neighborhood of the pyramids these granulations assume a linear appearance. The increase of the cortical substance either extends to the base of the pyramids only, or affects those portions also that dip down between the latter ; by this means the pyramids, and more particularly their apices, become compressed. The pyramids are of a pale-red color, and THE KIDNEYS. 153 from the granular cortical substance forcing its way between the tubuli and separating them, the basis of the pyramids presents a frayed or un- ravelled appearance, resembling a plume with dependent feathers, or a sheaf of wheat. The renal fascia is easily detached ; its tissue is swollen and opaque, the mucous membrane of the calices and pelvis of the kidney is red- dened, and there is a milky, turbid, viscid fluid in their cavities. Fourth form. The increase in size and weight is very considerable, and the consistency of the tissues is much diminished ; the cortical sub- stance is very tense, and here and there appears almost fluctuating ; its tissue is completely anaemic and very friable, and gorged with a large quantity of milky-white or yellowish juice. The granulations exceed the size of millet-seeds, and equal that of hemp-seeds ; and as this en- largement is chiefly effected in the peripheral layer, they project from the surface of the organ, and give it a racemose appearance. Occa- sionally, we find this increase of size occurring with great rapidity in sections, and we then have an accumulation of granulations shooting like a cauliflower from the surface, and producing irregularities and nodulated protuberances upon the kidney. The granulations are very soft, tear and dissolve upon the slightest touch ; the renal sheath is almost unattached, the pyramids are of a pale-red color and undefined, and the reddened calices and pelves contain a viscid creamy fluid. Fifth form. The kidneys are enlarged or of the normal size, or they may be reduced in size ; their surface is granular and racemose, or whilst certain portions present the nodulated and prominent appearance, others are irregularly furrowed, indented, and cicatriform. The cortical tissue is coarsely granulated, looser in texture, very vascular and con- gested, and the vessels are varicose ; or else we find it, as in the case of a diminution of the organ, of pale-yellow or ashy hue, exsanguineous, of coriaceous density, and mainly of a fibro-cellular texture ; the inden- tations at the surface here and there present a similar tissue, of a whitish or slaty color. We also not unfrequently see cysts, containing the most various substances, and varying in size from that of a poppy- seed to that of a pea or nut and more, scattered through the cortical structure. In the former case the attachment of the fascia propria is slight, in the second it is more intimate : the fascia is thickened, and the adipose layer indurated. The pyramids are small and atrophied, of increased density, and generally of a dirty brown color ; the calices and pelvis are slightly contracted. Sixth form. The organ is but little increased in size and weight, the cortical substance only presents a few undefined patches of a paler color, and the prevailing hue is either pale red, or it is found on closer examina- tion to offer transitions of a pale red, a white, yellow, or ashy color. It is infiltrated with inspissated matter, resembling thick cream or coagulated albumen ; and not only does not present greater laxity of texture, but is of the normal or even of increased consistency. The fascia propria is but slightly less adherent at these points than in the healthy condition, and the pyramids, as well as the calices and pelvis, are normal. 154 ABNORMITIES OF Seventh form. The increase of size is commonly trifling ; occasionally there is partial atrophy and diminution. There is increase of density and consistency. As in the last variety, the cortical substance only presents patches of a dull white color, which have no defined borders, and are often very extensive ; it arises from a coagulated, albuminous, larda- ceous-looking substance, in which no trace of the renal tissue remains. We here find considerable swelling of the kidney, owing to the copious deposition of the morbid growth ; or the organ otherwise seems shrunk, and presents the appearance and consistency of fatty cartilaginous tissue. One or more of the pyramids occasionally undergo a similar metamor- phosis. The fascia propria is agglutinated to the diseased portions of the kidney, and thickened ; the lining membrane of the calices and pelvis is tumefied. Eighth form. The kidney presents but a slight increase of size, or is of normal dimensions, but always considerably indurated. The general hue is a dirty red or brownish-yellow, and the cortical substance pre- sents a fatty waxy gloss, is unusually hard and brittle, and infiltrated with an albuminous, lardaceous, and transparent substance. Occa- sionally a whitish flocculent deposit is seen in the tissue, of the shape of fine granular dots and lines, giving to the surface and sections a marbled appearance. We have thus enumerated the forms which, in a general point of view, we think it proper to class under Bright's disease. The first seven forms undoubtedly belong to the latter, if the totality of the symptoms, as they appear in the living subject, be considered : they also occur complicated with one another, and the second, third, fourth, and fifth forms more particularly represent Bright's disease and Christison's granular degene- ration of the kidney. In the latter form the disease is generally chronic, though with an acute tendency and occasionally exacerbations ; the se- cond, third, and fourth forms represent progressive stages of degrees of the metamorphosis occurring in Bright's disease : they vary in duration, and pass from one to the other either gradually or, as is frequently the case, with very tumultuous symptoms. Each of these stages may prove fatal. The fifth form is the last link of the metamorphosis ; with it the process becomes retrograde, and the disorganized tissue of the viscus presents the condition of secondary atrophy. The different varieties are not un- frequently complicated with one another ; and we thus find the first de- gree (second form) attacking one kidney, or a section of one kidney, whilst the other kidney, or the other sections, present the metamorphosis of the third or fourth degree (third and fourth form). The peripheral layer of the cortical substance is generally in a more advanced stage than the deeper-seated layers. The sixth and seventh forms represent the less frequent or chronic varieties of the disease ; the latter (the seventh) must be looked upon as the terminal point of the metamorphosis, as the product of the disease is retained in a state of condensation and organization, and subsequently shrivels up. It is sometimes complicated with the varieties previously spoken of. The first form is extremely rare, and runs an acute course ; on the occurrence of powerful exciting causes, very tumultuous symptoms are THE KIDNEYS. 155 sometimes induced, which speedily reach their climax, and may termi- nate fatally on the fourteenth day. The eighth form is invariably chronic ; we shall for the present exclude its consideration from the following remarks, and advert to it subse- quently, for reasons that will then be apparent. The nature of the disease, and the scientific exposition of its charac- teristic symptoms, have been the subject of numerous discussions, and we neither venture to assume that our remarks will add great weight to the arguments of those who consider it inflammatory, nor do we wish to anticipate further investigations and statements of depth and originality. We consider the nature of Bright's disease to consist in an inflamma- tory process, which proceeds from a stage of hypersemia to one of stasis, and then gives rise to a product, which is not only remarkable by its peculiar character, but which, in well-marked cases, by its excessive accu- mulation, causes a singular alteration in the appearance and structure of the kidney. It commonly runs, as we have already stated, a chronic course, with occasional exacerbations, but it is sometimes acute. In the latter very important cases, in which, from the tumultuous violence of the exudation, the product is mixed with a large amount of serum, and is generally reddened by the coloring matter of the blood, and in which the characteristic milky or creamy or coagulated substance of well- marked Bright's disease is not formed, we should be obliged to consider the condition as one of very acute simple inflammation of the kidneys, were it not that the characteristic general symptoms and the constitution of the urine established it as a case of Bright's disease. The whitish or ashy, milky or creamy product, which may resemble albumen in its various degrees of coagulation, and consists of solitary and accumulated molecules, or of more or less globular fibrinous coagula and pus-corpuscles (Gluge), is an albumino-fibrinous substance, with a predominance of albumen ; the amount in which it occurs is proportioned to the amount of granular degeneration. The product may, as in simple inflammation, be deposited at every point of the renal parenchyma external to the vessels, but we find it more particularly in the Malpighian bodies (glands), and subsequently in the urinary tubuli; the granulations of Bright's disease are therefore in reality the Malpighian corpuscles charged with the above-named substance. The more the latter accumulates, the more it interferes with the circulation, hence the peculiar pallor or anaemic condition of the organ. The cause of the peculiar character of the product is the more obscure, since the question is generally evaded. As the amount of reaction that takes place in the renal tissue does not suffice to explain it, we are led to seek the cause in an anomalous constitution of the blood, consisting in an excess of albumen, which may originate in a decomposition of the fibrine. This becomes the more probable, when we consider that the most frequent exciting cause (cold) appears peculiarly adapted to give rise rather to a change in the blood, than to a disease of the kidneys, and that the infiltration of the kidney, which we have examined as the eighth form, is evidently developed as a sequel of the cachexise which we shall shortly investigate, and in complication with similar affections 156 ABNORMITIES OF of other organs (liver, spleen). Although we might offer numerous ob- servations on this connection, the real cause of the development of the renal disease from the crasis of the blood, which often takes place with such extreme rapidity, is to us an enigma. We look upon the anoma- lous condition of the blood in Bright's disease as the primary affection, which, from a peculiar relation to the kidneys, is followed by the se- condary and visible disorganization of the renal tissue ; this need not however always ensue, at all events it does not follow as rapidly as the structural disease of the kidney, consequent upon the vegetative dis- turbance that causes diabetes mellitus. By this means we explain how it happens that the two kidneys are generally attacked at the same time or at brief intervals. Graves is of opinion that the change of texture is induced by the free acids of the urine (phosphoric and nitric acids) coa- gulating the albumen as it passes into the urinary tubuli. Bright's disease is distinguished in the dead and the living subject by the following symptoms : a. We may briefly enumerate the following as occurring in well-marked cases in the kidneys themselves, increase in the size and weight of the organ, and especially of the cortical substance (the hypertrophy of French authors, a term which may easily give rise to a misapprehension) ; anaemia, pallor, laxness of the tissues, development of peculiar granula- tions, inflammatory sympathy of the renal fascia, on the one hand, and of the mucous membrane of the pelvis and calices, on the other. /?. The so-called consecutive symptoms : a constant and considerable amount of albumen in the urine, accompanied by a diminution of its spe- cific gravity (Gregory), a symptom considered by Kayer as belonging to the chronic form only ; a reduction of the solid constituents, viz. the salts and urea, a milky turbid appearance, or if tinged with blood and blood- corpuscles, dark discoloration, eminent serosity of the blood arising from the removal of the albumen, and accompanied by a diminished specific gravity of the serum ; dropsy, which is chiefly manifested as anasarca, marked pallor of the surface, and secondarily as serous effusion into the serous cavities, and especially of the pleura and peritoneum. Of the latter symptoms the albuminuria and the dropsy have long since been the special objects of explanatory attempts. Albuminuria is considered by Gregory as pathognomonic only when the specific gravity is simultaneously diminished ; it seems to ourselves to consist in a disturbance of the catalytic function of the kidney arising from the homologous infiltration of the renal tissue ; albumen is in part deposited in the channels of the urinary tubuli themselves, as a product of the reaction. There is not, however, a proportionate relation between the degree of the albuminuria and the amount of renal disease, as we may even find the former existing without the latter. Sabatier, whose views are not materially controverted by Rayer's ob- jection, attributes the dropsical affections to an attenuation of the blood produced by the removal of the albumen. This crasis of the blood must, therefore, be viewed as secondary. The lower degrees of Bright's disease are curable by resolution, without leaving any traces, like other moderate inflammatory processes. In the advanced stages a cure may be effected, but only with considerable altera- THE KIDNEYS. 157 tions of texture, as manifested in atrophy of the kidney with a racemose surface, varicosity of the vessels, cellulo-fibrous condensation of the tissue, fibro-lardaceous thickening of the renal fascia, and contraction of the pelvis and calices, in induration of the product, and its conversion into a contractile callus. A fatal termination is induced, with a greater or less rapidity, by dropsy, and especially by serous accumulations in the large cavities of the body, by the slow or sudden supervention of serous effu- sion into the ventricles of the brain, into the cerebral substance, and into the pulmonary parenchyma, by anaemia, by the retention of urea in the blood, or by morbid conditions of other tissues and organs, which present accidental or essential complications with the renal disease and its pre- disposing cause. In the case of retention of urea in the blood, the resulting symptoms are owing to the antagonism between the urea and the nervous matter ; they consist in coma, delirium, convulsions, and tetanus, and are not un- frequently caused by urinous effusions within the cavity of the cranium. The complications are chiefly dependent upon causes that operate sud- denly or repeatedly, and for a considerable period, such as catarrhs, and particularly bronchial catarrh, rheumatism, with or without endocarditis, and their sequels ; the complications may also originate in the secondary disorganization of the blood, and here again we meet with catarrhs, and also with extensive exudative processes, both on the mucous membranes (serous diarrhoea, pneumonia), 1 and, more especially, on the serous mem- branes, the arachnoid, pleura, peritoneum, and internal coat of the blood vessels (phlebitis). Hemorrhage and apoplexy are of rarer occurrence. There is great difficulty in accounting for the complication with granular liver, and with the ascites resulting from the latter affection. The super- vention of Bright's disease as a new complication may probably be ac- counted for by the greater liability of a previously diseased subject to the reception of noxious influences, whether operating continuously or temporarily ; we allude more particularly to the abuse of spirituous liquors, and to cold. The commonest and most evident cause of Bright's disease is cold, the sudden or constant influence of cold damp air, more especially ; at all events, the occurrence of Bright's disease after scarlatina in children and adults, is most frequently due to this cause ; the abuse of spirituous liquors is also considered as a cause, though chiefly in connection with the previously mentioned influences ; diuretics, though they do not originate, undoubtedly promote the disease. Numerous dyscrasic momenta are of considerable importance. We advert to the development of Bright's disease, subsequent to exanthe- matic fevers, particularly scarlatina, to typhus, to tubercular disease and tubercular suppuration, e. g. pulmonary phthisis, to cancerous diathesis, and to the affections which we are about to consider in connection with the eighth form. The eighth form invariably sets in without reaction, and springs from inveterate scrofulous or rickety disease, but especially from syphilitic and mercurial taint. It presents itself as a constitutional infiltration of 1 [Qy. Bronchitis? ED.] 158 ABNORMITIES OF the kidney, and is associated with analogous affections of the spleen and liver, in the shape of lardaceo-albuminous infiltration ; both the nature of this product and the anomalies of the blood and the urine as yet remain a perfect enigma. We have once noticed the complaint as a sequel of intermittent fever combined with a similar condition of the spleen. 4. Deposits in the kidneys. The same circumstances that give rise to deposits or metastases in the lungs, the liver, and the spleen, may induce them in the kidneys. They follow inflammations of the endocardium, and of the lining membrane of the vessels brought on by infection of the blood, arising from absorption of the inflammatory product, or they re- sult from suppuration and gangrene of membranous and parenchymatous tissues produced in a similar manner, or lastly they originate in sponta- neous pyaemia. We would again direct especial attention to the deposits arising from endocarditis, as they have not only been overlooked, in the same way as those occurring in the spleen have been, by the most dis- tinguished inquirers, but as of late Rayer has interpreted them falsely, and has viewed them as symptoms of rheumatic nephritis. They are found in endocarditis, generally coexistent with similar de- posits in the spleen, consequent upon primary phlebitis with a purulent exudation, or upon the absorption of pus or sanious matter from ulcera- ting surfaces or abscesses ; they co-exist with deposits in the lungs, the liver, the brain, the subcutaneous, and intermuscular cellular tissue, the interstitial cellular layers of the intestines, and with secondary phlebitis, in the most different portions of the venous system. There may be only a few, and in endocarditis we generally find one only, or they are as under the last-named conditions, very numerous ; in rare cases the kidney is entirely gorged with them. They occur chiefly in the cortical substance, and here again mainly in its peripheral strata ; so that they are at once apparent on the removal of the fascia albuginea ; it is only in exceptional cases, and when they are very numerous, that they occur in the pyramids. They vary much in size, from that of an almost imperceptible poppy-seed, to that of a millet- or hemp-seed, of a pea, a bean, or of a walnut ; the larger ones present the peculiar form described in the section on the spleen, as exhi- biting a pyramidal shape, the base of which is directed towards the sur- face, the apex towards the interior of the organ ; the smaller ones appear as rounded nodules. The intermediate sizes are the most frequent, but when very numerous, they generally remain so small as scarcely to exceed the size of millet-seeds. They commence in the renal parenchyma as dark-red indurated spots, which correspond in extent to the above-mentioned sizes ; they gradually assume a dirty brown, yellow, or yellowish-white color, and are surrounded by a light-red inflammatory halo, which indicates the reaction set up in the adjoining tissue, or if the disorganization advances to a high degree, by a dark-red, discolored ecchymosis. The latter appearance is coinci- dent with a very large number of the deposits, and as we have seen that these must then be very small, we find the renal tissue presenting in the advanced stage of the disease very numerous small red spots, in the centre of which an almost imperceptible yellowish-white spot is discovered. The further progress of the disease consists in a conversion of the de- THE KIDNEYS. 159 posit into a purulent or sanious fluid, and the abscess may be enlarged by an analogous transformation of the inflammatory halo ; the metamor- phosis may, however, be benignant, and the deposit become pale, and shrivel up ; it may then, together with the involved tissues, be absorbed, or partially retained as a pulpy or cretaceous mass, having a cicatriform cavity with a fibro-cellular investment, or a fibro-cellular callus, which corrugates and draws down the surrounding parts ; a greasy yellow sub- stance or chalky concretion is found buried in the callus, and like the investment of the first-mentioned cavity, this is agglutinated to the tunica albuginea. The deposit is essentially an exudative process, the product of which undergoes the described metamorphoses ; or it depends upon stasis and coagulation of the blood in the capillary vessels, and a conversion of the fibrine in the manner above described, a secondary angioitis (phlebitis) capillaris. Both metamorphoses are known to be induced by something that is taken up by the blood ; and we thus generally see deposits in the kidneys resulting from endocarditis, which go through the second meta- morphosis, and heal with loss of substance of a small section of the corti- cal tissue. In the case of solitary deposits, the parenchyma, with the exception of that adjoining the morbid product, does not participate in the local process ; when they are very extensive, reaction takes place throughout the organ, and is evidenced by tumefaction, enlargement, softening, and and infiltration of the parenchyma ; even the mucous membrane of the urinary passages appears congested, reddened, and softened. 5. Morbid growths, a. Fatty deposit in the kidneys. We shall exa- mine this subject under the head of Hypertrophy of the Fascia Adiposa. b. Formation of cysts. Although we explicitly exclude the considera- tion of all encysted tumors which have their origin in a dilatation of the urinary passages, and especially of the calices, we think it necessary at this place to discuss a. Cysts, that occur frequently in the renal parenchyma, and which we cannot positively state to be new formations. We allude to cysts which vary in size from that of a millet-seed, pea, or bean, to that of a walnut or even a goose's egg, and which contain a clear, colorless, or yellowish, serous, alkalescent matter, or a substance of a yellowish or brownish color, and of a melicerous or mucilaginous consistency, or again, of a lateritious, chocolate-colored or inky (melanotic) tint. They are formed by a serous membrane, in which a branched vascular network may be traced. They vary in number ; sometimes there is a solitary cyst of one of the above-named sizes ; generally there are several of different sizes ; and in rare cases, they are so numerous, that the kidney, being propor- tionately enlarged, appears converted into a collection of cysts varying both as to size and to contents, the renal tissues having given way to them. In very well-marked cases a diminution of the urinary secretion, and its consequences, have been observed. These cysts are chiefly de- veloped in the peripheral layer of the cortical substance, and project above the surface of the kidney, so as to be at once perceptible on the removal of the tunica albuginea. They occur at every period of life, and are sometimes even congenital. 160 ABNORMITIES OF They acquire additional importance if developed in consequence of renal inflammation, especially when this arises from lithiasis, and more par- ticularly in consequence of Bright's disease. Our own view, and that of German authors generally, is that they are not the dilated terminations of the Malpighian capillary tubes, but that they consist in a conversion of the cellular layer in the Malpighian cor- puscles into serous cysts, resulting from the pressure exerted by the Malpighian corpuscles when tumefied and gorged with the inflammatory product of these diseases upon the surrounding strata. The latter during their metamorphosis take up the vessels of the renal coil (Nierenknauel) for the purpose of the new secretions. It would not be surprising if their contents were occasionally urinous, but we have never been able to discover a trace of urinous precipitates or concretions in them. We have once found a cyst that was seated at the circumference, and was of con- siderable size, inflamed and ruptured, and its contents effused into the adipose layer. . The acephalocyst is a morbid product that occurs in the kidney ; less frequently certainly than in the liver, but more frequently than in any other organ. We have no particular remarks to offer in reference to the relations of this variety of encysted tumor, to its contents, or to the surrounding tissues, except that it occasionally reaches the extraordi- nary size of a fist or a child's head, and that it may discharge its con- tents in various directions. The following modes of discharge are im- portant : aa. Communication of the cyst with, and its discharge into, the colon (the ascending or descending colon), and consequent evacuation per anum, and y5/9. The communication of the cyst with, and its discharge into, the cavity of the renal pelves and calices. Small acephalocysts, or ruptured larger ones, may thus be conveyed by the ureters to the bladder, and be evacuated, as is particularly the case with females, by the urethra (mictus acephalocysticus), or they induce obstruction and dilatation of the urinary passages by their size. f. The composite cystoidea rarely occur in the kidneys ; though when they are formed, they attain a considerable size. We have in our mu- seum an illustrative specimen, in the left kidney of a boy of five years of age. c. Anomalous , fibrous, and osseous tissue. We find fibroid masses of various extent and shape developed in the products left by inflammation and Bright's disease ; and in rare cases a deposition of osseous substance is effected within them, in the same manner as we find occurring in the fibrous exudations of serous membranes. The calcareous concretions are not however in this case laminse, but irregular tuberculated masses. We also find that a fibrous tissue of recent formation constitutes the external layer of the acephalocysts and composite cystoidea, as well as the base and fundamental structure of cancerous growths in the kidneys. d. Tubercle. Tubercle exists in the kidneys under two distinct con- ditions ; in both, however, the cortical substance is the chief seat of the deposit. . In one case, it is the result of a very high degree of tubercular THE KIDNEYS. 161 dyscrasia ; a partial symptom of the development of tubercular disease in many or the majority of organs, and, in that case, frequently the pro- duct of a very tumultuous process of deposition. The tubercles are found to exist in great numbers, and occur in the shape of grayish-white, deli- cate vesicular, or larger, i. e. miliary granulations, surrounded by con- gested and ecchymosed parenchyma. The entire viscus is swollen, gorged, and softened ; it is hypersemie, and either darker than ordinary, or paler and infiltrated, and the mucous membrane of the urinary pas- sages is reddened and injected. If the morbid process takes place with less intensity and has a more chronic duration, the tubercular matter is found in less quantity, of the size of millet- or hemp-seeds, and sur- rounded by pale tissue, which presents no trace of reaction either in the vicinity of or at a distance from the tubercular deposit. This form of renal tubercle occurs as a complication of tubercular de- posit in most parenchymatous organs and membranous expansions ; and especially in conjunction with tuberculosis of the abdominal viscera, and more particularly of the spleen, the liver, and the peritoneum. Even when occurring under violent symptoms, it is rarely fatal by itself by paralysis of the renal functions, but it becomes so by the universal affection and by the coexistent disease of other organs. This variety of renal tubercle, even when its progress is less rapid, rarely proceeds fur- ther than to a yellow discoloration, and never advances to actual fusion. Both kidneys are commonly attacked uniformly. /?. In the other case, renal tubercle is a partial appearance of tuber- cular disease that is limited to the male urinary and sexual organs. It then generally attacks the testes and the allied lymphatic and prostate glands primarily, and extends from these to the urinary apparatus, i. e. the mucous membrane of the entire tract, to the kidneys, and, lastly, to the supra-renal capsules. It is commonly viewed as possessing a blennor- rhoic character or as gonorrhoeal tubercle ; but post-mortem examina- tions have not established the fact by demonstrating any peculiarity in the tubercular deposit. It very often supervenes upon a previous tuber- cular condition of the lungs, or the latter, as well as tubercle in other organs, allies itself to the advanced stage of renal tubercle. This variety of renal tubercle frequently reaches a high degree as regards the num- ber of the tubercles, and their gradual accumulation into extensive groups and coalition into large masses. The viscus is found to have increased in size and is nodulated, and the tissues in the vicinity of the tubercle, or throughout the organ, are in a state of chronic reaction, and appear pale and dense, and infiltrated with lardaceous matter, and the tunica albuginea is thickened. This form of renal tubercle frequently passes more or less rapidly into the stage of softening, giving rise to tubercular ulceration (vomica renis tuberculosa), tubercular suppuration, and tuber- cular phthisis of the kidneys. The disease generally attacks one kidney only in a very extensive degree. e. Carcinoma. Carcinomatous growths occur frequently in the kid- neys, and in the primary form. This is particularly the case with me- dullary cancer, which we find attaining a very large size, whereas areolar and hyaline cancer are extremely rare. Of these, we have observed the VOL. II. 11 ABNORMITIES OF THE KIDNEYS. former only twice, in combination with medullary cancer, and the latter only as a secondary affection accompanying universal cancerous deposit. Medullary cancer appears either in the shape of more or less numer- ous distinct, rounded, circumscribed masses, varying in size from that of a pea to that of a walnut and a hen's egg, of dense or soft texture (en- cephaloid), white or variously colored (melanotic) ; these circumstances generally attend the rapid development of universal carcinomatous de- position, and therefore indicate secondary cancer of the kidney ; as a primary affection, it appears in the shape of a carcinomatous tumor, ac- companied by partial infiltration and degeneration of the adjoining tissues ; this tumor rapidly increases to the size of a child's or adult's head, forming rounded nodulated masses, which perforate the fibrous sheath, extend to the peritoneum, the lymphatic glands of the lumbar plexus, and involve the periosteum and ligaments of the abdominal ver- tebrae ; the diseased tissue thus becomes fixed, after which occurrence it grows into the cavity of the renal pelves and calices, the renal veins and the vena cava, and causes their obturation. The latter variety generally remains the focus of the carcinomatous cachexia and the sole cancer occurring in the body, on account of its ex- treme vegetative power ; yet we not unfrequently discover in its vicinity and especially on the peritoneum, the diaphragmatic pleura of the dis- eased side, and in the liver, isolated cancerous deposits. An important complication, and one that points to an analogy with tubercular disease, is that with medullary cancer in the testicle of the same side. The two commonly coexist, or the renal cancer is developed shortly after that of the testis. We have noticed the disease not only in the middle period of life, but both in advanced age and in early youth (as early as in the fifth year). Both kidneys appear equally liable to the affection. When the growth is effected with great violence, hyperaemia and he- morrhage not unfrequently occur in medullary carcinoma of the kidney, and when it extends into the urinary passages, we find that blood is effused into them also. 6. Anomalous Contents. Besides the anomalies already alluded to, we have to advert to the following morbid contents of the urinary cana- liculi. a. The formation of calculous urinary concretions, which appear in the shape of delicate granular crystals, dispersed through the substance of the kidney, and which consist of lithic acid. b. Entozoa ; these are, besides the animalcules inhabiting the acephalo- cyst, the cysticercus and the very rare strongylus gigas. 8. Special disease of the Investments of the Kidneys. 1. Hy2^ertrophy of the adipose layer. The adipose tissue which sur- rounds the kidneys may increase in quantity coincidently with a universal increase of the fat of the body, or it may become hypertrophied by itself; in the latter case it may increase to such an extent as to force its way into the hilus of the organ, impede its nutrition, and cause a fatty infil- tration of the kidney, accompanied by anaemia and pallor. It appears that rare cases of this description have been occasionally taken for Bright's disease, and this has given rise to the latter being thought ana- DISEASES OF THE URINARY PASSAGES. 163 logous to fatty liver. "When it has advanced to the highest stage, the kidney presents the appearance of a mere piece of fat surrounded by a mass of adipose tissue, and without the slightest traces of renal organi- zation ; the urinary passages at the same time are atrophied and obli- terated. Independently of universal adipose deposit, we find a larger or smaller excess of fat enveloping the kidneys of old people, accompanied by atrophy of the organ ; it also accumulates when the kidney is affected by moderate but lasting inflammatory irritation, especially that caused by calculi, and in secondary atrophy, and obliteration of the kidney. 2. Per {nephritis. This comprehends inflammation of the tunica albu- ginea and of the fascia adiposa of the kidney. It results from wounds, concussion, and urinous infiltration, and accompanies both the inflamma- tion of the kidneys and that of the pelves and calices. Inflammation of the tunica albuginea is characterized, as we have al- ready had occasion to state, by development of the vessels of the cortical substance, by congestion and softening, succulence and condensation of its tissue, and by the facility with which it may be detached. It is always combined with inflammation of the cortical substance of the kidney. It is only when the latter terminates in suppuration that the disease in ques- tion has a similar issue; but it frequently leaves a fibroid thickening of various degrees, combined with induration, atrophy, and obliteration of the kidney, resulting from inflammation of the organ. Inflammation of the fascia adiposa, which is particularly apt to super- vene upon the tedious inflammation of the kidneys and their pelves, in- duced by calculous irritation, has the general characters of inflammation of fatty tissues ; it induces condensation and rusty discoloration ; atrophy and conversion of the fat into a white or slate-colored cellulo-fibrous tis- sue, which forms adhesions with the thickened albuginea and the perito- neum ; in some cases suppuration and abscess may ensue. SECT. II. DISEASES OF THE URINARY PASSAGES. 1. Defect and Excess of Formation. It is self-evident that where one kidney is deficient, the corresponding portion of the urinary passages must be entirely, or at least partially, absent ; but when the kidneys are present, exceptional cases occur in which the ureters terminate in a cul- de-sac in the vicinity of the bladder, and also in the neighborhood of the pelvis of the kidney ; or we may find in addition to a perfect ureter, a rudimentary one developed at the bladder ; or finally, the apparatus may have undergone an arrest of development, and be very narrow, and have very delicate coats. If the kidneys are increased in number, the urinary channels are also multiplied ; but more frequently the apparent excess is owing to fissure ; the calices opening into two or three pelves, which, in their turn, discharge themselves into two or three ureters. In a less marked degree there is a single pelvis, which is divided inferiorly so as to open into two ureters ; occasionally, these are also found to form partial subdivisions. This malformation, and particularly the fissured pelvis, which is then found partially detached from the organ, frequently accompanies a defective 164 DISEASES OF THE development of the hilus of the kidney ; it also coexists with an elongated state and a transverse division of the kidneys. The relation of the vesical orifice of the fissured ureters to the bladder varies. They generally coalesce in the neighborhood of the bladder, or within its coats, so as to form a single channel, which communicates with the cavity of the bladder by a single mouth ; they rarely open by sepa- rate orifices placed behind one another at one side of the trigonum Lieutaudi. When the kidney occupies an irregularly low position, the length of the ureter is correspondingly diminished. 2. Deviations of Calibre. The deviations of calibre consist in dilata- tion of the urinary passages, caused by accumulations of urine, which result from obstacles to its discharge, and frequently favored by an inflammatory condition of the mucous membrane, which paralyzes the external contractile layer. It will depend upon the position of the im- pediment whether the dilatation affects a larger or smaller section of the apparatus. If the former occupies the vesical orifice of the ureter, the entire ureter, the pelvis, and lastly, the calices, become gradually dilated ; it is evident, as we shall subsequently examine more fully, that more dis- tant impediments, as, for instance, those placed in the urethra, must also induce dilatation. The degree in which the dilatation occurs is very various ; the higher degrees offer on their own account, as well as on account of various con- secutive anomalies, numerous points of interest. Dilatation of the pelves and calices, by exerting pressure upon the renal substance, induces atro- phy of the latter. The papilla is first reduced ; it becomes condensed and coriaceous, and gradually disappears in the arch of the expanded calyx ; the superimposed renal tissue at the same time diminishing in thickness, becoming denser, and assuming a leathery toughness. At an advanced stage the substance of the kidney may be only one, or a few lines in thickness, and even disappear altogether, being converted into a mere membranous sac (hydrops renalis, Rayer's hydronephrose), with an external lobulated appearance, presenting cells within, and filled with a urinous, variously sedimentary fluid, or with clear serum ; the loculi may intercommunicate with one another, in consequence of atrophy or rupture of the contiguous parietes. These sacs sometimes attain, especially in cases which are unaccompanied by inflammation, the size of a child's or an adult's head ; but there is no doubt that, after the urinary secretion has ceased, in consequence of atrophy of the renal tissue, and especially of previous inflammation, they may be reduced. Dilatation of the ureters exhibits every possible degree ; the ureter may even attain the size of the small intestine. It is then found hyper- trophied, inasmuch as its parietes not only present the average but even increased thickness ; and as it is increased in length, and consequently, instead of being straight, appears coiled or bent. At the same time the dilatation is not uniform, as several portions of the ureter are narrower than others, the external cellulo-fibrous tissue accumulating at these points during the dilatation, and offering resistance. To this fact, also, is owing the peculiar direction the ureter assumes, as the curvature or URINARY PASSAGES. 165 flexure always occurs at these spots. It may also be observed that the tube rotates upon its axis at these points, a circumstance which further adds to the diminution of its calibre, and offers a new obstacle. The parietes of these cavities and canals always bear, as we ^have already remarked, that proportion to the dilatation, that they must be considered hypertrophied ; they only attain a remarkable and extravagant thickness, however, if there is concurrent inflammation. The following circumstances may induce the occurrence of dilatation : Compression of the ureter at different points by morbid growths, by the impregnated uterus, especially by cancer of the womb which extends to the bladder, by fibroid tumors of the uterus, by enlarged, and particularly by dropsical, ovaries, by accumulation of urine in the bladder itself, or by lasting contraction of the bladder consequent upon hypertrophy of its coats ; contraction of the ureter from tumefaction of its coats, con- sequent upon inflammation and its results ; obliteration of the ureter, and obturation of the calices, the pelvis, and ureter, by calculous concre- tions ; cancerous growths forcing their way inwards from without ; and, finally, numerous morbid conditions of the bladder, the prostate, and the urethra, which impede the discharge of the urine into the bladder, or the evacuation of the latter. These dilatations are consequently generally acquired in advanced life, though in the case of original occlusion (blind termination) of the urinary passages, they may be congenital. In a particular case that we have observed, the pressure exerted by an irregular branch of the emulgent artery, of one line in diameter, that descended from the upper end of the hilus, so as to form an arch over the convoluted transition of the pelvis to the ureter on the right side, caused a dilatation of the former. The contractions of the urinary passages are sufficiently explained in the above ; they are also the result of renal atrophy, and may amount to complete obliteration and closure of their calibre. 3. Anomalies of Position. As a congenital anomaly, we mention the detached position of the single or multiplied pelvis of the kidney ac- companying an imperfectly developed state of the renal labia, and especially occurring in cases of anomalous formation and position of the kidney : acquired anomalies of position are brought on by pressure exerted upon the ureter by irregularities of the neighboring organs. 4. Anomalies of Texture. 1. Inflammation of the urinary passages have to be first mentioned, and especially a. Catarrhal inflammation, both on account of its frequent occurrence, as on account of its consequences and its transition to the substance of the kidneys. As a primary disease, it appears in the shape of inflam- mation of the renal pelvis and the calices (pyelitis), with inflammation of the kidney, as may be gathered from the description of nephritis and Bright' s disease ; it may be secondary, owing to irritation exerted by accumulation of urine and urinary concretions on the mucous membrane of these parts (pyelitis calculosa) ; and it may also be and very often is metastatic, the inflammation of the bladder being transferred to the ureters, the pelves, and calices. 166 DISEASES OF THE It is either acute, as in the case of complication with acute nephritis, or more commonly chronic, being maintained by lasting and repeated noxious influences, or being the result of a chronic morbid process in the bladder, in which case we meet with temporary acute exacerbations. It is of extreme importance, and renders the following details necessary. The characters are, in proportion to the degree of intensity and dura- tion, a dusky reddish or brown-red congestive state, similar or ashy dis- colorations in the shape of solitary spots or islands, or of extensive con- nected patches, tumefaction and villosity of the mucous membrane, and secretion of a yellow puriform mucus, blennorrhoea. The longer the inflammatory condition lasts, the more the gradual di- latation of the urinary passages, with hypertrophy of the membranes, increases, both in consequence of the paralysis of the external contractile and irritable layer as from the accumulation of the renal and the morbid mucous secretion. At an advanced degree, as in the temporary exacerbation of chronic inflammation, the mucous membrane, particularly when subject to irrita- tion by gravel and calculi, which chiefly affect the calices and pelves, appears of a saturated red color, considerably swollen, spongy, and friable ; a purulent, more or less sanguineous, fluid is secreted (superficial suppuration), the surrounding cellular and adipose tissues are traversed by varicose vessels, and infiltrated. We find that moderate catarrhal inflammation of the ureters gradually extends to the kidney in the shape of chronic inflammation ; it equally attacks the kidney with tumultuous symptoms as acute inflammation when it has reached this advanced degree, and thus proves fatal. The above-mentioned high degree of inflammation is also found to pass into suppuration of the urinary passages, which spreads from the calices to the tissue of the kidneys, and causes in the latter the formation of abscesses or extensive ulcerative destruction, occasionally urinous infiltra- tion of the renal parenchyma, gangrenous ulceration, and gangrene of the calices and pelvis. We thus find it gradually proceeding in the ureters to perforation, slow infiltration of urine in the adjoining tissues, inflammation, suppuration, necrosis, and in fortunate cases, formation of circumscribed abscesses with indurated parietes. In these various conditions, the urinary passages contain an alkaline urinous fluid of a pungent odor, which is variously discolored ; it is mixed up with puriform mucus or true pus, sanies, blood, and portions of broken- up tissue, and it frequently deposits a sedimentary incrustation upon the inflamed mucous membrane. In rare cases the advanced stages of the disease terminate favorably in obliteration of the urinary passages. After the cessation of the urinary secretion, consequent upon complete atrophy of the renal tissue, from pressure exerted by the dilated renal calices, or more frequently conse- quent upon the coexisting chronic inflammation of the kidney, the tissues contract, the parietes become thickened, and the calibre of the passages is gradually reduced, till complete obliteration results. The fluid con- tained in the cavity of the calices, which consists of blennorrhoic mucus, pus, and urine, the latter being strongly impregnated with alkalies, salts of lime, and particularly with phosphates, first causes an incrustation on URINARY PASSAGES. 167 the parietes of the calices, and then becomes inspissated, so as to form a grayish or yellowish-white, greasy, and chalky pulp, which fills the ca- lices ; the kidney thus presents the appearance of a loculated cyst, the compartments of which contain the pulp, and radiate from the hilus to the circumference. This pultaceous substance is in due course converted into a dry mortar-like, gritty, dense, calculous mass, and the tissues con- tracting at the same time, the sac is reduced, the kidney and the efferent channels are obliterated. Occasionally this metamorphosis is observed to take place in one or more detached calices. Occasionally laminated, corded, nodulated, and amorphous bony con- cretions are formed in the membranes of the renal calices and pelves, after these have been previously converted into a fibroid or cartilaginous tissue by the inflammatory process ; the same may occur in the ureter, though we have not observed it ourselves. b. Exudative inflammation. This is on the whole an unusual occur- rence, and as far as we are able to judge, invariably a secondary affection ; we have never met with a case of idiopathic croup of the urinary organs. It is found complicated with products of the most various plasticity, fol- lowing typhus, exanthematic diseases, more especially variola and scarla- tina, exudative processes in other tissues, as diphtheritis and acute tuber- culosis, and purulent infection of the blood ; it is very frequently the consequence of extreme disorganization of the blood (especially the so- called status putridus), and then appears as hemorrhagic exudation with purple or dark-red discoloration, sanguineous infiltration, friability and solution of the mucous tissue, and hemorrhage. It may extend over a large surface, or be confined to isolated spots, and it not unfrequently implies gangrene. 2. Morbid growths. a. Fibroid tissue and calcareous concretions re- sult from chronic inflammation of the urinary passages in the manner above described. b. Cysts appear to be more frequent in the urinary passages than they are in and upon other excretory ducts. Without referring to older cases, we may notice two that have been observed in the Vienna Hospital. They represent cysts of the size of millet-seeds or peas, developed under the mucous membrane, and either grouped together or solitary, contain- ing a colorless or yellowish serous fluid, in which is found a soft glutinous or hard nodule, varying in size, and resembling amber or horn ; these cysts and the mucous covering occasionally burst, which is proved by the concretions having been discovered unattached in the bladder. They were found chiefly occupying the ureters, and in one case the pelves and calices of the kidneys. c. Tubercle. This occurs as tubercular affection of the mucous mem- brane, and is always a symptom of tubercular disease that has spread from the male genitals to the urinary organs. The earlier stages and the chronic course of the disease are marked by gray millet-sized granu- lations in the submucous cellular tissue, which speedily become yellow, soften, and after perforating the mucous membrane within a ring of re- active inflammation, give rise to small circular ulcers, which but rarely enlarge to the dimensions of a pea or a bean. When the disease sets in with great violence, the mucous membrane is attacked in larger sinuous 168 ABNORMITIES OF THE or annular patches, or becomes infiltrated throughout with the tubercular product of inflammation, which is at once detached as a cheesy purulent mass. The mucous membrane is, under these circumstances, converted into a thick, yellow, fissured, and purulent layer, the external cellulo- fibrous layer of which presents a lardaceous character ; the calibre of the canal is enlarged. At those parts which are not affected by this degeneration, we not unfrequently find numerous aphthous erosions, re- sembling those observed in pulmonary and laryngeal phthisis. Tubercular suppuration occasionally passes from the pelvis of the kid- ney to its parenchyma, and it here not unfrequently meets with soften- ing tubercles, or even with tubercular abscesses. d. Cancer. Cancer occurs very rarely as a primary disease of the mucous membrane of the urinary passages, and never except in company with one or several cancerous formations in other organs already in a process of development ; in these cases it affects the calices and pelvis of the kidney, and chiefly assumes the medullary or fungoid form. The parietes of the urinary passages are very often involved in a secon- dary degeneration by the encroachment of cancerous growths from with- out ; the calices and pelvis being attacked by carcinoma of the kidney, the ureters by cancer of the uterus. Their cavities are narrowed by the cancerous products, and even entirely closed up. SECT. III. ABNORMITIES OF THE URINARY BLADDER. 1. Defect and ^Excess of Formation. Arrest of development occurs in various forms and degrees. Complete defect is a very rare occurrence ; we may meet with it accom- panying a very imperfect development of the kidneys, with absence of the urethra, and commonly also as a complication of formative defects of other organs. If, under these circumstances, the ureters are well formed, they open at the navel, into the rectum, or the vulva. Occasionally the bladder is very small, whilst the other portions of the urinary apparatus are of normal size ; its parietes are then imper- fect ; it is, in fact, represented by a delicate mucous bag, a mere dilata- tion of the ureters. The various fissures of the bladder are other forms of arrest of deve- lopment. We allude, first to the very rare cases of fissure or division of the bladder by means of a perfect or an imperfect partition in the median line, the so-called double bladder. That variety of this species of defect is much more frequent, which has been termed, from its appearance, ectrophia or inversion of the bladder. It is the result of a fissure, or a defect of the anterior vesical parietes, and is not unfrequently associated with fissures of adjoining viscera in the mesian line. It is more parti- cularly accompanied by a defect of the symphysis pubis in the female sex by absence of the anterior commissure of the labia and the clitoris ; in the male sex, by fissure of the urethra on the dorsal surface of the penis, or epispadiasis. In the case of inversion of the bladder, we find in the hypogastrium, immediately beneath the navel, which is always placed very low, a red, mucous, dilated spot, the edges of which coalesce with the common integument : in the male sex it passes downwards, so as to URINARY BLADDER. 169 terminate in the fissure of the urethra ; in the female it is surrounded by two diverging tumors which represent the labia, and it terminates in the lamina of the general integument which invests the rima vulvae. The ureters open upon this mucous surface, and their orifice is generally found at the inferior half. The exposed vesical mucous membrane and, owing to the constant stilli- cidium of urine from the ureters, the neighboring cutaneous surface, become irritated, reddened, and excoriated. In a very old preparation taken from an adult, which has been transferred from the Anatomical Museum of the University to the Pathological Collection, I find the former in a state of fungoid degeneration. When the fissure of the urinary bladder occurs in an opposite direc- tion, and is accompanied by fissure of the genital cavities and the rectum, we obtain the formation of cloacae in their various degrees. The urachus may remain patent to a certain distance from the bladder, or throughout its entire extent. We have also to allude to defective development occurring in the shape of unusual contraction of the vesical orifice, or atresia vesicse. In biventral monsters, the bladder is found more or less competely double. 2. Deviations of Size and Form. Hypertrophy and atrophy of the bladder. With the exception of the above-mentioned congenital small- ness of the bladder, and the congenital dilatations of the organ from contraction or atresia of the urethra, the anomalies to be classed under this head are all acquired ; they are the conditions of permanent and excessive dilatation and contraction. Dilatation of the bladder is seen under various forms. It may be uniform and general, and in solitary cases attains such an extent, that the bladder is represented by a fluctuating paralyzed sac, with relatively thickened parietes, filling the entire pelvis and hypogastric region. It is caused by accumulation of urine, consequent upon insensibility and paralysis of the bladder, but more particularly by mechanical obstacles in the neck of the bladder and in the urethra ; in the last case espe- cially, that extreme degree is developed which is always accompanied by hypertrophy of the parietes. Dilatation of the ureters is a consequence of this affection ; it proves fatal by inflammation resulting from the influence of the stagnating and decomposed urine upon the mucous membrane, by the consequent suppu- ration and gangrene, and especially by peritonitis. Dilatation occasionally affects in a greater or less degree certain por- tions, or predominates in certain directions ; thus we find lateral expan- sions at the fundus vesicae, and saccular indentations produced by the pressure of calculi at or posterior to the triangle of Lieutaud. An important variety of partial vesical dilatation is presented to us in the hernial dilatation, or acquired diverticulum of the bladder. It is always developed in a bladder the muscular coat of which is hypertro- phied, and this hypertrophy, being accompanied by increased irritability of the bladder, affords an evident and intelligible explanation for the pre- disposition. The vesical mucous membrane insinuates itself between the 170 ABNORMITIES OF THE fissures left by the rounded or hypertrophied fleshy columns, is gradually forced through them, and forms saccular appendages to the bladder, which increase by degrees, and attain a size varying from that of a wal- nut or hen's egg to that of a fist or a human head. Their cavity at first communicates with the bladder by means of an elongated rhomboidal opening, and the more they increase, the more the latter, being enlarged at the same time, is converted into a round sphincter. These diverticula occur principally at the lateral portions and near the vertex of the bladder; they are also found at the posterior surface, and may frequently be seen at all these points at once. The diverti- culum is very rarely developed in the triangle near the perineum. Its parietes are formed of the mucous membrane of the bladder, which, under certain self-evident circumstances, is invested by the peritoneum. Sometimes a few muscular fibres traverse the diverticulum, which circum- stance may cause it to be viewed as congenital. If there happens to be concurrent calculous disease of the bladder, the diverticula acquire additional importance, as the calculi may pass into them, or be formed within their cavity, and either be firmly grasped or float unattached. The mucous membrane of small diverticula is fre- quently the seat of chronic inflammation, causing a muco-purulent secre- tion, and followed by ulcerative perforation and the formation of sinuses between the vesical coats ; these sinuses traverse the trabecular struc- ture of the muscular coat in the most various directions. Permanent contraction of the bladder occurs in various degrees as a consequence of enduring irritation, e. g. by a calculus ; or of increased irritability of the mucous membrane from inflammation. The longer these influences last, the more the parietes increase in thickness and hardness, so that they not unfrequently present the appearance of a ball contracted to the size of a duck's or hen's egg. The contraction is at times partial, and may then give rise to a per- manent coarctation of the bladder at one or even at several points. The bilocular vesicae, noticed by ancient anatomists, probably took their origin in a morbid contraction of this nature. As regards the diameter of the vesical parietes, we pass over nume- rous morbid conditions which give rise to thickening, and which will be investigated subsequently, and have now to examine the states of hyper- trophy and atrophy. Both are most apparent in the muscular coat ; hypertrophy of the mucous membrane is chiefly seen in connection with chronic congestion and catarrh of the bladder, and we shall examine into it more fully in speaking of these affections. Hypertrophy of the muscular coat takes place in consequence of catarrhal affections of the vesical mucous membrane ; of repeated and enduring irritation, especially from urinary concretions ; of excessive efforts made to overcome obstacles to the discharge of the urine. The latter may affect either the neck of the bladder or the urethra, and be caused by the pressure exerted upon these parts by enlarged or dislo- cated organs in the vicinity ; as by prolapsus, tumors, and degenerations of the uterus, uterine, vaginal, and rectal cancer, by the enlarged pro- state, strictures of the urethra, &c. The muscular fasciculi are found URINARY BLADDER. 171 thickened, so as to form rounded trabeculae, which project from the inner surface of the bladder in the shape of a trabecular network, com- parable to the inner surface of the right ventricle of the heart (vessie a colonne], the mucous membrane insinuates itself within its meshes, unless, the bladder ^be permanently contracted, and finally forces its way through them in the shape of diverticula. The bladder is at the same time either dilated, or if the irritability of the mucous membrane is increased, it is contracted. In the latter case especially, the entrance of the urine from the ureters is variously im- peded, and thus a dilatation of the urinary passages ensues. We must, however, be cautious not to mistake a bladder with thick walls, which is perfectly contracted after it has been completely emptied, for a case of hypertrophy. Atrophy of the vesical parietes occurs rarely. The mucous membrane may be reduced to a very delicate, shining membrane, resembling the arachnoid, and the muscular coat disappears, with the exception of a few almost imperceptible pale traces ; the contractile power of the bladder ceases, its parietes are in a state of permanent relaxation, soft, thin, transparent, pale, anaemic, and friable. We have twice observed atrophy of the vesical parietes of this description as a substantive disease. The shape of the bladder is liable to numerous deviations. All the congenital malformations that are connected with the above-mentioned anomalies of development belong to this head, and as acquired malfor- mations, we may mention those accompanying dilatation, especially when effected in one direction, and causing diverticula, those resulting from irregular and constant contraction, and those assuming the cylin- drical, cuneiform, or cordate form, in consequence of hypertrophic con- ditions. 3. Anomalies of Position. These involve the dislocation of the bladder from its normal position, and in various directions, by enlarged neighboring viscera, and voluminous morbid growths in the pelvic cavity, by contraction and malformation (especially that resulting from mollities ossium) of the pelvis ; the dragging down of the bladder by dislocated viscera in its vicinity, especially by the prolapsed uterus, and by large morbid growths in the perineum, the position occupied by the bladder in large inguinal, perineal, and vaginal hernise ; the intussusception of the bladder in the urethra, and its prolapsus through the latter in females ; the eversion of the bladder in consequence of a rupture affecting both it and the vagina. 4. Solutions of Continuity. We class under this head 1. Injuries of the bladder by means of cutting instruments, including the surgical wounds caused by cystotomy and puncture of the bladder ; the contusions produced by the head of the child during parturition, by obstetric instruments, by splinters of bone arising from pelvic fractures, or by concussion received by a fall or a blow ; rupture of the bladder ac- companied by more or less diffused infiltration of the vesical membranes and the surrounding cellular tissue, and hemorrhage. 2. The very rare spontaneous ruptures of the bladder resulting from excessive repletion and distension of the latter. 172 ABNOKMITIES OF THE In both cases the termination may vary ; in favorable circumstances a cure may result ; extravasation of urine into the peritoneal cavity and peritonitis, or urinous infiltration of the cellular tissue, with diffuse in- flammation, suppuration, gangrene, and under these circumstances com- monly a fatal issue, may take place ; or if the secondary processes are circumscribed, abnormal openings may be established, and vesical fistulas form. 3. The ulcerative solutions of continuity occurring from within as well as from without, together with the consequent and frequent con- stricted or patulous communications between the bladder and neigh- boring cavities and channels, the intestinal tube, and particularly the rectum, the uterine and vaginal cavities, abscesses, &c. 5. Anomalies of Texture. Here too the diseases of the mucous membrane are of main interest, as those of the muscular coat are rare in themselves, and when they occur are generally consecutive or secondary. We shall consider them in their proper places. 1. Hypercemia of the Bladder. Besides the congestion existing as a stage preparatory to and associated with inflammation, we find hyper- aemia occurring not unfrequently as a result of mechanical impediments to the circulation in the pelvic veins and the vena cava. It is commonly complicated with hyperaemia of the neighboring pelvic viscera, of the rectum, the uterus, and the vagina ; it gives rise to a more copious secre- tion of mucus in the bladder, to hypertrophy of the mucous membrane^ and is followed by a permanent dilatation of the vessels, and habitual congestion. The condition accompanying stases in the hemorrhoidal vessels of the rectum, in the shape of vesical hemorrhoids, is one of this nature. Extravasation or apoplexy of the vesical membranes, and hemorrhage into the cavity of the bladder, as a consequence of hypersemia, is a very rare occurrence. Even in those rare cases it is always limited to a few small spots, and they must be carefully distinguished from the dark-red suffusions of the vesical mucous membrane, into which the hypersemic condition which is followed by secondary exudative processes and gan- grene frequently degenerates. 2. Inflammation, a. Catarrhal inflammation. This occurs in the acute form, but more frequently as a chronic affection ; it is commonly presented to the morbid anatomist in the latter shape. Both generally offer the symptoms common to catarrhal inflammations. Relatively to the chronic form, we have the following observations to make: It may be developed gradually in consequence of repeated attacks of acute inflammation, or be left as a residuary affection after the incom- plete cure of the latter ; or, as is very frequently the case, catarrhal in- flammation results from an extension of gonorrhoeal catarrh to the bladder. It may also be induced by the continued irritation of long- retained and decomposed urine, as is the case when the discharge of the urine is impeded ; or lastly, by the irritation arising from calculi. It offers various degrees ; from a pale circumscribed redness, occa- sionally surrounding the crypts only, slight opacity and thickening, URINARY BLADDER. 173 increase of villosity and secretion of a grayish-white liquid mucus, to a dark reddish-brown, slaty or bluish-black discoloration, accompanied by considerable spongy tumefaction, and the secretion of mucus, which is partly vitreous and clotted, partly yellow and puriform (blennorrhoea). The longer the disease lasts, the more the mucous membrane, from its increased irritability and from the permanently increased innervation of the muscular coat, becomes hypertrophied ; the cavity of the bladder is diminished in consequence, and if this condition attains a certain point, paralysis of the muscular fibres and consequent dilatation of the bladder ensue. In this secondary condition, after the affection has lasted a considera- ble period, a rapid exacerbation of the chronic catarrh is frequently brought on by the irritation exerted upon the vesical mucous membrane by the accumulation of decomposed alkaline urine. The inflammation speedily attains a high degree, and terminates in exudation, fusion of the mucous tissue, suppuration, and gangrene. Under these circumstances the bladder is found dilated, and filled with decomposed, intensely alkaline urine, mixed up with blood of a brown color, viscid mucus and pus, sanies, lymph, and detached portions of mu- cous tissue in the shape of discolored flocculi or larger patches. From this liquid, which offers a pungent ammoniacal odor, a soft, pulverulent, mealy sediment, consisting of calculous matter bound together by lym- phatic exudation, is deposited upon the internal surface of the bladder. The parts themselves are discolored, and present a dark reddish-brown, greenish-gray, or bluish-black hue. The mucous membrane, when pre- senting a dark-red color, appears spongy, softened, and pultaceous, is easily detached and bleeds ; when chocolate-colored or greenish it is found purulent, infiltrated with sanious matter, or converted into a friable flocculent tissue, which is traversed by the urinary sediment ; or if the process of solution is completed, and the mucous membrane has become detached, the surface of the cellular and muscular coats is ex- posed in larger or smaller sinuous patches, appears frayed and pulpy, in- filtrated with purulent sanies, discolored, softened, and friable. Finally, the muscular coat is involved in the suppurative and gangrenous destruc- tion, and general peritonitis ensues ; or even before this takes place sinuses are formed between the vesical membranes, the parietes of the bladder are eaten through, and present a cribriform appearance, and the urine exudes into the surrounding cellular tissue and into the peritoneal cavity. The bladder is converted into a paralyzed sac, the coats of which are thickened, though they yield on slight pressure, they are dis- colored, and infiltrated with pus and sanies. The disease commonly proves fatal, either directly or by extension of inflammation to the ureters and kidneys. In other cases the disease has slight exacerbations from time to time, being limited to a more or less circumscribed spot, which undergoes a slower process of suppuration, and at last becomes perforated. If, under such circumstances, the tissues external to the bladder have become the seat of inflammatory action previous to the occurrence of perforation, a diffuse extravasation of urine is prevented in one direction by inflamma- tory condensation of cellular tissue in another, by free peritoneal exu- 174 ABNORMITIES OF THE dation and agglutination to an adjoining organ. The circumscribed sup- puration progresses slowly, and induces fistulous destruction of the tissues, and communications between the bladder and the external surface of the body, or with other hollow organs. Catarrh of the bladder is of importance, under all circumstances, from its extension to the ureters ; and, in bad cases, from its complication with renal inflammation. It may also extend to the seminal ducts. A very important variety of vesical inflammation is that developed in the course of paraplegia ; it generally passes into gangrene, and termi- nates fatally. The mucous membrane becomes the seat of extensive con- gestion and suffusion, which spread to the submucous cellular tissue and the muscular layer ; the bladder assumes a dark-red hue, is friable, dilated, and filled with urine ; or it is empty and collapsed, and the mucous mem- brane is then partly invested with a coat of ill-looking lymph, partly in- filtrated with pus, partly fused into a pulpy sanious tissue. The mus- cular fasciculi are pallid, ash-colored, and friable, and the cellular tissue is infiltrated with pus and sanies. The cavity of the bladder contains a sanguineous, dirty brown, or chocolate-colored urine, of a pungent amtno- niacal odor ; this is mixed up with the various products of the process, and deposits a white, soft, pulverulent sediment. This affection presents an extremely asthenic character, and although we are ready to admit that in many cases it originates, together with the concurrent inflammation of the kidneys, in paralysis, we consider that in others the irritation produced by the alkaline urine stagnating in the bladder, is to be viewed as the chief or as a collateral cause. b. JExudative processes. Primary croup of the vesical mucous mem- brane is extremely rare ; but secondary exudative processes are by no means as unusual as is commonly thought. The latter occur during the course of exanthematic diseases, especially of scarlatina and variola, during typhus as a symptom of an anomaly and degeneration of the typhous process, in consequence of absorption of pus in the blood, and associated with exudative processes in other mucous membranes. The affection gives rise to a more or less coagulable fibrinous exuda- tion of varying thickness, or to a viscid, gelatinous, discolored, purulent, or sanious product ; it rarely involves the entire bladder, or even a large portion of it, but is generally limited to round spots or striae. The mu- cous membrane presents the most various degrees of injection and red- ness, varying from an almost imperceptible change to complete saturation of some portions, with considerable thickening and tumefaction, and an induration proportionate to the coagulability of the deposit. According to the character of the process, the diseased tissue becomes softened and converted into a pale or dark-red, reddish-brown pulp, or a gelatinous, purulent, or sanious mass ; the local process not unfrequently assumes a gangrenous character^ and the tissues are then resolved into a putre- scent sanies, or become detached in the shape of an eschar. As the exuded matter coagulates, it not unfrequently takes up urinary sediments, or these are subsequently deposited, and give rise to an incrusted appearance of the coagula or of the bladder. We see the typhous process occurring in the vesical mucous membrane under various forms : URINARY BLADDER. 175 a. It is rarely presented in the genuine shape, i. e. characterized by a product resembling that formed in the intestinal follicles and in the mesenteric glands. /5. It is frequently met with as a degenerate exudative process in the shape of scattered, insulated, and soft exudations. Y. It is seen degenerated to an exudative process resembling a gan- grenous eschar. Opportunities of observing the complete metamorphosis of the products and their subjacent strata, in the shape of softening, fusion, and separation, are but rarely offered, as the general disease com- monly proves fatal prior to these events. c. Pustular inflammation. We advert to the rare formation of vario- lous pustules upon the authority of other observers. We have ourselves not seen pustules in the bladder, even in cases in which the urethral mucous membrane was intensely affected by the variolous disease. We may at the same time mention the occurrence of small millet-seed vesicles containing a clear serosity, and resembling a miliary eruption ; they accompany catarrhal inflammation and slight exudative processes in the vesical, in the same manner as in other mucous membranes, and are noticed chiefly at the fundus and neck of the bladder. It is also an in- teresting fact that we have found them in many cases of Asiatic cholera, accompanied by painful dysuria, for which alkaline fomentations afforded considerable relief. d. Pericystitis. We have already alluded to the more or less diffused inflammation of the cellular tissue surrounding the bladder, which super- venes upon intense inflammation of the muscular coat and suppuration of the bladder (vide p. 173), or is the result of infiltration of urine after accidental or intentional wounds of the bladder, of ulcerative perforation, and of an extension of inflammation from adjoining cellular structures ; but we have besides these a spontaneous inflammation of the cellular tissue surrounding the bladder, which is designated as pericytt&i*. Like the inflammatory, suppurative, and gangrenous processes of the subcu- taneous cellular tissue, or of the cellular tissue surrounding the caecum or rectum, it may be idiopathic, though it is more frequently a secondary process ; it is to be considered as a localization of pyaemia, which was either spontaneous or dependent upon an absorption of pus, or of a dege- nerate typhous or anomalous exanthematic process. It spreads with facility through the cellular tissue of the pelvis, to the cellular septum of the rectum, to the anus, and into the scrotum ; it attacks the submucous tissue of the bladder, and having passed into suppuration and necrosis, causes an exfoliation of the mucous membrane and perforation of the vesical parietes. The affection is sometimes of a chronic nature, and then gives rise to induration, callosity, and rigidity of the bladder. 3. Gangrene of the bladder. Gangrene is the result of intense inflam- mation, brought on by the contact or imbibition of anomalous urine in the affected tissues, in which cases it assumes the appearance of sphacelous fusion (vide p. 173) ; or it results from contusion, and then we find an eschar formed (vide p. 174), 4. Softening. Besides the fusion of the mucous membrane accom- panying the exudative process, we have but once observed a gelatinous 176 ABNORMITIES OF THE softening of the vesical mucous membrane. It occurred in a case of typhus which had reached the ulcerative stage, and the bladder was found to contain a large quantity (three pounds) of putrescent urine. 5. Adventitious growths. a. We have never observed the formation of cysts between the coats of the bladder, or in its mucous membrane, though from their occurrence in the ureters, pelvis, and calices (vide p. 167), we are not inclined to dispute the possibility of the former. We have to remark that the accounts of a discharge of hydatids or acepha- locysts from the bladder for the most part depend upon a descent of these growths from the kidneys, or from other organs (e. g. the liver), that have formed adhesions with the urinary passages, to the bladder, from which they are eliminated. b. Tubercle. Tubercle of the vesical mucous membrane is a very rare occurrence, and is not even always found as a complication of tu- bercular affection of the urinary apparatus, which, as we have already seen, is combined with and results from tuberculosis of the sexual organs. When it presents itself on the vesical mucous membrane, it is commonly also associated with tubercle of the urethra and prostate gland. It assumes the form of discrete granulation only, and is deposited, with more or less reaction and vascularity, under the mucous membrane ; it becomes softened with greater or less rapidity, and after perforating the mucous membrane within a vascular area, leaves a small circular ulcer. According to our observations, and owing probably to the rapid development of the tubercular disease in the other segments of this and the sexual system, as well as to the high degree of the universal cachexia, secondary tubercular deposition and secondary enlargement of the tu- bercular ulcer in the bladder, are found to be very unusual. The cervix and fundus of the bladder are the main seat of tubercle ; we sometimes however notice that the bladder is involved in secondary tubercular ulceration by an extension of the disease from the prostate gland. c. Carcinoma. The bladder is either attacked primarily by cancer, or the disease is consecutive, having spread from neighboring organs, especially the uterus, the vagina, and the rectum. The latter is by far the more common case. We have observed the following varieties of cancer : . Fibrous cancer occurs but rarely in the shape of cancerous degene- ration of the vesical membranes with thickening, cartilaginous indura- tion, and the characteristic metamorphosis of the muscular layer ; we have seen it spread over large surfaces, at the side of the bladder, both upwards and downwards, accompanied by carcinomatous degeneration of the female urethra. /3. Medullary cancer occurs in the shape of nodulated morbid growths between the coats of the bladder, and is commonly associated with cancer in the adjoining sexual organs of the female, and with cancer of the rectum. It perforates the mucous membrane, and occasionally gives rise to a characteristic carcinomatous ulcer with raised edges. Y' The most frequent form of cancer occurring in the bladder presents the appearance of soft, furred, cauliflower-like, vascular, and generally bluish-red vegetations, which bleed on the slightest touch, and are at- THE URETHRA. 177 tached by a rounded flattened peduncle ; they arise from the mucous membrane and the submucous cellular tissue with delicate fibres, and develope a very fine membranous tissue, within which a whitish or red- dish-white, creamy or medullary {encephaloid) mass is formed. They are either isolated or grouped together, and at last coalesce so as to form a very large, loose, fissured, succulent, globular mass (fungus), which fills out the bladder in proportion as the latter becomes hypertrophied and contracted, in consequence of the permanent irritation. They chiefly occupy the neck and fundus, the trigonum and the parts near the ure- thral orifices ; they are sometimes spread over the entire inner surface of the bladder, but they generally make their first appearance at the above-named spots, and it is there too that the large fungoid growths are found. Of several cases we may mention one in which these vege- tations occupied and nearly filled the cavity of a diverticulum of the size of a duck's egg, which descended from the fundus of the bladder to the rectum and perineum. The more they are developed, the more they are liable to produce considerable hemorrhage from their extreme vascularity ; with conse- quent cachexia and exhaustion ; they are occasionally found inflamed, covered, and interlaced with lymphatic exudation, and gangrenous. This variety of cancer is frequently complicated with cancer in other organs ; it is especially allied to the cauliflower excrescences occurring upon anomalous serous and fibro-serous membranes, and upon the inner surface of the compound cystoidea or of the peripheral follicles of areolar cancer that have been converted into large sacs ; as also to erectile tumors or epithelial formations on other mucous membranes. SECT. IV. ABNORMITIES OF THE URETHRA. 1. Defective Development. The urethra is absent in those rare cases in which the entire uropoietic system is wanting, as also in those in which the bladder is deficient ; it is also wanting in those cases in which there is a partial deficiency of the bladder, as in cases of fissure, of ectrophy in the female sex, and of cloacal formation. The urethra may be imperfectly developed, presenting on the upper (epispadiasis) or lower (hypospadiasis) surface of the penis, a fissure which extends either along its entire length, or only to a short distance from the external orifice ; fissure of the entire dorsal surface of the penis occurs as a com- plication of eversion of the bladder, that of the inferior surface with fissure of the scrotum. The latter malformation causes a resemblance to the vagina. In other cases a portion of the urethra is deficient, and the latter then terminates in a cul-de-sac, placed at a greater or less distance from the usual point of the orifice in the glans penis ; total ab- sence of the urethra equally gives rise to an imperforate penis. The urethra may, in consequence of a congenital arrest of develop- ment, not open externally, but communicate with the cavity of the rectum, or in the female sex with the vagina ; or vice versa, it may receive the rectum or vagina at the lower or posterior portion of its parietes. VOL. II. 12 178 ABNORMITIES OF 2. Deviations of Size. They affect, with exception of congenital shortness of the urethra, its calibre only. We find a more or less di- lated or contracted condition of the urethra occurring in both sexes as a congenital anomaly, and affecting its entire extent or small portions only ; it is of especial importance in the male sex. Dilatations as well as contractions of the urethra, the latter being particularly frequent and important, occur as acquired conditions. Dilatation affects the entire canal uniformly or detached spots only ; this depends upon the locality of a mechanical impediment, and upon the extensibility of various portions of the urethra. The pars membra- nacea of the male urethra is liable to the largest fusiform and pouchy dilatations ; a uniform dilatation of the entire canal is often brought on by the continued use of bougies. Contractions of the urethra originate in primary, but more frequently in secondary, textural changes of the urethral mucous membrane of the corpus cavernosum and its fibrous sheath, and we shall have to examine them more carefully when speaking of urethral inflammation and its con- sequences. Contractions of the urethra are also brought on in either sex by the pressure of morbid growths, in man by the enlarged prostate, in the female by neighboring organs that have been dislocated, e. g. the uterus, the prolapsed vagina, &c. The passage of the urethra may also be more or less permanently or dangerously narrowed or closed up by products of its own mucous membrane, as well as that of the bladder, e. g. a mucous plug, croupy exudation, renal and vesical calculi, acephalo- cysts, &c. 3. Deviations of Direction. Among these we reckon the serpen- tine, angular or inflected, and variously altered course given to the urethra by voluminous hernise in either sex, by large morbid growths in the vicinity, by the dislocation of neighboring organs (the uterus) in the female, and especially by the enlarged prostate in man ; the latter causes a contraction of the urethra, and pushes it aside, or divides it into two passages, which diverge in the direction of the bladder. Both the pressure which the urethra suffers, as well as the anomalous direction, and particularly the inflection induced, diminish the calibre of the urethra at various points. 4. Solutions of Continuity. We enumerate under this head, wounds of the urethra, contusions and rupture brought on by a concussion or fall, particularly upon the perineum ; rupture produced by the passage of large angular calculi, perforations brought on by rude efforts at catheterization, and ulcerative destruction. In all these cases incom- plete recovery very often takes place, leaving urinary fistulse of vary- ing extent, length, direction, and course. 5. Diseases of the Tissues. 1. Inflammation, a. Catarrhal inflammation. It commonly com- mences with a more or less acute or inflammatory stage, and subsequently passes into a protracted or chronic (blennorrhoic) stage. It results from THE URETHRA. 179 chemical or mechanical irritation by substances that have been intro- duced from without, or it may be developed spontaneously in children from a scrofulous, or in aged people from a gouty diathesis, and in either it may be connected with impetigo ; l though it has its origin most fre- quently in gonorrhoeal contagion (gonorrhoeal catarrh). We find the anatomical characters to be those belonging to catarrh generally ; in the acute stage there is, according to the violence of the process, redness, injection, tumefaction of the urethral mucous membrane, or secretion of puriform mucus ; in the chronic stage there is tumefac- tion of the mucous membrane, enlargement of the follicles, relaxation of the sinuses, and a white or colorless secretion. The inflammation is either uniformly diffused over the urethra, or is limited to one or more spots. The latter is especially the case in genuine gonorrhoea of the male urethra ; we here find not only the navicular fossa, but every point as far as the prostatic portion, and especially the vicinity of the bulb of the urethra, liable to become the seat of the disease. When the gonor- rhoea is very violent and obstinate, a small tubercular swelling, which results from the deposition of fibrinous matter in the spongy tissue of the urethra, is found at these points of the urethra. This subject has not hitherto received the attention it deserves, either in regard to gonor- rhoea itself, or in reference to the pathology of stricture consequent upon gonorrhoea, and to the gonorrhoeal ulcer of the urethra. The terminations and consequences of gonorrhoea are various. The most common result, which is caused by great violence of the affection, by improper dietetic and therapeutic treatment, and by repeated attacks, is condensation and hypertrophy of the submucous tissue, fusion of the latter with the mucous membrane, and conversion of the corpus caver- nosum into a white, resistant, fibrous, cartilaginous tissue. The entire urethra sometimes undergoes this metamorphosis, subsequent to repeated and mismanaged attacks of gonorrhoea, but more commonly detached portions only are affected, and this gives rise to partial contraction or stricture. Stricture of the urethra occurs in various shapes : the urethra is some- times contracted to the extent of several lines, the parietes presenting a cartilaginous appearance, and the lining membrane being either smooth or having nodulated projections, or longitudinal folds ; sometimes the stricture forms a rounded protuberance or an angular band encircling the entire canal or only surrounding a portion of the circumference ; at others, again, it appears in the shape of an irregular cicatrix, which causes the surrounding mucous membrane to be puckered up. The strictures may be solitary, or after a recurrence of gonorrhoeal attacks, there may be two, three, four, and more. Their seat corre- sponds to the seat of the previous inflammation. We have a unique preparation in the museum of Vienna, of a urethra of a man who had repeatedly been affected with gonorrhoea; it presents numerous cartila- ginous protuberances from the size of a millet-seed to that of a pea, in part coalescing and scattered over the inner surface, as far back as the bulb, leaving the passage however of adequate dimensions. 1 [See note, p. 22. ED.] 180 ABNORMITIES OF The degree attained by the stricture varies ; we not unfrequently find it so excessive, that the contracted part scarcely permits the passage of the finest bristle. The essential character of stricture consists in the same alterations of this submucous and mucous tissue which we observe accompanying and following violent inflammation of the mucous membranes, when it involves the submucous cellular tissue ; it does not bear any specific character. The inflammation attacks the spongy substances of the urethra at those spots at which the diseased action was most deve- loped, and gives rise to a deposit of the fibrinous matter in its meshes, which induces the above-mentioned swellings in the urethra. If reso- lution does not ensue this product remains, and the corpus cavernosum is converted above it into a wheal, varying in extent, shape, and thickness, and consisting of fibrous and fibroid tissue ; this is the more liable to in- duce a narrowing of the urethra, as it possesses a great tendency to con- tract, and the liability increases in proportion as the sound layer of the corpus cavernosum diminishes. The stricture is most considerable when the corpus cavernosum is involved throughout its entire thickness. It is evident that when the metamorphosis affects the innermost layer of the corpus cavernosum only, the gonorrhoea may be followed by dilatation of the urethra, and we actually find this to be the case in violent though diffused gonorrhoea. The stricture, consequently, consists of the corpus callosum urethras, which is converted into a fibroid callus with which the mucous membrane, including its epithelial and submucous layer, has become identified. It is in no way related to cancer, and particularly not to so-called scirrhus. However, mechanical irritation frequently brings on excoriation, inflam- mation of the tissue, and ulceration, which in favorable cases may be put a stop to after the passage of the urethra has been re-established, though it often involves the deeper parts, destroys the urethra, and in- duces urinary fistulse. Strictures maintain a tendency in the urethral mucous membrane to inflammatory attacks, which gradually extend to the bladder, the urinary passages, and the seminal ducts. They also lead to a dilatation of the urethra beyond the contracted part, to dilatation and hypertrophy of the bladder, and dilatation of the ureters. Those excrescences which are termed warts by medical practitioners, and which are probably polypous or condylomatous growths of the urethral mucous membrane, and which are said to be particularly liable to accompany stricture, are another consequence of gonorrhoea. We have observed them very rarely. Lastly, we find gonorrhoeal inflammation degenerating into ulceration, causing the gonorrhoeal ulcer, which has not been as yet sufficiently in- vestigated in the dead subject, and which not unfrequently gives rise to very fine capillary fistulse. True polypi, particularly of the female urethra, probably occur as a consequence of repeated and tedious catarrhal affections. I have found them in one preparation in the prostatic portion of the male urethra. b. JEJxudative processes. In very rare cases we find primary croup oc- curring on the urethral mucous membranes ; it induces a circumscribed THE URETHRA. 181 or a tubular exudation, according to the intensity of the process, and occurs chiefly in children. In the course of hectic fever, brought on by suppuration in the vicinity, we occasionally see more or less numerous aphthous exudations and ero- sions on the urethral mucous membrane. c. Pustular inflammation. We frequently observe variolous pustules in the urethra, when the disease is very intense on the general tegumen- tary surface. As in other mucous membranes, it is accompanied by an exudative process of varying intensity. 2. Ulcerative processes. Besides the gonorrhoea! ulcer, the ulcerating stricture and the ulcerative processes, with which the urethra is attacked from without (the prostate), and to which it is more or less exposed in conjunction with the penis, we have to notice the primary syphilitic ulcer chancre of the urethra. Cicatrices left by ulceration, and especially by the last variety, must be carefully distinguished from gonorrhoeal stricture, though this is rendered extremely difficult, as the cicatrix almost invariably induces stricture. 3. Adventitious formations. In addition to the fibroid tissues occur- ring after gonorrhoeal inflammation, and especially in strictures, to the problematic carunculge or warts of the urethra, we find that tubercle and tubercular ulceration (Tuberculosis urethrse) are formed in the urethra, though only in conjunction with tuberculosis of the entire urinary appa- ratus. The urethra is also attacked by cancer and cancerous ulceration ; in the male sex this accompanies, or is the consequence of, carcinoma of the penis, and especially of the glans. 6. Anomalous Contents of the Urinary Passages. The anomalous contents of the urinary passages are very various, and may be classified as follows : 1. The products of the organic affections of the secretory as well as the efferent apparatus ; they are the more intimately mixed with the urine, the nearer the point of their formation is to the place where the latter is secreted, and the greater their capability of suspension and their solubility. 2. The deviations which the urine presents, independent of the first- mentioned admixtures, whether accompanied by a demonstrable disease of the renal texture, or unassociated with any traces of structural dis- ease : they result from an anomaly in the vegetative sphere, and espe- cially in the blood ; they may also occur as a passing effect of certain indulgences, and they relate to the quantity and quality, and particularly to the physical characters of the urine. In reference to 1, we have to notice : a. The blood and certain of its component parts. The former (hsema- turia) is found in the urinary passages, to a larger or smaller amount, in the shape of rounded or cylindrical coagula of varying consistency, or mixed with the urine in a fluid condition. It appears in consequence of various injuries involving the kidneys and the urinary apparatus, pro- duced by means of cutting instruments, concretions, ruptures, apoplexy of the kidney, the bursting of an aneurism into the urinary passages, or of varicose veins into the bladder, ulcerative corrosion of a vessel, or 182 ABNORMITIES OF bleeding carcinomatous growths in the urinary organs. It results from hypersemia, nephritis, Bright's disease, hemorrhagic inflammation of the passages, and from disorganization of the blood. Sometimes it is not true blood blood-globules but mere haematosine, which passes into the urine from the serum in the kidneys. We also find other constituents of the blood, such as albumen and fibrine, in the urine. Albumen is discovered in the course of numerous diseases both accom- panied by and unassociated with renal disease. In many acute diseases, albuminous urine is secreted with an excess of lithic acid, and lithate of ammonia. Albumen is sometimes found with sugar in diabetic urine ; it always occurs in hemorrhage into and inflammation of the urinary pas- sages, in hypersemia, nephritis, &c. It is found to a large amount in Bright's disease of the kidney, frequently mixed up with blood-globules, or hsematosine. Its presence is demonstrated by milky turbidity of urine, by the urine foaming when air is blown into it, by coagulation of the albumen on the application of heat, the addition of alcohol or nitric acid, &c. Fibrine is said to have been found in the urine in some cases of dropsy ; in the case of hemorrhage into the urinary apparatus it forms coagula of various shapes and sizes, which are easily recognized. b. Exudations in the urinary passages, assuming the shape of flocculi, laminse and tubular concretions. c. Grayish, milky, vitreous, colorless, purulent yellow (blennorrhoic) mucus, pus and sanies, may be intimately blended with the urine, caus- ing it to be variously discolored or turbid, or forming flocculent concre- tions, and loose, crummy, viscid, glutinous sediments. Mucus appears in the urine as the effect of acute, but more frequently of chronic catar- rhal inflammation of the urinary passages. Pus and sanies are the result of suppuration of the kidneys, with discharge of the abscess into the urinary passages, and of suppuration, and the formation of sanies in the latter ; or these fluids reach the urinary cavities from neighboring organs by ulcerated communications ; they may also be the consequence of gangrene, tubercular or cancerous degeneration. We also find in the urine, besides the above-mentioned substances, epithelial lamellae, tuber- cular matter, elementary cells of cancer, &c. d. It is stated that the urine contains a substance resembling cerebral fat, when the kidney is affected with medullary cancer. The immediate condition of this occurrence has not as yet been determined ; it is pro- bably essential that the morbid growth should have forced its way into the urinary passages, or that it should project into them. e. Ancient and modern observers have noticed that hairs are some- times evacuated with the urine ; they may be formed within or external to the urinary organs. /. Within the most recent period, Curling has discovered a new ento- zoon, the dactylius aculeatus, in the bladder. A very recent case is also given of the discharge of cysticerci with the urine ; acephalocysts are frequently carried into the urinary passages both from the kidneys and from other organs, and are evacuated with the urine. In reference to 2, we observe that the deviations of the urine, as re- gards quantity, may consist in excessive or diminished secretion ; if the THE URETHRA. 183 quantity found in the dead subject be small, it is requisite to ascertain the evacuations that have taken place before death ; if considerable, the obstacles to its discharge must be inquired into. Urine presents various anomalies as to quality, affecting both its physical and chemical pro- perties. a. The color of the urine is either too intense, owing to a large amount of coloring matter, which is generally combined with lithic acid or urea ; or it is very pale, and, at the same time, less acid or neutral. The urine assumes a red color from an admixture of blood or its coloring matter ; if there is at the same time an excess of acid, it may become reddish-brown, brownish-black, or in very rare cases, which are probably dependent upon an alteration in the hsematosine, it may even become perfectly black. Biliary matter produces a yellow, yellowish-brown, or even greenish discoloration. We must finally allude to those anomalous appearances of the urine produced by the consumption of various sub- stances that are rich in coloring matter, as beet-root, madder, rhubarb, gamboge, chelidonium, indigo, ink. The urine may at the same time be transparent or turbid ; the latter, in so far as it is independent of the above-mentioned foreign admixtures, is proportionate to the lithic acid or lithate of ammonia contained in acid, or to the phosphates in alkaline urine. b. The odor of urine is either more or less powerful than in the normal condition ; thus the pale watery urine is frequently almost with- out smell, whereas the saturated urine of acute rheumatism or of pneu- monia smells very strongly. Occasionally the urine presents the odor of broth or of whey ; in diabetes mellitus it has a spirituous smell, owing to the commencement of fermentation, or its odor resembles that of de- composed straw, of putrid matter, or is very pungent. Different odors are perceived after the consumption of asparagus, turpentine, the balsams, leek, assafoetida, &c. In diabetes mellitus, the urine has a sweet taste. c. Specific gravity. This is either above or below the normal stan- dard. It is excessive in diabetes mellitus, and very low in diabetes insipidus. In the chronic form of Bright's disease it is diminished, as the proportion of urea and of the urinary salts is diminished, at the same time that the albumen increases ; in the acute form it is not unfre- quently increased. 3. As regards the chemical composition of the urine, we find that the normal constituents exist in irregular proportions, or that there are new and unusual substances. a. The watery portion of the urine is in excess in numerous affections of the nervous system, in hysteria, in diabetes insipidus, and according to Rayer and older observers, in advanced age ; its quantity is too small in proportion to the solid constituents in the saturated urine of acute diseases, especially at the period at which critical discharges occur. b. The urea does not, as was formerly believed, bear a direct relation to the coloring matter of the urine, a fact that has been distinctly proved by Prout in some cases of diabetes insipidus. It is more frequently morbidly diminished, as in diabetes mellitus, in Bright's disease, and numerous other diseases that have not as yet been clearly diagnosed, and in which, as the urea disappears, albumen is substituted. 184 ABNORMITIES OF Original deficiency of urea is to be carefully distinguished from that deficiency which results from its decomposition in consequence of stag- nation in the urinary passages, from the influence of mucus, purulent secretion, and pus. c. Uric acid, either free or combined with a base, and especially in the shape of urate of ammonia, is deposited in the form of small crystals, or of a yellow or lateritious powder. It is increased in quantity in rheu- matism, gout, and inflammatory affections ; in hysterical urine, in the urine voided during the cold stage of intermittent fever, and in nume- rous other diseases, it is diminished in quantity. If free acid is present in the urine it may be precipitated in the shape of gravel, though not itself in excess. d. The phosphates (phosphate of lime, phosphate of magnesia, and triple phosphate of ammonia and magnesia) are often present in excess. Phosphate of lime is deposited in the absence of a free acid, and phos- phate of ammonia and magnesia, as a basic salt; these form the phosphatic sediments. As the latter salt is formed in consequence of the development of ammonia, it occurs principally in urine containing much mucus, pus, seminal fluid, and other animal substances that are easily decomposed. The lithic acid is, at the same time, proportionally diminished, and the urine is neutral or alkaline. e. The alkaline state of the urine is of extreme importance ; in many cases that have not as yet met with a sufficient explanation, it appears to be the result of a morbid secretion, or it depends upon decomposition of the urine, and presents various degrees. The urine in this condition is commonly pale and turbid. It is particularly alkaline in chronic in- flammation of the kidney, and in numerous diseases of the urinary pas- sages ; it is so sometimes in a slight degree, and temporarily, in Bright's disease. The alkaline state of the urine in diseases of the spinal cord, in paraplegia, has attracted some attention, and has given rise to the question, whether this alkalescence is the result of a simple derangement of the act of secretion, i. e. whether the urine is secreted as an alkaline fluid ; or whether an acid urine becomes alkaline in consequence of de- composition, by means of the products of coexistent cystitis or nephritis. The question has not received a satisfactory reply. Post-mortem exa- minations have generally demonstrated the existence of the latter series of causes of alkaline urine ; the examinations of the urine in living sub- jects have been either neglected in the class of cases that come under this head, or they have but little value, on account of the insufficient diagnosis of existing inflammation of the urinary passages and the kid- neys. The only proofs in evidence of alkaline urine being secreted by the kidneys, are afforded by the vivisections of Krimer and others, in which, after the division of the spinal cord, urine of the appearance of pure water was secreted ; and by the clear neutral or alkaline urine passed in hysterical or epileptic attacks. Rayer has found the urine acid in cases of recent paraplegia, unaccompanied by retention of urine. The following substances are rarely found as constituents of the urine : a. Purpuric acid, a modification of lithic acid, produced by the pre- sence of nitric acid, and purpurates (purpurates of ammonia and soda), which are said to give a red color to the urinary sediments (Prout). THE URETHRA. 185 /9. Hippuric acid (Liebig), which has been found in children in the shape of hippurate of soda, and in diabetes. Y. Oxalic acid is, according to Prout, the result of a decomposition of lithic acid, and occurs as oxalate- of lime, in the form of a greenish or blackish sediment, or of gravel or calculous concretion. d. Benzoic, butyric, and cyanic acid, cyanurin and melanurin in blue and black urine, xanthic oxide (Marcet), and cystin (Wollaston). e . Sugar, in varying proportions, in diabetes mellitus. C. Cholesterin. T). Numerous medicinal substances. The formation of calculous concretions in the urinary organs is a mat- ter of extreme importance ; it takes place within the kidneys, in the pelvis and calices of the kidneys, in the ureters, the bladder, the urethra, the urachus, and even externally to these passages. The pelvis and ca- lices of the kidney and the bladder are, however, the parts in which cal- culi are most frequently formed. The latter present considerable varie- ties, both as regards their physical properties and their chemical compo- sition. aa. When the concretions are very small they are termed gravel, and may be very numerous or few in number. Gravel may be formed at any part of the urinary apparatus, and even in the kidney. The red variety consists chiefly of lithic acid, the white of phosphates. Calculi are larger concretions, which again differ much as to volume and weight. In size they vary from that of a millet-seed to that of a goose's egg, or a fist. #3. Vesical calculi are generally of a globular, ovate, or oval form; they are frequently flattened so as to present a discoid or lenticular shape ; if two or more coexist, friction planes are formed giving the cal- culi when numerous, a polyhedral shape. Large renal calculi are moulded according to the form of their nidus, and assume a branched appear- ance. In rare cases the calculi are hollow, forming tubular or conchoid concretions. Their surface is either smooth or rough, angular or fis- sured ; or it appears decaying, gnawed, granular, of a mulberry form, or set with sharp, prickly projections, crystalline, &c. 77. The number of the calculi present varies ; there are generally several renal calculi, whereas vesical calculi are commonly solitary ; however, there are cases on record in which fifty, a hundred, nay, several hundred calculi, especially of the phosphatic variety, were found. 3d. In color, consistency, and texture, they vary much, and these qualities depend upon their chemical composition. The substances entering into the chemical constitution of urinary cal- culi are numerous ; sometimes one only form the calculus or predomi- nates, at others several are mixed up together, or disposed in layers. They are not all equally frequent. a. Lithic acid enters into the composition of most calculi, inasmuch as many consist entirely of it, many in part, and as it forms the nucleus of the majority. Lithic-acid calculi are commonly of considerable hardness, smooth, light or dark brown, rounded, and often flattened. p. Lithate of ammonia and lithate of soda rarely enter into the com- position of calculi. Those consisting of the former are yellow, and of a loose texture ; those composed of the latter are white and chalky. 186 ABNORMITIES OP Y. Phosphate of lime rarely forms a calculus by itself. #. Phosphate of ammonia and magnesia forms small, friable, white calculi, that have a shining crystalline investment. Calculi consisting chiefly of the two last-named substances and car- bonate of lime, are very frequent. They are white, of a loose texture, and often of a considerable size ; they are generally formed in conse- quence of inflammatory affections of the kidneys and urinary passages, which in their turn are frequently induced by the presence of a lithic- acid calculus, or some other foreign body, which serves as a nucleus for the calculous deposit. &. Oxalate of lime forms the mulberry-shaped, nodulated, dark-brown or black, and very hard calculi. C'. Xanthic oxide and cystine are very rare. The latter we generally find combined with fat, resin, coloring matter, iron, silica. In rare cases we also find fibrinous coagula, in the shape of carneous or fibrous elastic masses, entering into the formation of calculi. Vesical calculi are either contained free and unattached in the bladder or are firmly grasped by the bladder, which has become hypertrophied in consequence of catarrhal attacks. They are found encysted in hernial diverticula of the bladder, or lie in saccular expansions of the vesical parietes, which they form for themselves during the contractions of the bladder ; they sometimes become agglutinated to these and other parts by means of fibrinous exudations. Urinary calculi offer mechanical obstacles to the conduction and dis- charge of the urine, and give rise to inflammations of the kidneys and urinary passages, proportionate to the size of the calculi, and the rough- ness and irregularity of their surface. They are sometimes, even when of considerable magnitude, discharged by the natural passages, espe- cially in the female ; still they more commonly cause severe injuries of the urinary channels, rupture of the urethra, &c. At other times they make their way by inflammation and suppuration into neighboring cavi- ties, as into the rectum, the vagina, or into abscesses, and from these by unnatural passages outwards. In very rare cases we find urinary calculi enclosed in cartilaginous capsules external to the urinary passages, having either forced their way out of the latter by rupture or ulcerative perforation, or having been formed at the spot where they are discovered, in urine that has been previously extravasated. Appendix. Diseases of the Suprarenal Capsules. The suprarenal capsules are occasionally deficient, especially when there is a deficiency in other organs also. They are not always absent in acephalous monstrosities ; and as their absence generally involves the absence of numerous other organs, the fact suggests no distinct inter- pretation as to their functions. They are, moreover, generally present when one kidney is absent, and this proves that they are perfectly inde- pendent of the kidneys and the sexual organs (Meckel) ; their diseases place them in a more distinct relation with the lymphatic glands. THE URETHRA. 187 The fusion which often occurs in the kidneys is not found to take place in the suprarenal capsules. Accessory suprarenal capsules, indicating an apparent excess of de- velopment, are of frequent occurrence. Several flattened acessory su- prarenal capsules are then found in the renal and solar plexuses, and on the ganglion of the latter, varying in size from a millet- or hemp-seed to that of a pea. They are occasionally of great magnitude, a circumstance which calls their foetal condition to mind, though it may result from morbid affec- tions. On the other hand they may be small ; and this may equally be the consequence of a congenital or an acquired anomaly. A reduction of size occurs in the shape of marasmus in advanced age, or at an earlier period of life ; the organ shrivels up, becomes tough and coriaceous, its cortical substance assumes a dirty yellow color, its vascular medullary substance is obliterated ; or in some cases it becomes friable, of the color of the lees of wine, or of a rusty brown, so as to resemble the spleen of old persons. The atrophy may also be the consequence of textural changes, appearing after inflammation in the shape of induration or obli- teration. The form of the suprarenal capsules is subject to various unimportant deviations ; in reference to their position we have to remark, that they do not follow the congenital dislocations of the kidneys, but in these cases invariably retain their normal position. Their textural diseases have hitherto met with little consideration. Hemorrhage not unfrequently occurs in them, on account of the vascu- larity of their medullary substance. The suprarenal capsule is found distended in proportion to the amount of extravasation caused by the rupture of a vein ; and according to the period that has elapsed since the occurrence of the hemorrhage, we find the blood, more or less discolored and changed in constitution, enclosed within the cortical substance, which has become pale and atrophied, and is finally converted into a fibroid layer. We scarcely ever have an opportunity of observing inflammation of the suprarenal capsules, except in its terminal stages, suppuration and induration. Some observers have found the suprarenal capsules con- verted into purulent pouches in the new-born infant, and even in the foetus (Andral). The morbid growths not unfrequently seen, are : tubercle and cancer- ous degeneration ; both, and particularly the latter, are found com- plicated with similar affections of other organs, and especially of the lymphatic glands. Tubercle commonly appears deposited in the suprarenal capsules in large masses, and either fuses into pus enclosed in a callous sac, or is converted into a chalky concretion, invested by a fibroid tissue, in which all traces of the proper tissue of the organ have disappeared. Cancer commonly appears in the form of medullary carcinoma, which very frequently involves the neighboring glands of the lumbar plexus, and the kidney, and causes a considerable enlargement of the suprarenal capsule. Hemorrhage occasionally takes place within the parenchyma 188 ABNORMITIES, ETC. of the cancerous growth, and causes it to be broken down into a choco- late-colored pulp. It frequently happens that the suprarenal capsules become adherent to the kidneys in consequence of inflammation, or of other diseases asso- ciated with inflammatory reaction. A much rarer, though very interest- ing, occurrence is congenital union of the two organs, in which case one tunica albuginea invests the two, and the concave surface of the supra- renal capsule adheres to the kidney by means of short, tense, vascular, cellular tissue. PART III. ABNOEMITIES OF THE SEXUAL OKGANS. CHAPTER I. ON ABNORMITIES OF THE SEXUAL ORGANS GENERALLY. THE sexual organs are occasionally entirely absent ; a defect that is commonly associated with imperfect development of other parts, and especially with acephalia ; a more or less important section of the appa- ratus is often defective, and one of the symmetrical organs, or one half of those organs which unite in the mesial line, may he absent ; or again, one of these organs, or halves of organs, may be imperfectly developed, and its cavity contracted or closed up ; or the apparatus may be com- plete in its different constituent portions and not have been duly deve- loped, remaining permanently small and inefficient, so that the individual presents no sexual character. Another defect of the sexual organs assumes the form of fissure, which is an arrest of various stages of embryonic development. The highest degree of this malformation is presented in the cloaca, which is to be ex- plained as a persistence of the original sinus urogenitalis, or an imperfect separation of the parts that form the latter. A lower degree of this species of deformity is presented in the fissured condition of the sexual organs, in which case the foetal or female character predominates ; we allude to the various fissures of the uterus, of the vagina, the penis, the urethra, or the scrotum, with or without a residuary trace of the urogeni- tal sinus. From these latter, apparently hermaphroditic formations, which de- pend upon an arrest of development, those pseudo-hermaphroditic forma- tions, which consist in an excessive development of certain portions of the female organs of generation according to the male type, form a transi- tion to true hermaphrodisia, i. e. hermaphrodisia per excessum ; in which case certain portions of the sexual apparatus of an opposite sex are superadded. In addition to the just-mentioned excess of formation we meet with another form in the shape of a repetition of certain sections of the appa- ratus, which may either present itself as excessive development of volume, or as precocity. Besides congenital deviations of size, we find many that are acquired ; in addition to those varieties which depend upon textural diseases, and particularly upon adventitious growths, they occur in the shape of hy- pertrophy and atrophy. The uterus in the female, the prostate in the male sex, are particularly liable to be affected by the former ; the latter, independently of the process of involution (tabes senilis), which more or 192 ABNORMITIES OF THE TESTES less uniformly involves the generative system, especially attacks the testes and the ovaries, and in a second degree the uterus. The sexual organs are subject to numerous congenital deviations as to form ; the uterus and its cavity are peculiarly liable in the female, the prostate in the male sex, to acquired malformations. The position of the external sexual organs depends upon the congenital or acquired degreee of inclination of the pelvis, and other malformations. The most important congenital deviation of position of single organs affects the testes ; the uterus presents very important acquired irregu- larities of this class. Diseases of the tissues are peculiarly frequent in the female organs of generation ; and among them the adventitious growths are most remark- able. We shall have occasion to advert in detail to many points of in- terest, relative to the morbid growths occurring in the sexual organs of either sex. CHAPTER II. ABNORMITIES OF THE MALE ORGANS OF GENERATION. SECTION I. THE TESTES AND VASA DEFERENTIA. 1. Defect and Excess of Formation. The testes are absent when the entire sexual apparatus is absent ; sometimes they are wanting when the other parts are defectively developed, or are represented by a few coils of a seminal duct : lastly they may be in existence, but of small size, and incapable of further growth. In this case the epididymis is particularly small, its ligament elongated, and the entire organ apparently broken up. This is very commonly the case when the testes remain in the abdominal cavity or in the inguinal canal, and there is an apparent absence of testicles (cryptorchis). The vas deferens may present a malformation, and after diminishing gradually, terminate blindly at some distance from the vesiculge seminales and generally in the inguinal canal. Excess of development, in the shape of a plurality of testicles, is un- doubtedly very rare : the fact itself is not supported by sufficient proofs. 2. Deviations of Size. Increase of size of the testicles depends upon hypersemia, upon inflammation and its consequences, i. e. upon the in- flammatory enlargement itself, and the residuary product of inflamma- tion and induration upon hypertrophy of the cellulo-fibrous stroma, and upon morbid growths and degenerations of the organ. Enlargements of the testicle are to be carefully distinguished from dis- tension of the tunica vaginalis. Besides congenital smallness of the testicle, dependent upon arrest of development, we not unfrequently meet with atrophy of the testicle. It AND VASA DEFERENTIA. 193 occurs not only in the shape of marasmus senilis, accompanied by flabby texture of the organ and a dirty yellow color of its tissue, but is found at earlier periods of life as a consequence of exhaustion, of gonorrhceal neuralgia of the testis, and from unexplained influences in the tropics (Larry). The testicle also becomes atrophied in consequence of pressure exerted by effusion in the vaginal sac, by large hernise, by exudations within its substance, and by morbid growths. 3. Deviations of Position. We have to notice the foetal position of the testicles within the abdominal cavity, or in the inguinal canal (crypt- orchis). It is important both from being commonly associated with de- fective development of the testicle, and on account of the doubt arising as to the sex of the individual, as well as on account of the descent of the testicle, which commonly occurs about the period of puberty, and the consequent occurrence of (congenital) inguinal hernia. In rare cases the descending testicle does not pursue its regular course ; it either passes under the crural arch, or sinks into the pelvic cavity. 4. Diseases of the Tissues. 1. Inflammation. a. Inflammation of the testicle is a common occur- rence ; but nevertheless, rarely a subject of cadaveric investigation. It may be either primary, secondary, or metastatic. It may also be acute, or, as is more frequently the case, chronic ; it either attacks the entire testicle, or the epididymis, or single lobules of the former chiefly. Accordingly, the tumefaction of the organ is either uni- form or irregular ; its tissue is at first more or less reddened, injected, and according to the coagulability of the inflammatory product, either firmer or looser than in the normal condition. Acute inflammation not unfrequently passes into suppuration ; the chronic form more frequently ends in induration and permanent enlarge- ment of the organ. The orchitic abscess not unfrequently discharges ex- ternally by one or more openings, after inducing perforation of the tunica albuginea, and of the agglutinated lamellae of the tunica vaginalis. The inflammatory product becomes more or less organized, and converted into a fibroid cartilaginous mass, and the resulting induration induces atrophy of the testicle. b. Chronic inflammation affecting the tunica albuginea, and its pro- cesses, in rare cases induces considerable thickening of this fibrous sheath, hypertrophy of the fibro-cellular tissue within the testicle, enlargement and morbid induration of the latter, and finally atrophy of its proper tissue. The progress of inflammations of the testicle would appear to be some- times impeded, and a cure brought on, by the pressure which an effusion into the tunica vaginalis exerts. 2. Morbid groivths. a. We have already found that fibroid tissue occurs as a consequence of chronic inflammation, and its termination in induration. b. The formation of cysts is very unusual, a fact that acquires special interest from the frequency of their occurrence in the ovaries. c. Enchondroma is equally rare. VOL. II. 13 194 ABNORMITIES OF THE d. An anomalous osseous substance is sometimes developed in the in- durated testicle, i. e. in the fibroid tissue ; and assumes the shape of round, tuberculated, or tendiniform concretions. e. Tubercle. Tubercle not unfrequently attacks the testicle primarily, and its chief seat is the epididymis. From this point it not only spreads to the vasa deferentia, the vesiculae seminales, the prostate, and the glands that are connected with the organs of generation generally ; but also to the lymphatics of the abdomen, the thorax, and even of the neck, on the one hand, or on the other to the urinary organs, in the manner pre- viously described (p. 161). In the former case we find the glands ag- gregated or strung together in large, shapeless, nodulated masses, and infiltrated with cheesy tubercular matter. Tubercle is developed in young subjects who are predisposed to tuber- cular affections, in consequence of excessive or unnatural gratification of the sexual desires. The pathological anatomist has been unable to de- monstrate its connection with gonorrhoea, or. in other words, to prove the blennorrhoic character of the general morbid affection, as well as of tubercle itself; and we, therefore, consider the gonorrhoeal theory of orchitic tubercle to be wanting in a most essential point. The affection proves fatal, either by the universal atrophy induced by the effusion of tubercle throughout the lymphatic system, or by the su- pervention of more or less acute tubercular deposition in the urinary organs, in the lungs, on the peritoneum, and in the spleen. Orchitic tubercle generally appears in the shape of rounded nodules, of the size of a millet- or hemp-seed, or a pea, which coalesce into larger masses ; they scarcely ever undergo a retrograde metamor- phosis, but fuse, and thus establish tubercular suppuration or phthisis orchitica. The increase in size of the testicle varies according to the number of the individual tubercles, and more still according to the size of the tubercular conglomerations. Its surface is irregular and nodulated. The tissue surrounding the tubercle and the tubercular abscess becomes cartilaginous, lardaceous, and tough. In the same manner as elsewhere, and especially in the lungs, we find inflammation of the serous investment supervening upon tubercular af- fections ; thus the tunica vaginalis testis is liable to attacks of inflamma- tion, accompanied by tuberculizing exudation of various forms. Tubercle of the testicle is of extreme interest as contrasted with the immunity from tubercle enjoyed by the ovary. /. Cancer. All the varieties of cancer undoubtedly occur in the tes- ticle, but both according to my own observations and those of others, medullary carcinoma is the most frequent. It always gives rise to very extensive degeneration, is very soft, and presents fluctuation ; sometimes it perforates the tunica vaginalis and the skin, and is thus converted into an open cancerous sore. It generally so completely takes the place of the proper orchitic tissue that no trace of the latter is left ; still many cases occur in which it oc- cupies the interstices of the hypertrophied fibro-cellular stroma of the testicle. It is peculiarly liable to a complication with renal cancer, and also with medullary growths in the cellular tissue surrounding the pelvis and the hip-joint, with medullary retro-peritoneal growths, and finally with universal cancerous cachexia. VESICUL^E SEMINALES. 195 The frequency of its occurrence in the testicle, especially as a primary affection, is of interest when contrasted with the rarity of its appearance in the ovary, and with the frequency of cysts and the allied form of areolar cancer, in the latter. The vas deferens is generally attacked by disease extending to it from the testicle, or the vesiculse seminales ; it is found to be affected by in- duration and thickening of its coats and ossification, which probably re- sult from inflammation, by tubercle, and cancerous degeneration. Appendix. Abnormities of the Tunica Vaginalis Testis. In consequence of an arrest of development, the cavity of the tunica vaginalis may remain in communication with the peritoneal cavity, and thus give rise to congenital inguinal hernia. All the diseases affecting the tissue of serous membranes are found to occur here ; inflammatory affections of every degree and variety, followed by the most various effusions, are common ; and of the sequelae, adhesion by means of various tissues of new formation, and ossification of the fibroid exudations, are not unfrequent. Among the morbid growths we notice the anomalous fibroid and osseous tissues in the form just mentioned, as well as subserous, fibro-cartilagmous, and osteoid formations, which we sometimes find as free corpuscles in the tunica vaginalis, and tubercle, occurring especially as tubercular exudation ; this must be distinguished from tuberculosis of the testicle, with which, however, it is often coinci- dent. Dropsy of the tunica vaginalis, or hydrocele, is a common disease, oc- casionally brought on by varicosity and stasis in the venous network of the testicle and the spermatic cord, in which case it has the character of a passive accumulation ; sometimes it is the result of slight inflammatory affections of the serous membrane. SECT. II. ABNORMITIES OF THE VESICULJS SEMINALES. 1. Arrest and ^Excess of Development. The vesiculae seminales are absent when the testicles are deficient, and are more or less abortive when the testicles are imperfectly developed. It is stated that they have been found increased in number in cases in which there were supernumerary testicles. 2. Deviations of size. Of calibre. Under this head we class, on the one hand, the dilatations of the vesiculse seminales and ductus ejacu- latorii, resulting from continued catarrhal irritation, which, according to Lallemand, accompanies spontaneous discharges of semen, and on the other, the atrophy and obliteration of the vesiculae seminales, which may, but does not necessarily, follow removal or atrophy of the testicle. 3. Diseases of the Tissues. 1. Inflammation. We not unfrequently have opportunities of observ- ing, in the dead subject, the effects of chronic catarrh and its sequelae, 196 ABNORMITIES OF upon the vesiculae seminales ; they are, especially, tumefaction and re- laxation of their mucous membrane ; secretion of a grayish or yellow purulent mucus (blennorrhoea), dilatation, and, finally, thickening of the parietes. In rare cases we find those portions of the inner surface in which the mucous membrane has been destroyed by suppuration, covered by a whitish or slate-colored, reticular pulp, of a cellulo-fibrous texture, the parietes considerably thickened and cartilaginous, and the cavity contracted and obliterated. This inflammation as rarely degenerates into ulcerative perforation of the vesiculae seminales, the formation of abscesses in their cellulo-fibrous nidus, into destruction of a neighboring coil, or communication of two contiguous tubuli. Chronic catarrh occurs chiefly in advanced age, accompanying mechani- cal hypersemia of the pelvic veins, stasis, varicosity, and the formation of phlebolithes ; as a consequence of chronic vesical catarrh, as a result of repeated gonorrhoeal catarrh of the urethra and the neck of the blad- der, of excessive venery, and especially of masturbation. 2. We find a low state of irritation developed in a similar manner in the cellulo-fibrous substratum of the vesiculse seminales ; this induces con- densation and hypertrophy in the latter, and causes its adhesion to the vesiculge seminales, which thus become fixed. 4. Morbid Growths. 1. Bony matter is sometimes deposited in the indurated coats of the vesiculse seminales, as well as in the terminal portion of the vas deferens (ossification). x 2. Tubercle. Tuberculosis of the mucous membrane of the vesiculse seminales is not an unfrequent disease. When seen in the dead subject, the disease has generally attained such a degree that the mucous mem- brane appears converted into a thick, yellow, cheesy, lardaceous, fissured, purulent layer of tubercular matter, filling up and closing the passage of the seminal vesicles, whilst the superficial layer of their coats is conside- rably thickened, and infiltrated with a lardaceous substance. The exter- nal investment occasionally becomes the seat of tubercular deposit, and, as this fuses, suppuration and perforation of the seminal vesicles are in- duced. Tubercular disease is associated with tubercle of the prostate, the tes- ticle, and the lymphatic glands that belong to the sexual apparatus, as well as with tubercle of the uropoietic system. It prevails during the prime of life, and appears never to occur before puberty ; in this it differs essentially from tubercular disease of the uterus and the Fallopian tubes. 3. Cancer affects the vesiculse seminales only by extension from neighboring organs. 5. Anomalies of the Contents of the Vesiculce Seminales. The seminal fluid may present various irregularities ; it is found mixed with a greater or less quantity of colorless, vitreous, grayish, yellow, puriform mucus, and with pus ; if the inner surface of the vesiculse seminales has undergone any change of texture there may be hemorrhagic exudation, tubercular pus, cancerous sanies, and, lastly, calculous concretions. The pus and sanies may, as in the ductus ejaculatorii, be introduced from THE PROSTATE. 197 neighboring abscesses, especially of the prostate, after perforation has taken place. SECT. III. ABNORMITIES OF THE PROSTATE. The prostate is generally found to be small when the organs of gene- ration are in an imperfect condition. Its most important anomalies con- sist in : 1. Abnormities of Size. And of these the most common is enlarge- ment, resulting from hypertrophy. It is one of the most frequent causes of the urinary obstructions occurring in advanced life. The substance of the gland in these cases appears normal, occasionally a little softened, of a spongy elastic consistency, and succulent, i. e. its ducts contain much secretion ; in other cases it appears tough and coriaceous, without visible alteration of structure. The formation of fibroid tumors (vide p. 198) is often complicated with this benignant variety of enlargement. The enlargement varies much in degree ; occasionally it is so consider- able that the gland attains the size of a fist. The lateral lobes are the chief seat of the enlargement, which affects both uniformly, or predomi- nates on one side ; but the development of a so-called middle lobe (Home) is of greater importance, in reference to the impediment it offers to the discharge of the urine ; it not unfrequently predominates in a most re- markable manner, even when the hypertrophy affects the entire gland. It rises from the posterior section of the prostatic ring, between the two lateral lobes, and, according to its size, projects more or less into the cavity of the bladder. It presents the appearance of a rounded tumor, of the size of a bean, or hazel-nut, which projects into the neck of the bladder ; it may increase to the size of a walnut, hen's or duck's egg, or more, and then protrudes into the cavity of the bladder in the shape of a smooth or rough, nodulated, slightly lobular, rounded or cqrdiform, pyramidal or cylindrical tumor. All enlargements of the prostate impose an obstacle to the passage of the urine, both by narrowing the neck of the bladder and the prostatic portion of the urethra, as well as by inducing a change in the direction of the channel, by diminishing its calibre, and by dividing it. The last two malformations are more particularly the result of unilateral develop- ment of the gland, and of increase of its middle lobe. The former not only produces a lateral contraction and deformity of the canal in the vertical direction, so as to produce a sickle-shaped fissure, but forces it out of the mesial line to the opposite side ; the middle lobe not only obstructs the internal orifice of the urethra, but often narrows the neck of the bladder by pushing it on one side, or divides it into two diverging passages, which reunite in the prostatic portion of the urethra. The results of this enlargement are hypertrophy of the bladder, dilata- tion of the urinary passages, &c. A diminution of the prostate, with relaxation of the glandular tissue, is observed in rare cases, as accompanying atrophy of the testicles. 2. Diseases of Tissue. 1. Inflammation. An opportunity is scarcely ever presented of study- 198 ABNORMITIES OF ing inflammation of the prostate in the dead subject, except in its results, suppuration and abscess, or induration. The former occurs not unfre- quently as the issue of chronic inflammation, which exacerbates from time to time. The abscesses, which vary in size and number, generally discharge themselves into the bladder, into the prostatic portion of the urethra, in which case the ejaculatory ducts are destroyed, into the vesi- culse seminales, the surrounding cellular tissue, or the rectum ; or they force their way along the urethra to the penis, or into the scrotum. 2. Morbid growths. a. We have never observed the formation of cysts in the prostate. 5. Fibroid tumors occur frequently, and generally induce considerable hypertrophy of the gland. They are commonly of the size of a pea, a bean, or a hazel-nut, round or oval, and when deposited in the peripheral layer of the gland, give rise to nodulated protuberances. Although they do not attain an extraordinary magnitude, they are of interest, on account of the relation they bear to analogous growths in the uterus. c. Tubercle. Tubercle of the prostate is always complicated with tubercle of the testis, of the vesiculae seminales, and of the allied lym- phatic glands. The softening process gives rise to tubercular abscesses, which are enlarged by the fusion of secondary tubercular deposits and thus extend beyond the gland, causing the devastations spoken of under the head of abscess. d. Cancer. Cancer in any shape rarely occurs in the prostate, which is curious as contrasted with the frequency of its occurrence in the uterus. Medullary carcinoma is occasionally found to attack the prostate, and to give rise to considerable enlargement of the gland ; it may sometimes perforate the fundus vesicae, and sprout into its cavity, causing a cancer- ous ulcer with raised edges, and of varying size. 3. Anomalous contents of the prostatic ducts. The prostatic ducts, in advanced age, very often contain calculous concretions ; they are gene- rally very minute, resembling fine sand or poppy-seeds, rarely attain the size of millet-seeds, and still less frequently form conglomerations of the size of hemp-seeds or peas. They present a black, blackish-brown, or yellowish-brown color, are very hard, and generally glossy. Their num- ber varies, but is often considerable, and a section of the gland shows them more or less uniformly scattered through its tissue. The gland at the same time appears very juicy, and the ducts are more or less dilated. SECT. IV. ABNORMITIES OF THE PENIS. 1. Defect and Uxcess of Formation. The penis may be smaller than usual, whilst the remainder of the sexual organs are normal, or them- selves imperfectly developed, or it may present some further anomalies depending upon an arrest of development ; in the latter case it is reduced in length, as is the case in hypospadiasis and hermaphrodisia ; the penis then bears a resemblance to the clitoris. Fissures of the penis, or rather of the urethra, which sometimes extend to the glans, and to the penis itself, are important. They are termed hypospadiasis and epispadiasis, the former of which is by far the most THE PENIS. 199 common. Both present various degrees, but the first is particularly liable to variations. We here find the fissure affecting a greater or less extent of the urethra from the glans backwards, or even involving the entire penis together with the scrotum } the penis remains in a corresponding state of imperfect development as to size and form ; the prepuce is also fissured and small, the glans divided ; in higher degrees, the smallness of the organ, the total absence of foreskin, the retraction of the scrotal fissure, and the imperforate condition, induce a resemblance to the cli- toris ; and mistake as to the sex of the individual will be the more likely to occur if the scrotal fissure leads to a cul-de-sac simulating the vaginal passage. Epispadiasis is a very unusual occurrence, and is either limited to the glans or extends over the entire urethra ; in the latter case it is complicated with eversion of the bladder (fissure of bladder). Excess of development, except as more or less remarkable enlargement of the penis, is very rare ; the few observations recorded of two perfect penes placed beside or above one another are not to be credited. 2. Deviations of Size. Atrophy of the penis, accompanied by obli- teration of the tissue of the glans and the corpora cavernosa, deserves notice ; it is probably always associated with atrophy of the testicles. An apparent diminution of the penis is presented in the retracted state, induced by large scrotal hernise, sarcocele, hydrocele, oedema of the scro- tum, &c., in consequence of the relaxation and advance of the common integument. 3. Diseases of the Tissues. They affect the glans and the corpora cavernosa of the penis. We meet with mechanical hyperaemia of all the spongy tissues as an accompaniment of most of the advanced stages of organic heart diseases ; we find a similar tumefaction of these parts in cases of asphyxia, espe- cially when produced by strangulation. Inflammation of the cutaneous investment of the glans, which is gene- rally complicated with inflammation of the internal lamina of the fore- skin, gives rise to excoriation, exudation of coagulable lymph, adhesion of the prepuce to the glans, suppuration, and ulceration ; when chronic, it induces exuberant formation of epidermis, and if the deeper parts of the parenchyma of the glans are involved, obliteration, cartilaginous induration, and atrophy follow. Inflammation of the coronal follicles in- duces increased secretion of a fluid, corroding smegma, and follicular ul- ceration. Ulcers of a specific character present deep, white, striated, more or less hard, cartilaginous cicatrices, which vary according to the size of the ulcerated surface, and the intensity of the surrounding reaction. Inflammation of the corpora cavernosa, though of rare occurrence, is brought on by contusions or by gonorrhoeal metastases ; it occasionally terminates in obliteration of the cells, and, by means of the inflammatory product, in the conversion of the latter into a cellulo-fibrous cicatrix ; the uniform turgescence of the penis in erection is thus permanently impeded. Among the morbid growths, we have to notice the warts occurring on the glans, and carcinoma, and carcinomatous ulcers on the glans and the 200 ABNORMITIES OF corpora cavernosa ; the former occur frequently, the latter very rarely. Cancer appears chiefly to assume the medullary form ; it gives rise to considerable malformation and enlargement, and to ulcerative destruction of the penis. We find an anomaly in the secretion occurring in the shape of abun- dant discharge of sebaceous matter, which, in the case of phimosis or a neglect of cleanliness, accumulates on the glans and round the corona in the shape of lamellae and tubercular masses, and, after long stagnation and decomposition, brings on inflammation, excoriation, and ulceration, or becomes inspissated, so as to form calculous concretions (calculi glandis). SECT. V. ABNORMITIES OF THE CUTANEOUS COVERING OF THE PENIS AND THE SCROTUM. 1. Defect and Excess of Formation. As a defect of formation, we notice the occurrence of extreme shortness or contraction (phimosis) of the prepuce; fissure and entire absence of the foreskin in hypospadiasis, and the clitoroid arrest of development of the penis. The scrotum is small when the sexual apparatus is imperfectly developed, and in cryptorchis, and is sometimes only represented by a slighthly corrugated cutaneous fold, which shows an almost imperceptible raphe, and occasionally con- tains adipose cellular tissue. In hermaphroditic formations it is fissured and resembles the labia of the female genitals, in those cases especially in which the two halves are empty, viz., when the testicles have been retained in the abdomen or in the inguinal canals. Excess of development occurs in the penis in the shape of exuberant formation of skin, as a very long foreskin (occasionally characteristic of a particular race), in the scrotum as considerable enlargement, and in either as extreme thickness of the common integument, with an unusually well-marked and projecting raphe, which is continued upwards on the penis; there is also an accumulation of the tissue of the tunica dartos and of the subcutaneous cellular tissue. 2. Anomalies of Size. Besides the congenital anomalies we have to notice the acquired enlargement of the scrotum resulting from hyper- trophy of the tunica dartos, sarcocele, or elephantiasis, accompanied by fibrous induration ; in Egypt more especially it attains the most enormous dimensions. 3. Diseases of the Tissues. The common integument of these parts is liable to the primary and secondary diseases to which the skin gene- rally is subject ; but it is also liable to primary and secondary inflam- matory process of a specific character, to ulcerative disorganization, to induration and condensation, and even to gangrenous destruction. Paraphimosis of the prepuce resulting from inflammatory swelling, and the ulceration which causes the glans to pass through the ulcerated open- ing, and denudes the glans of its foreskin, deserve special mention. The scrotum is frequently attacked by metastatic processes and by gan- grene ; it is remarkable for the facility with which it is reproduced ; it is also subject to leprous degeneration, discoloration, and to chimney- THE VAGINA. 201 sweeper's cancer. The tunica dartos is variously affected in the above- mentioned processes ; it is also found to be the seat of oedema, of san- guineous effusion (haematocele), of urinary infiltration, suppurative in- flammation, fibrous induration, which is sometimes confined to the sep- tum scroti, of urinary fistulas, and of various morbid growths. CHAPTER III. ABNORMITIES OF THE FEMALE SEXUAL ORGANS. THE EXTERNAL GENITALS. SECT. I. ABNORMITIES OF THE PUDENDA. ARREST of development occurs in the shape of total absence of the pudenda ; absence or defective development, i. e. unusual smallness of individual parts, the labia majora andminora, or the clitoris; absence of the rima or of the commissures, i. e. unusual fissures, such as we see at the superior commissure, accompanied by eversion of the bladder and separation of the symphysis pubis. Excess of development is met with as uniform or partial congenital enlargement of the labia, nymphae, and clitoris, causing the latter to re- semble a penis ; as increase in the number of individual parts, as of the nymphae, and as precocious or extravagant development during puberty. Congenital anomalies of form affect particularly the nymphae ; like the acquired anomalies, they present several varieties. The diseases of tissue are primary or secondary ; they consist in me- tastatic inflammatory processes, varying in degree and rapidity, accom- panied by increased sebaceous secretion, great epidermal development, excoriation, oedema, superficial and profound suppuration, condensation and induration, gangrene of the external and internal labia ; we meet with specific circumscribed inflammation and ulceration of the latter ; among adventitious products, condylomatous excrescences occur in them and on the clitoris, varying in size and number, and occasionally pro- ducing extreme deformities. We also find hemorrhagic effusion occur- ring within the labia spontaneously, or in consequence of external violence (sanguineous tumors), and, besides steatomatous (fibroid) tumors, all the adventitious growths occurring in the cellular tissue at large. SECT. II. ABNORMITIES OF THE VAGINA. 1. Defect and Excess of Formation. The vagina may be totally absent, or partially deficient ; in the latter case there is a cul-de-sac opening externally, or the vagina terminates blindly at a greater or less distance from the labia, or opens posteriorly into the urethra in this instance the development takes place from both points, but an intervening 202 ABNORMITIES OF portion is defective, thus forming a transition to congenital atresia. When the other parts of the sexual apparatus are atrophied, or certain of its sections, as, for instance, the clitoris, approach the male type, or in cases of hermaphrodisia per excessum, the vagina is not duly developed, and is found rather narrow than short, smooth, and without rugae. We must here allude to an apparent excess of development, called the double vagina, or division of the vagina into two channels which lie in juxtaposition to one another. It is produced by a vertical septum that descends along the mesial line of the vagina ; and in a low degree is indicated by a more ridge-like elevation of the columnar rugae. The division of the vagina may be complete, and is then associated with divi- sion of the uterus and its orifice, and with a double hymen ; or it may be incomplete, and in this case the septum ceases above, and the fornix vaginae is common to both passages, the os tincae being at the same time single or double ; or else the septum does not reach down to the vaginal entrance, which is protected by a single hymen, and the vagina is single to a greater or less extent ; or, lastly, the septum is incomplete, inasmuch as it presents partial defects. The deviation of the septum from the mesial line, which occurs in rare cases, is of interest and importance ; the passage on one side may then be imperfect, or have a blind termina- tion above or below. The following case, taken from our collection, is an instance : Sexual organs of a very imperfectly-developed female of fifteen, who was covered with scrofulous ulcers and cicatrices, and died of tubercular phthisis of the lungs and the intestines. Two very delicate, elongated, fusiform uteri, each provided with one Fallopian tube and one large ovary, unite at the point of the internal orifice at an obtuse angle (uterus bi- cornis), and are from this point separated by a vertical septum, so that each cervix has its distinct vagina. The two vaginae descend on both sides of a septum, which is a continuation of the septum uteri, down to the external pudenda, which are closed by a single hymen, the left vagina being considerably wider and presenting larger rugae than the right. The latter terminates at about the middle of the entire vagina, in a blind sac formed by the septum ; the left vagina immediately bulges out to the right in the shape of a single canal. The external organs are, like the uterus, in an extremely undeveloped condition. It is a curious coinci- dence that the right kidney was absent, the left being at the same time enlarged, and its hilus directed forwards. The hymen is often too large, owing to excess of development, so as almost to close up the entire passage ; it deviates at the same time from its normal shape and mode of attachment, inasmuch as it is generally connected with the internal labia by a small round column, by which means two orifices are formed which lead into the vagina. 2. Anomalies of Size. The congenital anomalies involve a greater or less dilatation, such as we find to be peculiar to some nations ; and the contraction which we have spoken of above, the highest degree of which is complete closure. Congenital atresia, which we have above classed with partial defect of the vagina, is commonly produced by an enlarged hymen, or, in excep- THE VAGINA. 203 tional cases, by a horizontal or obliquely placed membrane, which oc- cupies different parts of the passage ; if carefully examined we should probably find that it was formed by the adherent parietes of a vagina, ending above and below in a cul-de-sac. This form of atresia would, in that case, have to be considered as partial (and slight) deficiency of the vagina. The acquired irregularities appear, on the one hand, as unnatural elongation or dilatation ; on the other, as shortening or narrowing, amounting even to complete obturation. The vagina is liable to a uniform or partial elongation, with disap- pearance of the rugae and diminution of its arch, in consequence of traction exerted by the uterus or ovaries, owing to uterine tumors or enlarged ovaries that mount into the abdomen, or to morbid growths that force those organs upwards. Prolapsus uteri, tumors projecting into its cavity, especially fibroid tumors, polypi of the uterus, pessaries, and the like, induce dilatation of the vagina. Shortening or narrowing is the result of injury and loss of tissue that has been intentionally or accidentally induced, of ulceration and the resulting cicatrices. The vagina is also narrowed when the passage is elongated by traction, and its cavity is diminished when the cervix uteri becomes atrophied. Acquired atresia may be complete or incomplete, and result from ad- hesion of the anterior and posterior walls of the vagina to a greater or less extent, in consequence of excoriation or ulceration ; or it may be produced by flat or rounded cords that pass horizontally or diagonally across the vagina and reduce its calibre. The latter may consist of vaginal folds brought on by traction, or of the membranous bands left after the cure of ulcerative loss of substance. 3. Deviations in Position and Form. The form of the vagina is modified in a manner' corresponding to the anomalies which we have first examined, and in a medico-legal point of view we have to notice the unusual forms presented by the hymen after it has been ruptured. In- stead of the carunculae myrtiformes, a more or less considerable annular tumor remains ; or if the hymen was inserted into the nymphse, one half is left so as to form a species of valve, or it is entirely torn out in the shape of a ring. Among the deviations of position we notice intussusception and pro- lapsus of the vagina, which affect mainly the anterior wall of the vagina, and the eversion of the anterior or posterior vaginal parietes in vaginal hernia (cystocele vaginalis, hernia vaginalis posterior). 4. Solutions of Continuity. Besides the injuries inflicted by means of cutting instruments, which generally implicate various neighboring organs, and the ruptures caused by concussion and contusion, we have to mention the contusions and ruptures of the vagina occurring during parturition, whether or not occasioned by operative interference, and the loss of substance by ulceration. The contusions or lacerations affect the vagina alone, either superficially or throughout its tissues, or they are associated with contusions and lacerations of the uterus ; in the last 204 ABNORMITIES OF case, the injury affects the vagina and the uterus simultaneously, or a laceration of the latter is carried down to the former to a greater or smaller extent. Neighboring organs, and especially the bladder, may also be involved in the solution of continuity. In difficult or hurried parturition, when the parts have not been pro- perly supported, the vagina, the posterior commissure, and the perineum may be ruptured, and when the parturition is effected by the perineum, the vagina is perforated above the sphincter. Ulcerative destruction is not always limited to the vagina, but fre- quently gives rise to communications between the cavities of the vagina, the bladder, or the rectum, or with both at the same time by means of fistulas or large cloacae. 5. Diseases of the Tissues. 1. Inflammation. a. Catarrh affects the vagina very frequently in the protracted acute, or, if blennorrhoic, in the chronic form, and pre- sents the most various characters. It may be a simple benignant catarrh^ or have the specific qualities of the scrofulous, arthritic, syphilitic, im- petiginous, or gonorrhoeal catarrh ; it is sometimes complicated with blennorrhoea of other mucous membranes, and is either idiopathic or symptomatic, accompanying various local inflammatory, ulcerative, or de- generate processes in the vagina, the uterus, and neighboring organs. The vagina appears flabby, its mucous membrane tumefied and pale, invested with a pale thick coating of epithelium, or excoriated and red- dened, with enlargement of the follicles, which are surrounded by a vas- cular ring. It contains and discharges a secretion varying in quantity and quality, and mixed up with the products of the associated inflam- matory and ulcerative processes. In its pure condition it is a white, thin, milky, or creamy mucous, which is commonly secreted in consi- derable quantities, and indicates an abundant formation of epithelium and desquamation, or it appears as a vitreous, grumous, and viscid, or as a yellow puriform mucus. Catarrh of the vagina is an important disease, not only on account of the extreme loss of fluids which it often entails, but also on account of the imminent danger of its extension to the uterus and the Fallopian tubes, and the consequent morbid affection of these organs. It pre- disposes to intussusception of the vagina, owing to the relaxation it induces ; it leads to excoriation and superficial ulceration, both of the vagina, the external pudenda, the parts in their vicinity, and of the cervix uteri, to closure of the os tincae, to follicular suppuration, atresia vaginae, permanent hypertrophy of the follicles, and dilatation of the vaginal vessels. It follows that a cure is effected with extreme diffi- culty, and that relapses occur very frequently. b. Exudative processes. In rare cases primary croup occurs on the vaginal mucous membrane alone ; but it exists more frequently in com- plication with an exudative process on the internal surface of the uterus, in the shape of puerperal disease. As the latter generally predomi- nates, the affection is usually found to have spread from the uterus to the vagina. Exudative processes with various products occur more fre- quently in patches, or throughout the vagina as secondary diseases, both THE VAGINA. 205 a$ a result of puerperal affection of the uterus, as well as in consequence of an infection of the blood proceeding from other causes, or from a de- generation of the typhous and various exanthematic processes. They correspond to the condition of the blood and its products, and accord- ingly produce a solution of the mucous membrane and the submucous layer, varying in shape and depth, and not unfrequently resembling gangrenous destruction. A loss of substance may ensue, and to this cause undoubtedly many cicatrices found in these parts are to be attri- buted. They also not unfrequently extend to the pudenda, the peri- neum, and the nates, and give rise to extensive disorganization. We must make special mention of the secondary form of typhus occurring in the vagina. It does not appear to exhibit itself in the vaginal mucous membrane in its genuine form, but is often found de- generated into croup and gangrene. It is remarkable that an existing blennorrhcea, especially if of a gonorrhoeal or syphilitic character, exerts a powerful attraction upon it. c. Inflammation of the submucous cellular tissue of the vagina. It very rarely appears in the chronic form ; it leads to considerable thick- ening and coriaceous induration of the vaginal parietes ; the latter at the same time become less movable, so as to seem agglutinated to the adjoining parts. 2. Ulcer ative processes. We here meet with the simple (catarrhal) follicular ulcer, the circumscribed or diffused solution of the tissues re- sulting from exudative processes, the syphilitic ulcer, the phagedsenic ulcer of the os uteri, which generally spreads from the cervix uteri to the vagina, and the true cancerous ulcer. At the cervix we find some other ulcers, of which we shall have occasion to speak more fully at a future period. 3. G-angrene of the vagina. Gangrene is the result of pressure and contusion produced during difficult parturition ; it also occurs in the shape of gangrenous eschar and gangrenous or putrid fusion of the mucous and submucous layers. 4. Morbid growths. Their occurrence is altogether unusual, and even the fibrous and cancerous tumors that we meet with are but rarely ob- served. The cysts that are found in this region are developed in the cellular /tissue external to the vagina, and, anatomically speaking, bear a very subordinate relation to the latter. Fibroid productions almost invariably coexist with similar growths in the uterus ; they may be developed in the external fibro-cellular layer of the vaginal parietes, and especially at their posterior surface ; they then project with a larger or smaller segment, in the shape of round tumors, into the vaginal cavity. In other instances they are developed in the cellular tissue that is interposed between the vagina and the rectum, and, though in close relation to the vagina in point of origin, project chiefly into the rectum, and more or less obstruct its inferior portion. The latter circumstances are characteristic of the relation in which these morbid growths stand to the uterus and to the accumu- lations of cellular tissue which occur in these regions. Carcinoma of the vagina is, in most cases, cancer of the uterus which has spread to the vagina ; however it may exist, though the latter is in 206 ABNORMITIES OF a very undeveloped state, and even without it, in the shape of primary carcinoma of the vagina. It belongs to the fibrous or medullary variety, and, in proportion to its growth, induces thickening of the parietes, tu- berculated condensation of the internal surface, and corresponding con- traction of the passage ; the vagina becomes adherent to the neighboring parts, in consequence of cancerous degeneration of the cellular tissue surrounding it and the rectum, and finally cancerous ulceration and excrescences are established. The greater part of the vagina generally becomes involved, and the lower portion is prolapsed ; the disease ex- tends to the rectum, the bladder, the urethra ; by the pressure it exerts it causes retention of the urine and dilatation of the bladder, and, when it has reached the ulcerative stage, recto- and vesico-vaginal fistulse result. 6. Anomalies of the Contents of the Vagina. Under this head we class, besides the anomalies of the mucous secretion in vaginal catarrh, the products of exudative and ulcerative processes, the contents of the bladder and the rectum, when introduced by fistulous communications, the products of the diseased mucous membrane of the uterus and the Fallopian tubes ; blood that may be derived from various sources, and in various states of coagulation, discoloration, and decomposition. The presence of blood assumes particular importance when it is retained by a redundant hymen, or by congenital or acquired obturation ; we include in this category pessaries and the adherent calculous deposits, various substances that have been introduced from without, and, lastly, the pro- blematic cases of vaginal pregnancy. THE INTERNAL SEXUAL ORGANS. SECT. I. ABNORMITIES OF THE UTERUS. 1. Defect and Excess of Formation. Complete absence of the uterus must be considered as extremely rare ; in most cases in which the uterus was found deficient in the dead or living subject, rudiments of a uterine organ of different forms were discovered. 1 The most common case of arrest, which is generally considered as absence of the uterus, is that in which the fold of the peritoneum, which is destined for the reception of the internal sexual organs, contains, on one or both sides, posteriorly to the bladder, one or two small, flattened, solid masses, or larger hollow bodies, with a cavity of the size of a pea or a lentil, which is lined with mucous membrane. They are to be viewed as rudiments of the uterine horns, and the Fallopian tubes bear an exact relation to their development. These may either be totally de- ficient, or terminate in the vicinity of the uterus in the peritoneum as blind ducts, or they may communicate with the uterus with or without an open passage. 1 Oestr. Jahrb. xvii. 1. THE UTERUS. 207 This formation of the uterus, and especially the existence of two lateral, hollow, elongated and rounded uterine rudiments, each of which is connected with a corresponding Fallopian tube and ovary, constitutes what Mayer terms the uterus bipartite. From each of the uterine rudi- ments a flattened, round cord of uterine tissue ascends within the fold of the peritoneum, and the two from each side coalesce. The place of the uterus is occupied by cellular tissue, in which a few uterine fibres, de- rived from the just-mentioned cord, may be traced; it presents the general outline of a uterus, and, reaching downwards, rests upon the arch of a short vaginal cul-de-sac. The external sexual organs and the mammary glands, as well as the general sexual character of the indivi- dual, attain a normal development. If we pursue the progress of these uterine rudiments we find a de- velopment on one or both sides ; representing in the former case, a uterine half, or a uterus unicornis ; in the latter, a two-horned uterus, or uterus bicornis, varying in degree ; this is what is falsely called the double uterus, uterus duplex. These, and the following uterine forma- tions which depend upon fissure, offer considerable interest. The one-horned uterus may be always demonstrated to be a uterine half, developed from a rudimentary uterine horn, or the unsymmetrical half of a uterus bicornis, either of the right or the left side. It is a cylindrical or fusiform body, that is curved towards the corresponding side, and from the superior portion of which a tube passes to the ovary. The following are the proofs of its resulting from an arrest of develop- ment ; it presents : Firstly. A vertical diameter, which generally resembles that of a normal uterus ; Secondly. A diminution of the transverse diameter ; Thirdly. A small (virginal) fundus, with a preponderating thickness of the long and spacious cervix (foetal state) ; Fourthly. The arch in which this uterus is deflected from the meridian is variously curved ; Fifthly. The cervix, as it descends, corresponds more and more to the axis of the body, and its vaginal portion entirely coincides with it. In the virginal uterus the latter is always small, and the vagina narrow ; Sixthly. In the os tincae the palmse plicatae approach closer to the convex margin of the uterus ; Seventhly, The broad ligament on the side of the deficient uterine half is in some cases remarkably large ; it at least presents sufficient room for the absent symmetrical half of the uterus. The Fallopian tube of the defective side shows various relations ; if there is no indication of a uterine horn it is almost always absent, and the broad ligament generally forms a slightly fringed prolongation at the point corresponding to the free end of the tube. Occasionally it is even absent when there is a rudimentary uterine horn, and it presents the relations described at p. 206. In rare cases we find a total absence of one half of the uterus, whilst the corresponding tube terminates blindly in the convex margin of the one-horned uterus above its cervix. The ovary of the defective side is, with rare exceptions, present even when the Fallopian tube is wanting. 208 ABNORMITIES OF We are the more induced to extract the following remarkable case from the essay cited elsewhere (Vol. III.) as an instance of the transi- tion from the uterus bipartitus to the uterus bicornis, as the case of preg- nancy in a uterine rudiment (one-half of the uterus bipartitus), which we shall have occasion to quote at a future period, will thus be rendered more intelligible. The internal sexual organs of a tailor's wife, set. 34, who died in the lunatic asylum on the 24th of September, 1830, had always menstruated scantily, and bore no children, present the following relations. The uterus has a conical shape, is two inches and three lines in length, pre- sents a curve to the left, has tolerably thick parietes, and is acuminated above ; the fimbriated extremity of the Fallopian tube is agglutinated to its ovary. On the right side there is a very large ligamentum latum, within which, at a distance of two inches from the uterus just described, and on a level with its superior portion, there is a body of the size of a hazel-nut, consisting of uterine tissue, and presenting a cavity of the size of a lentil, into which a tube an inch and a half long, and of a sigmoid serpentine form, opens. Posteriorly this uterine rudiment sends off a carneous prolongation, representing the ovarian ligament, anteriorly it gives off a round ligament. On its inner side it is prolonged in the direction of its axis, i. e. obliquely downwards, as a solid band of uterine substance, which impinges upon the convex right margin of the left uterus one inch above its external orifice. Both ovaries are small and contracted, the cervix is small, the vagina narrow, and its arch infundi- buliform. If the two rudiments of the uterus bipartitus are developed uniformly, according to the type of the one-horned uterus, two uterine halves are formed, which unite at one point of their convexity, and thus give rise to the uterus bicornis. The degree of this abnormity varies, and de- pends chiefly upon the point at which the two halves coalesce. The nearer the latter approaches to the external orifice, the more obtuse will be the angle at which the junction takes place, and consequently the more extensive the fissure. The higher the point of union, the more acute will be the angle, and it may thus become so small that the two halves lie almost parallel to one another, and there is only a slight divergence of the two horns. In the latter case the uterus closely re- sembles the normal condition ; there is always a shallow excavation of the fundus between the projecting horns ; the uterine cavity is either simple or divided by a septum of varying length. The part that unites the two uterine halves always represents the fundus uteri ; the higher it is placed, the more this character becomes evident ; and when it attains the same level as the uterine horns and surmounts them with its arch, the form of the two-horned uterus disap- pears. We consequently find, firstly, that the commissure in all cases occupies a horizontal position in the angle in which the two uterine halves meet. Secondly. That the commissure is always developed in conformity with the fundamental type, viz. that it is a portion of uterine tissue presenting an arch posteriorly, or rather being obtuse-angled and thicker behind. THE UTERUS. 209 Thirdly. That when a septum exists it always proceeds from the com- missure. Fourthly. That, however low the commissure be placed, it exerts an evident influence upon the mutual position of the two uterine halves and the internal conformation of their cervices. This consists, in the first instance, in the slight convexity of the posterior, and the slight concavity of the anterior, surface of the uterus hicornis ; and in the peculiar rela- tion of the two uterine halves to one another, which is marked by a slight convergence and inclination anteriorly, thus affording the charac- ter of a normal uterus. The influence too that is exerted upon the pal- mae plicatse in the uterine halves is singular ; the anterior one is placed internally next to the septum, the posterior one lies more externally, and on account of the greater thickness of the fundus uteri correspond- ing to the normal character more towards the posterior surface. The fact of the fundus being wedged in between the cervices in its original form, causes the palma plicata posterior to diverge still more ; it induces a slight rotation of the uterine halves anteriorly, which is followed by the above-described form and position of the uterus bicornis. The septum, which descends from the fundus uteri, may reach down to the os tincse and divide it, or it does not reach so far, and then the orifice or the cervix is common to both halves, or, lastly, it may be nearly or totally absent, and we then find the cavity of the cervix and the uterus more or less uniform, in proportion as the fundus itself is more or less elevated. If the latter is much depressed and presents no septum, a single cervical channel conducts into two uterine halves that diverge considerably, sometimes so far as to assume a horizontal posi- tion. In rare cases, the two uterine halves do not coalesce, owing to coex- isting malformations, such as fissures of the abdominal and pelvic parie- tes, of internal organs, especially the bladder and the intestine ; the uterus thus remains completely divided, and the two halves are separated by the rectum, the colon, the small intestine, or by a rudimentary por- tion of either, by the mesentery, or the bladder. In the majority of cases, the inferior section of both, or at least of one uterine half, is but very imperfectly developed, and this applies still more to the vagina and to the pudenda. The lowest degree of uterine fissure is represented by the bilocular uterus. Here the projection of the uterine horns has entirely disap- peared ; the fundus uteri occupies a position level with the orifices of the Fallopian tubes, and its convexity projects above them. The uterine cavity is divided into two vertical partitions by a central septum ; the uterine horns present a normal divergence and the normal length. Yet even here the division of the uterine cavity is perceptible externally ; the body of the uterus presenting greater breadth, and generally a shal- low fundus, in consequence of which the uterus appears lower, and its dimensions do not, in most cases, exceed those of the normal uterus ; the division is also indicated by a shallow furrow running down the posterior surface of the organ. The division of the uterine cavity by a vertical septum into two loculi extends in rare cases into the external orifice, but more generally is VOL. II. 14 210 ABNORMITIES OF united to the cavity of the uterus, or the septum does not even suffice to divide the uterine cavity : when this malformation approaches the nor- mal character of the organ, we merely observe a ridge on the fundus and along the posterior wall of the uterus, representing a rudimentary sep- tum. If the septum does not reach the external orifice, its lower free border is always thinner, pointed, and falciform. It probably always descends lower at the posterior than at the anterior surface of the uterus, and this becomes particularly apparent when it merely exists in a rudimentary state. In the case of the uterus bicornis or bilocularis, the vagina is either single, or may in either be divided in all the forms and degrees described at p. 202. The most perfect fissure seen is that in which the septum of a uterus bicornis or bilocularis descends . to the external orifice, divides the latter, and extends to the vagina ; the septum may reach as far as the pudenda, and in the virginal state divide the hymen. In this case there is a separate vagina for each half of the uterus. All these malformations of the uterus occur associated with various irregularities in other organs, as also in individuals that in other respects are well developed. In reference to conception, pregnancy, and partu- rition, connected with the uterus bicornis, bilocularis, and unicornis, we have to make the following remarks. Firstly. Numerous well-authenticated observations prove that the ano- malous conditions of the uterus which we have discussed, i. e. the uterus bicornis and bilocularis, with or without division of the vagina, and even the uterus unicornis, are capable of being impregnated. In the first we find repeated pregnancy occurring in either half, but there is a prepon- derance in favor of the right side. There are even cases on record of a twin pregnancy occurring in one, or of concurrent pregnancy in both halves ; one fostus has been found less developed and smaller, and in solitary cases perhaps though this is to be received with certain doubts superfoetation had taken place. In the Viennese Museum we have even an example of pregnancy in a rudimentary uterine horn, which termi- nated fatally in the third month by rupture and sanguineous effusion into the peritoneal cavity. The case was formerly taken for impregnation of the Fallopian tube, until a further examination convinced me to the con- trary. It is highly instructive, and doubtless the only case of the kind on record. We shall, therefore, devote a little further attention to it. The true uterus is a uterus unicornis of the left side with a cervix, in which cicatrices that have been left by former births are visible ; the left Fallopian tube issues from its apex, which is turned to the left side. A tolerably thick, roundish, flattened, and hollow cord, consisting of uterine parenchyma, is inserted into the convex right margin of this uterus, and communicates by a millet-sized opening just above the internal os uteri with the cavity of the latter. This cord is above two inches in length, and is dilated externally into a sac of the size of a duck's egg, from the termination of which the right tube with its ovary, and from the lower surface a round ligament proceed. This sac, the rudimental right half of the uterus, contained a female foetus of the third month enclosed in the normal membranes ; it presented a transverse fissure, in the vicinity of the insertion of the umbilical cord, of almost two inches in length. All the membranes were ruptured. The left half of the uterus is twice THE UTERUS. 211 as large as it would be in an unimpregnated state, its walls thick, and its innner surface, as well as that of the channel of its parenchymatous process, invested by a deciduous membrane, and the cervix blocked up with a plug of coagulable lymph. The preparation was taken from a maid-servant twenty-four years of age, who had died suddenly after attacks of pain and spasm in the abdo- men on the 24th of March, 1824, and was examined by order of the sanitary board. The body was delicately built and rather emaciated ; four pounds of blood, which had been effused in consequence of the rup- ture of the pregnant rudimentary uterus and the foetal membranes, were found in the lower part of the abdomen. The formation of which we are speaking, is the same as the transition form from the uterus bipartitus to the uterus bicornis described at p. 208, with the exception that in this case the parenchymatous cord that passes from the rudimentary to the developed half of the uterus is hollow, and contains a channel which establishes a communication between the two, whereas in the other case the cord is solid. By means of this channel impregnation of the rudimentary uterus was rendered possible ; this pregnancy forms a species of transition from uterine to extra-uterine pregnancy, and particularly to pregnancy in the Fallopian tube. Secondly. In reference to the course of pregnancy and of parturition in uterine formations that are capable of being impregnated, Meckel concludes, from a review of the cases that had been published in his time, that of the comparatively small number of cases of fissured uterus the majority died during or after birth ; this ratio is increased by the con- sideration that in the great majority of these cases the malformations occurred in monstrosities, children, and virgins. Since Meckel, Carus has directed particular attention to the unfortunate issue of these cases. Numerous cases may now be opposed to the ancient and modern ob- servations of the above description, but it appears that the unfavorable ratio pointed out by Meckel still holds good with regard to the uterus bicornis and bilocularis. Various circumstances conspire to induce great distress or rupture of the womb, even during the early periods of pregnancy (Canestrini, Dionis), to give rise to abortion, flooding, difficult and slow parturition, with consequent exhaustion and predisposition in the uterus to puerperal disease. They become apparent on examining the fissured organ, and we find them to be the following. a. The absence of the necessary dimensions in the uterine half that undertakes the functions of the entire organ during pregnancy, and the development of which is only provided for by one set of vessels. This applies with additional force to a rudimentary uterine half, as in the case just detailed ; in reference to its termination in rupture also, it is allied to extra-uterine pregnancy, and especially to pregnancy in the Fallopian tubes. b. The obstacle opposed to the uniform development of the impregnated uterine half by the unimpregnated half. It appears that the latter, after the formation of a more or less complete decidua, keeps pace in its de- velopment with the impregnated half up to a certain point only, and then remaining stationary, forms an impediment to the uniform growth of that half. This observation is particularly applicable to the bilocular womb, 212 ABNORMITIES OF with a complete septum, as the latter being common to both cavities, re- mains undeveloped on the side of the unimpregnated portion; it applies less to the true uterus bicornis, the two sides of which are independent of one another.